MARION POINTE
For profit - Corporation
45 Beds
JAG HEALTHCARE
Data: November 2025
Trust Grade
75/100
#291 of 913 in OH
Photo by Kalee Heipp
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Marion Pointe has a Trust Grade of B, indicating it is a good choice for families looking for a nursing home. It ranks #291 out of 913 facilities in Ohio, placing it in the top half, and #3 out of 5 in Marion County, meaning only two local options are better. The facility is improving, with issues decreasing from 5 in 2024 to 4 in 2025. Staffing is rated average with a 3/5 star rating and a turnover rate of 49%, which matches the state average, suggesting some stability among the staff. On the downside, there have been concerning findings, including instances of food being improperly stored in a dirty kitchen, with mouse droppings found in storage areas and expired food items being served, which raises significant health concerns. Additionally, the RN coverage is less than that of 86% of Ohio facilities, indicating potential gaps in professional nursing oversight.
- Trust Score
- B
- In Ohio
- #291/913
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 49% 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 23 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
75/100
Top 31%
No red flags
5 → 4 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 4 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 49%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Chain: JAG HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 20 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
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were prov...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were provided activities per their interests. This affected one (#38) of one residents reviewed for activities. The facility census was 40.Findings include:Review of the medical record for Resident #38 revealed an admission date of 08/26/24 with diagnoses including but not limited to senile degeneration of the brain, type two diabetes, other symptoms and signs involving cognitive functions and awareness, visual hallucinations, major depressive disorder, muscle wasting and atrophy, difficulty walking, abnormal posture, schizoaffective disorder, mixed obsessional thoughts and acts, and anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had moderate cognitive impairment. Further review revealed the resident's activity preferences included it was very important to the resident to have books, newspapers, and magazines to read, be around animals such as pets, and participate in religious services or practices. It was somewhat important to listen to music she liked and keep up with the news. Resident #38 was dependent on staff for activities of daily living except for eating and was dependent on staff for wheelchair mobility. Review of Resident #38's comprehensive care plan dated 06/03/25 revealed there was no care plan for activities or indications why the resident could not get out of bed.Interview and observation on 09/03/25 at 9:50 A.M. with Resident #38 revealed she did not get out of bed because her legs were weak and she could not stand. Resident #38 stated she would like to get out of bed and stated the facility only uses a mechanical (Hoyer) lift to weigh her. Resident #38 stated the facility does not bring her anything to do while she is bedbound. Observation during the interview revealed Resident #38 did not have any books, magazines, or newspapers, and the television in the room was not on. Interview on 09/04/25 at 9:41 A.M. with the Administrator revealed she did not know why Resident #38 could not get out of bed or why she was in bed all the time. The Administrator verified there was no documentation regarding activities or the reason Resident #38 was in bed all the time. The Administrator verified there was no documentation Resident #38 refusing to get out of bed. The Administrator verified there was no documentation why Resident #38 did not have books, magazines, or newspapers for activities that were assessed as very important to the resident in the MDS assessment. Follow-up interview on 09/04/25 at 1:05 P.M. with Resident #38 revealed the resident would be scared to get up in her wheelchair but she would do it. Resident #38 stated she would like to do something besides lay in bed all day. Resident #38 stated she would like to have some books and magazines for activities.This deficiency represents an incidental finding discovered under Master Complaint Number OH00167412 (1366365).
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide tim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide timely incontinence care for a dependent resident. This affected one (#11) of four residents reviewed for bowel and bladder incontinence. The facility census was 40.Findings include:Review of medical record for Resident #11 revealed an admission date of 09/25/24 with diagnoses including but not limited to cerebrovascular disease, psychotic disorder with delusions, vascular dementia, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment and was assessed as frequently incontinent of bowel and bladder. Review of Resident #11's current care plan revealed a focus area for alteration in urinary elimination related to urinary incontinence. Interventions included to check the resident every two hours and assist with toileting as needed. Observation on 09/04/25 from 3:10 P.M. to 4:15 P.M. revealed Resident #11 was visibly incontinent. Resident #11 was wearing gray sweatpants which were visibly wet in the front and the resident was sitting in his wheelchair in his room. Second shift nurse aides were observed sitting with the first shift nurse aides and no room-to-room report was observed to be done. Continued observation revealed at 3:26 P.M. Resident #11 remained in his room with the door closed. Resident #11 remained in the same gray sweatpants that were wet in the front and the room had a slight musty smell. Social Services (SS) #212 entered Resident #11 room at 3:42 P.M. and exited the room at 3:50 P.M. The Surveyor entered Resident #11's room after SS #212 left the room and the resident remained in the same gray sweatpants that were wet and the room continued to have a musty smell. No nurse aides were observed on the 100 hall at that time. Resident #11 was checked by staff at 4:16 P.M. after the Surveyor brought it to the Director of Nursing's (DON) attention that Resident #11 had been sitting in a wet brief for an extended period of time with no staff intervention. Interview on 09/04/25 at 12:59 P.M. with Resident #11 stated second shift staff would sometimes leave him lay in a wet bed and/or brief for an extended period. Resident #11 stated it could be up to an hour or more before any staff come to change him. Interview on 04/09/25 at 4:15 P.M. with the DON confirmed Resident #11 was up in his wheelchair and his pants were wet in the front. The DON verified the room had a musty smell.Review of the undated policy titled, Activities of Daily Living (ADLs), Supporting, revealed residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.This deficiency represents non-compliance investigated under Master Complaint Number OH00167412 (1366365).
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect all 40 residents who receive food from th...
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Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect all 40 residents who receive food from the facility. The facility census was 40.Findings include:Observation on 09/03/25 from 8:45 A.M. to 8:50 P.M. of the kitchen dry storage area revealed one case of fudge rounds stored on the floor and four plastic grocery bags containing fruit-flavored cereal on the floor. Observation of the reach-in freezer revealed seven bags of unidentified product open and not dated.Interview on 09/03/25 at 8:47 A.M. with Dietary Staff (DS) #242 revealed the unidentified products in the reach-in freezer were fried chicken, chicken patties, chicken cordon bleu, sausage patties, hamburger patties, diced chicken, and vegetables. DS #242 verified the bags were not labeled or dated when opened and verified the case of fudge rounds and the four bags of cereal were on the floor.Review of the undated policy titled, Food Receiving and Storage, revealed food in designated dry storage areas are raised off the floor unless packaged for case lot handling, for example dollies, pallets, racks and skids, and clear of sprinkler heads, sewage/waste disposal pipes, and vents. All foods stored in the refrigerator or freezer are covered, labeled, and dated use by date.This deficiency represents an incidental finding investigated under Complaint Number OH00166601 (1366364).
