LAURELS OF HUBER HEIGHTS THE
For profit - Corporation
92 Beds
CIENA HEALTHCARE/LAUREL HEALTH CARE
Data: November 2025
Trust Grade
45/100
#711 of 913 in OH
Photo by Natalie Curtis
Photo by Laurels of Huber Heights
Photo by Laurels of Huber Heights
1 / 5 photos
Last Inspection: August 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
The Laurels of Huber Heights has a Trust Grade of D, indicating it is below average and has some concerning issues. It ranks #711 out of 913 facilities in Ohio, placing it in the bottom half of nursing homes in the state, and #31 out of 40 in Montgomery County, meaning only a few local options are worse. The facility is worsening, as the number of issues has increased from 6 to 12 over the past year. Staffing is average with a 2-star rating and a turnover rate of 56%, which is slightly higher than the state average, suggesting that while staff stay, there are challenges in maintaining consistency. Notably, while there have been no fines, the facility has faced serious concerns; for example, they failed to ensure proper water temperatures for showers, affecting resident comfort, and did not follow dietary guidelines for residents on special diets, which could lead to potential harm. Overall, while there are some strengths, such as no fines, the facility has significant weaknesses that families should consider.
- Trust Score
- D
- In Ohio
- #711/913
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 56% 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 ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 23%
No red flags
6 → 12 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 12 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
2-Star Overall Rating
Below Ohio average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 56%
Near Ohio avg (46%)
Frequent staff changes - ask about care continuity
Chain: CIENA HEALTHCARE/LAUREL HEALTH CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Ohio average of 48%
The Ugly 30 deficiencies on record
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
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 reviews, staff interview, and policy review, the facility failed to complete wound assessments at the ti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interview, and policy review, the facility failed to complete wound assessments at the time of admission and/or failed to timely initiate treatment for wounds. This affected two (#16 and #32) out of three residents reviewed for wounds. The facility census was 75. Findings include: 1.Review of the medical record for Resident #16 revealed an admission date of 05/23/25 with medical diagnoses of aftercare following surgical amputation, peripheral vascular disease, end stage renal disease, and diabetes mellitus (DM). Review of a quarterly Minimum Data Set (MDS) assessment, dated 08/16/25, indicated Resident #16 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene and bathing, partial/moderate staff assistance for bed mobility and was dependent upon staff for transfers. The MDS indicated Resident #16 admitted with two deep tissue injuries (DTI), DM foot ulcer, and surgical wound. Review of a nursing comprehensive assessment, dated 05/23/25, indicated under the skin assessment that Resident #16 had right toe amputation, redness to bilateral buttocks, coccyx, and heels. The assessment did not contain documentation to support measurements or description of skin issues. Review of wound/skin evaluations completed 05/28/25 indicated Resident #16 admitted with a vasculitic injury to left dorsum fifth digit (toe) which measured 2.0 centimeters (cm) by 1.8 cm with 20% slough and 50% eschar, a vasculitic injury to left heel which measured 4.2 cm by 3.2 cm and had 100% eschar, an other skin issue to right lateral malleolus which measured 3.0 cm by 2.5 cm with 100% eschar, a DTI to right heel which measured 5.2 cm by 3.8 cm with 100% eschar, an other skin issue to left lateral malleolus which measured 1.6 cm by 1.2 cm with 100% eschar, a surgical site to right dorsum first digit with partial dehiscence which measured 8.7 cm by 3.6 cm, an other skin issue to right dorsum foot which measured 1.9 cm by 1.3 cm, an other skin issue to left lateral midfoot which measured 2.1 cm by 1.9 cm and moisture associated skin damage (MASD) to sacrum with no measurements noted. Review of the physician orders for Resident #16 revealed no documentation to support treatment was initiated for the above wounds until 05/29/25. Review of medical record for Resident #16 revealed documentation to support Resident #16 was seen by a wound physician weekly starting 06/03/25 until discharged on 06/27/25. Review of the wound physician note dated 06/24/25 indicated Resident #16 had a DTI ulcer to left heel, unstageable pressure ulcer to right anterior ankle (formerly documented as right lateral malleolus), a surgical wound to right distal foot, an unstageable pressure ulcer to right dorsal foot, and a DTI to right heel. Interview on 09/11/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #203 confirmed the medical record for Resident #16 did not have documentation to support the wounds were evaluated upon admission on [DATE] until 05/28/25 and that a treatment for the wounds was not initiated until 05/29/25. 2. Review of the medical record for Resident #32 revealed an admission date of 07/17/25 with medical diagnoses of diabetes mellitus with foot ulcer, chronic ulcer of left heel and midfoot with fat layer exposed, congestive heart failure, anemia, and atrial fibrillation. Review of the admission MDS assessment, dated 07/24/25, indicated Resident #32 was cognitively intact and required partial/moderate staff assistance for bed mobility and was dependent upon staff for toilet hygiene, showers/bathing, and transfers. The MDS indicated Resident #32 had an infection to her foot with a surgical wound present. Review of nursing comprehensive assessment, dated 07/17/25, indicated Resident #32 had stitches to left small toe and left outer foot. The assessment did not include measurements or description of wounds. Review of medical record for Resident #32 revealed a physician order dated 07/18/25 for left foot surgical site to apply Vashe moistened gauze to surgical site five to ten minutes then remove, pat dry, apply xerofoam, abdominal pad, and wrap with kerlix and ace wrap. And to change every 48 hours. Review of treatment administration record revealed documentation to support treatment was completed as ordered. Review of the medical record for Resident #32 revealed documentation to support Resident #32 was seen by wound physician on 07/22/25. A wound physician note on 07/22/25 indicated Resident #32 had surgical site to left lateral foot which measured 6.5 cm by 2.5 cm with five interrupted sutures in place. Interview on 09/11/25 at 11:26 A.M. with LPN #203 confirmed Resident #32 admitted to the facility with surgical wounds on 07/17/25 but the medical record did not have documentation to support Resident #32 wounds were not measured until 07/22/25. Review of the facility policy titled, Skin Management, revised 09/19/24, stated the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. The policy stated upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic health record. The policy stated any residents admitted with any skin impairment would have appropriate interventions to promote healing, a physician's order for treatment and skin impairment location, measurements, and characteristics documented. This deficiency is based on incidental findings discovered during the course of this complaint investigation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to complete pressure ulcer assessments u...
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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 complete pressure ulcer assessments upon admission and failed to timely initiate treatment for pressure ulcers. This affected one (#16) out of the three residents reviewed for pressure ulcers. The facility census was 75. Findings include: Review of the medical record for Resident #16 revealed an admission date of 05/23/25 with medical diagnoses of aftercare following surgical amputation, peripheral vascular disease, end stage renal disease, and diabetes mellitus (DM). Review of a quarterly Minimum Data Set (MDS) assessment, dated 08/16/25, indicated Resident #16 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene and bathing, partial/moderate staff assistance for bed mobility and was dependent upon staff for transfers. The MDS indicated Resident #16 admitted with two deep tissue injuries (DTI), DM foot ulcer, and surgical wound. Review of a nursing comprehensive assessment, dated 05/23/25, indicated under the skin assessment that Resident #16 had right toe amputation, redness to bilateral buttocks, coccyx, and heels. The assessment did not contain documentation to support measurements or description of skin issues. Review of wound/skin evaluations completed 05/28/25 indicated Resident #16 admitted with a vasculitic injury to left dorsum fifth digit (toe) which measured 2.0 centimeters (cm) by 1.8 cm with 20% slough and 50% eschar, a vasculitic injury to left heel which measured 4.2 cm by 3.2 cm and had 100% eschar, an other skin issue to right lateral malleolus which measured 3.0 cm by 2.5 cm with 100% eschar, a DTI to right heel which measured 5.2 cm by 3.8 cm with 100% eschar, an other skin issue to left lateral malleolus which measured 1.6 cm by 1.2 cm with 100% eschar, a surgical site to right dorsum first digit with partial dehiscence which measured 8.7 cm by 3.6 cm, an other skin issue to right dorsum foot which measured 1.9 cm by 1.3 cm, an other skin issue to left lateral midfoot which measured 2.1 cm by 1.9 cm and moisture associated skin damage (MASD) to sacrum with no measurements noted. Review of the physician orders for Resident #16 revealed no documentation to support treatment was initiated for the above wounds until 05/29/25. Review of medical record for Resident #16 revealed documentation to support Resident #16 was seen by a wound physician weekly starting 06/03/25 until discharged on 06/27/25. Review of the wound physician note dated 06/24/25 indicated Resident #16 had a DTI ulcer to left heel, unstageable pressure ulcer to right anterior ankle (formerly documented as right lateral malleolus), a surgical wound to right distal foot, an unstageable pressure ulcer to right dorsal foot, and a DTI to right heel. Interview on 09/11/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #203 confirmed the medical record for Resident #16 did not have documentation to support the wounds were evaluated upon admission on [DATE] until 05/28/25 and that a treatment for the wounds was not initiated until 05/29/25. Review of the facility policy titled, Skin Management, revised 09/19/24, stated the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. The policy stated upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic health record. The policy stated any residents admitted with any skin impairment would have appropriate interventions to promote healing, a physician's order for treatment and skin impairment location, measurements, and characteristics documented. This deficiency is based on incidental findings discovered during the course of this complaint investigation.
