What is MEADOWBROOK CARE CENTER's CMS rating?

MEADOWBROOK CARE CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does MEADOWBROOK CARE CENTER have?

MEADOWBROOK CARE CENTER has 57 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at MEADOWBROOK CARE CENTER?

MEADOWBROOK CARE CENTER has a three-star staffing rating from CMS with 0.61 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MEADOWBROOK CARE CENTER located?

MEADOWBROOK CARE CENTER is located in CINCINNATI, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MEADOWBROOK CARE CENTER have?

MEADOWBROOK CARE CENTER has 146 certified beds.

Who owns MEADOWBROOK CARE CENTER?

MEADOWBROOK CARE CENTER is a for profit - limited liability company facility and is part of the CCH HEALTHCARE chain.

Is MEADOWBROOK CARE CENTER safe?

MEADOWBROOK CARE CENTER has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at MEADOWBROOK CARE CENTER stick around?

MEADOWBROOK CARE CENTER has high staff turnover at 66%. High turnover can mean less continuity of care as staff change frequently.

Was MEADOWBROOK CARE CENTER ever fined?

Yes, MEADOWBROOK CARE CENTER has been fined $28,841 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is MEADOWBROOK CARE CENTER on any federal watch list?

No, MEADOWBROOK CARE CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at MEADOWBROOK CARE CENTER?

Medicare inspectors have found 57 deficiencies at MEADOWBROOK CARE CENTER: 1 serious, 56 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting MEADOWBROOK CARE CENTER?

Families visiting MEADOWBROOK CARE CENTER should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MEADOWBROOK CARE CENTER compare to other nursing homes?

MEADOWBROOK CARE CENTER has a 1-star overall rating, which is below average compared to other nursing homes in OH. Families should carefully review inspection findings and consider alternatives.

MEADOWBROOK CARE CENTER

Name: MEADOWBROOK CARE CENTER
Address: 8211 WELLER ROAD, CINCINNATI, OH, 45242, US
Telephone: (513) 489-2444
Rating: 1.0

8211 WELLER ROAD, CINCINNATI, OH 45242 · (513) 489-2444

For profit - Limited Liability company 146 Beds CCH HEALTHCARE Data: November 2025

Trust Grade

25/100

#881 of 913 in OH

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Meadowbrook Care Center has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #881 out of 913 nursing homes in Ohio, placing it in the bottom half of facilities statewide, and #68 out of 70 in Hamilton County, meaning there are almost no better local options. The facility's performance is worsening, with issues increasing from 10 in 2024 to 24 in 2025. While staffing has an average rating of 3 out of 5 stars, the turnover rate is concerning at 66%, significantly higher than the state average of 49%. The center has also incurred $28,841 in fines, which is average for Ohio, but there have been serious health concerns, such as a resident being hospitalized due to a failure to monitor bowel function, leading to severe complications. Additionally, there were several sanitation issues, including improper food storage and unclean laundry facilities, which could pose risks to all residents.

Trust Score: F
In Ohio: #881/913
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 66% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $28,841 in fines. Lower than most Ohio facilities. Relatively clean record.
Skilled Nurses: 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: 57 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 10 issues

2025: 24 issues

The Good

4-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

1-Star Overall Rating

Below Ohio average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 66%

20pts above Ohio avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $28,841

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: CCH HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (66%)

18 points above Ohio average of 48%

The Ugly 57 deficiencies on record

1 actual harm

May 2025 24 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify resident physicians/medical providers of significant weight loss. This affected one (Resident #45) of eight residents reviewed for weight changes. The facility census was 89 residents. Findings include: Review of the medical record for Resident #45 revealed an admission date of 08/26/24 with diagnoses including chronic obstructive pulmonary disease (COPD), panic disorder, and pulmonary hypertension. Review of the physician's orders for Resident #45 revealed an order dated 10/07/24 for daily weights. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 03/05/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the weight record for Resident #45 revealed the following weights: 187 pounds on 12/04/24, 169 pounds on 12/05/24, 169.5 pounds on 12/06/24. Interview on 05/08/35 at 2:17 PM with Dietician #504 confirmed staff did not notify Nurse Practitioner (NP) #510 of Resident #45's significant weight loss from 12/04/24 to 12/06/24. Interview on 05/08/25 at 2:34 PM with NP #510 confirmed staff had not notified her of the weight change for Resident #45 from 12/04/24 to 12/06/24. NP #510 confirmed this was significant weight loss of 9.3 percent (%) and she should have been notified by staff members. NP #510 confirmed if the facility had notified her, she would have ordered lab work for the resident. Review of facility policy titled Impaired Nutrition/Unplanned Weight Loss dated September 2012 revealed staff members should observe and report significant weight gain or loss to the physician/provider. The policy defined significant weight loss as a 5 % loss and severe weight loss as greater than 5 %.

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 F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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3. Review of the medical record for Resident #43 revealed an admission date of 8/11/24 with diagnoses including diabetes mellitus, bipolar disorder, and Alzheimer's Disease. Review of the MDS assessment for Resident #43 dated 3/12/25 revealed the resident had severely impaired cognition and received insulin. Observation on 05/05/25 at 11:27 A.M. revealed Resident #43 was seated in the dining room with multiple residents who were waiting for lunch to be served. Registered Nurse (RN) #152 approached Resident #43 and told her she was going to check her blood sugar. RN #152 did not obtain consent from the resident. RN #152 then cleansed Resident #43's finger and pierced it with a lancet to obtain a blood sample to perform a blood sugar check. Interview on 05/05/25 at 11:35 A.M. with RN #152 confirmed she checked Resident #43's blood sugar in the dining room in the presence of other residents and did not provide visual privacy during treatment for the resident. This deficiency represents noncompliance investigated under Complaint Number OH00162453. 2. Review of the medical record for Resident #21 revealed an admission date of 04/08/21 with diagnoses including heart failure, vascular dementia, and major depressive disorder. Review of the MDS assessment for Resident #21 dated 02/18/25 revealed the resident had severely impaired cognition and was dependent on staff assistance with ADLs. Observation of incontinence care for Resident #21 on 05/07/2025 at 1:30.PM. per Certified Nursing Assistant (CNA) #133 and Licensed Practical Nurse (LPN) #146 revealed the curtain to the outside window which opened to the staff parking lot was not closed during provision of care. Interview on 05/07/25 at 1:35 PM with CNA #133 confirmed she had not closed the curtain to the window of the resident's room during incontinence care for Resident #21. Interview on 05/07/25 at 1:36 P.M. with LPN #146 confirmed staff members could potentially see inside Resident #21's window during incontinence care because the curtain was not drawn. LPN #146 further confirmed the curtain to the outside window should be drawn to provide visual privacy for the resident. Review of the facility policy titled Resident Rights undated revealed residents have the right to privacy. Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure resident personal privacy was maintained . This affected three (Residents#10, #21, and #43) of three residents reviewed for personal privacy. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 12/25/22 with diagnoses including diabetes, schizoaffective disorder, bipolar disorder, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident had severely impaired cognition and was dependent on staff for activities of daily living (ADLs.) Review of the nurse progress note for Resident #10 dated 04/03/25 revealed the resident's representative informed Registered Nurse Unit Manger (RNUM) #160 she did not want the resident's picture posted on social media. Interview on 05/06/25 at 3:16 P.M. of Activity Director (AD) #200 confirmed the facility had posted a picture of Resident #10 on social media a couple months ago and the picture remained online for a few weeks. Resident #10's representative reported her concerns to RNUM #160. AD #200 confirmed the facility had not obtained prior consent from the resident and/or the resident's representative before posting the resident's picture on social media. Interview on 05/06/25 at 3:44 P.M. with Medical Records Clerk (MRC) #179 confirmed Resident #10's record did not include consent to post the resident's picture on social media. Interview on 05/06/25 at 4:25 P.M. with RNUM #160 confirmed Resident #10's representative contacted her when she saw a picture of the resident posted on social media by the facility and asked for the picture to be removed. RNUM #160 confirmed Resident #10's representative had not consented for the facility to post the resident's picture on social media. Review of facility policy titled Videotaping, Photographing and Other Imaging of Residents dated April 2017 revealed the staff could not release images of any resident without explicit written consent from the representative prior to obtaining images. Transmitting unauthorized images of any resident through social media was considered a violation of resident rights.

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 F0605 (Tag F0605)

Could have caused harm · This affected 1 resident

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Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure hypnotic medications were used with adequate indications for administration and with adequate monitoring. This affected one (Resident #75) of five residents reviewed for unnecessary medications. The facility census was 89 residents. Findings include: Review of the medical record for Resident #75 revealed an admission date of 10/29/24 with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction. Review of the physician's orders for Resident #75 revealed an order dated 01/08/25 for Ambien five milligrams (mg) one table per mouth at bedtime for sleep assistance. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs) and received a hypnotic medication during the review period. Review of the care plan for Resident #75 last updated on 02/19/25 revealed the care plan did not address the use of Ambien, a hypnotic medication. Review of the diagnosis list for Resident #75 dated 05/07/25 revealed the resident had no diagnosis of a sleep disorder or related diagnosis. Interview on 05/08/25 at 8:05 A.M. with the Director of Nursing (DON) confirmed Resident #75 had an order for Ambien at bedtime for sleep assistance but the resident's record did not include an appropriate diagnosis or medical indication for hypnotic use. Interview with the DON on 05/08/25 at 8:31 A.M. confirmed the facility had not developed a care plan for Ambien use for Resident #75 to outline how the facility would monitor the resident for use of the hypnotic medication. Review of the facility policy titled Psychotropic Medication Use dated 01/19/24 revealed residents would not receive medications that were not clinically indicated to treat a specific condition. Residents receiving psychiatric medications would be monitored and assessed for adverse consequences. This deficiency represents noncompliance investigated under Complaint Number OH00161596.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure the accuracy of resident Minimum Data Set (MDS) assessments regarding resident dental status and range of motion and mobility. This affected three (Residents #19, #75 and #80) of 21 residents reviewed for MDS accuracy. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and was not coded as edentulous (having no natural teeth.) Observation on 05/05/25 at 11:35 A.M. of Resident #19 revealed the resident was edentulous. Interview on 05/05/25 at 11:36 A.M with Resident #19 confirmed he was edentulous and had been so upon admission to the facility. Interview on 05/06/25 at 4:20 P.M with MDS Registered Nurse (MDS RN) #175 confirmed Resident #19 was edentulous upon admission, and the facility had not correctly coded the resident's dental status on the resident's admission MDS dated [DATE]. 2. Review of the medical record for Resident #75 revealed an admission date of 10/29/24 with diagnoses including cerebral infarction, asthma, and anxiety disorder. Review of the occupational therapy evaluation and plan of treatment for Resident #75 dated 12/10/24 revealed the resident had a contracture of the left hand. Review of the quarterly MDS for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and had no functional impairment to the upper extremities. Review of the occupational therapy discharge summary for Resident #75 dated 03/27/25 revealed the resident was discharged from therapy with recommendations to wear a left carrot splint as tolerated and for staff to provide passive range of motion (PROM) to left upper extremity as tolerated. Observation on 05/05/25 at 11:46 A.M of Resident #75 revealed the resident had a contracture of his left hand and was unable to open his left hand. Interview on 05/05/25 at 11:46 A.M. with Resident #75 confirmed he had a contracture of the left hand which required the use of a carrot. Resident #75 reported he was unable to open his left hand. Interview with on 05/06/25 at 4:20 P.M. with MDS RN #175 confirmed Resident #75 had a left-hand contracture which the facility had not accurately coded on the quarterly MDS dated [DATE]. 3. Review of the medical record for Resident #80 revealed an admission date of 03/14/25 with diagnoses including type two diabetes mellitus, peripheral vascular disease, and cerebral infarction. Review of the admission MDS assessment for Resident #80 dated 03/20/25 revealed the resident was cognitively intact and the MDS was not coded for the presence of broken natural teeth. Interview on 05/05/25 at 3:58 P.M with Resident #80 confirmed he had a broken teeth which had broken prior to his admission to the facility. Observation on 05/05/25 at 4:20 P.M. of Resident #80 revealed the resident had a broken tooth on the rear left side of his mouth and had black spots on his back teeth. Interview on 05/06/25 at 4:20 P.M with MDS RN #175 confirmed the resident had a broken tooth on the rear left side of his mouth and had black spots on his back teeth which possibly could have been cavities. MDS RN #175 confirmed the facility had not accurately coded Resident #80's dental status on the admission MDS dated [DATE].

