Inspection visit
Health inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observation, resident interview, staff interview, and review of the facility
policy, the facility failed to ensure staff responded to resident requests in a timely manner. This affected one
(Resident #61) of two residents reviewed for call lights. Based on medical record review, observation, staff
interview and resident interview, the facility failed to ensure the automatic door opener to the front door was
functioning properly. This affected one (Resident #43) of 27 residents sampled. The facility census was 95
residents.
Residents Affected - Few
Findings include:
1.Review of the medical record for Resident #61 revealed an admission date of 02/10/25 with diagnoses
including hip fracture, Alzheimer's disease, and cerebrovascular attack (CVA).
Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 02/16/25 revealed the resident
was severely cognitively impaired and was dependent on staff assistance with activities of daily living
(ADLs.)
Observation on 03/11/25 of Resident #61's room revealed the resident's call light was on from 3:38 P.M. to
4:02 P.M. while the resident yelled for the nurse. Further observation revealed Certified Nurse Aide (CNA)
#33 entered the resident's room at 4:02 P.M. and what the resident was yelling about. Resident #61 told
CNA #33 he wanted a glass of ice water. CNA #33 said okay, turned off the call light, and left the room. At
4:07 P.M. Resident #61 yelled out for the nurse to bring him ice water. At 4:09 P.M. CNA #227 was walking
down the hall and Resident #61 yelled for her and said he wanted his water and a grilled cheese sandwich.
CNA #227 told the resident she would help him as soon as she was done caring for another resident and
left the room.
Interview on 03/11/25 at 4:25 P.M. with Resident #61 confirmed he often had to wait up to an hour for staff
to assist him
Interview on 03/11/25 at 4:31 P.M. with CNA #227 confirmed she was taking care of 20 residents and was
unable to get to the call lights in a timely manner. CNA #227 stated she had to change two people and get
two people out of bed, before she could take care of Resident #61's needs.
Interview with on 03/11/25 at 4:33 P.M with CNA #33 confirmed she answered Resident #61's call light and
he wanted ice water, and she had turned off the call light and left the room because he had water in his
room. She said she didn't know the code to get into the room where the ice was kept.
Review of the facility policy titled Answering the Call Light dated 2001 revealed staff should answer the
resident call system immediately. The staff person should identify themselves and respond to
(continued on next page)
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
Page 1 of 19
Event ID:
365374
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the resident politely and if a resident needed assistance the staff person should indicate approximately how
long it would take to respond to the request. If the request was something the person answering the light
could fulfill, the request should be completed within five minutes.
2. Review of the medical record for Resident #43 revealed an admission date of 03/28/23 with diagnoses
including vascular dementia, epilepsy, and major depressive disorder.
Review of the MDS assessment for Resident #43 dated 01/11/25 revealed the resident was cognitively
intact and required staff assistance with activities of daily living (ADLs.)
Observation 03/11/25 at 1:38 P.M of the front exterior door revealed the push button to automatically open
the front exterior door of the building did not open the front door of the facility when pressed.
Interview on 03/11/25 at 1:38 P.M. with Corporate Registered Nurse (CRN) #500 confirmed the push button
to automatically open the front exterior door of the building did not open the front door of the facility when
pressed.
Interview on 03/11/25 at 1:44 P.M. with Resident #43 confirmed she was unable to open the front door
without the use the push button which automatically opened the door. Resident #43 confirmed the push
button was not working on 03/11/25 and there had been other times when it had not worked.
This deficiency represents noncompliance investigated under Complaint Number OH00162297 and
Complaint Number OH00162213.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 2 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify
resident physicians of significant weight loss. This affected one (Resident #40) of three residents reviewed
for change in condition. The facility census was 95 residents.
Findings include:
Review of the medical record for Resident #40 revealed an admission date of 05/20/20 with diagnoses
including coronary artery disease, heart failure, diabetes, dementia, and aphasia.
Review of the quarterly Minimum Data Set (MDS) assessment for Resident #40 dated 11/26/24 revealed
the resident was severely cognitively impaired and required set up assistance for eating.
Review of the weight records for Resident #40 revealed the resident weighed 133 pounds (lbs.) on 02/06/25
and the resident weighed 123 lbs. on 03/12/25 which was a significant weight loss of 7.5 percent (%) in 33
days.
Review of the progress notes for Resident #40 dated 03/12/25 to 03/17/25 revealed the notes did not
include documentation of physician or provider notification of the resident's significant weight loss.
Interview on 03/17/25 at 11:36 A.M with Nurse Practitioner (NP) #300 confirmed the facility had not notified
him of Resident #40's significant weight loss.
Interview on 03/17/25 at 11:54 A.M. with Dietician #501 confirmed he had not been notified of Resident
#40's significant weight loss.
