Inspection·November 7, 2024

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** Based on medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure the interdisciplinary team members attended care conferences and failed to ensure the resident was invited to care conferences. This affected one (Resident #49) of one resident reviewed for care conferences. The facility census was 111. Findings include: Review of Resident #49's medical record revealed an admission date on 01/14/20. Diagnoses included skin cancer, anxiety, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact. Review of the care conference notes dated 08/09/24 revealed Social Service Designee (SSD) #388 was the only staff member in attendance. Resident #49 was documented as attending. The care conference notes dated 05/09/24 and 02/09/24 revealed Resident #49 or a representative/family member did not attend. SSD #388, Dietician #334, and Licensed Practical Nurse (LPN) #362 were documented as attending. Further review of Resident #49's medical record revealed no documentation of Resident #49 or representative/family member being notified of care conference dates. During an interview on 11/04/24 at 10:21 A.M., Resident #49 stated she had never had a care conference at the facility. During an interview on 11/06/24 at 10:40 A.M., SSD #388 confirmed he was the only staff member for a care conference with Resident #49 on 08/09/24. SSD #388 confirmed care team staff should be involved in resident care conferences. SSD #388 stated he informed residents of care conferences in person days before the care conference. SSD #388 stated representative/family members were invited through emails. SSD #388 was unable to provide any documentation informing Resident #49 of the care conferences on 02/09/24 and 05/09/24. Review of the facility's policy titled Care Conference dated revised August 2024 revealed the procedure during care conference is as follows, each discipline reviews the patients/responsible party problems, goals and interventions pertaining to their discipline. The interdisciplinary team discusses the progress of the patient in relation to the goals established. Patient/responsible party are part of the information exchange and decision making as to the patients care plan. Code status will be (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 4 Event ID: 366185 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 366185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillspring Health Care & Rehab 325 East Central Avenue Springboro, OH 45066 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)