Health inspection·September 26, 2022

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview , facility personal funds account review, and policy review, the facility failed to close the resident's account after the resident expired. This affected one resident (#137) of three residents who have expired with money in the facility's personal funds account. The facility failed to provide a notice of spend down for a resident whose balance exceeded the maximum asset permitted. This affected one resident (#30) of three resident records reviewed for personal funds accounts. The facility census was 33. Residents Affected - Few Findings include: 1. Review of Resident #137's medical record revealed an admission dated of [DATE]. admission diagnoses included hemiplegia and hemiparesis following cerebral infarction. Review of Resident #137's progress note dated [DATE] revealed the hospital called to inform the facility the resident had passed away. Review of the facility's current personal funds account balances for all residents revealed Resident #137 had a balance of $983.35. Interview on [DATE] at 9:22 A.M. with Business Office Manager (BOM) #136 confirmed the resident expired [DATE]. The BOM #136 confirmed the facility was required to close the resident's personal fund account thirty days after the resident expired. The BOM #136 revealed Resident #137 did not receive state funds. BOM #136 revealed the account was put on hold due to concerns with the resident's pension. The BOM #136 confirmed the facility should have closed the account. 2. Review of Resident #30's medical record revealed an admission date of [DATE]. admission diagnoses included acute and chronic respiratory failure, encephalopathy, cerebral infarction, diabetes and schizoaffective disorder. Further review of the resident's record revealed her son was the Power of Attorney (POA). Review of the facility's personal funds account balance revealed Resident #30 had a balance of $1132.07. Review of a separate-second statement account log for Resident #30 revealed Resident #30 had a balance of $13,000.00 additional spend down dollars. Interview on [DATE] at 9:22 A.M. with the Business Office Manager (BOM) #136 revealed the Resident #30 transitioned to Medicaid in [DATE]. The BOM #136 stated she did not list Resident's $13,000 on the current facility's Personal Fund Resident balances because she was trying to protect the Page 1 of 8 365626 365626 09/26/2022 Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's money for the resident. The BOM #136 stated she had called the son (POA) and informed him of the spend down several weeks ago and encouraged him to purchase funeral expenses. The BOM #136 confirmed she was aware of the spend down requirement. The BOM #136 confirmed she had never sent any spend down notices. The BOM #136 confirmed she had no documentation or evidence she notified the family of Resident #30's account balance and the need to spend down. The BOM #136 revealed the Resident had exceeded the #2000 maximum allowable amount since [DATE]. The BOM confirmed the total amount in Resident #30's account was $14,132.07. Interview on [DATE] at 10:40 A.M. with the Administrator confirmed the facility was aware of Resident #30's personal fund account had exceeded the maximum allowable amount. The Administrator confirmed spend-down notices are required when resident's accounts are near or exceed the maximum allowable amount. Review of the undated facility policy titled, Patient Resident Trust Fund Policy, revealed the facility will maintain all trust fund accounts in compliance with state and federal regulations. 365626 Page 2 of 8 365626 09/26/2022 Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on medical record review and interviews the facility failed to issue a bed hold notification letter to residents who went to the hospital. This affected Resident #13 and #34 who were reviewed for hospitalizations. The facility census was 33. Findings include: 1. Review of medical record for Resident #13 revealed admission date of 10/14/21 with server cognitive deficits. Resident #13 diagnoses included atrial fibrillation , type two diabetic , and encephalopathy. On 06/19/22, he was transferred to the hospital due to problems with his Foley catheter. On 06/24/22, Resident #13 was readmitted to the facility. Review of Resident #13 nurses progress notes from 06/01/22 to 07/01/22 revealed the facility did not send the representative a bed hold notification letter. On 09/20/21 at 5:15 P.M. interview with the Director of Nursing (DON) confirmed a bed hold letter was not issued to Resident #34 or his representative. 2. Review of medical record for Resident #34 revealed admission date of 7/21/22. The resident was admitted with diagnoses chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and type two diabetic. On 7/27/22, Resident #34 was sent out to dialysis, while receiving treatment, her vitals dropped and was sent out to the hospital. She did not return to the facility. Review of the nurses progress notes revealed Resident #34 or her representative was not notified of the bed hold policy and procedure. On 09/20/21 at 5:15 P.M. interview with the DON confirmed a bed hold letter was not issued to Resident #34 or her representative. 