Review of the facility policy titled Change in Resident's Condition or Status dated February 2021 revealed
the nurses should promptly notify the resident, his or her attending physician, and the resident
representative of changes in the resident's medical / mental condition and/or status. The nurse would notify
the resident's attending physician or physician on call when there had been a need to alter the resident's
medical treatment significantly. A significant change of condition was defined as a major decline or
improvement in the resident's status that would not normally resolve itself without intervention by staff.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 3 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observation, resident interview, staff interview, and review of the facility
policy, the facility failed to ensure activities of daily living (ADL) care was provided for dependent residents.
This affected two (Residents #43, #69) of six residents reviewed for ADLs. The facility census was 95
residents.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #43 revealed an admission date of 03/29/23 with diagnoses of
hemiplegia and hemiparesis following cerebral infarction, morbid obesity, vascular dementia, and anxiety
disorder.
Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 01/11/25 revealed the resident
was cognitively intact, had limited range of motion to one side of his bilateral upper and lower extremities
and was dependent on staff assistance with toileting hygiene and transfers.
Review of the care plan for Resident #43 dated 03/06/24 revealed the resident had a self-care deficit
related to weakness and impaired mobility due to right sided hemiparesis and hemiplegia following cerebral
vascular accident with the intervention that staff would assist the resident with hygiene and toileting as
needed.
Observation on 03/10/25 at 2:27 P.M. of Resident #43 revealed the resident's call light was activated.
Observation on 03/10/25 at 2:41 P.M. of Resident #43 revealed the resident's call light was still activated
and the resident's incontinence brief was saturated with urine.
Interview on 03/10/25 at 2:41 P.M. with Resident #43 confirmed his call light had been activated since 2:27
P.M. and he was awaiting staff assistance with incontinence care.
Interview on 03/10/25 at 2:47 P.M. with Certified Nursing Aide (CNA) #218 confirmed Resident #43's
incontinence brief was soaked with urine, and he needed incontinence care. CNA #218 she was unable to
get to Resident #43 in a timely manner to assist him.
2. Review of the medical record for Resident #69 revealed an admission date of 08/21/24 with diagnoses
including chronic obstructive pulmonary disease, congestive heart failure, and type two diabetes mellitus.
Review of the MDS assessment for Resident #69 dated 02/26/25 revealed the resident was cognitively
intact and required staff assistance with bathing.
Review of the care plan for Resident #69 dated 02/26/25 revealed the resident had a self-care deficit
related to weakness and deconditioning, congestive heart failure, chronic obstructive pulmonary disease,
and morbid obesity with an intervention for staff to provide assistance with bathing.
Review of the electronic medical record for Resident #69 revealed the resident was offered and received
only two bed baths between 02/13/25 through 03/11/25 with no refusals documented.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 4 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Interview on 03/10/25 at 2:42 P.M. with Resident #69 confirmed he has not been offered regular showers.
He only received two bed baths in the past month.
Interview on 03/12/25 at 12:48 P.M. with Licensed Practical Nurse (LPN) #238 confirmed Resident #69 had
only received two bed baths in the time period of 02/13/25 to 03/11/25.
Residents Affected - Few
Review of the facility policy titled Shower and Tub Bath dated February 2018 revealed the facility would offer
baths to residents to promote cleanliness, provide comfort to the resident and to observe the condition of
the resident's skin.
This deficiency represents noncompliance investigated under Complaint Number OH00163482 and
Complaint Number OH00162841 and Complaint Number OH00162213 and Complaint Number
OH00162183.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 5 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, resident interview, staff interview, and review of the facility policy, the
facility failed to properly and timely assess residents for change in condition. This resulted in Actual Harm
for Resident #235 who had constipation with abdominal and rectal pain and had to be treated at the
hospital for a fecal impaction. This affected one (Resident #235) of three residents reviewed for change in
condition. The facility census was 95 residents.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #235 revealed an admission date of 02/20/25 with diagnoses
including wedge compression fracture of T7 and T8 vertebra with routine healing, chronic obstructive
pulmonary disease, and fibromyalgia.
Review of the Minimum Data Set (MDS) assessment for Resident #235 dated 02/26/25 revealed the
resident was cognitively intact and required staff assistance with activities of daily living (ADLs.)
Review of the physician's orders for Resident #235 revealed an order dated 02/21/25 for oxycodone 5
milligrams (mg) every 6 hours as needed for pain, and orders dated 03/05/25 for Miralax Powder give 17
gram by mouth one time a day for constipation and Senokot give one tablet by mouth one time a day for
constipation.
Review of the care plan for Resident #235 dated 02/21/25 revealed the resident was at risk for pain related
to nasal fracture and lacerations to face, neuropathy, arthritis, fibromyalgia, weakness and deconditioning.
The care plan was revised on 03/11/25 to include the resident was at risk for complications with the
gastrointestinal system due to constipation with a goal of will have no complications related to constipation.
Interventions included the following: administer medications as ordered, listen to bowel sounds and
complete an abdominal assessment as indicated, notify physician of gastrointestinal complications such as
bloating, abdominal discomfort, changes in bowel patterns, record and monitor bowel movements.
Review of the bowel movement log in the electronic medical record (EMR) for Resident #235 revealed the
resident had a small, formed bowel movement on 02/22/25, a small, formed bowel movement on 03/04/25,
and a small, loose bowel movement and a small soft bowel movement on 03/09/25.
