Health inspection·June 18, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff and resident interviews, observations, review of a facility Self-Reported Incident (SRI), review of a video, and policy review, the facility failed to maintain an environment free from pests. This affected two (#60 and #19) of the three residents reviewed for the environment. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #60 revealed an admission date of 05/20/25 and discharged on 05/27/25. Diagnoses included chronic respiratory failure with hypoxia, tracheostomy (trach), nontraumatic intracerebral hemorrhage, and diabetes mellitus. Review of a physician order for Resident #60 dated 05/22/25, revealed the resident was ordered to have trach checks and observations completed four times per day and as needed. Review of the discharge Minimum Data Set (MDS) assessment for Resident #60 dated 05/27/25, revealed Resident #60 was dependent for all activities of daily living (ADLs). Review of the facility SRI, dated 05/29/25, revealed the facility completed staff and resident interviews and observations. Review of a statement by Certified Nursing Assistant (CNA) #209 stated when she went to help another aide care for Resident #60, there were ants crawling on the resident. Review of the statement by CNA #222 stated on 05/25/25, Resident #60 had ants on her bed and her body. CNA #222 stated Resident #60 was washed up and repositioned. CNA #222 stated a personal blanket was noted on her bed covered with ants which was bagged and set aside for the family to pick up. Further review of staff statements revealed a statement dated 05/28/25 by the Administrator which stated she watched a video provided by Resident #60's husband which showed two to four ants on Residents #60's tracheostomy but none in the throat area. Review of the SRI revealed after observations and staff and resident interviews, the facility did not substantiate the allegation of neglect due to lack of evidence. Interview on 06/17/25 at 9:50 A.M. with Respiratory Nurse #208 revealed on 05/25/25 around 2:00 A.M. she observed about five ants on Resident #60's upper arm and on her bed but not on the resident's trach. Respiratory Nurse #208 stated she immediately notified the nurse and aide who gave Resident #60 a bed bath and changed her linens. Respiratory Nurse #208 stated she did not know where the ants came from and had not seen the ants in Resident #60's room before when providing trach care. Interview on 06/18/25 at 9:03 A.M. with Administrator and Director of Nursing (DON) via phone, revealed the DON stated she was notified by Resident #60's husband that Resident #60 was found to have ants on and around her tracheostomy on the afternoon of 05/25/25. The DON stated she contacted the Page 1 of 2 366157 366157 06/18/2025 Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few housekeeping department to clean Resident #60's room, and she notified the Administrator. The Administrator and DON both confirmed they were not notified of the concerns about the ants found on Resident #60's by the facility staff when they were observed on 05/25/25 at 2:00 A.M. and were only notified of the concerns for ants by Resident #60's husband. The DON stated the facility staff provided personal care to Resident #60, changed her bed linens, and wiped down Resident #60's bed when the ants were observed on 05/25/25 at 2:00 A.M. The Administrator stated the facility received monthly pest control treatments and Resident #60's room was spot treated by the pest control company on 05/29/25. The Administrator stated she reviewed a video made by Resident #60's father which showed ants crawling around Resident #60's tracheostomy. The Administrator stated she completed an SRI after the hospital called on 05/29/25 related to neglect due to the ants found on Resident #60 per the family's video. Review of the medical record for Resident #19 revealed an admission date of 04/01/25. Diagnoses included atrial fibrillation and Parkinson's disease. Review of the admission MDS assessment for Resident #19 dated 04/08/25, revealed the resident had a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating the resident was cognitively intact. Interview on 06/16/25 at 11:25 A.M. with Resident #19, revealed there were gnats in her room at times. Observations of the facility on 06/16/25 and 06/17/25, revealed gnats to be flying around the facility and several noted on 300- Hall which is the ventilator unit. Interview on 06/17/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #201, revealed she sees a lot of gnats in the facility. Interview on 06/17/25 at 10:03 A.M. with Housekeeper #207, revealed she sees ants and gnats in the facility at times. Review of a video provided by the facility, which was not dated and time stamped, revealed Resident #60 lying in bed and two ants were noted to be crawling on Resident #60. One ant was observed to be crawling inside of Resident #60's trach mask and the other ant crawling on her trach ties. Review of the pest control company invoices, revealed documentation the facility received pest control treatments to the interior and exterior of the facility monthly and on 05/29/25. Review of the facility policy titled, Pest control, revised 08/12/18, stated if a pest situation was reported, the contractor would be notified and may be requested to make an unscheduled visit to address concerns. This deficiency represents non-compliance investigated under Complaint Number OH00166147. 366157 Page 2 of 2