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident Preadmission Screening and Resident Review (PASARR) was completed within 30 days of being admitted to the facility with a hospital exemption. This affected one (Resident #19) of four residents reviewed for PASARR completion. The facility census was 89 residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including osteoarthritis, benign prostatic hyperplasia, chronic kidney disease stage three, and unspecified intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the hospital exemption from preadmission screening notification for Resident #19 dated 03/22/25 revealed the resident had a mental disability that was not solely caused by mental illness and was manifested prior to age [AGE]. Resident #19's intellectual disability was listed on the hospital exemption. Further review of the hospital exemption revealed the nursing facility accepted responsibility for electronically initiating a PASARR prior to the 30th day following the resident's the admission from the hospital. Review of the medical record for Resident #19 revealed it did not include a completed PASARR. Review of the hospital record for Resident #19 dated 03/18/25 revealed the resident had a history of intellectual disabilities and presented to the emergency department on 03/18/25 from a group home after having progressively increased lower extremity swelling prior to admission to the facility. Review of the diagnosis list for Resident #19 revealed the resident's diagnosis of unspecified intellectual disabilities was added to the diagnosis list on 03/22/25, the date of the resident's admission to the facility. Interview on 05/07/25 at 2:12 P.M with Licensed Social Worker (LSW) #205 confirmed Resident #19 was admitted to the facility on [DATE] with a diagnosis of an intellectual disability which had manifested prior to the resident's 22nd birthday, and the facility had not completed a PASARR for the resident. Review of the facility policy titled Admissions dated March 2017 revealed the PASARR will be provided to the facility prior to or upon the resident's admission.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0646 (Tag F0646)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview facility failed to revise Preadmission Screening and Resident Review (PASARR) assessments after a change in resident condition. This affected one (Resident #58) of four residents reviewed for PASARR completion. The facility census was 89 residents. Findings include: Review of the medical record for Resident #58 revealed an admission date of 03/08/22 with diagnoses including cerebrovascular disease, chronic obstructive pulmonary disease, neurocognitive disorder, and diabetes. Review of the physician's orders for Resident #58 revealed an order dated on 09/11/24 for the resident to begin receiving hospice services. Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 02/28/25 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Interview on 05/08/25 at 9:20 A.M. with Social Worker (SW) #205 on 05/08/25 confirmed the facility should have completed an updated PASARR for Resident #58 when the resident was enrolled in hospice on 09/11/24, but the facility had not done so.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to develop comprehensive resident care plans. This affected two (Residents #19 and #75) of 21 residents reviewed for care planning. The facility census was 89. Findings include: 1.Review of the medical record for Resident #75 revealed an admission date of 10/29/24 with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction. Review of the physician's orders for Resident #75 revealed an order dated 01/08/25 for Ambien five milligrams (mg) one table per mouth at bedtime for sleep assistance. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs) and received a hypnotic medication during the review period. Review of the care plan for Resident #75 last updated on 02/19/25 revealed the care plan did not address the use of Ambien, a hypnotic medication. Review of the diagnosis list for Resident #75 dated 05/07/25 revealed the resident had no diagnosis of a sleep disorder or related diagnosis. Interview on 05/08/25 at 8:31 A.M with the Director of Nursing (DON) confirmed the facility had not initiated a care plan for Resident #75's use of Ambien, a hypnotic medication. 2. Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities. Review of the admission MDS assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and was not coded as edentulous (having no natural teeth.) Review of the dental care plan for Resident #19 dated 04/03/25 revealed Resident #19 had the potential for oral or dental health issues related to the disease process and an ADL self-care deficit. Interventions included the following: coordinate and arrange for dental care and transportation as needed, provide mouth care, occupational therapy screen for adaptive equipment as needed, diet as ordered and monitor, document and report as needed signs and symptoms of dental problems. The care plan did not address Resident #19's status as edentulous status. Observation on 05/05/25 at 11:35 A.M. of Resident #19 revealed the resident was edentulous. Interview on 05/05/25 at 11:36 A.M with Resident #19 confirmed he was edentulous and had been so upon admission to the facility. Interview on 05/06/25 at 4:20 P.M with MDS Registered Nurse (MDS RN) #175 confirmed Resident #19 was edentulous upon admission, and the facility had not correctly coded the resident's dental status on the resident's admission MDS dated [DATE]. MDS RN #175 also verified Resident #19's dental care plan did not address that Resident #19 was edentulous. Review of the facility policy titled Comprehensive Person-Centered Care Plans dated 10/10/22 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on medical record review, staff interview, and review of the facility policy, the facility failed to conduct quarterly care conferences. This affected three (Residents #10, #24, and #81) of four residents reviewed for care planning. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 12/25/22 with diagnoses including dementia, schizophrenia, bipolar disorder, and diabetes mellitus type two. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living (ADLs.) Review of the care conference records for Resident #10 revealed the revealed the facility did not conduct a quarterly care conference for Resident #10 for the first, second, and third quarters of 2024. The only documented quarterly care conference for Resident #10 was on 10/03/24. Interview on 05/08/25 at 11:52 A.M. with the Social Services Director (SSD) #205 confirmed care conferences were to be conducted on a quarterly basis, and Resident #10 did not have a care conference in the first, second and third quarters of 2024. 2. Review of the medical record for Resident #24 revealed an admission date of 01/01/23 with diagnoses of Parkinson's disease and dementia. Review of the MDS assessment for Resident #24 dated 03/07/25 revealed the resident had intact cognition and required staff assistance with ADLs. Review of the care conference records for Resident #24 revealed the facility did not conduct a quarterly care conference for Resident #24 during 2024. Interview on 05/08/25 at 11:53 A.M. with SSD #205 confirmed the facility had not conducted a care conference for Resident #24 during 2024. 3. Review of the medical record for Resident #81 revealed an admission date of 12/19/24 with diagnoses including chronic obstructive pulmonary disease, hypertension, and atrial fibrillation. Review of the MDS assessment for Resident #81 dated 04/17/25 revealed the resident had intact cognition and required staff assistance with ADLs. Review of the care conference records for Resident #81 revealed the facility did not conduct a quarterly care conference for Resident #81 in the first quarter of 2024. Interview on 05/08/25 at 11:52 A.M. with the SSD #295 confirmed the facility did not conduct a care conference for Resident #81 in the first quarter of 2024. Review of the facility policy titled Care Planning-Interdisciplinary Team dated 10/10/22, revealed the facility would include the resident and/or the resident's representative in the care planning process. Care plan meetings should be scheduled at the best time of the day for resident and family when possible.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, the facility failed to reassess resident nutritional status following hospitalization. This affected one (Resident #81) of two residents reviewed for readmission. The facility census was 89 residents. Findings include: Review of the medical record for Resident #81 revealed an admission date of 12/19/24 with diagnoses including end stage renal disease, congestive heart failure, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 03/26/25 revealed the resident had intact cognition and required minimal staff assistance for activities of daily living (ADLs.) Review of the May 2025 monthly physician's orders for Resident #81 revealed orders for the resident to have low concentrated sugar renal diet with a fluid restriction of 2000 milliliters (ml) per day. Review of hospital records for Resident #81 dated 03/31/25 to 04/11/25 revealed the resident was hospitalized for volume overload and had 44 pounds of fluid removed during the stay hospitalization. Resident #81's hospital admission weight was 256 pounds, and the discharge weight was 212 pounds. Review of the medical record for Resident #81 revealed the facility had not completed an assessment of the resident's nutritional status upon the return from the hospital per Registered Dietitian (RD) #504 and Dietitian Technician (DT) #505. Interview on 05/07/25 at 10:56 A.M. with DT #505 stated the she had not updated the resident's nutrition assessment upon Resident #81's readmission to the facility. DT #505 further confirmed she was unaware Resident #81 had been hospitalized and for a fluid volume overload of 44 pounds. Interview on 05/08/25 at 2:17 P.M. with RD #504 confirmed she had not completed a nutritional assessment for Resident #81 and had been unaware the resident had been hospitalized for fluid volume overload. RD #504 confirmed Resident #81's hospitalization was of nutritional significance and should have had a nutritional assessment upon return from the hospital.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to timely and adequately assess resident skin. This affected one (Resident #21) of three residents reviewed for pressure ulcers. The facility also failed to follow the physician's orders regarding wound care for pressure ulcers and also failed to document the completion of wound care in the resident's medical record. This affected one (Resident #19) of three residents reviewed for pressure ulcers. The facility census was 89 residents. Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of 04/08/21 with diagnoses including heart failure and vascular dementia. Review of the pressure ulcer risk assessment for Resident #21 dated 11/20/24, revealed the resident was at very high risk for developing pressures ulcers. Review of the physician's orders for Resident #21 revealed an order dated 12/06/24 to cleanse the resident's bilateral hips with normal saline, pat dry, and apply skin prep every shift and as needed as a preventative measure and an order dated 01/08/24 for the resident to have weekly skin checks to be documented in the electronic medical record (EMR.) Review of the care plan for Resident #21 dated on 01/21/25 revealed the resident was at risk for the development of pressure ulcers. Interventions included the following: administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown, inform the resident/family/caregivers of any new area of skin breakdown. Review of the Treatment Administration Records (TARs) for Resident #21 dated December 2024, January 2025, and February 205 revealed the preventative treatment to the resident's bilateral hips was signed off as completed. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 02/18/25 revealed the resident was severely cognitively impaired and required substantial staff assistance with activities of daily living (ADLs.) Review of the skin check for Resident #21 dated 02/19/25 revealed there were no new areas of skin impairment noted. Review of a nurse progress note for Resident #21 dated 02/20/25 per Licensed Practical Nurse (LPN) #146 revealed the resident's family noticed an open area to the resident's right hip. Staff notified Wound Nurse Practitioner (WNP) #502 who gave an order to cleanse the area and apply Medihoney and a border foam dressing two times a day. The note did not include measurements or a description of the open area to the resident's right hip. Review of the skin check for Resident #21 dated 2/21/25 revealed there was an open area to the resident's right hip. The skin check did not include measurements, staging or a description of the wound. Review of the visit note for Resident #21 dated 02/26/25 per WNP #502 revealed the resident had a facility-acquired unstageable pressure ulcer to the right hip which measured 1.3 centimeters (cm) in length by 4.0 cm. in depth by 0.3 cm in depth with a heavy amount of serous drainage from the wound and 100 percent (%) slough tissue present to the wound bed. WNP #502 gave an order to cleanse the wound daily with wound cleanser, apply medical grade honey to the wound and secure with a border foam dressing. Interview on 05/06/25 at 11:35 A.M. with LPN #146 confirmed Resident #21's family notified the nurse that Resident #21 had an open area to the right hip on 02/20/25. LPN #146 further confirmed he notified WNP #502 of the open area and he obtained orders for wound care, but the facility did not measure or document the appearance of the wound to the resident's right hip. Observation on 05/07/25 at 1:30 P.M. of wound care for Resident #21 per LPN #146 revealed the resident had a nickel- sized open area to the right hip. The wound bed was pink with no drainage. LPN #146 cleansed the wound with normal saline, applied Medihoney, and covered the wound with a border foam dressing. Interview on 05/07/25 at 1:45 P.M. with WNP #502 confirmed on 02/26/25 she examined Resident #21 and documented the resident had an unstageable facility-acquired pressure ulcer the resident's right hip. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated March 2014 revealed assessment of a pressure ulcer should include the nurse describing and documenting a full assessment of a pressure ulcer, including location, stage, length, width, and presence of exudate or necrotic tissue. 2. Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including osteoarthritis, benign prostatic hyperplasia glaucoma, chronic kidney disease, and intellectual disabilities. Review of the MDS assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired, required supervision with ADLS, and was admitted with two stage III pressure ulcers and one unstageable pressure ulcer. Review of the care plan for Resident #19 dated 04/01/25 revealed the resident was at risk for the development of pressure ulcers related to the disease process, decreased mobility and moisture exposure. Interventions included staff to administer treatments as ordered and monitor for the effectiveness and to follow facility protocols for the prevention of and treatment of skin breakdown. Review of the wound assessment for Resident #19 dated 04/02/25 per WNP #502 revealed upon admission the resident had the following three pressure ulcers: a stage three pressure ulcer to the left buttock which measured 3.5 centimeters (cm) in length, by 1.5 cm in width by 0.3 cm in depth, a stage three pressure ulcer to the right buttock which measured 0.5 cm in length by 0.5 cm in width by 0.3 cm in depth, an unstageable pressure ulcer to the left ischium which measured 7.5 cm in length by 3.5 cm in width by 2.3 cm in depth. WNP #502 gave an order to cleanse the wounds to the left and right buttocks with normal saline, apply medical grade honey, and cover with a border foam dressing and to cleanse the wound to the left ischium with normal saline (do not use wound cleanser), gently pack the wound with half-strength Dakin's solution moistened fluffed gauze and apply a border foam dressing every shift and as needed. Review of the wound assessment for Resident #19 dated 04/09/25 per WNP #502 revealed the pressure ulcer to the resident's left buttock was improving and the treatment changed to cleanse with soap and water, pat dry, apply triad paste and leave open to air every shift and as needed. The pressure ulcer to the right buttock was resolved. The pressure ulcer to the left ischium was improving and the treatment order was unchanged. Review of the wound assessment for Resident #19 per WNP #502 dated 04/23/25 revealed the pressure ulcer to the left buttock was resolved. The pressure ulcer to the left ischium was improving and the treatment was changed to cleanse the left ischium with wound cleanser, gently pack the wound with quarter-strength Dakin's solution moistened fluffed gauze and apply a border foam dressing every shift and as needed. Review of the TAR for Resident #19 dated April 2025 revealed the treatment order given by WNP #502 dated 04/02/25 to 04/09/25 to cleanse the wounds to the left and right buttocks with normal saline, apply medical grade honey and a border dressing daily were not noted in the TAR and there was no record of the treatments being completed. Further review of the TAR revealed the treatment order to cleanse the left buttock with soap and water, pat dry, apply triad paste and leave open to air every shift from 04/09/25 to 04/23/25 was not listed on the TAR and there was no record that the treatment was completed. The treatments to the left ischium were not documented as completed on 04/04/25, 04/16/25 and 04/29/25 on the night shift. The treatment order to the left ischium indicated the wound was to cleansed with wound cleanser but WNP #502's order from 04/02/25 to 04/09/25 indicated the left ischium wound should be cleansed with normal saline. Interview on 05/07/25 at 10:49 A.M. with the Director of Nursing DON confirmed the treatment orders for the pressure ulcers to Resident #19's right and left buttocks were not included in the April TAR for 04/02/25 to 04/09/25 and the facility had no evidence the treatments had been completed. The DON further confirmed the treatment order for the pressure ulcer to Resident #19's left buttock was not included in the April TAR for 04/09/25 to 04/23/25 and the facility had no evidence the treatments had been completed. The DON confirmed the treatment orders for the pressure ulcer to Resident #19's left ischium were not signed off as completed on the night shift on 04/04/25, 04/16/25 and 04/29/25 and the facility had no evidence the treatments had been completed on those dates. The DON confirmed wound cleanser was used on Resident #19's left ischium from 04/02/25 to 04/09/25 and WNP #502's wound care order indicated staff should cleanse the left ischium with normal saline and should not use wound cleanser on the left ischium until the order was changed on 04/09/25. Review of the facility policy titled Wound Care dated October 2010 revealed wound treatments should be completed per physician's orders. This deficiency represents noncompliance investigated under Complaint Number OH00161253 and Complaint Number OH00164317.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff administered resident tube feedings in a sanitary manner. This affected one (Resident #75) of one residents reviewed for tube feeding. The facility census was 89 residents. Findings include: Review of the medical record for Resident #75 revealed an admission date of 10/29/24 with dysphagia following cerebral infarction, generalized anxiety disorder, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and had a gastrostomy tube. Review of the physician's orders for Resident #75 revealed an order dated 10/24/24 for an enteral feeding two times a day of Jevity 1.5 to be administered via pump at 70 cubic centimeters (cc) per hour 8:00 P.M. to 6:00 A.M. Review of the care plan for Resident #75 dated 11/11/24 revealed the resident required tube feedings related to dysphagia. Interventions included the following: elevate the head of the bed 45 degrees during and thirty minutes after the tube feeding, check for tube placement, gastric contents and residual volume per facility protocol, provide care to the gastrostomy tube (g-tube) site as ordered and monitor for signs and symptoms of infection, Registered Dietitian (RD) to evaluate quarterly and as needed, speech therapy evaluation and treatment as ordered and discuss with the resident, family and caregivers concerns about the tube feeding. Observation on 05/06/25 at 4:20 P.M. revealed Resident #75 was lying in bed and the tube feeding pump next to the bed was not running. A container of Jevity 1.5 dated 05/05/25 was hanging on the pump and was connected to g-tube tubing which had a piece of paper towel stuck in the end of the tubing to keep the Jevity 1.5 from spilling out. Interview on 05/06/25 at 4:21 P.M with Registered Nurse (RN) #175 confirmed there was a partially used bag of Jevity 1.5 and g-tube tubing hanging on the tube feeding pump with a piece of paper towel stuck in the end of the tubing to keep the Jevity 1.5 from spilling out. Interview on 05/06/25 at 4:22 P.M. with Licensed Practical Nurse (LPN) #905 confirmed Resident #75's tube feed had been disconnected by night shift prior to the beginning of her shift, and the partially used bag of Jevity 1.5 should have been discarded after the feeding was disconnected on 05/06/25 at 6:00 A.M. Review of the facility policy titled Enteral Tube Feeding by Continuous Pump dated March 2015 revealed the facility should refrigerate formulas that have been reconstituted in advance and discard within 24 hours.

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 F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a medication error report, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #200) of one resident reviewed for medication errors. The facility census was 89 residents. Findings include:Review of the medical record for Resident #200 revealed an admission date of 01/17/25 with diagnoses including chronic diastolic heart failure, anxiety disorder, acute respiratory failure with hypoxia, hypertension, chronic obstructive pulmonary disease, and chronic kidney disease The resident discharged to the hospital on [DATE]. Review of the Minimum Data Set MDS assessment for Resident #200 dated 01/23/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.)Review of the medical record revealed the resident had no known medication allergies. Review of a progress note for Resident #200 dated 02/04/25 timed at 12:39 A.M. per Registered Nurse (RN) #503 revealed the nurse prepared medication intended for another resident, but she inadvertently administered the other resident's medications to Resident #200. RN #503 assessed the resident and notified the resident's physician and emergency contact of the medication error. The physician gave orders to monitor the resident for 72 hours. Review of the hospital transfer form for Resident #200 dated 02/04/25 revealed the resident was sent to the hospital per the family's request due to a medication error. The resident was a DNR-CC (do not resuscitate-comfort care) code statusReview of a progress note for Resident #200 dated 02/04/25 timed at 2:37 A.M. revealed Resident #200's family arrived at the facility after being notified of the medication error and requested the resident go to the hospital. Staff sent the resident to hospital via emergency medical services (EMS.) Review of the hospital note for Resident #200 dated 02/04/25 revealed the resident presented from her nursing facility with altered mental status following improper medication administration. The hospital performed lab work and an electrocardiogram (EKG) with no significant abnormalities. The hospital administered one liter of intravenous fluids to Resident #200 and monitored the resident for over eight until the resident returned to her baseline. Resident #200 was diagnosed with accidental drug overdose and altered mental status, and once stabilized the resident's family chose to place the resident in a different nursing facility.Review of the medication error report summary for Resident #200 revealed on 02/03/25 at approximately 11:37 P.M. staff administered the following medications to the resident in error: Aricept 5 milligrams (mg), gabapentin 600 mg, rosuvastatin 40 mg, duloxetine 30 mg, Keppra 500 mg, oxycodone 10 mg, ropinirole 0.25 mg, sennosides-docusate 8.6-50 mg (two tablets), and clonazepam 0.5 mg. As a result of the medication error, RN #503 was terminated, and all resident electronic health record pictures were audited and verified they matched the facility room name plates. All nursing staff were reeducated on the medication administration policy and procedure. Review of a written statement per RN #503 dated 02/05/25 timed at 4:05 P.M. revealed the nurse prepared the medications for Resident #148 and administered them to Resident #200, thinking she was Resident #148. RN #503 stated, approximately 20 minutes later, she realized what she had done and notified management and assessed Resident #200. RN #503 stated that when administering medications to Resident #200, she did not ask her name or attempt to identify her in any way. Review of the facility policy titled Administering Medications April 2019 revealed the individual administering medications was to verify the resident's identity before giving the resident their medications. Medications ordered for one resident must not be administered to another resident. This deficiency represents noncompliance investigated under Complaint Number OH00163155 and Complaint Number OH00161596.The deficient practice was corrected on 02/06/25, when the facility implemented the following corrective actions: -A medication error report was made for the 02/04/25 incident related to Resident #200. -The nurse involved in the incident was terminated.-All residents on the assignment of the nurse involved were audited to ensure accurate identification methods were present. -Nurses were educated on medication administration, including the proper methods to identify a resident.-Medication pass competency checks for five nurses weekly for four weeks, then monthly for two months were initiated.

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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview, and consulting pharmacist interview, the facility failed to ensure insulin pens were properly labeled and stored. This affected three (Residents #65, #39 and #34) of 21 facility- identified residents who received insulin. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #65 revealed an admission date of 02/18/25 with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) assessment for Resident #65 dated 03/25/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #65 revealed an order dated 02/18/25 for the resident to receive insulin lispro per sliding scale. Observation on 05/06/25 at 10:46 A.M. of the A-nursing unit front medication cart revealed the cart contained two insulin lispro pens for Resident #65 that were not dated. Interview on 05/06/25 at 10:46 A.M. with Licensed Practical Nurse (LPN) #260 confirmed the two insulin lispro pens for Resident #65 were not dated, and insulin is to be dated when removed from refrigeration storage and/or placed in the medication cart. 2. Review of the medical record for Resident #39 revealed an admission date of 11/14/18 with a diagnosis of DM. Review of the MDS assessment for Resident #39 dated 03/12/25 revealed the resident had intact cognition and required set-up assistance and supervision with ADLs. Review of the physician's orders for Resident #39 revealed an order dated 03/03/25 for insulin glargine twice daily. Observation on 05/06/25 at 11:05 A.M. of the C-nursing unit front medication cart revealed the cart contained an insulin glargine pen for Resident #39 that was not dated. Interview on 05/06/25 at 11:05 A.M. with LPN #172 confirmed the insulin glargine pen for Resident #39 was not dated and insulin is to be dated when removed from refrigeration storage and/or placed in the medication art. 3. Review of the medical record for Resident #34 revealed an admission date of 03/17/23 with a diagnosis of DM. Review of the MDS assessment for Resident #34 dated 04/08/25 revealed the resident had intact cognition and required set-up assistance with ADLs. Review of physician's orders for Resident #34 revealed an order dated 02/27/25 for insulin glargine twice daily. Observation on 05/06/25 at 11:05 A.M. of the C-nursing unit front medication cart revealed the cart contained an insulin glargine pen for Resident #34 that was not dated. Interview on 05/06/25 at 11:05 A.M. with LPN #172 confirmed the insulin glargine pen for Resident #34 was not dated, and insulin is to be dated when removed from refrigeration storage and/or placed in the medication art. Interview on 05/06/25 at 1:10 P.M. with the Director of Nursing (DON) confirmed insulin is to be dated when removed from refrigerator storage and/or placed in the medication cart. The DON confirmed the facility did not have a policy specific to the storage and dating of Insulin. Interview on 05/06/25 at 3:02 P.M. with the Consulting Pharmacist (CP) #250 confirmed insulin is to be refrigerated until needed for administration. The vial or injector pen was to be dated when removed from refrigerated storage or used for the first time.

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 F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide specified foods for residents with physician's orders to be on a renal diet. This affected one (Resident #81) of two residents reviewed for specialized diets. The facility total census was 89 residents. Findings include: Review of the medical record for Resident #81 revealed an admission date of 12/19/24 with diagnoses including end stage renal disease with dialysis, congestive heart failure, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #81 dated 03/26/25 revealed the resident had intact cognition and required minimal staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #81 revealed the resident was ordered a renal diet with low concentrated sugar and had a fluid restriction of 2000 milliliters (ml) per day. Review of the breakfast meal ticket for Resident #81 dated 05/07/25 revealed the resident was to receive six ounces of apple or cranberry juice and four ounces of milk for the entire day. Observation on 05/07/25 at 7:44 A.M. revealed Certified Nursing Assistant (CNA) #133 served Resident #81 a breakfast tray which included six ounces of orange juice and eight ounces of milk. Interview on 05/07/25 8:16 A.M. with Resident #81 confirmed he did not ask for the orange juice, but the CNA just gave it to him each morning on his meal tray, and he usually drank all of it. Resident #81 confirmed he always got eight ounces of milk, and he drank it each morning. Resident #81 confirmed he didn't know what foods he was permitted on the specialized renal low sugar diet. Interview on 05/07/25 at 8:35 A.M. with the Dietary Manger, (DM) confirmed Resident #81 should not have been served eight ounces of milk and six ounces of orange juice on his breakfast tray. The DM stated the CNA incorrectly served the juice and the kitchen staff incorrectly served the milk to Resident #81. Observation on 05/08/25 at 8:43 A.M. of breakfast for Resident #81 revealed the resident had consumed an eight ounces container of milk but the resident's meal ticket on the tray revealed the resident was to have a limit of four ounces of milk. Resident #81 received and consumed a portion of sugar syrup which was served on the breakfast tray. The meal ticket indicated the resident was to be served a low concentrated sugar diet. Interview on 05/08/25 at 8:44 A.M. with Resident #81 confirmed he had been served eight ounces of milk and regular sugar syrup at breakfast, and he had consumed all of it. Interview on 05/08/25 a 08:45 A.M. with Registered Nurse Unit Manager, (RNUM) #158 confirmed Resident #81 should not have received eight ounces of milk, and the resident should have received sugar-free syrup instead of regular syrup. Review of the facility policy titled Therapeutic Diets dated October 2017 revealed therapeutic diets were prescribed by the physician to support the resident's treatment plan. This deficiency represents noncompliance investigated under Complaint Number OH00165072 and Complaint Number OH00164317 and Complaint Number OH00161596.