Mar 2025
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and policy review, the facility failed to ensure a clean and sanitary environment in the dry storage room in the kitchen. This had the potential to affect all resident...
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Based on observation, interview, and policy review, the facility failed to ensure a clean and sanitary environment in the dry storage room in the kitchen. This had the potential to affect all residents who receive food from the kitchen. The facility census was 37.
Findings include:
Observation on 03/26/25 from 8:36 A.M. to 9:07 A.M. of the dry storage area in the kitchen revealed mouse droppings and urine in a box of thickened orange juice. Mouse droppings observed in the following: silverware container holding packets of ketchup, mustard, and A1 sauce with several packets of ketchup chewed into, on top of box with lasagna noodles, on several unopened boxes, on the top of three peanut butter tubs, on the bottom of soda cans, a bag of chocolate sprinkles, in a box of unopened lime gelatin packets (urine as well as droppings), and all over the storage area. One bag of French-fried onions was observed to be chewed through. Two bags of macaroni noodles, one bag of regular noodles, box of lasagna noodles, large box of shell noodles, and one bag of chocolate sprinkles were opened and not dated.
Interview on 03/26/25 at 8:53 A.M. with Dietary Staff #135 and #134 revealed the facility has been actively working on getting rid of the mice. Dietary Staff #135 stated if a mouse would chew through any food products, they would throw it out. Dietary Staff #135 verified the mouse droppings and urine throughout the dry storage area and on the food products. Dietary Staff #135 verified the French-fried onions were chewed through. Dietary Staff #135 stated they are in the process of putting all small single packed items in clear plastic containers with lids so the mice can't get to them.
Interview on 03/26/25 at 8:59 A.M. with Dietary Supervisor #136 revealed he verified the mouse droppings and urine throughout the storage area. Dietary Supervisor #136 stated they clean rack to rack to try and clean up the droppings and urine, but it had only been a few days and it is all back again. Dietary Supervisor #136 stated that they have been treating for mice for two months.
Interview on 03/26/25 at 10:25 A.M. with the Administrator revealed she was upset with the response from the dietary staff. Administrator stated the dietary staff was aware of the cleanliness issue but did not relay that to the appropriate staff. Administrator stated they have an awesome housekeeping staff that could have cleaned the storage area daily.
Review of policy titled, Sanitation-Dietary Services, not dated revealed all kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.
Review of policy titled, Food Receiving and Storage, not dated revealed non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled and kept clean. Dry food and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.
This deficiency represents non-compliance investigated under Complaint Number OH00163794.
Mar 2024
5 deficiencies
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 resident and staff interviews and record review, the facility failed to ensure a resident was offered and assisted with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to ensure a resident was offered and assisted with showers per the resident's preference and according to the shower schedule. This affected one (#31) resident of two residents reviewed for activities of daily living (ADL) care. The facility census was 36.
Findings include:
Review of the medical record for Resident #31 revealed an admission date of 08/07/23. Diagnoses included dementia, bipolar disorder, spinal stenosis, unspecified psychosis, and chronic obstructive pulmonary disease.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and required set up and clean up assistance with bathing.
Review of the paper shower sheets from 02/01/24 to 03/20/24 for Resident #31 revealed there was only documented evidence of a shower/bathing being provided on 02/02/24, 02/27/24, 03/12/24 and 03/19/24.
Review of the shower schedule for Resident #31, revealed showers should have been offered/provided included Tuesdays and Fridays on 02/02/24, 02/06/24, 02/09/24, 02/13/24, 02/16/24, 02/20/24, 02/23/24, 02/27/24, 03/01/24, 03/05/24, 03/08/24, 03/12/24, 03/15/24, and 03/19/24.
Review of the bathing tasks section in the electronic medical record for Resident #31 revealed from 02/19/24 to 03/20/24, baths/showers were only documented as being provided on 03/05/24, 03/08/24 and 03/12/24. It was documented supervision assistance with oversite help only was provided.
Review of the plan of care dated 03/07/24 for Resident #31 revealed the resident had an ADL care performance deficit and required set up and clean-up assistance with showering.
Interview on 03/19/24 at 8:58 A.M. with Resident #31 revealed she was not receiving showers per her preference and on her scheduled dates. Resident #31 revealed she regularly missed showers and revealed it would get so late in the day, and her showers got missed due to staff being busy. Resident #31 reported she would prefer them earlier in the day during the first shift. Resident #31 reported she typically misses about one shower weekly.
Interview on 03/21/24 at 9:00 A.M. with State Tested Nurses Assistants (STNAs) #207 and #208 revealed shower sheets were to be filled out for every shower including if/when a resident refused. STNA's #207 and #208 revealed shower sheets were placed into a binder and then collected almost daily by the medical records staff.
Interview on 03/21/24 at 12:50 P.M. with Director of Nursing (DON) confirmed Resident #31 only had documented showers on 02/02/24, 02/27/24, 03/12/24 and 03/19/24. The DON reported the facility had a process to audit the shower sheets weekly and revealed no knowledge of the missing 10 shower sheets for Resident #31.
Interview on 03/21/24 at 1:15 P.M. with the Administrator and DON confirmed they only had four shower sheets to provide for February and March 2024 and also confirmed there were three documented showers in the tasks section of the electronic medical record with one documented on both the electronic record and on the shower sheet for 03/12/24.
Review of facility policy titled, Bath, Shower undated, revealed the purpose was to promote cleanliness, promote comfort and observe resident skin. The documentation required for showers includes date and time shower was provided, names of staff who assisted, supervisor shall be notified if resident refuses a shower.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff interview, policy review and manufacturer instruction review, the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff interview, policy review and manufacturer instruction review, the facility failed to accurately complete insulin pen administration which resulted in a significant medication error. This affected one (#04) of the two residents observed for insulin administration. The facility identified nine (#03, #05, #18, #25, #26, #32, #33, and #35) residents who received insulin pen injections. The total facility census was 36.
Findings Include:
Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, pure hyperglycemia, and schizoaffective disorder.
Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04, revealed the resident was cognitively intact and the resident received injections and insulin on seven days of the review period.
Review of the physician's orders dated 01/22/24 for Resident #04, revealed the resident was ordered to receive Basaglar KwikPen injector (long-acting insulin) 100 units/milliliter (mL), inject 20 units subcutaneously in the morning and 40 units subcutaneously at bedtime for diabetes.
