How many inspection deficiencies does AVALON BY OTTERBEIN AT PERRYSBURG have?

AVALON BY OTTERBEIN AT PERRYSBURG has 36 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at AVALON BY OTTERBEIN AT PERRYSBURG?

AVALON BY OTTERBEIN AT PERRYSBURG has a three-star staffing rating from CMS with 0.47 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is AVALON BY OTTERBEIN AT PERRYSBURG located?

AVALON BY OTTERBEIN AT PERRYSBURG is located in PERRYSBURG, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does AVALON BY OTTERBEIN AT PERRYSBURG have?

AVALON BY OTTERBEIN AT PERRYSBURG has 60 certified beds.

Who owns AVALON BY OTTERBEIN AT PERRYSBURG?

AVALON BY OTTERBEIN AT PERRYSBURG is a non profit - church related facility and is part of the OTTERBEIN SENIORLIFE chain.

How does AVALON BY OTTERBEIN AT PERRYSBURG compare to other nursing homes?

AVALON BY OTTERBEIN AT PERRYSBURG has a 4-star overall rating, placing it above average compared to other nursing homes in OH. Higher-rated facilities typically have better inspection results and staffing levels.

AVALON BY OTTERBEIN AT PERRYSBURG

Name: AVALON BY OTTERBEIN AT PERRYSBURG
Address: 3525 - 3533 RIVERS EDGE DRIVE, PERRYSBURG, OH, 43551, US
Telephone: (419) 874-2428
Rating: 4.0

3525 - 3533 RIVERS EDGE DRIVE, PERRYSBURG, OH 43551 · (419) 874-2428

Non profit - Church related 60 Beds OTTERBEIN SENIORLIFE Data: November 2025

Trust Grade

70/100

#216 of 913 in OH

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AVALON BY OTTERBEIN AT PERRYSBURG nursing home in PERRYSBURG, OH

Last Inspection: February 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Avalon by Otterbein at Perrysburg has a Trust Grade of B, indicating it is a good choice for families seeking a nursing home, as it falls within the solid range of performance. It ranks #216 out of 913 nursing homes in Ohio, placing it in the top half of the state, and #4 of 11 in Wood County, meaning only three local options are better. However, the facility is experiencing a worsening trend in quality, with issues increasing from 4 in 2023 to 13 in 2024. While the staffing rating is average with a 50% turnover rate, it has concerning RN coverage, being less than 89% of Ohio facilities, which could impact resident care. Additionally, there were specific incidents noted, such as a failure to have a Registered Nurse present for at least eight hours daily, which could affect all residents, and concerns about food storage and infection control that could potentially harm residents. Overall, while there are strengths in quality measures, families should be aware of these weaknesses when considering this facility.

Trust Score: B
In Ohio: #216/913
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Ohio facilities.
Skilled Nurses: 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: 36 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2023: 4 issues

2024: 13 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: 50%

Near Ohio avg (46%)

Higher turnover may affect care consistency

Chain: OTTERBEIN SENIORLIFE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 36 deficiencies on record

