Blue Ash Health & Rehab

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure documentation of medication being administered was charted in residents' electronic medication administration record. (Emar). This affected 11 residents (Resident #60, #62, #64, #66, #68, #70, #72, #74, #76, #78, and #80) of the 12 residents reviewed for medication administration. The facility census was 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility had hot water in resident areas per resident preferences. This affected 18 residents (#02, #06, #08, #09, #10, #11, #12, #17, #18, #19, #23, #24, #25, #32, #33, #34, #35, and #36) out of 36 residents residing in the facility. The facility census was 36. Interview with Resident #08 on 03/12/26 at 8:17 A.M. revealed the water did not get hot at the facility. Resident #08 stated the water was also cold during bathing. Interview with Resident #11 on 03/12/26 at 8:19 A.M. revealed the water was cold at the facility and did not get hot. Resident #11 stated the water had been cold for approximately two months. Interview with Resident #17 on 03/12/26 at 8:39 A.M. revealed one side of the building had cold water for a long time. [...]

Inspectors wroteBased on observation, staff interview, resident interview, record review, and facility policy review, the facility failed to maintain mechanical equipment to heat residents' rooms. This affected four Residents (#33, #34, #35, and #36) out of four Residents reviewed. The facility census was 40.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to thoroughly investigate an allegation of abuse. This affected one (Resident #21) of three residents reviewed for abuse. The facility census was 40. Medical record review for Resident #19 revealed she was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, seizure, malignant neoplasm of the intrathoracic lymph node, delusional disorder, atrial fibrillation, essential primary hypertension, and multiple sclerosis. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had impaired cognition. Resident #19 was dependent on staff for activities of daily living (ADL). Review of the SRI (control number 266147) created on 10/08/25 at 1:41 P.M. related to an injury of unknown origin identified on 10/08/25. [...]

Inspectors wroteBased on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to provide a safe environment related to residents smoking. This affected one (Resident #36) of the one resident observed for smoking. The facility census was 40.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure a sanitary environment for preparing and serving food and failed to ensure staff wore hair restraints while in the kitchen. This had the potential to affect all 53 residents who resided in the facility as the facility identified all residents received food from the kitchen.

Inspectors wroteBased on staff interview and record review, the facility failed to maintain a facility Tuberculosis (TB) Risk Assessment. This had the potential to affect all 53 residents who resided in the facility. The facility also failed to ensure all newly hired employees were tested for TB and employees employed by the facility for more than a year were screened annually for TB. This affected four (Business Office Manager [BOM] #410, Licensed Practical Nurse [LPN] #305, Certified Nursing Assistant [CNA] #361, and CNA #332) of the five personnel files reviewed. This had the potential to affect all 53 residents of the facility. Findings Include: 1. Interview on 07/01/25 at 2:58 P.M. with the Administrator revealed the facility does not do a Tuberculosis Risk Assessment. [...]

Inspectors wroteBased on observation, staff interview, resident interview, review of facility documents, and review of the facility policy, the facility failed to ensure comfortable and safe temperatures were maintained throughout the facility in resident rooms and common areas. This had the potential to affect the 10 residents residing on the facility's A-hall (#03, #04, #07, #13, #16, #26, #36, #52, #204, and #206), the 13 residents residing on the facility's B-hall (#01, #02, #10, #17, #19, #24, #29, #35, #37, #39, #43, #47, and #50. The facility identified 16 residents who routinely ate meals in the dining room (#01, #02, #06, #11, #12, #15, #16, #20, #27, #30, #36, #37, #39, #40, #46, and #47). The facility census was 53 residents.

Inspectors wroteBased on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to provide residents with information regarding how to apply for Medicaid benefits. This affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53.

Inspectors wroteBased on review of Self-Reported Incidents (SRIs), review of personnel files, review of the Bureau of Criminal Investigation (BCI) background check logs, staff interview, and review of the facility policy, the facility failed to implement their policy by failing to conduct criminal background checks. This affected two (Residents #08 and #156) of three residents reviewed for abuse. The facility census was 53 residents.

Inspectors wroteBased on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to ensure a safe and orderly discharge. The affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53 residents.

Inspectors wroteBased on medical record review, staff interview, resident interview, and review of the facility policy, the facility provide an accurate notice of discharge to a resident before discharge and failed to provide a copy of the discharge notice to the Ombudsman. This affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53 residents.

