Inspection·August 16, 2023

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 observations, resident and staff interviews, and record review, facility failed to ensure physician ordered nutritional supplements were provided as ordered. This affected one (Resident #46) of three reviewed for nutritional supplements. The facility census was 71. Residents Affected - Few Findings include Review of the medical record for Resident #46 revealed an admission date of 01/21/19. Diagnoses included heart failure, depression, acute embolism, anemia, anxiety and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively impaired and required limited assistance with eating. Review of Resident #46's physician orders for July 2023 revealed an order dated 06/20/23 for house supplement, 120 milliliters (ml) to be given three times daily. Additionally, there was an active order for a health shake, three times daily with meals. Review of the plan of care dated 06/16/23 revealed Resident #46 was at risk for weight loss and malnutrition with interventions in place to provide the resident's diet as ordered, administer medications as ordered, and monitor weights. The care plan included use of the house supplement, but did not include the health shake. Review of the Medication Administration Record (MAR) for August 2023 revealed Resident #46 received the house supplement (med pass) and healthy shake on 08/15/23. Both were signed as administered by LPN #185. Review of Resident #46's meal ticket revealed the ticket did not include any nutritional supplements under the preferences section. Interview on 08/15/23 at 12:30 P.M. with Licensed Practical Nurse (LPN) #180 revealed State Tested Nurse Aides (STNAs) were responsible for ensuring supplements were put on residents trays during meals. LPN #180 reported supplements were located in the nutrition and snack rooms on each unit. Interview on 08/15/23 at 12:35 P.M. with LPN #185 revealed nurses provide the med pass supplement only and the aides or dietary staff were supposed to provide the other supplements. Observation on 08/15/23 at 12:36 P.M. revealed supplements available for use. (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: 366400 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 366400 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beavercreek Health and Rehab 3854 Park Overlooke Drive Beavercreek, OH 45431 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)