AYDEN HEALTHCARE OF BELLE SPRINGS.
For profit - Corporation
99 Beds
AYDEN HEALTHCARE
Data: November 2025
Trust Grade
50/100
#410 of 913 in OH
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Ayden Healthcare of Belle Springs in Bellefontaine, Ohio holds a Trust Grade of C, which means it is average and sits in the middle of the pack among nursing homes. It ranks #410 out of 913 facilities in Ohio, placing it in the top half, but it is last in its county, ranking #4 out of 4 in Logan County. The facility is experiencing worsening conditions, with issues increasing from 4 in 2023 to 10 in 2025. Staffing is a concern here, rated at just 1 out of 5 stars, with a high turnover rate of 61%, significantly above the state average. Although there have been no fines, which is a positive aspect, the RN coverage is only average, which may not provide the best oversight for resident care. Specific incidents of concern include a serious issue where a resident’s pressure ulcer was not monitored properly, resulting in significant deterioration that required medical intervention. Additionally, there were multiple concerns regarding food safety in the kitchen, including undated food items, which could pose health risks for residents. While the facility has strengths in quality measures, the combination of staffing challenges and recent incidents suggests that families should carefully consider these factors when researching care options.
- Trust Score
- C
- In Ohio
- #410/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Top 44%
Needs review
4 → 10 violations
★★★☆☆
3.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 4 issues
2025: 10 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Ohio average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 61%
15pts above Ohio avg (46%)
Frequent staff changes - ask about care continuity
Chain: AYDEN HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Ohio average of 48%
The Ugly 23 deficiencies on record
1 actual harm
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide a home-like environment in regards...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide a home-like environment in regards to facility's shower rooms being in good repair. This affected two residents (#1 and #4) with the potential to affect all residents residing in the facility. The current census is 87.
Findings include:
1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 include infective bursitis right elbow, diabetes type two, neuromuscular dysfunction of bladder.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was an extensive assist with Activities of Daily Living (ADLs).
Review of Resident #1's care plans dated 05/2024 revealed a focus for ADL assistance. Interventions include mechanical lift for transfers, and staff assist with bathing.
Interview on 06/23/25 at 12:55 P.M. with Resident #1 revealed the resident stated his main complaint with his care involved use of the shower room on the hall. Resident #1 stated every time he is being transported back to his room after his shower the shower chair wheels get stuck in the holes in the floor of the bathrooms causing the aides to have to push and pull his chair. Resident #1 stated it is uncomfortable and not homelike, and it upsets him the condition of the flooring in the bathrooms in the facility. Resident #1 stated he knows all the bathrooms in the facility are missing tiles in the floors as other residents have complained about the flooring.
2. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #4 include hypertension, heart failure, and chronic kidney disease.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required staff assist with ADLs including bathing.
Review of Resident #4's care plans dated 05/2025 revealed a focus for ADL self-care deficit. Interventions include mechanical lift for transfers, staff to assist with ADLs, and sponge bath if residents declines a shower.
Interview on 06/23/25 at 3:34 P.M. with Resident #4 revealed the resident stated she is getting her showers in the main bathroom on the 300-hall per the schedule. Resident #4 stated she did not like the fact there was a hole in floor tiles and stated the aides do have to be more careful with her in the shower chair as the chair sometimes gets stuck in the hole in the floor. Resident #4 stated it was not home-like in the shower room.
Observation on 06/23/25 at 1:00 P.M. of the 400-hall central shower room revealed there was one stall with a shower and a shower chair in the bathroom. Observed on the floor around the drain were several missing tiles and a depressed area of the floor.
Interview on 06/23/25 at 1:02 P.M. with Certified Nurse Aide (CNA) #192 and CNA #202 verified there were missing tiles and a hole in the floor in the shower area of the bathroom. CNA #192 verified the tiles had been missing and the hole was in the floor for over a year since the aide began working at the facility. Both CNA #192 and CNA #202 verified all residents on the 400-hall are showered in the central bathroom and many residents complained about the hole in the floor due to the chair's wheels catching the hole. Both aides denied any residents falling out of the chair in the shower room.
Observation 06/23/25 at 1:05 P.M. of the 300-hall central shower room revealed in the shower stall there were several missing tiles from the floor near the drain area.
Interview on 06/23/25 at 1:05 P.M. with CNA #161 verified there were missing tiles in the shower stall, and it caused the shower chair's wheels to jerk. CNA #161 verified all residents on the 300-hall showered in the central shower room.
Observation 06/23/25 at 1:10 P.M. of the 200-hall central shower room revealed in the shower stall there were several missing tiles from the floor near the drain area.
Interview on 06/23/25 at 1:10 P.M. with CNA #101 verified there were missing tiles in the shower stall, and it caused the shower chair's wheels to jerk. CNA #101 verified all residents on the 200-hall showered in the central shower room.
Interview on 06/23/25 at 1:55 P.M. with the Administrator verified in each of the central shower rooms on each of the 4 halls there were missing tiles and holes in the floor. The Administrator verified all residents use the central shower rooms for their showers and bathing.
This deficiency represents non-compliance investigated udner Complaint Number OH00165407.
Mar 2025
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, family interview, staff interview and policy review, the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, family interview, staff interview and policy review, the facility failed to ensure a resident's room was maintain in good repair. This affected for one (#22) of two residents reviewed for physical environment. The facility census was 77.
Findings include:
Review of medical record for Resident #22 revealed an admission date of 01/31/22. The resident was admitted with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and epilepsy.
Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had severe cognitive impairment. Resident #22 required setup or clean up assistance for eating. Supervision or touching assistance was required for oral hygiene. Substantial/maximal assistance was required for toilet hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Resident #22 is dependent for putting on/taking off footwear.
Review of the care plan revealed Resident #22's dignity and autonomy will be maintained at the highest level with interventions including keeping the environment quiet and calm and keeping lighting low and familiar objects near.
Observation on 03/12/25 at 4:29 P.M., revealed when entering Resident #22's room, the wall is damaged, the wall next to window is damaged with a large hole next to it, and the restroom wall is damaged.
Interview on 03/12/25 at 4:31 P.M. with Certified Nurse Aide (CNA) #178 confirmed the walls are damaged. CNA #178 revealed the walls have been that way since she started working here one year ago.
Observation and interview on 03/12/25 at 5:42 P.M., with the Director of Nursing (DON) confirmed the walls are damaged. The DON stated the large, damaged spot on the wall by the window is from the footboard of the bed that used to be in this room. The DON thinks the bed was moved months ago.
Interview on 03/13/25 at 8:30 A.M., with the DON stated Resident #22's bed was moved on 02/27/25.
Interview on 03/13/25 at 9:18 A.M., with Resident #22's daughter confirmed the walls are damaged. Resident #22's daughter stated Resident #22 would have wanted the walls fixed. Resident #22's daughter stated maintenance was notified but he said he had other projects to do first.
Observation on 03/13/25 at 10:25 A.M., with Maintenance Supervisor #163 confirmed the damage on the entrance wall measured 37 inches long by 5 inches wide, the hole in the wall by the window is 20 inches long by 10 inches wide, and the damaged wall in the bathroom is 37 inches long by 15 inches wide.
Review of the maintenance request log for the last 6 months revealed Resident #22's room is not listed on the log.
Review of the policy titled, Resident Environmental Quality, dated August 2023 stated, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to ensure care planned fall interventions were im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to ensure care planned fall interventions were implemented. This affected one (#4) of three residents reviewed for falls. The facility census was 77.
Findings include:
Review of medical record for Resident #4 revealed an admission date of 10/17/20, with diagnoses including morbid obesity with alveolar hypoventilation, type two diabetes, chronic kidney disease stage four, atrial fibrillation, sleep apnea, bipolar disorder, unsteadiness on feet, major depressive disorder, and anxiety.
Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Resident #4 required supervision or touching assistance for oral hygiene, toileting, and bathing. Partial/moderate assistance for upper and lower body dressing and personal hygiene. Supervision or touching assistance for bed mobility and transfers.
Review of care plan dated 02/17/25 revealed Resident #4 was at risk for accidental falls. Interventions included educate resident on wearing appropriate footwear, educate resident on sitting down when dressing, education on use of call light for assistance, encourage resident to utilize regular chairs while in the activity room instead of walker seat, encourage to wear proper fitting shoes in good repair, non-skid footwear at all times as tolerated, perimeter mattress, Reacher at bedside/recliner, remind to lock wheeled walker before attempting to sit on it, resident to use shower bench instead of shower chair during showers, keep bed in lowest position, provide rest periods, and low bed.
Observation on 03/13/25 at 10:54 A.M., of Resident #4's room revealed the resident was sitting in the recliner with proper fitting shoes. The wheeled walker was located across the room in front of the bookshelf. No Reacher was in view on the bedside table, bed, dresser, or walker. No perimeter mattress was on the bed.
Interview on 03/13/25 at 10:57 A.M., with Licensed Practical Nurse (LPN) #143 verified Resident #4 had a regular mattress with no perimeters. LPN #143 stated the resident does not sleep in the bed. LPN #143 stated the resident sleeps in her recliner. LPN #143 verified the resident's Reacher was not visible. LPN #143 asked Resident #4 where her Reacher was, and the resident shrugged her shoulders. Resident #4's roommate stated check under the mattress. LPN #143 checked under the mattress and located the Reacher.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to implement the policy on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to implement the policy on ensure oxygen tubing was changed weekly. This affected one (#36) of three residents reviewed for respiratory care. The facility census was 77.
Findings include:
Review of medical record for Resident #36 revealed an admission date of 02/04/24, with diagnoses including chronic atrial fibrillation, ischemic cardiomyopathy, type 2 diabetes, anxiety, vascular dementia, repeated falls, insomnia, pressure ulcer of left heel stage 4, acquired absence of right leg above knee, obstructive and reflux uropathy, fall on same level, acute respiratory failure with hypoxia.
Review of Annual Minimum Data Set assessment dated [DATE] revealed Resident #36 had severe cognitive impairment. Resident #36 received oxygen therapy.
Review of current physician orders for Resident #36 revealed oxygen via nasal cannula at a rate of 2 liters as needed for saturations below 90%.