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

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Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure staff followed guidelines for enhanced barrier precautions (EBP) and proper infection control practices during care. This affected one (Resident #79) of one resident observed for tracheostomy care. The facility identified one resident who currently had a tracheostomy. The facility also failed to use proper hand hygiene when assisting residents. This affected one (Resident #18) of five residents reviewed for infection control. The facility census was 89 residents. Findings include: 1.Review of the medical record for Resident #79 revealed an admission date of 03/05/25 with diagnoses including acute and chronic respiratory failure with hypoxia, hypertension, atrial fibrillation, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #79 dated 03/11/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #79 revealed an order dated 03/05/25 for the resident to have her tracheostomy cleaned at least every shift and as needed and an order dated 04/15/25 for the resident to have EBP in place. Observation on 05/07/25 at 9:50 A.M. of the EBP signage on Resident #79's door revealed everyone must clean their hands, including before entering and when leaving the room. Observation of tracheostomy care for Resident #79 per Licensed Practical Nurse (LPN) #143 revealed the nurse did not perform hand hygiene with alcohol-based hand sanitizer or soap and water prior to entering the resident's room and donning a gown. After donning the gown LPN #143 performed hand hygiene with soap and water for eight seconds. LPN #143 utilized the resident's overbed table as workspace but did not disinfect the tabletop prior to use. LPN #143 then opened the sterile tracheostomy kit and emptied the contents on the resident's overbed tabletop. LPN #143 then placed his non-sterile gloved thumb inside of the sterile tracheostomy kit to move it. The Surveyor then asked LPN #143 not to proceed with tracheostomy care due to infection control concerns. Interview on 04/16/25 at 10:08 A.M. with LPN #143 confirmed he did not perform hand hygiene upon entering Resident #79's room prior to donning the gown. LPN #143 confirmed he washed his hands for approximately eight seconds. LPN #143 confirmed he did not disinfect the resident's overbed tabletop prior to dumping the sterile contents of the tracheostomy kit on the dirty surface of the overbed tabletop. LPN #143 confirmed he should not have placed his non-sterile gloved thumb inside of the tracheostomy kit to move it. Interview on 05/07/25 at 11:21 A.M. with the Director of Nursing confirmed LPN #143 did not adhere to EBP guidelines for handwashing before entering Resident #79's room, did not perform hand hygiene for the recommended period of time, and did not maintain aseptic technique while attempting to perform tracheostomy care. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 04/24/24 revealed EBPs were utilized to prevent the spread of multi drug-resistant organisms (MDROs) to residents. EBPs employed targeted gown and glove use during high contact resident care activities when contact precautions did not otherwise apply. Examples of high-contact resident care activities which required the use of gown and gloves for EBPs included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care with any skin opening requiring a dressing. Review of the facility policy titled Handwashing/Hand Hygiene undated revealed the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene was indicated before performing an aseptic task. When washing hands staff should wet hands first with warm water, then apply an amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. The use of gloves did not replace hand washing/hand hygiene. Review of the facility policy titled Standard Precautions undated revealed standard precautions were used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presumed that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes might contain transmissible infectious agents. Review of the facility policy titled Tracheostomy Care dated 04/30/24 revealed the purpose of the policy was to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. Aseptic technique should be used during cleaning and sterilization of reusable tracheostomy tubes, and during tracheostomy tube changes, either reusable or disposable. Gloved hands should be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves should be used during aseptic procedures. Staff should perform hand hygiene and apply clean gloves, remove old dressings, pull soiled glove over dressing and discard into appropriate receptacle; and perform hand hygiene, open tracheostomy cleaning kit and set up supplies on sterile field and put on sterile gloves. 2. Review of the medical record for Resident #18 revealed an admission date of 02/22/25 with diagnoses including rhabdomyolysis,COPD, and chronic respiratory failure. Review of the MDS assessment for Resident #18 dated 03/06/25 revealed the resident had severe cognitive impairment and required staff assistance with ADLs. Observation on 05/06/25 at 10:59 A.M. revealed Certified Nursing Assistant (CNA) #882 was wearing gloves and entered Resident #18's room Observation on 05/06/25 at 11:00 A.M revealed CNA #882 exited Resident #18's room still wearing gloves and assisted the resident to the dining room. Interview on 05/06/25 at 11:02 AM with CNA #882 confirmed she entered Resident #18's room and she was wearing gloves. CNA #882 confirmed she assisted Resident #18 to the dining room and she was still wearing the same gloves that she was wearing upon entry to the resident's room. This deficiency represents noncompliance investigated under Master Complaint Number OH00165072 and Complaint Number OH00162543.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a residents and/or resident representative received education regarding the benefits and potential side effects of the influenza immunization. This affected one (Resident #10) of five residents reviewed for immunizations. The facility census was 89. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/25/22 with diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease. Review of the physician order's orders for Resident #10 revealed an order dated 10/24/24 for the resident to receive the influenza vaccine. Review of the Medication Administration Record (MAR) for Resident #10 dated October 2024 revealed on 10/24/24 the resident was documented as having refused the influenza vaccine. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the medical record for Resident #10 from 01/01/24 to 05/08/25 revealed the record did not include an influenza vaccine consent or declination form. Review of the immunization record for Resident #10 on 05/07/25 revealed the resident refused the influenza vaccine on an unknown date. Interview on 05/08/25 at 2:01 P.M. with the Director of Nursing (DON) confirmed Resident #10 refused the influenza vaccine on 10/24/24 but the facility did not have an influenza vaccine consent or declination form for the resident. Review of the facility policy titled Influenza Vaccine dated 10/05/22 revealed the facility should provide pertinent information about the significant risks and benefits of vaccines to residents or the resident's legal representatives.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered the Coronavirus (COVID-19) vaccine. This affected one (Resident #10) of five residents reviewed for immunizations. The facility census was 89. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/25/22 with diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease. Review of the immunization record for Resident #10 revealed the resident received a COVID-19 booster vaccine on 06/09/22 prior to admission to the facility. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the medical record for Resident #10 from 01/01/24 to 05/08/25 revealed the resident did not have a COVID-19 vaccine consent or declination form in his chart. Interview on 05/08/25 at 2:01 P.M with the Director of Nursing (DON) confirmed Resident #10 did not have did not have a COVID-19 vaccine consent or declination form in his chart and the facility had no documentation the resident was offered, declined or provided a COVID-19 vaccination since admission to the facility on [DATE]. Review of the facility policy titled COVID-19 Vaccination of Residents dated 04/29/24 revealed each resident was to be offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident was fully vaccinated. Booster doses should be provided in accordance with Centers for Disease Control and Prevention (CDC) guidance.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on record review, resident interview, staff interview, and review of the facility policy, the facility failed to document and follow up on resident concerns brought up in the Resident Council meetings. This affected 10 (Residents #12, #15, #33, #36, #40, #46, #51, #63, #72, #78) of 10 residents who regularly attended the Resident Council meetings. The facility census was 89 residents. Findings include: Review of the monthly Resident Council meeting minutes dated May 2024 to April 2025 revealed the facility did not follow up on concerns raised in Resident Council meetings. The section of the minutes titled Old Business was left blank and did not include follow up on previous concerns brought by residents which include agency staffing, call lights, medications, laundry, and menus. Interview on 05/07/25 at 10:06 AM with Resident #200 confirmed she was the president of the Resident Council, and the facility had not provided follow up to the group on concerns brought up during the meetings. Interview on 05/07/25 at 10:07 A.M. with Resident #51 confirmed the facility had not provided follow up to resident concerns raised in the Resident Council meetings. Interview on 05/07/25 at 10:08 AM with Activities Director (AD) #200 confirmed the facility had no documentation of follow-up to the concerns brought up by the Resident Council members for the monthly meetings dated May 2024 to April 2025. Review of the facility policy titled Resident Council dated 01/12/22 revealed the facility would track and document response and resolution to concerns raised by the Resident Council members.

CONCERN (E) 📢 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 multiple residents

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Based on observation and staff interview, the facility failed to ensure adequate lighting in resident rooms. This affected one (Resident #21) of 16 residents reviewed for adequate lighting. The facility also failed to ensure a clean environment. This affected the 48 residents residing on the C Unit who used the shower room (Residents #01, #03, #04, #06, #09, #11, #13, #14, #15, #16, #17, #18, #19, #21, #22, #25, #26, #27, #29, #32, #33, #34, #36, #39, #40, #41, #45, #46, #48, #49, #50, #51, #52, #59, #61, #64, #67, #75, #76, #77, #78, #80, #85, #89, #146, #147, #196, and #196). The facility census was 89 residents. Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of 04/08/21 with diagnoses including heart failure, vascular dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 02/18/25 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs.) Observation of wound care for Resident #21 on 05/07/25 at 1:32 PM per Licensed Practical Nurse (LPN) #146 revealed the resident's room did not have adequate overhead lighting when the curtain was closed. Light sources in Resident #21's room included a sink light, a bathroom light, and an over the bed light. Interview on 05/07/25 at 1:35 PM with LPN #146 confirmed Resident #21's room did not have adequate light for performing wound care and staff sometimes had to use a flashlight when providing care for Resident #21 due to inadequate overhead lighting when the curtain was closed. 2. Observation on 05/07/25 at 10:11 A.M. of the C Hall shower room with LPN #146 revealed there was an area measuring approximately two inches by three inches of brown skid marks of an unidentified substance on the wall by the toilet. Further observation revealed the walls surrounding the entire shower area contained a layer of a brown unidentifiable material where the wall met the floor, measuring approximately two inches up the wall. Interview on 05/07/25 with LPN #146 confirmed the brown skid marks on the wall by the toilet and the brown substance on the walls surrounding the shower and all of the C Hall residents had access to the shower room. This violation represents noncompliance investigated under Master Complaint Number OH00165072 and Complaint Number OH00164179 and Complaint Number OH00161596 and Complaint Number OH00161253

CONCERN (E) 📢 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 F0628 (Tag F0628)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #10 revealed and admission date of 12/15/22 with diagnoses including diabetes, schizoaffective disorder and chronic kidney disease. Resident #10 was hospitalized from [DATE] to 12/13/24 and returned to the facility. Review of the MDS assessment for Resident #10 dated 04/01/25 revealed the resident had severely impaired cognition and was dependent on staff for ADLs. Interview on 05/06/25 at 2:25 P.M. with Regional Operations Manager (ROM) #501 confirmed the facility failed to provide a bed hold notice to Resident #10's representative for the resident's hospitalization from 11/14/24 to 12/13/24. 3. Review of the medical record for Resident #06 revealed an admission date of 12/30/21 with diagnoses including hypothyroidism, cardiomegaly, and atrial fibrillation. Resident #06 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the MDS assessment for Resident #06 dated 03/21/25, revealed the resident had mild cognitive impairment and required staff assistance with activities of daily living (ADLs) Interview on 05/06/25 at 1:46 P.M. with Business Office Manager (BOM) #104 confirmed the facility failed to provide a bed hold notice to Resident #06 for the hospitalization from 02/15/25 and 02/20/25. Interview on 05/06/25 at 2:02 P.M. with the Administrator confirmed the facility failed to the notify the Ombudsman of Resident #06's transfer to the hospital on [DATE]. Based on medical record review and staff interview, the facility failed to issue appropriate bed hold notices and/or Ombudsman notification when residents were discharged or transferred to the hospital. This affected four (Residents #06, #10, #197, #200) of five residents reviewed for discharge and hospitalization. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #200 revealed an admission date of 01/17/25 with a diagnosis of acute on chronic diastolic heart failure. The resident discharged to the hospital on [DATE] and did not return to the facility. Review of the Minimum Data Set (MDS) assessment for Resident #200 dated 01/23/25 revealed the resident had intact cognition. Review of the medical record for Resident #200 revealed the record did not include documentation of Ombudsman notification of the resident's transfer to the hospital on [DATE]. Interview on 05/06/25 at 2:02 P.M. with the Administrator confirmed the facility failed to the notify the Ombudsman of Resident #200's discharge to the hospital on [DATE]. 2. Review of the medical record for Resident #197 revealed an admission date of 02/04/25 with diagnoses including right hip fracture and osteomyelitis. Resident #197 transferred to the hospital on [DATE] and returned to the facility on [DATE]. The resident transferred to the hospital again on 03/20/25 and did not return. Review of the MDS assessment for Resident #197 dated 03/11/25 revealed the resident had severely impaired cognition. Review of the medical record for Resident #197 revealed the record did not include documentation of Ombudsman notification of the resident's transfers to the hospital on [DATE] and 03/20/25. Interview on 05/06/25 at 2:02 P.M. with the Administrator confirmed the facility failed to the notify the Ombudsman of Resident #197's transfers to the hospital on [DATE] and 03/20/25.

CONCERN (E) 📢 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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on review of medical records, observation, staff interview and review of the facility policy, the facility failed to serve food portions as planned by the Registered Dietitian (RD). This affected six (Residents #9, #13, #21, #30, #38, #65) of six residents with orders for a pureed diet. The facility census was 89 residents. Findings include: Review of the medical records for Residents #9, #13, #21, #30, #38 and #65 revealed the residents had physician's orders to receive a pureed diet. Observation of lunch being served on 05/07/25 at 11:27 A.M. revealed [NAME] #188 served pureed portions of barbeque ham sandwiches and pureed potatoes for Residents #9, #13, #21, #30, #38, and #65. [NAME] #18 used a four-ounce scoop to plate the pureed barbeque ham sandwiches and a three-ounce scoop for the potatoes. Further observation revealed there was a poster in the kitchen which explained coded measurement indicators on utensils for reference when portioning food. Review of the dietary spreadsheet for lunch on 05/07/25 revealed the barbeque ham sandwich portion should be five and one-half ounces and the potato portion should be four ounces. Dietary manager confirmed that inappropriate scoop sizes were being used for the pureed barbeque ham and pureed potatoes servings. Interview on 05/07/25 at 11:45 A.M with the Dietary Manager (DM) confirmed [NAME] #18 had used the wrong scoop sizes to plate the pureed barbeque ham sandwiches and potatoes for Residents #9, #13, #21, #30, #38, and #65. The DM confirmed [NAME] #18 had not followed the spreadsheet which had been planned and approved by the RD. Review of facility policy titled Kitchen Weights and Measures dated April 2007 revealed staff were to be trained in appropriate measurement and type of serving utensil to use for each food. This deficiency represents noncompliance investigated under Complaint Number OH00161596 and Complaint Number OH00164317.

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

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Based on observation, staff interview, and review of the facility policy, the facility to properly store, label and date food, failed to monitor refrigerator temperatures, failed to dry dishes in sanitary manner, failed to ensure staff prepared food in a clean and sanitary manner, and failed to ensure staff wore beard restraints during food preparation. This had the potential to affect all of the residents residing in the facility. The facility census was 89 residents. Findings include: 1. Observation 05/05/25 at 8:50 A.M. of the free-standing refrigerator revealed the following contents: an open undated jar of grape jelly, unlabeled and undated pitchers of orange drink, lemonade and red punch. Interview on 05/05/25 at 8:50 A.M. with the Dietary Manager (DM) confirmed the jar of jelly and the pitchers of drinks were unlabeled and undated. 2. Observation on 05/05/25 at 8:54 A.M of the walk-in refrigerator revealed temperature logs posted on the front of the refrigerator had not been completed. The refrigerator contained the following: an open and undated carton of a thickened beverage, open and dated containers of barbeque sauce, mayonnaise, sweet and sour sauce, Italian dressing, mustard, and pickle relish. Interview on 05/05/25 at 8:54 A.M. with the DM confirmed the temperature log on the outside of the walk-in refrigerator was not complete and there were open and undated food items in the refrigerator. Dietary manager #180 confirmed all containers to be opened and undated. 3. Observation of the dry storage area on 05/05/25 at 9:07 A.M. revealed the following: an open and undated box of cornstarch, an open, undated, and unlabeled box of cereal, 12 unlabeled and undated individual bowls of cereal. Interview on 05/05/25 at 9:07 A.M. with the DM confirmed there open, unlabeled and undated items in the dry storage area. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed all food stored in the refrigerator or the freezer would be covered, labeled and dated. The functioning of refrigeration and food temperatures would be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state specified requirements. 4. Observation on 05/05/25 at 9:10 A.M. revealed the insulated lids being used to cover breakfast plates were stored in a manner that allowed for pooling of water after being washed. Interview on 05/05/25 at 9:10 A.M. with the DM confirmed the lids had excess water pooling inside and should have been stored upside down so the water would have run off and allowed the plates to dry properly. 5. Observation on 05/07/25 at 11:27 A.M. revealed [NAME] #189 was wearing gloves as he began plating foods. [NAME] #189 used a set of tongs to remove buns from the pan, but he opened and closed buns using his gloved hand. [NAME] #189 touched utensils, the counter, plates, and rubbed his head while plating the food and wore the same pair of gloves the entire time. Interview on 05/07/25 at 11:37 A.M. with the DM confirmed [NAME] #189 did not change gloves and wash his hands while plating food as per the facility policy. 6. Observation on 05/07/25 at 12:03 P.M. revealed [NAME] #189 was observed put oven mitts over his gloves to remove a pan of from the oven. After placing pan in the steam table, [NAME] #189 removed the oven mitts and then continued to plate food with gloved hands and touching sandwich buns with his gloved hands. Interview on 05/07/25 at 12:08 P.M. with the DM confirmed [NAME] #189 placed oven mitts over his gloves to take a plan from the oven and place it in the steam table and then removed the oven mitt and continued to wear the same gloves to plate food with gloved hands and touching sandwich buns with gloved hands. The DM confirmed [NAME] #189 was not changing gloves and washing hands during food preparation as required. Review of facility policy titled Food Preparation and Service dated October 2017 revealed staff would adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. 7. Observation on 05/07/25 at 12:10 P.M. revealed [NAME] #184, [NAME] #189 and Dietary Aide (AD) #185 all had facial hair and were not wearing beard restraints while preparing lunch. Interview on 05/07/25 at 12:15 P.M. with the DM confirmed [NAME] #184, [NAME] #189, and AD #185 were not wearing beard restraints while preparing food and they should have been wearing beard restraints. Review of facility policy titled Food Preparation and Service dated October 2017 revealed food and nutrition staff shall wear hair restraints and beard restraints while preparing food to prevent hair from coming in contact with the food.

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

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Based on observation and staff interview, the facility failed to the washers were maintained in a clean manner and free of leaks. This had the potential to affect all of the residents residing at the facility. The facility census was 89 residents. Findings include: Observation on 05/08/25 at 9:21 A.M. of the facility's laundry room revealed there were four washers that had brown, blue and white build-up on the top and along the sides of the washers. Further observation of the laundry room revealed water was coming out of the water reserve tank behind the washers which had run onto the floor in front of the washers. Interview on 05/08/25 at 9:21 A.M. with Housekeeping Supervisor (HS) #900 confirmed there a brown, blue and white build- up on the top and along the sides of the washers. HS #900 confirmed water was coming out of the water reserve tank behind the washers and the water had run on the floor in front of the washers. HS #900 stated that the water on the floor was from the water reserve tank overflowing, and the water reserve tank had been overflowing for over a week onto the laundry room floor.