Observation of the medication administration on 03/18/24 at 6:39 P.M. for Resident #04 and performed by Registered Nurse (RN) #258 revealed, RN #258 obtained the Basaglar KwikPen from the medication cart, placed the disposable needle on the pen, and dialed the dose to 40 units. RN #258 was observed to administer the medication to Resident #04 in the resident's abdomen as per standard. Observation revealed RN #258 did not prime the insulin pen prior to the administration.
During an interview with RN #258 on 03/18/24 at 6:50 P.M., the Surveyor questioned if RN #258 did anything to the Basaglar KwikPen after putting the disposable needle on the pen and prior to dialing up the ordered 40-unit dose and RN #258 replied no, you just have to dial up the dose and administer it to the resident. RN #258 verified she did not prime the Basaglar KwikPen prior to administering the insulin.
Review of the September 2014 facility policy titled Insulin Administration revealed the purpose was to provide guidelines for the safe administration of insulin to residents with diabetes. The instructions included the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use.
Review of manufacturer Basaglar KwikPen instructions for use revealed in step six included Priming the KwikPen. Prime the KwikPen before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps six to eight, but not more than four times. If you still do not see insulin, change the needle, and repeat the priming steps six to eight.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, facility policy review and manufacturer instructions review, the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, facility policy review and manufacturer instructions review, the facility failed to discard the disposable needle off an insulin pen in a safe and sanitary manner. This affected one (#4) of two residents observed for insulin administration. The facility also failed to prepare an insulin pen injection in a sanitary manner. This affected one (#05) of two residents observed for insulin administration. The facility identified nine (#03, #18, #25, #26, #32, #33, and #35) residents who received insulin injections. The facility census was 36.
Findings Include:
1) Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, pure hyperglycemia, and schizoaffective disorder.
Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04, revealed the resident was cognitively intact and the resident received injections and insulin on seven days of the review period.
Review of the physician's orders dated 01/22/24 for Resident #04, revealed the resident was ordered to receive Basaglar KwikPen pen-injector (long-acting insulin) 100 units/milliliter (mL), inject 20 units subcutaneously in the morning and 40 units subcutaneously at bedtime for diabetes.
Observation of medication administration on 03/18/24 at 6:39 P.M. for Resident #04 and performed by Registered Nurse (RN) #258, revealed RN #258 retrieved the Basaglar KwikPen from the medication cart, placed the disposable needle on the pen, and dialed the dose to 40 units. RN #258 was observed to administer the medication to Resident #04 in her abdomen as per standard. RN #258 was observed to remove the disposable needle off the insulin pen and place it in her soiled gloves and discard the gloves and the disposable needle in the trash can next to Resident #04's bed. As the nurse and Surveyor were exiting the resident's room, RN #258 reported the needle retracts after the injection so it could be disposed of in a regular trash can.
Interview with RN #258 on 03/18/24 at 6:50 P.M., verified the used insulin pen disposable needle was discarded in the regular trash can and not placed in a sharp's container.
Review of the policy titled Sharps Disposal revised January 2012, revealed the facility shall discard contaminated sharps into designated containers. Staff will discard them immediately or as soon as feasible into designated containers.
Review of the Basaglar KwikPen manufacturer instructions revealed when disposing of the pens and needles, put the used needles in a Food and Drug Administration (FDA) cleared sharps disposal container right away after use and do not throw away (dispose of) loose needles in a house hold trash.
2) Review of Resident #05's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy, anxiety, and retention of urine.
Review of the quarterly MDS assessment dated [DATE] for Resident #05, revealed the resident was cognitively intact and the resident received injections and insulin seven days of the review period.
Review of the physician's orders dated 11/13/23 for Resident #05, revealed the resident was ordered to receive Insulin Glargine /Lantus (long-acting insulin) 100 units/mL to inject 30 unit subcutaneously at bedtime for diabetes.
Observation of medication administration for Resident #05 on 03/18/24 at 8:34 P.M. by Licensed Practical Nurse (LPN) #215 revealed the nurse retrieved the insulin pen from the medication cart, removed the pen cap, placed a disposable needle on the pen, primed the pen with two units of insulin, and then dialed up the 30-unit dose for the Resident. LPN #215 was observed to administer the dose to the resident as per standard and discarded her disposable needle in the sharp's container on her medication cart after removing her gloves and performing hand hygiene. Observation revealed LPN #215 did not cleanse the rubber seal on the insulin pen prior to attaching the disposable needle.
Interview with LPN #215 on 03/18/24 at 8:38 P.M. verified she did not cleanse the rubber seal on the insulin pen prior to placing the disposable needle. LPN #215 reported she did not need to clean the rubber seal because the pen had a cover over it as it was being stored in the medication cart.
Review of the September 2014 facility policy titled Insulin Administration revealed the purpose was to provide guidelines for the safe administration of insulin to residents with diabetes. The instructions and steps in the procedures included disinfecting the top of the insulin container with an alcohol prep.
Review of the insulin Glargine (Lantus Solostar pen) manufacturer instructions revealed wipe the pen tip (rubber seal) with an alcohol swab then remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on the to pen.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0646
(Tag F0646)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents Pre-admission Screening and Resident Review ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents Pre-admission Screening and Resident Review (PASARRs) were completed accurately and updated when a new diagnosis was identified. This affected four (#01, #13, #31 and #35) of the five residents reviewed for PASARRs. The facility census was 36.
Findings include:
1) Review of the medical record for Resident #01 revealed an admission date of 04/12/17. Diagnoses included schizoaffective disorder, paranoid schizophrenia, personality disorder, depression, and anxiety.
Review of the PASARR dated 12/12/22 for Resident #01, revealed mood disorder, and schizophrenia were listed for the resident. Personality disorder was not documented.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15.
2) Review of the medical record for Resident #13 revealed an admission date of 09/10/21. Diagnoses included depression, chronic pulmonary disease, dementia, schizoaffective disorder bipolar type, anxiety, suicidal ideations, and cognitive impairments.
Review of the PASARR dated 03/17/21 for Resident #13, revealed mood disorder, panic disorder and alcohol abuse were listed. Schizophrenia or other psychotic disorders were not documented for the resident's diagnosis of schizoaffective disorder.
Review of the MDS assessment dated [DATE] revealed Resident #13 was cognitively intact with a BIMS of 15.
3) Review of the medical record for Resident #31 revealed an admission date of 08/07/23. Diagnoses included dementia, bipolar disorder, spinal stenosis, unspecified psychosis, and chronic obstructive pulmonary disease.
Review of the PASARR completed 07/23/23 for Resident #31 revealed the resident was documented to have schizophrenia and a mood disorder. Other psychotic disorders were not marked.