Review of care plan dated 02/19/25 for Resident #36 revealed the resident at risk for cardiopulmonary disease/exacerbation related to atrial fibrillation, coronary artery disease, hypertension, and oxygen use. Interventions included monitor oxygen saturation, oxygen as ordered, and change tubing weekly.
Observation on 03/10/25 at 9:23 A.M., of oxygen concentrator revealed the oxygen tubing was dated 02/16/25.
Observation on 03/10/25 at 3:02 P.M., of oxygen concentrator revealed the oxygen tubing remained dated 02/16/25.
Interview on 03/10/25 at 3:15 P.M. with Certified Nursing Assistant (CNA) #190 verified the oxygen tubing was dated 02/16/25 for Resident #36.
Interview on 03/11/25 at 10:50 A.M., with Director of Nursing (DON) revealed oxygen tubing is to be changed weekly. DON stated the changing of the tubing should be on a physician order.
Review of policy titled, Oxygen Administration, revised April 2023, revealed care and cleaning of equipment shall be in accordance with facility policies for each such equipment. Oxygen tubing and mask/cannula will be changed weekly and as needed if it becomes soiled or contaminated. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, review of medication package insert, review of manufacturer recommendations, and policy review, the facility failed to ensure medications and solutions were date...
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Based on observation, staff interview, review of medication package insert, review of manufacturer recommendations, and policy review, the facility failed to ensure medications and solutions were dated when opened and stored under recommended conditions. This had the potential to affect all new admissions and residents who have their blood sugars checked using the glucometer. The facility identified 10 (#5, #6, #7, #19, #21, #29, #36, #55, #60, and #73) residents who had their blood sugars checked using the glucometer. The facility census was 77.
Findings include:
Observation on 03/10/25 at 8:30 A.M., of the medication cart on 200 hallway revealed one bottle of Aplisol injection (tuberculin solution) 5/0.1 milliliter (ml) not refrigerated or dated when opened. Also observed a box of assure prism control solution 4 milliliters (ml) times two vials (control solution for glucometer) open and not dated.
Interview on 03/10/25 at 8:31 A.M., with Licensed Practical Nurse (LPN) #147 revealed the nurse verified the Aplisol was not refrigerated or dated. LPN #147 verified the Aplisol should be refrigerated. LPN #147 verified the glucometer control solution was opened and not dated. LPN #147 stated the night shift runs the controls on all the glucometer's and the control solution is usually in the med room.
Review of the undated manufacturer recommendation for the glucometer control solution revealed do not use beyond three months (90 days) after opening the vial. Record the discard date (three months from the day the vial was opened) on the vial label.
Review of the medication package insert for APLISOL® (Tuberculin Purified Protein Derivative, Diluted [Stabilized Solution]), dated November 2013, revealed failure to store and handle Aplisol as recommended may result in a loss of potency and inaccurate test results. Storage: DO NOT FREEZE This product should be stored at 2°-8°C (36°-46°F) and protected from light. Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.
Review of the undated policy titled, Medication Storage, revealed medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with Ohio Department of Health regulations. Medications requiring refrigeration will be stored in a refrigerator that is maintained between two to eight degrees Celsius (36-46 degrees Fahrenheit).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observations, staff interview, and policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving residents on a pureed diet. The deficient practi...
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Based on observations, staff interview, and policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving residents on a pureed diet. The deficient practice had the potential to affect 10 (#6, #15, #32, #34, #41, #51, #53, #54, #63, and #184) of 10 residents on a prescribed pureed diet. The facility census was 77.
Findings include:
Interview on 03/12/25 at 10:34 A.M., with [NAME] #109 revealed the menu for lunch was pot roast, mashed potatoes, and Normandy vegetables. [NAME] #109 revealed she would be doing the purees. [NAME] #109 stated she is looking for a baby food consistency with her purees. [NAME] #109 stated a resident doesn't have to chew a puree. [NAME] #109 stated a puree food is completed when there are no chunks and no pieces of food. [NAME] #109 revealed she does not taste the purees. [NAME] #109 confirmed they have ten residents who required a puree lunch.
Observation on 03/12/25 at 10:38 A.M., revealed [NAME] #109 started making the pot roast puree. On 03/12/25 at 10:41 A.M., [NAME] #109 stated the pot roast puree was done and ready to serve. Observation of the puree pot roast revealed it looked chunky.
Observation on 03/12/25 at 10:43 A.M., revealed the puree pot roast looked chunky and not smooth. The puree pot roast was tasted and it was found to be very chunky and had to be chewed.
Interview on 03/12/25 at 10:44 A.M., with Dietary Supervisor (DS) #122 and [NAME] #109 confirmed the puree was chunky.
Observation on 03/12/25 at 10:52 A.M., revealed [NAME] #109 started to puree the pot roast again. On 03/12/25 at 10:54 A.M., [NAME] #109 revealed the puree was done. The puree was tasted and was found to still have chunks of meat in it.
Interview on 03/12/25 at 10:54 A.M., with DS #122 confirmed the puree was still chunky.
Observation on 03/12/25 at 10:54 A.M., revealed [NAME] #109 started to puree the pot roast again. On 03/12/25 at 10:56 A.M., [NAME] #109 revealed the puree was finished. The puree was tasted and it was now smooth.
Review of the policy titled, Level One Puree Diet, dated 12/06/20 stated Individuals with severe chewing and/or swallowing problems may be prescribed a puree diet. All foods will be pureed to a moist mashed potato or smooth pudding like consistency that eliminates the need for chewing. Pureed foods are generally cohesive. Food is pureed in a food processor to achieve a consistent smooth and easy to swallow product.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, review of cleaning schedules, staff interviews, and policy reviews, the facility failed to ensure food products were dated when opened, kitchen sanitation was being maintained, ...
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Based on observations, review of cleaning schedules, staff interviews, and policy reviews, the facility failed to ensure food products were dated when opened, kitchen sanitation was being maintained, and the proper sanitizer test strips were used with the dish machine. This had the potential to affect all 77 residents who received food from the kitchen. The facility census was 77.
Findings include:
1. Observation on 03/10/25 at 8:00 A.M., of the kitchen revealed one bag of breadsticks open and undated in the walk-in freezer, one bag of shredded lettuce open and undated, one container of what appears to be crushed pineapple not labeled or dated, one bag of pepperoni open not dated, and two stacks of sliced cheese wrapped in saran wrap not dated observed in the walk-in refrigerator.
Interview on 03/10/25 8:15 A.M., with Dietary Supervisor (DS) #122 verified the open bag of breadsticks in the walk-in freezer was not dated. Also verified the undated and labeled items in the walk-in refrigerator.
Observation on 03/12/25 at 11:53 A.M., in the walk in cooler revealed three bottles of holiday nog dated 02/03/25. A large bag of orange shredded cheese was dated 03/02.
Interview on 03/12/25 at 11:59 A.M., with DS #122 confirmed the expiration date was 02/03/25 and the bottles of holiday nog should be thrown out. DS #122 revealed they keep food seven to ten days after opening and she learned that from her food safety class.
Review of the policy titled, General HACCP Guidelines for Food Safety, dated 2021, revealed the dietary staff will label and date foods.
Review of the policy titled, General Food Preparation and Handling, dated 2021, stated Use leftovers within 7 days per Food Code or discard. Check state regulations for more detail.
2. Observation on 03/12/25 at 11:39 A.M., revealed the kitchen utensil drawer had random debris inside the drawer with the kitchen utensils were sitting on.
Review of the kitchen cleaning schedule revealed the prep area is cleaned and sanitized twice a day.
Interview on 03/12/25 at 11:40 A.M., with DS #122 confirmed the drawer is dirty and it needed cleaned.
Review of the policy titled, General Sanitation of Kitchen, dated 2021 stated Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.
3. Interview on 03/12/25 at 11:48 A.M., with DS #122 revealed the dish machine is a low temperature chemical machine. DS #122 revealed it uses chlorine sanitizer and they ensure it reaches the proper chemical concentration by using test strips.
Observation on 03/12/25 at 11:48 A.M., with DS #122 revealed the facility is using quaternary ammonia (quat) test strips. DS #122 tested the dish machine with the quat test strips and confirmed there was no color change.
Interview on 03/12/25 at 11:48 A.M., with DS #122 revealed she was not aware the test strips she was using were quat. DS #122 revealed their chemical company are changing everything out. DS #112 confirmed they were using quat test strips to check the chlorine sanitizer dish machine.
Interview on 03/12/25 at 11:51 A.M., with DS #112 revealed she was asking if another kind of test strips were the correct test strips.
Observation on 03/12/25 at 11:51 A.M., with DS #112 revealed the next test strips she brought were quat test strips as well.
Interview on 03/12/25 at 12:36 P.M., with DS #112 revealed the dishwasher sanitizer is tested on ce every two weeks. DS #112 also revealed she is using quat test strips but probably shouldn't be using them.
Interview on 03/13/25 at 1:32 P.M., with the Administrator revealed the facility currently does not have the correct test strips for the dishwasher machine.
Review on 03/13/25 at 1:50 P.M., of the test strip log brought in by the Administrator revealed there are only two test strips on the sheet dated 07/05/24, 07/12/24, 07/22/24 and 08/30/24.
Interview on 03/13/25 at 1:50 P.M., with the Administrator revealed those are the only two strips they have on their log.
Interview on 03/13/25 at 2:49 P.M., with DS #122 confirmed there are only two strips on their test strip log and the test strips are quat test strips.
Review of the policy titled, Cleaning Dishes/Dish Machine, dated 2021 ,stated The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy also stated . Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift.
Review of the Sanitation of Dishes/Dish Machine policy dated 2021, revealed the low temperature dishwasher has wash temperature of 120°F and a sanitation of 50 PPM hypochlorite.
4. Observation on 03/12/25 at 11:01 A.M., revealed Dietary Aide (DA) #113 was in the kitchen at a long stainless steel table rolling silverware. DA #113 was not wearing a hairnet.
Interview on 03/12/25 at 11:03 A.M., with Dietary Aide #113 revealed he only wears a hairnet if he is in a food area.
