BRIARWOOD VILLAGE
For profit - Corporation
112 Beds
HCF MANAGEMENT
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
28/100
#842 of 913 in OH
Photo by Briarwood Village
Photo by Briarwood Village
Photo by Briarwood Village
1 / 5 photos
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Briarwood Village in Coldwater, Ohio, has received a Trust Grade of F, indicating significant concerns about the facility's operations and care. Ranking #842 out of 913 in Ohio places it in the bottom half of state facilities, and #5 out of 6 in Mercer County suggests that there is only one local option that is better. The facility is showing a trend of improvement, with the number of issues decreasing from 7 in 2024 to 6 in 2025, but there are still serious concerns. Staffing is a weakness, with a rating of 2 out of 5 stars and a 52% turnover rate, reflecting instability in personnel. Notably, a critical incident involved a resident falling due to inadequate supervision, resulting in serious injuries, and there was also a failure to report norovirus cases, which could have impacted all residents. However, it is worth noting that the facility has not incurred any fines, which is a positive aspect. Overall, families should weigh these strengths and weaknesses carefully when considering Briarwood Village for their loved ones.
- Trust Score
- F
- In Ohio
- #842/913
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 8%
Review needed
7 → 6 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 6 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: 52%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Chain: HCF MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 29 deficiencies on record
1 life-threatening
Sept 2025
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
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on review of resident council meeting minutes and staff interview, the facility failed to respond to resident concerns addressed in resident council meetings. This affected two residents (#242 a...
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Based on review of resident council meeting minutes and staff interview, the facility failed to respond to resident concerns addressed in resident council meetings. This affected two residents (#242 and #249) of four residents reviewed for Resident Council. The facility census was 95.1.Review of the Resident Council Meeting Minutes (RCMM) dated 07/01/25 revealed concerns with the dietary department. Further review revealed there was no evidence of action taken to address residents' concerns. Interview on 09/15/25 at 12:12 P.M. with the Administrator verified she was unable to locate evidence of staff action taken in response to concerns brought up by residents during the August 2025 Resident Council Meeting (RCM). 2. Review of the RCMM for 08/05/25 revealed residents' voiced concerns of receiving their medications late on the weekends due to nurse helping the aides. Nurses were sitting medications at bed side and leaving. Also, residents voiced concerns of sheets not fitting bigger sized beds. 2. Review of 08/05/25 RCMM revealed on the weekends residents were getting their medications late due to nurses helping aides and nurses just sitting medications on bed side table and leaving. Sheets are not fitting the bigger size beds.Further review revealed there was no evidence of action taken to address residents' concerns. Review of the Resident Council Response Form revealed more blue sheets for larger beds were put on on 08/14/25. Interviews on 09/15/25 at 10:00 A.M. with Resident #242 and Resident #249 revealed both ladies attend resident council meetings on a regular basis and verbalized multiple items have been brought up each month with no action.Interview on 09/15/25 at 12:12 P.M. with the Administrator verified she was unable to locate evidence of staff action taken in response to concerns brought up by residents during the September 2025 RCM. This deficiency represents non-compliance investigated under Complaint Number 2595568.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interviews, and staff interviews, the facility failed to complete residents' showers as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interviews, and staff interviews, the facility failed to complete residents' showers as scheduled. This affected three residents (#249, #242, and #212) of three residents reviewed for showers. The census was 951.Review of the medical record for Resident #249 revealed an admission date of 03/06/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #249 a Brief Interview for Mental Status (BIMS) score of eight, indicating impaired cognition. He required set-up or clean up assistance for Activities of Daily Living (ADLs).Review of Resident #249's shower sheets for the past 14 days revealed the following: 09/02/25 not applicable, 09/05/25 no shower given, 09/25/25 shower given, and 09/12/25 not applicable. Further review revealed Resident #249's scheduled shower days were Tuesdays and Fridays. Interview on 09/15/25 at 10:00 A.M. with Resident #249 revealed the resident needs help with her bathing and toileting. Resident #249 states she goes a long time without a shower because staff do not have enough time to help her.2. Review of the medical record for Resident #242 revealed an admission date of 12/26/23. Diagnoses included CPOS and respiratory failure with hypoxia. Review of the MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating intact cognition. The resident required moderate assistance with ADLs. Review of Resident #242's shower sheets for the past 14 days revealed the following: On 09/02/24, 09/09/25, and 09/12/25, the resident received a shower. On 09/05/25, the resident did not receive a shower. Resident #242's scheduled showers days were Tuesdays and Fridays. Interview on 09/15/25 at 10:00 A.M. with Resident #242 revealed the resident did not know when her shower days were and did not feel she was getting regular showers. Resident #242 voiced she did not feel she received an appropriate amount of showers.3. Review of the medical record for Resident #212 revealed an admission date of 08/16/25. Diagnoses included respiratory failure and hallucinations. Review of the MDS assessment dated [DATE] revealed a BIMS score of 13, indicating slight cognitive impairment. Resident #212 required moderate assistance with ADLs. Review of Resident #212's shower sheets for the past 14 days revealed the following: 09/04/25 the resident returned from the hospital, and 09/07/25 no shower given. Resident #212's scheduled shower days were Thursdays and Sundays. Interview on 09/15/25 at 10:44 A.M. with Resident #212's Family Member (FM) revealed family does not believe Resident #212 is receiving her showers. Observation at the time of the interview revealed Resident #212's hair appeared greasy. Interview on 09/15/25 at 3:20 P.M. with the Executive Director verified Residents #249, #242, and #212 were not receiving showers as scheduled.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical review, staff interview, and review of a facility policy, the facility failed to follow infection ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical review, staff interview, and review of a facility policy, the facility failed to follow infection control procedures for a resident positive with COVID-19. This affected one (Resident #249) of one resident reviewed for COVID-19 precautions. The facility census was 62.Review of the medical record for Resident #249 revealed an admission date of 03/06/23. The resident was admitted with diagnosis of COVID-19.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of eight, indicating moderately impaired cognition. This resident was assessed to require set or clean-up assistance for bathing, dressing, and toileting.Review of the progress note dated 09/09/25 revealed Resident #249 tested positive for COVID-19 and was placed in droplet isolation for ten days. Observation on 09/15/25 at 10:00 A.M. Resident #249 and Resident #242 were talking by Resident #242's doorway. Resident #242 was standing just outside of Resident #249's door talking with no mask on. This surveyor approached and introduced self and started a conversation. During conversation, the surveyor noticed personal protective equipment (PPE) in the hallway to the left of Resident #249's door along with dirty gowns in a laundry basket, dirty gowns on the floor, and leftover breakfast items (Styrofoam plate, plastic fork and spoon, Styrofoam bowl, and a regular coffee cup) on top of dirty laundry basket. No isolation signage was posted. Resident #242 stated Resident #249 was diagnosed with COVID-19 and is in isolation. Resident #249 states other residents are not allowed in her room or dining room but Resident #249 is allowed to stand at the doorway and visit her friends all she wants.Interview on 09/15/25 at 10:19 A.M. with Dietary Aide (DA) #515 verified Resident #249's door was open with Resident #242 standing outside her door, used breakfast items from Resident #249 were placed in the hallway on top of dirty linen container with used gown, and no isolation signs were in place.Interview on 09/15/25 at 10:25 A.M. with Register Nurse (RN) #40 revealed Resident #249 was diagnosed with COVID-19 and was placed on droplet isolation on 09/09/25. RN #40 confirmed no droplet isolation sign, dirty linen in hallway, Resident #249 door open and Resident #249 visits with friends at her doorway. RN #40 verbalized Resident #249 should be in her room with the door closed but no one follows the rules.Review of facility policy, dated 05/11/23, titled, PPE and Isolation Protocol, revealed the door is to remain closed, isolation signs placed entering and exiting room.Review of facility undated COVID-19 entry sign revealed staff is to wear N95 face mask, face shield, gown, and gloves at all times when entering.
Aug 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, review of facility investigation, physician interview, review of b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, review of facility investigation, physician interview, review of bed user service manual, and policy review, the facility failed to ensure Resident #01 was provided adequate supervision during the provision of activities of daily living. Resident #01 was cognitively impaired, and dependent on staff for transfer and bed mobility with bilateral lower extremity contractures. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 10:11 A.M. when two Certified Nurse Aides (CNA) directed attention away from Resident #01, who was lying in bed on her left side with the bed elevated. Resident #01 rolled from the elevated bed and fell to the floor, sustaining a laceration to the scalp requiring six staples, acute odontoid process fracture (second cervical vertebra [C2] in the neck) and closed displaced fracture of first cervical vertebra (C1 in the neck). On [DATE] Resident #01 expired as a result of the injuries sustained at the time of the fall from bed. This affected one (Resident #01) of three residents reviewed for accidents and supervision. On [DATE] at 3:00 P.M., the Administrator, Director of Nursing (DON), Executive Director (ED) #34, and Clinical Corporate Support Registered Nurse (CCSRN) #55 were notified Immediate Jeopardy began on [DATE] at 10:11 A.M. when CNAs #61 and #89 directed attention away from Resident #01, allowing the resident to be unsupervised in an elevated bed. Resident #01 was dependent on staff to roll side to side in bed, and for bed mobility, and transfers. Resident #01 had bilateral lower extremity contractures, and her legs were fixed in the flexed position (pulled up toward the torso). CNA #61 left the left side of the bed to obtain a lift sling located approximately three feet from the foot of the bed and CNA #89 left the right side of the bedside and proceeded to the left side of the bed to remove a trash bag from a trash can, directing attention away from the resident. CNAs #61 and #89 heard a scream and turned around to see Resident #01 rolling off the bed. CNA #89 ran and attempted to catch Resident #01 however, CNA #89 was unable to reach Resident #01 before she hit the floor. Resident #01 was subsequently transported to the hospital and was treated for six staples to the laceration to the head and discovered with two cervical (neck) fractures which required surgical intervention. Resident #01 and responsible party declined further treatment, and Resident #01 returned to the facility for palliative care. Resident #01 expired on [DATE] due to her injuries. Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: On [DATE], at 10:40 A.M., Registered Nurse (RN) #83 assessed Resident #01 and contacted emergency medical services. Resident #01was transported to the hospital for evaluation. Resident #01 returned to the facility from the hospital on the same day ([DATE]) at 4:50 P.M. and the plan of care was revised to include floor mats to side of bed as the resident reported that she tried to get out of bed when she fell and hit the floor. On [DATE], Resident #01 expired in the facility. On [DATE], the DON began educating all nursing staff on the facility policies regarding fall prevention, including the Fall Reduction Policy, care of residents at bed side, completion of fall documentation and assessments post fall. All 46 licensed nurses and CNAs were educated by [DATE]. On [DATE], the SDC #95, Physical Therapy Assistant (PTA) #109 and CNA #106 completed competencies for all 46 licensed nurses and CNAs nursing staff regarding bed mobility, turning and repositioning and safely caring for residents in bed. On [DATE], the DON, Regional Nurse #103, Staff Development Coordinator (SDC) #95 and Case Manager #97 audited all residents who had falls within the past 30 days to ensure appropriate investigation and fall interventions in place in room and on care plan. On [DATE], SDC #95 and DON reeducated all 46 licensed nurses and CNAs to ensure adequate supervision in accordance with the resident's plan of care is provided during the provision of resident activities of daily living (ADL). Staff not educated by [DATE] will not be permitted to work until education completed. On [DATE], Regional Nurse #103, DON and Minimum Data Set (MDS) Nurse #114 completed care plan audits on all 43 residents who were totally staff dependent for all ADL care while in bed to ensure all fall risk assessments were up to date and to ensure care plans accurately reflect assessment and fall risk interventions. On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted with Interdisciplinary Team (IDT) which included ED #34, Administrator, Human Resources Manager #115, MDS Nurse #114, Restorative Nurse #117, DON, and Medical Director #130 to discuss the incident and follow-up interventions in response to corrective actions that the facility needed to complete to keep their residents safe in the future. On [DATE], Regional Director of Operations #135 and Regional Nurse #103 educated ED #34, Administrator and DON on the need to ensure that investigations of falls are thorough. Beginning [DATE], the DON or designee will conduct daily observations of three residents receiving ADL care (e.g., bedside care, transfers, toileting, etc.) to ensure that supervision is being provided during the activity in accordance with the plan of care and resident needs. The audits will be completed daily for two weeks on varying shifts, and three days a week on varying shifts for four weeks. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included cerebral ischemia, anxiety disorder, and cardiomegaly. Review of the nursing plan of care, dated [DATE], revealed Resident #01 was at risk for falls related to decreased mobility, use of psychoactive medications, and incontinence. Interventions included anticipating and meeting Resident #01's needs, Resident #01 needs a safe environment with bed in low position at night, and personal items in reach. Review of the physician orders, dated [DATE], revealed an order for the use of a mechanical lift (Hoyer) for all transfers and a low air loss mattress placed to bed. There was no documentation in the medical record that Resident #01 was assessed for proper use of the bed or mattress. Review of the fall risk assessment dated [DATE] revealed Resident #01 was at a fall risk. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #01 was cognitively impaired and was dependent on staff for rolling side to side, bed mobility, and transfers. Resident #01 was always incontinent with bowel and bladder and did not have any falls during the review period. Resident #01 had lower leg contractures. Resident #01 was often non-compliant with care and frequently refused. Review of the progress note documented as a late entry on [DATE] at 10:11 A.M. revealed Licensed Practical Nurse (LPN) #69 heard CNA #61 yell out from Resident #01's room. Resident #01 was on the floor, on her left side beside her bed. Resident #01 was holding her head, and a pool of blood was on the floor. Resident #01 was moving around and was visibly upset about getting blood into her hair. LPN #69 looked at Resident #01's head and observed a laceration and called for Registered Nurse (RN) #83 to assess the resident. As RN #83 came into the room, LPN #69 contacted Physician Assistant (PA) #22 to obtain order to send the resident out to the emergency room (ER). LPN #69 called 911 and contacted the local hospital emergency room to provide report. LPN #69 met one squad member before returning to Resident #01's room. Upon her return to the room, Resident #01 was up in the wheelchair and the laceration had stopped bleeding. Resident #01 was taken to the local hospital for evaluation. This note was created as a late entry on [DATE] at 10:54 A.M. Review of the progress note dated [DATE] at 10:15 A.M., written by RN #83, revealed two CNAs (#61 and #89) had been assisting Resident #01 with incontinence care. Both CNAs had turned away from the bed to gather trash and the wheelchair when Resident #01 became upset and rolled herself from the bed, yelling as she fell. The two CNAs yelled for the nurse, who responded immediately, and then alerted RN #200. Resident #01 was contracted and transferred using a mechanical lift. Upon the nurse's arrival at the bedside, Resident #01 was lying on her left side with blood around her head. A laceration was noted to the left top side of head and a skin tear to the left elbow. Vital signs were stable, and Physician Assistant (PA) #22 was notified and ordered Resident #01 to be sent to the hospital for evaluation. Resident #01's daughter was also contacted. Review of the hospital note dated [DATE] at 10:59 A.M. revealed Resident #01 stated she was trying to get off the bed when she fell and hit the floor. Resident #01 reported hitting the top of her head without loss of consciousness. She complains of laceration and pain to the top of head and posterior neck. Assessment identified a four plus centimeter (cm) laceration that was subcutaneous on top of the head. Procedures included six staples placed to approximate the head wound edges. The computerized tomography (CT) results dated [DATE] revealed a closed displaced fracture of first cervical vertebra, closed odontoid fracture with type II morphology and posterior displacement. Follow-up recommendation was to assess cord compression. Physician consultation with Resident #01 and the responsible party requested no further treatment and hospice services would be obtained. Resident #01's responsible party refused higher level of care for evaluation for the cervical spine fractures. Resident #01 and responsible party understood the adverse outcomes including paralysis and cord injury. Resident #01 will be discharged back to the facility with hospice care. Resident #01 returned to the facility on [DATE] and was admitted under hospice care as discussed between the hospital physician and hospice physician due to cervical spine fractures. Resident #01 was non-compliant with wearing the c-collar. Resident #01's daughter took off the c-collar because the resident didn't want to wear it. Resident #01 expired in the facility on [DATE]. Review of incident report dated [DATE] noted Resident #01 rolled out of bed during check and change during agitated behavior towards staff. Review of the facility's investigation into the fall revealed Resident #01 was oriented to person, place and time. A note documented Resident #01 rolled out of bed during check and change and displayed agitated behavior towards staff. The facility identified the root cause was accidental and completed education on transferring. Review of CNA #89's written statement, dated [DATE], revealed CNA #61 and CNA #89 were changing Resident #01. After the resident was cleaned up and dressed, CNA #89 turned around to get the trash and CNA #61 went to get the wheelchair by the television (TV). CNAs #61 and #89 heard Resident #01 start to scream and turned around and she was rolling off the bed. CNA #89 ran and tried to catch her but did not make it in time to fully catch her before she hit the floor. CNAs #61 and #89 yelled for LPN #69 to come right away. Review of CNA #61's written statement, dated [DATE], revealed CNAs #61 and #89 were changing Resident #01 on her bed. When they were done changing the resident, Resident #01 was laying down. CNA #89 turned to take trash bag out of trash can and CNA #61 turned around to grab the wheelchair placed by the TV. CNAs #61 and #89 heard Resident #01 scream and turned around and Resident #01 was rolling off the bed. CNA #89 tried catching her but missed. LPN #69 immediately came to the room. The facility's investigation did not include an assessment of the bed and low air loss mattress, how Resident #01 was positioned in the bed, explain how Resident #01 could fall from her bed when she was dependent on staff rolling side to side and had bilateral leg contractures that were pulled up to the torso, did not identify CNAs #61 and #89 left Resident #01 unsupervised in a elevated bed, and did not identify Resident #01's root cause of the fall. The progress note dated [DATE] at 8:20 P.M. revealed Resident #01 was without vital signs. Review of the death certificate revealed the immediate cause of death was moderate to severe cervical canal stenosis with immediate cause of acute odontoid process fracture with comminuted first cervical body fracture. The approximate interval from onset and death was two days for the immediate causes of death. During an interview on [DATE] at 7:35 A.M., Maintenance Director #21 stated Resident #01 was on an air mattress owned by the facility. During an observation with Maintenance Director #21 at 10:10 A.M., the air mattress energized and operated (inflated) as designed with the firm setting. The air mattress edges (perimeters) compressed with little pressure or resistance. During an interview on [DATE] at 9:25 P.M., Director of Therapy (DT) #20 stated during a review of Resident #01's most recent occupational therapy (OT) Discharge summary dated [DATE], Resident #01 was assessed with bilateral lower extremity contractures and no lower extremity mobility. DT #20 stated Resident #01 was unable to position herself side to side due to contractures and legs being fixed in the flexed position (pulled up toward torso). Resident #01 was dependent on staff on mechanical lift transfers using two staff. DT #20 also confirmed Resident #01's bed and mattress were assessed by nursing to determine appropriated use. During an interview on [DATE] at 9:43 A.M., PA #22 stated Resident #01 required assistance with care. PA #22 stated Resident #01 was mostly seated in a wheelchair when observed. PA #22 stated she was informed resident fell and was bleeding. PA #22 placed an order to send Resident #01 to the ER. PA #22 reviewed hospital progress notes related to the incident and stated Resident #01 and her responsible party chose to go on hospice due to refusing further medical intervention for cervical fractures. Resident #01 was an unreliable historian with moderate cognitive impairment. PA #22 stated no further involvement or contact with Resident #01 occurred after the telephone order was given to have the resident sent to the ER on [DATE]. Further medical record review also confirmed the record lacked documentation by the primary physician following the [DATE] incident. During an interview on [DATE] at 11:01 A.M., CNA #45 stated on [DATE] at approximately 10:00 A.M. she was aware that CNA #61 and #89 were in Resident #01's room with the door closed. CNA #61 screamed from Resident #01's door for LPN #69. LPN #69 and RN #83 responded. CNA #45 entered the room and Resident #01 was observed with blood coming from the top of her forehead. No blood was observed on the dresser located next to the left side of the bed. Resident #01 was on left side of bed on the floor facing toward the room entry. Resident #01 was alert. With her head next to dresser within two inches. Resident #01's bed was elevated to approximately 36 inches. During an interview on [DATE] at 11:24 A.M. via telephone, CNA #61 stated on [DATE] Resident #01 needed changed. Resident #01 was on her bed and positioned on her left side. CNA #61 was standing on the left side of the bed with the bed elevated to approximately three feet from the floor. The bed was elevated to provide staff with sufficient access to Resident #01 which occurred during care. CNA #89 was standing on the right side of the bed. CNA #61 turned around to get the mechanical lift sling from the wheelchair which was located approximately one foot from the foot of the bed. At the same time CNA #89 left the right side of the bed and proceeded to the left side of the bed to obtain a trash can. CNA #61 confirmed CNAs #61 and #89 were not visualizing Resident #01 at that moment. Resident #01 screamed and proceeded to roll out of the left side of the bed onto floor. CNA #61 ran to the door of room and yelled for LPN #69 who was just outside door. CNA #61 verified Resident #01's bed was elevated at the time of the incident and both CNAs turned away from Resident #01 at the time of the incident. During an interview on [DATE] at 12:30 P.M., the DON confirmed the air mattress that was applied to Resident #01's bed provided little to no perimeter resistance when pressure was applied to the mattress edge. Additional interview verified no documentation contained in the medical record indicated Resident #01's air mattress or bed were assessed for appropriate use. During an interview on [DATE] at 1:05 P.M. via telephone, Hospice Physician #2 revealed the primary cause of Resident #01's death was due to cervical fractures sustained from the fall from bed on [DATE]. During an interview on [DATE] at 11:06 A.M. via telephone, CNA #89 confirmed Resident #01's bed was elevated approximately three feet when Resident #01 fell from the bed on [DATE]. CNA #89 walked around the foot of the bed to the left side of the bed and proceeded to access a trash can located at the left side of the bed. CNA #89 confirmed she took her visual focus away from Resident #01 while tending to the trash receptacle which left the resident unattended while in a elevated bed. CNA #89 responded to Resident #01 yelling out and observed the resident rolling from bed. CNA #89 lunged towards Resident #01. However, the resident proceeded to fall to the floor and sustained an injury to the head. CNA #89 confirmed she received training related to the transfer and use of mechanical lifts. However, no training included maintaining supervision to prevent accidents. Review of the policy titled Fall Reduction Policy, approved [DATE], revealed based on the outcome of fall assessments, a fall risk reduction plan will be incorporated into the resident's plan of care. The interdisciplinary team will review the residents' fall risk reduction plan at a quarterly minimum, during care conference and modify the plan as needed, based on the resident's functional status during the review period. Referrals will be made to other health professionals as needed. Follow-up investigations will be carried out to ascertain the cause of the incident to reduce the risk of further occurrences. Employee education will include body mechanics, transfer/ambulation techniques, transfer/ambulation equipment and assistive devices, maintenance of equipment and assistive devices. Review of the manual titled Joerns User-Service Manual dated 2023, documented important precautions included the following: Keep bed in lowest position except when providing care. Bed should be at lowest convenient height for entry or exit. Failure to do so could result in injury. Use of an improperly fitted mattress could result in injury or death. An optimal bed system assessment should be conducted on each resident by qualified clinician or medical provider to ensure maximum safety of the resident. This deficiency represents non-compliance investigated under Complaint Number 2565060.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policy, and review of the Ohio Department of Health (ODH) Ap...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policy, and review of the Ohio Department of Health (ODH) Application Gateway, the facility failed to report an incident of resident-to-resident physical abuse to the state agency. This affected one (#19) of three residents reviewed for abuse. The census was 92.