365626 Page 3 of 8 365626 09/26/2022 Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to provide services to prevent further decrease in range of motion and mobility. This affected one resident (Resident #33) out of two resident reviewed with splints. The facility census was 33. Findings include: Review of the medical record for Resident #33 revealed an admission date of 08/29/13 with medical diagnoses of unspecified intracranial injury with loss of consciousness, obstructive hydrocephalus, quadriplegia, and immobility syndrome, aphasia, contracture to joints, unspecified, and traumatic brain injury. Review of the medical record revealed the Minimum Data Set (MDS) dated [DATE] which stated Resident #33 was sometime able to understand information and rarely/never able to make self-understood. The MDS revealed Resident #33 had moderate impaired cognition. Further review of MDS revealed resident required extensive staff assistance of two staff members for bed mobility and toileting and was dependent upon staff for transfers and bathing. Review of the MDS revealed Resident #33 had limited range of motion (ROM) to one side of the body upper extremity and one side of the body lower extremity. Review of the medical record for Resident #33 revealed an order dated 08/15/19 which stated the resident was to wear elbow extension splint four to six hours per day seven days per week per resident tolerance. Review of the medical record for Resident #33 does not have documentation to support the resident had been offered or had worn the elbow extension splints as ordered. Observation on 09/19/22 at 9:00 A.M. revealed Resident #33 lying in bed without elbow splints in place. Resident #33 was observed to have contracture to right hand. Interview on 09/21/22 8:22 AM with State Tested Nursing Aide (STNA) #134 and STNA #127 stated Resident #33 did not have any splints for his contracture's. STNA #134 and STNA #127 stated they take care of Resident #33 routinely. Interview on 09/21/22 at 1:38 PM with Director of Nursing Services (DNS) #133 confirmed Resident #33 had an order for elbow extension splints to be applied four to six hours per day seven days per week per resident tolerance dated 08/15/19. DNS #133 confirmed Resident #33 did not have elbow extensive splints. 365626 Page 4 of 8 365626 09/26/2022 Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow infection control procedures when distributing medications and completing wound care. This affected two residents (Resident #10 and Resident #11) out of five residents reviewed. The facility census was 33. Residents Affected - Few Findings include: 1. Review of medical record for Resident #10 revealed an admission date of 02/05/22 with medical diagnoses of acute osteomyelitis, Diabetes Mellitus (DM), chronic kidney disease (CKD) stage 2, neuromuscular dysfunction of bladder, congestive heart failure (CHF), morbid obesity, major Depressive disorder, and status post partial traumatic amputation of right foot. Review of the medical record for Resident #10's revealed a Minimum Data Set (MDS) dated [DATE] which stated the Brief Interview for Mental Status (BIMS) was 15 indicating the resident had no cognitive impairment. Further review of the MDS revealed Resident #10 required extensive staff assistance of two staff members for bed mobility, transfers, dressing, toileting, and bathing. The MDS revealed the resident had an indwelling urinary catheter and was always incontinent of bowel. The MDS revealed Resident #10 admitted with one Stage III pressure ulcer, two unstageable pressure ulcers, one deep tissue injury and one surgical wound. Review of Resident #10's physician orders revealed an order dated 08/31/22 for left lower heel to be cleansed with wound wash, pat dry, apply skin prep and cover with abdominal (ABD) pad and then wrap with kerlix. Observation on 09/21/22 at 2:21 P.M. revealed Licensed Practical Nurse (LPN) #130 completed wound care to Resident #10's left foot surgical wound. LPN #130 was observed removing old dressing from Resident #10's left foot surgical wound. The old dressing was noted to have tannish colored drainage on the dressing. LPN #130 discarded the old dressing into the trash and proceeded to complete the treatment as ordered to left foot surgical wound without changing his gloves. Interview on 09/21/22 at 2:41 P.M. with LPN #130 confirmed he did not change his gloves after removing the soiled dressing for Resident #10's left foot surgical wound and before he applied the new treatment and dressing. 