Observation on 03/12/25 at 11:04 A.M, revealed DS #122 told Dietary Aide #113 that if he is wrapping silverware he has to wear a hairnet. Dietary Aide #113 put on a hairnet.
Interview on 03/12/25 at 12:36 P.M., with DS #122 revealed the hairnet policy is everyone has to wear one. If you come into the kitchen you put a hairnet on.
Review of the policy titled, Employee Sanitary Practices, dated 2021, stated All employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Note: This does not apply to employees who have a totally shaved or bald head; nor does it apply to employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food, clean equipment, utensils, and linens; and unwrapped single service and single-use articles.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interview, observation, and review of policies, the facility failed to ensure staff fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interview, observation, and review of policies, the facility failed to ensure staff follow enhance barrier precautions (EBP). This affected one (#31) of four residents reviewed for transmission based precautions. The facility failed to ensure clean laundry was not exposed to dirty surfaces and items. This had the potential to affect all residents of the facility. The facility also failed to prepare medications in a sanitary manner. This affected one (#22) of six residents reviewed for medication administration. The facility census was 77.
Findings include:
1. Review of Resident #31's medical record revealed an admission date of 10/04/22. Diagnoses listed included cerebral infarction, hypertensive heart disease, aphasia, dysphagia, hyperlipidemia, hemiplegia, and hemiparesis.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severe cognitive impairment and an indwelling urinary catheter.
Review of a care plan revealed Resident #31 was on EBP due to having an urinary catheter. Staff will use gown and gloves when providing high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use/maintenance, and chronic wound care.
Observation on 03/12/25 at 9:18 A.M., of Resident #31's suprapubic urinary catheter flushing revealed Licensed Practical Nurse (LPN) #204 was not wearing a gown. LPN #204 downed gloves, entered Resident #31's room, pulled back Resident #31's bed covering and flushed Resident #31's suprapubic catheter. LPN #204 held the catheter tubing in her gloved hands, separated the tubing , and then flushed the catheter.
Interview on 03/12/25 at 9:24 A.M., with LPN #240 confirmed Resident #31 was in EBP and she should have worn a gown while flushing his suprapubic catheter.
Review of the policy titled,Enhance Barrier Precautions (EBP), dated 04/01/24 revealed EBP are indicated for residents with an indwelling medical device. Devices listed include central line, peripheral inserted central catheter (PICC line), midline, urinary catheter, suprapubic catheters, central vascular lines, hemodialysis catheters, feeding tubes, tracheostomy, nephrostomy, chest tube, drain tubes, and ventilator if if the resident is not know to be infected or colonized with an multi-drug resistant organism (MDRO).
2. Observation on 03/12/25 at 12:22 P.M., of House Keeping Aide #137 pushing a cart in the hallway, with clean resident clothing hanging on hangers and folded in the bin not covered. Interview, at the time of the observation, with House Keeping Aide #137, verified the clean clothing was not covered.
Interview and observation on 03/13/25 at 10:16 A.M. to 10: 35 A.M., with the Assistant Director of Laundry and Environmental Services #131 confirmed there are two designated laundry areas, one is a clean laundry room, and one is the dirty room. No clean laundry should be around any dirty laundry . Observation of the clean room area revealed several shelves of clean laundry neatly folded and hanging on racks not covered. One shelf along the wall revealed the folded laundry and a designated area for employee personal belongings. There were two coffee cups with lids sitting on the shelves of clean laundry items. The door in the clean laundry room leading to the washers/dryers revealed two coats belonging to staff hanging on the back of the doors. Observation of the clean area housing the two dryers revealed a large trash bin with no lid containing discarded dirty disposable laundry bags verified by the Assistant Director of Laundry and Environmental Services #131.
Review of the policy titled,Laundry and Bedding, Soiled Policy, October 2018 revealed clean linen are protected from dust and soiling during transport and storage to ensure cleanliness. Clean linens are stored separately, away from soiled linens, at all times.
3. Observation on 03/10/25 at 8:50 A.M., of Licensed Practical Nurse (LPN) #153 revealed the nurse was preparing medications for Resident #22. LPN #153 was observed popping a pill out of the package from the narcotic drawer into her bare hands and placing the pill onto the top of the medication cart. Observation of the top of the medication cart revealed 5 loose pills on top of the cart and a medication cup with six pills. LPN #153 was observed picking up the 5 loose pills and putting them into a medication cup with her bare hands.
Interview on 03/10/25 at 8:51 A.M., with LPN #153 verified she picked up the pills with her bare hands from the top of the medication cart and placed them in the medication cup. LPN #153 stated she normally pops the medications from the narcotic drawer into her hand and would place them on the medication cart prior to putting them into a medication cup. LPN #153 stated she should not do that and should place the medications in a medication cup without touching them.
Review of policy titled, Administering Medications, revised April 2019, revealed staff follows established facility infection control procedures including handwashing, antiseptic technique, gloves, isolation precautions for the administration of medications as applicable.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, and policy review, the facility failed to maintain the kitchen microwave in a safe operating condition. This deficient practice had the potential to affect all 7...
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Based on observation, staff interview, and policy review, the facility failed to maintain the kitchen microwave in a safe operating condition. This deficient practice had the potential to affect all 77 residents who received meals from the kitchen. The facility census was 77.
Findings include:
Observation on 03/12/25 at 11:41 A.M., revealed the interior ceiling of the microwave had a large black/rusty color in the middle.
Interview on 03/12/25 at 11:42 A.M., with Dietary Supervisor #122 revealed the microwave is used to warm up food such as waffles and pancakes. Dietary Supervisor #122 confirmed there is rust in the microwave.
Review of the policy titled, Equipment Safety,dated 2021, stated Safety precautions will be followed when using electrical equipment. The policy also stated All equipment should be cleaned properly, following the instructions in the equipment manual.
Review of the policy titled, Resident Environmental Quality, dated August 2023, stated The facility shall maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The policy also stated All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue.
MINOR
(C)
Minor Issue - procedural, no safety impact
Employment Screening
(Tag F0606)
Minor procedural issue · This affected most or all residents
Based on employee file review, staff interview, and policy review, the facility failed to implement the policy to ensure employees were checked against the Ohio Nurse Aide Registry. This affected five...
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Based on employee file review, staff interview, and policy review, the facility failed to implement the policy to ensure employees were checked against the Ohio Nurse Aide Registry. This affected five (Certified Nursing Assistant (CNA) #178, CNA #175, Licensed Practical Nurse (LPN) #162, Registered Nurse (RN) #171, and Activities Assistant (AA) #101 of six employee files reviewed. This had the potential to affect all residents who reside in the facility. The facility census was 77.
Findings include:
Review of employee file for CNA #178 revealed no evidence of the employee being checked against the Nurse Aide Registry. CNA #178 was originally hired as a hospitality aide on 10/03/23. CNA #178 attended the CNA classes and passed the CNA testing on 04/20/24 which is when the employee was checked against the nurse aide registry.
Review of employee file for CNA #175 revealed no evidence of the employee being checked against the Nurse Aide Registry. CNA #175 was hired on 12/22/24 as a CNA. CNA #175 attended the CNA classes on 11/26/24 and completed the course on 12/20/24.
Review of employee file for LPN #162 with hire date of 02/14/25 revealed no evidence of the employee being checked against the Nurse Aide Registry.
Review of employee file for RN #171 with hire date of 03/14/22 revealed no evidence of the employee being checked against the Nurse Aide Registry.
Review of employee file for AA #101 with hire date of 07/15/24 revealed no evidence of the employee being checked against the Nurse Aide Registry.
Interview on 03/13/25 at 2:45 P.M., with Human Resources Director (HRD #140) revealed the HRD did not run all employees against the Ohio Nurse Aide Registry. HRD #140 stated they run the employees against the abuse registry. HRD #140 verified the above employees were not ran against the nurse aide registry at the time of employment. The affected staff was checked during the survey for the nurse aide registry and no violations were found.
Review of policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated on October 2024, revealed the facility will do the following prior to hiring a new employee: check the Ohio Nurse Aide Registry (and attempt to check other state registries if the individual is known to have worked in another state) for all potential new employees (licensed and unlicensed) and new volunteers to determine if there is a finding of abuse, neglect, or misappropriation of property against the individual prior to the use of that individual.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, policy review, and review of the Centers for Disease Control (CDC...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, policy review, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to conduct Coronavirus Disease 2019 (COVID-19) testing as per facility policy and CDC guidelines. This affected one (#54) resident out of the five residents reviewed for infection control. The facility census was 78.
Findings include:
1. Review of the medical record for Resident #54 revealed an admission date of 08/12/23 with medical diagnoses of Parkinson's disease, hypertensive heart disease, and chronic kidney disease Stage III.
Review of the medical record for Resident #54 revealed an admission minimum data set (MDS) assessment, dated 08/19/23, which indicated Resident #54 had moderate cognitive impairment and required extensive staff assistance for bed mobility, transfers, dressing and toileting. Further review of the medical record revealed documentation to support Resident #54 was up to date on COVID-19 vaccinations.
Review of the medical record for Resident #54 revealed Resident #54 shared a room with Resident #168, who his/her spouse. The medical record did not contain documentation to support Resident #54 had COVID-19 testing completed since admission to the facility.
Interview on 10/04/23 at 11:10 A.M. with Resident #54 confirmed Resident #168 was his/her spouse and the two residents shared a room. Resident #54 confirmed Resident #168 was transferred to the hospital where he/she tested positive for COVID-19. Resident #54 also confirmed he/she had not been tested for COVID-19 since admission to the facility. Resident #54 confirmed he/she had close contact with Resident #168.
2. Review of the medical record for Resident #168 revealed an admission date of 07/28/23 with medical diagnoses of pneumonia, congestive heart failure, hypertensive heart disease, and atrial fibrillation. Further review of the medical record revealed Resident #168 discharged to the hospital on [DATE] and that Resident #168 shared a room with his/her spouse (Resident #54).
Review of the medical record for Resident #168 revealed an admission MDS, dated [DATE], which indicated Resident #168 was cognitively intact and required extensive staff assistance with bed mobility, toileting, dressing and was dependent for transfers.
