Health inspection·February 21, 2019

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview the facility failed to ensure significant change assessments were timely completed upon admission to hospice. This affected one (#42) of 14 residents reviewed during the investigative phase of the survey. The facility census was 43. Residents Affected - Few Findings include: Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, schizophrenia, hepatic failure, malignant neoplasm of breast, and dementia. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfers, toileting, personal hygiene, and eating. A wheelchair was utilized for mobility. Resident #42 received hospice care. The previous MDS assessment was a quarterly assessment dated [DATE] which revealed no hospice care. Review of hospice communication sheet revealed Resident #42 was admitted to hospice on 11/20/18 for routine level of care. Review of physician order dated 11/20/18 revealed refer to hospice. A physician order dated 12/31/18 revealed admit to hospice as of 11/20/18. Review of care plan initiated 11/20/18 revealed Resident #42 received hospice services for terminal diagnosis of late stages of dementia. Observation on 02/19/19 at 1:56 P.M. revealed Resident #42 was in bed hollering out for help. The resident was unable to be interviewed due to confused mental status and inability to answer simple questions. Interview on 02/21/19 at 2:17 P.M. with Assistant Director of Nursing (ADON) MDS Nurse #4 reported he/she forgot to complete a significant change MDS assessment for Resident #42 upon admission to hospice. 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: 366296 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 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)