Findings include:
1. Review of Resident #19's medical record revealed an admission date of 11/30/21. Diagnoses listed included Alzheimer's disease, psychotic disorder, hearing loss, and generalized anxiety disorder.
Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was rarely understood by staff.
Review of progress notes revealed on 03/21/25 at 8:30 P.M. Resident #19 was walking with her walker and came to stop in front of of an empty recliner in the common area. A resident sitting in a nearby chair began yelling at Resident #19. A third resident came into the area and told Resident #19 to move. Resident #19 has confusion, and did not move. The resident sitting in the nearby chair began yelling more. The third resident then used her elbow and struck Resident #19 in the upper right arm, then immediately after doing so, placed both hands onto the resident's arm and pushed. Resident #19 stumbled but did not fall. The nurse was able to reach the residents before it escalated any further. The nurse removed Resident #19 from the area to ensure safety. No evidence of any injury was noted.
2. Review of Resident #23's medical record revealed an admission date of 11/30/21. Diagnoses listed included dementia, type II diabetes mellitus, atrial fibrillation, and major depressive disorder.
Review of a annual MDS dated [DATE] revealed Resident #23 was severely cognitively impaired.
Review of progress notes revealed on 03/21/25 at 8:30 P.M. a resident with a walker came to a stop in front of an empty recliner in the common area. A resident sitting in a nearby chair began yelling at the resident. Resident #23 came into the area and told the resident with the walker to move. The resident with the walker has confusion, and did not move. The resident sitting in the nearby chair began yelling more. Resident #23 then used her elbow and struck the resident with the walker in the upper right arm, then immediately after doing so, placed both hands onto the resident with the walker's arm and pushed. The resident with the walker stumbled but did not fall. The nurse was able to reach the residents before it escalated further. The nurse removed the resident with the walker from the area to ensure safety. No evidence of injury was noted on the resident with the walker. This nurse attempted to re-approach Resident #23 to see if they were ok, but the resident in the chair was still telling Resident #23 that she was in trouble, but should have been allowed to defend herself. All further attempts to provide care or follow up for Resident #23 resulted in agitation. The nurse monitored the situation until Resident #23 decided to go to into her room. The nurse asked Resident #23 if they needed assistance with getting ready for bed, and Resident #23 replied, no and don't touch me.
Interview with the Administrator on 04/03/25 at 10:30 A.M. confirmed there was a physical altercation between Residents #19 and Resident #23 on 03/21/25. Resident #23 struck Resident #19 in the arm and pushed her. The Administrator confirmed the incident was not reported to ODH.
Interview with Certified Nurse Aide (CNA) on 04/03/25 at 11:52 A.M. revealed Resident #19 obtained a bruise on her right upper arm when Resident #23 hit her on 03/12/25. CNA #180 did not witness the incident, but worked the morning after and was informed of what happened.
Observation of of Resident #19's right upper arm with Registered Nurse (RN) #60 on 04/03/25 at 1:31 P.M. revealed a pale yellow bruise to the right upper arm. RN #60 stated it was the result of Resident #23 hitting Resident #19.
Interview with Regional Director of Clinical Services (RDCS) #150 on 04/07/25 at 8:50 A.M. confirmed the physical altercation on 03/21/25 when Resident #23 struck Resident #19 should have been reported to ODH. RDCS #150 confirmed that Resident #23 striking Resident #19 met the definition of physical abuse per the facility's policy.
Review of the ODH's Application Gateway website revealed the facility had not reported the resident-to-resident physical abuse between Resident #19 and Resident #23.
Review of the facility policy titled, Abuse, Neglect, Injuries of Unknown Source, and/or Misappropriation of Resident Property Policy, dated 2016 revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The Administrator or his/her designee will notify ODH of all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, and injuries of unknown source as soon as possible, but in no event later than twenty-four (24) hours from the time the incident/allegation was made known to the staff member.
This deficiency represent non-compliance investigated under Complaint Number OH00164181.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, local health department staff interview, and review of facility policy, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, local health department staff interview, and review of facility policy, the facility failed to report norovirus cases and multiple resident's gastrointestinal (GI) symptoms (nausea/vomiting/diarrhea) to the local health department. This had the potential to affect all 92 residents of the facility. The census was 92.
Findings include:
1. Review of Resident #4's medical record revealed an admission date of 09/19/22. Diagnoses listed included chronic kidney disease, obstructive sleep apnea, hypothyroidism, and morbid obesity.
Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact.
Review of progress notes revealed Resident #4 was not feeling well and was sent to the emergency room (ER) for evaluation on 02/25/25. Resident #4 returned to the facility on [DATE].
Review of hospital documentation revealed Resident #4 tested positive for norovirus on 02/25/25.
2. Review of Resident #107's medical record revealed an admission date of 09/19/22. Diagnoses listed included chronic kidney disease, obstructive sleep apnea, hypothyroidism, and morbid obesity.
Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact.
Review of progress notes revealed Resident #107 was sent to the ER for shortness of breath, abdominal pain, and difficulty urinating on 02/21/25. Resident #107 returned to the facility on [DATE].
Review of hospital documentation revealed Resident #4 tested positive for norovirus on 02/22/25.
Review of facility timeline documentation revealed Resident #107 returned to the facility from the hospital on [DATE] and was positive for norovirus. Resident #4 was sent to the hospital on [DATE] and tested positive for norovirus on admission to the hospital. Between 02/23/25 and 03/05/25 16 residents (#30, #50, #61, #63, #64, #68, #83, #108, #77, #82, #84, #87, #97, #112, #120, and #121) throughout the facility experienced GI symptoms. Residents (#30, #68, #77, #84, #87) were tested and were negative for norovirus. The remaining residents with GI symptoms were put in contact isolation, but not tested. On 03/05/25 residents in the memory care unit started with GI symptoms and the entire unit was put on contact isolation. 16 residents (#13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #28) resided in the memory care unit.
Interview with Licensed Practical Nurse (LPN) #50 on 04/03/25 at 10:44 A.M. revealed Resident #107 tested positive for norovirus when sent to the hospital. LPN #50 reported two staff members were tested at a local hospital and were positive for norovirus. All staff had been educated on how to prevent the spread of norovirus. LPN #50 stated the local health department had not been made aware of the norovirus cases.
Interview with the Administrator on 04/03/25 at 1:50 P.M. confirmed two residents (#4 and #107) and two CNAs (#100 and #110) tested positive for norovirus at a local hospital. The Administrator confirmed multiple residents throughout the facility had GI symptoms. The Administrator confirmed the local health department was not called.
Review of facility provided documentation revealed CNA #100 and CNA #110 were off work form 02/28/25 through 03/04/25. Test results for norovirus were not provided.
Phone interview with Local Health Department Registered Nurse (LHDRN) #200 on 04/03/25 at 2:23 P.M. confirmed the local health department had not been contacted regarding residents and staff testing positive for norovirus and multiple residents with GI symptoms throughout the facility.
Phone interview with LHDRN #210 on 04/07/25 at 10:53 A.M. confirmed the local health department had not been contacted regarding residents and staff testing positive for norovirus and multiple residents with GI symptoms throughout the facility. LHDRN #210 confirmed the facility should have called and reported.
Interview with Regional Director of Clinical Services (RDCS) #150 on 04/07/25 at 8:50 A.M. confirmed norovirus cases and GI symptoms throughout the facility should have been reported to the local health department.
Review of the facility policy titled, Reportable Diseases Ohio, dated revised April 2022 revealed it is the purpose of the facility to report diseases declared to be dangerous to the public health. It is the policy of the facility that all infectious, contagious or communicable diseases be reported in accordance with Ohio rules.
The following diseases are classified as Class C and shall be reported by the facility to the local health department by the end of the next business day. This applies to an outbreak, unusual incidence, or epidemic of other infectious diseases from the following sources:
(1) Community
(2) Foodborne
(3) Healthcare-associated
(4) Institutional
(5) Waterborne; and
(6) Zoonotic;
(7) If the outbreak, unusual incidence, or epidemic, including but not limited to, histoplasmosis, pediculosis, scabies, and staphylococcal infections, has an unexpected pattern of cases, suspected cases, deaths, or increase incidence of disease that is of a major public health
This deficiency represent non-compliance investigated under Complaint Number OH00164181.
Oct 2024
1 deficiency
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
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, staffing record review, and staff interviews, the facility failed to employ a Director of Nursing (DON) full time at the facility. This had the potential to affect all 86 residen...
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Based on observation, staffing record review, and staff interviews, the facility failed to employ a Director of Nursing (DON) full time at the facility. This had the potential to affect all 86 residents.
Findings include:
Interview on 09/30/24 at 7:17 A.M. at the time of entrance with the Administrator revealed there was no DON employed at the facility. A second interview with the Administrator on 10/01/24 at 10:11 A.M. revealed the facility had not had a DON or acting DON since 09/18/24.
Record review of the staffing sheets from 09/23/24 through 09/29/24 revealed no DON had been scheduled.
Aug 2024
6 deficiencies
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and the review of the facility policy, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and the review of the facility policy, the facility failed to develop and initiate a care plan in regards to a corrective device for a resident. This affected one resident (#195) of three residents reviewed for range of motion. The facility census was 99.
Findings include:
Record review for Resident #195 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #195 included post surgical care for digestive tract, overactive bladder, sciatica, and pulmonary hypertension.
Further review of Resident #195's list of diagnoses revealed there were no diagnosis relating to a fracture of the leg noted in the medical records.
Review of Resident #195's care plans dated 07/26/24 revealed no focus for the plan of care for a walking cast.
Review of Resident #195's physician orders revealed no orders for a walking cast.
Observation and interview on 08/05/24 at 11:22 A.M. with Resident #195 revealed the resident was alert and oriented. Resident #195 stated she was wearing the walking boot due to having a broken foot. Resident #195 stated she was not informed of any care plans regarding the walking cast and stated she did not know when the walking cast was to be removed. Resident #195 denied any issues with her skin on her right leg but stated she was unsure of the actual condition of the skin.
Interview on 08/07/24 at 8:49 A.M. with Licensed Practical Nurse (LPN) #321 verified there was no care plan or physician orders relating to Resident #195's walking cast. Per LPN #321, the resident stated she had a broken foot. LPN #321 verified there was no diagnosis for the resident's right leg noted in the medical records.
