Inspection·July 24, 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 NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of medical records, staff interview, and policy review, the facility failed to ensure a licensed nurse communicated a resident incident, that was later determined to be a fall, to the oncoming licensed nurse to allow for ongoing monitoring and/or potentially prevent further incidents or falls. This affected one (#2) of three residents reviewed for falls. The census was 62. Findings include: Review of Resident #2's medical record revealed an admission date of 10/02/23. Diagnoses listed included anxiety disorder, right femur fracture, atrial fibrillation, hypertension, and repeated falls. Review of a quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. Resident #2 had not had any reported falls. Review of progress notes dated 06/12/24 at 1:14 P. M revealed when nurse went into Resident #2's room to pass medications Resident #2 state, I fell sometime last night and my right leg has been hurting ever since. Resident #2 denied hitting head at this time. The nurse called the physician and obtained an order for X-ray (X-radiation) of right leg and ankle. Resident #2's family, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. Review of progress notes dated 06/12/24 at 6:08 P.M. revealed X-ray technician was performing X-ray on Resident #2 on 06/12/24 at 2:40 P.M. The physician was in the room observing X-ray and noticed a possible fracture and ordered a right hip X-ray for clarification. Results were positive for right hip fracture. Resident #2 was sent to a local hospital on [DATE] at 3:45 P.M. Review of a progress note dated 06/12/24 at 11:55 P.M. revealed Resident #2 was observed on the floor by the state tested nursing assistant (STNA) at about 6:00 A.M. The nurse was notified and upon arriving at the scene Resident #2 was in sitting position between a chair and her bed. Resident #2 insisted multiple times that she intentionally sat on the floor because she forgot her walker and did not want to fall. Resident #2 was assisted off the floor by the nurse and STNA. Resident #2 denied any pain throughout the nurse's presence in the room. Review hospital documents dated 06/12/24 through 06/18/24 revealed Resident #2 required surgery to repair a right hip fracture. (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: 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 07/24/2024 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)