Inspection·February 9, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure resident assessments were accurately completed. This affected two (Residents #6 and #48) of four residents reviewed for Minimum Data Set (MDS) 3.0 assessments recorded for pain. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 09/06/22 with diagnoses including diabetes mellitus and pain in the right shoulder. Review of the pain assessment dated [DATE] revealed Resident #6 had pain in the previous five days to her lower extremities rating it as a six on a scale of zero to ten. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #6 had intact cognition. Review of section J revealed the question, should staff attempt to conduct an interview with the resident, was marked yes. However, the pain assessment interview was answered not assessed. The assessment was signed by Licensed Practical Nurse (LPN) #821, dated 12/10/22. Interview on 02/07/23 at 10:40 A.M. with LPN #821 verified the pain assessment on the quarterly MDS 3.0 assessment was not completed and she had answered not assessed as she believed it had to be done on the Assessment Reference Date (ARD) as it had a look-back period of five days. LPN #821 stated she used the information from the pain assessments that the nursing staff completed in the medical record. Interview on 02/07/23 at 11:38 A.M. with the Director of Nursing (DON) revealed pain assessments are done weekly but don't always coincide with the resident's MDS assessment as she does not know when the MDS assessments are scheduled. Interview on 02/07/23 at 2:13 P.M. with LPN #821 verified the RAI manual stated the look-back period on section J of the MDS 3.0 assessment is five days and the assessment should be conducted close to the end of the five day look-back period, preferably on the day before or the day of the ARD. She verified there was a pain assessment dated [DATE] and the MDS was dated 12/07/22. 2. Review of the medical record for Resident #48 revealed an admission date of 09/27/22 with diagnoses including hypertension, dementia, difficulty in walking, anxiety and depression. Review of the pain assessment dated [DATE] revealed Resident #48 had pain over the previous five days to her bilateral lower extremities rating it as happening occasionally and at a seven on a scale (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 5 Event ID: 366260 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 366260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683 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)