Health inspection·August 29, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility staff interview, and policy review the facility failed to timely repositioning and turn one resident (#36) of three reviewed for pressure ulcers. The facility census was 42. Residents Affected - Few Findings Included: Review of medical record for Resident #36 revealed a re-admission date of 08/11/24, and an initial admission date of 06/17/24. Diagnoses included anoxic brain damage, stage four pressure ulcer of left elbow and sacrum which were documeted to be present on admission to the facility. Review of plan of care dated 06/18/24 revealed that Resident #36 had actual stage four pressure ulcer to the left elbow. Interventions included turning and repositioning schedule per assessment, turn side to side in bed every one to two hours, and treatments as ordered. Resident #36 also had a stage four pressure ulcer to right sacrum plan of care that included interventions of pillows for positioning, low air loss mattress, turning and repositioning and weekly wound assessment. Resident #36 was at risk for pressure ulcers due to impaired mobility. Interventions included weekly skin inspection, and repositioning schedule per assessment. Review of Braden Scale for predicting pressure ulcer risk dated 08/11/24 revealed Resident #36 was at high-risk to develop pressure ulcer with a score of 10.0. The Braden scale scoring criteria was severe risk scored 9 or less, high risk scored 10 through 12, moderate risk scored 13 through 14, mild risk scored 15 through 18, and no risk scored 19 through 23. Observation on 08/14/24 from 9:40 A.M. through 11:42 A.M. revealed Resident #36 was laying in bed on their left side. At 11:42 A.M. Registered Nurse #329 and State Tested Nursing Assistant (STNA) #405 were observed to provide Resident #36 incontinence care, wound care and repositioning. Interview on 08/14/24 at 10:50 A.M. with STNA #405 confirmed she was caring for Resident #36 and verified she had not turned or repositioned Resident #36 on the day shift on 08/14/24. STNA #406 stated she clocked in later due to being called in to work. Interview on 08/14/24 at 1:43 P.M. with STNA #284 who stated Resident #36 was on her assignment and verified she worked the day shift but left the facility around 8:30 A.M. due to not feeling well. STNA #284 verified she had not provided any care, repositioning or turning to Resident #36 on 08/14/24. Interview on 08/14/24 at 3:37 P.M. with STNA #369 who worked the overnight shift verified stated Resident #36 was changed and repositioned in bed at 5:00 A.M. on 08/14/24 to his left side. STNA #369 (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 3 Event ID: 365626 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 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 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)