Review of the hospital emergency room note for Resident #235 dated 03/10/25 timed at 8:11 P.M. revealed
upon rectal exam the resident had very soft stool in the rectum that was partially disimpacted but very soft
and mobile. A CT scan of the abdomen and pelvis showed fecal loading and distention of the rectum
consistent with constipation. Hospital staff gave the resident a soap-suds enema which did not yield any
results. The physician with the assistance of nursing staff had to manually remove a fecal impaction from
the resident's rectum. The hospital staff then administered a docusate enema which resulted in the resident
having a bowel movement.
Observation on 03/10/25 at 9:00 A.M. revealed Resident #235 was lying in bed and moaning loudly.
Interview on 03/10/25 at 1:55 P.M. with Resident #235 confirmed the resident had felt sick all weekend and
no one had helped her. Resident #235 further confirmed she had a cold sore on her rectum, and it was
hurting, and she had also been having abdominal spasms all weekend.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 6 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0684
Level of Harm - Actual harm
Residents Affected - Few
Interview on 03/10/25 at 2:06 P.M. with Licensed Practical Nurse (LPN) #70 confirmed she was aware
Resident #235 wanted to go to the emergency room (ER) and was requesting to go by ambulance. LPN
#70 further confirmed the facility was awaiting transport to take Resident #235 to the hospital and the nurse
would give the resident a dose of as needed oxycodone for the resident's complaints of abdominal spams
and rectal pain.
Observation on 03/10/25 at 2:18 P.M. of revealed Resident #235 was screaming out in pain.
Interview on 03/10/25 at 2:20 P.M. with Certified Nursing Assistant (CNA) #229 confirmed Resident #235
had screamed out all weekend in pain. CNA #229 confirmed he tried to reposition the resident to make her
comfortable and the resident did have a small bowel movement on 03/09/25.
Observation on 03/10/25 at 2:24 P.M. revealed Resident #235 was screaming out in pain.
Interview on 03/10/25 at 2:30 P.M. with LPN #70 confirmed the Resident #235 had asked to go the ER due
to abdominal spasms and pain to her abdomen and rectum. LPN #70 confirmed Resident #235 had not
asked to go to the ER via emergency transport. LPN #70 confirmed she contacted Nurse Practitioner (NP)
#300 prior to the resident's request to go to the ER and the NP gave an order for hemorrhoid cream.
Interview on 03/11/25 at 8:02 A.M. with the Director of Nursing (DON) confirmed Resident #235 had gone
to the ER on [DATE] at 2:35 P.M., was treated at the hospital for a fecal impaction, and then returned to the
facility.
Interview on 03/12/25 at 1:58 P.M. with CNA #229 confirmed aides were responsible to document resident
bowel movements in the bowel movement log in the resident EMR.
Interview on 03/13/25 at 10:00 A.M. with LPN #79 confirmed Resident #235's bowel movement log in the
EMR revealed the resident had only four small bowel movements from 02/20/25 through 03/09/25. LPN #79
further confirmed the facility had no documentation of notification to the physician or the NP of the
resident's small infrequent bowel movements. Further interview with LPN #79 confirmed if a resident had
not had a medium or large bowel movement every three days the nurses should notify the physician or NP
for further instructions.
Interview on 03/17/25 at 10:17 A.M. with the DON confirmed the facility did not have standing orders or a
clinical protocol related to bowel movements.
Interview on 03/17/25 at 10:38 A.M. with NP #300 confirmed the facility nurses should contact the physician
or NP when a resident hasn't had a medium or large bowel movement within three days. NP #300 further
confirmed the facility staff had not notified him Resident #235 had only four small bowel movements
between 02/20/25 and 03/09/25 and the facility staff should have contacted him or the physician for orders
or treatment for the resident's constipation.
Review of the facility policy titled Change in Resident's Condition or Status policy dated February 2021
revealed the facility staff would promptly notify the resident, his or her attending physician, and the resident
representative of changes in the resident's medical/mental condition and/or status. The nurse would notify
the resident's attending physician or physician on call when there had been a need to alter the resident's
medical treatment that will not normally resolve without intervention.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 7 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0684
This deficiency represents noncompliance investigated under Complaint Number OH00162841.
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 8 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
Based on medical record review, observation, staff interview, resident interview, review of staffing
schedules, and review of the facility policy, the facility failed to ensure there was adequate staffing to meet
residents' needs. This affected one (Residents #61) of two residents reviewed for activities of daily living
(ADL) and 10 (Residents #33, #28, #32, #59, #14, #52, #51, #31, #46, #186) of 27 residents sampled. The
facility census was 95 residents.
Findings include:
1.Review of the medical record for Resident #61 revealed an admission date of 02/10/25 with diagnoses
including hip fracture, Alzheimer's disease, and cerebrovascular attack (CVA).
Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 02/16/25 revealed the resident
was severely cognitively impaired and was dependent on staff assistance with activities of daily living
(ADLs.)
