Inspection·November 17, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure refrigerator temperature logs in resident's rooms were accurately completed accurately. This affected five (#14, #15, #16, #17, and #18) out of five residents reviewed for having refrigerators in their rooms. The facility census was 97. Findings include: 1) Review of the medical record for Resident #14 revealed he was admitted to the facility on [DATE]. Diagnoses included respiratory failure unspecified with hypercapnia, chronic kidney disease stage three, anemia, major depressive disorder, hyperlipidemia, type two diabetes mellitus with diabetic neuropathic arthropathy, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #14 revealed the resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and was totally dependent on staff for transfer. Review of the refrigerator temperature logs from 09/01/23 through 09/30/23 for the refrigerator in Resident #14's room revealed Former Housekeeping Aide (FHA) #200's initials were listed and crossed out by Housekeeping Supervisor (HS) #140's initials on 09/12/23, 09/13/23, and 09/20/23. 2) Review of the medical record for Resident #15 revealed she was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, anemia, congestive heart failure, dementia, and chronic obstructive pulmonary disease. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #15, revealed the resident had intact cognition evidenced by a BIMS score of 15. This resident was assessed to require extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent on staff for eating and transfer. Review of the refrigerator temperature logs from 09/01/23 through 09/30/23 for the refrigerator in Resident #15's room revealed FHA #200's initials were listed and crossed out by HS #140's initials on 09/12/23, 09/13/23, and 09/20/23. 3) Review of the medical record for Resident #16 revealed he was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, quadriplegia, and type two (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 3 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 11/17/2023 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)