Feb 2024 13 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one (Resident #5) of two residents reviewed for catheter dignity. The facility identified three residents with indwelling catheters. In addition, the facility failed to provide a dignified dining experience to Resident #157 related to disposable dishware and utensils which had the potential to affect 11 additional residents in the 500 home (Residents #2, #4, #13, #23, #35, #51, #158, #159, #160, #161, and #162). The facility census was 58. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, potential for discomfort, anticoagulant use with risk for side effects, potential for drug related complications, multiple sclerosis, hospice services, risk for pain, and potential for impaired skin integrity. Observation on 02/20/24 at 10:56 A.M. of Resident #5 found him lying in bed with his urinary catheter bag hanging on the side of his bed near the foot of the bed. The urinary catheter bag was 1/4 full of yellow urine and visible from the hallway. Interview on 02/20/24 at 11:00 A.M. with Resident #5's daughter revealed Resident #5 always had his catheter bag hanging on the side of the bed facing the door. Resident #5's daughter reported she had never seen it covered and commented it would be nice. Observation on 02/20/24 at 4:19 P.M. of Resident #5 found his catheter bag hanging on the side of his bed with yellow urine visible from the hallway. Interview on 02/20/24 at 4:23 P.M. with State Tested Nursing Assistant (STNA) #334 verified Resident #5's catheter bag was uncovered and visible from the hallway. STNA #334 reported Resident #5's catheter bag had always been that way and she was not aware there was a cover for it. 2. Observation on 02/20/24 from 11:45 A.M. to 12:30 P.M. of the lunch meal service in the 500 unit revealed all residents were served lunch with plastic cups, plastic spoons, plastic forks, and Styrofoam cups. Interview on 02/20/24 at 12:30 P.M. with State Tested Nurse Aide (STNA) #307 verified the residents were being served their meals with plastic cups, plastic silverware, and Styrofoam cups. Record review of Resident #157's medical record revealed the resident was admitted on [DATE]. Diagnoses for Resident #157 included cellulitis of left lower limb, diabetes type two, insomnia, heart failure, chronic kidney disease, and lymphedema. Review of Resident #157's physician orders dated 02/15/24 revealed the resident was ordered to have a regular diet. Observation on 02/21/24 T 10:00 A.M. of Resident #157 revealed the resident was eating breakfast in her room. Resident #157 was observed drinking out of a Styrofoam cup and eating with plastic silverware. Interview on 02/21/24 at 10:02 A.M. with Resident #157 revealed the resident stated she did not like eating with plastic silverware and drinking from a Styrofoam cup. Review of the undated facility policy titled, Resident Rights, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes, maintains, and enhances quality of life.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change assessment in the Minimum Data Set (MDS) when a resident was started on hospice. This affected one resident (#17) of two residents reviewed for hospice services. The facility census was 58. Findings include: Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #17 included anemia, dementia, chronic obstructive pulmonary disease, heart disease, and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessments revealed there was no significant change assessments in the resident's medical records. Review of Resident #17's care plans dated 11/20/23 revealed the resident had a focus for hospice services relating to chronic obstructive pulmonary disease and dementia. Interventions were appropriate for the focus. Interview on 02/22/24 at 1:55 P.M. Licensed Practical Nurse (LPN) #311 revealed he was the facility's MDS nurse and responsible for entering all MDS assessments into residents' medical records. LPN #311 verified after Resident #17 received an order on 11/20/23 to receive hospice services the MDS nurse had 14 days to complete a significant change assessment in the resident's medical records. LPN #311 verified he did not initiate or complete a significant change assessment in the medical records for Resident #17 after she started receiving hospice services.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure dependent residents received assistance with nail care. This affected one (#43) of one resident reviewed for nail care. The facility census was 58. Findings include: Review of the medical record for Resident #43 revealed an admission date of 07/02/22 with diagnoses of anxiety and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and was dependent on staff for showering, bathing, and personal hygiene. Review of the current care plan for Resident #43 revealed she had an activities of daily life (ADL) deficit and required assistance from staff for care. An intervention included checking nail length, trimming and cleaning on bath day and as necessary. Observation on 02/20/24 at 9:58 A.M. revealed Resident #43 lying in bed. The fingernails on her right hand were irregular lengths and appeared discolored and to have debris under them. Observation on 02/21/24 at 9:20 A.M. revealed Resident #43 lying in bed. The fingernails on her right hand were irregular lengths and appeared discolored and to have debris under them. Observation on 02/22/24 at 11:56 A.M. revealed State Tested Nurse Aide (STNA) #300 providing the noon meal to Resident #43 in her room. STNA #300 repositioned Resident #43 in bed to allow her to eat her meal more comfortably. STNA #300 offered assistance with eating to Resident #43 who stated she did not need any help with her meal. STNA #300 began to leave the room when the surveyor asked her to observe Resident #43's nails on her right hand. The nails on Resident #43's right hand were long and had darkness under them. Resident #43 stated it was chocolate. Upon inquiry, STNA #300 stated Resident #43 ate chocolate the day before. STNA #300 confirmed there was darkness under Resident #43's nails. Interview on 02/22/24 at 2:45 P.M. with the Director of Nursing (DON) confirmed Resident #43's care plan stated staff should provide nail care as needed.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure ordered pressure ulcer reduction interventions were implemented as ordered. This affected one resident (#5) of three residents reviewed for pressure ulcer prevention. The facility census was 58. Findings include: Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Reviewed of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, multiple sclerosis, hospice services, risk for pain, and potential for impaired skin integrity. Interventions for potential skin impairment included bilateral heel boots when in bed. Review of Resident #5's physician orders revealed an order dated 11/22/22 for heel boots when in bed every shift. Observation on 02/20/24 at 10:56 A.M. of Resident #5 found him lying on his back in bed with his heels on the bed. Resident #5's blue pressure relief boots were observed on the floor in front of his dresser. Interview on 02/20/24 at 11:00 A.M. with Resident #5's daughter verified Resident #5's was to be wearing his pressure relief boots when he was in bed and he did not have them on. Resident #5's daughter stated he normally had them on and she was not sure why he was not wearing them. Interview on 02/21/24 at 9:16 A.M. with Licenses Practical Nurse (LPN) #366 revealed Resident #5's pressure relief boots were taken off around 9:30 A.M. on 02/20/24. LPN #366 verified they had not been reapplied as they should have been. LPN #366 reported they should have been put back on after care was completed. Review of the facility policy titled, Skin Care Management, revised 11/17/22 revealed identified individual at risk for development of pressure ulcers and initiated management programs which stabilize or minimize underlying risk factors or change in condition.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of video recordings, staff interview, record review, and review of a personnel file, the facility failed to appropriately transfer a resident using a mechanical lift. This affected one (#46) of one resident reviewed for transfers. The facility census was 58. Findings include: Review of the medical record for Resident #46 revealed an admission date of 01/20/23 with diagnoses of dementia and contractures of both knees. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was rarely/never understood and was dependent on staff for transfers. Review of the current care plan revealed Resident #46 required a mechanical lift with two staff for transfers. Further review revealed Resident #46 used an electronic video and/or audio monitoring device in her private room. Observation on 02/20/24 at approximately 10:40 A.M. revealed a sign inside Resident #46's door indicating voice and video recordings were in use. Review of video footage provided by the Ombudsman revealed a date-stamped video dated 02/13/24 at 1:07 P.M., lasting two minutes, and revealed Resident #46 being transferred from her wheelchair to the bed via mechanical lift. One staff, identified as State Tested Nurse Aide (STNA) #352, was observed performing the task. Additional observation of videos time stamped 02/13/24 at 1:23 P.M., 1:24 P.M., 1:26 P.M. and 1:27 P.M. revealed additional footage of STNA #352 transferring Resident #43 from the bed and attempting to transfer her to the wheelchair. Additional observation of the footage revealed Resident #43 hanging from the mechanical lift above her wheelchair and STNA #352 turning away from Resident #43 and appearing to leave the room at 1:27:16 P.M. Review of the subsequent video revealed STNA #352 returning to the room with the Director of Nursing (DON) at 1:27:57. Interview on 02/21/24 at 4:03 P.M. with the DON stated she was not aware of any family reporting concerns regarding transfers with a mechanical lift. Further, the DON stated she was not aware of any staff performing mechanical lifts alone (without a second person). The DON stated the expectation was for two staff to be present at all times when transferring a resident with a mechanical lift. The DON further stated she made herself available to assist with transfers and assisted recently with a mechanical lift transfer for Resident #43. The DON stated Resident #43 was ready to be transferred when she entered the room and did not respond to a question regarding whether Resident #43 was already suspended from the lift when she entered the room. Interview on 02/21/24 at 4:33 P.M. with Coach #370 confirmed she received videos regarding the mechanical lift transfer of Resident #43. Coach #370 stated she supervised all STNAs and identified STNA #352 was in the video with Resident #43. Further interview and observation of the video dated 02/13/24 at 1:07 P.M. to 1:09 P.M. with Coach #370 verified STNA #352 transferred Resident #43 using a mechanical lift with nobody else in the room. Coach #370 verified two staff should be used every time residents were transferred using a mechanical lift. Coach #370 stated she provided verbal education to STNA #352 via telephone explaining the requirement of two staff when transferring residents with a mechanical lift. Coach #370 stated she did not complete a disciplinary action against STNA #352, did not provide education to any additional staff after the incident, and did not do any audits on STNA #352 or other staff to ensure the appropriate process was followed when using a mechanical lift. Follow-up interview with Coach #370 on 02/21/24 at approximately 5:40 P.M. revealed she shared the concern identified in the videos with the Administrator and the DON. Interview on 02/22/24 at 11:03 A.M. with the DON revealed Coach #370 advised her previously regarding Resident #43's daughter's concerns, but did not provide specifics on the concerns until 02/21/24. The DON was not aware the expressed concerns regarded a mechanical lift transfer with Resident #43 until 02/21/24. Further interview revealed the DON recalled Resident #43 was hanging from the mechanical lift, alone in her room, when she and STNA #352 returned to her room to complete the transfer to her wheelchair. Follow-up interview on 02/22/24 at approximately 11:30 A.M. with the DON revealed she did not provide any education to STNA #352 at the time she found Resident #43 alone in her room in a mechanical lift because the previous Administrator of the facility required all education and disciplinary action of STNAs to be solely through Coach #370. The DON stated she informed Coach #370 of the incident regarding STNA #352 using a mechanical lift without a second staff present. The DON further stated the current Administrator was altering that expectation and allowing the DON to educate or complete disciplinary action toward STNAs as appropriate. The facility did not have a policy or procedure regarding the use of mechanical lifts.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facilities bowel regime for constipation, the facility failed to ensure a resident received care and interventions for constipation. This affected one resident (#18) of two residents reviewed for bowel and bladder. The facility census was 58. Findings include: Review of Resident #18's medical record revealed an admission date of 05/22/20. Diagnoses included muscle weakness, symbolic dysfunction, constipation, dementia, major depressive disorder, anxiety disorder, insomnia, and restlessness and agitation. Review of Resident #18's Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of eight, indicating Resident #18 was moderately cognitively impaired. Resident #18 was dependent on staff for toilet use, bathing, dressing and personal hygiene. Resident #18 displayed verbal behavioral symptoms directed toward others four to six days during the review period. Review of Resident #18's care plan revised 01/24/24 revealed supports and interventions for risk for constipation. Interventions included administer medications as ordered, monitor bowel movements frequency, and monitor for complaints of abdominal pain. Resident #18's goal was to have a regular formed bowel movement at least every three days. Review of Resident #18's physician orders revealed an order dated 01/14/23 for Bisacodyl rectal suppository every 24 hours as needed for constipation. Review of the corresponding Medication Administration Record (MAR) revealed Resident #18 received no as needed suppository in the month of January 2024 or February 2024. An order dated 07/03/23 for Senna tablet 8.6 milligram two tablets every two hours as needed for constipation. Review of the corresponding Medication Administration Record (MAR) for January 2024 and February 2024 revealed Resident #18 received no as needed Senna tablets. Review of Resident #18's bowel movement tracking revealed it was documented Resident #18 did not have a bowel movement on 01/21/24, 01/22/24, 01/23/24, or 01/24/24. Review of Resident #18's progress notes revealed there was no documentation as to interventions for Resident #18's lack of bowel movement on 01/21/24, 01/22/24, 01/23/24, or 01/24/24. Interview on 02/20/24 at 4:17 P.M. with State Tested Nursing Assistant (STNA) #334 revealed Resident #18 was not always able to make her needs known. Resident #18 was confused and it depended on the day as to if Resident #18 was able to communicate what her needs were. STNA #334 reported all Resident #18's bowel movements and assistance needs were recorded in the electronic medical record. Interview on 02/21/24 at 7:07 A.M. with Licensed Practical Nurse (LPN) #366 revealed Resident #18 was confused and anxious. LPN #366 reported the bowel protocol was for any resident who went three days without a bowel movement to have an intervention completed. LPN #366 reported the aides would document when residents had bowel movements and when the residents did not. If there was three days with no bowel movement, they would start an intervention. All the residents had standing orders for constipation interventions and some had interventions unique to them. Interview on 02/21/24 at 8:54 A.M. with the Director of Nursing (DON) verified it was documented Resident #18 had not had a bowel movement documented for four consecutive days 01/21/24, 01/22/24, 01/23/24, or 01/24/24. Interview on 02/21/24 at 9:39 A.M. with the DON revealed no additional information was provided regarding interventions for Resident #18's lack of bowel movements for the four consecutive days in January where Resident #18 had no bowel movement. Review of the facility's undated bowel regime for constipation revealed residents were to receive Dulcolax Rectal Suppository 10 milligrams rectally daily if they had no bowel movement in the last three days.

