Health inspection·July 9, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff interviews and policy review, the facility failed to ensure staff smoked only in designated areas of the facility in accordance with the facilities smoking policy. This affected one (Resident #58) of three reviewed for oxygen usage. The facility census was 62. Findings include: Review of the medical record for Resident #58 revealed an admission date of 09/22/23 with diagnoses of traumatic subarachnoid hemorrhage, anoxic brain damage, metabolic encephalopathy and tracheostomy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had severe cognitive impairment and had range of motion impairment of bilateral upper and lower extremities. Resident #58 was non-communicative and dependent on staff for all Activities of Daily Living (ADLs). Review of the physician orders for July 2024 revealed Resident #58 had a tracheostomy with continuous oxygen and received nutrition through an enteral feeding tube. Observation of the video with date and time that was blurred and unable to be visualized provided by the family through a camera located in the room of Resident #58 revealed Registered Nurse (RN) #222 visibly lighting an unidentified smoking paraphernalia on two occasions in the room of Resident #58. Observation of Resident #58 on 07/09/24 throughout the survey in her room revealed continuous oxygen was in use and administered through a tracheostomy. Further observations of Resident #58's room door on 07/09/24 revealed signage in place stating, Oxygen in use / No-Smoking Permitted. Interview on 07/09/24 at 3:10 P.M. The Administrator and [NAME] President of Clinical Operations (VPCO) #333 confirmed smoking is not permitted inside any part of the facility and in any area where oxygen is being used or stored. The Administrator and VPCO #333 confirmed RN #222 was observed on video camera smoking in Resident #58's room on 06/25/24. The Administrator and VPCO #333 confirmed the facility became aware of RN #222 smoking in Resident #58's room on 06/25/24 and the police were called and RN #222 was immediately removed from duty. The Administrator and VPCO #333 stated they were unable to determine what RN #222 was smoking in Resident #58's room. (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: 366288 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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)