Health inspection·May 8, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident's emergency contact was notified of a fall and a change in condition. This affected one (Resident #3) of three reviewed for notification of changes. The facility census was 91. Findings include: Review of Resident #3's closed medical record revealed an admission date of 01/24/24. Diagnoses included muscle weakness, vascular dementia, heart failure, and pleural effusion. Resident #3 was transferred to a local hospital on [DATE] and did not return to the facility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10. Review of the progress notes dated 04/06/24 at 3:46 P.M. revealed Resident #3 was found by an State Tested Nursing Assistant (STNA) sitting upright on the floor next to his bed with his wheelchair next to him. The wheelchair was locked and Resident #3 was wearing gripper socks. Resident #3 stated he was standing to transfer from his wheelchair to his bed and his feet slipped out from under him causing him to slide to the floor landing on his bottom. Resident #3 denied any head injury. Resident #3's physician and son were notified. Resident #3's son was not listed as an emergency contact. Review of the neurological checks conducted post-fall revealed Resident #3's level of consciousness (LOC) had declined from one (alert wakefulness: responds quickly and appropriately) on 04/07/24 at 3:15 A.M. to a two (drowsy/lethargic: responds to stimuli appropriately, but with delay and slowness) on 04/07/24 at 7:15 A.M. Resident #3's LOC was documented as two on 04/07/24 at 11:15 A.M. and 3:15 P.M. The progress notes dated 04/07/24 at 1:28 P.M. revealed Resident #3 was increasing lethargic and drowsy. Resident #3's blood pressure was trending low. There was no documentation of Resident #3's emergency contact being notified of the decline in LOC until 04/07/24 at 7:50 P.M. when Resident #3's emergency contact came to the facility and had concerns about Resident #3's hallucinations and twitching. Resident #3 was sent the the emergency room (ER) for evaluation. Interview on 05/08/24 at 11:20 A.M. with the Director of Nursing (DON) and Register Nurse (RN) #75 revealed when Resident #3 fell on [DATE], Licensed Practical Nurse (LPN) #50 was the nurse assigned (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 2 Event ID: 365422 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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)