CONCERN (D)

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

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure clarification was received and physician orders were implemented. This affected one resident (#19) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: Record review for Resident #19 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 include chronic respiratory failure, seizures, chronic kidney disease, and dementia with psychosis. Review of Resident #19's care plans dated 06/12/22 revealed a focus for impaired cognitive function related to dementia, short term memory loss and long term memory loss. Interventions include administer medications per physician order. Review of Resident #19's care plans dated 05/11/22 revealed a focus for antipsychotic medication use. Interventions include administer medications per physician order, consult with pharmacy and with physician to consider dosage reduction when clinically appropriate or at least quarterly, discuss with physician and family the need for ongoing use of medication. Review of Resident #19's prescribed medications dated 02/2024 revealed no order was in the resident's medical records for Aricept (treats memory loss and confusion) 10 milligrams (mg). Review of a physician order form for Resident #19 dated 01/23/24 revealed an order stating 'resident requested her memory pill' Aricept 10 mg. Check with house physician. Review of Resident #19's physician progress notes, nurses notes, and physician orders revealed no response or order for Aricept 10 mg. Interview on 02/22/24 at 10:00 A.M. with the Director of Nurse (DON) verified the orders for Resident #19 dated 01/23/24 came from an outside provider, the resident's psychiatrist, and were sent back with the resident to the facility with the written order form. The DON stated the nurse who received the orders did not enter the Aricept order on the form, and did not consult with the primary physician regarding the order to verify the order and frequency. The DON stated it was protocol to notify the primary physician and request clarification for all outside orders.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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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 pharmacy recommended and physician approved laboratory (lab) orders were completed as recommended. This affected one resident (#5) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Reviewed of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, potential for discomfort, anticoagulant use with risk for side effects, potential for drug related complications, multiple sclerosis, hospice services, risk for pain, and potential for impaired skin integrity. Review of Resident #5's pharmacy recommendations revealed on 01/24/23 the pharmacist recommended considering checking Resident #5's ammonia levels due to the last level being completed 06/28/22 and a recent decrease in responsiveness and hallucinations which led to the increase of Seroquel. The physician reviewed the recommendation and agreed. On 02/24/23 the pharmacist noted on 01/26/23 the physician agreed to check Resident #5's Ammonia level. No corresponding order was found. Please follow up. Review of Resident #5's laboratory (lab) results found no corresponding lab results for Resident #5's ammonia level. The pharmacy recommendation was not acted on and the lab for ammonia levels was not completed. Review of Resident #5's lab orders revealed his most recent order for ammonia levels was ordered 08/06/22. There was no order written in response to the 01/24/23 pharmacy recommendation. Interview on 02/22/24 at 11:03 A.M. with the Director of Nursing (DON) stated she would contact the lab and get the results if they were completed. Interview on 02/22/24 at 2:33 P.M. with the DON verified the ammonia lab was not completed.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility policy, the facility failed to ensure pharmacy recommendations for gradual dose reductions for psychotropic medications were addressed. This affected two (#43 and #19) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 07/02/22 with diagnoses of anxiety and depression. Resident #43 was under hospice care since 07/25/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and received antianxiety and antidepressant medications. Review of a physician order dated 07/25/22 revealed Resident #43 received lorazepam (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every four hours as needed. Review of a physician order dated 11/11/22 revealed Resident #43 received buspirone (an antianxiety medication), 2.5 mg by mouth twice daily. Review of a documented titled, Note to Attending Physician/Prescriber, dated 05/27/23, revealed the pharmacist recommended the provider address the ongoing as-needed prescription for lorazepam for Resident #43 and for the provider to provide a length of treatment, and if more than 14 days, a rationale for ongoing use. Further review revealed no response from the provider. Review of a documented titled, Note to Attending Physician/Prescriber, dated 06/28/23, revealed the pharmacist recommended the provider address a gradual dose reduction for buspirone for Resident #43. Further review revealed no response from the provider. Interview with the Director of Nursing (DON) on 02/21/24 at approximately 3:00 P.M. revealed the facility could provide no additional evidence the provider responded to the pharmacist's recommendations on 05/27/23 or 06/28/23. 2. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 included chronic respiratory failure, seizures, chronic kidney disease, and dementia with psychosis. Review of Resident #19's MDS annual assessment dated [DATE] revealed the resident had impaired cognition. No psychosis diagnosis was noted in the assessment. Per the assessment no Gradual Dose Reduction (GDR) had been attempted or had physician documentation stating a GDR was clinically contraindicated. Review of Resident #19's care plans dated 05/2022 revealed a focus for anti-psychotic medication for behavioral disturbance. Interventions included pharmacy to recommend gradual dose reduction when appropriate and at least quarterly. Review of the resident's physician prescribed medications dated from 01/2023 to 02/2024 revealed the resident was to receive Olanzapine (for depression) 2.5 mg one time in the morning and Olanzapine (for psychotic disorder) 5 mg one time at bedtime, Escitalopram (for depression) 20 mg one time a day, and Primidone 50 mg in the morning for seizures. Review of the facility's pharmacy reviews dated from 01/2023 to 01/2024 for irregularities in the medication records for Resident #19 revealed the pharmacist found irregularities in the months of 02/24/23, 04/24/23, 7/24/23, and 01/23/24. Review of the physician responses for 02/24/23 revealed the pharmacist recommended the physician to attempt a GDR for the Escitalopram 20 mg for depression. No GDR was recommended for the Olanzapine medication. On the document there was no response documented from the physician. Review of the pharmacist's recommendation dated 04/24/23 revealed a notation for the facility to obtain the psychiatry notes for reviews of the current anti-psychotic medications. Further review of the resident's medical records revealed no physician response for the 04/24/23 recommendation and no documentation for the psychiatrist in the medical records. No documentation for the pharmacist or physician was in the medical records for the 07/24/23 and 01/23/24 irregularities found. Interview on 02/21/24 at 4:00 P.M. with the DON revealed the primary physician had not responded to the pharmacy recommendations dated 02/24/23, 04/24/23, 07/24/23, and 01/23/24. Per the DON, Resident #19's anti-psychotic medications are managed by her outside psychiatrist. The DON stated there has been no attempted GDRs for any of her medications and the facility didn't have any of the outside psychiatrist's documentation or rationales for the GDR attempts. The DON verified when the pharmacist has made recommendations to attempt GDRs for Resident #19, the primary physician refers the DON to have the outside psychiatrist review the medications. The DON stated the facility has attempted to get information for the medical records from the outside psychiatrist but has been unsuccessful and has not attempted recently to receive information from the psychiatrist regarding the medications. Review of the facility policy titled, 'Gradual Dose Reduction, dated 10/2022 revealed GDRs will be attempted for all anti-psychotic and anti-depressant medications at least annually after the first year the resident's are prescribed the medications.