A list of the most recent deficiencies for Beavercreek Health and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-28 | 2024-01-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-06 | 2023-11-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-16 | 2023-09-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-29 | 2023-07-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-07-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-09 | 2023-05-30 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-09 | 2023-05-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-17 | 2023-03-17 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-01 | 2023-03-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-01 | 2023-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-03-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-01 | 2023-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-01 | 2023-03-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-01 | 2023-03-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-02-01 | 2023-03-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-01 | 2023-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-01 | 2023-03-01 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-02-01 | 2023-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-01 | 2023-03-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-01 | 2023-03-01 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-24 | 2023-03-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-24 | 2023-03-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-24 | 2023-03-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-24 | 2023-03-01 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-02-01 | 2023-02-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-15 | 2022-11-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-15 | 2022-11-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-15 | 2022-11-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-15 | 2022-11-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-15 | 2022-11-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-20 | 2022-09-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-10 | 2022-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-10 | 2022-08-23 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-08-10 | 2022-08-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-17 | 2022-08-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-14 | 2022-03-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-14 | 2022-03-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-14 | 2022-03-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-08 | 2022-03-25 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-01-12 | 2022-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-12 | 2022-01-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-22 | 2021-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-22 | 2021-11-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-22 | 2021-11-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-20 | 2021-06-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-03 | 2020-01-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-03 | 2020-01-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-01-03 | 2020-01-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-03 | 2020-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-03 | 2020-01-24 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-03 | 2020-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-03 | 2020-01-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2020-01-03 | 2020-01-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-03 | 2020-01-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-03 | 2020-01-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-03 | 2020-01-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-12-31 | 2020-01-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-31 | 2020-01-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-12-11 | 2019-02-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-11 | 2019-02-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-11 | 2019-02-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-12-11 | 2019-02-08 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-12-11 | 2019-02-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-11 | 2019-02-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-11 | 2019-02-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-11 | 2019-02-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-12-11 | 2019-02-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-11 | 2019-02-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-11 | 2019-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-11 | 2019-02-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-12-11 | 2019-02-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-12-11 | 2019-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-11 | 2019-02-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-11 | 2019-02-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-11 | 2019-02-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-11 | 2019-02-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-11 | 2019-02-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-12-11 | 2019-02-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-11 | 2019-02-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-12-11 | 2019-02-01 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-12-11 | 2019-02-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-11 | 2019-02-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-12-11 | 2019-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-11 | 2019-02-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-12-11 | 2019-02-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-04 | 2019-02-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-12-04 | 2019-01-11 | N |