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
Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (#20) ou...
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Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (#20) out of two residents observed for medication administration. The facility census was 75. Findings include: Review of the medical record for Resident #20 revealed an admission date of 12/30/21 with medical diagnoses of cerebral infarction, dysphagia, vascular dementia, hypertension, and diabetes mellitus. Review of the medical record for Resident #20 revealed physician orders dated 08/03/24 for Oyster Calcium tablet 500 milligram (mg) one tablet by mouth daily, galantamine 12 mg one tablet by mouth daily, and Memantine 5 mg one tablet by mouth daily, physician orders dated 08/04/25 for aspirin 81 mg one tablet by mouth daily, chlorthalidone 12.5 mg one tablet by mouth daily, senna 8.6-50 mg one tablet by mouth daily, nifedipine 90 mg one tablet by mouth daily, and an order for Depakote 125 mg three tablets by mouth three times per day. Observation on 09/11/25 at 9:05 A.M. revealed Licensed Practical Nurse (LPN) #207 prepared medications for Resident #20 and was observed placing aspirin tablet, Oyster Calcium tablet, and senna tablet into her bare hands prior to placing the medications into the medication cup. LPN #207 was observed placing medications into a plastic sleeve and crushing the medications prior to placing them into a medication cup along with applesauce. LPN #207 was observed to administer medications to Resident #207. Interview won 09/11/25 at 9:27 A.M. with LPN #207 confirmed she placed Resident #20's aspirin, Oyster Calcium tablet, and senna tablet into her bare hands prior to medication administration. Review of the facility policy titled, Medication Administration, revised 10/17/23 stated resident medications are to be administered in an accurate, safe, timely, and sanitary manner. The policy stated medications are administered in accordance with written orders of the attending physician. The policy stated staff are to perform hand hygiene prior to medication preparation for each medication pass and after direct resident contact. The policy stated to place medications in medicine cups without touching the inside of the cup and if medications come into contact with the bare hands of the nurse/med tech or with the care, the medication should be disposed of per policy and new medications obtained. This deficiency is based on incidental findings discovered during the course of this complaint investigation.
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
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, policy review and review of the Ohio Revised Code (ORC), the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, policy review and review of the Ohio Revised Code (ORC), the facility failed to ensure the administration of total parental nutrition (TPN) was completed in accordance with professional standards of practice. This affected two (#57 and #89) of three residents reviewed for intravenous (IV) administration. The facility census was 88.
Findings include:
1. Medical record review for Resident #57 revealed an admission on [DATE] with diagnoses with surgical aftercare on the digestive system, fistula of intestine, chronic pain syndrome, colostomy status and protein calorie malnutrition.
Review of the quarterly Minimum Data Set (MDS) assessment for Resident #57 dated 02/27/25 revealed impaired cognition. Resident #57 required set up assistance for eating and maximum assistance for toileting assistance and dependent for transfers and bed mobility.
Review of the plan of care for Resident #57 revealed resident has an alteration in nutritional and hydration related to fistula of intestine. Resident #57 has history of TPN discontinued on 11/03/24. Interventions include administer medication as ordered, administer diet as ordered and obtain laboratory/diagnostic tests as ordered.
Review of the physicians orders for Resident #57 revealed an order dated 08/09/24 and discontinued on 11/03/24 for TPN adult cyclic on day shift nonstandard TPN. Registered Nurse (RN) to mix Infuvite (multivitamin) 10 milliliters (ml) start at 55 ml/hour (hr) and increase to 178 ml/hr for nine hours, decrease to 50 ml/hr for one hour the discontinue every day shift.
Review of the Medication Administration Record (MAR) for Resident #57 for the month of October 2024 revealed Licensed Practical Nurse (LPN) #5 signed Resident #57's TPN as administered on 10/02/24, 10/05/24, 10/06/24, 10/10/24, 10/16/24, 10/19/24, 10/20/24, 10/24/24, 10/15/24, 10/30/24 and 10/31/24. LPN #29 signed Resident #57's TPN as administered on 10/03/24 and 10/17/24. LPN #35 signed Resident #57's TPN as administered on 10/09/24 and 10/28/24. LPN #31 signed Resident #57's TPN as administered on 10/11/24, 10/12/24, and 10/23/24.
2. Medical record review for Resident #89 revealed an admission on [DATE] and a discharge on [DATE] with diagnoses including surgical after care following digestive system for perforation of the intestine, severe protein malnutrition and adult lymphoma leukemia.
Review of the plan of care for Resident #89 dated 06/19/24 revealed resident was at nutritional risk related to diagnoses of lymphoma. Resident #89 had a history of TPN discontinued on 12/04/24. Interventions include administer medications as ordered, refer to dietitian as needed and obtain laboratory test as ordered.
Review of the quarterly MDS assessment dated [DATE] for Resident #89 revealed resident had an intact cognition. Resident #89 requires supervision for eating, bed mobility, transfers and toileting.
Review of the physician's orders for Resident #89 for the month of November 2024 revealed an order dated 07/18/24 and discontinued on 12/10/24 for TPN adult cyclic on day shift nonstandard TPN, 5.5 percent (%) AA, seventeen % dextrose and three % intravenous lipid emulsion ([NAME]) kilocalorie's (KCAL) provided per day 1713 protein grams/day. RN to mix Infuvite (multivitamin) 10 milliliters (ml) start at 60 mix mix one hour, increase to 120 ml/hr times twelve house and decrease to 60 ml per hour and then discontinue every day shift for nutrition.
Review of the MAR for Resident #89 for the month of November 2024 revealed LPN #31 signed the TPN as administered on 11/01/24, 11/04/24, 11/07/24, 11/09/24, 11/10/24, 11/12/24, 11/14/24, 11/15/24, 11/18/24, 11/19/24, 11/21/24, 11/23/24, 11/24/24, 11/26/24 and 11/29/24. LPN #25 signed Resident #89's TPN as administered on 11/03/24, 11/06/24, 11/08/24, 11/11/24, 11/13/24, 11/16/24, 11/17/24, 11/20/24, 11/22/24, 11/25/24, 11/27/24, 11/28/24 and 1130/24.
Interview on 04/08/24 at 3:07 P.M. with the Director of Nursing (DON) states she was unaware that the LPN's were documenting on the MAR indicating they were administering the TPN solution for Resident #57 or #89. DON verified that LPN's cannot administer TPN as it is out of their scope of practice. Additionally, the DON stated that once it was brought to her attention, she interviewed the LPN's regarding who was administrating the solution. LPN's reported the RN's working administered the TPN solution and the LPN's had just signed the MAR off as completed. DON verified LPN's should not be signing for the administration of TPN or documenting it on the MAR as administered. DON confirmed LPN's can not initiate or maintain TPN.
Interview on 04/08/25 at 4:09 P.M. with LPN #31 verified that he did not administer any TPN solution for Resident #57 and #89. LPN #31 only signed the MAR as completed. LPN #31 confirmed LPN's can not initiate or maintain TPN.
Interview on 04/09/25 at 2:00 P.M. with Unit Manager LPN #76 denied any knowledge of any LPN's completing the administration of TPN and that they were just signing off the MAR for the RN. LPN #76 verified administration of TPN solution was out of the scope of practice for LPN's. LPN #76 confirmed LPN's can not initiate or maintain TPN.
Review of the facility policy titled Total Parental Nutrition dated 12/10/24 revealed staff should monitor for signs of complications related to TPN administration.
Review of the facility policy titled Medication Administration dated 10/17/23 revealed under authorized personnel medications are prepared, administered and recorded only by licensed nursing authorized by state law and regulations.
Review of the ORC Section 4723.18 titled Administration of Adult Intravenous Therapy at https://codes.ohio.gov/ohio-revised-code/section-4723.18 revealed LPN's shall not perform any of the following: initiate or maintain any intravenous therapy procedures that include solutions for total parental nutrition.
This deficiency represents non-compliance investigated under Complaint Number OH00162510.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure staff implemente...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure staff implemented enhanced barrier precautions when changing wounds that require dressings. This affected one (#26) of three residents reviewed for wound care. The facility census was 88.
Findings include:
Review of the medical record for Resident #26 revealed an admission on [DATE] with diagnoses including cerebral infarction (stroke), heart failure, end stage renal disease, type two diabetes and severe vascular dementia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed a severely impaired cognition. Resident #26 requires extensive assistance for activities of daily living.
Review of the plan of care for Resident #26 dated 04/02/24 revealed resident has venous stasis skin impairment to left [NAME] related to peripheral vascular disease (PVD). Interventions include skin injury will decrease in size, enhanced barrier precautions, observe and report signs and symptoms of infection, and evaluate wound for size, depth, and margins.
Review of the active physician orders for Resident #26 reveal an order dated 03/15/25 to cleanse area to right frontal lateral leg, pat dry and apply adaptic (petroleum gauze), cover with abdominal dressing (ABD) and wrap with kerlix daily and as needed, an or dated 03/19/25 to cleanse laceration wound to right mid anterior shin and right mid lateral skin with normal saline, pat dry, apply xeroform to eschar, cover with ABD, wrap with Kerlix and secure with ace bandage daily, an order dated 03/29/25 to cleanse skin tear to left buttock with normal saline, apply xeroform to wound bed, cover with silicone dressing every day, and cleanse wound to left medial calf (hematoma) with normal saline, pat dry and apply xeroform, cover with ABD, wrap with kerlix daily and as needed.