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, and review of the policy for medication storage, the facility failed to ensure medication carts were secured and medications were placed in the medication cart. This affected two (Residents #29 and #34) of two residents observed for medication administration. The facility census was 58. Findings include: 1. Observation of medication pass on 02/20/24 at 4:00 P.M. with Licensed Practical Nurse (LPN) #366 with Resident #29, revealed LPN #366 prepared the correct amount of Humalog into the syringe. LPN #366 placed the Humalog on top of the medication cart. LPN #366 followed Resident #29 into his room and shut the door to inject his insulin in his abdomen. LPN #366 was not in direct sight of the medication cart which was not secured and the insulin was left on top of the medication cart. Interview with LPN#366 on 02/20/24 at 4:08 P.M. verified he left the medication of Humalog on top of the unsecured medication cart and should have put back into the cart and secured the cart. 2. Observation of medication pass on 02/20/24 at 4:44 P.M. with LPN #378 with Resident #34, revealed she removed Dilaudid one half tablet and then realized she did not have any water or ice to pass for the resident. LPN #378 was observed walking away from the unsecured medication cart and went into another room to retrieve ice, which was out of sight of the unlocked medication cart. Interview with LPN #366 on 02/20/24 at 4:44 P.M. verified she walked out of sight of the unsecured medication cart while retrieving ice from another room. Review of facility policy titled, Medication Storage, dated 07/23/19 revealed medications and biologicals are stored safely, securely and properly following manufacturer's recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members authorized to administer medications.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure food intolerance's were honored at meals. This affected one (#5) of one resident reviewed for meal intolerance's. The facility census was 58. Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/10/18 with diagnoses multiple sclerosis and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's level of cognition was not assessed. Resident #5 was on a therapeutic, mechanically altered diet and required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of the current physician order dated 01/08/24 revealed Resident #5 received regular diet with pureed texture and thin liquids. Review of the allergies documented in the electronic medical record for Resident #5 revealed lactose intolerance was added to his profile on 04/05/23. Review of the meal intake documentation for 02/21/24 revealed Resident #5 consumed 26-50% of the evening meal. Observation on 02/21/24 at 8:09 A.M. revealed State Tested Nurse Aide (STNA) #335 preparing breakfast for Resident #5. STNA #335 prepared oatmeal using lactose-free milk after explaining Resident #5 was lactose intolerant. Observation on 02/21/24 at 5:22 P.M. revealed STNA #377 preparing Resident #5's evening meal. STNA #377 used regular milk to thin the meatloaf she pureed and plated for Resident #5. STNA #377 also scooped a serving of mashed potatoes onto Resident #5's plate. Interview at that time with STNA #377 confirmed she prepared the mashed potatoes using regular milk and butter. STNA #377 stated Resident #5 did not have any food allergies. Interview on 02/22/24 at 9:38 A.M. with STNA #301 found a list of diet orders for residents printed 02/20/24. Review of the printout revealed nothing regarding lactose intolerance for Resident #5. Further interview with STNA #301 revealed she was unaware whether Resident #5 had any food allergies. Interview on 02/22/24 at 11:32 A.M. with the Administrator verified Resident #5's allergy list included lactose intolerance. The Administrator stated his intolerance to lactose was not a true allergy. Additionally, the Administrator confirmed Resident #5 consumed approximately 26-50% of his meal on the evening of 02/21/24. Interview on 02/22/24 at 2:31 P.M. with STNA #377 revealed she received in report from the previous shift Resident #5 had diarrhea in the morning on 02/22/24. STNA #377 stated Resident #5 did not normally have diarrhea.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility recipes, and review of the facility menus, the facility failed to follow menus as planned by not following recipes, by not using portioned serving utensils, by not offering all menu items to each resident, and by not offering the main meal before offering a nutritionally unequal alternative. This affected Resident #5 and Resident #34 and had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #40, #42, #43, #46, #47, and #59) and House 3 (#1, #16, #18, #22, #26, #27, #37, #38, #48, and #49). The facility census was 58. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 12/10/18 with diagnoses multiple sclerosis and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's level of cognition was not assessed. Resident #5 was on a therapeutic, mechanically altered diet and required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of the current physician order dated 01/08/24 revealed Resident #5 received regular diet with pureed texture and thin liquids. 2. Review of the medical record for Resident #34 revealed an admission date of 12/23/22 with diagnoses of epilepsy, hemiplegia and hemiparesis affecting right dominant side. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was rarely/never understood and required partial/moderate assistance for eating. Review of a physician order dated 10/25/23 revealed Resident #34 received a regular diet with mechanical soft textures and thin liquids. Review of the current care plan for Resident #34 revealed no meal preferences. Observation on 02/21/24 at 3:51 P.M. revealed State Tested Nurse Aide (STNA) #304, in House 2, preparing chicken fried rice for the evening meal. Interview with STNA #304 on 02/21/24 at 3:51 P.M. revealed she did not follow a recipe to prepare the chicken fried rice, but felt comfortable making it from her basic knowledge of cooking. Further interview and observation revealed STNA #304 used a three-pound bag of chicken tenderloins. STNA #304 stated she made three cups of rice and expected to use three eggs when assembling the meal. STNA #304 stated she was preparing enough for approximately ten residents because Resident #43 usually ate waffles, and Resident #34, on a mechanical soft diet, would receive Malt-o Meal (hot cereal) instead of the prepared meal so she would not choke. Interview on 02/21/24 at 4:19 P.M. with Dietetic Technician (DT) #337 and Registered Dietitian (RD) #379 revealed each House developed its own menu through a web-based menu program. The menu was approved weekly by RD #379 or another RD who worked at the facility once weekly. Continued interview with RD #379 confirmed the menu provided the expected portion size to provide to residents to meet their nutritional needs. RD #379 confirmed if correct portions were not used, the facility could not ensure each resident received the daily calorie and nutrient needs as estimated in the menu program. Continued interview with DT #337 stated a recipe book was available for staff, and if no recipe was available, DT #337 would provide verbal guidance on meal preparation to the staff. Observation and interview on 02/21/24 at 4:55 P.M. revealed STNA #304, in House 2, using a slotted silver spoon to serve cauliflower and a slotted spatula to serve chicken fried rice. STNA #304 confirmed the serving utensils were not intended to provide a specific portion size. STNA #304 stated she ultimately used five eggs in the chicken fried rice. Observation and interview on 02/21/24 at 5:00 P.M. with STNA #377 in House 3 revealed she made meatloaf for dinner and did not use a recipe. STNA #377 stated she used three pounds of ground beef when making the meatloaf. STNA #377 further stated there was a recipe available but she chose not to use it. Additionally, STNA #377 confirmed she used a spatula to serve the mashed potatoes and a slotted spoon to serve the mixed vegetables and neither tool was able to measure the quantity provided. Observation on 02/21/24 at 5:22 P.M. revealed STNA #377 preparing a pureed meal for Resident #5. STNA #377 pureed the meatloaf and provided a portion of mashed potatoes on Resident #5's plate. Interview at that time with STNA #377 confirmed she did not puree the mixed vegetables and did not plan to provide mixed vegetables to Resident #5 because she believed Resident #5 had plenty to eat with the meatloaf and mashed potatoes. Interview on 02/21/24 at 5:31 P.M. with STNA #304 revealed Resident #34 was on a mechanical soft diet and STNA #304 had not yet prepared or served Resident #34. Continued observation revealed STNA #304 microwaving water and preparing Malt-o Meal for Resident #34. STNA #304 stated she planned to provide a nutrition supplement with 240 kilocalories and 10 grams of protein along with the cream of wheat for the evening meal. Interview on 02/21/24 at approximately 5:40 P.M. with RD #379 confirmed the chicken fried rice and cauliflower on the menu could be prepared to an appropriate mechanical soft texture and provided to Resident #34. Observation at that time revealed a blender on the counter. Further interview with RD #379 revealed the substitution of Malt-o Meal and a nutrition supplement for the evening meal would be appropriate if it was based on Resident #34's preference. Follow-up interview on 02/21/24 at 5:44 P.M. with STNA #304 revealed STNA #304 did not offer Resident #34 the main meal because Resident #34 had impaired cognition. Review of the facility recipe for meatloaf for 12 servings revealed the portion of ground beef should be 4 and 3/4 cup and the recipe should also include one cup of ground pork. Regarding the recipe for chicken fried rice, the facility provided a statement indicating the meal should have come pre-packaged and cooked according to the directions on the bag.