Interview on 08/07/24 at 9:46 A.M. Regional Clinical Services (RCS) #602 verified there were no orders, no care plans, and no diagnoses in regards to Resident #195's walking cast. Per RCS #602, the resident was admitted with the cast and there have been no skin assessments or care plans for the care of the resident's leg.
Review of the facility policy titled, 'Comprehensive Care Plan', dated 11/2016, revealed the facility must develop a comprehensive care plan for all care to be provided for the health and well being of the residents.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor bruises once observed. This affected one resident (#59) of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor bruises once observed. This affected one resident (#59) of one resident reviewed for bruising. The facility census was 99.
Findings include:
Review of medical record for Resident #59 revealed an admission date of 03/29/24 with diagnoses including but not limited to Parkinson's disease, dementia, anxiety, pain in right hip, and syncope and collapse.
Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment with no behaviors. Resident #59 required supervision/touching assistance for activities of daily living.
Review of the care plan dated 07/10/24 revealed Resident #59 was at risk for bleeding/bruising related to platelet aggregated therapy. Interventions included medications as tolerated and monitor for signs and symptoms of bruising or bleeding every shift.
Review of current physician orders for Resident #59 revealed clopidogrel (blood thinner) 75 milligrams (mg) daily and monitor for signs and symptoms of bruising/bleeding-anticoagulant therapy.
Review of change in condition note dated 06/23/24 at 4:17 A.M. revealed State Tested Nursing Assistant (STNA) informed this nurse that she found bruising while giving the resident a shower. Upon assessment, two bruises noted to left buttock measuring 12 centimeters (cm) by 6 cm and 9 cm by 6 cm next to each other. When the resident was asked what happened he stated, I was packing at the house and suddenly fell.
Review of weekly skin and body review dated 06/26/24 revealed no new areas noted and subsequent weekly skin and body reviews through 08/08/24 revealed no new areas noted. No assessment noted with the description of bruises to determine age or when the bruises had healed.
Interview on 08/08/24 at 10:23 A.M. with Regional Clinical Services (RCS) #602 verified they could not find any documentation regarding the nurses were monitoring the bruises to Resident #59's left buttock besides the normal physician order to monitor for signs and symptoms of bruising/bleeding-anticoagulant therapy. RCS #602 verified she could not locate any other documentation as to what the bruises looked like or when the bruises healed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Medscape review, medical record review, interview, and policy review, the facility failed to ensure reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Medscape review, medical record review, interview, and policy review, the facility failed to ensure residents did not receive outdated insulin. This affected one (Resident #30) of two residents reviewed for insulin. The facility census was 99.
Findings include:
Review of the medical record for Resident #30 revealed an admission date of 10/07/21 with diagnoses including but not limited to type two diabetes with diabetic neuropathy, type two diabetes with diabetic cataract, type two diabetes with hypoglycemia without coma, long-term (current) use of insulin, and dementia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #30 received insulin seven out of seven days during the look back period.
Review of current physician orders revealed insulin aspart solution 100 unit/ml inject per sliding scale: if 150-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350 give 8 units; 351-400 give 10 units; and 401 and greater give 12 units and update the physician, subcutaneously before meals.
Observation on 08/07/24 at 11:06 A.M. revealed Licensed Practical Nurse (LPN) #319 removed an insulin vial from the locked cupboard in the residents room. Insulin (Novolog) was dated 07/05/24. LPN #319 cleansed the port of the insulin vial with alcohol pad and drew up eight units of insulin into a syringe. LPN #319 administered insulin into the residents right lower abdomen.
Interview on 08/07/24 at 11:10 A.M. with LPN #319 verified insulin (Novolog) was dated 07/05/24. LPN #319 believed the insulin was good for a month after opening. Verified today's date was 08/07/24. LPN #319 called someone to ask about the insulin who stated that the insulin was good for 31 days (vials) after opening.
Interview on 08/07/24 at 12:39 P.M. with Director of Nursing (DON) verified Novolog was to be discarded 28 days after opening.
Review of Medscape revealed Novolog to be stored at room temperature below 30 degrees for up to 28 days.
Review of skills competency checklist for medication administration dated 04/2013 revealed multidose vials are good for 28 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were not left at the bedside. This affected one (Resident #26) of one residents observed. The facility census was 99.
Findings include:
Review of the medical record of Resident #26 revealed an admission date of 01/04/23. Diagnoses included congestive heart failure, rheumatoid arthritis, diabetes mellitus type II, anxiety disorder, depression, and cerebral ischemia. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #26 was cognitively intact.
Observation on 08/05/24 at 10:10 A.M. revealed a small plastic cup containing 18 pills/capsules sitting on the over bed table next to Resident #26. The medications included acetaminophen 325 milligrams (mg) 2 tablets, ascorbic acid 500 mg two tablets, cyanocobalamin 500 micrograms (mcg) tablet, isosorbide mononitrate extended release 30 mg capsule, multivitamin tablet, omeprazole 40 mg capsule, sitagliptin phosphate 50 mg tablet, spironolactone 25 mg tablet, zinc 50 mg tablet, carvedilol 12.5 mg tablet, ferrous sulfate 325 mg tablet, gabapentin 100 mg capsule, gabapentin 600 mg capsule, methocarbamol 500 mg tablet, sennosides 8.6 mg tablet, and oxycodone hydrochloride 7.5 mg tablet.
Interview on 08/05/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #319 verified the medications left at the bedside. LPN #319 stated she had handed Resident #26 the cup of medications as she was ambulating back to her room from breakfast and did not ensure she had taken them.
Review of the facility policy titled, Medication Storage in the Facility, dated 02/11/21 revealed medications are stored safely and securely.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on employee file review and interview the facility failed to ensure State Tested Nursing Assistant (STNAs) had 90 day evaluations and/or annual performance evaluations. This affected four of six...
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Based on employee file review and interview the facility failed to ensure State Tested Nursing Assistant (STNAs) had 90 day evaluations and/or annual performance evaluations. This affected four of six employee files reviewed. This had the potential to affect all residents. The facility census was 99.
Findings include:
1. Review of employee file for STNA #353 with hire date of 05/14/19 revealed no annual evaluation for July of 2023 or any for 2024.
2. Review of employee file for STNA #374 with hire date of 11/06/18 revealed no annual evaluation for 2020, 2021, and 2023.
3. Review of employee file for STNA #370 with hire date of 01/10/24 revealed no 90 day evaluation.
4. Review of employee file for STNA #331 with hire date of 10/05/23 revealed no 90 day evaluation.
Interview on 08/08/24 at 11:04 A.M. with Human Resources (HR #508) verified the evaluations were not in the employee files for STNAs #353, #374, #370, and #331.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on employee file review, interview, and policy review, the facility failed to ensure State Tested Nursing Assistants (STNAs) completed 12 hours of education. This affected two of three STNA file...
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Based on employee file review, interview, and policy review, the facility failed to ensure State Tested Nursing Assistants (STNAs) completed 12 hours of education. This affected two of three STNA files reviewed for annual training. This had the potential to affect all residents. The facility census was 99.
Findings include:
1. Review of employee file for STNA #353 with hire date of 05/14/19 revealed no education training for 2023 or 2024.
2. Review of employee file for STNA #389 with hire date of 02/09/22 revealed no education training for 2023 or 2024.
Interview on 08/08/24 at 11:02 A.M. with Executive Director (ED) verified the employees were not compliant with their education. ED stated the employees are scheduled to take courses.
Review of policy titled, Inservice Education, dated 10/2003 revealed Nursing Assistants are required to have 12 hours of training per year calculated from their date of hire.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review, the facility failed to notify a resident's representative of a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review, the facility failed to notify a resident's representative of a resident's increased, severe pain. Additionally, the facility failed to honor the resident's representative request of being notified when as needed (PRN) pain medication was administered. This affected one (Resident #101) of three reviewed for notification. The facility census was 76.
Findings include:
Review of the medical record for Resident #101 revealed an admission date of 04/15/20 and discharge date of 11/19/22 with diagnoses including but not limited to Alzheimer's, dementia with other behavioral disturbance, anxiety, major depressive disorder, pain in right hip, pain in unspecified knee, osteopenia, osteoporosis, disorder of bone, spondylosis, stiffness of unspecified shoulder, unspecified fracture of shaft of humerus unspecified arm, and unspecified psychosis not due to a substance or known physiological condition.
Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #101 revealed a Brief Interview for Mental Status (BIMS) score of two which indicated severe cognitive impairment. Resident #101 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident received hospice services.
Further review of physician orders for Resident #101 revealed an order for morphine sulfate (concentrate) solution 100 milligrams (mg) per five milliliters (ml) give five mg by mouth every hour as needed for mild pain or shortness of breath (SOB). 5 mg = 0.25 ml document pain level. Document non-pharmacological intervention used by yes/no answer. Give 10 mg = 0.5 ml every hour as needed for moderate pain/SOB document pain level. Document non-pharmacological interventions by yes/no answer. Give 20 mg = 1 ml every hour as needed for severe pain/SOB. Document pain level and non-pharmacological interventions by yes/no answer.
Review of eMAR (electronic medication administration record) Medication Administration Note dated 11/17/22 at 9:23 P.M. for SR #101 revealed morphine sulfate (concentration) 100 mg/5 ml give 20 mg as needed for severe pain/SOB give 1 ml. was administered due to the resident complaining of right arm pain, constantly moaning and yelling out because of pain.
Review of eMAR medication administration note dated 11/17/22 at 10:37 P.M. revealed morphine sulfate 20 mg- 1 ml given due to resident still moaning and yelling due to so much pain.
Further review of Resident #101's medical record revealed no documentation Resident #101's representative was notified of the resident's pain to the right arm.
Phone interview on 12/19/22 with Registered Nurse (RN) #666 at 1:11 P.M. reported on 11/17/22, Resident #101 was not acting like herself. The resident was yelling, and crying in her room regarding her right arm hurting. Resident #101 reported her, Arm was broken, it is cracked. RN #666 assessed the resident's arm and did not notice any injury at the time. Resident #101 was moaning, crying, and in so much pain. RN #666 administered pain medication per physician order. RN #666 stated that an hour later, Resident #101 was still yelling and miserable and the nurse checked on her again. Resident #101 was saying, It still hurts so bad, it didn't work. RN #666 administered pain medication per physician order. RN #666 verified she did not notify the resident's representative of the new onset of pain to the resident's right arm.
Review of the eMAR for November 2022 revealed on 11/17/22 Resident #101 was administered 20 mg of morphine at 9:23 P.M. and 10:38 PM. Resident #101 received 10 mg of morphine on 11/18/22 at 11:53 A.M., and 11/19/22 at 11:23 A.M. On 11/19/22 at 8:41 A.M. Resident #101 was administered 5 mg of morphine.
Further review of the medical record revealed no documentation supporting the resident's representative's wishes to be notified when PRN pain medication was administered to Resident #101. Additionally, there was no documentation the resident's representative was notified of PRN pain medication administered on 11/17/22, 11/18/22, and 11/19/22.
Interview on 12/18/22 at 9:14 A.M. Resident #101's representative verified she wanted to be notified prior to adminstration of PRN medications and the facility was aware and did not notify her.
