Health inspection·February 17, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed record review, staff interviews, policy review, and review of hospital documentation, the facility failed to ensure a resident received adequate assistance during a transfer to prevent an avoidable fall. This resulted in Actual Harm to Resident #95 when on 12/21/25 she fell on to the floor in the bathroom while being assisted with toileting by one staff member. Resident #95 sustained a fracture of the right femoral head and the left distal femur. This affected one (Resident #95) of three residents reviewed for falls. The facility census was 90.Findings include:Record review for Resident #95 revealed an admission date of 05/02/25. Diagnoses included congestive heart failure, polyneuropathy, difficult ambulation, muscle weakness, and chronic obstructive pulmonary disease. Review of the Lift, Transfer, Reposition Assessment, dated 05/16/25, revealed Resident #95 was at risk for falls and required two-persons substantial/maximal assist for transfers with the use of a gait belt.Review of the care plan, dated 06/18/25, revealed Resident #95 had intact cognition, and she was at risk for falls due to weakness and poor balance. The interventions included encouraging proper footwear when out of bed. Review of the care plan, dated 10/09/25, revealed Resident #95 required a functional maintenance program for transfers to restore their ability to assist with transfers between surfaces. Interventions included utilizing a gait bait belt with moderate-maximum assistance.Review of the Minimum Data Set (MDS) assessment, dated 12/01/25, revealed Resident #95 was cognitively intact. Resident #95 required substantial/maximal physical assistance for all transfers. Resident #95 was not steady and was unable to stabilize without staff assistance for moving from a seated to standing position, walking, and surface to surface transfer. Review of the progress note, dated 12/21/25 at 1:05 P.M. by Licensed Practical Nurse (LPN) #600, revealed Certified Nursing Assistant (CNA) #920 walked up to the nursing station for LPN #600 to come to Resident #95's room. Upon entry, LPN #600 observed Resident #95 sitting on the bathroom floor, complaining of left knee pain with multiple abrasions. Resident #95 was assisted to bed by the nurse and CNA #920. At 1:30 P.M. a STAT (without delay) order for imaging was obtained for both lower extremities including both hips. Fifteen-minute checks and neurological checks were initiated, with all being completed.Review of the Imaging Report dated 12/21/25 revealed a study time of 5:28 P.M. The facility was notified of the results at 7:34 P.M. The results of this imaging showed severe right hip degenerative changes with deformity in the right femoral neck. The left femur showed an acute distal femoral metadiaphysis fracture (the anatomical region of a long bone that encompasses the junction between the widened end and the shaft) with generalized osteopenia. The progress note dated 12/21/25 at 7:28 P.M. revealed notification to the physician of preliminary imaging reports and an order was obtained to send Resident #95 to the emergency room via emergency medical system (EMS) transport.The progress note dated 12/22/25 at 1:01 A.M. revealed Resident #95 was being admitted to the hospital with active diagnoses Page 1 of 3 365398 365398 02/17/2026 Best Care Health and Rehabilitation 2159 Dogwood Ridge Road Wheelersburg, OH 45694

F 0689 Level of Harm - Actual harm Residents Affected - Few of a right hip fracture along with a fracture to the left femur.The progress note dated 12/22/25 at 6:38 A.M. revealed the receiving hospital was transferring Resident #95 to another hospital due to compartment syndrome (severe, often acute, condition where high pressure builds with muscle compartment, restricting blood flow and causing oxygen deprivation) related to the left femur fracture. Review of the Fall Assessment Quality Assurance Performance Improvement (QAPI) report revealed Resident #95 had a fall on 12/21/25 at approximately 1:05 P.M. in the bathroom and sustained a major injury and was sent to the emergency room. The investigation stated the care plan interventions/strategies were in place. Resident #95 fell during transfer to the toilet, and the possible root cause was knee giving out. The QAPI action plan was to utilize the sit-to-stand lift to transfer Resident #95. The investigation did not address that Resident #95 required two persons to transfer and during this incident, only one person transferred Resident #95. The investigation did not address that CNA #920 did not utilize a gait belt which was part of the resident's plan of care. The report did not include any staff names involved with the QAPI action plan.The witness statement (undated) by CNA #920 revealed on12/21/25 at 1:05 P.M., CNA #920 was taking Resident #95 to the restroom and the resident stated that her knee was hurting her. Resident #95 was holding on to the bar in the bathroom. CNA #920 moved the wheelchair and was behind Resident #95 when Resident #95 began falling to her side. Resident #95 fell backwards toward the other bathroom door. Nurse was notified.Review of Resident #95's hospital records from Hospital #1, dated 12/22/25, revealed Resident #95's imaging showed a left distal femur fracture and a right hip fracture. This resident also arrived at the hospital being hypotensive (low blood pressure) with no external signs of bleeding or hemorrhage. The discharge plan was a closed left femoral fracture, fracture of right hip, anemia, and acute hypotension. Resident #95's condition at discharge was serious. Resident #95 was transferred to a Level One Trauma Center at Hospital #500 due to suspicions of internal bleeding of the left thigh. The family elected hospice services on 12/31/25.Review of Hospital #500's records revealed Resident #95 was treated for hemorrhagic shock and acute on chronic shock. The physician stated the left femur fracture was pathological due to a combination of osteopenia and trauma and that alone would not have resulted in fracture.Review of the death certificate and coroner's report dated 01/09/26 revealed Resident #95's cause of death to be medical decline following a left distal femur fracture with surgical therapy as a consequence of a ground level fall.During an interview on 02/13/26 at 2:34 P.M., LPN #600 stated Resident #95 fell on [DATE] while CNA #920 was assisting her to the toilet by herself. LPN #600 stated CNA #920 came to get him at the nursing station and said Resident #95 had fallen. LPN #600 stated Resident #95 required a two-person assist and this transfer was completed by only CNA #920. During an interview on 02/17/26 at 12:31 P.M., the Director of Nursing (DON), Assistant Director of Nursing (ADON) #330, [NAME] President of Clinical Operations #900, and Regional Resource Nurse #910 verified CNA #920 improperly transferred Resident #95 alone without the use of a gait belt for a safe transfer. They verified Resident #95 sustained a right hip fracture and a left femur fracture because of the transfer, with CNA #920 being terminated on 12/29/25 for inadequate work performancesReview of the policy titled Falls/Accidents/Incidents, dated 07/17/23, revealed the intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. An avoidable accident means the accident occurred the facility failed including implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the resident of an accident.The deficient practice was corrected on 02/06/26 when 365398 Page 2 of 3 365398 02/17/2026 Best Care Health and Rehabilitation 2159 Dogwood Ridge Road Wheelersburg, OH 45694

F 0689 Level of Harm - Actual harm Residents Affected - Few the facility implemented the following corrective actions:-On 12/21/25, Resident #95 was sent to the hospital and did not return to the facility.-On 12/22/25, a QAPI meeting was conducted following identification of the incident and ongoing four weeks with all required individuals in attendance to ensure compliance.-Beginning 12/22/25, all falls will be reviewed Monday-Friday in the clinical whiteboard meeting by the interdisciplinary team (IDT) with detailed investigation to ensure the event was completed correctly, a root cause analysis was conducted, with all care plans updated, interventions implemented, physician and family notifications completed.-Beginning 12/22/25, members of the IDT team will observe staff completing activities of daily living (ADLs) for five residents to ensure all are provided per plan of care and Kardex on each shift daily for two weeks, then five daily on Monday-Friday for four weeks on different shifts.-By 12/24/25, all current residents had a new fall risk assessment completed to ensure proper identification of all residents who are at risk for falls. The facility identified 38 residents at risk for falls.-By 12/26/25, all 38 residents who were identified for falls had care plans reviewed to ensure that all falls care plans were up to date with current interventions. This included the type of assistance the residents required with ADL.-By 12/26/25, all 38 residents who have fall prevention interventions present on care plans were assessed to ensure the interventions were in place for residents and available for resident utilization. were assessed to ensure all fall interventions on the care plan were implemented.-By 12/26/25, the DON, Assistant Director of Nursing (ADON) #330, Staff Development Coordinators (SDC) #650, Unit Manager #790, and/or Administrator educated all staff on accident and incident policies and procedures, following care plans, utilization of assistive devices and use of gait belts. Post-education test was given until 100% passing score for all staff. -Beginning 12/22/25, members of the IDT will review five residents total per day on all units on all shifts to ensure all fall interventions are in place. This was daily for two weeks, then Monday-Friday for two weeks, then weekly for six weeks.-Beginning the week of 12/27/25, a post-test will be conducted for five random staff members weekly starting on 12/27/25 to ensure retention of education. This was ongoing for four weeks. -On 12/29/25, CNA #920 was terminated for poor work performance.-On 02/13/26, record reviews for Residents #27, #38, and #64 who had a fall history with major injury revealed no concerns relates to their falls.-Observation on 02/13/26 revealed Resident #38 was transferred safely to wheelchair from bed by staff.-Interviews on 02/13/25 with LPN #600, LPN #740, CNA #470, and CNA #630 revealed staff were educated on the facility's policies and procedures related to accidents and incidents, following care plans, and utilizing assistive devices and use of gait belts.This deficiency substantiates Complaint Number 2714886. 365398 Page 3 of 3