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, review of the temperature logs, and review of facility policies, the facility failed to ensure refrigerator and dishwasher temperatures were monitored and documented, failed to ensure safe food storage, and failed to sanitize thermometers between food items. This had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #34, #40, #42, #43, #46, #47, and #59) , House 4 (#3, #9, #12, #17, #19, #21, #25, #39, #41, #52, #156, and #60), and House 5 (#2, #4, #13, #23, #35, #51, #157, #158, #159, #160, and #161). The facility identified all residents in these houses received food from the kitchen. The facility census was 58. Findings include: Interview on 02/20/24 at 8:34 A.M. with State Tested Nurse Aide (STNA) #302 revealed she did not know the process for documenting refrigerator and freezer temperatures. Interview and observation on 02/20/24 at 8:42 A.M. with STNA #317, in House 2, confirmed two containers of food labeled for Resident #59 were undated. One container contained deviled eggs with liquid around the bottom of the container. Additional observation and interview confirmed a personal food item for Resident #47 with an illegible date. Additionally, STNA #317 confirmed the strawberries in the refrigerator were moldy. Concurrent observation revealed a sign posted on the refrigerator directing staff to date all food items. Further interview with STNA #317 revealed she could not find the refrigerator thermometer. Continued observation and interview with STNA #317 confirmed there were scoops in the flour, sugar, and cereal bins. STNA #317 said the scoops were washed periodically, but remained in the containers for convenience. Interview on 02/20/24 at 9:06 A.M. with STNA #338, in House 4, revealed she was not sure how to monitor the refrigerator temperature. Interview and observation of the refrigerator and dishwasher logs on 02/20/24 at 9:08 A.M. with STNA #306 confirmed no documentation of P.M. refrigerator and freezer temperatures since 02/09/24, and no temperatures were documented for any shift on 02/18/24 and 02/19/24. Additionally, the dishwasher temperature log was blank from 02/01/24 through 02/09/24 for day shift, and no documentation was completed for night shift for the month of February 2024. Observation on 02/20/24 at 9:15 A.M. in House 5 revealed an opened gallon of milk dated 02/04/24 and a full gallon of milk dated 02/14/24 in the refrigerator. Interview on 02/20/24 at 9:16 A.M. with STNA #307 confirmed the milk was expired. Further interview revealed she did not serve any residents milk that morning. Further observation of the refrigerator and interview with STNA #307 on 02/20/24 beginning at 9:16 A.M. revealed two plastic bags of bacon were previously opened and undated and one plastic bag of sausage was previously opened and undated. Additionally, STNA #307 stated she did not know how to use the probe thermometer in the refrigerator to verify refrigerator temperatures. STNA #307 stated she used the temperature visible inside the refrigerator. Observation revealed the temperature she documented was a lighted read-out of the temperature setting for the refrigerator, not a thermometer. Observation and interview on 02/20/24 at 9:25 A.M. with STNA #364 confirmed the refrigerator/freezer temperature log for February 2024 was missing documentation for all entries on 02/03/24, 02/04/24, 02/17/24, and 02/18/24, and was missing P.M. temperatures for all days except 02/09/24. Interview on 02/20/24 at 9:27 A.M. with Dietetic Technician (DT) #337 stated she was involved in oversight of food safety and temperatures logs. DT #337 stated the facility was attempting to improve their documentation on temperatures. Interview on 02/21/24 at 8:09 A.M. with DT #337 revealed scoops should not be left in food bins. Observations on 02/21/24 between 4:49 P.M. and 4:55 P.M. in House 2 revealed STNA #304 taking temperatures of chicken fried rice, egg rolls, and cauliflower. STNA #304 used a digital thermometer and wiped it on a paper towel between foods. Interview on 02/21/24 at 4:54 P.M. with STNA #304 confirmed she wiped the thermometer on the same paper towel between taking the temperature of the next food. Review of the policy Refrigerator and Freezer Temperatures Policy & Procedure, revised 05/2013, revealed refrigerator and freezer temperatures should be checked twice daily and recorded on the log. Review of the policy Dishwashing, revised 04/27/21, revealed the dishwasher temperature should be recorded on the Dishwasher Monitoring Log. Review of the policy Food Handling and Preparation, revised 04/26/21, revealed clean, sanitized utensils should be used when preparing food. Review of the policy Food Storage Policy & Procedure, revised 05/2013, revealed the purpose of the policy was to assure that all food was stored, labeled, and dated properly to assure stock rotation and prevent food illness. Review of the undated document Resource for Families revealed all foods in unmarked or unlabeled containers should be marked with the current date the food item was stored.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interviews, and review of policy, the facility failed to ensure medications were not left unattended in resident rooms. This had the potential to affect one (#9) of one resident identified by the facility with cognitive impairment and independently mobile. The facility census was 59. Finding include: Observation on 03/17/23 at 6:50 A.M., noted Resident #1 in bed with with eyes closed. The resident did not wake to verbal greeting. Located on the night stand next to the bed, discovered a medication cup, with a white oval tablet that was broken in half and a oval orange tablet contained inside. The medications were not contained inside of an identifiable package. Observations on 03/17/23 at 6:57 A.M., with Licensed Practical Nurse (LPN) #200 verified the medications were left unattended at the bedside and stated the facility medication administration policy requires the nurse to observe a resident consume medications before leaving sight of the resident. Review of the medical record for Resident #1 revealed an admission of 02/14/20, with the diagnosis including, depression, chronic obstructive pulmonary disease, anemia, chest pain, pulmonary embolism, hypertension, orthostatic hypotension, glaucoma, and unsteadiness on feet. Review of the Minimum Data Set assessment dated [DATE], assessed Resident #1 with moderate cognitive impairment, requires supervision with activities of daily living, incontinent of bladder, and no skin impairment or injury. Review of physician orders dated 11/14/22 revealed the physician ordered the administration of Potassium Chloride Extended Release (ER) 20 milliequivalents (meq) one tablet twice daily for the treatment of Hypertension in the morning between 8:00 A.M. and 11:00 A.M., and at bedtime between 7:00 P.M. and 10:00 P.M. On 11/14/22, an order for Apixaban 5 milligrams (mg) to be administered two times daily for the treatment of Pulmonary Embolism. The Apixaban was also scheduled for the morning between 8:00 A.M. and 11:00 A.M., and at bedtime between 7:00 P.M. and 10:00 P.M. Observation and medical record review, on 03/17/23 at 7:00 A.M., with LPN #200, identified the medications as Apixaban 5 milligrams (mg) and Potassium Chloride extended release 20 milliequivalents (meq). LPN #200 indicated the medications were to be administered at bedtime. Interview on 03/17/23 at 7:45 A.M., with the Director of Nursing (DON) and Administrator verified medications are to be administered by the nurse and observed to be consumed by the resident. No medications are to be left unattended at the bedside. Interview on 03/17/23 at 11:15 A.M., with the Administrator identified one Resident (#9) as cognitively impaired and independently mobile. The Administrator also indicated the nurse working the previous shift was contacted via telephone (Licensed Practical Nurse (LPN) #201) and stated the medications for Resident #1 were left unattended at the residents bedside during the night shift. Review of the policy titled Medication Administration Procedure, dated revised November 9, 2021, revealed medications are to be administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications are administered at the time they are prepared. The person who prepares the dose for administration is the person who administers the dose. The resident is always observed after administration to ensure the dose was completely ingested.