Review of the MDS assessment dated [DATE] revealed Resident #31 was cognitively intact with a BIMS of 15.
4) Review of the medical record for Resident #35 revealed an admission date of 08/29/23. Diagnoses included unspecified dementia, schizotypal disorder, depressive disorder, lack of coordination and altered mental status.
Review of the PASARR dated 03/17/21 for Resident #35, revealed no dementia or mental disorders were listed. The Dementia section was marked no, and mental disorders were not selected.
Review of the MDS assessment dated [DATE] revealed Resident #35 was cognitively impaired with a BIMS of 12.
Interview on 03/20/24 at 11:03 A.M. with Social Services Director (SSD) #201 confirmed the facility staff discuss changes in diagnoses and discuss when a new PASARR was needed. SSD #201 confirmed the PASARR for Resident #01 did not have personality disorder documented, Resident #13 had diagnosis of Schizoaffective disorder and confirmed the diagnosis was not included on the PASARR, Resident #31 did not have a diagnosis of schizophrenia but had it marked on the PASARR and also had a diagnosis of unspecified psychosis which was not identified on the PASARR under other psychotic disorder and Resident #35 had a diagnosis of dementia which was not identified on the PASARR and a diagnosis of schizotypal disorder and depression which were not identified on the PASARR.
Review of facility policy titled, PASRR Completion Policy undated, revealed the Administrator would designate a staff member to ensure PASARR was done on all potential residents. The policy did not state a process for ensuring documentation was updated from a change in diagnosis or to ensure accuracy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observations, staff interview, review of portion size documents and review of the facility policy, the facility failed to ensure the recipes for pureed foods were followed to ensure nutrition...
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Based on observations, staff interview, review of portion size documents and review of the facility policy, the facility failed to ensure the recipes for pureed foods were followed to ensure nutritional value. This had the potential to affect four (#01, #07, #10, #20) of the four residents who received pureed diets. The facility census was 54.
Findings include:
Observation of [NAME] # 220 preparing puree meals on 03/20/24 at 11:15 A.M. revealed [NAME] #225 added water and bread to make the pureed chicken patty and did not add any chicken base. Interview with [NAME] #220 at the same time verified she always used water to put in the pureed foods and does not follow a recipe.
Interview with Dietary Manager (DM)#285 on 03/20/24 at 11:20 A.M. verified they always use water to do their pureed foods. DM #285 reported the facility did not follow a specific recipe for pureed foods and this was the way she had been trained.
Interview with Registered Dietitian Nutritionist, Licensed Dietitian #400 on 03/20/24 at 3:45 P.M. verified the DM#285 and the cook should be following the recipes for all meals.
Review of the facility documents for sandwich chicken breaded pureed, revealed the portion size to be one each chicken breast fritter, a chicken base, hot water, food thickener and pureed bread.
Review of the facility policy titled Nutrient Retention of Foods dated 04/07 revealed the facility will endeavor to prepare and serve foods in such a manner as to conserve the nutritive value of foods. Supervisors will instruct the cooks to prepare food in accordance with guidelines to minimize nutrient loss.
Dec 2022
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 F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the hospital records, and policy review, the facility failed to ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the hospital records, and policy review, the facility failed to ensure a baseline care plan was completed for a newly admitted resident. This affected one resident (#40) out of three residents reviewed for diabetes. The facility census was 38.
Findings include
Review of the medical record for Resident #40 revealed an admission date of 03/18/22 and discharge date [DATE]. Diagnoses included pneumonitis due to inhalation of food and vomit, sepsis from pneumonitis, metabolic encephalon, respiratory failure, type two diabetes, kidney disease and Alzheimer's disease.
Review of the hospital history and physical dated 03/16/22 revealed residents blood sugar upon admission was 352 milligram per deciliter (mg/dL).
Review of the hospital progress note dated 03/17/22 by the attending hospitalist revealed Resident #40 had uncontrolled diabetes with recommendation to start sliding scale insulin (SSI). The note reported resident's blood sugars had been variable but poor food intake with recommendation to continue SSI and hold the metformin (an oral blood sugar reducing medication).
Review of the hospital continuity of care form dated 03/18/22 revealed Resident #40 had physician orders for insulin lispro (admeLOG, HumaLOG) injection zero to 30 units with instructions to be given three times daily before meals and to use the normal sensitivity scale. Resident #40 also had physician orders for insulin lispro (admeLOG, HumaLOG) injection zero to 15 units with instructions to be given nightly for corrective use only for blood sugars over 300 mg/dL. No doses were given within 24 hours of hospital discharge.
Review of the hospital discharge instructions and summary dated 03/18/22 revealed Resident #40 should stop taking metformin 500 MG tablet and was admitted to the hospital with uncontrolled diabetes with a hemoglobin A1C of 7.6 percent.
Review of the baseline care plan dated 03/18/22 revealed Resident #40's plan had not mentioned the resident was diabetic and included no interventions to maintain a healthy status with his diabetes.
Review of the physician order dated 03/18/22 identified an order for linagliptin tablet 5 MG with instructions to provide one tablet by mouth in the evening for diabetes. Review of the physician order dated 03/21/22 identified an order for metformin Hcl Tablet 500 MG with instructions to provide one tablet in the morning and one tablet in the evening for diabetes. Review of the physician order dated 03/22/22 identified an order for Novalog solution pen injector of 100 unit solution with instructions for sliding scale insulin: to be provided subcutaneously before meals and at bedtime for blood glucose readings: (0-150 mg/dL give zero units; 151-200 mg/dL give 2 units; 201-250 mg/dL give four units; 251-300 mg/dL give six units; 301-350 mg/dL give eight units; and 351-400 mg/dL give 10 units.)
Review of the progress notes dated 03/19/22 revealed nursing spoke with nurse practitioner regarding medication at the family's request. The family had requested Resident #40 be on metformin. Nurse Practitioner reported she would need to review labs next time she was at the facility to see if he should be on metformin. Progress note dated 03/21/22 revealed nurse practitioner was at facility and nurse informed them of resident's loose stools. Resident was on antibiotics. At that time, nurse also informed nurse practitioner of family request regarding restarting metformin for twice daily. Nurse Practitioner reported metformin would start once loose stools were better and antibiotic was completed due to side effects. Progress note dated 03/22/22 revealed resident was not responding as normal and was clammy. The nurse assessed Resident and took his blood glucose reading which was documented as high. The nurse notified the nurse practitioner and was instructed to give 20 units of Novalog and retake the blood sugar reading after 30 minutes. If the blood sugar reading was still high, the resident should be sent out to the emergency room. Progress note dated 03/22/22 revealed the retesting of Resident #40's blood sugar was 589 mg/dL. The resident's family requested the resident be transferred to the hospital. The nurse contacted the ambulance and the nurse practitioner regarding the hospital transfer.
