Health inspection·June 27, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on medical record review and staff interview the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected two (Residents #2 and #45) of three residents reviewed for PASARR documents. The facility census was 73 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/26/11 with diagnoses including psychotic disorder with delusions, dementia without behaviors, major depressive disorder, and hypertension. Review of the PASARR for Resident #2 dated 10/17/11 revealed it did not include the diagnosis of psychotic disorder recorded on the document. Review of the annual Minimum Data Set (MDS) assessment for Resident #2 dated 06/04/24 revealed the resident was severely cognitively impaired, used a wheelchair to aid in mobility, and was always incontinent of bowel and bladder. Interview on 06/27/24 at 10:25 A.M with Director of Business Development (DOB) #142 confirmed Resident #2's PASARR did not include the resident's admitting diagnosis of psychotic disorder was not included and the PASARR needed to be updated. 2. Review of the medical record for Resident #45 revealed an admission date of 11/13/21 with diagnoses including cerebral infarction due to unspecified occlusion, type two diabetes mellitus with hyperglycemia, schizoaffective disorder bipolar type (added 11/11/22), dementia without behaviors, senile degeneration of brain, and anxiety disorder (added 01/19/21). Review of the PASARR for Resident #45 dated 01/24/22 revealed it did not include the diagnoses of schizoaffective disorder or anxiety disorder. Review of the quarterly MDS assessment for Resident #45 dated 04/01/24 revealed the resident was cognitively intact, used a wheelchair and walker to aid in mobility, and was frequently incontinent of bladder and always continent of bowel. Interview on 06/27/24 at 10:25 A.M with DOB #142 confirmed Resident #2's PASARR did not include the resident's diagnoses of schizoaffective disorder, and anxiety disorder and needed to be updated. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365786 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)