Feb 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure resident wishes for life-sustaining treatment were clearly reflected in the medical record. This affected two residents (#33 and #41) out of three residents reviewed for advanced directives. The facility census was 60. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, dementia, anxiety disorder, major depressive disorder, hypertension, hyperlipidemia, obesity, and edema. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. Resident #33 required the extensive assistance of two persons for bed mobility, transfers, personal hygiene and required total dependence for locomotion, and toilet use. Resident #33 was always incontinent of bowel and bladder. Review of Resident #33's physician orders identified an order dated 03/19/22 for do not resuscitate, comfort care (DNR-CC) and an order for hospice services on 04/21/22. Review of Resident #33's paper medical record revealed Resident #33's code status was identified as a Full Code with a green sheet of paper in the front of the chart that read FULL CODE. Review of Resident #33's electronic medical record revealed the code status for Resident #33 was DNR-CC. Interview on 02/28/23 at 7:35 A.M. with Licensed Practical Nurse (LPN) #303 verified Resident #33's code status was listed as a Full Code in the paper record and verified the code status in the electronic medical record was DNR-CC. LPN #303 stated the orders conflict one another and required clarification. Interview with the Director of Nursing (DON) on 02/28/23 at 9:05 A.M. verified Resident #33 had received Hospice services since April 2022 and verified Resident #33 had signed DNR-CC paperwork dated 04/21/22. The DON verified the paper medical record stated Resident #33 was a Full Code and removed the green FULL CODE paperwork from the paper medical record. 2. Review of the medical record for Resident #41 revealed an admission date of 12/19/20. Diagnoses included type II diabetes mellitus, hypertension, chronic pancreatitis, heart failure, vitamin B12 deficiency, anemia, major depressive disorder, and rectal adenocarcinoma diagnosed January 2023. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. Resident #41 required supervision for transfers, walking, locomotion, dressing and eating and extensive assistance with the physical help of one person for bed mobility, toilet use and personal hygiene. Resident #41 was identified as occasionally incontinent of urine and frequently incontinent of bowel. Review of Resident #41's physician orders identified an order dated 03/19/22 for do not resuscitate, comfort care (DNR-CC). Review of Resident #41's paper medical record revealed Resident #41's code status was identified as a Full Code, a green sheet of paper in the front of the chart that read FULL CODE. Review of Resident #41's electronic medical record revealed the code status for Resident #41 was DNR-CC and contained a copy of the signed DNR-CC paperwork dated 03/18/22. Interview on 02/28/23 at 7:35 A.M. with LPN #303 verified Resident #41's code status was listed as a Full Code in the paper medical record and verified the code status in the electronic medical record was DNR-CC. LPN #303 stated the orders conflict one another and required clarification. Interview with the DON on 02/28/23 at 9:05 A.M. stated Resident #41 was a Full Code. Review of the electronic medical record with DON verified Resident #41 had signed DNR-CC paperwork dated 03/18/22. The DON verified the paper medical record stated Resident #41 was a Full Code, the DON was observed removing the green FULL CODE paperwork from the paper medical record at the time of the interview. Review of the policy titled Advanced Directives, dated 03/22/1999 revealed documentation, written or oral of informed consent to withhold or withdraw treatment must be placed in the residents medical record together with the attending physician order regarding the withholding or withdrawal of treatment. The physicians order should also be noted on the residents plan of care and on the inside and outside of the residents medical 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to timely notify the ordering physician of laboratory test results and further failed to notify the resident representative timely of a change in condition and of a resident fall . This affected one resident (#41) out of three residents reviewed for change in condition. The facility census was 60. Findings include: Review of the medical record for Resident #41 revealed an admission date of 12/19/20. Diagnoses included type II diabetes mellitus, hypertension, chronic pancreatitis, heart failure, vitamin B12 deficiency, anemia, major depressive disorder, and rectal adenocarcinoma diagnosed January 2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Resident #41 required supervision for transfers, walking, locomotion, dressing and eating and extensive assistance with the physical help of one person for bed mobility, toilet use and personal hygiene. Resident #41 was identified as occasionally incontinent of urine and frequently incontinent of bowel. Review of a progress note dated 11/29/22 and timed 5:04 P.M. revealed Resident #41 experienced a fall and the resident representative had not been called. The progress note stated Resident #41 was his own power of attorney. Review of the undated Power of Attorney (POA) paperwork for Resident #41 revealed Resident #41 had a POA. The POA paperwork had been scanned into the electronic medical record on 03/31/21 identified a POA who was also listed as the first emergency contact. Review of the progress note dated 12/28/22 and timed 8:40 A.M. revealed Resident #41 had a strong musty bowel movement odor and when peri-care was performed the brief had dark brown old blood looking stool. The note lacked documentation the resident representative was notified. Review of the progress note dated 12/28/22 and timed 9:12 A.M. revealed Resident #41 had increased difficulty ambulating and transferring form the toilet to the bed. Vital signs were taken and the resident was found to have a blood pressure of 88/57 millimeters of mercury (mmHg), a pulse rate 88 beats per minute and oxygen saturation of 98 percent. Resident #41 was placed in a recliner with legs elevated above the level of the heart. Recheck of blood pressure revealed a result of 98/62 mmHg. The progress note indicated the resident would be monitored and lacked documentation of the resident representative notification. Review of the progress note dated 01/06/23 and timed 11:00 A.M. revealed Resident #41 felt dizzy and lightheaded upon ambulation. Blood pressure 98/54 mmHg. The Nurse Practitioner was called and review of the laboratory tests from 12/30/23 were reviewed upon the inquiry of the Nurse Practitioner. The Nurse Practitioner recommended the resident be sent to the hospital for evaluation. Review of the laboratory tests collected on 12/30/22 at 2:02 A.M. and reported on 12/30/22 at 12:49 P.M. to the facility revealed a hemoglobin of 7.9 grams per deciliter (g/dl), reference range 13.5 to 17.5 g/dl; and a hematocrit of 24.9 percent (reference range 41 to 53 percent). Interview on 02/28/23 at 2:20 P.M., with the Nurse Practitioner (NP) #306 revealed no knowledge of the 12/30/22 laboratory results for Resident #41 until 01/06/23 when notified of the resident being dizzy and lightheaded. Interview with Licensed Practical Nurse (LPN) #305 on 02/28/23 at 3:41 P.M., verified NP #306 inquired about the 12/30/22 laboratory results on 01/06/23 when LPN #305 called notification of the residents change in condition. LPN #305 stated she had to look for the laboratory results as the results were not in the medical record but were found in the laboratory system. LPN #305 stated the resident representative was at the bedside of Resident #41 and was notified of the laboratory results at the time of transfer. LPN #305 stated the resident representative was upset of the results not addressed prior to Resident #41 required transfer. Review of the policy titled Laboratory and Radiology Results, undated revealed when laboratory results are received the nurses review the results and the ordering provider is notified of the results. Review of the policy titled Notification of Change in Condition, dated 11/22/21 stated the facility will promptly notify the resident, the resident's physician and the representative for the resident of any laboratory test results that fall outside the clinical reference ranges. This deficiency represents non-compliance investigated under Master Complaint Number OH00140085.