Review of the Discharge summary dated [DATE] from the nursing facility revealed resident was discharged due to hyperglycemia.
Review of the hospital admission paperwork dated 03/22/22 revealed resident was admitted with sepsis.
Interview on 12/08/22 at 4:56 P.M., with the Director of Nursing (DON) verified the diagnosis of diabetes, monitoring, and treatment were not marked on the baseline care plan and were blank. The DON revealed Resident #40's diabetes was monitored by nursing and the nurse practitioner regardless of it not being on the baseline care plan.
Review of the facility policy titled Care plans - baseline, dated 02/2018 revealed the interdisciplinary team would review the orders and implement a baseline care plan to meet the resident's care needs.
This deficiency represents non-compliance investigated under Complaint Number OH00137878.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure an elopement care plan was comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure an elopement care plan was completed related to resident's at risk for elopement. This affected one resident (#29) out of three reviewed for elopement. The facility census was 38.
Findings include
Review of the medical record for the Resident #29 revealed an admission date of 09/14/21. Diagnoses included encephalon, urinary tract infection (UTI), vascular dementia, heart disease, and depression.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had mild cognitive impairment and required extensive assistance of one staff members for transfers and ambulation.
Review of the quarterly assessments for elopement risk with most recent assessments dated 02/20/22 scored a four, 05/14/22 scored a four, and 10/28/22 scored a seven. Review of the 10/28/22 assessment revealed Resident #29 upon admission had a diagnosis of dementia or mental illness and exhibited a high level of frustration. Resident #29 was to be placed on elopement protocols. Resident #29 had a combined score of three triggers including the physical ability to leave, he became easily agitated, confused, and disoriented. Scores of three or more triggers reveal the possible elopement risk. The risk assessments dated 02/20/22, 05/14/22, and 10/28/22 revealed resident was At risk for elopement with risk protocol was indicated and a care plan for risk behavior was to be completed.
Review of the progress notes dated 11/09/22 revealed resident was found outside by staff with another resident sitting on the front yard grassy area. Resident was asked about why he left and resident stated he was going for a walk with a friend. Resident was assessed by the nurse and educated to get staff assistance to go outside.
Review of the plan of care dated 11/10/22 revealed Resident #29 was independently mobile and expressed a desire to leave the facility unattended. Resident was at risk for elopement and injury with interventions including a wander guard to be placed on the resident and monitored for function, escort the resident when outside, divert attention if possible when the resident insists on leaving, and create elopement assessments quarterly and as needed. Resident #29 had no elopement mentioned in his care plan at the time of the elopement.
Interview on 12/08/22 at 4:56 P.M., with the Director of Nursing (DON) verified Resident #29's care plan had wandering and elopement added to it after the incident occurred and would look into what was being done prior to the elopement as Resident #29 was listed as being high risk for elopement in several prior elopement assessments. The DON verified Resident #29 should have had a care plan for wondering and elopement due to his risk assessment determination.
A follow-up interview on 12/12/22 at 3:15 P.M., with the DON revealed resident #29 was listed as high risk for elopement according to his behaviors and had never had exit seeking behaviors. The DON revealed Resident #29 had elopement risk in the care plan dated 10/2021, but when reviewing the care plan history, the elopement risk was resolved 12/13/21 and was not put back on the care plan until after the resident eloped on 11/09/22.
Review of facility policy titled Care plans - baseline, dated 02/2018 revealed revealed the interdisciplinary team would review the orders and implement a care plan to meet the resident's care needs.
This deficiency represents non-compliance investigated under Complaint Control Number OH00137529.
Apr 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews, the facility failed to ensure a resident's bruises were monit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews, the facility failed to ensure a resident's bruises were monitored. This affected one (#24) of one residents reviewed for skin impairment. The census was 41.
Findings include:
Review of the medical record for Resident #24 revealed an admission date of 12/23/19, with diagnoses of cerebral infarction, aphasia, hemiplegia affecting the left nondominant side, weakness, encephalopathy, osteoarthritis, atrial fibrillation, and altered mental status.
Review of the Medicare 5 Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 had a Brief Interview of Mental Status (BIMS) of 00, indicating she is rarely or never understood and she required extensive two staff assistance for bed mobility and toilet use, total dependence of two staff for transfers, and extensive assistance of one staff for personal hygiene. It also stated the resident had wounds and was at risk for skin impairment.
Review of Resident #24's physician orders revealed orders for Apixaban 2.5 milligrams (mg) in the morning and night for atrial fibrillation and Lispro insulin per sliding scale (unit amount of insulin is based on the blood glucose amount) every six hours.
Review of the care plan dated 05/13/20 revealed the resident was at risk for abnormal bleeding and abnormal lab values related to use of anti-coagulant due to a stroke. Interventions included give medications per physician orders, handle the resident carefully when turning,positioning or transferring, and monitor skin for bruising. Review of the care plan dated 02/16/22 revealed the resident as at risk for hypo/hyperglycemic reactions, abnormal lab values and diabetic ulcers related to the use of antidiabetic medications with interventions to obtain accuchecks per physician orders, medications per physician orders, monitor skin weekly and monitor for signs of hypo/hyperglycemia.
Review of the skin assessment dated [DATE] revealed the resident had no documented evidence of bruising to her right arm. Review of the skilled notes dated 04/05/22 and 04/07/22 revealed there were no concerns with bruising on her skin.
Observation on 04/05/22 at 7:54 A.M., revealed Resident #24 with a quarter sized, dark purple/red bruise noted to her right upper arm.
Interview on 04/07/22 at 8:59 A.M., with the Director of Nursing (DON) revealed if a resident is on an anticoagulant, staff are to monitor bruising and document it under skin assessments. She confirmed Resident #24 had a bruise and there was no documented evidence of Resident #24's bruise being monitored.
Interview on 04/07/22 at 1:43 P.M., with the Administrator revealed Resident #24's shower days are on Saturdays per the families request so each Saturday they scan for abnormal bruising. She stated the DON is doing education with staff that anytime they give insulin, to look for bruising and it is expected. She stated staff were thinking that it was not abnormal for her to have the bruising due to her history and her medication use (insulin and anticoagulant).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to assess a resident after a fall that r...
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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 assess a resident after a fall that resulted in injury. This affected one (#6) of two residents reviewed for falls. The facility census was 41.