Nov 2024 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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of facility policy, the facility failed to ensure their policy regarding abuse was implemented when facility staff found a male and female resident in a bed together. This affected one (#4) of the two residents reviewed for abuse. The facility census was 95. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia, malnutrition, anxiety, depression and hypertension. Resident #4 resided on the secured memory care unit. Resident #4 had been deemed incompetent. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had severely impaired cognition, no range of motion impairment of upper and lower extremities and was frequently incontinent of bowel and bladder. The resident required supervision with eating, bed mobility and transfers, moderate assistance for oral and personal hygiene, toileting and dressing and maximal assistance for bathing. Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses of dementia and diabetes mellitus type II. Resident #41 resided on the secured memory care unit. Review of the quarterly MDS assessment dated [DATE] revealed the Resident #41 had moderate cognitive impairment, no range of motion impairment of upper and lower extremities and was always continent of bowel and occasionally incontinent of bladder. The resident required set up assistance with eating, supervision with oral hygiene, personal hygiene, toileting, bathing, and dressing and was independent for transfers. Review of Resident #41's admission MDS dated [DATE], quarterly MDS dated [DATE] and quarterly MDS dated [DATE] revealed the resident exhibited no physical or behavioral symptoms directed towards others. Review of the documents provided by the facility revealed facility staff statements were obtained from Registered Nurse (RN) #320, Licensed Practical Nurse (LPN) #415, Medication Technician #575, Certified Nursing Assistant (CNA) #550 and Resident #41 for a reported incident which occurred on 11/19/24. Additionally, the facility provided staff education on 11/20/24 for resident rights, abuse and neglect protocol and that all observed or suspected allegations are to be reported immediately to the Director of Nursing and to the Administrator, in relation to the alleged incident. The facility did not conduct a formal investigation of this incident or issue the formal findings. Review of the written statement submitted on 11/19/24 by Medication Technician #575 revealed Resident #4 was found in Resident #41's bed undressed and Resident #41 was sitting on the side of the bed. Resident #41 seemed confused and stated that Resident #4 had an odor. Review of the written statement submitted on 11/19/24 by LPN #415 revealed she did not witness any of the alleged events between Resident #4 and Resident #41. What she knows is only what was alleged by CNA #550. LPN #415 stated Resident #4 was previously seen in the living room which is next to Resident #41's room. Review of the interview document with RN #320, as provided by the Director of Nursing, revealed LPN #415 approached RN #320 regarding the alleged incident between Resident #4 and Resident #41. LPN #415 stated she overheard CNA #550 talking to other staff about the alleged incident in a casual and flippant manner. LPN #415 told RN #320 she never saw Resident #4 undressed but did see Resident #41 sitting on the edge of his bed. Resident #41 told LPN #415 he heard the girls talking and he was not on top of Resident #4. Resident #4 told LPN #415 that Resident #4 smells, and he wanted her out of his bed. LPN #415 confirmed Resident #41's bed was soaked, and she changed the sheets. Later that evening she stated she overheard CNAs talking about trying to get LPN #415 fired for not reporting this alleged incident. At the end of the shift RN #320 asked LPN #455 to walk LPN #415 to her car because CNA #550 was overheard talking about swinging on LPN #415. Review of the interview document with CNA #550 dated 11/20/24, as provided by the Director of Nursing, revealed CNA #550 walked into Resident #41's room and found him laying on top of Resident #4 with one hand in front of female and one hand in back like they were cuddling. She stated Resident #41 was dressed and Resident #4 didn't have a brief on and her gown was hanging on the bed. When she walked in Resident #41 rose up and sat on the edge of the bed. Review of the interview document with Resident #41 dated 11/20/24, as provided by the Director of Nursing, revealed Resident #41 thought a female resident followed him into his room. He was not sure if she was already in his room when he entered, but thought she may have followed him. He reported she lay down in his bed and then he laid down. Resident #41 stated he wanted to go to sleep, and the female resident smelled like explicit term. He reported he was next to her in the bed and said she acted like she didn't want to go anywhere. He told her she could stay but had to go to the unoccupied bed in the room. He repeated the female resident smelled really bad. When asked if he laid on top of her, Resident #41 stated, God no, you know the life, she was dead weight. I tried to move her, and the girl came in and it was all. I sat there (on the side of the bed). Resident #41 stated she had a gown on and was not sure if she had a brief on or if she took it off, but he denied removing her clothing or brief. He denied touching the resident's private parts and stated he was just trying to get her to move to the other bed. Interview on 11/25/24 at 12:28 P.M. with the Director of Nursing verified the alleged incident happened on the evening of 11/19/24 and she was not notified until 11/20/24. She verified she should have been notified on 11/19/24, a Self-Reported Incident (SRI) initiated, a formal investigation completed, and a formal report generated and submitted. The Director of Nursing verified staff statements were obtained from RN #320, LPN #415, Medication Technician #575 and CNA #550, that staff education was provided on 11/20/24 in the areas of resident rights, abuse and neglect protocol and that all observed or suspected allegations are to be reported immediately to the Director of Nursing and to the Administrator and that the Resident #41 was placed on one : one supervision on 11/20/24. Interview on 11/25/24 at 2:40 P.M. with Resident #41, revealed he had known the Resident #4 a long time and stated when he came into his room that evening, she was in the bed closest to the door. Resident #41 resides alone in a semi-private room with two beds. He wanted Resident #4 to move to the bed closest to the window and said he was going to lift her, but she smelled terrible. He said he laid down beside her to go to sleep, but she smelled terrible and that is when staff found her in his bed. He said there was no kissing or touching. He did not remember if the Resident #4 was dressed but he just kept saying she stinks, she stinks. Interview on 11/25/25 at 3:00 P.M. with the Administrator verified the facility policy on Abuse and Neglect was not followed with the incident involving Residents #4 and #41. The Administrator verified he was not notified until 11/20/24 and should have been notified on 11/19/24 of the incident. He also verified the alleged incident should have been reported within 24 hours, a formal investigation completed, and a formal report generated and submitted. Telephone interview on 11/26/24 at 9:17 A.M. with CNA #550 revealed she was not working on the secured memory care unit the evening of 11/19/24 but went there for resident nutrition supplies and that is when she was told by LPN #415 and Medication Technician #575, they were looking for Resident #4. CNA #550 said she assisted the staff by going room-to-room and that is when she found Resident #4 in bed with Resident #41. CNA #550 stated Resident #4 was dressed with a gown on and brief off, in the bed nearest the door and Resident #41 who was fully dressed was in the bed too. CNA #550 stated she did not see Resident #41 touching Resident #4 inappropriately in any way. In her statement dated 11/20/24, CNA #550 initially stated Resident #41 was on top of Resident #4 but when interviewed on 11/26/24 she stated Resident #41 was more lying next to Resident #4 in the bed. She stated Resident #41 just kept saying she stinks, she stinks. CNA #550 confirmed Resident #4's brief and the bed were soaked with urine. She finished by stating she reported what she saw to LPN #415, who with Medication Technician #575 came immediately to Resident #41's room. Telephone interview on 11/26/24 at 10:09 A.M. with LPN #415 verified she did not witness Resident #41 and Resident #4 in the bed together. LPN #415 said she observed Resident #41's bed had what appeared to be coffee stains on the sheets and she changed his bed linen after this incident had occurred. LPN # 415 referred to Resident #41 as a gentleman. When asked who she reported this incident to, LPN #415 stated she reported the allegation to RN #320 within 30 minutes of the incident occurrence. She was not sure when RN #320 reported it to the Director of Nursing. Interview on 11/26/24 at 11:24 A.M. with Medication Technician #575 verified she did not see Resident #41 physically touch Resident #4. By the time she got to the room Resident #41 was sitting on the side of the bed. Review of Self-Reported Incidents (SRIs) on the State of Ohio website revealed the facility did not complete an SRI related to this alleged incident. Review of the facility policy titled, Abuse and Neglect Protocol, revised date of 06/13/21, revealed it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Administrator or Director of Nursing. If such incidents occur after hours or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such an incident. If an incident of suspected abuse occurs, the facility shall report immediately, but not later than two hours after forming the suspicion, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to designated state agency. An immediate investigation will be made and a copy of the findings of such an investigation will be provided to the state agency within five working days or as designated by state law. This deficiency represents noncompliance investigated under Complaint Number OH00160042.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of facility's Self-Reported Incidents (SRIs), and facility policy review, the facility failed to timely report an an alleged incident of abuse. This affected one (#4) of the two residents reviewed for abuse. The facility census was 95. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia, malnutrition, anxiety, depression and hypertension. Resident #4 resided on the secured memory care unit. Resident #4 had been deemed incompetent. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had severely impaired cognition, no range of motion impairment of upper and lower extremities and was frequently incontinent of bowel and bladder. The resident required supervision with eating, bed mobility and transfers, moderate assistance for oral and personal hygiene, toileting and dressing and maximal assistance for bathing. Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses of dementia and diabetes mellitus type II. Resident #41 resided on the secured memory care unit. Review of the quarterly MDS assessment dated [DATE] revealed the Resident #41 had moderate cognitive impairment, no range of motion impairment of upper and lower extremities and was always continent of bowel and occasionally incontinent of bladder. The resident required set up assistance with eating, supervision with oral hygiene, personal hygiene, toileting, bathing, and dressing and was independent for transfers. Review of Resident #41's admission MDS dated [DATE], quarterly MDS dated [DATE] and quarterly MDS dated [DATE] revealed the resident exhibited no physical or behavioral symptoms directed towards others. Review of the documents provided by the facility revealed facility staff statements were obtained from Registered Nurse (RN) #320, Licensed Practical Nurse (LPN) #415, Medication Technician #575, Certified Nursing Assistant (CNA) #550 and Resident #41 for a reported incident which occurred on 11/19/24. Additionally, the facility provided staff education on 11/20/24 for resident rights, abuse and neglect protocol and that all observed or suspected allegations are to be reported immediately to the Director of Nursing and to the Administrator, in relation to the alleged incident. The facility did not conduct a formal investigation of this incident or issue the formal findings. Review of the written statement submitted on 11/19/24 by Medication Technician #575 revealed Resident #4 was found in Resident #41's bed undressed and Resident #41 was sitting on the side of the bed. Resident #41 seemed confused and stated that Resident #4 had an odor. Review of the written statement submitted on 11/19/24 by LPN #415 revealed she did not witness any of the alleged events between Resident #4 and Resident #41. What she knows is only what was alleged by CNA #550. LPN #415 stated Resident #4 was previously seen in the living room which is next to Resident #41's room. Review of the interview document with RN #320, as provided by the Director of Nursing, revealed LPN #415 approached RN #320 regarding the alleged incident between Resident #4 and Resident #41. LPN #415 stated she overheard CNA #550 talking to other staff about the alleged incident in a casual and flippant manner. LPN #415 told RN #320 she never saw Resident #4 undressed but did see Resident #41 sitting on the edge of his bed. Resident #41 told LPN #415 he heard the girls talking and he was not on top of Resident #4. Resident #4 told LPN #415 that Resident #4 smells, and he wanted her out of his bed. LPN #415 confirmed Resident #41's bed was soaked, and she changed the sheets. Later that evening she stated she overheard CNAs talking about trying to get LPN #415 fired for not reporting this alleged incident. At the end of the shift RN #320 asked LPN #455 to walk LPN #415 to her car because CNA #550 was overheard talking about swinging on LPN #415. Review of the interview document with CNA #550 dated 11/20/24, as provided by the Director of Nursing, revealed CNA #550 walked into Resident #41's room and found him laying on top of Resident #4 with one hand in front of female and one hand in back like they were cuddling. She stated Resident #41 was dressed and Resident #4 didn't have a brief on and her gown was hanging on the bed. When she walked in Resident #41 rose up and sat on the edge of the bed. Review of the interview document with Resident #41 dated 11/20/24, as provided by the Director of Nursing, revealed Resident #41 thought a female resident followed him into his room. He was not sure if she was already in his room when he entered, but thought she may have followed him. He reported she lay down in his bed and then he laid down. Resident #41 stated he wanted to go to sleep, and the female resident smelled like explicit term. He reported he was next to her in the bed and said she acted like she didn't want to go anywhere. He told her she could stay but had to go to the unoccupied bed in the room. He repeated the female resident smelled really bad. When asked if he laid on top of her, Resident #41 stated, God no, you know the life, she was dead weight. I tried to move her, and the girl came in and it was all. I sat there (on the side of the bed). Resident #41 stated she had a gown on and was not sure if she had a brief on or if she took it off, but he denied removing her clothing or brief. He denied touching the resident's private parts and stated he was just trying to get her to move to the other bed. Interview on 11/25/24 at 12:28 P.M. with the Director of Nursing verified the alleged incident happened on the evening of 11/19/24 and she was not notified until 11/20/24. She verified she should have been notified on 11/19/24, a Self-Reported Incident (SRI) initiated, a formal investigation completed, and a formal report generated and submitted. The Director of Nursing verified staff statements were obtained from RN #320, LPN #415, Medication Technician #575 and CNA #550, that staff education was provided on 11/20/24 in the areas of resident rights, abuse and neglect protocol and that all observed or suspected allegations are to be reported immediately to the Director of Nursing and to the Administrator and that the Resident #41 was placed on one : one supervision on 11/20/24. Interview on 11/25/24 at 2:40 P.M. with Resident #41, revealed he had known the Resident #4 a long time and stated when he came into his room that evening, she was in the bed closest to the door. Resident #41 resides alone in a semi-private room with two beds. He wanted Resident #4 to move to the bed closest to the window and said he was going to lift her, but she smelled terrible. He said he laid down beside her to go to sleep, but she smelled terrible and that is when staff found her in his bed. He said there was no kissing or touching. He did not remember if the Resident #4 was dressed but he just kept saying she stinks, she stinks. Interview on 11/25/25 at 3:00 P.M. with the Administrator verified the facility policy on Abuse and Neglect was not followed with the incident involving Residents #4 and #41. The Administrator verified he was not notified until 11/20/24 and should have been notified on 11/19/24 of the incident. He also verified the alleged incident should have been reported within 24 hours, a formal investigation completed, and a formal report generated and submitted. Telephone interview on 11/26/24 at 9:17 A.M. with CNA #550 revealed she was not working on the secured memory care unit the evening of 11/19/24 but went there for resident nutrition supplies and that is when she was told by LPN #415 and Medication Technician #575, they were looking for Resident #4. CNA #550 said she assisted the staff by going room-to-room and that is when she found Resident #4 in bed with Resident #41. CNA #550 stated Resident #4 was dressed with a gown on and brief off, in the bed nearest the door and Resident #41 who was fully dressed was in the bed too. CNA #550 stated she did not see Resident #41 touching Resident #4 inappropriately in any way. In her statement dated 11/20/24, CNA #550 initially stated Resident #41 was on top of Resident #4 but when interviewed on 11/26/24 she stated Resident #41 was more lying next to Resident #4 in the bed. She stated Resident #41 just kept saying she stinks, she stinks. CNA #550 confirmed Resident #4's brief and the bed were soaked with urine. She finished by stating she reported what she saw to LPN #415, who with Medication Technician #575 came immediately to Resident #41's room. Telephone interview on 11/26/24 at 10:09 A.M. with LPN #415 verified she did not witness Resident #41 and Resident #4 in the bed together. LPN #415 said she observed Resident #41's bed had what appeared to be coffee stains on the sheets and she changed his bed linen after this incident had occurred. LPN # 415 referred to Resident #41 as a gentleman. When asked who she reported this incident to, LPN #415 stated she reported the allegation to RN #320 within 30 minutes of the incident occurrence. She was not sure when RN #320 reported it to the Director of Nursing. Interview on 11/26/24 at 11:24 A.M. with Medication Technician #575 verified she did not see Resident #41 physically touch Resident #4. By the time she got to the room Resident #41 was sitting on the side of the bed. Review of Self-Reported Incidents (SRIs) on the State of Ohio website revealed the facility did not complete an SRI related to this alleged incident. Review of the facility policy titled, Abuse and Neglect Protocol, revised date of 06/13/21, revealed it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Administrator or Director of Nursing. If such incidents occur after hours or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such an incident. If an incident of suspected abuse occurs, the facility shall report immediately, but not later than two hours after forming the suspicion, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to designated state agency. An immediate investigation will be made and a copy of the findings of such an investigation will be provided to the state agency within five working days or as designated by state law. This deficiency represents noncompliance investigated under Complaint Number OH00160042.

Jul 2024 5 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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure residents had access to call lights. This affected one (Resident #46) of five residents sampled for call lights. The facility census was 93. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type II diabetes, and chronic viral hepatitis C. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of care plan dated 11/22/2022 revealed Resident #46 had an Activities of Daily Living (ADL) self-care performance deficit related to disease process and required staff assistance to complete ADL tasks. Interventions included encourage the resident to utilize the call light for assistance as needed, keep the call light within reach, and encourage the resident to participate as possible with each interaction. Observation on 07/25/2024 at 9:08 A.M. State Tested Nurse Aide (STNA) #155 sanitized hands, donned gloves, and entered Resident #46's room. The room had a sign on the door for Enhanced Barrier Precautions (EBP) which indicated gowns and glows were to be worn for high-contact patient care including incontinence care, and there was plastic bin located outside of the door in the hallway which contained Personal Protective Equipment (PPE) including boxes of gloves and individually wrapped isolation gowns. STNA #155 provided incontinence care, repositioned the resident in the bed, and placed the bedside table over the bed per the resident request. The call light was on the floor. STNA #155 doffed her gloves, washed her hands with soap and water, and exited the room. Observation on 07/25/2024 from 9:18 A.M. to 9:51 A.M. revealed no staff entered Resident #46's room. At 9:51 A.M. STNA #25 asked Resident #46 if he was finished with his breakfast and removed the dishes per his request. STNA #25 moved the tray table away from the bed and stated she would return to provide repositioning after she took the dishes to the kitchen cart. Resident #46's call light remained on the floor behind the bed. STNA #25 doffed her gown and gloves, sanitized her hands and left the room with the dishes. Observation on 07/25/2024 at 9:55 A.M. STNA #25 repositioned Resident #46 in bed and clipped his call light to the top blanket. During an interview on 07/25/2024 at 10:02 AM STNA #25 verified she had not been in Resident #46's room since before breakfast and had not checked to ensure Resident #46 had access to his call light before she left the room with his breakfast dishes. STNA #25 verified Resident #46's call light had been non the floor under the bed and was out of the resident's reach. Review of policy titled Answering the Call Light dated 03/2021 revealed the call light was placed within easy reach of residents who were in bed or confined to a chair. This deficiency represents noncompliance investigated under complaint number OH00154541.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to ensure residents received wound care as ordered. This affected one (Resident #41) of one resident of two reviewed for wounds. The facility census was 93. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included ataxic cerebral palsy, idiopathic gout, morbid obesity, type II diabetes, chronic diastolic heart failure, unspecified Chronic Obstructive Pulmonary Disease (COPD), and hemiplegia/hemiparesis following cerebral infarction. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 06/27/2023 revealed Resident #41 was at increased risk for pressure ulcer development related to disease process. Interventions included, administer medications as ordered, administer treatments as ordered, and follow facility protocols for the preventions and treatment of skin breakdown. Review of progress note dated 07/20/2024 at 10:45 PM revealed Resident #41 reported he had hit his leg on the air conditioning unit causing a skin tear. Review of the medical record revealed Resident #41 had a physician order dated 07/20/2024 to cleanse skin tear to left shin with Normal Saline (NS), apply Xeroform dressing, and cover with bordered dressing every day on night shift until resolved. Observation on 07/24/2024 at 10:10 A.M. revealed Resident #41 asked Licensed Practical Nurse (LPN) #90 to look at the bandage on his left lower leg. Resident #41 stated he had bumped his leg on his air conditioning unit a few days ago and the dressing had never been changed. Resident #41 had a bordered gauze dressing with noticeable scant, dark red drainage that was dated 7/21/2024. During an interview on 07/24/2024 at 10:10 A.M. LPN #90 verified Resident #41 had a dressing on his left lower leg that was dated 07/21/2024. Review of policy titled Wound Care dated 10/2010 revealed wound care was completed as per physician's orders to promote healing. This deficiency represents noncompliance investigated under complaint number OH00154541.

