Health inspection·February 20, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interviews, and policy review, the facility failed to adequately monitor weights and implement appropriate interventions in a timely manner. This affected one Resident (#64) of the three resident reviewed for significant weight changes. The facility census was 60. Residents Affected - Few Findings include: Review of the closed medical record for Resident #64 revealed an admission date of 06/06/24 with a discharge date of 01/15/25. Diagnoses included epilepsy, major depressive disorder, anxiety disorder, and cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #64 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require setup with eating, dependent with toileting, substantial assistance with bathing and dressing, and partial assistance with transfers. Review of the care plan dated 01/14/25, revealed Resident #64 had increased nutrition/hydration risk related to seizures, cerebral infarction, and weight gain for three months. Interventions included monitor laboratory (lab) values per order, review preferences per routine and as needed (PRN), respect dietary choices, monitor weight per protocol, and monitor dietary intake. Review of the weight records for Resident #64 revealed the following dates and weights: a) On 06/07/24 a weight of 193.4 pounds (lbs.) was recorded. b) on 07/09/24 the resident was 193 lbs. c) On 08/06/24 the resident was 215.8 lbs. d) On 09/04/24 the resident was 242.4 lbs. e) On 10/21/24 the resident was 265.8 lbs. f) On 11/04/24 the resident was 267.4 lbs. g) On 12/2024, there was no weight recorded h) On 01/01/25 the resident was 283.6 lbs. Page 1 of 3 366157 366157 02/20/2025 Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 09/11/24 at 5:09 P.M., revealed Resident #64 had a significant weight gain of 12.3 percent (%), which was 26.6 lbs. in one month, and 25.3 %, which was 49 lbs. in three months. Registered Dietician (RD) #50 requested a re-weight to ensure accuracy of the weight gain. Resident #64 consumed 76-100 % of meals and supplements. RD #50 discontinued ProStat (dietary supplement) due to no longer needed as wound had healed. Residents Affected - Few Interview on 02/19/25 with RD #50 revealed on 09/11/24 she requested a re-weight on Resident #64. RD #50 verified she did not follow up the following week to ensure a re-weight was completed. RD #50 verified Resident #64 was not weighed again until 10/21/24, where she had a 23.4 lbs. increase. RD #50 stated she discontinued Resident #64's ProStat as it was no longer needed. RD #50 reported she had not requested weekly weights on Resident #64 to monitor weight gain more frequently. RD #50 revealed she spoke with Resident #64 regarding weight gain but could not provide documentation of the encounter. Review of the facility policy titled, Resident Weight Policy, dared 12/12/23 revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk was identified, or as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00161977. 366157 Page 2 of 3 366157 02/20/2025 Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and staff interviews, the facility failed to ensure medications were available and administered per physician orders. This affected one Resident (#65) of the three residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #65 revealed an admission date of 01/06/25 with a discharge date of 01/20/25. Diagnoses included congestive heart failure (CHF), cerebral infarction, and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require setup with eating, dependent with toileting and transfers, and substantial assistance with bathing and dressing. Review of the physician order dated 01/13/25, revealed Resident #65 was ordered Anbesol liquid (pain relief) 10 percent (%) to rinse mouth and spit out for thrush twice a day. Review of the medication administration record (MAR) dated January 2025, revealed Resident #65 did not receive Anbesol 10 % mouth wash from 01/13/25 through 01/20/25 due to unavailability. Interview on 02/19/25 at 11:14 A.M. with Pharmacy Representative #70, revealed the facility was responsible for obtaining the medication because it was considered an over the counter (OTC) prescription. Interview on 02/19/25 at 11:23 A.M. with Pharmacy Representative #71, revealed the facility was notified on 01/13/25 that Anbesol was on backorder and a substitution Nystatin could be ordered in replace of, which was reported to Licensed Practical Nurse (LPN) #22. Interview on 02/19/25 at 11:26 A.M. with Director of Nursing (DON), verified Resident #65 did not receive Anbesol mouth wash from 01/13/25 through 01/20/25. Interview on 02/19/25 at 11:40 A.M. with Nurse Practitioner (NP) #60, revealed she was never informed of Resident #65 medication's being on backorder. This deficiency represents non-compliance investigated under Complaint Number OH00162025. 366157 Page 3 of 3