Observation on 04/08/25 at 8:00 A.M. of signage for Resident #26 to the right of the entrance and above her name revealed the resident was on enhanced barrier precaution. The sign stated everyone must clean their hands before entering and when leaving the room. Additionally, the sign stated that providers and staff must also wear gloves, and a gown for the following high contact resident care activities including dressing, bathing, showering, transferring, changing linen, providing briefs or assisting with toileting, device care for central line, urinary catheter, feeding tube and tracheostomy and wound care for any skin opening requiring a dressing
Observation on 04/08/25 at 8:10 A.M. revealed Licensed Practical Nurse (LPN) #5 and Certified Nurse Assistant (CNA) #84 enter Resident #26's room and donned gloves. LPN #5 advised Resident #26 that they were going to remove old dressing and measure the areas. LPN #5 removed the dressing to Resident #26's bilateral legs leaving dressing in place on the lower extremities. Wound Physician #101 donned gloves and entered room and addressed the resident, advising her he was there to measure the wounds. Wound Physician #101 measured each of the three wounds using separate disposable wound measuring devices. LPN #5 changed gloves completed hand hygiene and donned new gloves and applied dressing to left lower hematoma, leaving the right wound uncovered as the physician discontinued treatment and advised they were resolved. CNA #84 assisted Resident #26 to roll onto her right side for the physician to measure the wound to her left buttocks. Treatment to area was discontinued and physician documented area was resolved.
Interview on 04/08/25 at 8:25 A.M. with LPN #5, CNA #84, Wound Physician #101 all verified they did not don gowns prior to entering the room for Resident #26 and should have. LPN #5, CNA #84 and Wound Physician #101 confirmed Resident #26 was to be in enhanced barrier precautions.
Interview on 04/08/25 at 8:30 A.M. with the Director of Nursing (DON) verified the facility did not have a three chest drawer in the hallway to store personal protective equipment for use with Resident #26 and would get one in place outside of the door for Resident #26. The DON confirmed Resident #26 was to be in enhanced barrier precautions.
Review of the facility policy titled Infection Preventions Program Overview dated 02/28/25 stated the facility established a program (infection prevention and control program) that is based on the facility assessment and follows accepted national standards.
This deficiency represents non-compliance investigated under Complaint Number OH00162510.
Jan 2025
7 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 F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility to honor resident smoking rights. This affected one (Resident #3) of one resident r...
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Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility to honor resident smoking rights. This affected one (Resident #3) of one resident reviewed for smoking. The facility identified 10 residents who smoked independently. The facility census was 85 residents.
Findings include:
Review of the medical record for Resident #3 revealed an admission date of 12/30/21 with diagnoses including cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes.
Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 10/13/24 revealed the resident was severely cognitively impaired and required supervision/touching assistance for eating, and substantial/maximum assistance for toileting, bed mobility, and transfers.
Review of care plan for Resident #3 dated 10/30/24 revealed the resident wished to use smoking materials and was assessed as unsafe to smoke. The resident would go out to the smoking area and look for cigarette butts to smoke or ask other residents that smoked for cigarettes. Interventions included the following: staff members to distribute smoking materials to residents who smoke at the designated times, staff to supervise and maintain safety during smoking, staff members to maintain all smoking paraphernalia for unsafe and safe smokers such as cigarettes and lighters.
Review of smoking assessment for Resident #3 dated 11/01/24 revealed the resident was an unsafe smoker because he couldn't safely light the smoking materials, couldn't hold the materials safely, couldn't dispose of ashes in the ashtray safely, couldn't extinguish cigarette safely, and couldn't follow the policy. The summary of the assessment revealed Resident #3 was an unsafe smoker and he would be a supervised smoker.
Interview on 01/29/25 at 8:30 A.M with the Director of Nursing (DON) confirmed if a resident was admitted into the facility and could smoke independently the resident could smoke outside whenever they wished. If a resident was assessed as an unsafe smoker, the resident was not permitted to smoke on the facility grounds. The DON further confirmed the facility did not offer supervised smoking.
Interview on 01/29/25 at 10:20 A.M. with Resident #3 confirmed the resident was able to answer questions appropriately. Resident #3 confirmed he had been a smoker for quite some time and the facility would not allow him to smoke and he didn't know why.
Review of the facility policy titled Smoking Policy dated 10/17/23 revealed if the interdisciplinary team (IDT) determined that a resident was an unsafe smoker, the resident was required to wear a protective smoking vest/apron and should be supervised while smoking. The degree of supervision was determined by the team and was based on the smoking evaluation, the physical attributes of the smoking area, and other relevant factors. Staff members would maintain all smoking paraphernalia for all unsafe and safe smokers, e.g., cigarettes, cigars, pipes, lighter fluid, or any other matter or substance that contained a tobacco product. Staff members would distribute smoking materials to residents that were unsafe to smoke at the designated smoking times.
Review of the facility policy titled Resident Rights dated 05/14/24 revealed the facility must promote the exercise of rights for each resident, including any who face barriers such as communication problems, hearing problems and cognition limits in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to follow and implement the abuse policy rega...
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Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to follow and implement the abuse policy regarding allegations of abuse by failing to report abuse to the state agency in a timely manner, failing to provide abuse education as detailed in the SRI, failing to protect residents during an abuse investigation by suspending accused staff, and failing to complete a timely and thorough abuse investigation. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents.
Findings include:
1.Review of the medical record for Resident #87 revealed an admission date of 11/15/24 with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of 01/04/25.
Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.)
Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel.
Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting. Further review of the SRI revealed there was no documentation of education completed with the staff on abuse and neglect prevention.
Further review of the SRIs revealed there was no SRI initiated for the complaint received from the insurance company regarding Resident #87.
Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation.
Interview on 01/29/25 at 1:51 P.M. with the Administrator confirmed the facility did not have documentation of staff education on abuse and neglect prevention which was to be completed as a result of the investigation of the SRI dated 01/08/25.
Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87.
2. Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.
Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs.
Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25.
Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25.
Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25.
Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed.
This deficiency represents noncompliance investigated under Complaint Number OH00161688.
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
Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state a...
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Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state agency in a timely manner. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents.
Findings include:
1.Review of the medical record for Resident #87 revealed an admission date of 11/15/24 with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of 01/04/25.
Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.)
Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel.
Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting.
Further review of the SRIs revealed there was no SRI initiated regarding the complaint received from the insurance company regarding Resident #87.
Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation.
Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87.
2. Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.
Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs.
Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25.
Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25.
Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25
Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed.
This deficiency represents noncompliance investigated under Complaint Number OH00161688.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to complete timely and thorough investigation...
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Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to complete timely and thorough investigations and failed to protect residents during an abuse investigation by suspending accused staff. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents.
Findings include:
1.Review of the medical record for Resident #87 revealed an admission date of 11/15/24 with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of 01/04/25.
Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.)
Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel.
Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting. Further review of the SRI revealed there was no documentation of education completed with staff on abuse and neglect prevention.
Further review of the SRIs revealed there was no SRI initiated regarding the complaint received from the insurance company regarding Resident #87.
Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation.
Interview on 01/29/25 at 1:51 P.M. with the Administrator confirmed the facility did not have documentation of staff education on abuse and neglect prevention which was to be completed as a result of the investigation of the SRI dated 01/08/25.
Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87.
2. Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.
Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs.
Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25.
Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25.
Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25
Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed.
This deficiency represents noncompliance investigated under Complaint Number OH00161688.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and review of the facility policy, the facility failed to provide the appropriate level of supervision to prevent accidents involving residents while s...
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Based on medical record review, staff interview, and review of the facility policy, the facility failed to provide the appropriate level of supervision to prevent accidents involving residents while smoking cigarettes. This affected one (Resident #3) of one resident reviewed for smoking practices. The facility identified 10 residents in the facility who smoked independently. The facility census was 85 residents.
Findings included:
Review of the medical record for Resident #3 revealed an admission date of 12/30/21 with diagnoses including cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes.
Review of the annual Minimum Data Set (MDS) assessment for Resident #3 dated 10/13/24 revealed the resident was severely cognitively impaired and required supervision/touching assistance for eating and substantial/maximal assistance for toileting, bed mobility, and transfers.
Review of care plan for Resident #3 dated 10/30/24 revealed the resident wished to use smoking materials and was assessed as unsafe to smoke. The resident would go out to the smoking area and look for cigarette butts to smoke or ask other residents that smoke for cigarettes. Interventions included the following: staff members to distribute smoking materials to residents who smoke at the designated times, staff to supervise and maintain safety of residents during smoking, staff members to maintain all smoking paraphernalia for unsafe and safe smokers such as cigarettes and lighters.
Review of the smoking assessment for Resident #3 dated 11/01/24 revealed the resident was an unsafe smoker because he couldn't safely light the smoking materials, couldn't hold the materials safely, couldn't dispose of ashes in the ashtray safely, couldn't extinguish cigarettes safely, and couldn't follow the policy. The summary of the assessment revealed Resident #3 was an unsafe smoker and he should be supervised while smoking.