Review of the medical record for Resident #168 revealed a nurses note, dated 09/29/23 at 7:09 A.M., which stated resident complained of shortness of breath and oxygen saturation was 68% on high flow oxygen. The note stated the physician was notified and Resident #168 was sent to the hospital. Further review revealed a nurse's note, dated 09/29/23 at 10:58 A.M. which stated Resident #168's son came to the facility and informed the nurse Resident #168 was transferred to a different hospital and he/she had tested positive for COVID-19.
Interview on 10/04/23 at 2:15 P.M. with Director of Nursing (DON) stated the facility follows CDC guidelines for staff and resident testing for COVID-19. DON confirmed Resident #54 and Resident #168 were in the same room at the time Resident #168 was discharged to the hospital on [DATE]. DON also confirmed Resident #168 tested positive for COVID-19 at the hospital. DON confirmed Resident #54 had not been tested for COVID-19 since admission to the facility. DON confirmed Resident #54 had close contact with Resident #168.
Review of facility policy titled COVID-19, revised May 2023, stated staff and resident testing would be conducted following nationally accepted standards, such as CDC guidelines.
Review of the CDC website revealed the CDC guidelines stated asymptomatic patients with close contact with someone with SARS-CoV-2 (also known as COVID-19) infection should have a series of three viral tests for COVID infection. Close contact is being within six feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection. The testing is recommended immediately (but no earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This would typically be on day one (where day of exposure is zero), day three, and day five.
This deficiency represents non-compliance investigated under Complaint Number OH00146953.
May 2023
1 deficiency
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0837
(Tag F0837)
Minor procedural issue · This affected most or all residents
Based on record review and interview, the facility failed to ensure the Administrator's license was active. This has the potential to affect all residents residing in the facility. Current census is 8...
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Based on record review and interview, the facility failed to ensure the Administrator's license was active. This has the potential to affect all residents residing in the facility. Current census is 83.
Findings include:
Review of the Administrator's employee file revealed the Administrator was placed in the position of Administrator on 08/03/21. The employee file revealed a letter from the Bureau of Executives of Long-Term Services and Supports, (BELTSS) dated 07/02/21 informing the Administrator her current license would be inactive as of 07/02/22 if renewal, including 20 hours of education, and renewal payment of the licensure fee was not completed prior to 07/01/22.
Review of the BELTSS website, https://beltss.age.ohio.gov/license, revealed the Administrator's license was inactive as of 07/01/22.
Review of a printed email from the Director of Nursing (DON) revealed the Administrator had paid the license renewal fee. The screen shot did list the Administrator's renewal status for 06/30/22 as late-missed deadline and there was no Licensed Nursing Home Administrator (LNHA) Continuing Education (CE) marked as satisfied. There was no date on the document identifying when it was sent or received.
Review of the Board of Executives of Long-Term Services and Supports website titled Continuing Educations Requirement revealed the license will marked as inactive if more than 10 CE's are completed online, but as long as you have more than 20 CE's completed submit the information with the renewal payment and the license will be renewed.
During interview on 05/04/23 at 8:31 A.M., BELTSS board member #1 stated as of 07/01/22 the Administrator's license was considered inactive due to the requirements of the renewal not being completed. The board member stated the BELTSS website was updated daily and at the time of the survey the Administrator's license was not active.
During interview on 05/04/23 at 2:20 P.M. with the Administrator via conference call, revealed the Administrator stated she contacted BELTSS office in 2021, and was informed due to the pandemic she would not have to complete the 20 hours of education and her license was to remain inactive, however it would not affect her working at the facility. The Administrator stated she no longer possessed the email notification from BELTSS stating she did not have to complete the education in person due to the pandemic and still retain her license. The Administrator stated she did, however, have evidence she paid the re-instatement fee for her license.
This deficiency represents non-compliance investigated under Complaint Number OH00142478.
Mar 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy, review of the Self-Reported Incident system, Power of Attorney (POA) and staff intervi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy, review of the Self-Reported Incident system, Power of Attorney (POA) and staff interviews, the facility failed to report an alleged incident of resident-to-resident abuse to the state agency. This affected one (#1) of four residents reviewed for potential abuse. The current census is 81.
Findings include:
Review of Resident #1's medical record revealed an admission date of 09/20/22, with diagnoses including encephalopathy, seizures, heart disease, vascular dementia, and falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, a fall risk, and was a two-person assist for Activities of Daily (ADL).
Review of Resident #1's care plans dated 12/05/22 revealed a focus for fall relating to inability to walk and weakness. Interventions include frequent checks, allow for rest periods, and monitor for changes.
Review of Resident #1's neurological checks dating from 02/16/23 to 02/18/23 revealed all systems the resident allowed the nurse to assess were documented as within normal limits. Multiple entries were documented as resident refused.
Review of Resident #1's progress notes revealed on 02/16/23 at 4:15 P.M., the nurse was notified Resident #1 had fallen in her wheelchair when another resident pushed her over. Bruising noted to the hand and a bump on the temporal area on left side of head. Neurological checks were within normal limits, per the note the Power of Attorney (POA), management, and physician were notified.
Interview on 03/20/23 at 11:35 A.M., revealed Licensed Practical Nurse (LPN) #100 was caring for Resident #1 on 02/16/23. LPN #100 stated she was called into the dining room to assess Resident #1 after she was on the floor from being tipped over in her wheelchair by another resident. LPN #100 stated she assessed the resident, started neurological checks which were normal. Notification to the POA and the physician of the resident was made and was given orders to monitor for any changes. LPN #100 stated she reported the incident to the DON. LPN #100 stated she did not see the incident but was told by the activity aide another resident pushed Resident #1 over in her wheelchair. LPN #100 stated she did not see any clear signs of injuries at the time of the incident.
Interview on 03/20/23 at 2:15 P.M., with Resident #1's POA revealed the facility did inform the POA of the incident which occurred on 02/16/23. Per the POA, the nurse stated Resident #1 was pushed over in her wheelchair by another resident during activities.
Interview on 03/20/23 at 3:15 P.M., with the Administrator revealed the facility did not investigate the incident on 02/16/23 with Resident #1 and Resident #2 as a fall or as a possible resident to resident abuse. The Administrator stated she could not determine if the incident between the residents was abuse or accidental. The Administrator stated she was unsure if Resident #2 was acting aggressive when he pushed over Resident #1's wheelchair. Per the Administrator a resident-to-resident interaction would need to be investigated to determine if abuse occurred. The Administrator verified the facility did not initiate a Self-Reported Incident (SRI) for the incident or report to the state agency.
Interview on 03/21/23 at 12:50 P.M., with Activity Aide (AA) #311 revealed the aide was in the activity room with Resident #1 and Resident #2 on 02/16/23. AA #311 stated she was assisting another resident when she heard the commotion. AA#311 stated she had her back to the residents and turned around when she heard the crash. Resident #1 was lying on the floor. AA #311 stated she immediately separated the residents, called for a nurse, and stayed with Resident #1 until the nurse came. AA #311 stated she reported the incident to the management as per policy.
Review of the Enhanced Information Dissemination & Collection (EIDC) system used to report Self-Reported Incident (SRI) reporting revealed there was no incident reported on 02/16/23 for the event occurring between Resident #1 and Resident #2.
Review of the undated policy titled, Resident-to Resident Abuse, revealed the facility will report all incidents, findings, and corrective measures to appropriate agencies, including State Agency.
This deficiency represent non-compliance in regards to the allegations reported in complaints OH00140578 and OH00140615.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy, review of the Self-Reported Incident system, Power of Attorney (POA) and staff intervi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy, review of the Self-Reported Incident system, Power of Attorney (POA) and staff interviews, the facility failed to thoroughly investigate an alleged incident of resident-to-resident abuse. This affected one (#1) of four residents reviewed for potential abuse. The current census is 81.
Findings include:
Review of Resident #1's medical record revealed an admission date of 09/20/22, with diagnoses including encephalopathy, seizures, heart disease, vascular dementia, and falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, a fall risk, and was a two-person assist for Activities of Daily (ADL).
Review of Resident #1's care plans dated 12/05/22 revealed a focus for fall relating to inability to walk and weakness. Interventions include frequent checks, allow for rest periods, and monitor for changes.
Review of Resident #1's neurological checks dating from 02/16/23 to 02/18/23 revealed all systems the resident allowed the nurse to assess were documented as within normal limits. Multiple entries were documented as resident refused.
Review of Resident #1's progress notes revealed on 02/16/23 at 4:15 P.M., the nurse was notified Resident #1 had fallen in her wheelchair when another resident pushed her over. Bruising noted to the hand and a bump on the temporal area on left side of head. Neurological checks were within normal limits, per the note the Power of Attorney (POA), management, and physician were notified.
Interview on 03/20/23 at 11:35 A.M., revealed Licensed Practical Nurse (LPN) #100 was caring for Resident #1 on 02/16/23. LPN #100 stated she was called into the dining room to assess Resident #1 after she was on the floor from being tipped over in her wheelchair by another resident. LPN #100 stated she assessed the resident, started neurological checks which were normal. Notification to the POA and the physician of the resident was made and was given orders to monitor for any changes. LPN #100 stated she reported the incident to the DON. LPN #100 stated she did not see the incident but was told by the activity aide another resident pushed Resident #1 over in her wheelchair. LPN #100 stated she did not see any clear signs of injuries at the time of the incident.
Interview on 03/20/23 at 2:15 P.M., with Resident #1's POA revealed the facility did inform the POA of the incident which occurred on 02/16/23. Per the POA, the nurse stated Resident #1 was pushed over in her wheelchair by another resident during activities.
Interview on 03/20/23 at 3:15 P.M., with the Administrator revealed the facility did not investigate the incident on 02/16/23 with Resident #1 and Resident #2 as a fall or as a possible resident to resident abuse. The Administrator stated she could not determine if the incident between the residents was abuse or accidental. The Administrator stated she was unsure if Resident #2 was acting aggressive when he pushed over Resident #1's wheelchair. Per the Administrator a resident-to-resident interaction would need to be investigated to determine if abuse occurred. The Administrator verified the facility did not initiate a Self-Reported Incident (SRI) for the incident or report the incident to the state agency.