Interview on 12/18/22 at 11:06 A.M. with Licensed Practical Nurse (LPN) #620 stated she worked with Resident #101 once or twice and knew the resident's representative wanted notified prior to administering as needed pain medication.
Interview on 12/18/22 at 11:34 A.M. with RN #662 revealed it was a verbal request for Resident #101's representative to be notified prior to as needed medication administration. RN #622 verified she was told in report when Resident #101 was moved from Assisted Living to the nursing side. RN #622 verified there were no written instructions provided to notify the resident's representative of PRN pain medication administration.
Phone interview on 12/19/22 at 8:45 A.M. with Hospice Staff #701 revealed Resident #101's representative wanted notified prior to administration of PRN morphine and hospice staff were aware of this.
Interview on 12/19/22 at 1:11 P.M. with RN #666 verified there was no documentation contained in Resident #101's medical record to notify the resident's representative prior to administering PRN pain medication.
Interview on 12/19/22 at 1:55 P.M. with LPN #580 verified there was no documentation contained in Resident #101's medical record to notify the resident's representative prior to administering morphine.
Review of policy titled, Notification of Changes Policy, revised 11/2016 revealed the manor will inform the resident, the attending physician, and the resident's representative or interested family member of changes which affect the resident. The manor must inform the resident immediately, the attending physician, and the resident's representative or interested family member when there is an accident involving the resident, which may or may not result in injury, a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment, and a decision to transfer or discharge the resident from the manor.
This deficiency represents non-compliance investigated under Complaint Number OH00137993.
Oct 2022
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #64 revealed admission date of 08/22/10. Diagnoses included myotonic muscular dystrophy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #64 revealed admission date of 08/22/10. Diagnoses included myotonic muscular dystrophy, anemia and muscle weakness.
The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition. The resident required extensive two person assistance for bed mobility, toilet use, one person assistance for eating and was totally dependent for transfers.
Interview and observation on 10/17/22 at 10:35 A.M. with Resident #64 and a visitor revealed a medicine cup had been under the bed for several days. Observation revealed a medicine cup was on the floor about mid mattress and approximately two feet from the end of the bed. Observation on 10/18/22 at 1:41 P.M. revealed a medicine cup remained under the bed. Observation on 10/20/22 at 9:41 A.M. revealed a medicine cup remained under the bed.
Interview on 10/20/22 at 9:49 A.M., with the Housekeeping Supervisor #344 revealed rooms were cleaned daily, which included sweeping the floors. The Housekeeping Supervisor #344 verified a medicine cup remained under Resident #64's bed.
Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure resident rooms remained clean. This affected two residents (#21 and #64) out of 73 residents' rooms observed. The facility census was 73.
Findings include:
1. Review of the medical record of Resident #21 revealed an admission date of 11/12/10 and a readmission date of 12/08/20. Diagnoses included aphasia following a cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, osteoarthritis, benign neoplasm of peripheral nerves and autonomic nervous system, disorders of brain, and cerebrovascular disease.
Review of the annual minimum data assessment dated [DATE] revealed Resident #21 was cognitively intact and had 12 to 14 days of feeling down, depressed, or hopeless. She had trouble falling or staying asleep or sleeping too much two to six days, and felt tired or had little energy seven to 11 days. The total score was a six indicating a moderate potential for depression. The assessment indicated she required extensive assistance of two staff for bed mobility, dressing, toilet use and personal hygiene, and was totally dependent on two staff for transfers. The assessment indicated she had not received any therapy for the two week period.
Interview on 10/17/22 1:42 P.M., with Resident #21 revealed the housekeepers had not cleaned the room. She said the toilet in the bathroom had been dirty for awhile now and the mirror had toothpaste spray on it for over a week.
Observation on 10/17/22 1:58 P.M. of Resident #21's room revealed the floor to the left of the bed had a black, dried substance. The bathroom toilet had dried stool inside the toilet on the riser. The mirror had dried white blotches on the lower section. A pink bedpan was noted on the floor, under the counter, in a clear plastic bag.
Observation on 10/18/22 1:21 P.M. of Resident #21's room revealed the dried black substances to the left of the bed remained on the floor, the dried stool remained in the toilet. The white blotches were still on the mirror. A pink bedpan was on the floor, under the counter, in a clear plastic bag and stool was visible on the pan.
Interview on 10/18/22 at 1:39 P.M., with the Assistant Director of Nursing (ADON) #276 verified the above condition of Resident #21's room and bathroom.
Review of the facility policy titled Housekeeping Services, dated 01/20 revealed in resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. Horizontal surfaces included toilet seats.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff and family interview, the facility failed to ensure a comprehensive skin ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff and family interview, the facility failed to ensure a comprehensive skin assessment was completed on residents. This affected one resident (#46) out of 18 residents sampled. The facility census was 73.
Findings include:
Review of medical record for Resident #46 revealed admission date of 08/19/22. Diagnoses included dementia without behaviors, chronic obstructive pulmonary disease, depression, and congestive heart failure.
The admission Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and required extensive two-person assistance for bed mobility, toilet use, one person for transfers and supervision for eating. No skin alterations documented.
Review of the plan of care for potential/actual impairment to skin integrity related to fragile skin was created on 09/21/22. No other skin care plans were in place.
Review of a progress note for Resident #46 dated 08/19/22 revealed a large brown protruding mole to the top of the scalp which measured two centimeters by two centimeters.
Interview and observation on 10/17/22 at 1:13 P.M. with Resident #46's son revealed he had been a resident in the facility's assisted living area and had known skin cancer area to the top of his head. Resident #46's son believed the staff were putting something on it, and as far as he knew it had not continued since being moved to the skilled side and the son felt the area had doubled in the last four weeks. An area approximately 25 millimeters (mm) in diameter growth was protruding from the top of Resident #46's head.
Review of the physician progress note dated 10/12/22 revealed Resident #46 had exophytic (growing outward beyond the surface epithelium from which it originates) mass growing from the top of his head and the side of his face.
Interview on 10/20/22 at 11:28 A.M., with the MDS Registered Nurse (RN) #230 revealed the initial skin assessment for Resident #46 provided no documentation on the admission assessment for any skin conditions, therefore it was not added to the care plan. RN #230 confirmed Resident #46 was an established resident of the facility Medical Director and she was unaware why there was no diagnosis addressing the area on the admitting history and physical. The skin area was present on Resident #46 during the initial admission MDS assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident # 17 revealed an admission date of 02/02/22. Diagnoses included dementia with behaviors, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident # 17 revealed an admission date of 02/02/22. Diagnoses included dementia with behaviors, type two diabetes, anxiety disorder and mood affective disorder.
Review of the quarterly Minimum Data Set (MDS) assessment for Resident #17 revealed a severely impaired cognition. Resident #17 required extensive to total assistance for activities of daily living. Resident #17 was coded as having dementia with behaviors, and mood affective disorder.
Review of the plan of care for Resident #17 dated 02/11/22 and revised on 7/21/22 revealed the resident had cognitive deficits and confusion. Resident #17 had diagnoses including dementia, anxiety and mood disorders. Interventions included secure care to ankles, offer support and reassurance as needed observe for moods, anxiety and behaviors, and encourage resident to express thoughts and feelings.
Review of the Preadmission Screening and Resident Review (PASRR) Identification Screen dated 02/05/22 revealed Resident #17 had a diagnosis of dementia. Section E of the PASRR had no indication of serious mental illness.
Interview on 10/20/22 at 2:15 P.M., with the RSC #306 verified the diagnosis of mood disorder for Resident #17 was not on the PASRR as it should have been.
Based on record review and staff interview, the facility failed to ensure an updated assessment was completed when residents had a new diagnosis added. This affected three residents (#47, #38, and #17) out of five residents reviewed for Preadmission Screening and Resident Review. The facility census was 73.
Findings include:
1. Review of the record for Resident #47 revealed she was admitted [DATE]. Diagnoses included Parkinson's disease, chronic obstructive pulmonary disease, asthma, depression, hypokalemia, atherosclerotic heart disease, osteoarthritis, neuromuscular dysfunction, abdominal hernia, intervertebral disc degeneration of lumbar region, cerebral ischemia, acute kidney failure, cardiomyopathy, dementia without behavioral disturbance, hypotension, benign paroxysmal vertigo, psychotic disorder with hallucinations, hypothyroidism, anemia and hyperlipidemia.
Review of the Minimum Data Set, dated [DATE] revealed Resident #47 had moderate cognitive impairment and required supervision with eating. The resident required extensive assistance with dressing, toilet use, personal hygiene, bed mobility and transfers.
Review of the Preadmission Screening and Resident Review (PASRR) for Resident #47 dated 05/10/22 revealed no diagnosis of dementia or of mental illness.
Review of the physician's orders revealed Resident #47 had a diagnosis of dementia and a diagnosis of psychotic disorder with hallucinations added on 06/02/22.
During an interview with the Resident Services Coordinator (RSC) #306 on 10/20/22 at 10:27 A.M. verified she had not completed an updated assessment for Resident #47 when she received her new diagnoses on 06/02/22.
Review of the policy titled Preadmission Screening, revised 03/17/15 revealed its purpose was to ensure that individuals with mental illness and intellectual disabilities received the care and services they needed in the most appropriate setting. The facility must not admit any residents with mental illness or intellectual disability unless those boards have determined they need the level of services provided by a nursing home and if the resident required any specialized services.
2. Review of the medical record of Resident #38 revealed an admission date of 11/11/15. Diagnoses included other speech disturbances, unspecified hydrocephalus, contusion of left knee sequela, unspecified constipation, other dysphagia, unspecified systolic (congestive) heart failure, paroxysmal atrial fibrillation, non-ST elevation myocardial infarction, and rhabdomyolysis.
Review of the PAS (Pre-admission Screen) Review dated 04/11/13 revealed Resident #38 had no indications of serious mental illness nor a developmental disability.
Review of the medical record revealed a diagnosis of unspecified psychosis not due to a substance or known physiological condition dated 09/27/17, and a diagnosis of unspecified dementia, unspecified severity with agitation dated 10/03/22. The record had no documentation of any additional PAS Reviews were completed.
Interview on 10/20/22 at 1:35 P.M. with RSC #306 verified the lack of a second screening completed for Resident #38.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an actual skin concern was developed in the plan of ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an actual skin concern was developed in the plan of care. This affected one resident (#46) out of 18 residents sampled. The facility census was 73.
Findings include:
Review of medical record for Resident #46 revealed admission date of 08/19/22. Diagnoses included dementia without behaviors, chronic obstructive pulmonary disease, depression, and congestive heart failure.
The admission Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and required extensive two-person assistance for bed mobility, toilet use, one person for transfers and supervision for eating. No skin alterations documented.
Review of the plan of care for potential/actual impairment to skin integrity related to fragile skin was created on 09/21/22. No other skin care plans were in place.
Review of a progress note for Resident #46 dated 08/19/22 revealed a large brown protruding mole to the top of the scalp which measured two centimeters by two centimeters.
Interview and observation on 10/17/22 at 1:13 P.M. with Resident #46's son revealed he had been a resident in the facility's assisted living area and had known skin cancer area to the top of his head. Resident #46's son believed the staff were putting something on it, and as far as he knew it had not continued since being moved to the skilled side and the son felt the area had doubled in the last four weeks. An area approximately 25 millimeters (mm) in diameter growth was protruding from the top of Resident #46's head.
