Best Care Health And Rehabilitation

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and facility policy review, the facility failed to notify the Ombudsman of discharge. This affected three Residents (23, #68 and #120) of four reviewed for discharge. The facility census was 79.Findings include:1.Review of the medical record for Resident #23 revealed an admission date of 08/21/25, discharged to the hospital on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with diagnoses including chronic lymphocytic leukemia of B cell type in remission, chronic kidney disease stage four, cirrhosis of the liver, diabetes mellitus type two, fibromyalgia and mood disorder. Review of the discharge return not anticipated Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #23 was cognitively intact with verbal behaviors towards others. Resident #23 required assistance from the staff to complete activities of daily living. Review of the nursing progress notes revealed no documentation the facility notified the Ombudsman of Resident #23 discharge on [DATE REDACTED]. 2.Review of the medical record for Resident #68 revealed an admission date of 08/21/25, discharged to hospital on [DATE REDACTED] and readmitted to

the facility on [DATE REDACTED] with diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type two, chronic kidney disease with dialysis. Review of the discharge return not anticipated Minimum Data Set (MDS) most recent completed, dated 08/28/25 revealed Resident #68 was cognitively intact with no behaviors. Review of the nursing progress notes for Resident #68 revealed no documentation the Ombudsman was notified of resident's discharge on [DATE REDACTED].3.Review of the closed medical record for Resident #120 revealed an initial admission date of 08/12/25, discharged to the hospital

on [DATE REDACTED], readmitted to the facility on [DATE REDACTED] and discharged to hospital on [DATE REDACTED] with diagnoses including pleural effusion, chronic kidney disease stage three, cirrhosis of the liver, atrial fibrillation diabetes mellitus type two and Clostridium difficile (C-diff). Review of the Minimum Data Set (MDS) revealed Resident #120 had two admission assessments (limited information) and two discharge return not anticipated assessments. Review of the nursing progress notes revealed no documentation the Ombudsman was notified of Resident #120 discharges to the hospital.Review of the 48 hour plan of care revealed no concerns. Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing confirmed the facility had not notified or had been notifying the Ombudsman of discharges from the facility. Interview on 09/17/25 at 3:20 P.M. with Social Services Director #40 revealed it was a new position and did not know of the notification of the Ombudsman regarding discharge. The Social Services Director #40 stated she called the Ombudsman and received information related to notification of resident discharge.Review of the facility policy titled Bed Hold and Return to Center policy dated 04/20/18 revealed if the facility determined that it can no longer provide the needed services for the resident and was unable to accept the resident in return

after transfer, then refer to the Notice of Transfer Discharge policy. That policy was not provided by the facility.This deficiency represents non-compliance investigated under Complaint Number 1382712.

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

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Best Care Health and Rehabilitation

2159 Dogwood Ridge Road Wheelersburg, OH 45694

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 0635

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview and medical record review the facility failed to ensure physician orders were in place for Resident #68 foley catheter. This affected one (Resident #68) of one resident resident reviewed for foley catheters. The facility census was 79.Findings include: Review of the medical

record for Resident #68 revealed an admission date of 08/21/25 with diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type two, chronic kidney disease with dialysis.

Review of the physician orders dated 09/25 revealed no orders in place for Resident #68 indwelling foley catheter.Review of the discharge return not anticipated Minimum Data Set (MDS) most recent completed, dated 08/28/25 revealed Resident #68 was cognitively intact with no behaviors. Resident #68 was dependent on staff for toileting hygiene, bed mobility, and transfers and required substantial assistance with bathing. Resident #68 had an indwelling catheter.Review of the nursing progress notes for Resident #68 revealed no documentation of physician orders for Resident #68 indwelling foley catheter.Review of the Certified Nursing Assistant documentation revealed care was provided for Resident #68 indwelling foley catheter. Review of the plan of care revealed no plan of care for Resident #68 indwelling foley catheter.Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing confirmed Resident #68 had no physician orders for indwelling foley catheter.Observations made during the survey revealed Resident #68 had an indwelling foley catheter to bedside drainage bag with privacy cover.The facility did not have a policy related to physician orders for indwelling foley catheter.This was an incidental finding discovered during investigation of Master Complaint Number 2603203 and Complaint Number 1382712.

Residents Affected - Few

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

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

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Best Care Health and Rehabilitation

2159 Dogwood Ridge Road Wheelersburg, OH 45694

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

stretcher. The resident was assisted from stretcher onto the bed with assistance of five people. Resident was oriented to room, call light and bed controls. A note dated 08/22/25 at 11:16 A.M. lactulose solution 10 grams/15 milliliters (ml) give 30 ml by mouth two times daily, awaiting from pharmacy. A note dated 08/23/25 at 8:56 A.M. lactulose solution 10 grams/15 ml give 30 ml by mouth two times daily, not available will call the pharmacy for delivery of medication. Interview on 09/17/25 at 9:45 A.M. with Resident #68 revealed no concerns with medication now, however, when the resident was first admitted he did not receive the medication he takes for his bowels. Resident #68 denied any adverse effects from not having

the medication.Interview on 09/17/25 at 12:46 P.M. with LPN #68 confirmed Resident #68 did not receive scheduled lactulose medication for two days after admission. LPN #68 stated he called the pharmacy about

the medication and was not sure it was documented in nursing notes. Interview on 09/17/25 at 12:54 P.M. with LPN #21 confirmed there was a problem getting medications from pharmacy timely especially with admissions. LPN #21 stated if a resident missed a medication the procedure was to call the pharmacy, notify the Nurse Practitioner (NP) or physician, and document. The facility has a Pixus system with medications on hand but does not always have what the resident was ordered. LPN #21 stated the facility was working on a new pharmacy. Interview on 09/17/25 at 1:15 P.M. with NP (on site) revealed Resident #68 had no adverse effects from missing the medication.Interview on 09/17/25 at 2:55 P.M. with the Director of Nursing (DON) confirmed Resident #68 did not receive the medication lactulose for three days

after admission. The DON confirmed there was no documentation in the nursing progress notes the physician or NP were notified. Observation of Resident #68 on 09/17/25 at 9:45 A.M. revealed no concerns related to not receiving medication upon admission.Review of the facility policy titled Medication Administration with effective date of 06/17/17 revealed during medication administration if the medication was unavailable, the nurse would contact the pharmacy and document accordingly.This deficiency represents non compliance investigated under Master Complaint Number 2603203.

Event ID:

Facility ID:

If continuation sheet