Review of the progress note for Resident #3 dated 12/21/24 revealed the resident was sitting outside of the nursing station and Registered Nurse (RN) #113 noticed a smoke smell and saw Resident #3 with smoke coming from his left pant leg with an ember lit area. Staff put out the embers with water and assisted Resident #3 with changing his clothes. The nurse completed a skin check following the incident of unsupervised smoking and noted a small, reddened area to the top of resident's left thigh.
Interview on 01/28/25 at 3:30 P.M. with the Administrator confirmed Resident #3 was an unsafe smoker and had poor safety awareness. The Administrator confirmed the resident should be monitored for safety while smoking to ensure the safety of the resident and the other residents in the facility.
Interview on 01/28/25 at 3:43 P.M. with RN #113 confirmed on 12/21/24 Resident #3 was sitting by the nursing station and the nurse smelled smoke and saw Resident #3 had smoke coming from his paint leg with a lit ember. Staff threw water on the resident and the ember was extinguished. RN #113 did a skin assessment on the Resident #3 and discovered a small, reddened area to the top of the resident's left upper thigh. RN #113 confirmed Resident #3 wasn't supposed to go out to smoke, but he had a behavior of going outside and getting cigarette butts left by other resident smokers. RN #113 believed Resident #3 had gotten a lit cigarette butt which caused the injury to his upper thigh.
Review of the facility policy titled Smoking Policy dated 10/17/23 revealed if the interdisciplinary team (IDT) determined that the resident was an unsafe smoker, the resident was required to wear a protective smoking vest/apron and was to be supervised while smoking. The degree of supervision was determined by the team and was based on the smoking evaluation, the physical attributes of the smoking area, and other relevant factors. Staff members would maintain all smoking paraphernalia for all unsafe and safe smokers, e.g., cigarettes, cigars, pipes, lighter fluid, or any other matter or substance that contains a tobacco product. Staff members would distribute smoking materials to residents that were unsafe to smoke at the designated smoking times.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on medical record review, review of facility Self-Reported Incidents (SRIs), and staff interview, the facility failed to ensure the medical record was complete and included pertinent resident in...
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Based on medical record review, review of facility Self-Reported Incidents (SRIs), and staff interview, the facility failed to ensure the medical record was complete and included pertinent resident information. This affected one (Resident #61) of three reviewed for medical records. The facility census was 85 residents.
Findings include:
Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.
Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with activities of daily living (ADLs.)
Review of the progress notes for Resident #61 dated 01/15/25 revealed there was no documentation of a phone call from the hospital social worker to the facility social worker regarding concerns of possible resident mistreatment.
Review of the facility SRI dated 01/23/25 revealed a hospital social worker called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications.
Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record.
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
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff maintained appropriate enhanced barrier precautions (EBP) during wo...
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Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff maintained appropriate enhanced barrier precautions (EBP) during wound care and incontinence care and failed to ensure staff practiced appropriate hand hygiene during incontinence care. This affected one (Resident #23) of three residents reviewed for incontinence care and wound care. The facility census was 85 residents.
Findings include:
Review of the medical record for Resident #23 revealed an admission date of 01/04/25 with diagnoses including fracture of superior rim of left pubis, heart failure, and atrial fibrillation.
Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 01/11/25 revealed the resident had intact cognition and required partial assistance with eating and transfers, substantial assistance with toileting and bathing, and was dependent with dressing.
Review of the progress note for Resident #23 dated 01/06/25 timed at 4:10 P.M. revealed the resident had an unstageable pressure ulcer to the buttock which measured 10.5 centimeters (cm) in length by 12.2 centimeters in width.
Review of the physician's orders for Resident #23 dated January 2025 revealed the resident did not have orders for enhanced barrier precautions (EBP).
Observation on 01/29/25 at 8:56 A.M. of wound care for Resident #23 per Registered Nurse (RN) #131 with the assistance of Certified Nursing Assistant (CNA) #96 revealed the nurse and aide did not don gowns prior to providing wound care.
Observation on 01/29/25 at 9:09 A.M. of incontinence care for Resident #23 per CNA #96 revealed the aide did not don a gown during care. Prior to care, CNA #96 completed hand hygiene and applied gloves. CNA #96 did not change gloves during care or after completing incontinence care. CNA #96 used soiled gloves to touch bed controls, the call light, and the bedside table after care was completed.
Interview on 01/29/25 at 9:21 A.M. with CNA #96 confirmed she did not wear a gown when performing incontinence care or when assisting the nurse with wound care for Resident #23. CNA #96 confirmed she did not remove soiled gloves before touching the resident's bed controls, the call light, and the bedside table.
Interview on 01/29/25 at 9:24 A.M. with RN #131 confirmed she did not wear a gown when completing wound care for Resident #23. RN #131 further confirmed she thought Resident #23 should be in EBP due to the unstageable wound and wearing a gown was required for provision of direct care for residents in EBP.
Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed EBP were indicated for residents with any of the following: infection of colonization with a Centers for Disease Control (CDC)-targeted multidrug resistant organism (MDRO), when contact precautions did not otherwise apply, resident had a wound or indwelling medical device, even if the resident was not known to be infected or colonized with a MDRO. The EBP for a resident with a wound or indwelling medical device should remain in place for the duration of a resident's stay or until resolution of the wound or discontinuation of the indwelling medical device. Chronic wounds generally included for EBP chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Staff should post signage for EBP precautions on the door or wall outside of the resident's room indicating type of precautions and the required personal protective equipment (PPE.). Health care personnel caring for residents on EBP should wear gloves and gowns during high-contact resident care including dressing, bathing, transferring, hygiene, changing linens, changing briefs, or wound care.
Review of the facility policy titled Hand Hygiene dated 10/11/23 revealed hand washing was generally considered the most important single procedure for preventing healthcare-associated infections. Hand hygiene should be performed before and after contact with the resident, after contact with blood, body fluids, visibly contaminated surfaces or other objects in the resident's room, after removing personal protective equipment, and direct resident contact.
Dec 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure staff timely answered a resident's call light. This affected one (#9) of six residents reviewed for call lights. The census was 83.
Findings include:
Review Resident #9's medical record revealed an admission date of 08/14/24. Diagnoses listed included type two diabetes mellitus, hypertension, major depressive disorder, and acute kidney failure.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment, was frequently incontinent of bowel, and had a indwelling urinary catheter.
Observation on 12/23/24 at 10:04 A.M. revealed the call light was on for Resident #9's room. The light above the door was illuminated and an audible beeping could be heard. At 10:12 A.M. Licensed Practical Nurse (LPN) #160 could be seen sitting at the nurse's station at the end of the hall. Resident #9's room call light remained on. At 10:25 A.M. LPN #160 walked by Resident #9's room and LPN #160 did not address the call light. At 10:26 A.M. the Administrator and entered Resident #9's room to answer the call light.
During an interview on 12/23/24 at 10:29 A.M. interview with the Administrator revealed Resident #9 had his call light on to ask to had incontinence brief changed. The Administrator confirmed a call light should be answered timely. The Administrator confirmed confirmed 22 minutes was not considered timely. The Administrator confirmed any staff member can address a resident call light. The Administrator confirmed LPN #160 should have addressed Resident #9's call light.
Interview with Resident #9 on 12/23/24 at 12/23/24 at 10:33 A.M. revealed he had his call light on due to concerns with his urinary catheter leaking. Resident #9 stated it takes awhile to have call lights answered.
Review of the facility policy titled Call Lights dated effective 04/01/22 revealed call lights should be answered in a timely manner.
This deficiency represents non-compliance investigated under Complaint Number OH00160868.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure a resident's call light was kept within reach. The affected one (#7) of six residents reviewed for call lights. The census was 83.
Findings include:
Review of Resident #7's medical record revealed an admission date of 08/04/23. Diagnoses listed included type two diabetes mellitus, vascular dementia, and glaucoma.
Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intake.
Observation on 12/23/24 at 8:40 A.M. revealed Licensed Practical Nurse (LPN) #170 asked Resident #7 to put on her call light so an aide could assist her with getting out of bed. Resident #7 could not find her call light. Resident #7 stated she could not find her call light all night. LPN #170 looked for Resident #7's call light and found it behind a dresser drawer cabinet located to the left and behind Resident #7's bed. LPN #170 had to move the dresser drawer cabinet to get Resident #7's call light.
During an interview during the observation on 12/23/24 at 8:40 A.M. LPN #170 stated that stuff like this happens a lot. LPN #170 confirmed she was referring to call lights being found not within a residents' reach. LPN #170 confirmed Resident #7's call light was not within her reach.
Review of the facility policy titled Call Lights dated effective 04/01/22 revealed call lights should be within a resident's reach.
This deficiency represents non-compliance investigated under Complaint Number OH00160868.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility resident census, the facility failed to ensure water temperatures ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility resident census, the facility failed to ensure water temperatures were comfortable for residents. This had the potential to affect 42 (#5, #6, #7, #9, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) residents residing on the 300 and 400 halls. The census was 83.
