Inspection·December 19, 2018

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to ensure activity care plans were person centered for two residents ( #57 and #38) of two reviewed for activities. The facility census was 66. Findings include: 1. Medical record review revealed Resident #57 was admitted to the facility on [DATE]. Medical diagnoses included Alzheimer's Disease and psychotic disorder. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Review of care plan dated 12/17/18 revealed Resident #57's was dependent on staff for activities, cognitive stimulation and social interaction related to cognitive deficits. The only intervention was the resident needed assistance with activities of daily living (ADLs) as required during the activity. Interview with Activity Director #223 on 12/18/18 at 11:10 A.M., confirmed the activities care plan for Resident #57 was not person centered. 2. Medical record review for Resident #38 revealed an admission date of 03/15/17 with diagnoses including to dementia, unspecified psychosis not due to a substance or known physiological condition, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of the care plan dated 06/05/17 revealed the Resident #38 was dependent on staff for activities, cognitive stimulation and social interaction related to cognitive deficits. The interventions listed were to assure the activities the resident was attending were compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed, compatible with individual needs and abilities; and age appropriate. Interview on 12/18/18 at 11:12 A.M., with Activities #223 confirmed care plan for Resident #38 was not person centered and not individualized. Activities #223 revealed there were no known interests documented. Review of the facility policy titled, Care Planning, undated revealed the interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. 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 5 Event ID: 365894 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 365894 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MCV Health Care Facilities, Inc 411 Western Row Road Mason, OH 45040 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)