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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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 residents received pain medications timely. This affected one (Resident #75) of six residents sampled for medication administration. The facility census was 93. Findings include: Review of the medical record revealed Resident #75 admitted to the facility on [DATE] with diagnoses including chronic ischemic heart disease, vitamin chronic pain disease, depression, adjustment disorder with depressed mood, pain in right hip, pain in right shoulder, anxiety disorder, and dermatitis. Resident #75 had no recorded diagnosis for Alzheimer's disease or any other form of dementia. Review of Resident #75's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, had no behaviors, did not wander, and did not reject care. Review of care plan dated 03/24/2024 revealed Resident #75 had chronic pain related to arthritis and depression. Interventions included to administer analgesia medications per physician orders, monitor and document each pain episode, monitor/document the effects of pain medication, and notify the physician if interventions were unsuccessful or there was a significant change from the resident's experience of pain. Review of the medical record revealed Resident #75 had a physician's order for routine pain medication dated 07/02/2024 for Oxycodone (opioid) 10 milligrams (mg) by mouth four times a day and an order dated 07/16/2024 at 2:50 A.M. for Oxycodone 10 mg one tablet by mouth one time only for pain. Review of the Medication Administration Record dated July 2024 revealed Resident #75 had last had her scheduled Oxycodone 10 mg on 07/15/2024 at 9:00 P.M. and the one-time dose of Oxycodone 10 mg was not administered until 07/16/2024 at 5:21 A.M. During an interview on 07/24/2024 at 3:11 P.M. Resident #75 stated she saw a psychiatrist about a year ago who told her family she was bordering on Alzheimer's disease. She said she only took Xanax (antianxiety) and an anti-depressant but no dementia medications. Resident #75 stated the nurses never identified the medications they administered and often didn't know when you asked what they were. Resident #75 stated that one night a few weeks ago, unspecified, she looked for a nurse for three hours because she needed something for abdominal pain, and no one could find her. During an interview on 07/25/2024 at 6:46 A.M. the Director of Nursing (DON) stated there was a nurse she had terminated last week, because Resident #75 had complained she could not find her. The DON investigated Resident #75's complaint and determined a nurse had been off the floor for an undetermined amount of time on 07/15/24. The DON reveaeld the nurse said she had to run home for an unidentified reason and stated the drive one-way was approximately 30 minutes. When the DON checked the time-punch records, the nurse had only been clocked out for about 20 minutes. When asked to explain the nurse became very defensive, used profanity and disconnected the call. During an interview on 07/25/2024 at 8:07 A.M. Human Resources (HR) #115 confirmed she was present on the team telephone call when the DON questioned Licensed Practical nurse (LPN) #145. HR #115 stated LPN #145 stated she had to run home and it was a thirty-minute drive. She stated she had clocked out. They checked the punches and she had been clocked out less than thirty minutes. When they asked LPN #145 to explain she began to swear and would not let the DON get a word in. She hung up and essentially terminated her own employment. During a telephone interview on 07/25/2024 at 12:27 P.M. Registered Nurse (RN) #68 stated he had worked night shift on 07/15/2024. RN #68 stated Resident #75 came to him and stated her nurse had been gone for over an hour. RN #68 stated Resident #75 had no visible signs of distress and was complaining of pain. RN #68 stated he looked around the facility and asked staff. No one had seen LPN #145 or knew her whereabouts. I told Resident #75 that LPN #145 had not stated to any staff that she was leaving and asked her to wait an additional 15 minutes for the nurse to return. RN #68 stated that Resident #75 did not have an order for pain medication due at that time, so he called the nurse practitioner and got a one-time order for Oxycodone. LPN #145 returned in about 15 minutes. RN #68 stated he could not confirm what time LPN #145 left or how long she had been absent. RN #68 stated she reported to LPN #145 that Resident #75 needed pain medications and educated the LPN that she needed to notify staff before leaving the floor. RN #68 stated that LPN #145 put the order in for the Oxycodone right away, but he returned to his unit and did not witness the medication being administered. RN #68 stated he had been assigned to Resident #75 's care before and knew she was routinely taking Oxycodone 10 mg. RN #68 stated the medication would have been available in the med cart and there would not have been a delay in administration related to having to get authorization to pull from the emergency drug kit. During an interview on 07/16/2024 the DON confirmed that the records revealed LPN #145 had entered a physician order on 07/16/2024 at 2:50 A.M. for Resident #75 for a one-time dose of Oxycodone 10 mg and the dose was not administered until 5:21 A.M. Review of policy titled Administering Medications dated April 2019 revealed medications were administered in a timely manner in accordance with prescriber orders. This deficiency represents noncompliance investigated under complaint number OH00154541.

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and policy review, the facility failed to ensure residents received medications as ordered and to maintain a medication error rate of less than 5%. This affected two (Residents #41 and #51) of six residents sampled for medication administration. The facility census was 93. Findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included ataxic cerebral palsy, idiopathic gout, morbid obesity, type II diabetes, chronic diastolic heart failure, unspecified Chronic Obstructive Pulmonary Disease (COPD), and hemiplegia/hemiparesis following cerebral infarction. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the medical record revealed Resident #41 had physician orders for Cymbalta Delayed Release (antidepressant) 20 mg capsule by mouth once daily, Amlodipine (antihypertensive) 10 mg, and Pataday (allergy eye drop) ophthalmic solution 0.1% - Instill one drop in both eyes once daily. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included unspecified Parkinsonism, unspecified dementia, unspecified COPD, type II diabetes, and Barrett's esophagus without dysplasia. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 04/01/2024 revealed Resident #51 had Parkinson's. Interventions included adaptive devices as ordered, diet as ordered, encourage daily exercise, and give medications as ordered by physician. Review of the medical record revealed Resident #51 had physician orders dated 03/19/2024 for Rytary Oral Capsule Extended Release (antiparkinsonian agent) 23.75-95 MG give one capsule by mouth two times a day for Parkinson's. Observation on 07/24/2024 from 8:57 A.M. to 10:10 A.M. of medication pass revealed Licensed Practical Nurse (LPN) #90 administered 26 out of 30 ordered medications to five residents (Residents #41, #51, #52, #73, and #64) resulting in an error rate of 13.3% . Resident #51 did not receive Rytary Extended Release (ER) 23.75-95 mg for Parkinson's, and Resident #41 did not receive Amlodipine 10 mg (hypertension), Cymbalta Delayed Release 20 mg (depression), and Pataday 0.1% ophthalmic solution (allergy)- one drop to both eyes once daily- as ordered due to the medications were unavailable. During an interview on 07/24/2024 at 10:10 A.M. LPN #90 verified Residents #41 and #51 were not administered all their prescribed medications because the medications were unavailable. Review of policy titled Administering Medications dated April 2019 revealed medications were administered in accordance with prescriber orders. This deficiency represents noncompliance investigated under complaint numbers OH00154906 and OH00154541.

CONCERN (F) 📢 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 most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing high-contact care to residents in Enhance Barrier Precautions (EBP). This had the potential to affect all residents. The facility census was 93. Findings include: Review of the medical record revealed Resident # 46 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type II diabetes, and chronic viral hepatitis C. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 04/26/2024 revealed Resident #46 had Enhanced Barrier Precautions (EBP) secondary to increased risk for potential infection related to Candida Auris. Interventions included educating residents and caregivers regarding infection prevention, following EBP, and performing hand hygiene before and after delivery of care. Review of the medical record revealed Resident #46 had physician orders dated 05/26/2023 for Isolation: Enhanced Barrier Precautions due to Candida Auris positive. Observation on 07/25/2024 at 9:08 A.M. State Tested Nurse Aide (STNA) #155 sanitized hands, donned gloves, and entered Resident #46's room. The room had a sign on the door for Enhanced Barrier Precautions (EBP) which indicated gowns and glows were to be worn for high-contact patient care including incontinence care, and there was plastic bin located outside of the door in the hallway which contained Personal Protective Equipment (PPE) including boxes of gloves and individually wrapped isolation gowns. STNA #155 provided incontinence care, repositioned the resident in the bed, and placed the bedside table over the bed per the resident request. STNA #155 doffed her gloves, washed her hands with soap and water, and exited the room. During an interview on 07/25/2024 at 9:14 A.M. STNA #155 verified she did not wear a gown while providing incontinence care. STNA State she was educated regarding general isolation precautions but did not know what Enhanced Barrier Precautions (EBP) were or why Resident #46 was in EBP. Review of policy titled Enhanced Barrier Precautions dated 08/2022 revealed gloves and gowns were applied prior to high-contact resident care to prevent the spread of multi-drug resistant organisms to residents. This deficiency represents noncompliance investigated under complaint numbers OH00154906 and OH00154541.

May 2024 3 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, and staff and resident interviews, the facility failed to ensure a pressure ulcer dressing change was completed per physician orders. This affected one (#93) of three residents reviewed for pressure ulcers. The facility identified four pressure ulcers in the facility. The facility census was 99. Findings include: Review of Resident #93's medical record revealed an admission date of 11/14/23. Diagnoses included neurogenic bladder, peripheral vascular disease, depression, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/21/24, revealed Resident #93 was cognitively intact. Further review revealed Resident #93 required set-up and clean-up assistance for eating, partial/moderate assistance for toileting, and supervision/touching assistance for bed mobility. Additionally, Resident #93 was coded for a stage four pressure ulcer to her sacrum and had a colostomy. Review of the most recent care plan revealed Resident #93 had a pressure ulcer to her sacrum related to immobility. Interventions included to document treatments as ordered and follow the facility policies/protocols for prevention/treatment of skin breakdown. Additionally, if the resident refused the treatment, confer with the resident, interdisciplinary team (IDT) and family to determine why and document. Review of a physician order, dated 04/18/24, revealed to cleanse the wound to the sacrum with normal saline, pat dry, pack the wound with calcium alginate with silver and cover with a Mepilex (antimicrobial foam dressing) and change on every shift. Review of the Treatment Administration Record (TAR) dated 04/30/24 revealed Resident #93's wound care treatment was documented as completed on the night shift. Observation on 05/01/24 at 9:07 A.M. of Resident #93's wound dressing to the sacrum revealed the dressing was undated. Concurrent interview with Resident #93 revealed her dressing was not changed on 04/30/24. Resident #93 denied refusing wound care treatment. Interview on 05/01/24 at 10:05 A.M. with agency Licensed Practical Nurse (LPN) #131 confirmed she did not complete Resident #93's wound treatment on the night shift on 04/30/24. LPN #131 stated the resident refused the treatment but she did not document Resident #93 refused. LPN #131 verified she documented the treatment as completed even though it had not been done. This deficiency represents non-compliance investigated under Complaint Number OH00152739.

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 F0691 (Tag F0691)

Could have caused harm · This affected 1 resident

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Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure proper colostomy care was provided. This affected one (#77) of three residents reviewed for colostomy care. The facility identified three residents with colostomies. The facility census was 99. Findings include: Review of Resident #77's medical record revealed an admission date of 03/13/23. Diagnoses included chronic ischemic heart disease, coronary artery disease, renal insufficiency, anxiety, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 03/14/24, revealed Resident #77 was cognitively intact. Further review revealed Resident #77 required substantial/maximal assistance for toileting and partial/moderate assistance for bed mobility and transfers. Resident #77 was coded as having a colostomy. Review of the plan of care, dated 03/20/24, revealed Resident #77 required the use of a colostomy. Interventions included to provide ostomy care per order to prevent odors and keep the ostomy patent. Observation on 05/07/24 at 1:14 P.M. of colostomy care for Resident #77, with Licensed Practical Nurse (LPN) #140, revealed he washed his hands and applied gloves. LPN #140 removed the dressing and the wafer. Under the wafer there was dried feces on the resident's skin. LPN #140 proceeded to clean the stool from the resident's skin with wipes and a dry towel. LPN #140 opened the package of skin prep and applied around the area of the stoma, opened the wafer package and placed the wafer over the stoma and opened the dressing package and placed a dressing on the wafer. LPN #140 did not perform hand hygiene or change his gloves during the observation. Interview on 05/07/24 at 1:30 P.M. with LPN #140 verified he did not perform hand hygiene or change his gloves when moving from dirty to clean while performing colostomy care for Resident #77. Review of the facility policy titled Colostomy/Illestomy Care, revised October 2010, revealed the procedure included the following steps: wash and dry hands thoroughly, put on gloves, remove drainage bag, remove gloves, wash hands, put on clean gloves, cleanse skin with appropriate skin cleansing preparation, discard disposable items into designated containers, remove and discard gloves, and wash and dry hands thoroughly. This deficiency represents non-compliance investigated under Master Complaint Number OH00153494.

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 F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

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Based on medical record review, staff interview and review of facility policy, the facility failed to ensure the attending physician completed resident visits every 60 days. This affected two (#2 and #3) of three residents reviewed for physician visits. The facility census was 99. Findings included: 1. Review of the medical record for Resident #2 revealed an admission date of 01/24/21. Diagnoses included hypertension, hyperlipidemia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/30/24, revealed Resident #2 was severely cognitively impaired. Further review of Resident #2's medical record from 12/01/23 through 05/07/24 revealed no evidence of a physician visit. 2. Review of the medical record for Resident #3 revealed an admission date of 01/13/23. Diagnoses included hypertension, dementia, hyperlipidemia, and traumatic brain injury. Review of quarterly MDS assessment, dated 04/24/24, revealed Resident #3 was severely cognitively impaired. Further review of Resident #3's medical record from 12/01/23 through 05/07/24 revealed no evidence of a physician visit. Interview on 05/07/24 at 11:59 A.M. with Nurse Practitioner (NP) #150 revealed she visited the facility on Tuesdays and Thursdays. She stated Medical Doctor (MD) #160 only visited the facility if there was a new admission or if a resident was sick. Interview on 05/09/24 at 1:21 P.M. with MD #160 verified she had not seen Residents #2 and #3 since December 2023 and it had been an oversight on her part. Review of the policy entitled Physician Visits dated 04/01/13 revealed the attending physician must make visits in accordance with applicable state and federal regulations. Further review revealed the attending physician must visit his/her patients at least once every 30 days for the first 90 days following a resident's admission and then at least every 60 days thereafter. After the first 90 days, if the attending physician determines that a resident need not be seen by him/her every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A Physician Assistant or Nurse Practitioner may make alternate visits after the initial 90 days following admission, unless restricted by law or regulation. This deficiency represents non-compliance investigated under Master Complaint Number OH00153494.