Findings include:
Observation of the shower room located in the 400 hall with Maintenance Director (MD) #100 on 12/23/24 at 2:48 P.M. revealed hot water temperatures in shower stalls did not reach 105 degrees Fahrenheit (F). Water temperatures in each of two shower stalls reached a maximum temperature of 90 degrees F. MD #100 confirmed hot water temperatures only reached 90 degrees F. MD #100 denied any recent hot water concerns.
Review of water temperature logs revealed hot water temperatures below 105 degrees F had been documented consistently since 10/25/24 on the 400 hall. Issues with 400 hall hot water and working with a local plumbing company to solve the issue was noted. Water temperatures of 89 degrees F were documented on 12/17/24, 90 degrees F on 12/16/24, and 88 degrees F on 12/10/24 on the 400 hall.
During an interview on 12/30/24 at 10:00 A.M. the Administrator and MD #100 confirmed the 400 hall had been having hot water concerns. A local plumbing company had been contracted to fix the problem. The Administrator and MD #100 confirmed that temperatures below 105 degrees F had been documented for the 400 since October 2024. MD #100 shower room [ROOM NUMBER] hall did not reach 105 degrees F on 12/23/24. MD #100 reported he had recently adjusted a water temperature mixing valve to help correct the problem. The Administrator confirmed residents that resided in the 300 and 400 halls would take showers in the 400 hall shower room.
Review of facility census revealed 42 (#5, #6, #7, #9, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) residents resided on the 300 and 400 halls.
This deficiency represents non-compliance investigated under Complaint Number OH00160422 and Complaint Number OH00160868.
Jul 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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, staff interview and review of the facility policy, the facility failed to ensure resident repres...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident representatives were notified of significant changes in residents health status. This affected one (Resident #90) of three residents reviewed for change in health condition. The facility census was 84 residents.
Findings include:
Review of the medical record for Resident #90 revealed an admission date of 04/22/24 and a discharge date of 04/30/24. Resident #90 returned to the facility on [DATE] and discharged to the hospital on [DATE] and did not return to the facility. Resident #90's diagnoses included gram negative sepsis, congestive heart failure, non-pressure chronic ulcer of part of left lower leg, and renal disease.
Review of the Minimum Data Set (MDS) assessment for Resident #90 dated 04/29/24 revealed the resident had intact cognition and required extensive assistance from two staff members for completion of activities of daily living (ADLs).
Review of the progress note for Resident #90 dated 04/29/24 timed at 4:51 P.M. revealed the resident had a large intact blister noted to the calf of the right leg. Staff notified the Nurse Practitioner (NP) who gave orders for the wound care physician to see the resident.
Interview on 06/26/24 at 10:10 A.M. with Licensed Practical Nurse (LPN) #157 confirmed the progress note for Resident #90 did not include documentation related to family notification of the blister to the resident's calf.
Interview on 06/26/24 at 3:40 P.M. with Director of Nursing (DON) confirmed the facility had no record of notification to Resident #90's family of the resident's impaired skin integrity observed on 04/29/24.
Review of the facility policy titled Change of Condition Notification dated 02/14/2024 revealed the facility should notify the resident's representative of changes in condition which included changes in the resident's physical, mental or psychosocial status that were a deterioration in health, mental, or psychosocial status.
This deficiency represents noncompliance investigated under Complaint Number OH00154584.
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
Based on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to notify th...
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Based on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to notify the Ohio Department of Health (ODH) of an injury of unknown origin. This affected one (Resident #10) of three residents reviewed for abuse. The census was 84 residents.
Findings include:
Review of the medical record for Resident #10 revealed an admission date of 11/21/22 with diagnoses including heart disease, dementia without behavioral disturbances, mood, anxiety and protein calorie malnutrition.
Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 03/23/24 revealed the resident was severely cognitively impaired and required the assistance of one staff member for bed mobility, dressing and personal hygiene and used a wheelchair for mobility.
Review of the hospice visit report for Resident #10 dated 06/10/24 per Hospice Registered Nurse (RN)#600 revealed the resident had a bruise to the right cheek and the aide reported they were unaware of the origin of the bruise. Unit Manager (UM) #148 signed the report.
Review of the incident report for Resident #10 dated 06/12/24 revealed the resident had a black eye. Further review of the report revealed State Tested Nursing Assistant (STNA) #137 reported to Unit Manager (UM) # 148 she was giving incontinence care during the night on 6/11/24 and Resident #10 hit her glasses and possibly her head on the arm of a chair placed against the right side of the bed.
Review of the investigation for the bruise to Resident #10 dated 6/12/24 revealed the resident could not recall how the incident occurred. State Tested Nursing Assistant (STNA) #137 reported Resident #10 was agitated while she was giving P.M. care and while she was rolling Resident#10, the resident bumped her face on the chair next to the bed.
Review of a timeline written by the Director of Nursing (DON) dated 6/12/24 revealed UM #148 interviewed all residents following Resident #10's bruise to determine if there were any abuse concerns. The document did not include assessment of cognitively impaired residents for bruising on their skin or injuries of unknown origin. Further review revealed STNA #137 was educated in abuse, dementia care, and customer service and was assigned to work on the day shift for two shifts for additional training.
Review of the facility Self-Reported Incidents (SRIs) revealed there were no reports filed for Resident #10's injury of unknown origin.
Interview on 06/20/24 at 10:36 A.M. with Resident # 55 confirmed she was concerned about Resident #10 having a black eye and she believed it was from a night shift aid giving care.
Observation on 06/20/24 at 10:40 A.M. of Resident #10 revealed the resident had bruising under her right eye and down her right side of cheek with dark color and yellowing. Resident #10 wore glasses which sat on her right cheek on the bruise extending from her right eye. (Resident #10 was non-interviewable.)
Interviews with STNA #137 were attempted by telephone on 06/20/24 at 2:30 P. M. and on 06/24/24 at 3:15 P.M. but were unsuccessful.
Interview on 06/27/24 at 9:18 A. M. with Hospice RN #600 confirmed she visited Resident #10 on 06/10/24 and identified a bruise on the resident's right cheek. RN #600 further confirmed she asked an STNA how the bruise occurred, but they didn't know. RN #600 confirmed the resident was unable to explain how she was bruised. RN #600 confirmed she reported the bruising to UM #148 and had the facility nurse sign the note dated 06/10/24 which noted the bruising.
Interview on 06/27/24 at 11:00 A.M. with the DON confirmed the facility did not file an SRI related to the bruising of unknown origin to Resident #10's face documented on 06/10/24 and 06/12/24.
Interview on 06/27/24 at 11:15 A.M. with UM #148 confirmed she completed the incident report and investigation for Resident #10's bruise but she did not consider filing an SRI. She confirmed the cognitively impaired residents were not evaluated for skin issues after the bruising was identified on Resident #10 and after STNA #137 reported the issues with Resident #10's care.
Interview on 07/01/24 at 11:00 A.M. with Unit Manager #148 confirmed she signed the hospice progress note for Resident #10 on 06/10/24 but was unaware Resident #10 had a bruise.
Review of the facility abuse policy dated 10/14/22 revealed allegations of abuse including injuries of unknown origin should be reported to the state agency within two hours of the allegation and no later than 24 hours.
This deficiency represents noncompliance investigated under Complaint Number OH00154913.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to thoroughl...
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Based on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown origin and failed to protect the resident from potential abuse. This affected one (Resident #10) of three residents reviewed for abuse. The census was 84 residents.
Findings include:
Review of the medical record for Resident #10 revealed an admission date of 11/21/22 with diagnoses including heart disease, dementia without behavioral disturbances, mood, anxiety and protein calorie malnutrition.
Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 03/23/24 revealed the resident was severely cognitively impaired and required the assistance of one staff member for bed mobility, dressing and personal hygiene and used a wheelchair for mobility.
Review of the hospice visit report for Resident #10 dated 06/10/24 per Hospice Registered Nurse (RN)#600 revealed the resident had a bruise to the right cheek and the aide reported they were unaware of the origin of the bruise. Unit Manager (UM) #148 signed the report.
Review of the incident report for Resident #10 dated 06/12/24 revealed the resident had a black eye. Further review of the report revealed State Tested Nursing Assistant (STNA) #137 reported to Unit Manager (UM) # 148 she was giving incontinence care during the night on 6/11/24 and Resident #10 hit her glasses and possibly her head on the arm of a chair placed against the right side of the bed.
Review of the investigation for the bruise to Resident #10 dated 6/12/24 revealed the resident could not recall how the incident occurred. State Tested Nursing Assistant (STNA) #137 reported Resident #10 was agitated while she was giving P.M. care and while she was rolling Resident#10, the resident bumped her face on the chair next to the bed.
Review of a timeline written by the Director of Nursing (DON) dated 6/12/24 revealed UM #148 interviewed all residents following Resident #10's bruise to determine if there were any abuse concerns. The document did not include assessment of cognitively impaired residents for bruising on their skin or injuries of unknown origin. Further review revealed STNA #137 was educated in abuse, dementia care, and customer service and was assigned to work on the day shift for two shifts for additional training. The document did not include education of other staff or interviews with other staff who may have had knowledge of how the bruise occurred.
Review of the facility Self-Reported Incidents (SRIs) revealed there were no reports filed for Resident #10's injury of unknown origin identified on 06/10/24 and 06/12/24.