2. Review of medical record for Resident #11 revealed an admission date of 01/19/22 with medical diagnoses chronic respiratory failure with hypoxia, asthma, major Depression, Diabetes Mellitus (DM), hypertension (HTN), and anxiety disorder. Review of the medical record for Resident #11 revealed the MDS dated [DATE] which stated Resident #11 was alert and oriented to person, place, and time. Further review of the MDS revealed the resident required extensive staff assistance with bed mobility, transfers, dressing and toileting and was dependent upon staff for bathing. Review of the medical record revealed physician orders for aspirin 81 milligrams (mg) by mouth once daily, multivitamin 1 tablet by mouth once daily, claritin 10 mg by mouth once daily, losartan potassium-hydrochlorothiazide 100-25 mg one tablet by mouth once daily, ropinirole 0.25 mg one tablet by mouth once daily, effexor XR 37.5 mg by mouth once daily, and tamsulosin 0.4 mg one capsule by 365626 Page 5 of 8 365626 09/26/2022 Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305

F 0880 mouth once daily. Level of Harm - Minimal harm or potential for actual harm Observation on 09/20/22 at 7:36 AM revealed LPN #130 place Resident #11's medications into his bare hands prior to putting the medications into a medication cup. LPN #130 did not wash or sanitize his hands prior to touching Resident #11 medications. LPN #130 was observed giving the medications to Resident #11 in the medication cup. Residents Affected - Few Interview on 09/21/22 8:37 AM with LPN #130 confirmed LPN #130 put Resident #11 medications directly into his bare hands from the medication packages and then put the medications into a medication cup. LPN #130 confirmed he gave the medication cup to Resident #11. LPN #130 confirmed he did not wash or sanitize his hands prior to putting Resident #11's medications into his bare hands or wear gloves during the medication pass. Review of facility policy titled Standard Precautions, revealed staff are to change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. The policy also stated staff are to wash hands between tasks and procedures on the resident when contaminated with body fluids to prevent cross-contamination of different body sites. 365626 Page 6 of 8 365626 09/26/2022 Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident record review, and policy review, the facility failed to ensure residents were offered their pneumococcal vaccine. This affected two residents (Resident #9 and #21) of five residents reviewed for immunizations. The facility census was 33. Residents Affected - Few Findings include: 1. Review of Resident #9 revealed an admission dated of 07/30/18. admission diagnoses included acute and chronic respiratory failure, anoxic brain damage, chronic obstructive pulmonary disease, congestive heart failure, and dependence on respiratory ventilator. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) unable to be completed. The MDS revealed the resident required total two-person dependence for bed mobility, dressing, toileting and personal hygiene. The MDS revealed transfers and eating had not occurred during the evaluation period. Review of Resident #9's plan of care dated 08/05/22 revealed the resident had an alteration in respiratory status due to chronic obstructive pulmonary disease and was dependent on the ventilator. Review of Resident #9's immunization record revealed a historical pneumovax was administered on 04/18/18. The resident's medical record was silent for a second pneumococcal vaccine. Interview on 09/22/22 at 9:22 A.M. with the Director of Nursing confirmed the resident had not been offered her second pneumococcal vaccine. 2. Review of Resident #21's medical record revealed an admission date of 11/21/17. admission diagnoses included chronic respiratory failure, persistent vegetative state, chronic obstructive pulmonary disease, disease, dependence on respirator, sepsis, and diabetes. Review of Resident #21's MDS dated [DATE] revealed a BIMS unable to be assessed. The MDS revealed the resident required two-person total dependence for bed mobility, dressing, toileting, and personal hygiene. The MDS revealed transfers and eating had not occurred during the evaluation time period. Review of Resident #21's plan of care dated 07/28/22 revealed he had an alteration in respiratory status due to chronic obstructive pulmonary disease and was dependent on the ventilator. Review of Resident #21's immunization record revealed Resident #21 received her Prevnar-13 on 06/30/17. Interview on 09/22/22 at 9:22 A.M. with the Director of Nursing confirmed the resident had not been offered her second pneumococcal vaccine. Interview on 09/22/22 at 1:11 P.M. with the Director of Nursing confirmed Resident #9 and #21 should have been offered a second pneumococcal vaccine. Review of the facility policy titled, Pneumococcal Vaccinations, dated 02/2022 revealed adults older than sixty-five years old or those with underlying medical conditions should receive one dose of 365626 Page 7 of 8 365626 09/26/2022 Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305

F 0883 pneumococcal vaccine followed by a second dose of pneumococcal vaccine greater than or one year later. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365626 Page 8 of 8