Inspection·August 22, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure residents comprehensive Minimum Data Set (MDS) assessments were completed timely. This affected four (#10, #16, #110, and #118) out of the four residents reviewed for comprehensive MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 05/15/23 with medical diagnoses of convulsions cerebral infarction, and psychotic disorder. Review of the medical record for Resident #10 revealed an admission MDS with assessment reference date (ARD) of 05/21/23 revealed the MDS had a completion date of 06/23/23. 2. Review of the medical record for Resident #16 revealed an admission date of 06/17/21 with medical diagnoses of atherosclerosis heart disease (ASHD), visual loss both eyes, and chronic kidney disease (CKD) stage III. Review of the medical record for Resident #16 revealed an annual MDS with ARD of 06/26/23 revealed the MDS had a completion date of 07/15/23. 3. Review of the medical record for Resident #110 revealed an admission date of 04/15/22 with medical diagnoses with chronic respiratory failure, cardiomyopathy, cerebral palsy, and paraplegia. Review of the medical record for Resident #110 revealed an annual MDS with ARD 05/08/23 revealed the MDS had a completion date of 06/11/23. 4. Review of the medical record for Resident #118 revealed an admission date of 05/11/23 with medical diagnoses of orthostatic hypotension, chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the medical record for Resident #118 revealed an admission MDS with ARD 05/18/23 revealed the MDS had a completion date of 07/04/23. Interview on 08/22/23 at 9:15 A.M. with MDS Nurse #67 stated the facility utilizes the RAI manual guidelines as the facility's policy for MDS assessments and completion dates. MDS Nurse #67 confirmed the admission MDS assessments for Resident's #10 and #118 and the annual MDS assessments for Residents #10 and #16 were not completed timely. (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: 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 08/22/2023 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)