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Complaint Investigation

Best Care Health And Rehabilitation

September 17, 2025 · Wheelersburg, OH · 2159 Dogwood Ridge Road
Citations 3
CMS Rating 2/5
Beds 101
Provider ID 365398
Healthcare Facility
Best Care Health And Rehabilitation
Wheelersburg, OH  ·  View full profile →
Inspection Summary

BEST CARE HEALTH AND REHABILITATION in WHEELERSBURG, OH — inspection on September 17, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0628
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Review of the discharge return not anticipated Minimum Data Set (MDS) dated [DATE] 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]. 2.

Review of the medical record for Resident #68 revealed an admission date of 08/21/25, discharged to hospital on [DATE] and readmitted to the facility on [DATE] 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].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], readmitted to the facility on [DATE] and discharged to hospital on [DATE] 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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Best Care Health and Rehabilitation

2159 Dogwood Ridge Road Wheelersburg, OH 45694

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Best Care Health and Rehabilitation

2159 Dogwood Ridge Road Wheelersburg, OH 45694

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WHEELERSBURG, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BEST CARE HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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