Health inspection·May 9, 2019

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #4's medical record revealed an admission date of 03/24/16. Diagnoses included but hypertension, benign prostatic hyperplasia, adrenocortical insufficiency, hearing loss bilateral, heart failure, anxiety, diabetes mellitus, depression, arteriovenous fistula, anemia in chronic kidney disease, sick sinus syndrome, chronic kidney disease stage five, legal blindness. Review of Resident #4's quarterly MDS assessment, dated 02/19/19, revealed he was cognitively intact. Review of Resident #4's medical record was silent for care conferences. Interview on 05/09/19 at 10:19 A.M. with Registered Nurse (RN) #111 who stated the facility had no care conferences in the electronic charting system or in paper format version. RN #111 stated the facility had identified this was a problem and had initiated Quality Assurance and Performance Improvement (QAPI) measures that included reviewing all of the residents charts and scheduling care conferences that were due, inviting families, reviewing care plans, reviewing orders and code status. Review of the facility policy titled, Plan of Care Meetings, dated 06/02/19 revealed plan of care meetings will be held on each resident upon admission, quarterly and as needed. Policy additionally revealed participants will include residents, resident's representative, nursing, dietary, social services, activities and therapy as needed. Based on record review, facility policy review and family and staff interview, the facility failed to ensure care conferences were conducted and included residents and the resident's representatives. This affected two residents (Resident #4 and #5) of sixteen residents reviewed. The facility census was 42. Findings include: 1. Review of Resident #5's medical records revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, dementia, anxiety and unspecified psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 02/21/19, revealed the resident had severe cognitive impairment. The resident required extensive assistance for bed mobility, eating and dressing and required total dependence for toileting and transfers. Review of the resident's medical record revealed no documentation related to care conferences in the past year. Interview on 05/07/19 at 9:30 A.M. with Resident #5's guardian stated he/she has attended only one care conference since the resident was admitted on [DATE]. Resident #5's guardian denied being Page 1 of 2 365934 365934 05/09/2019 Crestwood Ridge Skilled Nursing and Rehab 141 Willettsville Pike Hillsboro, OH 45133

F 0657 invited or being knowledgeable of the quarterly or annual care conferences. Level of Harm - Minimal harm or potential for actual harm Interview on 05/08/19 at 2:51 P.M. with the Director of Nursing (DON) and Corporate Registered Nurse (CRN) #111 confirmed the facility was not able to provide any documentation related to Resident #5's care conferences in the past year. CRN #111 confirmed there was no evidence Resident #5 or resident's representative attended the care conference. CRN #111 stated the previous care conferences were completed on paper and the documentation has not been found. The facility was not able to provide evidence or documentation of Resident #5's care conferences from the past year. Residents Affected - Few 365934 Page 2 of 2