Interview on 06/20/24 at 10:36 A.M. with Resident # 55 confirmed she was concerned about Resident #10 having a black eye and she believed it was from a night shift aid giving care.
Observation on 06/20/24 at 10:40 A.M. of Resident #10 revealed the resident had bruising under her right eye and down her right side of cheek with dark color and yellowing. Resident #10 wore glasses which sat on her right cheek on the bruise extending from her right eye. (Resident #10 was non-interviewable.)
Interviews with STNA #137 were attempted by telephone on 06/20/24 at 2:30 P. M. and on 06/24/24 at 3:15 P.M. but were unsuccessful.
Interview on 06/27/24 at 9:18 A. M. with Hospice RN #600 confirmed she visited Resident #10 on 06/10/24 and identified a bruise on the resident's right cheek. RN #600 further confirmed she asked an STNA how the bruise occurred, but they didn't know. RN #600 confirmed the resident was unable to explain how she was bruised. RN #600 confirmed she reported the bruising to UM #148 and had the facility nurse sign the note dated 06/10/24 which noted the bruising.
Interview on 06/27/24 at 11:00 A.M. with the DON confirmed the facility did not initiate an investigation of abuse related to the bruising to Resident #10's face which was first documented on 06/10/24. The DON further confirmed the facility investigated the bruising documented on 06/12/24 but did not complete a full abuse investigation. The DON confirmed the facility investigation did not include assessment of like residents for injuries of unknown origin, did not include interviews with other staff who may have had knowledge of the incident, and did not include measures to protect the resident during the investigation.
Interview on 06/27/24 at 11:15 A.M. with UM #148 confirmed she completed the incident report and investigation for Resident #10's bruise but she did not consider filing an SRI. She confirmed the cognitively impaired residents were not evaluated for skin issues after the bruising was identified on Resident #10 and after STNA #137 reported the issues with Resident #10's care.
Interview on 06/27/24 at 9:18 A. M. with Hospice RN #600 confirmed she visited Resident #10 on 06/10/24 and identified a bruise on the resident's right cheek. RN #600 further confirmed she asked an STNA how the bruise occurred, but they didn't know. RN #600 confirmed the resident was unable to explain how she was bruised. RN #600 confirmed she reported the bruising to UM #148 and had the facility nurse sign the note dated 06/10/24 which noted the bruising.
Interview on 07/01/24 at 11:00 A.M. with Unit Manager #148 confirmed she signed the hospice progress note for Resident #10 on 06/10/24 but was unaware Resident #10 had a bruise.
Review of the facility abuse policy dated 10/14/22 revealed allegations of abuse including injuries of unknown origin should be thoroughly investigated and the facility should protect residents from abuse during the investigation.
This deficiency represents noncompliance investigated under Complaint Number OH00154913.
Aug 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, review of Resident Assessment Instrument (RAI) Manual 3.0, and policy rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, review of Resident Assessment Instrument (RAI) Manual 3.0, and policy review, the facility failed to conduct care plan review meetings quarterly and with significant change in residents' health status. This affected two (#4 and #9) out of the four residents reviewed for care plan meetings. The facility census was 68.
Findings include:
1. Review of the medical record for Resident #4 revealed an admission date of 12/05/22 with medical diagnoses of chronic kidney disease Stage III, arthritis, anemia, and heart disease.
Review of the medical record for Resident #4 revealed a quarterly Minimum Data Set (MDS) 3.0, dated 07/21/23, indicated Resident #4 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and bathing.
Review of the medical record for Resident #4 revealed documentation the facility conducted a care conference on 02/09/23 with the resident, resident's daughter, and IDT. Further review of the medical record revealed no documentation to support the facility conducted a care conference since 02/09/23.
Interview on 08/14/23 at 11:27 A.M. with Resident #4 stated she had not been invited or attended a care conference recently.
Interview on 08/16/23 at 8:44 A.M. with Social Service Supervisor (SSS) #316 confirmed the medical record did not contain documentation to support the facility conducted a quarterly care conference for Resident #4 since 02/09/23.
2. Review of the medical record for Resident #9 revealed an admission date of 06/11/18 with medical diagnoses of Friedreich's ataxia, paraplegia, polyneuropathy, and attention to gastrostomy.
Review of the medical record for Resident #9 revealed a quarterly MDS, dated [DATE], which indicated Resident #9 was cognitively intact and required extensive staff assistance with bed mobility, transfers, dressing, toileting, and was dependent for eating. Further review of the medical record revealed Resident #9 had significant change MDS assessments completed on 12/09/22 due to Resident #9 enrolled onto Hospice services and 03/07/23 due to Resident #9 discontinued Hospice services.
Review of the medical record for Resident #9 revealed documentation to support the facility conducted a quarterly care conference on 06/21/22 and on 04/13/23. Further review of the medical record revealed no documentation to support the facility conducted quarterly or significant change in health status care conferences after 06/21/23 until 04/13/23. Review of the medical record revealed no documentation to support the facility conducted a care conference when Resident #9 enrolled and discontinued Hospice services.
Interview on 08/14/23 at 2:24 P.M. with Resident #9 stated he had not been invited or attended a care conference recently.
Interview on 08/16/23 at 8:43 A.M. with SSS #316 confirmed the medical record did not contain documentation to support the facility conducted quarterly or significant change in health status care conference after 06/21/22 until the quarterly care conference on 04/13/23.
Review of the policy titled, Care Planning Conference, revised 06/24/21, stated the IDT would hold a care planning conference with the resident, family, or representative in participation. The policy stated the interdisciplinary care conferences would be held for the following reasons: admission, annual, quarterly, significant change, discharge as needed, and as needed.
Review of the Resident Assessment Instrument Manual 3.0 page 4-11 states the residents care plan must be reviewed after each assessment and revised based on changing goals, preferences and need of the resident and in response to current interventions. The RAI manual 3.0 page 4-11 also states the IDT with input from the resident, family or resident representative is needed to determine when a problem or potential problem needs to be addressed in the resident's care plan.
CONCERN
(D)
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 record review, observation, staff and resident interviews, and policy review, the facility failed to provide oral hygie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interviews, and policy review, the facility failed to provide oral hygiene care for a dependent resident. This affected one (#29) out of three residents reviewed for assistants with Activities of Daily Living (ADL). The facility census was 68.
Findings include:
Review of the medical record for Resident #29 revealed an admission date of 09/21/18 with medical diagnoses of right sided flaccid hemiplegia following cerebral infarction, diabetes mellitus, and hypertension.
Review of the medical record for Resident #29 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #29 had moderate cognitively impairment and required extensive staff assistance for bed mobility, personal hygiene, dressing and was dependent for transfers, bathing, and toileting. The MDS indicated Resident #29 received nutrition via tube feedings and did not indicate any oral or dental issues.
Review of the medical record for Resident #29 revealed ADL care plan, dated 09/11/19, which stated Resident #29 had his own teeth, broken teeth, and carious teeth. The care plan stated Resident #29 was dependent upon staff for oral hygiene care.
Observation with interview on 08/16/23 at 10:28 A.M. of Resident #29 revealed Resident #29 sitting in specialized wheelchair in common area on the unit. Observations revealed a white film on Resident #29's lips and his teeth which appeared to be covered in a thick mucus film. Resident #29 stated staff had not completed oral care this morning. Resident #29 stated he does not take anything by mouth and is dependent upon staff to complete oral cares.
Interview on 08/16/23 at 10:30 A.M. with State Tested Nursing Assistant (STNA) #360 confirmed she was the STNA taking care of Resident #29 and that she had not conducted oral cares for the resident. STNA #360 stated she was not sure how to perform oral care on Resident #29 because he is to be receiving nothing by mouth (NPO). STNA #360 confirmed Resident #29 had a white film on his lips and his teeth were covered in a thick mucus film.
Interview on 08/16/23 at 10:36 with Licensed Practical Nurse (LPN) #380 confirmed Resident #29 was dependent on staff for oral care which should be completed every morning, every evening, and as needed. LPN #380 stated staff are to use moistened mouth swabs to complete oral cares for Resident #29.
Review of the policy titled, Routine Resident Care, revised 03/07/23, stated residents are to receive the necessary assistance to maintain good grooming and personal/oral hygiene. The policy stated daily personal hygiene includes assisting with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing denture care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely consult psychiatric (psych) services for a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely consult psychiatric (psych) services for a resident. This affected one (#32) of five residents reviewed for unnecessary medications. The census was 68.
Findings include:
Review of Resident #32's medical record revealed an admission date of 01/06/23. Diagnoses listed included anxiety, major depressive disorder, schizoaffective disorder and hypertension.
Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was moderately cognitively impaired and was receiving a anti-psychotic medication.
Review admission documents revealed Resident #32 was admitted and treated at a geriatric psychiatric facility in December 2022. Resident #32 was deemed incompetent and appointed a guardian in 2021.
Review of nurse practitioner (NP) notes dated 01/09/23 revealed Resident #32 was diagnosed with schizoaffective disorder and was receiving the anti-psychotic medication Abilify. Psych services was noted to be consulted.
Review of physician notes dated 01/14/23 revealed Resident #32 was diagnosed with schizoaffective disorder and was receiving the anti-psychotic medication Abilify. Psych services was noted to be consulted.
