Health inspection·November 8, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 interview the facility failed to properly submit Minimum Data Set (MDS) 3.0 assessments in the required timeframes. This affected two residents (#64 and #113) of 14 sampled residents reviewed during the annual survey. Residents Affected - Few Findings include: 1. Record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, dysphagia, epistaxis, atrial fibrillation, chronic obstructive pulmonary disease, and thrombocytopenia. Review of nursing and physician assessments, completed on 10/16/22 revealed the resident had no cognitive impairments and was able to make her needs known at all times. Review of the Minimum Data Set Entry Assessment, dated 10/16/22 which noted the current status was export ready on 11/07/22. A five-day Medicare admission Assessment, initiated on 10/21/22 revealed a current status of in progress. On 11/07/22 at 3:45 P.M. interview with MDS Nurse #200 verified both MDS assessments were past the required submittal dates. MDS Nurse #200 revealed she had not yet had a chance to complete them. 2. Record review revealed Resident #113 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, Parkinson's disease, major depressive disorder and anxiety disorder. Review of the entry MDS 3.0 assessment, dated 10/13/22 revealed the assessment had been completed on 10/19/22 but had not been exported as of 11/07/22, 19 days after it had been completed. Review of the five day MDS 3.0 assessment, dated 10/19/22 revealed the assessment was still in progress and had not been completed, 19 days after it had been opened. Review of the admission MDS assessment, dated 10/19/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 (out of 15). The resident was assessed to require limited assistance from two staff members for bed mobility and extensive assistance from two staff members for transfers and toileting. On 11/07/22 at 3:35 P.M. interview with MDS Nurse #200 verified the assessments had not been completed and submitted in the required timeframes. 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: 366470 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 366470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Woods at New Albany 4588 Wesley Woods Blvd New Albany, OH 43054 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)