Interview on 03/21/23 at 12:50 P.M., with Activity Aide (AA) #311 revealed the aide was in the activity room with Resident #1 and Resident #2 on 02/16/23. AA #311 stated she was assisting another resident when she heard the commotion. AA#311 stated she had her back to the residents and turned around when she heard the crash. Resident #1 was lying on the floor. AA #311 stated she immediately separated the residents, called for a nurse, and stayed with Resident #1 until the nurse came. AA #311 stated she reported the incident to the management as per policy.
Review of the Enhanced Information Dissemination & Collection (EIDC) system used to report Self-Reported Incident (SRI) reporting revealed there was no incident reported on 02/16/23 for the event occurring between Resident #1 and Resident #2.
Review of the undated policy titled, Resident-to Resident Abuse, revealed the facility will evaluate the circumstance/events leading up to the incident.
This deficiency represent non-compliance in regards to the allegations reported in complaints OH00140578 and OH00140615.
Nov 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on interviews, record review and policy review the facility failed to issue a bed hold letter to one resident ( #79) out of two residents reviewed for hospitalization. The census was 83.
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Based on interviews, record review and policy review the facility failed to issue a bed hold letter to one resident ( #79) out of two residents reviewed for hospitalization. The census was 83.
Review of medical record for Resident #79 revealed admission date of 08/30/22 with limited cognitive deficits. The resident was admitted with diagnoses cerebral vascular disease, calculus of kidney, hyperlipidemia, and heart failure.
On 09/22/22 Resident #79 was having outpatient testing for an upcoming surgery. At 5:15 P.M. Resident #79 representative notified the facility Resident #79 was being admitted directly into the hospital due to passing out during a magnetic resonance imaging (MRI) test earlier in the day.
Review of the billing information in Resident #79 medical record revealed a stop date for services due to discharge was on 09/22/22.
Review of Resident #79 nurses progress notes revealed no indication a bed hold notification was discussed or mailed to the resident or his representative.
Interview on 11/03/22 at 10:05 A.M. interview with Business Office Manager #408 confirmed Resident #79 or his representative did not receive a bed hold notification letter in person or by mail after being discharged from the facility.
Review of the Discharge Summary and Plan Policy(no date) revealed no information about a bed hold policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews , record reviews, and policy and procedure review, the facility failed to update one resident's elopement as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews , record reviews, and policy and procedure review, the facility failed to update one resident's elopement assessment quarterly. This had the potential to affect one Resident ( #09) out of one resident reviewed for elopement. The facility census was 83.
Findings include:
Review of medical record for Resident #09 revealed resident was admitted on [DATE] with diagnoses including but not limited to dementia with behavioral disturbance, repeated falls, muscle weakness, schizoaffective disorder, seizures, anxiety, schizophrenia, depression, suicidal ideation's, insomnia, auditory hallucinations, visual hallucinations, and wandering.
Review of Minimum Data Set (MDS) dated [DATE] revealed resident had moderately impaired cognition. Resident #09 had inattention and disorganized thinking that fluctuated. Resident #09 required extensive assist of one staff member for Activities of Daily Living (ADL's).
Review of Care Plan dated 08/01/22 revealed Resident #09 was at risk for elopement/wandering related to dementia, impaired cognition, and schizophrenia. Interventions included but not limited to administer medications as ordered, monitor and report changes in behavior, monitor side effects of medications, provide one on one visits as needed, provide diversional activities of interest as needed, redirection as needed, wander guard to be worn at all times check placement and function, and monitor skin under wander guard.
Review of Elopement Risk Assessments dated 10/27/21, 02/27/22, 06/27/22, and 10/27/22 revealed assessments were completed every four months.
Interview on 11/03/22 at 11:58 A.M. with Director of Nursing (DON) verified elopement risk assessments were completed every four months. DON verified that it was not completed quarterly. DON verified assessment should be done every three months for quarterly.
Review of policy titled Wandering and Elopements not dated revealed residents are assessed upon admission, quarterly, and with change of status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews the facility failed to update a Residents Comprehensive Care Plan . This had the potential to affect one Resident (#42) out of four residents reviewed for care p...
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Based on interviews and record reviews the facility failed to update a Residents Comprehensive Care Plan . This had the potential to affect one Resident (#42) out of four residents reviewed for care plan's. The facility census was 83.
Findings include:
Review of medical record for Resident #42 revealed admission date of 10/17/20 with moderate cognitive deficits. The resident was admitted with Type 2 diabetes mellitus , bipolar disorder, anemia, depression, anxiety, and chronic kidney disease.
Review of the dentist progress notes on 02/11/22 revealed patient received her dentures for the first time. She has no history of dentures in the past. Patient was having a hard time by herself seating the dentures on her gums for a complete seal. Patient would benefit from denture adhesive until she can completely seat them on her own.
Review of Resident #42 Minimum Data Set (10/17/22) did not indicate the resident was edentulous.
Review of Resident #42 Plan of Care last updated 10/17/22 revealed no indication resident had dentures.
On 11/01/22 at 9:25 A.M. observation and interview with Resident #42 revealed her to be tooth less and not wearing dentures. She requested to have her dentures.
On 11/03/22 at 9:50 A.M., the Director of Nursing confirmed Resident #42's plan of care was updated on 11/03/22 to include denture care and wear after surveyor intervention.
On 11/03/22 at 11:30 A.M., Resident #42 was observed eating lunch without her dentures. When asked where her dentures were , she stated I need my bottom teeth.
On 11/03/22 at 11:57 A.M., interview with State Tested Nursing Assistant (STNA) # 403 revealed she was aware Resident #42 has dentures. She confirmed Resident #42 was not wearing her dentures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and review of facility policy, the facility failed to provide documentation to suppor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and review of facility policy, the facility failed to provide documentation to support Foley catheter care was provided and Foley catheter outputs were monitored for Resident #30. This affected one (Resident #30) of one resident reviewed for urinary tract infection. The facility census was 83.
Findings include:
Review of the medical record for Resident #30 revealed admission date of 08/09/22. Diagnoses included sepsis, urinary tract infection, multiple myeloma, lymphedema, Klebsiella Pneumoniae, hypothyroidism, syncope and collapse, morbid obesity, atrial fibrillation (A Fib), sick sinus syndrome, intra-abdominal and pelvic swelling, mass and lump, and peripheral vascular disease.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had impaired cognition. The resident required extensive assistance of two plus persons for bed mobility, transfers, toilet use, and personal hygiene. The resident had in indwelling Foley catheter.
Review of the Care Plan dated 08/10/22 revealed the resident had urosepsis infection with goal infection will resolve without complications. Interventions include administer antibiotics as ordered, assess for pain per facility policy and medication as ordered, assess for signs of infection and report to physician: redness, swelling, increased pain, purulent drainage, elevated temperature, change in color of sections, cough, congestion, abnormal lung sound, diarrhea, vomiting, monitor for signs of urinary tract infection (UTI): foul smelling urine, cloudy urine, sediment, decreased output, and vital signs as ordered. Resident is at risk for alteration in elimination. Resident will be free of complications related to appliance use. Interventions included change Foley catheter as ordered and as needed, empty Foley catheter bag every shift and as needed, Foley catheter to straight drain, keep Foley bag below level of bladder, and intake and output, record results.
Review of physician orders dated 08/16/22 revealed Foley catheter output every shift, every day and night shift for monitoring.
Review of physician orders dated 08/22/22 revealed Foley catheter care routinely and as needed, every shift for Foley catheter care.
Review of the Treatment Administration Record (TAR) for August 2022 revealed documentation for Foley catheter care routinely and as needed, every shift for Foley catheter care, was silent from 08/09/22 to 08/22/22. Documentation post catheter care order dated 08/22/22 was silent on 08/25/22 for day and night. Documentation for Foley catheter output every shift, every day and night shift for monitoring, was silent on 08/17/22 day and night shift, 08/18/22, 08/19/22, 08/21/22, 08/22/22, and 08/23/22 day shift, 08/24/22 and 08/25/22 day and night shift. The Foley catheter was discontinued on 08/26/22.
Interview on 11/03/22 at 12:58 P.M. the Director of Nursing (DON) stated the resident was admitted with a Foley catheter related to severe lymphedema. She stated he had a compromised immune system because of chemotherapy treatments. She stated he had a cystoscopy last week related to chronic UTI and was followed by urology.
Interview on 11/03/22 at 1:30 P.M. the DON verified no documentation for Foley care and outputs. She stated State Tested Nurse Aid (STNA) may have documented in Point of Care (POC) and she would check nursing notes for additional documentation. She verified Foley care would be routine practice for any resident with an indwelling Foley catheter. At 3:00 P.M., the DON stated she was unable to locate additional documentation for Foley catheter care or catheter output.
Interview on 11/03/22 at 3:03 P.M. Resident #30 stated staff were emptying his Foley bag twice a day, but he could not be sure they provided catheter care every shift.
The facility had no current residents with indwelling Foley catheters.
Review of facility policy titled Catheter Care, Urinary, revised date September 2014, revealed the purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintain an accurate record of the resident's daily output, per facility policy and procedures. Empty collection bag at least every eight hours. Changing the indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. The following information should be recorded in the resident's medical record: the date and time the catheter care was given. The name of the individual(s) giving catheter care. All assessment data obtained when giving catheter care. Character of urine such as color, clarity, and odor. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and intervention taken.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure medications were stopped per prescription wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure medications were stopped per prescription which led to resident receiving prednisone for an extended period of time. This affected one (Resident #28) of five residents reviewed for unnecessary medications. Facility census was 83.
Findings include:
Review of medical record for Resident #28 revealed resident was admitted on [DATE] with diagnoses including but not limited to encephalopathy, sleep apnea, non-pressure chronic ulcer of left calf limited to breakdown of skin, occlusion and stenosis of unspecified carotid artery, anxiety, non-pressure chronic ulcer of left heel and midfoot, protein-calorie malnutrition, type two diabetes, hyperlipidemia, major depressive disorder, heart failure, chronic venous hypertension with ulcer of bilateral lower extremity, typical atrial flutter, hypertension, and rheumatoid arthritis.