Observation on 03/11/25 of Resident #61's room revealed the resident's call light was on from 3:38 P.M. to
4:02 P.M. while the resident yelled for the nurse. Further observation revealed Certified Nurse Aide (CNA)
#33 entered the resident's room at 4:02 P.M. and what the resident was yelling about. Resident #61 told
CNA #33 he wanted a glass of ice water. CNA #33 said okay, turned off the call light, and left the room. At
4:07 P.M. Resident #61 yelled out for the nurse to bring him ice water. At 4:09 P.M. CNA #227 was walking
down the hall and Resident #61 yelled for her and said he wanted his water and a grilled cheese sandwich.
CNA #227 told the resident she would help him as soon as she was done caring for another resident and
left the room.
Interview on 03/11/25 at 4:25 P.M. with Resident #61 confirmed he often had to wait up to an hour for staff
to assist him.
Interview on 03/11/25 at 4:31 P.M. with CNA #227 confirmed she was taking care of 20 residents and was
unable to get to the call lights in a timely manner. CNA #227 stated she had to change two people and get
two people out of bed, before she could take care of Resident #61's needs. CNA #227 confirmed there had
been a mistake on the schedule and they didn't have enough aides.
Interview on 03/17/25 at 3:51 P.M. with Scheduler #72 confirmed the facility was supposed to have four
aides scheduled on for second shift from 3:00 P.M. to 11:00 P.M. on 03/11/25 but there were only three
aides working. Scheduler #72 further confirmed the shift wasn't filled because no one had signed up to take
the shift and this would be a staffing issue because the three aides working had to take on more residents.
Review of the schedule dated 03/11/25 for the 200 Hall revealed there were spaces on the schedule for four
aides, but there were only three aides scheduled.
Review of the facility policy titled Answering the Call Light dated 2001 revealed staff should answer the
resident call system immediately. The staff person should identify themselves and respond to the resident
politely and if a resident needed assistance the staff person should indicate approximately how long it
would take to respond to the request. If
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 9 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2. Review of the medical record for Resident #33 revealed an admission date of 06/16/15 with diagnoses
including atrial fibrillation, heart failure, hypertension and dementia.
Review of the physician's orders for Resident #33 revealed the following orders dated 03/10/25 for
hydroxyzine 50 milligrams (mg) one tablet three times per day, Isosorbide Mononitrate extended release
(ER) 60 mg one time per day, Lisinopril 10 mg one time per day, potassium chloride ER 10 milliequivalents
(mEQ) one time per day, Lasix 20 mg one time per day, Sennosides 86 mg two tablets two times per day.
Review of the Medication Administration Record (MAR) for Resident #33 dated 03/10/25 revealed the
resident's medications were scheduled to be administered at 7:00 A.M. but were not signed off as given
until 1:46 P.M.
3. Review of the medical record for Resident #28 revealed an admission date of 12/23/24 with diagnoses
including non-traumatic brain injury, dementia and depression.
Review of the physician's orders for Resident #28 revealed orders dated 03/10/25: Memantine 10 mg one
time per day, Galantamine Hydrobromide ER 16 mg one time per day, Lisinopril 10 mg one time per day,
Duloxetine delayed release sprinkles one time per day.
Review of the MAR for Resident #28 dated 03/10/25 revealed the resident's medications were scheduled to
be administered at 7:00 A.M. but were not signed off as given until 12:14 P.M.
4. Review of the medical record for Resident #32 revealed an admission date of 08/07/24 with diagnoses
including non-traumatic brain injury, coronary artery disease, heart failure and dementia.
Review of the physician's orders for Resident #32 revealed the following orders dated 03/10/25: Docusate
Sodium Capsule 100 mg once per day, Risperdal 2 mg once per day, Lithium Carbonate 300 mg one tablet
twice per day, Midodrine 10 mg one tablet three times per day, Sotalol 80 mg one tablet twice per day,
Benztropine Mesylate 1 mg one tablet three times per day, Miralax 17 gram one time per day, Lactulose
oral solution 30 milliliters (ml) twice per day.
Review of the MAR for Resident #32 dated 03/10/25 revealed the resident's medications were scheduled to
be administered at 7:00 A.M. but were not signed off as given until 12:09 P.M.
5. Review of the medical record for Resident #59 revealed an admission date of 01/07/24 with diagnoses
including atrial fibrillation, heart failure, coronary artery disease, and dementia.
Review of the physician's orders for Resident #59 revealed orders dated 03/10/25 for the following:
Dapagliflozin 10 mg once per day, Insulin Glargine 45 units once per day, Duloxetine sprinkles 60 mg one
time per day, Plavix 75 two times per day, Apixaban 5 mg one tablet two times per day, Aspirin 81 mg once
per day, Carvedilol 3.125 mg one tablet twice per day, Lasix 20 mg once per day, Morphine 30 mg ER to
give one tablet twice per day, Pantoprazole Sodium delayed release 40 mg one tablet twice per day, Miralax
17 gm one time per day.