Findings include
Review of the medical record for Resident #6 revealed an admission date of 08/23/21, with diagnoses including: heart failure, weakness, hemiplegia, atrial fibrillation, depression, anxiety, chronic obstructive pulmonary disease, kidney disease stage three, hypertension, and muscle atrophy.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and required supervision assistance for transfers and mobility.
Review of the plan of care dated 01/11/22 revealed Resident #6 revealed resident was at risk for falls with a history of falls with injury. The interventions included having common articles within reach, reinforce to call for assistance, ensure environment is free of clutter, complete a fall risk assessment quarterly and as needed and have therapy screen and treat as needed.
Review of the progress notes dated 03/27/22 revealed Resident #6 informed the nurse of a bruise 3 x 3 centimeters (cm) purple in color with a skin tear. Resident #6 informed the nurse he fell when going to the bathroom last night. Resident #6 stated to the nurse, he did not tell any staff about his fall until after it occurred. The nurse informed the family and the physician of the fall. A progress note dated 03/27/22 revealed resident had a second fall when he leaned over to kiss his wife who was also admitted to the facility. Nurse completed fall assessment and found no new injuries and resident denied new pain.
Review of the fall risk assessment dated [DATE] revealed Resident #6 scored a 9 and was at low risk for falls. Review of the fall risk assessment dated [DATE] revealed Resident #6 scored a 13 and was at a high risk for falls. The falls assessment dated [DATE] revealed the resident had a fall this date, when he leaned over and kissed his wife. There was no mention about a fall that occurred either 03/26/22 or 03/27/22 which caused injury.
Interview on 04/06/22 at 10:17 A.M., with Licensed Practical Nurse (LPN) #152 revealed if a resident reported a fall occurred they should be assessed for possible injuries and emergency contact and physician should be notified.
Interview on 04/07/22 at 8:58 A.M. and 10:41 A.M., with the Director of Nursing (DON) revealed she would expect staff to assess residents after each fall for injuries and complete an assessment detailing any injuries found. DON confirmed Resident #6 did not have an assessment after the first fall on 03/27/22. DON revealed staff were informed of the first fall on 03/27/22 at 11:00 A.M. and Resident #6 had another fall about 3 hours later. DON revealed if staff did not have time to assess his injuries and document a separate fall assessment for the first fall, then the first fall should have been mentioned in the later fall assessment. DON confirmed their was no mention of the earlier fall in the fall assessment dated [DATE].
Interview on 04/07/22 at 9:55 A.M., with LPN #129 revealed after a resident reports a fall, a fall assessment needs to be completed to check for any pain and injuries.
Review of the policy titled Falls and Managing Falls Risk dated 02/2018, revealed facility policy does not include fall assessments, but only addresses fall interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure a resident was not started on a anti-psychoti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure a resident was not started on a anti-psychotic medication (Seroquel) without adequate indications of the need of its use. This affected one (#15) of five residents reviewed for unnecessary medications. The facility census was 41.
Findings include:
Review of Resident #15's medical records identified admission to the facility occurred on 06/11/21, with medical diagnosis including: dementia, glaucoma, high blood pressure, anxiety and depression. Resident #15 was additionally diagnosed with COVID-19 on 01/20/22.
Review of the facility quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #15 as having moderately impaired cognition and required supervision with ambulation.
Review of Resident #15's medication regime identified on 01/31/22 the anti-psychotic medication Seroquel 25 mg was started daily. The progress notes identified on 01/20/22, Resident #15 was diagnosed with COVID-19 and was on isolation until 01/30/22. The medical record and progress notes identified no evidence of any concerns that would warrant the use of psychotropic medications.
Review of the medical record identified since the start of the Seroquel, Resident #15 has fallen on 02/07/22, 02/10/22, 03/07/22, 03/16/22 and 03/22/22 without major injuries.
Review of the undated written plan of care for the use of the psychotropic medications identified it was being used for depression and anxiety. The plan lacks any documented evidence of a reason for the use of a antipsychotic medication.
Interview on 04/06/22 at 11:39 A.M., with the Director of Nursing, revealed Resident #15 had no documented evidence of the need for a antipsychotic medication in the record. The interview additionally confirmed Resident #15 has had a increase in falls since the start of the Seroquel.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the facility failed to offer the pneumococcal vaccine to a resident. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the facility failed to offer the pneumococcal vaccine to a resident. This affected one (#14) of five residents reviewed for immunizations. The facility census was 41.
Findings include:
Review of the medical record for Resident #14 revealed an admission date of 07/19/21, with diagnoses including: diabetes type two, encephalopathy, chronic obstructive pulmonary disease, muscle wasting, atrophy, dysphagia, dysfunction of the bladder, dementia with behaviors, heart disease, depression, Alzheimer's and chronic kidney disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderate cognitive impairment. Review of section O of the MDS revealed Resident was not given the pneumococcal vaccine and it was not offered to the resident.
Further review of resident's medical record revealed no evidence resident received or was ever offered the pneumococcal vaccine.
Interview on 04/07/22 at 10:41 A.M., with the Director of Nursing (DON) verified Resident #14 did not get the pneumococcal vaccine. DON revealed she contacted the physician and the vaccine was ordered for her to receive 04/07/22.
Review of the policy titled Pneumococcal Vaccine, dated February 2018, revealed prior to admission or within five working days, residents would be assessed for eligibility to receive the pneumococcal vaccine. The policy revealed the pneumococcal vaccine will be administered to residents unless medically contraindicated, refused or already given) according to facility protocol. For residents who receive the vaccine the date, lot number, expiration date, person administering the vaccine and the site of the vaccination will be documented in the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review, the facility failed to ensure medications were stored appropriately. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review, the facility failed to ensure medications were stored appropriately. This had the potential to affect six (#2, #6, #15, #22, #23, and #25) of 41 residents in the facility. The facility census was 41.
Findings include:
1. Observation of the 200 hall medication cart on [DATE] at 8:00 A.M., with Licensed Practical Nurse (LPN) #128 revealed three Biscodyl 5 milligram (mg) tablets loose in the top drawer of the cart and one bottle of Aspirin 325 mg that expired in February 2022.
Interview on [DATE] at 8:00 A.M., with LPN #128 confirmed the above findings.
2. Observation of the 300 hall medication cart on [DATE] at 8:40 A.M., with LPN #126 revealed a bottle of Preservision tablets that expired in [DATE].
Interview on [DATE] at 8:40 A.M., with LPN #126 confirmed the above findings.