Review of Minimum Data Set (MDS) dated [DATE] for Resident #28 revealed resident had moderately impaired cognition. Resident #28 required extensive assist of two for bed mobility, transfers, and toileting.
Review of Care Plan dated 09/26/22 for Resident #28 revealed resident exhibits non compliance related to refusal of preventative care, BiPap, wearing foam boots while in bed, medications, wound care, mask, blood sugar testing, incontinence care, and breakfast. Interventions include document educational attempts made with resident and family related to non compliance, educate resident, family or responsible party on negative outcomes related to non compliance, and notify physician of non compliance.
Review of discharge orders from hospital dated 03/15/22 for Resident #28 revealed prescription for Prednisone (steroid) 20 milligrams (mg) give 40 mg orally daily with breakfast. Dispense 10 tablets.
Review of Medical Practitioner Note for Resident #28 dated 03/20/22 revealed date of service 03/18/22 stated for chronic obstructive pulmonary disease (COPD) complete prednisone and albuterol.
Review of Medication Administration Record (MAR) dated March 2022 through June 2022 for Resident #28 revealed resident received Prednisone 20 mg- 2 tablets in the morning every day starting on 03/16/22 through 06/04/22.
Review of General Progress note dated 06/04/22 at 5:07 P.M. for Resident #28 revealed new order received from Nurse Practitioner to start titrating Prednisone. New order consisted of Prednisone 30 mg for one week then Prednisone 10 mg for one week then discontinue.
Review of MAR for June 2022 for Resident #28 revealed Prednisone 30 mg given 06/05/22 through 06/11/22. Prednisone 10 mg given 06/12/22 through 06/18/22 then discontinued.
Review of Medical Practitioner Note dated 06/06/22 for Resident #28 revealed tapering Prednisone, COPD controlled. Resident #28 followed wound clinic. Resident #28's legs remained bright red, non-tender, no drainage, and mild swelling compared to baseline. Consider drug reaction to doxycycline (antibiotic) or prolonged use of prednisone.
Interview on 11/03/22 at 9:38 A.M. with Director of Nursing (DON) verified Prednisone 40 mg was taken daily from 03/16/22 through 06/04/22 when NP titrated the dose for Resident #28. DON verified discharge order stated 10 tablets.
Review of policy titled Administering Medication revised April 2019 revealed medications are administered in accordance with prescribed orders, including any required time frame.
This deficiency substantiates complaint number OH00135112.
Oct 2019
4 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, observation, review of a facility policy, and review of information from the N...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, observation, review of a facility policy, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure monitoring of a pressure ulcer was completed to ensure appropriate care and treatment was provided to prevent deterioration of a pressure ulcer. This resulted in actual harm when Resident #39's pressure ulcer was not monitored on a weekly basis and resulted in the pressure ulcer to the coccyx developing to an unstageable deep tissue injury. Consequently, Resident #39's pressure ulcer to the coccyx required wound physician intervention including debridement of the area to remove necrotic tissue and the wound was assessed as a stage IV post debridement. This affected one (#39) of one resident reviewed for pressure ulcers. The facility identified two residents currently residing in the facility with pressure ulcers. The facility census was 60.
Findings include:
Review of Resident #39's medical record revealed an admission date of 05/06/19. Medical diagnoses included cerebral infarction, unspecified behavior syndrome, type two diabetes mellitus, hypertension, hypothyroidism, hyperlipidemia, obesity, and weakness.
Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impairment in cognition. She had physical behaviors to others one to three days. She experienced no rejection of care. She required extensive assistance with two plus staff for bed mobility, dressing, and hygiene. She was assessed as not having a pressure ulcer, but was at risk for a pressure ulcer. The resident had a pressure reducing device for her chair and bed.
Review of the resident's care plan revealed a care plan initiated on 05/07/19 for potential impairment to skin integrity related to cerbrovascular accident, impaired mobility, and incontinence of bowel and bladder. The goal was for the resident to maintain intact skin. Interventions included assist to turn and reposition frequently and as needed, preventative dressing as ordered, pressure reducing cushion to chair, pressure reducing mattress, weekly skin audit, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.
Review of physician's orders dated 05/07/19 revealed an order for weekly skin audits (assessments) by the nurse.
Review of the resident's weekly pressure skin grids revealed she originally had a stage two pressure ulcer to her coccyx on 07/08/19 measuring 1.0 centimeters (cm) x 0.4 cm x 0.1 cm depth. The wound bed was described as pink with reddened surrounding skin. The physician was notified on 07/08/19.
Review of the resident's nursing notes dated 07/08/19 revealed a new pressure ulcer was noted to the coccyx, stage two open area 1.0 cm x 0.4 cm x less than 0.1 cm. No drainage was noted and no signs of infection. The wound bed was pink with surrounding skin reddened. New treatment order was obtained.
Review of physician's orders dated 07/08/19 revealed an order to update the skin grid pressure form every Tuesday.
Continued review of the physician's orders revealed an order dated 07/08/19 and renewed on 07/29/19 to cleanse wound to coccyx with normal saline, apply skin prep to surrounding areas and cover with adhesive foam every three days, and as needed. House barrier cream apply topically to affected areas after each incontinent episode.
Review of the weekly pressure skin grid dated 07/09/19 revealed an area to the coccyx with original date of wound documented as 07/09/19. There were no measurements. The wound was described as having a pink wound bed with reddened surrounding skin. The physician was notified on 07/09/19.
Review of the weekly pressure skin grids revealed no further grids were completed until 07/23/19. The description was a coccyx pressure wound originated on 07/09/19. The wound bed was pink with reddened surrounding skin, no drainage, no tunneling, and unchanged. No measurements were documented.
Review of the weekly pressure skin grids revealed no further grids were completed until 08/07/19. The original date of the coccyx pressure area was 08/07/19 and the wound was described as pink wound bed with reddened surrounding skin. No drainage and no tunneling were noted and the wound was improved. No measurements were documented.
Review of the resident's Braden scale (a tool to assess a resident's risk of developing a pressure ulcer) dated 09/05/19 revealed she was at moderate risk for a pressure ulcer.
Review of the weekly pressure skin grids revealed no further grids were completed until 09/10/19. The original date of the pressure ulcer to the coccyx was 09/10/19. The wound was described as slight pink wound bed. Measurements were 0.5 cm x 0.5 cm x 0 cm. The stage was marked not applicable, and the wound was documented as healed.
Review of the resident's weekly skin assessments revealed an assessment was completed on 09/21/19 and indicated the resident had no pressure ulcers.
Review of the weekly pressure skin grids revealed on 09/24/19 the resident had a coccyx pressure ulcer that was healed and slightly pink.
Review of the resident's shower sheets revealed one completed on 09/24/19 with no open areas. One was also completed on 09/27/19 with the sacrum area circled and open area written in. No further shower sheets after 09/27/19 were provided.
Review of the resident's weekly skin assessments revealed an assessment was completed on 09/28/19 and indicated the resident had no pressure ulcers.
Review of the resident's nursing notes revealed no nursing notes regarding the resident's coccyx pressure ulcer after 07/08/19 until 10/15/19. On 10/15/19, Licensed Practical Nurse (LPN) #224 documented the resident was seen by the wound physician for an unstageable deep tissue injury to the sacrum. Pressure reducing mattress noted on resident's bed, along with pressure reducing pad in wheelchair. The unstageable deep tissue injury was noted to be 3.5 cm x 3.5 cm with light serous drainage noted, with 70% viable tissue and 30% skin. New wound order obtained. The resident was recommended to be off-loaded as tolerated, obtain consent for debridement of wound, and add multivitamin.
Review of the resident's October Treatment Administration Record (TAR) revealed weekly skin audits were not signed off as completed on 10/05/19 or 10/12/19. Updated skin grids weekly were not signed off on 10/01/19 or 10/08/19. Nurses continued to sign off on the treatment to cleanse the wound to coccyx with normal saline, apply skin prep to surrounding areas and cover with adhesive foam every three days, and as needed, until 10/13/19. The last nurse to sign off the order as completed was LPN #242 on 10/13/19.
Review of the weekly pressure skin grids revealed on 10/15/19 the resident had an unstageable deep tissue injury to the coccyx with an original date of 10/15/19. Measurements were 3.5 cm x 3.5 cm, no depth was noted. Wound was noted to be dark purple in color with light serous drainage.
Review of Wound Physician #267's note dated 10/15/19 revealed the resident had an unstageable deep tissue injury sacrum wound with light serous exudate. She had no pain. The wound measured 3.5 cm x 3.5 cm x not measurable. The etiology was pressure. The physician ordered Leptospermum honey apply once daily, cover with foam with border, skin prep to peri-wound daily. Off-load wound, reposition per facility protocol, and obtain consent for debridement. Follow up in seven days.
Review of the weekly pressure skin grids revealed on 10/22/19, the wound was described as an unstageable pressure ulcer with measurements of 3.5 cm x 3.5 cm. The wound was described as a deep tissue injury with light serous drainage and dark purple in color. Wound status was marked as declined with the physician aware.
Review of physician order dated 10/22/19, revealed the order was changed to cleanse the wound with in house wound cleanser, pat dry and apply desitin to wound, cover with foam border dressing change daily.
Review of Wound Physician #267's note dated 10/22/19 revealed the resident continued with an unstageable deep tissue injury to the sacrum measuring 3.5 cm x 5.5 cm x 0.1 cm with light serous exudate. The wound was noted to contain 20% slough, 50% other viable tissues (subcutaneous fat, dermis, muscle), and 30% skin. The wound was debrided to remove necrotic tissue and establish the margins of viable tissue. Surface area was documented as 19.25 square cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed to a depth of 0.2 cm and healthy bleeding tissue was observed. MDS post debridement stage of pressure ulcer was stage four. A new treatment was ordered for zinc ointment covered with foam with border, and apply skin prep to peri-wound area once daily. Off load wound, reposition per facility protocol, low air loss mattress. Follow up in seven days.
