Health inspection·May 5, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility policy review, the facility failed to ensure a resident's code status (level of medical interventions a patient wishes to have started if their heart or breathing stops) matched the State of Ohio DNR (Do Not Resuscitate) document for Resident #48. This affected one of four residents reviewed for advance directives. The facility census was 83. Findings include: Review of the medical record for Resident #48 revealed an admission date of [DATE]. Diagnoses included sepsis, urinary tract infection, obstructive and reflux uropathy, type two diabetes, chronic atrial fibrillation, old myocardial infarction, abdominal aortic aneurysm, unspecified dementia, diverticulitis, cognitive communication deficit, and dysphagia. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of 11 indicating moderate cognitive impairment. She required the extensive assistance of two staff members for bed mobility, transfers, toileting, and total dependence on staff for bathing. Review of Resident #48's chart revealed the facility form titled Advanced Directives dated [DATE]. This form stated Resident #48 was a full code meaning that all life sustaining measures would be performed in the event her heart or breathing would stop. Further review of the chart revealed a signed State of Ohio DNR-CC (do not resuscitate-comfort care) form indicating in the event Resident #48's heart or breathing stopped no life sustaining measures would be provided to the resident. This form was located on the back side of the Advanced Directives page that stated Resident #48 was a full code. The DNR form was dated [DATE]. Review of the physician orders for [DATE] identified an order dated [DATE] stating the resident was a full code. A physician order dated [DATE] identified an order stating the resident was a DNR-CC. Interview on [DATE] at 3:04 P.M. with the Director of Nursing (DON) verified there was conflicting information regarding code status in Resident #48's chart. The DON verified the first page in the chart stated the resident was a full code, and the DNR form on the back of the page stated she was a DNR-CC. Review of the facility policy titled Advance directives revised [DATE], revealed the Social Services Director or designee would provide written information to the resident and or representative concerning the right to make decisions and formulate advance directives and accept or refuse medical or (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 3 Event ID: 366129 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 366129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gillette Nursing Home 3310 Elm Rd Warren, OH 44483 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)