Review of the MAR for Resident #59 dated 03/10/25 revealed the resident's medications were scheduled to
be administered at 7:00 A.M. but were not signed off as given until 11:19 A.M.
6. Review of the medical record for Resident #14 revealed an admission date of 03/30/22 with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 10 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0725
diagnoses including diabetes, thyroid disorder, heart failure and dementia.
Level of Harm - Minimal harm
or potential for actual harm
Review of the physician's orders for Resident #14 revealed orders dated 03/10/25 for the following:
Magnesium Oxide 400 mg one per day, Metformin 500 mg once per day, Salmeterol inhaler one puff once
per day, Breo Ellipta inhaler one puff once per day, Topiramate 25 mg three tablets two times a day.
Residents Affected - Some
Review of the MAR for Resident #14 dated 03/10/25 revealed the resident's medications were scheduled to
be administered at 7:00 A.M. but were not signed off as given until 11:30 A.M.
7. Review of the medical record for Resident #52 revealed an admission date of 04/12/24 with diagnoses
including non-traumatic brain injury, coronary artery disease, renal disease, and diabetes.
Review of the physician's orders for Resident #52 revealed orders dated 03/10/25 for the following:
Buspirone 10 mg two tablets three times per day, Tylenol 325 mg two tablets three times a day.
Review of the MAR for Resident #14 dated 03/10/25 revealed the resident's medications were scheduled to
be administered at 1:00 P.M. but were not signed off as given until 2:15 P.M.
8. Review of the medical record for Resident #51 revealed an admission date of 12/15/24 with diagnoses
including atrial fibrillation, heart failure, hypertension and coronary artery disease.
Review of the physician's orders for Resident #51 revealed an order dated 03/10/25for Gabapentin 400 mg
one tablet every eight hours.
Review of the MAR for Resident #51 dated 03/10/25 revealed the resident's medications were scheduled to
be administered at 1:00 P.M. but were not signed off as given until 2:35 P.M.
9. Review of the medical record for Resident #31 revealed an admission date of 12/21/24 with diagnoses
including heart failure, hypertension, and diabetes.
Review of the physician's orders for Resident #31 revealed orders dated 03/10/25 for the following:
Sucralfate one gram two times per day and Tramadol 50 mg one tablet three times per day.
Review of the MAR for Resident #31 dated 03/10/25 revealed the resident's Sucralfate was scheduled to be
administered at 11:00 A.M. but was not signed off as given until 1:00 P.M. and the Tramadol was scheduled
to be administered at 1:00 P.M. but was not signed off as given until 2:41P.M.
10. Review of the medical record for Resident #46 revealed an admission date of 12/20/21 with diagnoses
including non-traumatic brain injury, coronary artery disease, diabetes, hypertension, and dementia.
Review of the physician's orders for Resident #46 dated 03/10/25 revealed orders for the following:
Humalog insulin per sliding scale before meals, hydralazine 50 mg once per day.
Review of the MAR for Resident #46 dated 03/10/25 revealed the resident's Humalog insulin was
scheduled to be administered at 11:00 A.M. but was not signed off as given until 3:15 P.M. and the
hydralazine was scheduled to be administered at 1:00 P.M. but was not signed off as given until 3:16 P.M.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 11 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0725
11. Review of the medical record for Resident #186 revealed an admission date of 08/07/24.
Level of Harm - Minimal harm
or potential for actual harm
Review of the physician's orders for Resident #186 revealed orders dated 03/10/25 for the following:
Albuterol Sulfate nebulizer 3 ml once per day, Metoprolol Tartrate 25 mg three times per day.
Residents Affected - Some
Review of the MAR for Resident #186 dated 03/10/25 revealed the resident's Albuterol inhaler was
scheduled to be administered at 12:00 P.M. but was not signed off as given until 3:20 P.M. and the
metoprolol tartrate was scheduled to be administered at 1:00 P.M. but was not signed off as given until 3:30
P.M.
Interview on 03/10/25 at 2:09 P.M. with Licensed Practical Nurse (LPN) #20 confirmed she was late with
medication administration on 03/10/25 for Residents #33, #28, #32, #59, #14, #52, #51, and #31. LPN #20
further confirmed the facility was supposed to have five nurses working for a census of 95 residents but
they only had three nurses working on 03/10/25.
Interview on 03/10/25 at 2:56 P.M. with Registered Nurse (RN) #58 confirmed she was late with medication
administration on 03/10/25 for Residents #46 and #186. RN #58 reported she was late giving medications
because she was training a new nurse, and the facility didn't have enough nurses scheduled on 03/10/25 to
be able to do the training and be on time for the medications.
Review of the schedule dated 03/10/25 revealed there were four nurses scheduled and a trainee. There
was one nurse who called off which made three nurses and a trainee for 03/10/25.
Interview on 03/17/25 at 3:51 P.M. with Scheduler #72 confirmed the facility scheduled five nurses during
the day, but on 03/10/25 there was a nurse who called off and there was another nurse who was training a
new nurse so that left three nurses on the halls and a trainee. Scheduler #72 confirmed when the nurse
called off sick she didn't replace the nurse and there wasn't enough staff ensure medications were passed
in a timely manner.