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 F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to timely notify the ordering physician of laboratory test results. This affected one resident (#41) out of three residents reviewed for notification of laboratory test results. The facility census was 60. Findings include: Review of the medical record for Resident #41 revealed an admission date of 12/19/20. Diagnoses included type II diabetes mellitus, hypertension, chronic pancreatitis, heart failure, vitamin B12 deficiency, anemia, major depressive disorder, and rectal adenocarcinoma diagnosed January 2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Resident #41 required supervision for transfers, walking, locomotion, dressing and eating and extensive assistance with the physical help of one person for bed mobility, toilet use and personal hygiene. Resident #41 was identified as occasionally incontinent of urine and frequently incontinent of bowel. Review of the progress note dated 12/28/22 and timed 8:40 A.M. revealed Resident #41 had a strong musty bowel movement odor and when peri-care was performed the brief had dark brown old blood looking stool. Review of the progress note dated 12/28/22 and timed 9:12 A.M. revealed Resident #41 had increased difficulty ambulating and transferring form the toilet to the bed. Vitals were taken and the resident was found to have a blood pressure of 88/57 millimeters of mercury (mmHg), a pulse rate 88 beats per minute and oxygen saturation of 98 percent. Resident #41 was placed in recliner with legs elevated above the level of the heart. Recheck of blood pressure revealed a result of 98/62 mmHg. The progress note indicated the resident would be monitored. Review of the progress note dated 12/28/22 and timed 4:21 P.M. revealed the Nurse Practitioner (NP) was notified and orders received for laboratory tests, a complete blood count and basic metabolic panel, Losartan (antihypertensive medication) was reduced to 12.5 milligrams (mg) once daily and a follow up appointment with gastroenterologist was to be scheduled. The resident's power of attorney was notified and updated to the orders received. Review of the progress note dated 01/04/23 and times 6:32 P.M. revealed the gastroenterologist appointment was made for the wrong office and Resident #41 returned to the facility. Review of the progress note dated 01/06/23 and timed 11:00 A.M. revealed Resident #41 felt dizzy and lightheaded upon ambulation. Blood pressure was 98/54 mmHg. The Nurse Practitioner was called and review of the laboratory tests from 12/30/23 were reviewed upon the inquiry of the NP. The NP recommended the resident be sent to the hospital for evaluation. Review of the laboratory tests collected on 12/30/22 at 2:02 A.M. and reported on 12/30/22 at 12:49 P.M. to the facility revealed a hemoglobin of 7.9 grams per deciliter (g/dl), reference range 13.5 to 17.5 g/dl; and a hematocrit of 24.9 percent (reference range 41 to 53 percent). Interview on 02/28/23 at 2:20 P.M. with the NP #306 revealed no knowledge of the 12/30/22 laboratory results for Resident #41 until 01/06/23 when notified of the resident being dizzy and lightheaded. Interview with Licensed Practical Nurse (LPN) #305 on 02/28/23 at 3:41 P.M. verified NP #306 inquired about the 12/30/22 laboratory results on 01/06/23 when LPN #305 called notification of the residents change in condition. LPN #305 stated she had to look for the laboratory results as the results were not in the medical record but were found in the laboratory system. Review of the policy titled Laboratory and Radiology Results, undated revealed when laboratory results are received the nurses review the results and the ordering provider is notified of the results. Review of the policy titled Notification of Change in Condition, dated 11/22/21 stated the facility will promptly notify the resident, the resident's physician and the representative for the resident of any laboratory test results that fall outside the clinical reference ranges. This deficiency represents non-compliance investigated under Master Complaint Number OH00140085.

