Inspection·November 20, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review, staff interviews and policy review, the facility failed to ensure a medical record contained accurate and complete documentation. This affected one (#55) out of the three residents reviewed for management of blood sugars. The facility census was 47. Findings include: Review of the medical record for Resident #55 revealed an admission date of 09/26/24 with medical diagnoses of encephalopathy, Parkinson's disease, dementia, diabetes mellitus, and malignant neoplasm of the left female breast. Review of the medical record revealed Resident #55 discharged on 10/28/24. Review of the medical record for Resident #55 revealed an admission Minimum Data Set (MDS) assessment, dated 09/30/24, which indicated Resident #55 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene and bathing, partial/moderate staff assistance with transfers and supervision with bed mobility. The MDS indicated Resident #55 received insulin injections. Review of the medical record for Resident #55 revealed a physician order dated 09/28/24 for Humalog Kwikpen per sliding scale before meals, if blood sugar less than 70 or greater than 400 to call the physician. Review of the medical record for Resident #55 revealed October 2024 Medication Administration Record (MAR) which revealed no documentation to support the facility obtained Resident #55's blood sugar levels or administered insulin on 10/15/24 before lunch or supper or on 10/27/24 and 10/28/24 before breakfast. Review of the medical record for Resident #55 revealed lunch meal intake on 10/15/24 to be between 76-100%, breakfast intake on 10/27/24 to be between 51-75%, and breakfast intake on 10/28/24 to be between 51-75%. The medical record did not have documentation to support a supper intake on 10/15/24. Interview on 10/20/24 at 2:40 P.M. with Director of Health Services (DHS) confirmed the medical record for Resident #55 did not contain documentation to support the facility obtained Resident #55's blood sugar levels on 10/15/24 before lunch or supper, 10/27/24 before breakfast, or 10/28/24 before breakfast or Resident #55 received any insulin on those days. Interview on 10/20/24 at 2:45 P.M. with Registered Nurse (RN) #200 confirmed she was the nurse that provided care of Resident #55 on 10/16/24, 10/27/24, and 10/28/24. RN 3200 confirmed she did not (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 2 Event ID: 366482 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 366482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Springs Health Campus 7250 Gateway Avenue Hamilton, OH 45011 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)