Review of the schedule dated 03/10/25 revealed there were four nurses scheduled and a trainee working
with RN #186. One of the four nurses was marked as a call off which left three nurses and a trainee for
03/10/25.
Review of the facility policy titled Staffing dated 04/01/07 revealed the facility provided adequate staffing to
meet care and service needs for the resident population.
Review of the facility policy titled Administering Medications dated 04/01/19 revealed medications were to
be administered in a safe and timely manner, and as prescribed. The staffing schedules would be arranged
to ensure that medications were administered without unnecessary interruptions.
This deficiency represents noncompliance investigated under Complaint Number OH00163482 and
Complaint Number OH00162885 and Complaint Number OH00162841 and Complaint Number
OH00162213.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 12 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observation, staff interview, and review of the facility policy, the facility
failed to ensure residents did not receive unnecessary medications. This affected one (Resident #43) of five
residents reviewed for unnecessary drugs.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #43 revealed an admission date of 03/29/23 with diagnoses
including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and anxiety disorder.
Review of the weekly skin assessment for Resident #43 dated 12/11/24 revealed staff identified a fungal
wound to the resident's scrotum on 12/04/25.
Review of the physician's orders for Resident #43 revealed an order dated 12/14/24 revealed for Mupirocin
ointment to the scrotum / tip of penis topically every shift for wound.
Review of the wound progress note for Resident #43 dated 12/23/24 revealed there was a wound noted the
central anterior scrotum with an order to apply Mupirocin ointment two times daily for seven days and then
discontinue.
Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 01/11/25 revealed the resident
was cognitively intact and required staff assistance with activities of daily living (ADLs).
Review of the Medication Administration Records (MARs) for Resident #43 dated December 2024, January
2024, February 2024, and March 2024 (through 03/12/24) revealed staff applied Mupirocin topically to the
resident's penis
Interview on 03/12/25 at 1:06 P.M. with Licensed Practical Nurse (LPN) #15 confirmed he was not aware of
Resident #43 having any wound to his penis.
Observation on 03/12/25 at 1:38 P.M. of wound care for Resident #43 with LPN #15 revealed the resident
did not have a wound on his penis.
Interview on 03/12/25 at 2:06 P.M. with Registered Nurse (RN) #502 confirmed she had applied Mupirocin
ointment to Resident #43's penis earlier in the day on 03/12/25.
Interview on 03/13/25 at 2:16 P.M. with LPN Infection Control #61 confirmed if the antibiotic did not have a
stop date she contacted the physician and got a stop date or had the medication stopped. Interview also
confirmed she makes sure the physician or Nurse Practitioner (NP) documents the need.
Interview on 03/13/25 at 3:32 P.M. with LPN #15 confirmed Resident #43 was seen by the wound nurse
practitioner on 12/23/24 who gave orders to continue Mupirocin ointment to the scrotum / tip of penis
topically two times daily for seven days, then discontinue. LPN #15 further confirmed the Mupirocin
ointment to Resident #43's penis should have been discontinued on 12/31/24 and the medication was
unnecessary.
Review of the facility policy titled Administering Medications dated April 2019 revealed were to be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 13 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
administered in a safe and timely manner, and as prescribed and should be administered in accordance
with prescriber orders, including any required time frame.
Review of the facility policy titled Antibiotic Stewardship dated December 2016 revealed antibiotics would
be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship
program. If an antibiotic was indicated, prescribers would provide complete antibiotic orders which included
duration of treatment, start and stop date, and/or number of days of therapy.
Event ID:
Facility ID:
365374
If continuation sheet
Page 14 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on review of menus and spreadsheets, observation, staff interview, medical record review, resident
interview, and review of the facility policy, the facility failed to ensure menu portion sizes were followed and
menus were reviewed by a dietitian in advance. This affected all of the residents residing in the facility
except for one (Resident #61) who received no food by mouth. The facility failed to ensure the resident got
to make choices concerning breakfast. This affected three (Residents #22, #45, and #21) of three residents
reviewed for choices during the annual survey. The facility census was 95 residents.
Findings include:
1. Review of the handwritten menu spreadsheet dated 03/11/25 revealed residents on regular and
mechanical soft diets were to receive a number 12 or 2.66 ounce (oz) scoop of scrambled eggs with
cheese, one slice of toast, and 6 oz of oatmeal, and residents on pureed diets were to receive a number 12
or 2.66 oz scoop of pureed scrambled eggs with cheese, a number 16 or 2 oz scoop of pureed bread, and
a 6 oz scoop of cream of wheat.
Observation of the kitchen on 03/11/25 at 7:25 A.M. revealed residents on regular and mechanical soft
diets were served a number 16 or 2 oz scoop of scrambled eggs with cheese, one slice of toast, and 6 oz
of oatmeal, and pureed diets were served a number 16 or 2 oz scoop of pureed scrambled eggs with
cheese, a number 20 or 1.6 oz scoop of pureed bread, and a 6 oz scoop of cream of wheat.
