Beavercreek Health and Rehab

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure the baseline care plan identified a resident's fall risk and included interventions to reduce the risk of falling. This affected one (#4) of three residents reviewed for falls. The census was 61.

Inspectors wroteBased on observation, resident and staff interview, and policy review, the facility failed to ensure adequate water temperatures throughout the building were maintained. This had the potential to affect all residents. The facility census was 62.

Inspectors wroteBased on record review, review of hospital records, staff interviews, and review of facility policy, the facility failed to ensure a safe transfer via a mechanical Hoyer lift. This resulted in Actual Harm on 12/16/25, when one staff member transferred Resident #63 via Hoyer lift and the Hoyer pad broke causing the resident to fall, which resulted in fractures of her bilateral femurs and a Lumber #1 (L1) fracture to her spine, requiring admission to the hospital for surgical repair to her bilateral femurs. This affected one (Resident #63) of three residents reviewed for accidents. The facility census was 62.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to assess and implement new interventions after an unstageable pressure ulcer was found on Resident #16's left foot. This affected one (Resident #16) of three residents reviewed for pressure wounds. The facility census was 62. Medical record review for Resident #16 revealed an admission date of 07/17/25 with diagnoses including quadriplegia and polyneuropathy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was cognitively intact. Her functional status was dependent for bathing, dressing, and positioning. Review of the care plan for Resident #16 revealed the resident is at risk for pressure ulcers. Interventions included weekly skin checks, floating heels, turning and repositioning, pressure reducing mattress, and wheelchair cushion. [...]

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to administer medications per physician orders. This affected two (Residents #05 and #08) of three residents reviewed for medication administration. The facility census was 62.

Inspectors wroteBased on medical record record review and staff interview the facility failed to document discharge planning for one (Resident #27) of three residents reviewed for discharge planning. The facility census was 69 residents.

Inspectors wroteBased on medical record review, staff interview and online information on pressure ulcers from Medscape the facility failed to timely treat pressure wounds. This affected one (Resident #10) of three residents reviewed for pressure ulcers. The facility census was 69 residents.

Inspectors wroteBased on medical record review, review of recorded video footage, staff interview, and review of the facility policy, the facility failed to ensure staff timely reported falls, failed to assess residents for injuries following falls, and failed to investigate falls. This affected one (Resident #17) of three residents reviewed for falls. Based on medical record review, observation, and staff interview, the facility failed to ensure fall prevention interventions were implemented per the resident care plan. This affected one (Resident #12) of three residents reviewed for falls. The facility census was 69 residents.

Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to ensure a newly identified skin issue was assessed timely and treatments were initiated. The facility also failed to ensure treatments to a pressure ulcer were completed as ordered. This affected one (#30) out of the three residents reviewed for pressure ulcers. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#75) out of five residents reviewed for medication administration. The facility census was 70.

Inspectors wroteBased on medical record review, observations, staff interviews, and policy review, the facility failed to follow infection control procedures for a resident in Contact Precautions. This affected one (#13) out of three residents reviewed for wound care. The facility census was 70.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure dairy products were served at the appropriate temperature. This had the potential to affect 68 residents in the facility. The facility identified two residents (#08 and #21) who did not receive food from the kitchen. The facility census was 70.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was stored and prepared in a manner to prevent against the potential spread of foodborne illness. This had the potential to affect 68 residents in the facility. The facility identified two residents (#08 and #21) who did not receive food from the kitchen. The facility census was 70.

Inspectors wroteBased on resident interviews, staff interviews, and record review, facility failed to document and follow up on resident concerns from the resident council meetings. This affected seven (#09, #19, #26, #30, #56, #62, and #221) residents who participated in resident council. The facility census was 70.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to treat all residents with dignity and respect. This affected two (#28, and #29) of three residents reviewed for dignity. The facility census was 70. Findings Include: 1) Review of Resident #28's medical record revealed an admission date of 07/24/24. Diagnoses included dysphasia, atrial fibrillation, and hemiplegia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 was severely cognitively impaired and required substantial assistance with eating. Observation of Resident #28 on 09/23/24 at 11:30 A.M., revealed he was in the dining room/lounge area with other residents and the afternoon meal was being served by the staff. All the other residents were served their lunch, and they were eating with the exception of Resident #28. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure accuracy of code status in the medical record. This affected three (#29, #32, and #58) of nineteen residents reviewed for advanced directives. This had the potential to affect all 70 residents in the facility.

