Health inspection·December 7, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy, and staff interview, the facility failed to ensure the resident's care plan was accurate to reflect the use of oxygen and advance directives. This affected three residents (#4, #31, and #50) of twenty-four residents reviewed during the annual recertification. The facility census was 77. Findings include: 1. Review of Resident #50's medical record revealed an admission date of 09/24/21. Diagnoses included dementia, hemiplegia, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition. Review of the plan of care dated 09/27/21 revealed Resident #50 was at risk for impaired respiratory infection related to potential COVID-19. Further review of the resident's plan of care revealed no goals or interventions related to oxygen administration and Resident #50 frequently removed her oxygen. Review of Resident #50's physician order dated 11/20/22 revealed oxygen was to be administered at two liters per minute per nasal cannula continuously. Observation on 12/06/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #70 in Resident #50's room revealed the resident's oxygen concentrator was on two liters per minute. The resident's oxygen tubing was on the floor tangled in the bed frame. LPN #70 attempted to replace the resident's oxygen, as the resident was pushing the oxygen away. The LPN #70 educated the resident on the importance of the oxygen. Interview on 12/06/22 at 2:40 P.M. with LPN #70 revealed Resident #50 frequently would remove her oxygen. Interview on 12/07/22 at 2:40 P.M. with the Director of Nursing (DON) confirmed Resident #50's plan of care made no mention of oxygen administration. 2. Review of Resident #31's medical record revealed an admission date of 07/18/22. Diagnoses included diabetes mellitus, multiple sclerosis, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. Review of the plan of care dated 09/17/22 revealed Resident #31 Advanced Care planning was reviewed (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: 366466 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 366466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Trace Health and Rehabilitation 250 West Social Row Road Centerville, OH 45458 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)