3. Observation of the medication room on [DATE] at 10:00 A.M., with LPN #152 revealed a bottle of Simethicone 80 milligrams (mg) that expired in February 2021 and four containers of Benecal 330 calorie supplement that expired on [DATE].
Interview on [DATE] at 10:00 A.M., with LPN #152 confirmed the above findings.
Interview on [DATE] at 2:50 P.M., with the Administrator revealed there were no residents receiving Benecal or Preservision. She provided information stating Resident #15 was the only resident receiving Aspirin 325 mg, two Residents (#2 and #23) were receiving Simethicone, and three Residents (#6, #22, and #25) were receiving Biscodyl 5 mg tablets.
Review of the policy titled, Storage of Medications, dated February 2018, revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biological's and such drugs shall be returned to the dispensing pharmacy or destroyed. It further stated that all nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manager. The policy revealed that drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview and policy review, the facility failed to safety store food in dry storage area and in the refrigerator. This affected 40 of 40 residents (except #24) who eats fo...
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Based on observation, staff interview and policy review, the facility failed to safety store food in dry storage area and in the refrigerator. This affected 40 of 40 residents (except #24) who eats food from the kitchen. The facility census was 41.
Findings include:
Observation on 04/04/22 at 6:34 P.M., revealed a six pound can of country sausage gravy with a large fist sized dent. A tied bag of Oreo's and a tied bag of coconut were found to be undated. Review of the refrigerator revealed a turkey sandwich wrapped in foil with no date and four cups of apple juice that expired in November 2021.
Interview on 04/04/22 at 6:45 P.M., with [NAME] #162 confirmed the can had a large dent and revealed the facility would serve food from a dented can if it could be opened with the can opener. [NAME] #162 confirmed the Oreo's and coconut was not dated. [NAME] #162 confirmed the turkey was not dated and the four apple juice containers were expired.
Observation on 04/06/22 at 9:38 A.M., revealed the can of country sausage gravy remained on the shelf but was placed behind a another can without a dent. Two cups of apple juice remained in the refrigerator and had expired November 2021.
Interview on 04/06/22 at 9:38 A.M., with Kitchen Manager (KM) #177 revealed any cans found with dents should be marked refused and returned to the supplier. KM #177 confirmed the can of country sausage remained on the shelf and had a large dent. KM #177 confirmed the apple juice in the fridge expired November 2021 and should not be served.
Review of the policy titled, Food Receiving and Storage, dated February 2018, revealed when food was delivered it would be inspected for safe transport and quality before being accepted. All food in the refrigerator would be dated with a use by date. The policy did not specify what facility would do with dented cans and open food should be cover/sealed and dated.
Aug 2019
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #6 revealed an admission date of 08/12/16 and a readmission date of 04/26/19. Diagnoses in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #6 revealed an admission date of 08/12/16 and a readmission date of 04/26/19. Diagnoses included schizoaffective disorder, bipolar type, end stage renal disease, herpes viral dermatitis, acute upper respiratory infection, dependence on renal dialysis, acquired arteriovenous fistula, borderline personality disorder, urinary incontinence, encephalopathy, major depressive disorder and hidradenitis suppurative.
Review of the annual MDS assessment dated [DATE] revealed the resident was alert and oriented. She was assessed to need limited assistance from staff for all her activities of daily living (ADL) except eating and was assessed for receiving hemodialysis for end stage renal disease.
Review of the current physician's orders identified an order dated 03/17/19 for renal dialysis, three days per week.
Review of Resident #6's 48-hour baseline care plan dated 04/26/19 revealed no documentation for hemodialysis in the care plan.
Interview on 08/07/19 at 5:51 P.M. with Registered Nurse #100 confirmed no documentation related to receiving hemodialysis was listed on the 48-hour care plan.
Review of the facility's policy titled JAG - Care Plans - Baseline dated March 2017, revealed to include pertinent resident specific care, treatment and services on the resident's 48-hour base-line care plan.
Based on observation, record review, interview and policy review, the facility failed to provide a 48-hour baseline care plan that summarized the care the residents needed upon admission. This affected two (Resident #38 and #4) of three residents reviewed for baseline care plans. The census was 44.
Findings include:
1. Resident #38 was admitted to the facility on [DATE] with diagnoses including fracture of the neck of left femur, altered mental status, unspecified bipolar disorder and post-traumatic stress syndrome. The minimum data set (MDS) assessment completed on admission revealed the resident could make her needs known and required the assistance of one person for activities of daily living and was mobile throughout the facility.
Review of Resident #38's medical record documented that the Social Service Designee #102 met with Resident #38 and her husband upon admission and learned that Resident #38 came from the local hospital with a hip fracture and was receiving Suboxone treatment. At the time of admission, the plan was for Resident #38 to return home after receiving physical therapy.
Review of Resident #38's 48-hour care plan dated 04/05/19, completed by Licensed Practical Nurse (LPN) #131 revealed no indication of what care Resident #38 needed when admitted . The 48-hour care plan indicated the goals of the facility; however, did not indicate Resident #38's functional level, dietary needs, activity level and current medications to be given.
On 08/05/19 at 3:27 P.M. interview with Resident #38 revealed she was upset because she could not have over the counter medication at her bedside. Recently a nurse removed hydrogen peroxide, that she used for different things, from her room. Resident #38 was not sure what care the facility provides for her daily and could not recall anyone telling her she could not have over the counter medicines.
On 08/07/19 from 12:10 P.M. to 12:18 P.M. interview with Registered Nurse (RN) #100 confirmed the nurse on duty completes the 48-hour care plan when a resident is admitted . The next day the Director of Nursing begins to develop the resident's care plan to meet all the resident's needs. The 48-hour care plan should reflect all the needs of the resident upon admission. RN #100 reviewed Resident #38's 48-hour care plan and confirmed it was not complete. The care plan did not list Resident #38's function level, dietary needs, activity level and current medications to be given when she was admitted .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure compression stockings were provided as ordered ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure compression stockings were provided as ordered by the physician. This affected one (Resident #17) of two residents reviewed for edema. The census was 44.
Findings include:
Resident #17 was admitted to the facility on [DATE] with diagnoses including pain in the left hip, severe morbid obesity and non-infective disorder of lymphatic vessels and lymph nodes. Resident #17's minimum data set (MDS) assessment completed on admission revealed she was alert and oriented to person, place and time. She required one person assist for activities of daily living.
Review of Resident #17's Physician Order Summary Report for July and August 2019 revealed that on 07/08/18, the physician ordered that Resident #17 have compression stockings to both lower legs, apply in he morning and remove at bed time.