Nov 2023 15 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected two (Residents #47 and #44) of two residents reviewed for dignity and respect. The census was 97. Findings included: 1. Medical record review for Resident #47 revealed an admission date of 09/15/18. Medical diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Her functional status was supervision for eating, substantial/maximal for toileting, supervision for transfers, and partial/moderate assistance for bed mobility. She was always incontinent for bladder and frequently incontinent for bowels. Observation on 11/14/23 at 11:30 A.M. revealed State Tested Nurse Aide (STNA) #168 was assisting Resident #47 with getting dressed. The resident said, Help me, constantly and STNA #160 said in a hateful tone of voice, Stop it, I am helping you. STNA #160 continued to help the resident and said in a hateful tone again, Stop making all of that noise. With the surveyor present, STNA #168 continued to help the resident while the resident continued to say, Help me, and STNA #168 said, What am I chopped liver? I am helping you. STNA #168 put on the resident's sweatshirt while the resident said, Help me and STNA #168 said again, What am I chopped liver? I am helping you. Interview on 11/14/23 at 11:49 A.M. with STNA #168 confirmed she was irritated with Resident #47 because she kept repeating herself constantly while she was helping her. STNA #168 stated she knew the resident suffered from dementia and had behaviors of repeating herself, but it still irritated her. STNA #168 stated she was only joking with the resident. 2. Medical record review for Resident #44 revealed an admission date of 02/03/18. Medical diagnoses included coronary artery disease, heart failure, diabetes, Alzheimer's, dementia, and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was severely cognitively impaired. Her functional status was substantial/maximal for eating, bed mobility, dependent for toileting, and she required a Hoyer lift for transfers. Observation on 11/13/23 at 11:51 A.M. revealed agency STNA #170 was in the dining room feeding Resident #44 standing up with gloves on. Interview on 11/13/23 at 11:53 A.M. with STNA #170 confirmed she was standing in the dining room feeding the resident and was wearing gloves to feed her. Interview at the time of observation revealed she shouldn't be feeding the resident this way. Observation on 11/16/22 at 8:22 A.M. revealed agency STNA #171 wearing gloves in the dining room while residents were eating. She opened a carton of orange juice and placed a straw in the carton and placed the straw up to Resident #44's mouth to drink with her gloves on. Interview on 11/16/23 at 8:25 A.M. with STNA #171 confirmed she was wearing gloves in the dining room and confirmed she had gloves on while serving Resident #44 her orange juice, and stated she wasn't supposed to wear gloves in the dining area unless she was touching food. Review of policy entitled Dignity dated 02/01/21 revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are always to be treated with dignity and respect. Staff are always to speak respectfully to residents. Review of policy entitled Using Gloves dated 04/01/13 revealed the staff should wear gloves: 1. When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. 2. When the employee's hands have any cuts, scrapes, wounds, chapped skin, or dermatitis. 3. When cleaning up spills or splashes of blood or body fluids. 4. When cleaning potentially contaminated items.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives were consistent within the medical record. This affected one resident (Resident #33) of eight residents reviewed for advanced directives. The facility census was 97. Findings include: Review of Resident #33's medical record revealed an admission date of 02/08/22. Diagnoses included Parkinson's disease, acute and chronic respiratory failure, acute pulmonary edema, heart failure, psychotic disorder with delusions due to known physiological, dementia, anxiety, and major depression disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was mildly cognitively impaired. Review of Resident #33's paper medical record revealed a Do Not Resuscitate (DNR) Order Form dated 02/09/22 revealing the resident's advanced directive was DNR Comfort Care Arrest. Review of the current physician order dated 08/15/22, located in the electronic medical record (EMR), revealed Resident #33's advanced directive was Do Not Resuscitate Comfort Care (DNRCC), meaning providers will conduct an initial assessment, perform basic medical care, clear airway of obstruction or suction, if necessary for comfort or to relieve distress, may administer oxygen, CPAP or BiPAP, if necessary, may obtain access for hydration or pain medication to relieve discomfort, but not to prolong death, if possible, may contact other appropriate health care providers. Interview on 11/13/23 2:19 P.M. with Licensed Practical Nurse (LPN) #158 stated staff members could check either the paper chart or the EMR to determine a resident's advanced directives, if needed. LPN #158 verified Resident #33's advanced directives order in the EMR did not match the order in the paper chart, and stated she would take care of correcting it. Review of facility policy titled, Do Not Resuscitate Order, dated April 2017 revealed documentation of advanced directives will be maintained by the facility in the resident's medical record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident received regular care conferences. This affected one (Resident#29) of one reviewed for care conferences. The census was 97. Findings include: Review of Resident #29's medical record revealed an admission date of 12/26/22. Diagnoses listed included prostate cancer, spinal stenosis, major depressive disorder, hypertension, and Parkinson's disease. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact and required extensive assistance with activities of daily living (ADLs). Further review of MDS information revealed quarterly assessments were completed on 04/04/23, 07/04/23, and 09/07/23. Review of social service progress notes revealed a care conference was last held for Resident #29 on 03/16/23. During an interview on 11/15/23 at 10:28 A.M. the Administrator confirmed a care conference was not held for Resident #29 since March 03/16/23. The Administrator confirmed care conferences should be held at least quarterly.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide incontinence care per standards of care. This affected one (Resident #47) of one resident observed for incontinence care. The facility census was 97. Findings include: Medical record review for Resident #47 revealed an admission date of 09/15/18. Medical diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was severely cognitively impaired. Her functional status was supervision for eating, substantial/maximal for toileting, supervision for transfers, and partial/moderate assistance for bed mobility. She was always incontinent for bladder and frequently incontinent for bowels. Observation of incontinence care for Resident #47 on 11/14/23 at 11:43 A.M. revealed STNA #168 removed a soiled brief from the resident, stood her up on her walker, and took a wet towel and bent the resident over and wiped her from the front to the back, and then took a dry towel and dried the resident from front to back. STNA #168 did not clean the labia and she did not wash the peri area on the front of the resident. Interview with STNA #168 on 11/14/23 at 11:49 A.M. confirmed she did not clean Resident #47's labia or peri area. Review of the facility policy titled, Perineal Care, dated 10/01/10 revealed for a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia. (3) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (4) Gently dry perineum. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, resident interview, and review of facility policy, the facility failed to complete a urinalysis as ordered. This affected one (Resident #78) of one resident reviewed for laboratory services. The facility census was 97. Findings include: Review of medical record for Resident #78 revealed an admission date of 03/17/23. Diagnoses included delusional disorders, chronic viral hepatitis C, depression, type 2 diabetes mellitus with hyperglycemia, opioid abuse, other stimulant abuse, vascular dementia moderate with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had a Brief Interview of Mental Status score of 15, indicating no cognitive impairment. Resident #78 required staff assistance to complete Activities of Daily Living (ADL) tasks. Resident #78 was occasionally incontinent of bladder. Review of nurse's notes for Resident #78 dated 10/18/23 at 4:18 P.M. revealed the resident was noted with increased behaviors as well as reports dysuria (painful urination). Urine was with foul odor. The physician was notified and a new order for urinalysis and culture and sensitivity was received. Review of physician orders revealed an order dated 10/18/23 for a urinalysis and culture and sensitivity. Review of nurse's notes for Resident #78 dated 10/19/23 at 5:57 A.M. revealed the resident was encouraged to void in the bathroom in order to obtain urine for the urinalysis. Resident #78 was noted to be incontinent throughout the shift and changed her pull ups. Review of nurse's notes for Resident #78 dated 10/20/23 at 12:37 A.M. revealed the resident voided in a collection hat earlier in the shift but the specimen was contaminated with feces. Further review of the nurses' notes revealed no documentation the resident's urine was collected for the urinalysis or a urinalysis was completed, and no documentation showing the physician was notified of staff being unable to obtain urine. Further review of the medical record revealed no orders for straight catherization. Interview on 11/15/23 at 8:49 A.M. with Licensed Practical Nurse (LPN) Unit Manager #87 revealed she thought the physician was notified, along with family, that the facility was unable to obtain urine for Resident #78, and that the physician ordered a straight catheterization but the resident refused. LPN Unit Manager #87 verified there was not an order for the straight catheterization. LPN Unit Manager #87 also verified there was no documentation showing the physician was notified of urinalysis not being completed. Interview on 11/15/23 at 4:29 P.M. with Resident #78 revealed she did not refuse catheterization for a urine sample last month, and that it was never offered. Further interview revealed a urine sample was collected yesterday, 11/14/23, via catheterization. Interview on 11/16/23 at 8:26 A.M. with the Director of Nursing verified the urinalysis was not collected and there was no documentation related to physician notification of the urinalysis not being completed. Review of the Urinary Tract Infections/Bacteriuria - Clinical Protocol dated June 2014 revealed as part of the initial assessment, the physician will help identify individuals who have a history of symptomatic urinary tract infection, and those who have risk factors for urinary tract infections. The physician will order appropriate treatment for verified or suspected urinary tract infections based on a pertinent assessment.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of the medical record for Resident #78 revealed an admission date of 03/17/23. Diagnoses included delusional disorders, chronic viral hepatitis C, depression, type 2 diabetes mellitus with hyperglycemia, opioid abuse, other stimulant abuse, vascular dementia moderate with agitation. Review of the MDS assessment dated [DATE] revealed Resident #78 had a Brief Interview of Mental Status score of 15, indicating the resident was cognitively intact. Resident #78 required staff assistance with completion of Activities of Daily Living (ADLs). Resident #78 was occasionally incontinent of bladder. Observation on 11/13/23 at 10:17 A.M. with Resident #78 revealed thick dust present on the television, dresser and bedside table. Resident #78's room smelled of urine and the bed was noticeably wet with yellow color noted. Observation on 11/14/23 at 8:40 A.M. with Resident #78 revealed thick dust continued to be present on the television and dresser. Interview with Resident #78 revealed she has concerns with housekeeping and thinks they have been on strike for a couple weeks. Resident #78's room smelled of strong urine odor. Interview on 11/14/23 at 8:43 A.M. with the Administrator verified Resident #78's television and dresser had thick dust built up and the room smelled of strong urine odor. Review of the Two-Week Employee Schedule for Housekeeping revealed all rooms are scheduled to be cleaned thirteen out of fourteen days. Review of facility Bedroom Policy Statement dated May 2017 revealed all residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. 5. Observation on 11/13/23 at 11:16 A.M. of Unit B Memory Care dining room revealed food stains and dried food on the interior wall measuring one foot by two foot. Over the entire wall surface, measuring 8 foot by six foot, the wall paint was discolored with splotchy areas of red and turquoise areas. Surrounding walls were gray blue with no splotchy areas. Interview on 11/13/23 at 11:16 A.M. the Unit Manager #75 verified the wall was spoiled with dried food and was discolored due to improper use of a chemical cleaner. Observation on 11/13/23 11:19 A.M. revealed Housekeeper #81 attempting to clean dried food on the interior wall of the dining room. The chemical cleaner made splotchy areas and turned the wall a turquoise color as it was cleaned. Interview with Housekeeper #81 verified the wall was being discolored by the cleaner she was using, which included bleach. She stated the wall should have been a blue gray, like the remaining walls in the dining room. Housekeeper #81 verified the wall had dried food and it did not appear homelike with the discolored wall. Interview on 11/13/23 at 11:28 A.M. with Housekeeping Supervisor #76 verified the wall was discolored due to incorrect cleaner being used and the wall should be repainted. 6. Record review of Resident #55 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #55 included Alzheimer Disease, restlessness and agitation, and psychotic disturbance. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive assistance with bed mobility and transfers. Observation on 11/15/23 at 10:17 A.M. revealed Resident #55's bed's headboard was loose, and on the left side, was not attached to the bed. Resident #55's wheelchair armrests, left and right sides, were cracked with jagged edges exposing a non-cleanable material. Interview on 11/15/23 at 10:18 A.M. with State Tested Nurse Aide, (STNA) #52 verified the bed's headboard was not attached to the bed on the left side. She stated the headboard appeared to be missing a screw and stated she did not know how long it had been unattached from Resident #55's bed. STNA #52 also verified both wheelchair armrests were split open exposing non cleanable material. STNA stated Resident #55's skin was fragile skin and the armrests were often soiled during meals. 7. Record review of Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #30 included malignant neoplasm of the skin infections of the central nervous system and dementia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive assistance for bed mobility. Observation on 11/15/23 at 10:03 A.M. revealed Resident #30 had a bed mattress with no linen. The mattress had a split along the left outer edge, from the top of the mattress to the middle length of the mattress, about four foot long and the eight inches width of the mattress. The split mattress protective layer exposed the inner foam of the mattress. Interview on 11/15/23 at 10:10 A.M. with State Tested Nurse Aide (STNA) #52 verified the mattress was split and the inner foam was exposed. STNA #52 stated the resident grabs the side of the mattress when moving in bed and was unsure how long the mattress had been split open. STNA #52 verified the resident was incontinent and the mattress foam could become soiled. Based on observation, staff interviews, resident interviews, and policy review, the facility failed to ensure residents had a safe, comfortable, and homelike environment. This affected eight (Residents #36, #13, #58, #45, #86, #55, #30, and #78) of eight residents reviewed for environment. Additionally, this affected all residents residing on the Unit B Memory Care Unit (MCU). The census was 97. Findings included: 1. Observation of Resident #36's and Resident #13's room on 11/13/23 at 2:19 P.M. revealed the walls in the room had plaster on them that didn't match the paint, there were scuff marks on the sliding door that went into the bathroom, and the top of the vanity was scarred up and had ink of newspaper imbedded in the top of it. 2. Observation of Resident #58's and Resident #45's room on 11/14/23 at 7:18 A.M. revealed dry wall was missing from the sliding door that went into the bathroom. 3. Observation and interview 11/15/23 at 8:21 A.M. with Resident #86 revealed she was sitting in her room with a jacket on and said it was cold in her room. She stated she told a nurse about the room temperature, but no one came to look at it. Resident #86 said her sliding glass door was cloudy too. A text message was sent to Maintenance Director (MD) #112 by Licensed Practical Nurse (LPN) #4 requesting him to look at the temperature in Resident #86's room. Interview on on 11/15/23 at 1:30 P.M. with MD #112 verified he hasn't checked his text messages, and proceeded to check them and discovered he had one from the nurse about the temperature in Resident #86's room. Observation on 11/16/23 at 8:30 A.M. revealed Resident #86 was in the hall with a jacket on and said no one came to look at her temperature in her room. Observation and interview on 11/16/23 at 9:00 A.M. with MD #112 revealed he looked at the Resident #86's unit in her room yesterday but needed a part to fix it. He checked the temperature in the room of the resident, and it was 69.5 degrees. He got down on his knees and opened the heating and air conditioning unit and said he was able to fix it. Review of policy titled, Quality of Life-Homelike Environment, dated 05/01/17 revealed residents are provided with a safe, clean, comfortable, and homelike environment. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility will also provide comfortable and safe temperatures (71 degrees Fahrenheit (F) - 81 F). 4. Observations of Unit B Memory Care Unit (MCU) on 11/15/23 at 8:30 A.M. revealed a ceiling tile sticking up into the ceiling. Additionally, the door going off the front hall revealed the paint was scraped off the door. The sitting room had scratches and paint that were scrapped off the walls. The halls going down the B unit had paint coming off them and walls were all scuffed up. There was paint off the doorway going into the dining room. Lastly, there were drawers in the dining area with the molding around the drawers with paint gouged off them.

CONCERN (E) 📢 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 F0694 (Tag F0694)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications to residents. This affected three (Resident #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the unlicensed company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily Living (ADLs). Review of Resident #87's physician orders revealed an order dated 08/21/23 for IV Company #700 hydration therapy for nutrition infusion 500 milliliters (ml) per hour per peripheral intravenous (IV) line. 2. Medical record review for Resident #47 revealed an admission date of 09/15/18. Diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Review of Resident #47's physician orders revealed an order dated 06/13/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for cognitive decline infusion 500 ml per hour per peripheral intravenous (IV) line. 3. Record review of Resident #78 revealed and admission date of 03/08/22. Diagnoses included frontotemporal neurocognitive disorder, essential hypertension, type two diabetes mellitus without complications, morbid obesity due to excess calories, chronic systolic congestive heart failure, major depressive disorder, anxiety, chronic obstructive pulmonary disease. Review of the 10/20/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #78 was cognitively intact. Review of Resident #78's physician orders revealed an order dated 04/25/23 for IV Company #700 micronutrient hydration therapy for nutrition infusion 250 mls at 100 ml per hour per peripheral intravenous (IV) line on 04/27/23. Flush per protocol. An order dated 05/30/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 mls at 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. Review of the Ohio State Pharmacy Board website on 11/15/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 11/15/23 at 8:50 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There was different types of nutritional IV bags for skin and hydration, and the facility nurses got with facility physicians, who wrote an order for IV Company #700 services. Informed consent and assessments were completed. IV Company #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was August and Regional Nurse #300 was unsure why corporate stopped services, and reported services was on a trial basis and there was a cost per bag. IV Company #700's nurse brought all supplies, ran the IV sessions, and took all supplies when they left. Interview with Regional Nurse #300 on 11/16/23 at 1:40 P.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to August 2023. Phone interview with Ohio State Pharmacy Board Worker #305 on 11/16/23 at 9:38 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. This deficiency represents non-compliance investigated under Master Complaint Number OH00148169.

CONCERN (E) 📢 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications. This affected three (Residents #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily Living (ADLs). Review of Resident #87's physician orders revealed an order dated 08/21/23 for IV Company #700 hydration therapy for nutrition infusion 500 milliliters (ml) per hour per peripheral intravenous (IV) line. 2. Medical record review for Resident #47 revealed an admission date of 09/15/18. Diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Review of Resident #47's physician orders revealed an order dated 06/13/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for cognitive decline infusion 500 ml per hour per peripheral intravenous (IV) line. 3. Record review of Resident #78 revealed and admission date of 03/08/22. Diagnoses included frontotemporal neurocognitive disorder, essential hypertension, type two diabetes mellitus without complications, morbid obesity due to excess calories, chronic systolic congestive heart failure, major depressive disorder, anxiety, chronic obstructive pulmonary disease. Review of the 10/20/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #78 was cognitively intact. Review of Resident #78's physician orders revealed an order dated 04/25/23 for IV Company #700 micronutrient hydration therapy for nutrition infusion 250 mls at 100 ml per hour per peripheral intravenous (IV) line on 04/27/23. Flush per protocol. An order dated 05/30/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 mls at 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. Review of the Ohio State Pharmacy Board website on 11/15/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 11/15/23 at 8:50 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There was different types of nutritional IV bags for skin and hydration, and the facility nurses got with facility physicians, who wrote an order for IV Company #700 services. Informed consent and assessments were completed. IV Company #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was August and Regional Nurse #300 was unsure why corporate stopped services, and reported services was on a trial basis and there was a cost per bag. IV Company #700's nurse brought all supplies, ran the IV sessions, and took all supplies when they left. Interview with Regional Nurse #300 on 11/16/23 at 1:40 P.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to August 2023. Phone interview with Ohio State Pharmacy Board Worker #305 on 11/16/23 at 9:38 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. This deficiency represents non-compliance investigated under Master Complaint Number OH00148169.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and staff interview, the facility failed to provide puree foods per the spreadsheet approved by the dietitian. This had the potential to affect six (Residents #52, #30, #13, #4, #45 and #55) who received puree consistency diets from the kitchen. The facility census was 97. Findings include: Medical record review for Residents #52, #30, #13, #4, #45, and #55 revealed all residents were ordered to receive puree diets. Review of the dinner menu spreadsheet dated 11/14/23 revealed the puree consistency diet was to be prepared with puree carrots and the carrots and the bread was to be pureed separately. The puree carrot portion was four ounces and the puree bread was two ounces. Observation on 11/14/23 at 2:56 P.M. revealed [NAME] #107 prepared puree corn and puree bread together for the vegetable puree. The puree bread was not separated from the puree corn. [NAME] #107 prepared corn, and not carrots as listed on the spreadsheet. The menu spreadsheet and recipe were not used by [NAME] #107. Interview on 11/14/23 at 2:56 P.M. [NAME] #107 verified he had not prepared carrots as listed on the spreadsheet for the puree vegetable, and he pureed the vegetable and bread together. [NAME] #107 verified he used a total of four ounces for the portion of vegetable and bread instead of four ounces of vegetables and two ounces of bread in a separate serving. [NAME] #107 stated he did not follow the spreadsheet or recipes as he had prepared puree foods for a long period of time. Interview on 11/14/23 at 3:08 P.M. with Diet Manager #105 revealed she did not know carrots were to be substituted for corn, and the puree bread was to be prepared separately, according to the menu spreadsheet. She stated [NAME] #107 had been employed so long, he did not follow the spreadsheets for every meal. DM #105 verified the four-ounce portion of combined puree vegetable and bread was underserved by two ounces for the puree consistency diet. Review of policy titled, Kitchen Weights and Measures, dated April 2007, revealed the Food Service Supervisor will train staff in proper use of cooking and serving measurements.

CONCERN (E) 📢 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 F0837 (Tag F0837)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Residents #47, #78, and #87) of three reviewed for medications administered by IV Company #700. The facility identified 22 Residents (#1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily Living (ADLs). Review of Resident #87's physician orders revealed an order dated 08/21/23 for IV Company #700 hydration therapy for nutrition infusion 500 milliliters (ml) per hour per peripheral intravenous (IV) line. 2. Medical record review for Resident #47 revealed an admission date of 09/15/18. Diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Review of Resident #47's physician orders revealed an order dated 06/13/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for cognitive decline infusion 500 ml per hour per peripheral intravenous (IV) line. 3. Record review of Resident #78 revealed and admission date of 03/08/22. Diagnoses included frontotemporal neurocognitive disorder, essential hypertension, type two diabetes mellitus without complications, morbid obesity due to excess calories, chronic systolic congestive heart failure, major depressive disorder, anxiety, chronic obstructive pulmonary disease. Review of the 10/20/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #78 was cognitively intact. Review of Resident #78's physician orders revealed an order dated 04/25/23 for IV Company #700 micronutrient hydration therapy for nutrition infusion 250 mls at 100 ml per hour per peripheral intravenous (IV) line on 04/27/23. Flush per protocol. An order dated 05/30/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 mls at 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. Review of the Ohio State Pharmacy Board website on 11/15/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 11/15/23 at 8:50 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There was different types of nutritional IV bags for skin and hydration, and the facility nurses got with facility physicians, who wrote an order for IV Company #700 services. Informed consent and assessments were completed. IV Company #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was August and Regional Nurse #300 was unsure why corporate stopped services, and reported services was on a trial basis and there was a cost per bag. IV Company #700's nurse brought all supplies, ran the IV sessions, and took all supplies when they left. Interview with Regional Nurse #300 on 11/16/23 at 1:40 P.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to August 2023. Phone interview with Ohio State Pharmacy Board Worker #305 on 11/16/23 at 9:38 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. This deficiency represents non-compliance investigated under Master Complaint Number OH00148169.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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Based on review of the facility's infection control log, staff interview, and review of facility policy, the facility failed to have an affective antibiotic stewardship program. This affected five (#2, #23, #41, #61, and #91) of five residents reviewed on the infection log. The census was 97. Findings include: Review of the facility's infection log for October 2023 revealed Resident #2, Resident #23, Resident #41, Resident #61, and Resident #91 were ordered and received antibiotic medications for suspected urinary tract infections (UTIs). On 10/01/23, Resident #61 had increased confusion with no elevated temperature and was started on an antibiotic. Resident #61 was noted to have a UTI without a urinary catheter. On 10/04/23, Resident #91 was admitted to the facility with a UTI without a urinary catheter, no elevated temperature, and was started on an antibiotic. On 10/06/23, Resident #2 was admitted to the facility with a UTI without a urinary catheter, no elevated temperature, and started on an antibiotic. On 10/17/23, Resident #23 had no elevated temperature, but was determined to have a UTI with a urinary catheter in place, and started on an antibiotic. On 10/21/31, Resident #41 displayed increased confusion with no elevated temperature, was found to have a UTI without a urinary catheter, and was started on an antibiotic. Further review of the infection control log revealed the antibiotics were continued when it was determined the five (#2, #23, #41, #61, and #91) identified residents suspected with UTIs did not meet McGeer's criteria (resource for infection surveillance standards). During an interview on 11/16/23 at 10:13 A.M., Registered Nurse (RN) #88, the facility's infection control designee, stated that a resident's physician was not called when a suspected UTI did not meet McGeer's criteria to justify the continued use of an antibiotic. RN #88 confirmed the physician was not notified when the five (#2, #23, #41, #61, and #91) identified residents with suspected UTIs did not meet McGeer's criteria and the antibiotics were continued. Review of the facility policy titled, Antibiotic Stewardship, revised December 2016, revealed the purpose of the program was to monitor the use of antibiotics in residents. When a culture and sensitivity is ordered laboratory results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of a facility document titled, McGeer's Definitions for Healthcare Associated Infections for Surveillance for Long Term Care Facilities, approved on 06/15/12, revealed urinary tract infections includes only symptomatic urinary tract infections. Surveillance for asymptomatic bacteria in the urine absent of new signs and symptoms of a urinary tract infection is not recommended, and represents baseline status for many residents. For symptomatic urinary tract infections, one of the following criteria must be met: The resident does not have an indwelling urinary catheter and has at least three of the following symptoms: Fever (greater than or equal to 38 degrees Celsius (C) or 100.4 degrees Fahrenheit (F) or chills; new or increased burning or pain on urination, frequency, or urgency; may be new or increased incontinence; new flank or suprapubic pain or tenderness; change of character of urine; or worsening of mental or functional status. If the resident has a urinary catheter and at least two of the following signs or symptoms criteria is met. Signs and symptoms include: Fever or chills; new flank or suprapubic pain or tenderness; change in character of urine; or worsening of mental or functional status.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and review of facility policy, the facility failed to ensure call lights located in resident bathrooms had pull cords and residents would be able to activate if on the floor. This affected four (#29, #31, #89, and #407) of four residents reviewed for call light functionality. The census was 97. Findings include: Observation of four (#29, #31, #89, and #407) resident's bathrooms on 11/14/23 from 3:40 P.M. to 3:45 P.M. revealed the bathroom call lights did not have pull cords to activate the lights. During an interview on 11/14/23 at 3:50 P.M., the Director of Nursing (DON) confirmed Resident #29, Resident #31, Resident #89, and Resident #407's bathroom call lights did not have pull cords. The DON confirmed the four identified residents would not be able to activate the call light if the resident was on the floor in the bathroom. The DON also confirmed the four identified residents were capable of independently activating a call light. Review of the facility policy titled, Answering the Call Light, dated 01/12/20, revealed staff should be sure that a call light is plugged in and functioning at all times. Staff should report all defective call lights to the nurse supervisor promptly.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on employee file review and staff interviews, the facility failed to ensure they employed a qualified dietary manager. This had the potential to affect all 96 residents who received food from the kitchen. The facility census was 97. Findings include: Review of Dietary Manager (DM) #105's employee file revealed DM #105 was hired on 04/07/23 and was not a certified diet manager or food service director in the state. The Director of Food Service Job Description, signed by the Diet Manger #105 and the Administrator on 04/07/23, revealed the diet manager must be a food service director in the state. Interview on 11/14/23 at 3:08 P.M. Dietary Manager #105 revealed the registered dietitian was part time, a diet technician visits two times a week, and there was no certified dietary manager at the facility. DM #105 verified she was not a certified dietary manager, had not enrolled in a certified dietary manager course or food service director program from the state. DM #105 stated she had no dietary manager orientation training. Interview on 11/14/23 at 3:08 P.M. with the Administrator verified the facility did not have a qualified certified dietary manager or full time registered dietitian. The Administrator verified the current dietary manager was not enrolled in a certified dietary manager course or food service director program from the state.

