Health inspection·November 29, 2023

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policy the facility failed to ensure smoking assessments were completed with a quarterly according to the facility's smoking policy. This affected three residents (#10, #25, and #29) of three residents reviewed for smoking. The facility identified six residents (#10, #25, #26, #29, #36, and #37) who smoked at the facility. The facility census was 65. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including sepsis, acute kidney failure, chronic obstructive pulmonary disease, and personal history of nicotine dependence. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Further review of Resident #10's medical record revealed that smoking assessments were not done quarterly. Smoking assessments were completed on 12/13/22 and then another smoking assessment was completed on 11/16/23 after an incident with another smoker (Resident #29). 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and tobacco use. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #25 was cognitively intact. Further review of Resident #25's medical record revealed that smoking assessments were not completed quarterly. Smoking assessments were completed on 12/13/22 and then another smoking assessment was completed on 11/16/23 after an incident with another smoker (Resident #29). 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and tobacco use. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #29 was cognitively intact. Interview on 11/29/23 at 11:04 A.M. with MDS Nurse #210 verified that quarterly smoking assessments were not completed for Residents #10, #25, and #29. (continued on next page) 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: 365993 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 365993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Louisville Ctr for Rehab & Nsg Care 7187 St Francis Street, NE Louisville, OH 44641 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)