On 10/22/19 at 7:28 P.M., LPN #224 documented Resident #39 was seen by the wound physician during rounds to follow up on wound to sacrum. She was noted to have a fair appetite. The resident's unstageable deep tissue injury wound was noted to deteriorate. Measurements were 3.5 cm x 5.5 cm x 0.1 cm. The physician completed surgical excisional debridement to remove necrotic tissue and establish margins of viable tissue. Procedure surgically excised tissue including slough, bio-film, and non-viable tissue. Hemostasis was achieved and a clean dressing was placed. Wound noted to have light serous drainage and was 20% slough, 50% viable tissue, 30% skin. Physician also noted the resident had moisture associated dermatitis. New orders were obtained. Recommendation from the physician was for the resident to be on a low loss air mattress.
Observation of Resident #39's wound care on 10/23/19 at 2:30 P.M. revealed the resident was lying in bed on a pressure relieving mattress (not low air loss). An open area to the resident's sacrum measured 2.0 cm x 2.5 cm with tunneling of unknown depth noted. Surrounding skin was red and macerated.
Interview with LPN #224 and the Director of Nursing (DON) on 10/23/19 at 5:55 P.M. revealed Wound Physician #267 came to the facility on [DATE] around 9:30 A.M. until 11:30 A.M. LPN #224 stated she did not get time to put the orders in until approximately 7:45 P.M. and this was after Maintenance Director #258 had left for the day. She stated she told Maintenance Director #258 about the resident's order for a low air loss mattress the morning of 10/23/19 verbally. LPN #224 and the DON verified the resident did not have a low air loss mattress at this time. The facility had low air loss mattresses in house. The DON stated the resident had a pressure relieving mattress for management of pressure ulcers up to stage two.
Interview with Maintenance Director #258 on 10/24/19 at 8:27 A.M. revealed he was not informed the resident needed a low air loss mattress until the evening of 10/23/19, after he had already left the building. He stated he received a text message.
Telephone interview with LPN #242 on 10/24/19 at 10:10 A.M. revealed she changed the resident's dressing on 10/13/19. She stated the resident's coccyx wound was healed. She stated there was no open area and the skin was blanchable. When asked what open area she cleansed per the order, she stated the resident had a bowel movement and she cleaned her up. She stated she did not question why the order was to cleanse wound to coccyx. She verified she did not document an assessment of the wound or attempt to clarify the order.
Interview with Wound Physician #267 via telephone on 10/24/19 at 11:37 A.M. revealed he did not want to speculate as to how the resident's pressure ulcer deteriorated. He stated it was possible the wound had not completely healed as documented on 09/24/19. He stated he saw the wound on 10/15/19 and it appeared as an unstageable deep tissue injury with light drainage. He stated when he debrided the wound on 10/22/19, he saw muscle fibers, so he staged it as a stage four pressure ulcer.
Further interview with the DON on 10/24/19 at 3:20 P.M. revealed she asked the wound physician to look at the resident's wound on 10/15/19 as she thought they were still padding and protecting the resident's intact sacrum as a preventative measure. She did not realize the resident's order was for an open area to the coccyx. She stated she wanted the wound physician to observe the wound to see if the foam dressing was still appropriate. She verified the wound physician found an unstageable deep tissue injury on the resident's sacrum on 10/15/19 that was debrided on 10/22/19 and classified as a stage four pressure ulcer. She verified the facility did not document weekly on the resident's coccyx pressure ulcer in the skin grids or nursing notes. She stated they did not have any additional assessments. She verified the nurses were signing off for an open wound dressing, which would indicate a need for a weekly assessment. She verified the sacrum wound was first identified on 07/08/19 as a stage two pressure ulcer, with no further documentation until 07/23/19 with no assessment or measurement of the wound. She verified there was no further documentation until 08/07/19 with no measurement of the wound, then 09/10/19 with measurements of 0.5 x 0.5 x 0 depth slightly pink wound bed, improved, healed. She verified there was no further documentation on the resident's coccyx wound except the nurses continued to sign off every three days on a dressing to an open area on the coccyx until 10/13/19.
Review of the NPUAP website revealed an unstageable deep tissue injury was defined as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.
Continued review of the NPUAP website revealed, a stage four pressure ulcer was defined as a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location.
Review of a facility policy titled Skin Assessment & Documentation Policy & Procedure dated 12/01/18 revealed a weekly skin assessment must be completed by the nurse and documentation of completion of the assessment is required by initialing the TAR. Document any findings in the nurse's notes or on the weekly skin assessment form. Once a new pressure area is identified, take the following steps: (including) Measure each area once a week and as needed for any changes in the wound. Record the measurements and description on the skin grid pressure form for the appropriate wound. Any changes in skin condition should be reported to the nurse and physician for follow-up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure tre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure treatments were in place to prevent a reduction in range of motion (ROM). This affected two (Resident #3 and #7) of three residents reviewed for limited range of motion. The facility identified nine residents with contractures. The facility census was 60.
Findings include:
1. Review of Resident #7's medical record revealed an admission date of 10/12/18. Medical diagnoses included malignant neoplasm of recto-sigmoid junction, aphasia following cerebrovascular disease, colostomy status, neuromuscular dysfunction of bladder, and secondary malignant neoplasm of liver and intrahepatic bile duct. The resident was receiving hospice services since 02/13/19.
Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems. He was able to recall staff names and faces and able to recall that he was in a nursing home. His cognition was severely impaired. He had no behaviors and no rejection of care. He required extensive assistance with one staff for bed mobility, locomotion, dressing, toilet use, and hygiene. He had impairment on both sides of the upper and lower extremities. He had not received any range of motion or splint/brace assistance.
Review of the resident's physician's orders revealed an order dated 11/02/18 for resident to wear left hand splint up to six hours per day as tolerated, preferably at night, and to wear carrot orthotic when not wearing splint as tolerated. Continued review of the physician's order revealed no order to discontinue orthotic use to the resident's left hand until 10/23/19.
Review of the resident's rehabilitation screening dated 12/15/18, revealed the resident was referred from nursing. The resident was recently discharged from occupational and physical therapy on 11/02/18, with restorative ROM recommended for upper and lower extremities. Recommendation was to continue use of the carrot in left hand at all times as tolerated except when using left hand wrist hand finger orthotic (WHFO) six hours per day as tolerated, as per orders written 11/02/18. No changes since that date.
Review of the resident's care plan revealed a care plan revised on 02/12/19 for activities of daily living (ADLs) self care deficit as evidenced by needs assist with bathing, dressing, mobility, toileting, hygiene related to hydrocephalus. The goal was to receive assistance necessary to meet ADL needs. Interventions included left hand splint was to be on six hours per day and hand carrot to be in place when splint is not on as tolerated (11/05/18).
Review of the resident's Treatment Administration Records (TARs) revealed no documentation of WHFO orthotic or carrot orthotic since 04/07/19.
Review of the resident's nursing notes from 04/07/19 through 10/24/19 revealed no documentation of the resident refusing to wear a splint or carrot device.
Observation of Resident #7 on 10/21/19 at 10:25 A.M. and on 10/23/19 at 9:08 A.M., 10:30 A.M., 11:12 A.M., and 2:50 P.M. revealed his left hand had limited range of motion. He had no type of splint device in place and none was noted in his room.
Review of the resident's document titled Bedside [NAME] Report dated 10/23/19 revealed a mobility section with interventions of left hand splint was to be on six hours per day and hand carrot to be in place when splint was not on as tolerated.
Interview with State Tested Nursing Assistant (STNA) #206 on 10/23/19 at 11:12 A.M. stated she had not seen a carrot or splint for the resident for at least a month or so. STNA #206 looked through the resident's room and could not find carrot or splint device. She looked on the STNA computerized care card and verified the resident was to have a left hand splint six hours per day and a hand carrot to left hand when splint not tolerated.
Interview with Licensed Practical Nurse (LPN) #232 on 10/23/19 at 11:34 A.M. revealed she was not sure what the resident's splint schedule was. She stated she had been at the facility for a few months and had not seen a splint device for the resident. She verified there was no documentation on the current TAR for a carrot or splint orthotic. LPN #232 looked in the resident's room and could not find a carrot or splint.
Interview with STNA #254 on 10/23/19 at 2:50 P.M. revealed she had placed a carrot device in the resident's left hand at times, but she had not seen the carrot device lately. She was able to locate the resident's carrot device in his drawer. She asked him if she could put it in his left hand and he shook his head yes. The device fit in the resident's left hand with no indication of pain. She was not able to locate the WHFO device.
Interview with the Director of Nursing (DON) on 10/23/19 at 3:31 P.M. verified the resident's splint and carrot device had not been on the TAR or current physician's orders since April 2019. She stated the orders for the splint devices did not show up on May orders. She did not know why the orders fell off. She verified there was no discontinuation order (until 10/23/19) and the resident was still care planned to receive a splint and carrot device for his left hand.
2. Review of the medical record for Resident #3 revealed an admission dated of 04/19/19. Diagnoses included acute and chronic respiratory failure with hypoxia, unspecified voice and resonance disorder, diabetes type two, hyperlipidemia, hypertension, non traumatic intracranial hemorrhage, dysphagia, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, muscle weakness, cognitive communication deficit and gastrostomy status.
Review of admission MDS assessment completed 04/23/19 documented Resident #3 had moderately cognitively impaired. Further review documented she required an extensive two person assist for extensive assistance for dressing. She was also assessed as having impairment to one side of her body. The MDS did documented occupational therapy (OT)minutes of therapy given to the resident.
Review of comprehensive care plan documented Resident #3 had an ADL self care deficit related to her cardiovascular accident (CVA), and respiratory failure. Further review documented an intervention to wear cervical collar five hours daily which included to monitor the skin prior to application and when removed and to report any areas to the nurse/physician.
Review of the STNA's visual/bedside [NAME] report undated documented intervention to wear cervical collar five hours daily which included to monitor the skin prior to application and when removed and to report any areas to the nurse/physician.
Review of OT evaluation and plan of treatment dated 04/15/19 lacked any documentation of Resident #3 having a contracture to her neck. Further review of an assessment documented she had normal tone to her upper extremities and was dependent of staff for all her ADL care.
