Health inspection·August 2, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of manufacturer's recommendations, staff and representative interview, the facility failed to ensure the battery was changed on an external defibrillator vest as ordered. This affected one (#100) of one resident reviewed for external defibrillator care. The facility census was 61. Residents Affected - Few Findings included: Review of the closed medical record revealed Resident #100 was admitted to the facility on [DATE] and discharged on 07/12/23. Resident #100 diagnoses included hyperlipidemia, peripheral vascular disease, type II diabetes with circulatory complications, chronic systolic (congestive) heart failure, hypothyroidism, end stage renal disease, bariatric surgery status, chronic venous hypertension (idiopathic) with ulcer and inflammation of the left lower extremity, cardiac arrest, generalized anxiety disorder, major depressive disorder, moderate protein-calorie malnutrition, atherosclerotic heart disease of the native coronary artery, gastro-esophageal reflux disease, anemia in chronic kidney disease, dysphagia, metabolic encephalopathy, acquired arteriovenous fistula, presence of a heart assistive device, and ischemic cardiomyopathy. Review of Resident #100's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating she had moderate cognitive impairment. Resident #100 needed extensive assist of one staff for bed mobility, dressing, and personal hygiene. Resident #100 required extensive assist of two staff for transfer; did not walk; was totally dependent on one staff for locomotion, toilet use, and bathing; and was independent with setup help needed for eating. Review of the physician's orders revealed Resident #100 had an order dated 05/31/23 to change life vest battery every night shift. One battery was to be on charge at all times. Review of the Resident #100's Medication Administration Record (MAR) for June 2023 revealed the entry for changing the battery every night shift on 06/07/23 at 7:00 P.M., was coded 19 which meant other/see nurses notes. The note revealed she went out to the hospital for a fall on 06/07/23 at 7:12 P.M. Further review of the nursing notes revealed she returned on night shift at approximately 3:00 A.M. The record was silent regarding the battery being changed on that shift. Interview via telephone call was received from [NAME] Life Vest Representative #83, company technical support, on 08/02/23 at 3:21 P.M., revealed the information recorded by the company regarding Resident #100's battery level and when the battery was changed. [NAME] Life Vest Representative #83 stated the battery was changed on 06/06/23 at 8:23 P.M. (the battery read fully charged). The battery was not changed on 06/07/23 at 8:00 P.M., and showed the battery was completely depleted on 06/08/23 (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: 366157 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 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 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)