Review of physician notes and NP notes dated 02/26/23 through 05/08/23 revealed psych services was documented as managing Resident #32's schizoaffective disorder and Abilify use.
Further review of Resident #32's medical record revealed a consult to Psych services was not completed until 06/09/23 for concerns with wandering.
Review of Resident #32's care plan revealed he was at risk for adverse reactions and side affects related to receiving anti-depressant/ anti-psychotic medications for schizoaffective disorder. An intervention listed was to consult psych services as needed.
During an interview on 08/16/23 at 2:32 P.M. the Director of Nursing (DON) confirmed that psych services was noted to need consulted on 01/09/23 by the NP and and on 01/14/23 by the physician. The DON confirmed NP and physician documented that psych services was managing Resident #32's schizoaffective disorder and Abilify. The DON confirmed psych services was not consulted until 06/09/23 for concerns with Resident #32's wandering.
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 record review, staff and resident interviews, and policy review, the facility failed to provide a resident with routine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, and policy review, the facility failed to provide a resident with routine dental services. This affected one (#29) out of the three residents reviewed for dental services. The facility census was 68.
Findings include:
Review of the medical record for Resident #29 revealed an admission date of 09/21/18 with medical diagnoses of right sided flaccid hemiplegia following cerebral infarction, diabetes mellitus, and hypertension.
Review of the medical record for Resident #29 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #29 had moderate cognitively impairment and required extensive staff assistance for bed mobility, personal hygiene, dressing and was dependent for transfers, bathing, and toileting. The MDS indicated Resident #29 received nutrition via tube feedings and nothing by mouth (NPO). The MDS did not indicate any oral or dental issues.
Review of the medical record for Resident #29 revealed an at risk for infection, pain or bleeding in the oral cavity and has dental health problems related to some or all natural teeth missing and NPO status. The care plan included interventions for staff to coordinate arrangements for dental care, transportation as needed, dental consult as needed and to provide/assist/encourage oral hygiene per protocol.
Review of the medical record revealed a dentist progress note, dated 03/23/22, which stated Resident #29 had severe periodontics, poor oral hygiene, and severe calculus. Review of the medical record did not contain documentation to support Resident #29 had been seen or refused to be seen by a dentist since 03/23/22.
Interview on 08/14/23 at 12:02 P.M. with Resident #29 stated he had not seen a dentist in a long time. Resident #29 denied any mouth/oral pain.
Interview on 08/16/23 at 8:38 A.M. with Social Service Supervisor (SSS) #316 stated the dentist usually visits the facility every six months and the dentist was last at the facility on 02/15/23. SSS #316 confirmed Resident #29 had not been seen by the dentist since 03/23/22.
Review of the policy titled, Dental Service, revised 09/10/21, stated the facility would provide or obtain from an outside resource, routine dental services which include annual inspection of oral cavity for signs of disease, diagnosis of dental disease, dental cleaning, dental radiographs as needed, filling (new and repairs) minor dental plate adjustments, smoothing of broken teeth and limited prosthodontic procedures.
Feb 2020
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, and facility policy review the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, and facility policy review the facility failed to ensure residents were treated in a dignified manner when staff failed to ensure they had permission to enter a residents room. This affected one (Resident #188) of three reviewed for dignity. The census was 85.
Findings include:
Medical record review for Resident #188 revealed an admission date of 12/15/19. Medical diagnoses included diabetes and respiratory failure.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #188 was cognitively intact.
During an interview with Resident #188 on 02/03/20 at 5:55 P.M., he revealed he had a concern with staff barging into his room unannounced. He stated he spoke with the resident council about the problem and it stopped for a couple of days and then started back up again. During the interview, the door barged open and State Tested Nursing Aide (STNA) #89 came in the door. He started to knock on the door after opening it and making eye contact with the surveyor. Resident #188 said he didn't know if the STNA knocked on the door.
Interview with STNA #89 on 02/03/20 at 6:00 P.M. revealed he knocked on the door before coming in and questioned the surveyor if she had heard him. STNA #89 verified he didn't wait for the resident to say it was ok to come in and he stated he should have waited for someone to give permission for him to enter into the room.
Review of facility policy entitled Promoting Dignity revised 04/01/03 revealed Social Services will advocate of guests to promote care in a manner and in an environment that maintains and enhances each guest's dignity and respect in full recognition of his/her individuality.
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
Based on medical record review, event monitor education review, observation, staff and family interview, the facility failed to ensure interventions were put in place for a resident with a cardiac mon...
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Based on medical record review, event monitor education review, observation, staff and family interview, the facility failed to ensure interventions were put in place for a resident with a cardiac monitor. This affected one (Resident #185) of one resident reviewed for cardiac monitor. The census was 85.
Findings include:
Medical record review for Resident #185 revealed an admission date of 01/20/20. Medical diagnoses included scoliosis and hypertension.
Review of Event Monitor Education paperwork dated 01/19/20 revealed instructions to change the patch and charge the sensor for the cardiac monitor on 01/24/20, 01/29/20, and 02/03/20.
Review of admission summary completed on 01/20/20 revealed Resident #185 was cognitively intact. She was an extensive assistance for bed mobility, transfers, toileting, and eating.
Review of nursing comprehensive evaluation for skin and cardiovascular dated 01/20/20 revealed no mention of the cardiac monitor.
Review of progress notes, physician orders and care plan from 01/20/20 through 02/03/20 for Resident #185 revealed no evidence of addressing the cardiac monitor device.
Review of shower sheets dated on 01/28/20, 01/29/20 and 02/01/20 revealed no documentation of the cardiac monitor device.
Interview with Resident #185's family member on 02/03/20 at 12:24 P.M. revealed the resident had a cardiac monitoring device on her chest. The device was used to check her for atrial fibrillation and was placed on the resident while she was at the hospital (prior to admission). The family stated they were concerned the facility wasn't monitoring the cardiac device for the resident. Observation of Resident #185 at the same time of the interview revealed the resident had an external device taped to the left side of her chest close to her heart.
Interview with Unit Manger (UM) #39 on 02/06/20 at 9:00 A.M. revealed she didn't know Resident #185 had a cardiac monitoring device and would have to review the documentation for it. At 12:42 P.M., UM #39 still have not brought any information to the surveyor.
Interview with Licensed Practical Nurse (LPN) #58 on 02/06/20 at 9:41 A.M. revealed she was the nurse who did the skin assessment for the resident on 01/20/20. LPN #58 said she looked at the residents skin but didn't see the cardiac device.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to have respiratory care orders in place f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to have respiratory care orders in place for a resident with a tracheostomy (trach). This affected one (Resident #234) of five residents reviewed for respiratory care. The census was 85.
Findings include:
Review of Resident #234's medical record revealed an admission date of 01/21/20. Diagnoses included malignant neoplasm of lung, acute respiratory failure with hypoxia, malignant neoplasm of left breast, and malignant neoplasm of bone. A comprehensive Minimum Data Set (MDS) had not yet been completed.
Further review of Resident #234's medical record revealed she was admitted to the facility with a trach in place.
Observation of Resident #234 on 02/03/20 at 11:15 A.M. revealed she had a trach in place, and was receiving humidified oxygen through that trach.
Review of physician orders revealed no documentation of trach care or respiratory care orders related to a trach being entered before 02/04/20.
Review of medication administration records (MARs) and treatment administration records (TARs) revealed no documentation of trach care or respiratory care orders related to a trach being entered before 02/04/20.
Interview with the Director of Nursing (DON) on 02/04/20 at 3:48 P.M. confirmed trach care and respiratory care orders related to a trach were not entered entered until 02/04/20. The DON confirmed Resident #234 entered the facility with a trach and orders for care should have been entered on admission [DATE]. The DON also stated there was no documentation of trach care being provided to Resident #234 before 02/04/20, but she knew the care had been provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to timely follow-up with physician recommendations. This affected one (Resident #80) of seven residents reviewed for unnecessary...
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Based on medical record review and staff interview, the facility failed to timely follow-up with physician recommendations. This affected one (Resident #80) of seven residents reviewed for unnecessary medications. The census was 85.
Findings include:
Review of Resident #80's medical record revealed an admission date of 01/06/20. Diagnoses included radiculopathy of lumbar region, syncope and collapse, hypokalemia, major depressive disorder, anxiety disorder, hypertension, and obesity.
Review of a pharmacy recommendation dated 01/08/20 revealed as needed (PRN) hydroxyzine (antihistamine) was recommended to be discontinued. Further review revealed it was signed by a physician on 01/08/20 who agreed with the recommendation to discontinue the PRN hydroxyzine.
Review of physician orders revealed the PRN hydroxyzine was not discontinued until 01/31/20.
Interview with the Director of Nursing (DON) on 02/04/20 at 2:09 P.M. confirmed a physician had signed a pharmacy recommendation to discontinue PRN hydroxyzine on 01/08/20 and it was not discontinued until 01/31/20.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 interview, the facility failed to have clear documentation in resident me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to have clear documentation in resident medical records. This affected one (Resident #38) of two residents reviewed for urinary tract infection (UTI). The census was 85.
Findings include:
Review of Resident #38's medical record revealed an admission dated of of 11/07/19. Diagnoses included anxiety disorder, major depressive disorder, hypertension, type 2 diabetes mellitus, UTI with extended spectrum beta lactamase (ESBL) resistance.
Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 had a multi-drug resistant organism (MDRO).
Review of physician orders dated 01/05/20 revealed contact precautions for ESBL in urine.
Review of treatment administration records (TARs) for January 2020 and February 2020 revealed contact precautions were signed off as being provided three times a day by nursing staff from 01/05/20 through 02/05/20.
Review of nurse practitioner (NP) notes dated 02/04/20 revealed Resident #38 was recently treated at the emergency room (ER) on 01/27/20. Chronic colonization of ESBL was suspected and antibiotics would not be continued after current treatment ends.
Observation of Resident #38's room on 02/04/20 at 8:34 A.M. revealed no isolation cart, personal protective equipment (PPE), or sign outside the room warning of isolation precautions. When the surveyor knocked on the door, staff members where inside the room and were not wearing any PPE, such as gowns.
Follow-up observation at 02/05/20 at 8:03 A.M. revealed no isolation cart, PPE, or sign outside the room warning of isolation precautions.
Interview with the Director of Nursing (DON) on 02/05/20 at 11:06 A.M. revealed Resident #38 was no longer on contact precautions following a recent ER visit.
Follow-up interview with the DON on 02/06/20 at 7:48 A.M. and 8:50 A.M. revealed Resident #38's physician had removed isolation precaution on her return form the ER on [DATE] due to ESBL being colonized and chronic. The DON confirmed the documentation regarding Resident #38's isolation precautions were unclear and were documented as completed through 02/05/20.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
Based on personnel record review, staff interview and facility policy review, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the emp...
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Based on personnel record review, staff interview and facility policy review, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 85 residents residing in the facility.
Findings include:
Review of personnel records revealed no evidence of employees being checked against the State Nurse Aide Registry prior to employment for the following employees: the Director of Nursing (DON) had a hire date of 02/14/19, Assistant Director of Nursing (ADON) #38 had a hire date of 09/20/19, Licensed Practical Nurse (LPN) Unit Manager #39 had a hire date of 02/21/19, Registered Nurse (RN) #42 had a hire date of 02/12/19, RN #45 had a hire date of 11/27/19, RN #47 had a hire date of 11/27/19, LPN #49 had a hire date of 12/05/19, LPN #51 had a hire date of 07/25/19, LPN #52 had a hire date of 11/27/19, LPN #53 had a hire date of 01/16/20, LPN #54 had a hire date of 08/15/19, LPN #55 had a hire date of 10/17/19, LPN #57 had a hire date of 01/09/20, LPN #58 had a hire date of 02/14/19, LPN #59 had a hire date of 02/28/19, LPN #60 had a hire date of 11/21/19, LPN #3 had a hire date of 01/17/20, LPN #5 had a hire date of 10/10/19, LPN #6 had a hire date of 01/09/20, LPN #8 had a hire date of 01/09/20, LPN #10 had a hire date of 01/16/20, Physical Therapy (PT) #105 had a hire date of 06/17/19, Speech Therapist (ST) #128 had a hire date of 09/23/19, Activities Aide (AA) #131 had a hire date of 10/10/19, Dietary Aide (DA) #132 had a hire date of 01/30/20, DA #133 had a hire date of 01/23/20, DA #134 had a hire date of 08/01/19, DA #136 had a hire date of 01/16/20, DA #137 had a hire date of 12/05/19, DA #138 had a hire date of 08/01/19, DA #140 had a hire date of 03/14/19, DA #141 had a hire date of 12/19/19, DA #143 had a hire date of 12/05/19, DA #145 had a hire date of 06/20/19, DA #146 had a hire date of 09/05/19, Dietary Manager (DM) #144 had a hire date of 08/15/19, Housekeeping (HSKP) #147 had a hire date of 12/19/19, HSKP #148 had a hire date of 09/20/19, HSKP #151 had a hire date of 01/23/20, HSKP #152 had a hire date of 10/31/19, HSKP #107 had hire of 04/11/19, Laundry Aide (LA) #110 had a hire date of 08/29/19, LA #111 had a hire date of 09/23/19, Medical Records (MR) #113 had a hire date of 01/03/19, Social Services (SS) #115 had a hire date of 10/03/19, Receptionist #117 had a hire date of 09/19/19 and Receptionist #120 had a hire date of 01/30/20.
Interview with Human Resources (HR) #119 on 02/04/20 at 8:10 A.M. confirmed she was not aware the facility needed to check the State Nurse Aide Registry for all employees. HR #119 stated the facility did check the Nurse Aide Registry to see if the Certified Nurse Aides (CNAs) were in good standing but was not aware other employees were required to be checked against the Nurse Aide Registry. HR #119 verified the facility did not check the above mentioned employees on the Nurse Aide Registry to see if they were in good standing or had been reported to the Nurse Aide Registry.
Review of the facility's policy titled Resident Abuse Prohibition, revised 10/01/18, revealed the facility would screen all prospective employees in order to not employ individuals who have been found guilty of abusing, neglecting, mistreating or misappropriating property/resources of residents by a court of law, or who is listed on the State Nurse Aide Registry. State Nurse Aide Registries for all states in which the applicant has worked are to be checked prior to employment. Any disqualifying findings eliminate the applicant from being considered for employment.
Dec 2018
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurately coded. This affected one resident (#13) of 19 residents reviewed for MDS accuracy. The facility census was 93.
Findings include:
Review of Resident #13's medical record revealed an admission date of 04/22/11. Medical diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, diabetic neuropathy, heart failure, morbid obesity, chronic kidney disease, and depressive disorder.
Review of the resident's last wound physician visit on 11/28/18 revealed the resident had an unstageable pressure ulcer to her left buttock and a stage three pressure ulcer to her sacrum.
Review of the resident's MDS dated [DATE] revealed the resident had one unhealed, unstageable pressure ulcer.
Interview with the Director of Nursing (DON) on 12/12/18 at 3:18 P.M., verified the resident's MDS dated [DATE] was not coded correctly, as it did not include her stage three pressure ulcer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, review of a facility spreadsheet, staff interview, and review of a facility policy, the facility failed to ensure the dietitian approved spreadsheets were followed for all reside...
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Based on observation, review of a facility spreadsheet, staff interview, and review of a facility policy, the facility failed to ensure the dietitian approved spreadsheets were followed for all residents receiving meals. The facility identified six residents (#17, #43, #63, #71, #240 and #390) who did not receive anything by mouth (NPO). In addition, the facility failed to ensure the spreadsheet was followed for residents (#82 and #241) receiving a renal diet. The facility census was 93.
Findings include:
Observation of lunch service on 12/12/18 at 11:35 A.M.,revealed residents receiving all meal types did not receive bread or a roll with their meals. The facility did not have pureed bread prepared. Additionally, residents (#82 and #241) receiving renal diets received black forest pudding.
Review of the facility spreadsheet revealed all meal types were to receive a roll or bread with their lunch meal. Residents on pureed diets were to receive a puree dinner roll or bread. Residents on renal diets were to receive two cookies in place of the black forest pudding.
Interview with Dietary Manager #500 on 12/12/18 at 11:44 A.M., verified they did not serve bread or rolls per the facility spreadsheet. She verified pureed bread was not prepared. She also verified they did not serve the residents on renal diets cookies instead of black forest pudding per the spreadsheet.
Review of a facility policy titled Menus dated 04/10 revealed menus shall meet the nutritional needs of the guests in accordance with the Recommended Dietary Intakes of the Food and Nutrition Board. Menus shall be planned in advance and followed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Ohio facilities.
Concerns
- • 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (45/100). Below average facility with significant concerns.
- • 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Laurels Of Huber Heights The's CMS Rating?
CMS assigns LAURELS OF HUBER HEIGHTS THE an overall rating of 2 out of 5 stars, which is considered 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 Laurels Of Huber Heights The Staffed?
CMS rates LAURELS OF HUBER HEIGHTS THE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Laurels Of Huber Heights The?
State health inspectors documented 30 deficiencies at LAURELS OF HUBER HEIGHTS THE during 2018 to 2025. These included: 30 with potential for harm.
Who Owns and Operates Laurels Of Huber Heights The?
LAURELS OF HUBER HEIGHTS THE 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 CIENA HEALTHCARE/LAUREL HEALTH CARE, a chain that manages multiple nursing homes. With 92 certified beds and approximately 81 residents (about 88% occupancy), it is a smaller facility located in HUBER HEIGHTS, Ohio.
How Does Laurels Of Huber Heights The Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, LAURELS OF HUBER HEIGHTS THE's overall rating (2 stars) is below the state average of 3.2, staff turnover (56%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Laurels Of Huber Heights The?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Laurels Of Huber Heights The Safe?
Based on CMS inspection data, LAURELS OF HUBER HEIGHTS THE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Laurels Of Huber Heights The Stick Around?
Staff turnover at LAURELS OF HUBER HEIGHTS THE is high. At 56%, the facility is 10 percentage points above the Ohio average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Laurels Of Huber Heights The Ever Fined?
LAURELS OF HUBER HEIGHTS THE 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 Laurels Of Huber Heights The on Any Federal Watch List?
LAURELS OF HUBER HEIGHTS THE 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.