Inspectors wroteBased on observations, staff interview and record review, the facility failed to ensure residents had to a safe, clean, comfortable and homelike environment. This affected one (#18) resident of one reviewed for physical environment. The facility census was 70.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents were provided with notification indicating the reason for transfer upon a transfer to the hospital. This affected three (#21, #43, and #56) residents of the four residents reviewed for hospitalization. The facility census was 70.

Inspectors wroteBased on record review and staff interview, facility failed to ensure residents were provided with bed hold notification upon a transfer to the hospital. This affected three (#21, #43, and #56) residents of four residents reviewed for hospitalization. The facility census was 70.

Inspectors wroteBased on record review, staff interview, and review of hospital records, the facility failed to allow a resident to return to the facility timely following a hospital stay. This affected one (#43) of four residents reviewed for hospitalization. The facility census was 70.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents were provided adaptive equipment as ordered. This affected one (#55) of one resident reviewed for adaptive equipment. The facility identified ten residents who utilized adaptive equipment. The facility census was 70.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of medical records, staff interview, and policy review, the facility failed to ensure a licensed nurse communicated a resident incident, that was later determined to be a fall, to the oncoming licensed nurse to allow for ongoing monitoring and/or potentially prevent further incidents or falls. This affected one (#2) of three residents reviewed for falls. The census was 62.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure treatments (i.e. moon boots) were in place as prescribed. This affected one (#30) of three residents reviewed for treatment implementation. The facility census was 68.

Inspectors wroteBased on record review, observations, staff and pharmacy interviews and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#30 and #60) of three residents reviewed for medication administration. Facility census was 68.

Inspectors wroteBased on medical record review, review of hospital documentation and staff interview, the facility failed to ensure documentation regarding nursing assessments and/or the circumstances surrounding a residents hospitalization was documented in the medical record. This affected one (#84) of three residents medical records reviewed for hospitalization. Facility census was 68.

Inspectors wroteBased on review of the facility menu, observations, resident and staff interviews, review of recipes, the facility failed to provide nutritious and palatable meals to residents. This had the potential to affect 67 residents in the facility who received meals prepared in the kitchen. The census was 68.

Inspectors wroteBased on observations, interviews, and medical record review, the facility failed to ensure a resident had access to their call light. This affected one (Resident #10) of two residents reviewed for call light access. The facility census was 67.

Inspectors wroteBased on record review, observation, policy review, staff interviews, the facility failed to ensure medications were properly stored. This had the potential to affect four residents (#12, #14, #54, and #65) who were cognitively impaired and independently mobile.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure staff wore hairnets while in food preparation areas and failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect all residents in the facility who receive food from the kitchen. The facility identified four resident (#10, #11, #55, and #57) who did not receive food from the kitchen. The facility census was 71.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure physician records were readily accessible. This affected six (#4, #26, #38, #50, #70, and #276) of 24 residents reviewed for medical record accuracy. The facility census was 71.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure preadmission screening and resident reviews (PASARR) were completed accurately and the facility failed to ensure residents were re-screened for Level II services when given a new mental health diagnosis. This affected two (#15 and #57) of three residents reviewed for PASARR. The facility census was 71.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure care plans were updated timely status post a resident's fall and failed to conduct quarterly care conferences timely. This affected three (#12, #39, and #68) of 24 residents reviewed for care plans. The facility census was 71.

Inspectors wroteBased on record review and staff interview, the facility failed to complete discharge summary and recapitulation of stay for residents who discharged from the facility. This affected two (#71 and #73) of three residents reviewed for discharges. The facility census was 71.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to ensure residents that required assistance with activities of daily living (ADL) received adequate assistance with bathing and repositioning. This affected three (#38, #68, and #276) of six residents reviewed for ADLs. The facility identified 69 residents who required assistance with ADLs. The facility census was 71.

Inspectors wroteBased on staff interview, observation, record review and policy review, the facility failed to administer medications according to physician orders and failed to initiate treatment orders for wound care. This affected three (Residents #16, #28, and #276) of twenty-four residents reviewed for wound care. The facility census was 71.

