Beavercreek Health And Rehab

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 REDACTED] 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.

Review of the nursing notes dated 12/21/25 revealed that while Resident #16 was being provided a bed bath, a wound measuring 2.9 x 2 x.2 was found on the the ball of Resident #16's left foot. Review of the triage notes dated 12/21/25 revealed the facility was instructed to keep a pillow under Resident #16's foot to relieve pressure and contact the primary care provider on Monday for an evaluation. Review of the Interdisciplinary Team note date 12/22/25 revealed that Resident #16 believes her wheelchair's left foot rest caused the wound. Resident #16 has no feeling in her legs and couldn't tell it was rubbing while up in wheelchair. Therapy will evaluate Resident #16 in the wheelchair and adjust the left footrest to not rub against her foot. Observation on 12/22/25 at 2:00 P.M. revealed Resident #16 was in her wheelchair without

a pillow placed under her foot. Interview on 12/22/25 at 2:57 P.M. with Resident #16 verified the facility had not started any new interventions to alleviate pressure from her left foot. Review of the Wound Evaluation and Management Summary notes dated 12/23/25 revealed the wound on Resident #16's left foot was unstageable and measured 3 x 3 x 0.1 cm. Interview on 12/23/25 at 10:36 A.M. with Licensed Practical Nurse (LPN) #446 revealed she believed the bolsters on Resident #16's bed caused the pressure ulcer due to how the resident prefers to be positioned. Interview on 12/23/25 at 10:09 A.M. with Director of Nursing (DON) #423 verified they did not evaluate Resident #16 after the pressure ulcer was found. DON #423 verified that they were not sure if the bolsters on the bed or the wheelchair foot pedals caused the pressure injury. DON #423 verified that Resident #16 has not been evaluated by therapy and there have not been any new interventions added. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, with a revision date of March 2014, revealed nursing staff and attending physician will asses and document a resident's significant risk factors for developing pressure sores.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beavercreek Health and Rehab

3854 Park Overlooke Drive Beavercreek, OH 45431

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)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

compression fracture. Interview confirmed Resident #63 was still in the hospital at this time. Interview also confirmed the facility did a sweep of all the Hoyer pads in the facility to ensure they were all in good condition and if they weren't in good condition they were thrown away. The DON was unable to give a number of Hoyer pads that were discarded due to not being in good condition. Interview on 12/22/25 at 8:59 A.M. with CNA #490 confirmed on 12/16/25 she was called into Resident #63's room to help with a transfer. Upon entering the room, she stopped on the other side of the curtain, to wash her hands and put

on gloves. Before she could get her gloves on, CNA #470 lifted Resident #63 with the Hoyer, the Hoyer pad broke and Resident #63 fell from the Hoyer onto the floor. Interview confirmed she did not see CNA #470 lift Resident #63 in the Hoyer, and she did not see Resident #63 fall out of the Hoyer, she just heard it happen.

Interview confirmed staff are to use two persons at all times with Hoyer transfers. Interview on 12/22/25 at 3:17 P.M. with CNA #490 confirmed she, along with other CNAs, had reported the Hoyer pads needing replaced and management didn't do anything about it until the fall happened with Resident #63. Review of

the Lifting Machine, Using A Mechanical policy dated July 2017 revealed at least two nursing assistants are needed to safely move a resident with a mechanical lift and make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition. This deficiency represents non-compliance investigated under Master Complaint Number 2697275 and Complaint Number 2695861.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beavercreek Health and Rehab

3854 Park Overlooke Drive Beavercreek, OH 45431

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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

11/03/25, 11/17/25, 12/01/25, and 12/17/25 the Repatha was not administered and signed as, 'see nurses notes.'Review of the Pharmacy Packing Slip Proof of Deliver forms for Resident #05 revealed Repatha Injection 140 mg/ml quantity of one was delivered on 06/28/25, 08/12/25, 08/25/25, 09/22/25, and 12/01/25.Interview on 12/23/25 at 2:46 P.M. with the DON confirmed Resident #08 did not receive their Repatha as ordered every two weeks starting on 06/26/25. Interview also confirmed the physician orders were routinely, but the pharmacy was not delivering the medication per orders. Interview confirmed when

the facility noted it was not available, they would sometimes discontinue the orders and write a new order so the resident would get it delivered. Interview confirmed the medication has a short shelf life so the pharmacy would not deliver it early. Interview also confirmed that the resident received only four of the eleven doses of Repatha between 06/26/25 and 12/17/25. Interview also confirmed that only five doses show as delivered.Review of the facility policy, Administering Medication, dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame.This deficiency represents non-compliance investigated under Master Complaint Number 2697275 and Complaint Number

1. 2695861. Event ID:

Facility ID:

If continuation sheet