Review of the physician progress note dated 10/12/22 revealed Resident #46 had exophytic (growing outward beyond the surface epithelium from which it originates) mass growing from the top of his head and the side of his face.
Interview on 10/20/22 at 11:28 A.M., with the MDS Registered Nurse (RN) #230 revealed the initial skin assessment for Resident #46 provided no documentation on the admission assessment for any skin conditions, therefore it was not added to the care plan. RN #230 confirmed Resident #46 was an established resident of the facility Medical Director and she was unaware why there was no diagnosis addressing the area on the admitting history and physical. The skin area was present on Resident #46 during the initial admission MDS assessment.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and resident and staff interviews, the facility failed to ensure dependent resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and resident and staff interviews, the facility failed to ensure dependent residents were repositioned. This affected one resident (#39) out of one resident reviewed for positioning. The facility census was 73.
Findings include:
Review of the medical record for Resident #39 revealed an admission date of 03/20/18. Diagnoses included unspecified dementia, displaced oblique fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing (10/06/22), displaced oblique fracture of shaft of right fibula (10/06/22), unspecified disorder of adult personality and behavior, and history of falling.
Review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #39 had impaired cognition and was totally dependent on two people for bed mobility and transfers. Resident #39 had not rejected care.
Review of a physician order dated 11/05/18 revealed Resident #39 needed to be checked every two hours for incontinence.
Review of the current care plan for Resident #39 revealed she had a self care deficit related to decreased mobility. Interventions included two people to assist with bed mobility.
Observations throughout the day on 10/17/22 and 10/18/22 revealed Resident #39 lying in bed. Interview at the same time with Resident #39 revealed she preferred staying in bed.
Observation on 10/19/22 at 7:53 A.M. revealed Resident #39 sleeping on her back. Her shoulders and hips appeared flat on the bed, no bolsters or pillows were observed.
Observation on 10/19/22 at 10:22 A.M. revealed Resident #39 sitting up in bed with the head of bed elevated. No bolsters or pillows were observed at that time. Concurrent interview with Resident #39 revealed staff had not repositioned her that day.
Observation on 10/19/22 at 11:26 A.M. revealed Resident #39 sleeping. Her position appeared unchanged from the previous observation.
Observation on 10/19/22 at 12:05 P.M. revealed Resident #39 was awake, looking at a word search puzzle. Resident #39's position appeared to be unchanged from the previous observation. Concurrent interview with Resident #39 revealed staff had not repositioned her.
Interview on 10/19/22 at 1:54 P.M. with State Tested Nurse Aide (STNA) #266 revealed she was assigned to care for Resident #39, and verified she had not repositioned Resident #39 since prior to 10:22 A.M. that morning.
Interview on 10/19/22 at 2:07 P.M. with STNA #236 confirmed she had not repositioned or provided care for Resident #39 since first thing this morning.
Interview on 10/19/22 at approximately 6:00 P.M. with the Director of Nursing (DON) verified Resident #39 could not reposition herself in bed.
A follow-up interview on 10/20/22 at 9:35 A.M. with the DON revealed Resident #39 had no skin breakdown on her backside.
This deficiency shows non-compliance related to allegation in Complaint Number OH00135342.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure pressure ulcers were accurately assess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure pressure ulcers were accurately assessed and documented treatment in place. This affected one resident (#46) out of three residents reviewed for pressure ulcers. The facility census was 73.
Findings include:
Review of medical record for Resident #46 revealed admission date of 08/19/22. Diagnoses included dementia without behaviors, chronic obstructive pulmonary disease, depression, and congestive heart failure.
The admission Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and required extensive two-person assistance for bed mobility, toilet use, one person for transfers and supervision for eating. No skin alterations documented.
Review of the plan of care for potential for pressure ulcer development on 08/20/22 due to decreased mobility. Interventions in place included a pressure relieving mattress and a cushion in the wheelchair.
Review of the progress note dated 09/23/22 revealed the hospice aid reported reddened areas to Resident #46's spine. Two areas were documented as measuring one centimeter (cm) by two cm. The areas blanched but were sluggish. The physician and the hospice staff were updated.
Review of the hospice notes dated 09/29/22 revealed documentation of a pressure ulcer which measured 0.4 cm by 0.4 cm to the lower spine of Resident #46.
Review of the physician orders for Resident #46 revealed an order on 09/24/22 for a foam border dressing to the residents back and change every three days thru 10/8/22.
Review of the weekly skin assessments for Resident #46 revealed no new areas was documented on 09/24/22, 10/01/22, 10/08/22, 10/15/22, and on 10/22/22. There was no documented assessment of the current pressure area including measurements and descriptions.
Review of the hospice note dated 10/12/22 revealed the documented pressure ulcer for Resident #46 increased in size to 1.2 cm by 1.0 cm with sloughing noted. Interventions were a bordered dressing change every three days with a start effective date of 10/05/22.
Review of the physician orders dated from 10/08/22 to 10/19/22 revealed no documentation for the bordered dressing order.
Review of the Treatment Administration Record (TAR) dated from 10/08/22 to 10/19/22 revealed no documentation of the bordered dressing.
Review of the wound assessment dated [DATE] revealed a stage three pressure ulcer wound which measured 2.5 cm by 2.0 cm continued to Resident #46's mid-spine, the wound was red/pink in color with white/tan slough in center. A second scabbed area to the mid-spine was documented and an Optifoam dressing was applied and encouragement to offload pressure to the area was provided.
Review of the physician orders revealed an order for the Optifoam dressing to the mid spine every three days, assess wounds, and report any worsening with a start date of 10/19/22.
Observation on 10/17/22 at 10:55 A.M., revealed a pressure reducing mattress was in place on Resident #46's bed. On 10/18/22 at 1:15 P.M., Resident #46 asked the surveyor to leave the room and would not allow observation of the residents back. Resident #46 was observed in bed and up in his wheelchair throughout the survey.
Interview on 10/20/22 at 2:12 P.M. with the Director of Nursing (DON) revealed skin assessment were done weekly, however Resident #46's documented pressure area was not assessed or measured by the facility until 10/19/22. The DON verified it was the expectation of the facility areas of pressure and documented skin concerns should be assessed, measured, and documented on weekly.
A follow-up interview on 10/24/22 at 2:10 P.M. with the DON verified there were no treatment orders in place for Resident #46 from 10/08/22 until 10/19/22.
Review of the policy titled Pressure Ulcer Policy last reviewed 04/2016 revealed all residents would be assessed for pressure ulcer risk on admission, monitored weekly and reviewed quarterly and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure as-needed (PRN) psychotropic me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure as-needed (PRN) psychotropic medications were limited to 14 days, and failed to ensure a physician evaluated the resident before continuing a PRN psychotropic medication. This affected two residents (#48 and #66) out of seven residents reviewed for unnecessary medications. The facility census was 73.
Findings include:
1. Review of the medical record for Resident #48 revealed an admission date of 01/16/13 and a readmission date of 02/23/21 with medical diagnoses of Alzheimer's disease, anxiety disorder, dementia with behavioral disturbance, and unspecified abnormalities of gait and mobility.
Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #48 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, toileting, extensive assistance of one person for hygiene, and limited assistance of one person for eating. Further review revealed she received an antipsychotic during the previous seven days.
Review of the current care plan revealed Resident #48 used daily scheduled psychotropic medications and as-needed (PRN) psychotropic medications. Interventions included monitoring the resident for side effects of medication use, notifying the physician of any adverse side effects, and using non-pharmacological interventions and documenting their effectiveness
Review of the physician orders for Resident #48 revealed an order dated 09/30/20 for lorazepam (an anti-anxiety medication) tablet 0.5 milligrams (mg), give one tablet by mouth every eight hours as needed for anxiety/agitation/sleep. The order ended on 08/21/21.
Further review of the orders revealed Resident #48's orders for PRN lorazepam continued until 10/14/21.
Review of a new PRN order dated 12/08/21 for lorazepam tablet 0.5 mg, give 0.5 mg by mouth every four hours as needed for anxiety/shortness of breath related to anxiety disorder. The order ended on 09/12/22.
Interview on 10/19/22 at 5:10 P.M., with the Regional Director of Clinical Services #347 verified the PRN order for lorazepam dated 09/30/20 was the first time PRN lorazepam was ordered for Resident #48, and confirmed the end date for the order was 08/21/21 and exceeded 14 days. Further interview at that time revealed the facility could not provide verification Resident #48 was evaluated by the physician 14 days after the PRN order for lorazepam dated 09/30/20. It was confirmed the order dated 12/08/21 for PRN lorazepam had an end date of 09/12/22 and the facility could provide no verification the physician evaluated Resident #48 after 14 days of receiving a PRN psychotropic medication.
2. Review of the medical record for Resident #66 revealed an admission date of 03/26/21 and medical diagnoses of anxiety disorder, urge incontinence, and chronic obstructive pulmonary disease.
Review of the quarterly MDS dated [DATE] revealed Resident #66 had intact cognition and required extensive assistance of two people for bed mobility, transfers, toileting, and extensive assistance of one person for personal hygiene.
Review of the current care plan for Resident #66 revealed she received psychotropic medications for diagnoses of anxiety and depression. Interventions included administering medications as ordered and monitor and document side effects and effectiveness, and monitor/record/report to the physician any PRN side effects and adverse reactions of psychoactive medications.
Review of the physician orders for Resident #66 revealed an order dated 03/27/21 for alprazolam (an anti-anxiety medication) tablet 0.5 mg, give one tablet by mouth every six hours as needed for anxiety. The order ended on 09/07/21.
Interview on 10/20/22 at 11:58 A.M. with the Regional Director of Clinical Services #347 verified the PRN order for alprazolam began on 03/27/21 and ended on 09/07/21 which exceeded 14 days. Further interview revealed Resident #66 had a PRN order for alprazolam dated 03/26/21 and discontinued on 03/27/21, and the order started 03/27/21 was the first PRN order that extended at least 14 days. The facility could not provide verification Resident #66 was evaluated by the physician 14 days after the PRN order for alprazolam dated 03/27/21.
Review of the facility policy titled Psychotropic Drugs, revised March 2017 revealed psychotropic medications used on a PRN basis with a physician's note indicating that the use of the drug, or continued of the drug is clinically appropriate, and the reasons why this use is clinically appropriate. This note must demonstrate that the physician has carefully considered risk/benefit to the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored at proper temperatures. This affected 15 residents (#11, #56, #14, #42, #14, #48, #34, #...
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Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored at proper temperatures. This affected 15 residents (#11, #56, #14, #42, #14, #48, #34, #26, #15, #13, #61, #07, #06, #37 and #274) and had the potential to affect all 59 residents on the A, B, C, and D halls. The facility identified three resident medication refrigerators. The facility census was 73.
Findings include:
1. Interview and observation on 10/19/22 at 1:20 P.M. with Registered Nurse (RN) #245 of the A, B, C, and D hall refrigerator revealed the third shift charge nurse was responsible to check the refrigerator temperatures and log them daily. The log sheet on the refrigerator had temperatures on 10/03/22, 10/05/22, 10/17/22, 10/18/22, and 10/19/22 and each were documented within the 35 to 46 degree Fahrenheit parameters. The temperature during the observation the temperature during observation was 50 degrees. This was verified at the time of finding.
2. Interview and observation on 10/19/22 at 1:28 P.M. with RN #245 of the refrigerator in the infection preventionist's office revealed the temperature was 44 degrees Fahrenheit. RN #245 verified there was no log for temperature checks and could not provide documentation.