Interview on 03/11/25 at 8:00 A.M with Dietary Manager (DM) #215 confirmed residents on regular and
mechanical soft diets were served a number 16 or 2 oz scoop of scrambled eggs with cheese and they
should have received a number 12 or 2.66 oz scoop of scrambled eggs with cheese per the menu
spreadsheet. DM #215 also confirmed residents on pureed diets were served a number 16 or 2 oz scoop of
pureed scrambled eggs with cheese, and a number 20 or 1.6 oz scoop of pureed bread and they should
have received a number 12 or 2.66 oz scoop of pureed scrambled eggs with cheese and a number 16 or 2
oz scoop of pureed bread per the menu spreadsheet.
2.Review of the handwritten menu spreadsheets for breakfast, lunch and dinner for 03/11/25 to 03/14/25
revealed the spreadsheets had not been reviewed by a dietitian.
Interview on 03/11/25 at 8:00 A.M. with DM #215 confirmed she had written the spreadsheets for all three
meals for 03/11/25 to 03/14/25 by hand and the dietitian had not reviewed the spreadsheets. DM #215
confirmed the facility served breakfast was served on 03/11/25 without the dietitian's approval of the
spreadsheet.
Interview on 03/11/25 at 10:16 A.M with Registered Dietitian (RD) #501 confirmed he had not reviewed the
meal spreadsheets for 03/11/25 to 03/14/25.
Review of the facility policy titled Menus dated October 2017 revealed menus for regular and therapeutic
diets were written at least two weeks in advance and were dated and posted in the kitchen at least one
week in advance. The dietitian approved all menus.
4. Review of the medical record for Resident #22 revealed an admission date of 04/08/17 with diagnoses
including neurogenic bladder, diabetes and arthritis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 15 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Review of the Minimum Data Set (MDS) for Resident #22 dated 01/30/25 revealed the resident was
cognitively intact.
Interview on 03/10/25 at 2:27 P.M. with Resident #22 confirmed he didn't get a choice for breakfast meals.
He reported the staff deliver a paper at lunchtime with lunch and dinner choices on it, but there were no
breakfast choices.
Observation on 03/13/25 at 11:50 A.M. with Resident #22 revealed the resident had a paper which listed
lunch and dinner options to pick for the next day with no breakfast choices available.
5. Review of the medical record for Resident #45 revealed an admission date of 08/03/18 with diagnoses
including hypertension, depression and anxiety.
Review of the MDS assessment for Resident #45 dated 11/29/24 revealed the resident was cognitively
intact.
Observation on 03/13/25 at 11:39 A.M. with Resident #45 revealed the resident had a piece of paper on his
tray which listed choices for lunch and dinner for the next day.
Interview on 03/13/25 at 11:39 A.M. with Resident #45 confirmed he didn't get to pick what he wanted for
breakfast.
6. Review of the medical record for Resident #21 revealed an admission date of 09/11/23 with diagnoses
including dementia, anemia, and diabetes.
Review of the MDS assessment for Resident #21 dated 01/30/25 revealed the resident was cognitively
intact.
Observation on 03/13/25 at 11:40 A.M. with Resident #21 revealed the resident had a piece of paper on his
tray which listed choices for lunch and dinner for the next day.
Interview on 03/13/25 at 11:40 A.M. with Resident #21 confirmed he didn't get to pick what he wanted for
breakfast.
Interview on 03/13/25 at 12:04 P.M. with Certified Nursing Assistant (CNA) #57 confirmed the residents
received a paper to pick what they wanted for lunch and dinner the next day. CNA #57 confirmed residents
did not get to choose what they wanted for breakfast.
Interview on 03/13/25 at 12:10 P.M with DM #215 confirmed the facility no longer had residents choose
breakfast items. DM #215 confirmed the facility used to let the residents choose breakfast items, but the
residents were getting the same thing over and over again and it was a waste of time so they only ordered
lunch and dinner items now.
This deficiency represents noncompliance investigated under Complaint Number OH00162213 and
Complaint Number OH00162183.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 16 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on review of dietary spreadsheets, observation, staff interview and review of facility recipes, the
facility failed to ensure pureed eggs and pureed bread were prepared in a form to meet resident needs.
This affected four (Residents #33, #42, #57, and #68) of four facility-identified resident who received pureed
diets. The facility census was 95 residents.
Findings include:
Review of the dietary spreadsheet dated 03/11/25 revealed residents on pureed diets pureed scrambled
eggs with cheese, pureed bread, and cream of wheat for breakfast.
Observation in the kitchen on 03/11/25 at 7:25 A.M. of food to be served to residents on pureed diets
revealed the pureed scrambled eggs had dime-sized chunks of eggs in them and the pureed bread had
chunks of bread which were approximately one quarter inch in diameter.
Interview on 03/11/25 at 8:00 A.M with Dietary Manager (DM) #215 confirmed the pureed scrambled eggs
had chunks of egg which had not been blended and there were chunks of bread that were mixed in with the
pureed bread. DM #215 confirmed that the pureed eggs and the pureed bread should have been blended
until smooth and free of chunks.
