Inspection·May 12, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and review of the facility policy, the facility failed to ensure staff completed appropriate neurological checks for a resident with an unwitnessed fall. This affected one resident (#73) of three residents reviewed for falls. The facility census was 72. Residents Affected - Few Findings include: Review of the closed medical record for Resident #73 revealed an admission date of 03/31/23 with diagnoses including chronic respiratory failure with hypoxia, moderate protein calorie malnutrition, major depressive disorder, gastroparesis, anxiety disorder, anemia, history of infrarenal abdominal aortic aneurysm, atherosclerotic heart disease, Barrett's esophagus, hypertension (HTN), and a discharge date of 04/25/23. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #73 dated 04/13/23 revealed the resident was cognitively intact and required extensive assistance of one staff member with activities of daily living (ADLs.) Review of nurse progress notes for Resident #73 dated 04/24/23 timed at 4:12 P.M., revealed the resident was assessed following a fall from the bed and had no injuries. Staff assisted resident back to bed and initiated neurological checks per protocol. Review of the facility fall investigation for Resident #73 dated 04/24/23, revealed the resident had an unwitnessed fall from bed on 04/24/23 at approximately 3:00 P.M. The resident was found on the floor next to her bed and staff reported the resident was on the floor because it was cooler on the floor. Review of the facility document titled Neurological Check Worksheet for Resident #73 revealed the staff completed checks per protocol which included the following information: level of consciousness, pupil response, strength of hand grasps, motor function of extremities, blood pressure, pulse, respirations, temperature. Further review of the worksheet initiated on 04/24/23 revealed an incomplete neurological (neuro) check was conducted at 10:00 P.M. on 04/24/23 which did not include pupil response or motor function. A neurological check was due to be completed on 04/25/23 at 3:00 A.M.; however, there was no documented evidence the neuro check for Resident #73 was completed. Interview on 05/12/23 at 12:33 P.M. with the Director of Nursing (DON) confirmed the neuro checks for Resident #73 were not fully completed after the resident had a recorded fall on 04/24/23. DON confirmed the neuro check due at 10:00 P.M on 04/24/23 was not completed and the neuro check due on 04/25/23 at 3:00 A.M. was not completed. (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 4 Event ID: 365515 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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)