Inspectors wroteBased on resident and staff interview, eye center interview, and record review, the facility failed to ensure residents received adequate care to maintain vision. This affected one (Resident #12) of two residents review for vision services. The facility census was 71.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to provide the care and services to prevent a pressure ulcer and the facility failed to initiate physician's orders to treat a pressure ulcer in a timely manner. This affected two (#28 and #70) of five residents reviewed for pressure ulcers. The facility identified nine residents with current pressure ulcers. The facility census was 71.

Inspectors wroteBased on medical record review, observation, and staff interviews, the facility failed to ensure a fall prevention was in place for a resident at risk for falls. This affected one (Resident #3) of three residents reviewed for falls. The facility census was 71.

Inspectors wroteBased on record review, observations, resident and staff interview, and policy review, the facility failed to ensure incontinence care was provided timely to residents. This affected two (Residents #4 and #50) of three residents reviewed for incontinent care. The facility census was 71.

Inspectors wroteBased on record review and staff interview, the facility's Binding Arbitration Agreement failed to explicitly grant the resident or resident representative the right to rescind the agreement within 30 days of signing the agreement. This affected four (#9, #22, #68, and #276) residents reviewed for Binding Arbitration Agreements. The facility had 41 residents who had signed a Binding Arbitration Agreements. This had the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on observation and staff and resident interview, the facility failed to lighting level was adequate and comfortable in a facility dining room. This had the potential to affect 11 (#10, #13, #17, #21, #23, #26, #36, #50, #48, #50 and #63) residents residing in the red dining room. The facility census was 73.

Inspectors wroteBased on medical record review, observations and staff interviews, the facility failed to ensure staff provided a dignified dining experience while feeding cognitive impaired residents. This affected one (Resident #39) out of one reviewed for dignity and respect. The facility census was 73.

Inspectors wroteBased on medical record review and facility staff interview the facility failed to accurately code minimum data set (MDS). This affected one (Resident #217) of 22 residents records reviewed during the annual survey. The total facility census was 73. Findings Include: Review of Resident #217's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizo affective disorder depressive type, traumatic brain injury, diabetes mellitus type two, acute osteomyelitis, peripheral vascular disease, and weakness. Review of the admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had no delusions nor hallucinations but had rejection of care one to three days of the review period. The resident was coded as having traumatic brain injury, and psychotic disorder other than schizophrenia. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's baseline care plan was accurate regarding the resident's skin, safety and elopement risk/interventions. This affected one (#217) of 13 new admission care plans reviewed. The total facility census was 73.

Inspectors wroteBased on medical record review, observation, and resident and staff interview the facility failed to ensure dependent residents were provided shaving assistance. This affected one (Resident #10) of four reviewed for activities of daily living (ADL). The total facility census was 73.

Inspectors wroteBased on medical record review, observations and staff and resident interview, the facility failed to provide a resident with activities in accordance with the resident's preferences including providing a newly admitted resident with an activity calendar identifying activities provided by the facility. This affected one (#120) of one reviewed for activities. The total facility census was 73.

Inspectors wroteBased on medical record review, observation, and resident and staff interviews the facility failed to provide ordered skin care. This affected one (Resident #12) of one resident reviewed for non pressure skin alteration. The total facility census was 73.

Inspectors wroteBased on medical record review, hospital record review, facility staff and physician interview and review of Self Reported Incident (SRI) the facility failed to meet the behavioral health needs of residents. This affected one (Resident #217) of two reviewed for behavioral emotional services. The total facility census was 73.

Inspectors wroteBased on medical record review, hospital record review, and facility staff interview the facility failed to ensure medication irregularities were identified by the pharmacist. This affected one (Resident #217) of six reviewed for unnecessary medications. The facility census was 73.

Inspectors wroteBased on record review, hospital record reveiw and facility staff interview the facility failed to ensure residents received medications as ordered. This affected Resident #217 who had orders for an antiphyscotic upon dischage from the hospital. The order was not followed up on and the resident was not adminsiterd the mediation while at the facility for eight days. This affected one (Resident #217) of two reviewed for behavioral emotional services. The total facility census was 73. Findings Include: Review of Resident #217's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizo affective disorder depressive type, traumatic brain injury,diabetes mellitus type two, acute osteomyelitis, peripheral vascular disease, and weakness. [...]

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to ensure medications were not expired. The facility identified two residents (#52 and #54) who had orders for Vitamin D and lived on the 300 unit, there were no residents identified who received Aspirin 325 milligrams (mg). The facility census was 73.