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
record review and staff interview, the facility failed to ensure a residents' advanced directives matched in
the electronic record and the paper record. This affected one (Resident #14) of two residents reviewed for
advanced directives. The facility census was 77.
Findings include:
Record review for Resident #14 revealed an admission date of 10/03/13. Diagnoses included dementia and
Alzheimer's disease.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident
#14 had mildly impaired cognition.
Review of Resident #14's electronic medical record on 05/02/23 revealed the electronic record had the
resident as a Do Not Resuscitate Comfort Care (DNRCC).
Review of Resident #14 paper medical record on 05/03/23 revealed the paper chart had the resident as a
Do Not Resuscitate Comfort Care- Arrest (DNRCC-A).
Interview with Registered Nurse (RN) #569 on 05/03/23 at 10:35 A.M. verified Resident #14's code status
in the paper chart and the electronic record does not match.
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:
366351
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
366351
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ohio Veterans Home - Georgetown
2003 Veterans Blvd
Georgetown, OH 45121
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)
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview and record review, the facility failed to have the necessary paperwork for a resident
when they discharged to the hospital. This affected one (Resident #12) of three residents reviewed for
hospitalization. The facility census was 77.
Findings include:
Record review for Resident #12 revealed an admission date of 11/23/15. Diagnoses included myocardial
infarction, type II diabetes mellitus, dementia, anxiety, and peripheral vascular disease. Review of the
Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was
moderately cognitively impaired.
Review of a progress note dated 02/28/23 at 7:00 P.M. revealed a state tested nurse aide (STNA) came to
the nurse and asked the nurse to check on Resident #12 because he claimed he felt weak and had
shortness of breath. Resident #12 did require more assistance to transfer to bed due to generalized
weakness, vital signs were taken and the nurse was made aware. The progress note dated 03/01/23 at
10:01 A.M. revealed Resident #12 was admitted to the hospital for pneumonia.
Review of the medical record on 05/03/23 revealed the facility did not have discharge documents in the
medical record when Resident #12 transferred out to the hospital on [DATE].
Interview with Registered Nurse (RN) #810 on 05/03/23 at 11:12 A.M. verified there was no assessment
transfer paperwork in the medical record when Resident #12 transferred to the hospital on [DATE].
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366351
If continuation sheet
Page 2 of 3
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
366351
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ohio Veterans Home - Georgetown
2003 Veterans Blvd
Georgetown, OH 45121
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)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews and staff interview, the facility failed to ensure pre-admission screening and resident review
(PASARR) was completed timely after a significant change. This affected one (Resident #63) of four
residents reviewed for PASARR during the annual survey. The facility census was 77.
Findings include:
Record review for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses
included Alzheimer's disease, dementia, post-traumatic stress disorder, and chronic kidney disease.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/08/23, revealed Resident #63 had
minimal cognitive impairments.
Review of current medical diagnoses revealed diagnoses of mood disorder and bipolar disorder were
added to the resident record on 11/04/21.
Review of the PASARR completed on 09/25/20 revealed bipolar disorder and mood disorder were not
captured on this review. No other PASARR has been completed after 09/05/20 to reflect the addition of
mood disorder or bipolar Disorder.
Interview with Social Worker #469 on 05/03/23 at 10:47 A.M. verified a new PASARR has not been
completed. She verified the PASARR was completed on 09/25/20 by a sending facility and the diagnoses of
mood disorder and bipolar disorder were included on their medical record. She verified both diagnoses
were not captured on the PASARR that was completed and a new one was never done.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366351
If continuation sheet
Page 3 of 3