Interview on 10/19/22 at 4:38 P.M., with the Director of Nursing revealed individual medications and contingency medications were being disposed of by recommendation of the pharmacy due to the low temperatures in the refrigerators.
Review of the policy titled Medication Storage in Facility, revised 02/11/22 revealed medications requiring refrigeration were to be kept in a refrigerator with a thermometer, with temperatures to be recorded daily.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on staff interview and review of personnel files, the facility failed to provide newly hired State Tested Nurse Aides (STNA) with training on caring for residents with a diagnosis of dementia. T...
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Based on staff interview and review of personnel files, the facility failed to provide newly hired State Tested Nurse Aides (STNA) with training on caring for residents with a diagnosis of dementia. This had the potential to affect 44 residents (#41, #51, #40, #328, #50, #27, #30, #48, #68, #277, #26, #60, #03, #07, #39, #69, #17, #56, #38, #12, #06, #19, #374, #62, #04, #28, #63, #70, #46, #08, #35, #37, #02, #29, #31, #15, #47, #36, #18, #67, #22, #124, #375, and #13) out of 44 residents diagnosed with dementia. The facility census was 73.
Findings include:
Review of the personnel file for STNA #231 revealed a hire date of 12/29/21. Further review revealed no documented training for residents with dementia.
Review of the personnel file for STNA #236 revealed a hire date of 04/01/22. Further review revealed no documented training for residents with dementia.
Interview on 10/20/22 at 1:31 P.M. with the Human Resources Director #248 verified the personnel files for STNA #231 and STNA #236 contained no verification they had received training on caring for residents with dementia.
Interview on 10/20/22 at 3:15 P.M. with the Assistant Director of Nursing (ADON) #276 revealed she trained newly hired nurse aides and further revealed the training included no specific training on caring for residents with dementia.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, review of the kitchen daily cleaning schedule, and policy review, the facility failed ensure foods were labeled and dated, discard expired foods, and resident me...
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Based on observation, staff interview, review of the kitchen daily cleaning schedule, and policy review, the facility failed ensure foods were labeled and dated, discard expired foods, and resident meals trays were covered during transport to resident rooms. In addition, the kitchen area and equipment was not maintained in a sanitary manner. This had the potential to affect all residents who resided in the facility and received food from the kitchens. The facility census was 73.
Findings include:
Observation on 10/17/22 at 9:20 A.M. of the facility kitchen and storage area revealed the following sanitation violations:
1. In the dry food storage one large bag of brown sugar next to a large plastic storage bin with brown sugar both open and undated. The large plastic storage container storing the brown sugar was sitting on a plastic food service tray with brown sugar laying on the surface.
In the walk-in refrigerator, the following items were opened, unlabeled and undated,
1. Open package of cheddar cheese.
2. Open package of mozzarella cheese,
3. Open package of shredded lettuce,
4. Opened package of ham base.
5. Opened package of pepperoni.
6. Opened package of smoked ham.
In the facility walk in freezer, the following items were opened, unlabeled and undated. Further observation revealed the food was not sealed properly.
1. Opened, undated and unsealed bag of broccoli.
2. Opened, undated and unsealed package of Garden burgers.
3. Opened, undated and unsealed package of cubed potatoes.
Interview on 10/17/22 at 10:02 A.M. with Assistant Dietary Manager #246 verified the findings and the foods should have been labeled and dated with an open date. She verified perishable foods should have been discarded on the expiration date or 7 days after opening.
2. Observation on 10/17/22 at 10:22 A.M. of the facility main kitchen revealed six heated food storage carts being utilized for storage of warm food until transportation to individual serveries. All six food storage carts had multiple unidentified spills inside the units, on the doors and side of the carts and the wheel casters had accumulation of unknown brown, black colored substances.
Observation on 10/17/22 at 10:25 A.M. of the facility main kitchen revealed a long stainless-steel worktable in the middle of the kitchen. The table had shelves under the top surface area. The shelves had multiple brown/black and yellow colored streaking on the legs, shelves and wheel castors.
Observation on 10/17/22 at 10:30 A.M. of the facility main kitchen revealed cook units had unidentified gray/white dry flaky debris on top of the units. Further observation revealed unidentified streaking down the sides of both units and brown, black colored accumulation around inside shelves oven racks.
Observation on 10/17/22 at 10:35 A.M. in the facility main kitchen revealed three black serving carts. The serving carts had three shelves. Observation on all three carts revealed multiple streaking of unidentified material on the handles, shelves and wheel castors.
Review of the kitchen daily routine cleaning schedule posted for staff to initial revealed the last documentation was dated 03/22.
Interview on 10/17/22 at 10:45 A.M. verified the observations regarding the heated food storage units, shelves under stainless steel tables, cook units and serving carts were not kept in a sanitary manner. Further confirmed the daily cleaning schedule was not completed as it should have been.
Interview on 10/20/22 at 12:40 P.M. with the Administrator and completed a tour of the dry storage area, and main kitchen cook areas and verified the daily cleaning schedule was not current and the last month the schedule was utilized was March 2022. The Administrator further verified the kitchen areas were not maintained in a sanitary manner regarding the heated storage carts, ovens, and stainless-steel table shelves.
Interview on 10/20/22 at 4:10 P.M. with the Director of Nursing (DON) verified the facility had no residents that did not receive food from the dietary department at the time of the survey.
3. Observation on 10/17/22 at 11:34 A.M. of Dietary cook #221 preparing meal tray to be transported from the unit serveries to residents eating in their room. Dietary Staff #270 transported a lunch tray for Resident #36 without appropriate coverings.
Observation on 10/17/22 at 11:36 A.M. of Dietary [NAME] #221 prepare a meal tray to be transported form the unit serveries to residents eating in their room. Dietary Staff #270 transported a lunch tray for Resident #16 without appropriate coverings.
Observation on 10/17/22 at 11:42 A.M. of Dietary [NAME] #221 prepare a meal tray to be transported form the unit serveries to residents eating in their room. Dietary Staff #270 transported a lunch tray for Resident #86 without appropriate coverings.
Interview on 10/17/22 at 11:50 A.M. with Dietary [NAME] #221 stated the meal trays should be covered when they are transported to the resident's room. Dietary [NAME] #221 verified trays were not covered as they should have been.
Review of facility policy titled Food Storage, dated 02/07/2018 revealed the facility failed to implement the policy as written. Letter A of the policy states food storage areas will be clean at all times. Letter B of the policy states all packaged food, or food items will be dated, kept clean and dry and dry at all times.
Review of facility policy titled Sanitation, dated 02/17/2016 revealed the facility failed to implement the policy as written. Letter B of the policy states all utensils, counters, shelves and equipment will be kept clean and maintained in good repair.
Jan 2020
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview and policy review, the facility failed to provide a resident with r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview and policy review, the facility failed to provide a resident with requested dental services. This affected one (#82) of one resident reviewed for dental services. The facility identified 58 residents who receive dental services from the facility dental provider. The facility census was 107.
Findings include:
Review of the medical record for Resident #82 revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnoses include atrial fibrillation (irregular heart beat), heart failure, diabetes mellitus type II, obstructive sleep apnea, valvular heart disease, morbid obesity, anemia, polyarthritis and acute kidney failure.
Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits or abnormal behaviors. Extensive assistance was required for bed mobility, transfers, walking, dressing, toileting and personal hygiene. Supervision was required for locomotion and eating. The resident was on a routine scheduled pain medication regime and also received as needed pain medications and non-medication intervention for pain for frequent pain, rated as a seven on a zero to 10 scale. Resident #82 has a significant weight gain not prescribed by the physician. No dental issues were identified. Opioids were received seven days of the assessment period. The assessment further revealed the resident did not receive therapy services or restorative nursing programs during the assessment period.
Review of the plan of care for Resident #82 dated 09/23/19 revealed the resident had dental health problems related to a broken tooth from biting down onto a hard item. Interventions included coordinating arrangements for dental care, including transportation if needed.
Review of an authorization for professional services dated 09/19/19 included the use of dental services provided by Mobile Dental Group #1 and was signed by Resident #82.
Review of an undated Dental exam and hygiene authorization form provided by the Director of Nursing (DON) revealed the form had Resident #82's name on it and it was from the dental service office. The form revealed different levels of treatment that could be provided as well as the cost of the service that would need to be paid prior to the service being rendered. The form further revealed for medicaid residents, they were to call the office and notify the dental office to change their financial status. Several of the services listed were to be covered by Medicaid.
Review of a notification note dated 11/08/19 revealed the facility shared an authorization form with Resident #82 and had the resident sign the form on 11/20/19 for a dental exam and hygiene.
Review of progress notes dated 10/17/19 revealed Resident #82 was approached due to her request to see the dentist. It further revealed the resident would like to see in-house dentist A request for orders for ancillary services was to be put in at this time.
Review of physician progress notes dated 01/03/20 revealed the resident voiced the need to see a dentist.
Further review of the medical record for Resident #82 provided no documentation the resident had been provided dental services.
Interview with Resident #82 on 01/13/20 at 10:42 A.M. revealed she had a broken bottom right molar tooth as well as a cavity that needed to be fixed. Resident #82 stated she did not have constant pain due to this, but it did hurt frequently as she ate. She stated she had asked to see a dentist on seven occasions since she had been admitted to the nursing facility. Resident #82 further stated she was told the dentist came every three months and she asked if she could have her name added to the waiting list. Resident #82 further stated when she asked the nurses the last time, she was informed the dentist had been to the facility in November and how she would have to wait until he came back in February.
Interview with the DON 01/16/20 at 3:00 P.M. revealed the facility had a binder of residents who were supposed to see the dentist. The DON stated the dentist did come every three months and could also have emergency appointments if needed. The DON stated Resident #82 was on the list of residents to be seen by the dentist at sometime in the next 10 days. The DON stated she had received a letter from the dentist to give to the resident for payment. The DON stated those forms were for private pay residents. She stated when the dentist was at the facility in 11/20/19, Resident #82 had been given a form but had not provided payment. The DON further verified Resident #82 received Medicaid services and should have not been provided a form for payment. She further verified the facility should have notified the dental group of the resident's financial status when she signed the authorization in 09/2019. She stated the facility should have realized when the dentist was here in 11/20/19, that the resident was covered by Medicaid and did not have to pay for dental services. The DON further verified the facility still had not notified the dental group when they received the same form for the resident. The DON stated the form she had been given by the dental group to be seen in 01/2020 was also for the resident's need for payment and fee that was required. The DON verified she should have called the dental group at the time she received the notice to be sure it was fixed, but she had not. The DON further stated usually the second shift charge nurse was responsible for adding residents' name to the ancillary service list. She stated they had been unable to keep that position filled and she was not responsible for this duty.
Further interview with the DON on 01/16/20 at 4:00 P.M. verified although she was not aware of a previous request from Resident #82 to see a dentist, she should have noticed the discrepancy in financial status when she received a 10 day notice of which residents were to be seen by the dentist. She verified she should have taken time to realize the discrepancy and to take care of the discrepancy before the dentist arrived. The DON further verified the plan of care for Resident #82 dated 09/2019 shortly after the resident's admission, revealed the need for the resident to see a dentist due to a broken tooth and it had not been done by the facility.