Review of Resident #17's physician progress note dated 07/08/19 revealed the physician's plan for her edema was for her to have compression stockings to both lower legs.
Review of the nursing progress notes from 07/08/19 to 07/21/19 revealed no mention of the compression stockings. On 07/29/19, it was documented the compression stockings were not available.
Review of the treatment administration record for August 2019 revealed the resident is to have compression stockings to her lower legs, apply in the morning and remove at bedtime.
During observation on 08/06/19 at 6:35 P.M., Resident #17 did not have compression stockings on her legs.
On 8/07/19 at 1:11 P.M. interview with Resident #17 revealed she is aware her physician has ordered her to wear compression stockings and does not have them.
On 08/07/19 at 2:16 P.M. interview with the Director of Nursing (DON) and review of Resident #17's medical record revealed there was no documentation to indicate the facility had ordered compression stockings for the resident. The DON could not state why there are no compression stockings available for the resident. She assumed it was due to the size of the resident's lower legs. She stated the physician was not notified the faciltiy was unable to provide compression stockings for Resident #17.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review, interview and policy review, the facility failed to ensure post-fall resident assessments were completed every shift for 72 hours. The affected two (Residents #10 and #21) of t...
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Based on record review, interview and policy review, the facility failed to ensure post-fall resident assessments were completed every shift for 72 hours. The affected two (Residents #10 and #21) of two residents reviewed for falls. The facility census was 44.
Findings include:
1. Review of the medical record for Resident #10 revealed an admission date of 10/01/17. Diagnoses included anemia, anorexia, diaphragmatic hernia, diverticulosis, wedge compression fracture of the second lumbar vertebra, heart failure, Colles' fracture of the right radius, anxiety disorder, Alzheimer's disease, major depressive disorder, traumatic subdural hemorrhage and osteoporosis.
A review of the quarterly Minimum Data Set (MDS) assessment, dated 06/05/19, revealed moderate to severe cognitive deficiency. Resident #10 was assessed to need extensive assistance of two staff for her activities of daily living (ADL). The MDS documented the resident to have sustained one fall with major injuries.
Review of the nursing progress notes dated 12/10/18 through 12/14/18 revealed on 12/10/18 Resident #10 was documented as sustaining a fall which resulted in a trip to the emergency room, where the resident received five staples to her head. Review of the proceeding 72 hours of nurse's notes revealed no documentation related to the resident's post-fall condition.
Review of the nursing notes dated 05/19/19 through 05/22/19, revealed a description of the fall Resident #10 sustained on 05/19/19. There was documentation of a post fall assessment of the resident on 05/20/19 at 3:30 P.M. but no other documentation related to Resident #10's post fall condition was documented.
On 08/07/19 at 5:10 P.M. MDS Registered Nurse (RN) #100 confirmed post-fall documentation had not been completed on every shift for 72 hours for any of the fall sustained by Resident #10.
2. Review of the medical record for Resident #21 revealed an admission date of 02/06/15 with a readmission date of 08/09/17. Diagnoses included dementia, cystitis, major depressive disorder, generalized anxiety disorder, Type 2 Diabetes Mellitus, history of urinary tract infections, osteoarthritis, borderline personality disorder, bipolar disorder, obesity, Alzheimer's disease and history of falls.
A review of the annual MDS assessment, dated 07/03/19, revealed severe cognitive impairment. Review of Resident #21's functional status revealed she required extensive assistance from the staff for her ADL's.
Review of the fall risk assessments dated 03/02/19, 06/03/19 and 07/11/19 all revealed Resident #21 to be at high risk for falls.
Review of the facility's fall log dated January 2019 through August 2019, revealed Resident #21 sustained falls on 02/25/19, 03/18/19, 07/09/19 and 07/24/19. The resident did not sustain any injuries from any of the falls.
Review of the nursing progress notes dated 02/25/19 documented Resident #21's fall from her bed. Nursing notes dated 02/26/19 at 8:04 A.M. documented that Resident #21 denied any pain from her fall the previous day, and neuro checks were with in normal limits (WNL). On 02/27/19 at 8:10 A.M. nursing notes documented no complaints from Resident #21 from fall on the 25th. Resident #21 had full range of motion. No other post-fall documentation was noted for the fall dated 02/25/19.
Review of the nursing progress notes dated 03/18/19 documented Resident #21's fall from her chair at 4:40 P.M. The resident was sent to the emergency room for evaluation and returned to the facility the same day. No post-fall documentation was noted after 03/18/19.
Review of the nursing progress notes dated 07/09/19, revealed Resident #21 fell while holding on to her wheel chair. No injuries were documented. On 07/10/19 at 1:18 A.M. Resident #21 was documented as having no injuries, her range of motion was WNL as were her neuro checks. On 07/10/19 at 2:45 P.M. the nursing notes documented Resident #21 as having no complaints and her range of motion full. No post-fall documentation was noted on third shift for 07/10/19, or on any shift for 07/12/19.
Review of the nursing progress notes dated 07/24/19 revealed Resident #21 slid out of a low bed onto the floor at 9:10 A.M. sustaining no injuries. No post-fall documentation was noted in the progress notes after the documentation of the initial fall.
On 08/07/19 at 5:10 P.M. MDS RN #100 confirmed post-fall documentation had not been completed on every shift for 72 hours for any of the fall sustained by Resident #21.
Review of the facility's policy titled Guidelines for Fall Documentation, undated, revealed documentation should be completed in the resident's clinical record every shift for 72 hours after a fall incident.
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
- "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
- • 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Marion Pointe's CMS Rating?
CMS assigns MARION POINTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Marion Pointe Staffed?
CMS rates MARION POINTE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 49%, compared to the Ohio average of 46%.
What Have Inspectors Found at Marion Pointe?
State health inspectors documented 20 deficiencies at MARION POINTE during 2019 to 2025. These included: 20 with potential for harm.
Who Owns and Operates Marion Pointe?
MARION POINTE 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 JAG HEALTHCARE, a chain that manages multiple nursing homes. With 45 certified beds and approximately 39 residents (about 87% occupancy), it is a smaller facility located in MARION, Ohio.
How Does Marion Pointe Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, MARION POINTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (49%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Marion Pointe?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Marion Pointe Safe?
Based on CMS inspection data, MARION POINTE 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 4-star overall rating and ranks #1 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 Marion Pointe Stick Around?
MARION POINTE has a staff turnover rate of 49%, which is about average for Ohio nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Marion Pointe Ever Fined?
MARION POINTE 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 Marion Pointe on Any Federal Watch List?
MARION POINTE 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.