Inspectors wroteBased on observation, staff, resident and physician interviews and record review, the facility failed to conduct pain assessments and administer pain medication as ordered. This affected one (#36) of the two residents reviewed for pain medication administration. The facility census was 53.

Inspectors wroteBased on medical record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected one (#29) of the five residents who received Insulin stored in the A/B medication cart and of the 24 residents with medications stored in the A/B medication cart. The facility census was 53.

Inspectors wroteBased on observations, staff interview, and review of facility policy, the facility failed to provide clean, sanitary kitchen. This had the potential to affect all 55 residents residing in the facility who receive food from the kitchen.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a resident was provided the correct diet texture. This affected one (Resident #52) of three residents reviewed. The facility census was 55.

Inspectors wroteBased on record review, observations, interview, and policy review, the facility failed to implement fall prevention interventions for residents. This affected one (Resident #46) of three residents reviewed for falls. The facility census was 55.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen was administered as ordered by a physician and in accordance with professional standards of practice for respiratory care. This affected three (Residents #3, #14, and #18) of three residents reviewed for oxygen administration. The facility census was 51 residents.

Inspectors wroteBased on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility discharged a resident from the facility without a physician's order or proper documentation of a rationale for the facility-initiated discharge. This affected one (Resident #42) of two residents reviewed for transfer or discharge. The facility census was 51 residents.

Inspectors wroteBased on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility discharged a resident from the facility and failed to a written notice of discharge to the resident and resident representative before the discharge. This affected one (Resident #42) of two residents reviewed for transfer or discharge. The facility census was 51 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours every day. This had the potential to affect all residents residing in the facility. The facility census was 52 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents' Medicaid coverage was maintained. This affected two (Residents #14 and #15) out of three residents reviewed for payor source. The facility census was 52 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed guidelines for wearing personal protective equipment (PPE) during care for residents on enhanced barrier precautions (EBP.) This affected one (Resident #16) of three residents reviewed for catheter care. The facility census was 52 residents.

Inspectors wroteBased on medical record review, review of hospital records, and resident and staff interviews the facility failed to provide adequate care and services to prevent constipation. This resulted in harm on 08/22/2024 when Resident #15 was sent to the hospital and received treatment for a large fecal impaction. This affected one of three resident sampled for constipation. The facility census was 51.

Inspectors wroteBased on observation, review of the medical record, resident and staff interview, and policy review, the facility failed to ensure urine collection bags were stored in a sanitary manner. The facility identified one resident (Resident #15) with a catheter. The facility census was 51.

Inspectors wroteBased on review of time sheets, staff interviews and policy review, the facility failed to ensure staff completed medication counts at shift change and failed to ensure narcotic lock box keys were securely locked when not in possession of the designated nurse. This had the potential to affect 17 (#29, #23, #25, #24, #39, #28, #27, #41, #31, #42, #37, #32, #40, #30, #45, #35, and #34) residents who had narcotics stored on the medication cart and 32 (#29, #3, #20, #46, #23, #37, #36, #32, #22, #33, #13, #1, #38, #47, #8, #21, #44, #5, #16, #25, #24, #39, #15, #28, #10, #43, #27, #26, #12, #19, #4, and #17) residents who were ambulatory or could self-propel with mobility assistive devices and that could access the medication cart. The census was 45.

Inspectors wroteBased on medical record review, staff interview, and review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure the required Minimum Data Set (MDS) assessments were completed in a timely manner. This affected one (#124) of 17 residents reviewed for assessment. The facility census was 22.

Inspectors wroteBased on observation, record review, resident and staff interview and review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately complete the Minimum Data System (MDS) information. This affected one (#7) of 17 residents assessments reviewed. The facility census was 22.

Inspectors wroteBased on observation, resident interview, staff interview, record review and review of policy, the facility failed to ensure smoking materials were secured. This affected one (#16) of 13 residents identified by the facility, who smoked at the facility. The facility census was 22.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure laboratory test were completed as ordered. This affected one (#6) of five residents reviewed for unnecessary medication. The facility census was 22.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure the vets were maintained in a clean manner. This had the potential to affect 22 of 22 residents in the facility. The facility census was 22.