Review of the facility recipe for pureed scrambled eggs dated 01/15/25 revealed the eggs should be
blended until smooth.
Review of the facility recipe for pureed bread dated 01/15/25 revealed the bread should be proceeded until
smooth.
This deficiency represents noncompliance investigated under Complaint Number OH00162183.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 17 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
Based on medical record review, observation, staff interview and resident interview, the facility failed to
ensure residents were not served food items to which they were allergic. This affected one (Resident #7) of
27 residents sampled. The facility census was 95 residents.
Findings include:
Review of the medical record for Resident #7 revealed an admission date of 01/27/25 with diagnoses
including displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease, type two
diabetes mellitus, vascular dementia, and congestive heart failure.
Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 02/04/25 revealed the resident
was moderately cognitively impaired and required set up assistance with eating.
Review of the nutritional care plan for Resident #7 dated 02/05/25 revealed the resident was allergic to
eggs. Interventions included staff should provide the diet per the physician order.
Review of the nutritional assessment for Resident #7 dated 02/05/25 per Registered Dietitian (RD) #501
revealed the resident was ordered a mechanical soft diet and had an egg allergy.
Review of the physician's orders for Resident #7 dated March 2025 revealed the resident was ordered a
regular diet, mechanical soft texture with thin liquids.
Review of the physician's progress note for Resident #7 dated 03/08/25 per Physician #502 revealed the
resident was allergic to eggs and egg derived products.
Observation on 03/11/25 at 7:25 A.M. of meal preparation for Resident #7 per [NAME] #26 revealed
Resident #7's meal ticket indicated the resident was allergic to eggs but [NAME] #26 added eggs to the
resident's plate.
Interview on 03/11/25 at 7:25 A.M with [NAME] #26 on confirmed she had added scrambled eggs to
Resident #7's plate and also confirmed the resident was allergic to eggs.
Interview on 03/11/25 at 10:16 A.M with RD #501 confirmed Resident #7 was allergic to eggs and should
not receive eggs or egg products on her tray.
Interview on 03/13/25 at 10:39 A.M. with Resident #7 confirmed she was allergic to eggs, and she felt like
her throat closed up when she ate eggs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 18 of 19
Printed: 05/15/2026
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
365374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beavercreek Post Acute
1974 North Fairfield Road
Dayton, OH 45432
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure the kitchen and food items
were maintained in a manner to prevent foodborne illness. This affected all residents in the facility except for
one resident (#61) that received no food by mouth. The facility census was 95.
Findings include:
Observation on 03/10/25 at 8:48 A.M of the kitchen with Dietary Manager (DM) #215 revealed the following
kitchen sanitation concerns: there was built up dirt behind the dishwasher, the garbage disposal had rust in
the bowl of it, in the dishwasher room there were splashes of a substance running down the walls from the
celling to the floor, there were rusty and dusty vents above the steam table area, the window in the kitchen
had cobwebs, the wall behind the sink in the kitchen area had splashes of a substance running down the
walls, there was an open rusted drain on the floor, the handwashing sink had a white substance running
down the entire sink outside and inside, all of the kitchen walls had splashes of a substance on the walls
from top to bottom.
Interview on 03/10/25 at 9:10 A.M. with DM #215 confirmed the kitchen sanitation concerns and confirmed
the areas should be cleaned.
Observation on 03/11/25 at 7:25 A.M of the kitchen with DM #215 revealed the following sanitation
concerns: there was a black area on the ceiling above the three compartment sink, there was standing
water in the handwashing sink, the air vent on the ceiling near the door to exit the kitchen had a gray fuzzy
substance on it, there was black and white build up on the floors, there was a gray substance on the shelf
above the stove that left a gray mark on a paper towel when wiped, there was a black substance on the
nozzle of the juice dispenser. Observation of the dry storage area revealed there was an updated packed of
uncooked pasta which was open to air. Observation of the walk-in refrigerator revealed a pan of peas and a
pan of spinach which were undated, uncovered and open to air.
Interview on 03/11/25 at 7:25 A.M. with DM #215 confirmed the kitchen sanitation concerns and also
confirmed the improperly stored foods in the dry storage area and the walk-in refrigerator.
Review of the facility policy titled Food Receiving and Storage policy dated November 2022 revealed all
food stored in the refrigerator or freezer should be covered, labeled and dated. Dry foods should be
handled and stored in a manner that maintained the integrity of packaging until they are ready to be used.
Review of the facility policy titled Sanitization dated November 2022 revealed all kitchen areas should be
kept clean, and shelves and equipment should be kept clean and maintained in good repair.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365374
If continuation sheet
Page 19 of 19
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the March 20, 2025 survey of BEAVERCREEK POST ACUTE?
This was a inspection survey of BEAVERCREEK POST ACUTE on March 20, 2025. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BEAVERCREEK POST ACUTE on March 20, 2025?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.