Review of facility policy Dental Services dated 05/09/17 revealed the facility was to assist the residents in obtaining routine and 24 hour emergency dental care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to ensure fall interventions were utilized...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to ensure fall interventions were utilized as identified in the plan of care. This affected one (#57) of one resident reviewed for falls. Additionally, the facility failed to ensure chemicals were stored in a safe manner. This had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105, #106, #258 and #259) residents the facility identified as cognitively impaired and independently mobile. The census was 107.
Findings include:
1. Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses include Parkinson's disease, dementia, psychosis, anxiety, mood disorder, dysphonia, hypokalemia, hypertension, heart disease, history of falls, speech disturbances, and muscle weakness.
Review of a care plan revision date 09/06/19, revealed Resident #57 was a high risk for falls related to a history of multiple falls at home prior to admission, decreased mobility, generalized weakness, episodes of confusion, incontinence and complaints of pain at times. The care plan revealed the resident was impulsive a times and would self transfer/ambulate without calling for assist. The resident had poor safety awareness, a history of crawling out of bed, and removing shoes. Interventions included dycem above and below cushion in wheelchair and hipsters to be worn daily.
Review of a progress note dated 12/11/19 at 10:50 P.M. revealed Resident #57 was observed on the living room floor, laying on his/her right lateral side with knees slightly bent and head resting on the floor. A head to to assessment was completed with no injuries observed. A neurological assessment was documented as within normal limits for the resident. Continued review of the progress note revealed the resident was not wearing hipsters and there was no dycem on top of Resident #57's wheel chair cushion.
Interview on 01/16/20 at 9:21 A.M. with Registered Nurse (RN) #177 revealed Resident #57 had an unwitnessed fall from his/her wheel chair on 12/11/19 at approximately 10:50 P.M. RN #177 verified Resident #57 was not wearing hipsters and there was no dycem on top of the resident wheel chair cushion as identified in the residents plan of care.
2. Observation on 01/15/20 at 9:12 A.M. revealed a can of air freshener and deodorizer had been left unattended on the hand rail near the Social Service Office. The can read danger: extremely flammable aerosol. Causes serious eye irritation. May cause drowsiness or dizziness.
Interview on 01/15/20 at 9:15 A.M. with the Housekeeping Supervisor #316 provided verification the air freshener and deodorizer can had been left, unattended, on the hand rail. The facility confirmed the unlocked and unsecured air freshener and deodorizer had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105, #106, #258 and #259) residents who cognitively impaired and independently mobile.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and policy review, the facility failed to ensure medication was secured in the medication cart. This had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, ...
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Based on observation, staff interview, and policy review, the facility failed to ensure medication was secured in the medication cart. This had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105, #106, #258 and #259) residents the facility identified as cognitively impaired and independently mobile. The census was 107.
Findings include:
Observation on 01/15/20 at 7:30 A.M. revealed Registered Nurse (RN) #101 was in a communal area, located next to a kitchette and a dining room, preparing medication for Resident #33. Observation of the immediate area revealed resident's were in the dining room eating and being served breakfast by dietary staff and state tested nurse aides (STNA's). RN #101 placed Resident #33's medications in a medication cup, walked away from the medication cart, down a hallway and out of sight of the medication cart to deliver/administer the medication to Resident #33 in the resident's room. The observation revealed RN #101 did not secure or lock the medication cart prior to leaving the cart unattended. Further observation revealed RN #101 returned to the medication cart to continue medication administration on 01/15/20 at 7:37 A.M.
Interview on 01/15/20 at 7:37 A.M. with RN #101 verified the failure to lock the medication cart when he/she left the cart unattended to administer medications to Resident #33. RN #101 confirmed the medication cart contained prescription and over-the-counter medications. The facility confirmed the unlocked and unsecured medication cart had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105, #106, #258 and #259) residents who were cognitively impaired and independently mobile.
Review of a facility policy titled, Medication Storage in the Facility dated 09/04/19, revealed medications were to be stored safely, securely, and properly following the manufacturer's recommendations. The medication supply was to be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, staff and resident interview, review of a food temperature form and policy review, the facility failed to ensure the food was palatable and at the correct holding temperature. Th...
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Based on observation, staff and resident interview, review of a food temperature form and policy review, the facility failed to ensure the food was palatable and at the correct holding temperature. This had the potential to all residents residing in the facility except two (#20 and #47) residents who were ordered to receive nothing by mouth. The facility census was 107.
Findings include:
Observation of Oakbridge Section D with Dietary Staff #552 on 01/14/19 at 5:11 P.M. revealed the staff member plated food from the hot holding area onto a test tray. The temperature of the test tray was immediately checked which revealed the chicken temped at 106 degree Fahrenheit (F), carrots temped at 119 degrees F and mashed potatoes temped at 127 degrees F. Dietary Staff #552 and the surveyor tasted the food which did not taste warm, chicken was tough and cold.
Interview with Resident #82 on 01/14/20 at 5:30 P.M. revealed her chicken for supper meal was cold and dry.
Interview with Food Services Supervisor #507 on 01/14/20 at 5:45 P.M. revealed the only temperatures taken of the food prior to service in completed in the kitchen. The food is taken from the main kitchen out to the neighborhoods via hot boxes and placed in the warmers. The facility confirmed this had the potential to affect 105 out of 107 residents receive their meals from the kitchen and that two (#20 and #47) residents were ordered to receive nothing by mouth.
Observations of temperatures on 01/15/19 at 9:30 A.M. taken in the kitchen for lunch revealed the staff took temperatures at 9:30 A.M. then placed in hot box then not taken to the neighborhoods until 11:30 A.M.
Review of the facility's Daily Food Temperature Form revealed there were no temperatures taken at any of the neighborhoods before or during food service.
Review of the facility's undated policy Food Safety Code Regulations revealed handling hot and cold holding cooking or cooling foods shall be maintained at 135 degrees F or above.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, staff and resident interview, review of a local health department inspection report, review of a facility food temperature form and policy review, the facility failed to ensure ...
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Based on observations, staff and resident interview, review of a local health department inspection report, review of a facility food temperature form and policy review, the facility failed to ensure staff practiced proper hand hygiene when serving food to residents. Additionally, the facility failed to maintain safe foods temperatures for food items held in the neighborhood kitchens. This had the potential to affect all residents except for two (#20 and #47) who were ordered to receive nothing by mouth. The census was 107.
Findings include:
1. Observation on 01/13/20 at 11:25 A.M. revealed Dietary Staff #500 entered Resident #28's room with a lunch tray and moved personal items from the over bed table. Dietary Staff #500 placed the tray onto the over bed table and spoke with resident about her shoes. Dietary Staff #500 proceeded to touch the tops of Resident #28's shoe. Dietary Aide #500 exited the room and proceeded to enter the kitchenette in Maple Run and began to touch dishes.
Interview on 01/13/20 at 11:30 A.M. with Dietary Staff #500 provided verification she had not changed her gloves or washed her hands, or used hand sanitizer, after touching numerous personal items and shoes of Resident #28 prior to starting to touch other dishes to serve other residents.
2. Observation on Oakbridge section D on 01/14/20 at 4:59 P.M. revealed Dietary Staff #552 had placed gloves on and opened the microwave, opened the refrigerator, then opened the freezer and took out a bag of frozen hot dogs. Dietary Staff #552 opened up the bag and reached in with her contaminated glove and put a hotdog on a plate. Dietary Staff #552 verified she should have changed her contaminated gloves before touching the hotdog.
3. Observation of on 01/14/19 at 5:07 P.M. of Dietary Staff #510 on Oakbridge Section D revealed she had gloves on then she touched the countertop, the cabinet door and moved the hotbox looking for the residents personal bread. Dietary Staff #510 found the bread under the counter and with the contaminated gloves opened up the bag of bread and started to get out a slice of bread. Dietary Staff #510 verified she should have changed her gloves due to being contaminated before touching any food.
4. Observation of Oakbridge Section D with Dietary Staff #552 on 01/14/19 at 5:11 P.M. revealed the staff member plated food from the hot holding area onto a test tray. The temperature of the test tray was immediately checked which revealed the chicken temped at 106 degree Fahrenheit (F), carrots temped at 119 degrees F and mashed potatoes temped at 127 degrees F. Dietary Staff #552 and the surveyor tasted the food which did not taste warm, chicken was tough and cold.
Interview with Resident #82 on 01/14/20 at 5:30 P.M. revealed her chicken for supper meal was cold and dry.
Interview with Food Services Supervisor #507 on 01/14/20 at 5:45 P.M. revealed the only temperatures taken of the food prior to service in completed in the kitchen. The food is taken from the main kitchen out to the neighborhoods via hot boxes and placed in the warmers. Food Services Supervisor #507 confirmed food temperatures are not checked when the food is being held on the hot holding areas to ensure the food is at an appropriate and safe level. The facility confirmed there have been no food borne illness; however, further confirmed this had the potential to affect 105 out of 107 residents who receive their meals from the kitchen and that two (#20 and #47) residents were ordered to receive nothing by mouth.
Observations of temperatures on 01/15/19 at 9:30 A.M. taken in the kitchen for lunch revealed the staff took temperatures at 9:30 A.M. then placed in hot box then not taken to the neighborhoods until 11:30 A.M.
Review of the local health department inspection reported dated 11/14/19 revealed the facility received two violations from the local health department. The report documented violations regarding Time/Temperature Control for Safety (TCS) foods not being held at the proper temperature. One instance was found in one of the satellite kitchens where the hot food items were not at 135 degrees F and the food item had to be discarded. Additionally, TCS foods not being cold held at the proper temperature in the following refrigeration units: main kitchen 2-door reach in (44 degrees F); Oak A refrigerator (47 degrees F); Cedar (46-50 degrees F).
Review of the facility's Daily Food Temperature Form revealed there were no temperatures taken at any of the neighborhoods before or during food service to ensure foods were maintained at a safe temperature.
Review of the facility's undated policy Food Safety Code Regulations revealed handling hot and cold holding cooking or cooling foods shall be maintained at 135 degrees F or above.
Review of the facility policy titled Hand Hygiene Procedures dated 03/09, revealed alcohol hand sanitizer should be used before entering or exiting a resident room and after contact with inanimate objects.
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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Ohio facilities.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 29 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Briarwood Village's CMS Rating?
CMS assigns BRIARWOOD VILLAGE 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 Briarwood Village Staffed?
CMS rates BRIARWOOD VILLAGE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 52%, compared to the Ohio average of 46%. RN turnover specifically is 61%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Briarwood Village?
State health inspectors documented 29 deficiencies at BRIARWOOD VILLAGE during 2020 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 28 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Briarwood Village?
BRIARWOOD VILLAGE 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 HCF MANAGEMENT, a chain that manages multiple nursing homes. With 112 certified beds and approximately 95 residents (about 85% occupancy), it is a mid-sized facility located in COLDWATER, Ohio.
How Does Briarwood Village Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, BRIARWOOD VILLAGE's overall rating (1 stars) is below the state average of 3.2, staff turnover (52%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Briarwood Village?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Briarwood Village Safe?
Based on CMS inspection data, BRIARWOOD VILLAGE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Ohio. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Briarwood Village Stick Around?
BRIARWOOD VILLAGE has a staff turnover rate of 52%, which is 6 percentage points above the Ohio average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Briarwood Village Ever Fined?
BRIARWOOD VILLAGE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Briarwood Village on Any Federal Watch List?
BRIARWOOD VILLAGE 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.