Review of OT Discharge summary dated [DATE] documented Resident #3 had a discharge goal to tolerate neck brace six hours per day with no irritation to prevent neck left lateral neck contracture and preserve skin integrity. Further review documented a discharge recommendation for 24 hour nursing care and splint and brace (Cervical/Miami J collar).
Review of physician order dated 07/02/19 documented patient was to wear cervical collar as tolerated up to five hours per day.
Review of physician orders from 09/01/19 through 10/22/19 lacked any documented order to to discontinue Resident #3 cervical J collar.
Review of nursing notes from 09/01/19 through 10/04/19 lacked any documentation of Resident #3 refusing to wear the brace or documentation of the brace being applied when and for how long it was tolerated.
Review of the TAR for September 2019 documented an order for patient to wear cervical collar as tolerated up to five hours per day. Further review lacked any documentation of the task being completed with for your information written to the side of the order.
Review of TAR for October 2019 documented an order for patient to wear cervical collar as tolerated up to five hours per day. Further review lacked any documentation of the task being completed with for your information written to the side of the order. The order was also crossed out like it was discontinued but lacked any initials or date of discontinuation.
On 10/21/19 1:49 P.M. an observation was made of Resident #3. Her neck appeared to have a contracture leaning towards her left shoulder while laying on her back in bed. There was no splint device observed.
On 10/21/19 at 4:00 P.M. an observation was made of Resident #3, her neck was leaning towards her left should with no splint device in place.
On 10/22/19 at 3:20 P.M. interview with STNA #204 verified she worked with Resident #3 on a regular basis and was not aware of her having a cervical J collar neck brace. She stated she had never put a neck brace on and it had not been in place as far as she knew. She also verified usually an order for a brace would be on the STNA's [NAME] (care plan) when they were to apply the braces for a resident.
On 10/22/19 at 3:22 P.M. interview with LPN #236 verified she thought the order for Resident #3 cervical J collar brace had been discontinued sometime this month due to non compliance. She revealed she took care of Resident #3 frequently. She also revealed the order was for up to five hours a day as tolerated. She verified there was no documentation for how long Resident #3 was able to tolerate the brace or documentation of her refusing to wear the brace. She also revealed there was no schedule or specific directions on when and who was to apply the brace for the five hours a day as tolerated. She then verified the cervical J collar had not been in place on 10/21/19 and 10/22/19.
On 10/22/19 at 3:23 P.M. interview with Certified Occupational Therapy Assistant (COTA) #265 verified the J collar was recommended for Resident #3 when she was discharged from therapy. He stated this would have been communicated to nursing. He verified if it was recommended it should be kept in place until an evaluation was done again or a physician discontinued it because of non use. He further verified per the original assessment from the therapist the resident did not have a neck contracture documented with a degree of contracture. He verified a therapist would need to evaluate her to assess her neck for a contracture and prescribed need therapy for them to make determination on what she would need now before they could provide her any therapy care.
On 10/22/19 at 3:27 P.M. interview with DON verified Resident #3 did have a care plan in place for nursing and on the STNA's [NAME] (care plan) to wear the cervical J collar as tolerated for five hours a day. She further verified there was no specific instruction of when this was to be done and/or by whom. She verified typically the STNA's put the splint devices in place and the nurses ensure the devices are in place. The nurses should document in the nursing notes if a resident refused. She verified they there was no documentation of refusal in the nursing notes. She also verified there was a current physician order for the cervical J collar and it should have been in place as ordered. She also verified it was crossed out on the treatment record for October 2019 and she did not know why.
On 10/24/19 at 10:22 A.M. during an interview OT #266 verified Resident #3 did not have any contracture to her neck when she was evaluated for OT. She further revealed upon her discharge from OT the cervical J collar was in place to prevent a contracture to her neck from occurring as documented per the resident goal.
On 10/24/19 at 10:51 A.M. an observation of an OT assessment completed per OT #266 revealed Resident #3 did not have a contracture to her neck. She revealed the muscles were tight and with massage and stretching of Resident #3 neck, she was able to complete full passive range of motion of Resident #3's neck.
Review of policy and procedure for Splint/Brace device dated June 2014 documented splint/braces are removable devices used to prevent or control the progression of contractures, and the stabilization of muscles and joints. Further review documented to review the splint order and follow all specifications related to the physician order of the splint device. It also revealed to document the application and removal of the splint device, condition of the site, range of motion and resident tolerance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview the facility failed to ensure physicians responded timely to pharmacy recommendations. This effected two (Residents #6 and #19 ) of five residents re...
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Based on medical record review and staff interview the facility failed to ensure physicians responded timely to pharmacy recommendations. This effected two (Residents #6 and #19 ) of five residents reviewed for unnecessary medications. The facility census was 60.
Findings include:
1. Review of the medical record of Resident #6 revealed an admission date of 09/27/14. Diagnoses included essential hypertension, abnormal posture, hypothyroidism, dysphagia, muscle weakness, mixed receptive-expressive disorder, generalized anxiety disorder, Alzheimer's dementia with combative features, and depression.
Review of the physician recommendation form dated 06/14/19 revealed the pharmacist recommended laboratory (lab) tests of basic or complete metabolic panel (to evaluate kidneys, blood glucose level, and electrolyte and acid/base balance), a hemoglobin A1C (tells average level of blood sugar over the past two to three months), a liver function test or lipid panel (to evaluate functioning of the liver) and a complete blood count (to evaluate overall health) every six months related to Resident #6 receiving an anti-psychotic medication. The form remained absent for any response from the physician.
A second physician recommendation form dated 08/09/19 revealed the antipsychotic medication, quetiapine, was due to be reviewed for possible gradual dose reduction. The physician indicated The benefits outweigh the risks. The physician signed the form on 10/15/19.
2. Review of the medical record of Resident #19 revealed an admission date of 10/29/15. Diagnoses included type 2 diabetes mellitus with unspecified complications, acquired absence of right leg below knee, abnormal findings on diagnostic imaging of other parts of musculoskeletal system, abnormal posture, other obstructive an reflux uropathy, bladder-neck obstruction, polyneuropathy unspecified, iron deficiency anemia unspecified, left bundle-branch block unspecified, gastro-esophageal reflux disease without esophagitis, Barrett's esophagus with dysplasia unspecified, muscle weakness generalized, diabetic neuropathy unspecified, hyperlipidemia unspecified, paranoid schizophrenia, bipolar disorder, unspecified, essential hypertension, unspecified atrial fibrillation, constipation, other congenital malformations of vas deferens, epididymis, seminal vesicles and prostate, iron insufficiency anemia, and lower obstructive reflux uropathy.
Review of the physician recommendation form dated 05/15/19 for Resident #19 revealed the pharmacist recommended a thyroid stimulating hormone test related to Resident #19 receiving levothryroxine and a lipid panel and liver function test related to the resident receiving atorvastatin. The form remained absent of any response from the physician.
Interview on 10/22/19 at 3:15 P.M. with the Administrator and Corporate Nurse (CN) #264 provided verification of the three month lapse in the physician acting upon a pharmacy recommendation for Resident #6.
Interview on 10/24/19 at 2:00 P.M. with Licensed Practical Nurse (LPN) #224 provided verification the facility failed to ensure the physician responded to a recommendation from the pharmacy regarding Residents #6 and #19's suggested lab tests.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on review of employee files and staff interview the facility failed to provide documentation of State Tested Nursing Assistants (STNA) having completed 12 hours annual in-service training. This ...
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Based on review of employee files and staff interview the facility failed to provide documentation of State Tested Nursing Assistants (STNA) having completed 12 hours annual in-service training. This affected two STNAs (#206 and #229) of two reviewed for annual in-service training. This had the potential to effect all 60 residents residing in the facility.
Findings include:
Review of the employee file of STNA #206 revealed a hire date of 07/09/08. The file did not contain the required 12 hour annual in-service training.
Review of the employee file of STNA #229 revealed a hire date of 05/30/84. The file did not contain the required 12 hour annual in-service training.
Interview on 10/24/19 at 2:40 P.M. the Administrator verified the facility was unable to provide documentation confirming any STNA had completed the required 12 hour annual in-service training.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Ohio facilities.
Concerns
- • 23 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (50/100). Below average facility with significant concerns.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Ayden Healthcare Of Belle Springs.'s CMS Rating?
CMS assigns AYDEN HEALTHCARE OF BELLE SPRINGS. an overall rating of 3 out of 5 stars, which is considered average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Ayden Healthcare Of Belle Springs. Staffed?
CMS rates AYDEN HEALTHCARE OF BELLE SPRINGS.'s staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 64%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Ayden Healthcare Of Belle Springs.?
State health inspectors documented 23 deficiencies at AYDEN HEALTHCARE OF BELLE SPRINGS. during 2019 to 2025. These included: 1 that caused actual resident harm, 20 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Ayden Healthcare Of Belle Springs.?
AYDEN HEALTHCARE OF BELLE SPRINGS. is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AYDEN HEALTHCARE, a chain that manages multiple nursing homes. With 99 certified beds and approximately 78 residents (about 79% occupancy), it is a smaller facility located in BELLEFONTAINE, Ohio.
How Does Ayden Healthcare Of Belle Springs. Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, AYDEN HEALTHCARE OF BELLE SPRINGS.'s overall rating (3 stars) is below the state average of 3.2, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Ayden Healthcare Of Belle Springs.?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Ayden Healthcare Of Belle Springs. Safe?
Based on CMS inspection data, AYDEN HEALTHCARE OF BELLE SPRINGS. has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Ayden Healthcare Of Belle Springs. Stick Around?
Staff turnover at AYDEN HEALTHCARE OF BELLE SPRINGS. is high. At 61%, the facility is 15 percentage points above the Ohio average of 46%. Registered Nurse turnover is particularly concerning at 64%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Ayden Healthcare Of Belle Springs. Ever Fined?
AYDEN HEALTHCARE OF BELLE SPRINGS. has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Ayden Healthcare Of Belle Springs. on Any Federal Watch List?
AYDEN HEALTHCARE OF BELLE SPRINGS. is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.