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

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Based on observation, staff interview, and review of a facility policy, the facility failed to store food, drink, and meal services items in a safe and sanitary manner. This had the potential to affect all 96 residents who received food from the kitchen. The facility identified one (#1) resident who had orders for nothing by mouth. The facility census was 97. Findings Include: 1. Observation of the kitchen during tour on 11/13/23 from 8:45 A.M. to 9:05 A.M. revealed an unlabeled and undated three gallon pitcher of liquid, a container of sauerkraut dated 11/09/23, and an open container of whole milk with no date in the reach-in refrigerator; an open container of grape jelly with no open date and six bags of rolls with no open or expiration date on the food preparation counter; no thermometer inside the milk cooler; no thermometer in the ice cream freezer and no documentation ice cream freezer temperatures from October and November 2023; there were open containers and bags of french fried onions and pasta with no open dates, boxes of cream of wheat, oats, and rice with no received dates, and a container of coleslaw mix with an expiration date of June 2023 in the dry storage and preparation area; and there were open containers of oats, sugar, and macaroni with no open dates on a shelf under the food preparation table, and insulated lids for resident meal plates stored upright with water collected inside in the main kitchen area. Interview on 11/13/23 at approximately 9:10 A.M with Dietary Manager (DM) #105 verified foods should be labeled and dated with received and open dates, thermometers should be in refrigerators and freezers, expired foods should be discarded, and meal tray lids should be stored to ensure water was drained prior to covering resident meal trays. DM #105 confirmed the findings in the kitchen tour at that time. 2. Observation on 11/14/23 at 7:15 A.M. of the Unit B nursing station resident refrigerator, revealed four bowls of unlabeled and undated food and two open and undated containers of juice. Additional observation of the Unit B nursing station revealed the inside lower surface of the microwave was covered with a brown thick substance. Interview on 11/15/23 at 7:15 A.M. with State Tested Nurse Aide (STNA) #52 verified the food and drink in the resident refrigerator was not labeled or dated, and verified the microwave needed to be cleaned. 3. Observation on 11/15/23 at 7:32 A.M. of the Unit A nursing station resident refrigerator revealed a sign on the refrigerator indicating the refrigerator was only to be used for resident food storage. Further observation revealed two open juice containers with no open dates and a clear bag containing nursing supplies. Interview on 11/15/23 at 7:32 A.M. with Licensed Practical Nurse (LPN) #21 verified all foods should be labeled and dated, and the nursing supplies should not be stored in the resident refrigerator. 4. Observation on 11/15/23 at 7:38 A.M. of the Unit C nursing station resident refrigerator revealed two large brown bags containing food which were unlabeled and undated, and a frozen milkshake with no date. Interview on 11/15/23 at 7:382 A.M. with Registered Nurse (RN) #88 verified all items in the resident refrigerator must be labeled and dated. Review of the facility policy titled, Food Receiving and Storage, dated October 2017, revealed all packaged foods stored in refrigerators will be covered, labeled, and dated with a use by date, and items will be properly sealed.

Jul 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident representative interview, staff interview, and review of the facility policy, the facility failed to notify the resident's representative of the onset of two new unstageable pressure ulcers (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). This affected one (Resident #106) of three residents reviewed for notification of change in condition. The facility census was 104. Findings include: Review of the medical record for Resident #106 revealed an original admission date of 02/19/18. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, diabetes mellitus (DM), vascular dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was cognitively impaired and was coded negative for the presence of pressure ulcers. The MDS assessment dated [DATE] revealed Resident #106 was coded for the presence of two unstageable pressure ulcers which were not present upon admission to the facility. Review of the power of attorney (POA) paperwork revealed Resident #106 had designated Resident Representative (RR) #610 to serve as her durable POA for healthcare on 12/19/14. Review of the nursing progress note dated 05/18/23 revealed Resident #106 had an open area to her upper right thigh and all parties were made aware of the new area. Review of the wound nurse practitioner (NP) note dated 05/24/23 revealed the NP assessed Resident #106 for new unstageable pressure ulcers to the sacrum and right buttock. The unstageable pressure area to the sacrum measured eight centimeters (cm) in length by four cm in width by 0.1 cm in depth and had 25-59 percent (%) slough noted to the wound bed. The unstageable pressure ulcer to the right buttock measured five cm in length by 2.5 cm in width by 0.2 cm in depth and had one to 24 % slough and one to 24 % eschar noted to the wound bed. Review of the nurse progress notes for Resident #106 dated 05/24/23 to 06/01/23 revealed there was no documentation of notification to Resident #106's representative, RR #610, of the newly developed unstageable pressure ulcers to the resident's sacrum and buttocks. The nurse progress note dated 06/01/23 revealed Resident #106 was sent to the hospital for altered mental status and was admitted to the hospital. Interview on 07/18/23 at 2:17 P.M. with RR #610 confirmed a nurse told her Resident #106 had an open area to her upper thigh on 05/18/23 but was not told it was a pressure ulcer. RR #610 confirmed no one from the facility notified her Resident #106 had developed unstageable pressure ulcers to her sacrum and buttocks. RR #610 confirmed when Resident #106 was admitted to the hospital on [DATE], the hospital nurse told her Resident #106 had unstageable pressure ulcers which were present upon admission to the hospital. Interview on 07/19/23 at 8:30 A.M. with the Director of Nursing (DON) confirmed the facility had no documentation that RR #610 had been notified of Resident #106's two unstageable pressure ulcers identified by the wound NP on 05/24/23. The DON confirmed RR #610 was resident's representative/power of attorney for healthcare, and Resident #106 was unable to make medical decisions for herself. The DON confirmed RR #610 should have been notified of the new onset of unstageable pressures identified by the wound NP on 05/24/23. Review of the facility policy titled Change in a Resident's Condition or Status, dated February 2021, revealed a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00144009.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to thoroughly assess the resident's skin for newly developed open areas. This affected one (Resident #106) of three residents reviewed for pressure ulcers. The facility census was 104. Findings include: Review of the medical record for Resident #106 revealed an original admission date of 02/19/18. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, diabetes mellitus (DM), and vascular dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was cognitively impaired and required extensive assistance from staff with activities of daily living (ADLs). Resident #106 was coded negative for the presence of pressure ulcers. The MDS assessment dated [DATE] revealed Resident #106 was coded for the presence of two unstageable pressure ulcers (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) which were not present upon admission to the facility. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #106 was at risk for the development of pressure ulcers. Review of the care plan revealed Resident #106 was at risk for skin breakdown related to incontinence, immobility, diabetes, and poor nutritional status. Interventions included the following: to assist with showers two to three times weekly and complete head to toe skin checks, attempt to keep linens dry and wrinkle free, encourage and assist the resident out of bed daily as tolerated, encourage small frequent position changes and off-loading of heels while in bed and as tolerated by the resident, encourage/assist resident to maintain proper body alignment with weight distributed, follow facility policies/protocols for the prevention/treatment of skin breakdown, heel protector boots to bilateral feet (added 06/16/23), low air loss mattress to bed (added 05/23/23), monitor nutritional status, serve diet as ordered, monitor intake and record, monitor skin daily for reddened areas, changes with direct care/hygiene, bathing, report to nurse, nursing to perform complete head to toe skin checks weekly document results report new findings to physician, and pressure reduction cushion to chair. Review of the weekly skin check for Resident #106 dated 05/12/23 revealed no areas of skin impairment were noted. Review of weekly skin check for Resident #106 dated 05/18/23 completed by agency nurse, Licensed Practical Nurse (LPN) #620 revealed an area to resident's right gluteal fold measuring four centimeters (cm) in length by three cm in width was noted. The depth of the area was not recorded. The skin check revealed the nurse had checked the area was a pressure ulcer and under the stage had marked not applicable. Review of the nurse progress note for Resident #106 dated 05/18/23 per LPN #620 revealed the aide reported to agency nurse that resident had an open area to her upper right thigh which measured four cm in length by three cm in width. Area was red with bright red drainage. Review of the medical record for Resident #106 dated 05/18/23 to 05/24/23 revealed there was no documentation of follow up assessment of the resident's skin either in the nursing notes or the assessments section of the electronic medical record to determine the classification of the open area to resident's skin noted by agency LPN #620 on 05/18/23. Review of the wound nurse practitioner (NP) note dated 05/24/23 revealed NP assessed Resident #106 for new unstageable pressure ulcers to the sacrum and right buttock. The unstageable pressure area to the sacrum measured eight centimeters (cm) in length by four cm in width by 0.1 cm in depth and had 25-59 percent (%) slough noted to the wound bed. The unstageable pressure ulcer to the right buttock measured five cm in length by 2.5 cm in width by 0.2 cm in depth and had one to 24% slough and one to 24% eschar noted to the wound bed. Review of the provider note per NP working with Resident #106's attending physician dated 05/23/23 revealed resident's skin was warm, dry, and intact. Interview on 07/18/23 at 3:30 P.M. with the Director of Nursing (DON) confirmed LPN #620 identified a red open area to resident's upper thigh on 05/18/23. The DON further confirmed she had never visualized Resident #106's wounds and that she did not look at wounds. The DON confirmed none of the facility nurses had recorded an assessment of Resident #106's skin as a follow up to LPN #620's concerns identified on 05/18/23. The outside wound NP employed by the facility assessed the resident's skin on 05/24/23. The DON confirmed on 05/24/23 wound NP #625 identified unstageable pressure ulcers to the sacrum and the right buttock. Interview on 07/19/23 at 11:00 A.M. with the Administrator confirmed NP #625 was not available for interview but her supervisor, NP #605 was available for interview. Interview on 07/19/23 at 11:48 A.M. with wound NP #605 confirmed she was NP #625's supervisor and she was able to review Resident #106's record. NP #605 confirmed NP #625 assessed and identified two unstageable ulcers for Resident #106 on 05/24/23 and stated the pressure ulcers were unavoidable. NP #620 confirmed a licensed nurse from the facility should have done a thorough skin assessment on 05/18/23 or 05/19/23 to determine the stage of ulcer reported by the agency nurse on 05/18/23 and to determine if there was further skin injury and to ensure the facility's treatment plan was appropriate. NP #605 confirmed the low air loss mattress was ordered on 05/23/23 and perhaps could have been implemented sooner based upon the facility's assessment of resident's skin. Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated March 2014, revealed the facility nurse shall describe and document and report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue. This deficiency represents non-compliance investigated under Complaint Number OH00144009.

Feb 2023 3 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interview the facility failed to ensure resident sling was in place per physician's order. This affected one (Resident #8) of three residents reviewed for devices. The census was 105. Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/18/23. Diagnoses included fracture to the left humerus, fracture to the left shoulder, epilepsy, and moderate intellectual disabilities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively impaired and required supervision and physical assistance with activities of daily living (ADLs.) Review of the hospital discharge orders dated 01/14/23 revealed Resident #8 had left shoulder surgery and was discharged to the facility with orders for the resident to be non-weight bearing to left upper extremity and to wear a sling to the left arm for four weeks. Review of the admission physician orders dated 01/18/23 revealed an order for Resident #8 to be non-weight bearing to the left upper extremity. There was no order for Resident #8 to wear a sling to the left arm for four weeks. Review of the January and February 2023 Treatment Administration Record (TAR) for Resident #8 revealed there were no orders for the sling to the left arm. Review of the care plan dated 01/26/23 revealed Resident #8 was resistive to care and non-compliant with the sling. Interventions included the following: to allow the resident to make decisions about treatment regime, to provide sense of control, consider using the repeat-back method of teaching to ensure the resident fully understands the information and instructions provided regarding non-compliance and risks and benefits of both, document a description of the non-compliance, as well as education provided to the resident/family member/significant other, regarding non-compliance as well as any consequences of not following recommended care/treatment plan, try to determine the reason for non-compliance with the care/treatment. Review of the orthopedic surgeon notes dated 02/10/23 revealed Resident #8 was examined in the surgeon's office approximately three weeks following left shoulder replacement surgery. Resident #8 was to wear the sling for another week (until 02/17/23) and then begin weaning off wearing the sling. There was nothing mentioned in the medical record besides the care plan if Resident #8 wore the sling to the left shoulder during the five weeks the physician recommended for Resident #8 to wear the sling. There was no update to the physician to notify of Resident #8's non-compliance with the sling. Observation and interview on 02/23/23 at 12:05 P.M. revealed Resident #8 was not wearing a sling to her left arm. Resident #8 stated she was not required to wear the sling anymore. Interview on 02/23/23 at 3:59 P.M. with the Director of Nursing (DON) confirmed Resident #8 was discharged from the hospital with orders from the surgeon to wear a sling to the left arm for four weeks. The DON confirmed the order to wear the sling for four weeks was not included in resident's admission orders. The DON confirmed the facility was not tracking the resident's acceptance of wearing the sling. The DON confirmed she knew Resident #8 was non-compliant with wearing the sling at times but the facility should have written an order for the sling so it would flow to the TAR, and they could monitor compliance with the physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00139989 and represents ongoing noncompliance from the survey dated 02/01/23.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, review of the facility policy, and review of online medication resource, the facility failed to appropriately monitor a resident's heart rate in conjunction with Digoxin (to treat irregular heartbeat) administration. This affected one (Resident #10) of three residents reviewed for medication monitoring. The facility identified one residents with orders for Digoxin. The facility census was 105. Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/31/23. Diagnoses included acute congestive heart failure (CHF), sick sinus syndrome, cardiac arrhythmia, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the February 2023 monthly physician orders for Resident #10 revealed an order dated 01/31/23 for Digoxin 125 micrograms (mcg) one tablet daily for heart rate. Observation on 02/23/23 at 8:44 A.M. revealed Licensed Practical Nurse (LPN) #229 checked Resident #10's heart rate using a battery-operated wrist cuff monitor. Resident #10's heart rate read 107. The nurse did not listen to Resident #10's heart rate or check the heart rate manually to determine regularity of resident's pulse. LPN #229 then administered Digoxin to Resident #10. Interview on 02/23/23 at 9:00 A.M. with LPN #229 confirmed Resident #10's Digoxin order did not have any parameters for administration but he checked the heart rate using the automated wrist cuff for convenience. LPN #229 confirmed he had not listened to the resident's heart rate (apical pulse using a stethoscope), nor had he taken a manual radial pulse to determine the regularity of Resident #10's heart rate. Interview on 02/23/23 at 3:59 P.M. with the Director of Nursing (DON) confirmed prior to administration of Digoxin, nurses should assess the resident's heart rate manually to determine if the heart rate was regular or irregular and also to determine if the heart rate (beats per minute) was in an acceptable range prior to administration as Digoxin slows and strengthens the heart rate. The DON confirmed if a nurse assessed the heart rate using an automated cuff, there was no opportunity to assess the regularity of the heart rate. If the heart rate was irregular or excessively low (under 50 beats per minute), the physician should be notified. Review of the facility policy titled Medication Monitoring, dated 2020, revealed when administering Digoxin, the nurse should check the radial immediately before administering, with resident at rest. If the pulse is less than fifty (50) or irregular, hold dose of Digoxin. Contact physician if dose is held for three consecutive days. Review of the facility policy titled Administering Medications, dated April 2019, revealed medications should be administered in a safe and timely manner, and as prescribed. Review of [NAME] Drug Guide on 12/08/22 and online medication reference at https://nursing.unboundmedicine.com/nursingcentral/view/[NAME]-Drug-Guide/51218/all/digoxin revealed the nurse should monitor apical pulse for one full minute before administering Digoxin. The nurse should withhold the dose and notify health care professional if pulse rate is less than 60 beats per minute and should also notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. This deficiency represents non-compliance investigated under Complaint Number OH00140370.

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

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Based on record review, observation, staff interview, review of manufacturer's recommendations, and review of the facility policy, the facility also failed to ensure staff practiced appropriate infection control practices and hand hygiene with intravenous therapy (IV) access devices and wound vacs. This affected one (Resident #12) of three residents observed for medication administration. The facility census was 105. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/21/23 with diagnoses including sepsis, noninfective gastroenteritis, colitis, and osteomyelitis. Review of the admission orders for Resident #12 dated 02/21/23 revealed orders for a continuous intravenous (IV) of Piperacillin (antibiotic) to run at 40 milliliters (ml) per hour and an order for a wound vac to the resident's abdomen to be changed on Monday, Wednesday, and Friday. Observation on 02/23/23 at 9:28 A.M. revealed Resident #12 had Piperacillin per IV to the resident's right arm running at 40 ml per hour per pump. Resident #12 had a wound vac to her abdomen. The IV pump and wound vac were attached to a pole with wheels on the bottom so it could moved around. The observation revealed Resident #12 asked LPN #229 to assist her to the bathroom before he administered her medications. LPN #229 donned gloves and disconnected Resident #12's IV infusion and wound vac leaving the pump and wound vac on the pole by the resident's bedside. LPN #229 then provided hands on assistance with transfer from bed to wheelchair and from wheelchair to commode. LPN #229 stood outside the bathroom to provide privacy while Resident #12 used the commode. LPN #229 then provided hands on assistance to Resident #12 with transfer off commode back into wheelchair and then from wheelchair to bed. Resident's wound vac tubing was dragging on the ground and made direct contact with the floor of the resident's room while Resident #12 was being wheeled back to bed. While wearing the same contaminated gloves, LPN #229 wiped resident's IV access with an alcohol prep pad and reconnected the IV to the pump. The surveyor intervened and then LPN #229 removed his gloves, washed his hands, donned clean gloves, wiped the wound vac tubing with an alcohol prep pad, and reconnected resident's wound vac. Interview on 02/23/23 at 9:44 A.M. with LPN #229 confirmed he did not roll the pole with the IV pump and the wound vac to the bathroom with Resident #12 because he thought that would be too complicated. LPN #229 further confirmed he reconnected Resident #12's IV while wearing contaminated gloves and failed to perform hand hygiene prior to reconnecting the IV. LPN #229 further confirmed Resident #12's wound vac tubing was touching the floor while he pushed her wheelchair from the commode back to her bed. Interview on 02/23/32 at 3:59 P.M. with the Director of Nursing (DON) confirmed Resident #12's IV was continuous and should not have been disconnected until the next bag of medication was due to be hung. The DON confirmed the nurses should wash hands and don clean gloves prior to connecting an IV. The DON confirmed the wound vac was also a closed system and by disconnecting it unnecessarily, the nurse was increasing the risk of infection to the resident. The DON confirmed the wound vac tubing should not make contact with the floor. The DON confirmed the IV pump and wound vac were on a pole with wheels so they would not have to be disconnected while the resident moved about her room, including trips to the bathroom. Review of wound vac manufacturer's guidelines, undated, revealed the system should remain on and in use for the duration of the prescribed treatment. Review of the facility policy titled Negative Pressure Wound Therapy, dated October 2011, revealed staff should use aseptic technique when handling wound vacs. Review of the facility policy titled Administering Medications via Secondary Tubing, dated December 2012, revealed the facility would provide safe and aseptic administration of medications via IV. Prior to connecting IV, the nurse should perform hand antisepsis and don non-sterile gloves. The nurse should leave the IV administration in place until next medication is scheduled to be administered. This deficiency represents non-compliance investigated under Complaint Number OH00139989.

Feb 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews with facility staff and Nurse Practitioner (NP) #350, and review of the facility policy, the facility failed to monitor a residents bowel function. This resulted in Actual Harm for Resident #105 when the resident went multiple days with no recorded bowel movements and was subsequently treated at the hospital for severe fecal impaction. This affected one (Resident #105) of three residents reviewed for constipation. The census was 97. Findings include: Review of the medical record for Resident #105 revealed an admission date of 09/20/20. Diagnoses include multiple sclerosis, hemiplegia and hemiparesis following cerebral infarction, quadriplegia, and neuromuscular dysfunction of bladder. Resident #105 discharged from the facility on 01/14/23. Review of the Minimum Data Set (MDS) assessment for Resident #105 dated 10/20/22 revealed the resident was cognitively intact and required extensive assistance of one staff to total dependence of two staff with activities of daily living (ADL's). Resident #105 was always incontinent of bowel. Review of the care plan for Resident #105 dated 07/18/22 revealed the resident was at risk for constipation due to decreased mobility, and wheelchair was primary form of locomotion. Goal of care was for Resident #105 to pass a soft, formed stool at the preferred frequency of at least every three days. Interventions included the following: encourage exercise and movement with activities, monitor and record bowel movement pattern each day, monitor medications for side effects of constipation, keep physician informed of any problems, monitor/document/report to physician as needed any signs and symptoms of complications related to constipation: change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, bradycardia (slow, low pulse), abdominal distension, vomiting, small loose or stools, fecal smearing, bowel sounds, diaphoresis, abdomen: tenderness, guarding and rigidity. Review of January 2023 physician orders for Resident #105 revealed an order dated 01/05/23 for Miralax 17 grams by mouth daily for treatment of constipation. Further review of Resident #105's physician orders revealed the resident had no other orders for routine or as needed laxatives, stool softeners, fiber products, etc. Review of the January 2023 Medication Administration Record (MAR) for Resident #105 revealed the resident received Miralax 17 grams by mouth daily. Further review of Resident #105's MAR revealed the resident had no other routine or as needed laxatives, stool softeners, fiber products, etc. Review of the bowel records for Resident #105 dated 12/14/22 to 01/14/23 revealed the resident had no bowel movements on the following dates: 12/14/22, 12/15/22, 12/16/22, 12/18/22, 12/19/22, 12/20/22, 12/21/22, 12/22/22, 12/23/22, 12/24/22, 12/26/22, 12/28/22, 12/29/22, 12/30/22, 12/31/22, 01/01/23, 01/03/23, 01/04/23, 01/05/23, 01/06/23, 01/07/23, 01/08/23, 01/09/23, 01/10/23, 01/12/23 and 01/14/23. Review of bowel record for Resident #105 revealed the resident had a small bowel movement on the following dates: 12/17/22, 12/25/22, 12/27/22, 01/06/23, 01/11/23 and 01/13/23. Review of bowel record revealed Resident #105 had a medium bowel movement on 01/02/23. The bowel record included no further description of the bowel movements. Review of the nurses progress notes for Resident #105 dated 12/14/22 to 01/14/23 revealed the notes did not include an assessment of the resident's condition, including an abdominal assessment of resident for signs of constipation per the resident's care plan. Review of the progress notes revealed the documentation did not include physician notification of absence of bowel movements for multiple consecutive dates in December 2022 and January 2023. Review of the progress note for NP #350 dated 01/10/23 revealed Resident #105's abdomen was described as soft, non-tender, no masses/distention, and bowel sounds active times four. There was no other documentation in NP #350's progress note regarding Resident #105's bowel function/status. Review of the nurse's progress note for Resident #105 dated 01/14/23 revealed the resident had decreased responsiveness and was unable to swallow fluids or medication. The facility had obtained labs and a chest-x-ray and were awaiting results. The provider on call for Resident #105's attending physician was notified and gave an order to send the resident to the hospital for an evaluation. Review of the nurse's progress note for Resident #105 dated 01/15/23 revealed the resident was admitted to the hospital with septicemia, kidney infection, and pneumonia. Review of hospital records for Resident #105 dated 01/15/23 revealed a fecal impaction was listed as one of the resident's admission diagnoses. Review of the hospital notes revealed there was a massive manual disimpaction of stool which was performed in the emergency department. Further review of the notes revealed Resident #105 was noted to have a distended and firm abdomen and a fecal impaction which was disimpacted with improvement of her abdomen. Resident #105 was also was noted to have what appeared to be stool coming from her suprapubic catheter. Review of the Computed Tomography (CT) scan of the abdomen and pelvis results revealed Resident #105 had a massive fecal impaction. There were new findings of hydronephrosis and hydroureter of the right kidney with multiple stones in the renal pelvis and mid and upper kidney. There was wall thickening throughout the renal pelvis and ureter which may relate to infection of the kidney as well. The ureter could not be traced entirely to the pelvis because of massive rectal fecal impaction. Interview on 02/01/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) #325 confirmed the aides recorded resident bowel movements (BM) in the electronic medical record. LPN #325 confirmed if a resident went three or more days without a bowel movement the nurse should physically assess the resident and the physician should be notified to determine treatment for resident's constipation. Interview on 02/01/23 at 5:17 P.M. with NP #350 confirmed she examined Resident #105 on 01/10/23 and she listened to the resident's bowel sounds on that date. NP #350 confirmed she did not review Resident #105's BM records and she relied on the nursing staff to notify her and/or the attending physician if a resident has had a string of days without a BM. NP #350 confirmed she was not notified of multiple consecutive days in December 2022 and January 2023 where Resident #105 had no BM. NP #350 confirmed she was aware that Resident #105 presented with a fecal impaction at the hospital on [DATE]. Interview on 02/01/23 at 5:42 P.M. with the Administrator confirmed Resident #105's bowel records showed she had no BM's for multiple consecutive dates in December 2022 and January 2023. The Administrator confirmed Resident #105's nurses progress notes did not include an assessment of the resident for constipation or notification of the physician of resident's absent bowel movements. Administrator confirmed Resident #105 was admitted to the hospital on [DATE] with fecal impaction as one of her admitting diagnoses. Review of the facility policy titled Bowel (Lower Gastrointestinal GI Tract) Disorders - Clinical Protocol dated September 2012 revealed staff should identify residents with lower GI conditions including an alteration in bowel movements. The nurse's assessment should include the following: quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount, consistency, etc.), change in mental status or level of consciousness, presence of fecal impaction, signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status), an abdominal assessment, digital rectal examination, presence of cramps and bloating, onset duration and frequency of symptoms. Findings should be reported to the attending physician. This deficiency represents non-compliance investigated under Complaint Number OH00139585.

Dec 2022 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview, review of police report, review of facility Self-Reported Incident (SRI) and employee statements, and review of facility policy, the facility failed to ensure residents were free from staff to resident abuse. This affected one (Resident #27) of three residents reviewed for abuse. The census was 111. Findings include: Review of the medical record for Resident #27 revealed an admission date of 09/15/18 with diagnoses of Alzheimer's disease, major depressive disorder, chronic kidney disease (CKD), atherosclerotic heart disease, hypothyroidism, and diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) for Resident #27 dated 10/24/22 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL). Review of the care plan for Resident #27 dated 07/15/22 revealed the resident had impaired cognitive function and impaired thought processes related to Alzheimer's disease. Interventions included the following: ask yes/no questions in order to determine the resident's needs, use the resident preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions- turn off television, radio, close door etc., resident needs supervision/assistance with all decision making, resident requires approaches that maximize involvement in daily decision making and activity (limit choices, use cueing, task segmentation, verbal instructions) resident understands consistent, simple, directive sentences, provide the resident with necessary cues- stop and return if agitated. Review of the care plan for Resident #27 dated 07/15/22 revealed resident had an ADL self-care performance deficit related to impaired mobility and dementia. Interventions included the following: encourage the resident to participate to the fullest extent possible with each interaction, staff to assist with toileting, dressing, hygiene, and personal care. Review of facility Self-Reported Incident (SRI) #230127 dated 12/14/22 revealed Resident #27 alleged State Tested Nursing Assistant (STNA) #200 had hit her. Licensed Practical Nurse (LPN) #225 notified the Director of Nursing (DON) on 12/14/22 at 4:56 A.M. by telephone that the abuse allegedly occurred on 12/14/22 at 4:50 A.M. in resident's room. STNA #200 was immediately removed from the facility and was suspended pending investigation. Local police were contacted and came to the facility and made a report. At the time of the survey the facility had not completed the SRI and had not made a determination regarding whether or not abuse had occurred. Review of signed statement per LPN #225 dated 12/14/22 revealed nurse heard Resident #27 yelling while STNA #200 was in resident's room. Review of statement revealed resident said, Stop hitting me. LPN #225 turned her phone on to record and entered Resident #27's room and asked what was going on in the room. Resident #27 stated, She hit me. Nurse asked STNA #200 if she had hit resident and aide said, Yes, I just popped her. Resident #27 then said, She's always hitting me. LPN #225 asked STNA #200 to stop providing care to the resident and to clock out and leave the building immediately. LPN #225 then notified the DON of the incident. Review of signed statement per STNA #200 dated 12/14/22 revealed aide was trying to pull Resident #27's pants up and resident didn't want her to do so. Review of statement revealed aide was trying to get resident's hand out of the way so she could pull resident's pants up and resident said aide had hit her hand. Review of the police report regarding the incident between Resident #27 and STNA #200 revealed Police Officer (PO) #375 arrived at the facility on 12/14/22 at 6:30 A.M. and spoke with LPN #225. Resident #27 was up in a wheelchair because she was being sent out to the hospital regarding a fall and did not participate in the interview. Review of the report revealed LPN #225 told police on 12/14/22 at approximately 4:50 A.M. she heard Resident #27 say stop hitting me, while STNA #200 was in resident's room providing care. LPN #225 began recording on her phone and entered the room. Resident #27 was in the bathroom with STNA #200 pulling resident's brief up. LPN asked what was going on, and Resident #27 said, She hit me. LPN #225 asked STNA #200 if she had hit Resident #27 and aide said, Yes, I did hit her. LPN #225 asked STNA #200 a second time if she hit Resident #27, and aide said, Yes, I popped her. Resident #27 then said, She is always hitting me. LPN #225 advised STNA #200 she needed to stop providing care and clock out. STNA #200 continued dressing the resident and nurse told her again to stop and leave. LPN #225 escorted aide out of the care area and had her write a written statement before being escorted out of the building. LPN #225 said aide told her that she had only really grabbed her and had only popped her. In STNA #200's written statement dated 12/14/22 she only admitted to pulling resident's hand while she was pulling resident's pants on. LPN #225 notified the DON of the incident and when she went back to the room to assess Resident #27 further, she had removed her clothing and was found on the floor, so the physician wanted resident to go the hospital for an evaluation. Interview on 12/16/22 at 12:34 P.M. with the DON confirmed Resident #27 went to the hospital for an evaluation of a fall without injury on 12/14/22. DON confirmed that prior to the fall at approximately 4:56 A.M. , LPN #225 called her and said Resident #27 had alleged STNA #200 had hit her. DON confirmed she told LPN #225 to clock aide out and send her home immediately. DON confirmed LPN #225 told her STNA #200 had admitted to hitting Resident #27 and had reported that resident wouldn't allow the aide to pull her brief up. DON confirmed LPN #225 played the recording she made on her phone in which nurse asked STNA #200 if she had hit the resident, and DON heard aide say, Yes, I popped her. DON confirmed the facility did not have the recording, but it had been provided to the local police who were also investigating the incident. DON confirmed PO #375 had completed a report on 12/14/22 and provided his contact information to the facility. The Administrator and Regional Clinical Director (RCD) #250 were also present during this interview and RCD #250 confirmed the facility had not yet made a final determination as to whether abuse had occurred. RCD #250 confirmed Resident #27 was not injured and STNA #200 remained on suspension from work pending the outcome of the investigation. RCD #250 confirmed the facility had not been able to obtain a copy of the police report at the time of the survey and they wanted to include this information in the investigation. RCD #250 also confirmed that Director of Clinical Operations (DCO) #275 had been working in the facility on 12/15/22 and had spoken with STNA #200 regarding the incident. RCD #250 confirmed the facility did not have any further information regarding DCO #275's interview with STNA #200, and they wanted this information to be included in the investigation. Interview on 12/16/22 at 1:03 P.M. with DCO #275 confirmed she was in the facility in the evening of 12/15/22 and she had heard about the abuse investigation initiated regarding Resident #27 and STNA #200. DCO #275 confirmed she saw STNA #200 enter the facility and attempt to go on the floor to work, but she stopped her, because she knew the aide was still suspended and she instructed the aide she was not to enter the facility unless she was called to do so by the DON or Administrator. DCO #275 confirmed she told STNA #200, You know, you can't hit anyone. DCO #275 confirmed STNA #200 said, I didn't really hit her. I didn't try to hurt her. She kept trying to grab my linens, so I tapped her on the hand. Interview on 12/16/22 at 1:09 P.M. with Police Clerk (PC) #350 confirmed Police Officer (PO) #375 had completed a report regarding Resident #27 and an allegation of abuse per STNA #200. PC #350 further confirmed PO #375 was not in the office on the day of the survey, but she was able to provide the police report dated 12/14/22. Review of the facility policy titled Abuse and Neglect Clinical Protocol dated 06/13/21 revealed residents had the right to be free from abuse and the facility did not condone resident abuse by anyone. This deficiency represents non-compliance investigated under Complaint Number OH00138401.

Jan 2020 1 deficiency

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to revise the care plans when new conditions were identified for two (#33 and #102) out of 26 residents reviewed for care plans. Facility census was 131. Findings include: 1. Review of the medical record revealed Resident #33 was admitted on [DATE]. Diagnoses included multiple sclerosis, pseudomonas, anoxic brain damage, chronic respiratory failure, tracheostomy, gastrostomy, epilepsy, dysphagia, tachycardia, altered mental status, and supplemental oxygen. Review of the quarterly Minimum Data Set assessment, dated 11/05/19, revealed Resident #33 had moderately impaired cognitive skills, required total dependence from staff for all activities of daily living. Resident #33 has impairments to bilateral upper and lower extremities. Review of Occupational Therapy (OT) notes, dated 05/30/19, revealed a goal for Resident #33 to tolerate assessment and trial/provision of hand splint for right hand with contractures noted at proximal interphalangeal (PIPS) of all fingers excluding thumb. Review of the current care plan did not address Resident #33's care of contractures of the PIPS. Observation on 01/28/20 at 10:00 A.M. revealed Resident #33 was in bed with head of bed elevated. The resident's right hand was across chest with contractures to the PIPs of four fingers, excluding the thumb. Interview on 01/29/20 at 2:22 P.M. with the Director of Nursing (DON) verified there was no care plan for Resident #33's contracture. 2. Review of the medical record for Resident #102 revealed an admission date of 10/02/19. Diagnoses included atrioventricular block, neuromuscular dysfunction of the bladder, morbid obesity, encephalopathy, chronic obstructive pulmonary disease (COPD), bradycardia, atrial flutter, acute kidney failure, and diabetes mellitus. Review of acute charting guidelines for Resident #102 dated 12/28/19 revealed the resident had a new skin issue on his left heel. Review of nurse progress notes for Resident #102 dated 12/28/29 revealed the resident was assessed to have an unstageable pressure ulcer to the left heel. Review of the skin grid for Resident #102 dated 12/28/19 revealed the resident was assessed to have an open lesion on the left heel Review of then Minimum Data Set (MDS) 3.0 assessment, dated 01/01/20, revealed Resident #102 had intact cognition, required extensive assistance for activities of daily living (ADLs). Review of section M (skin conditions) revealed resident was assessed with an unstageable pressure ulcer due to coverage of wound bed by sough and/or eschar. Review of wound specialist nurse practitioner progress notes for Resident #102, dated 01/03/20, revealed resident was seen for an unstageable pressure ulcer on the left calcaneus. There was large amount of necrotic tissue within the wound bed and the wound was to be cleaned and ointment applied daily. Review of the current plan of care for Resident #102 revealed no care plan had been developed to address the care and treatment of the unstageable pressure ulcer on his left heel discovered on 12/28/19. Interview with Resident #102 on 01/29/20 at 9:35 A.M. revealed he had a sore on his left heel that was being cared for by the nurses and a wound specialist. Interview with wound Nurse Practitioner (NP) #170 on 01/29/20 at 10:00 A.M. revealed resident had an unstageable pressure ulcer on his left heel which was discovered on 12/28/19 Interview with the DON on 01/30/20 at 2:18 P.M. verified the plan of care for Resident #102 was not revised when resident was assessed to have an unstageable pressure ulcer/injury on his left heel.

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

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• 57 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• $28,841 in fines. Higher than 94% of Ohio facilities, suggesting repeated compliance issues.
• Grade F (25/100). Below average facility with significant concerns.
• 66% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Meadowbrook's CMS Rating?

CMS assigns MEADOWBROOK CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Meadowbrook Staffed?

CMS rates MEADOWBROOK CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 66%, which is 20 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Meadowbrook?

State health inspectors documented 57 deficiencies at MEADOWBROOK CARE CENTER during 2020 to 2025. These included: 1 that caused actual resident harm and 56 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Meadowbrook?

MEADOWBROOK CARE CENTER 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 CCH HEALTHCARE, a chain that manages multiple nursing homes. With 146 certified beds and approximately 93 residents (about 64% occupancy), it is a mid-sized facility located in CINCINNATI, Ohio.

How Does Meadowbrook Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, MEADOWBROOK CARE CENTER's overall rating (1 stars) is below the state average of 3.2, staff turnover (66%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Meadowbrook?

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 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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.

Is Meadowbrook Safe?

Based on CMS inspection data, MEADOWBROOK CARE CENTER 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 1-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 Meadowbrook Stick Around?

Staff turnover at MEADOWBROOK CARE CENTER is high. At 66%, the facility is 20 percentage points above the Ohio average of 46%. 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 Meadowbrook Ever Fined?

MEADOWBROOK CARE CENTER has been fined $28,841 across 1 penalty action. This is below the Ohio average of $33,367. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Meadowbrook on Any Federal Watch List?

MEADOWBROOK CARE CENTER 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.

Facility Details

Beds: 146
Avg. Residents: 93
Occupancy: 63.8%
Ownership: For profit - Limited Liability company
Chain: CCH HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Actual Harm citation: -5
57 Deficiencies: -10
Fines ($28,841): -5
Final Score: 25/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 365375