Dec 2021 12 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

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Based on medical record review, policy review, staff and resident interviews, the facility failed to provide a written copy of the baseline care plan to a resident. This affected one (#145) of three sampled residents reviewed for baseline care plans. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set had not been completed at this time. Further review revealed a baseline care plan dated 12/26/21 had been completed. There was no documentation that the resident received a copy of the baseline care plan. Interview on 12/29/21 at 12:52 P.M., with Resident #145 revealed he had not received a copy of his baseline care plan. Resident #145 stated he had not signed any type of care plan since he had been at the facility. Interview on 12/29/21 at 8:47 A.M., with Licensed Practical Nurse (LPN) #436 verified Resident #145 had not received a copy of his baseline care plan. Review of the facility policy titled Baseline Care Plan, dated 11/13/17, revealed the baseline care plan will be developed within 48 hours. The facility will provide the resident and/or representative with a summary of the baseline care plan.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to develop a comprehensive plan of care to address a resident's communication needs. This affected one (#27) of 15 residents reviewed for care planning. The facility census was 49. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included hearing loss, asthma, major depressive disorder, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was moderately cognitively impaired. Review of the plan of care, revised 12/28/21, revealed Resident #27 had a communication problem related to poor hearing. Additionally, Resident #27 read lips, would do a thumbs up or down to indicate likes and dislikes. Interventions included using a thumbs up and down and a dry erase board. Observation on 12/27/21 at 10:28 A.M., of Resident #27 revealed the resident in bed watching television. A sign was hanging in the resident's room indicating the Resident's hearing aides were broken. Attempts to interview Resident #27 were unsuccessful. Resident #27 stated he could not hear. Interview on 12/28/21 at 12:38 P.M., of the Director of Nursing (DON) and Quality of Life (QOL) staff #432 revealed Resident #27 did not like to wear hearing aids. The DON stated it was more of a choice the resident did not wear them. QOL #432 stated an amplifying speaker box was purchased for Resident #27, but after a couple of days, he refused to use them. The DON and QOL #432 stated staff used a whiteboard most of the time to communicate with Resident #27. In addition, Resident #27 read lips well, but now that staff had to wear a facemask all of the time, he was not able to do that, which was frustrating for him. Both the DON and QOL #432 stated Resident #27 was able to communicate with a variety of gestures, such as thumbs up and down and staff who were familiar with him knew his gestures and how to communicate with him. The DON verified the facility used a number of agency staff and QOL #432 stated communication strategies were in Resident #27's plan of care. Interview on 12/28/21 at 12:47 P.M., of Elder Assistant (EA) #407 revealed Resident #27 had his own set of signs that he used to communicate with staff. EA #407 stated staff who worked with the Resident were familiar with his non-verbal signs of communication. Subsequent interview on 12/28/21 at 3:04 P.M., of QOL #432, after this surveyor reviewed Resident #27's plan of care, verified she added communication strategies to Resident #27's plan of care after this surveyor inquired about it. QOL #432 stated she had care planned Resident #27's hearing loss but, after speaking with this surveyor, thought it was a good idea to include communication strategies to assist new and agency staff. Review of facility policy titled Comprehensive Care Planning Procedure, effective 11/13/17, revealed the resident comprehensive care plan will include services to attain or maintain the resident highest practicable physical, mental, and psychosocial well-being. The care plan will discuss needs, focus, strengths, and resident preferences.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview and policy review, the facility failed to provide dressing changes as ordered and apply compression stockings to the legs. This affected one (#145) of one resident reviewed for wound care and compression stockings. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set was not completed at this time. Review of the baseline care plan dated 12/26/21 revealed Resident #145 had no care plan to address wound care or application of compression stockings. Review of the hospital discharge physician orders dated 12/26/21 revealed Resident #145 had an order to cleanse abdomen and lower back with normal saline and place dry ABD pad daily, until no drainage then leave open to air one time a day for dressing change and compression sock to right lower extremity on in morning and off at night. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed there was no evidence the nurses provided dressing changes to Resident #145's abdomen and back. In addition, there was no evidence of the nursing staff applying a compression stocking to Resident #145's right leg. Observation on 12/27/21 at 10:00 A.M., revealed Resident #145's dressing to his abdomen was dated 12/22/21 and was not wearing a compression stocking to his right leg. Observation on 12/28/21 at 12:56 P.M., revealed the dressing to the back was dated 12/28/21, the abdominal dressing was dated 12/22/21 and had no compression stocking on his right leg. Interview on 12/28/21 at 12:56 P.M., at the time of the observation, revealed the dressing to his back had just been changed. Interview on 12/28/21 at 2:34 P.M., with Licensed Practical Nurse (LPN) #431 verified she changed the dressing to Resident #145's back without having a physician order, because it was saturated and verified there was no compression stocking on Resident #145's right leg. Interview on 12/29/21 at 2:10 P.M., with the Director of Nursing (DON) verified there were no physician orders on the TAR or MAR for dressing changes to the abdomen and back or for the application of compression stocking to the right leg. The DON also verified that there were physician orders on the hospital discharge sheet for the compression stocking to the right leg and was missed. The DON verified the nursing staff should have verified with the physician what to do with the dressings since there were no orders.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on medical record review, staff interview and policy review, the facility failed to provide care and services for a resident's Peripheral Inserted Central Catheter (PICC) intravenous line. This affected one (#145) of one resident reviewed for intravenous therapy. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set was not completed at this time. Review of the care plan dated 12/26/21 revealed Resident #145 received Intravenous (IV) antibiotic therapy. Resident will not experience complications related to IV therapy. Change my IV primary and secondary tubing per protocol. Flush my peripheral, PICC (peripheral inserted central catheter), or midline per protocol. The care plan did not include interventions for wound care. Review of the hospital discharge physician orders dated 12/26/21 revealed Resident #145 had an order for heparin lock flush solution 100 unit/milliliter (ml) use three ml IV for PICC maintenance heparin flush using 10 ml syringe one time a day, flush with three ml of heparin after flushing with five ml of normal saline, sodium chloride 0.9% use five ml IV one time a day for PICC normal saline flush maintenance followed with heparin flush. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed there was no evidence the nurses flushed the PICC line with normal saline followed by heparin to keep the PICC line patent until 12/28/21. Interview on 12/29/21 at 2:10 P.M., with the Director of Nursing (DON) verified there were no physician orders on the TAR or MAR for flushing the PICC line daily. The DON verified the staff had not flushed the PICC line since admission and the facility protocol is to flush the PICC line daily. Review of the policy titled Peripheral Inserted Central Catheter Flushing and Locking, revised 08/20/21, revealed the PICC line is to be flushed daily or after each use.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to store oxygen tubing in a sanitary manner and failed to have a system in place to ensure oxygen tubing was changed regularly. This affected two (#2 and #42) of two residents reviewed for oxygen administration. The facility identified eight residents who received oxygen therapy. The facility census was 49. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 04/21/18. Diagnoses included respiratory failure, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired. Review of the plan of care, initiated 03/27/19 revealed Resident #2 had oxygen therapy related to ineffective gas exchange. Interventions included oxygen via nasal prongs at 1-2 liters (L) as needed. Review of a physician order dated 04/21/20 revealed Resident #2 was ordered oxygen 2 L per nasal cannula for shortness of breath and/or pulse oxygen below 90 %. Observation on 12/27/21 at 10:59 A.M., of Resident #2's room revealed an oxygen concentrator next to the Resident's bed. Oxygen tubing was connected to the concentrator, with the tubing hanging on the concentrator. Continued observation revealed the oxygen tubing was undated and the cannula was uncovered and hanging within inches of the garbage can. Interview on 12/27/21 at 11:21 A.M., with Elder Assistant (EA) #402 verified Resident #2's oxygen tubing was undated and the cannula was uncovered and hanging next to the garbage can. 2. Review of the medical record for Resident #42 revealed an admission date of 05/22/20. Diagnoses included respiratory failure, type II diabetes, hypertension, congestive heart failure, dementia with behavioral disturbance, and obstructive sleep apnea. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 was moderately cognitively impaired. Review of the plan of care, revised 12/27/21, revealed Resident #42 had an alteration in respiratory status related to congestive heart failure. Interventions included oxygen as ordered. Additional review revealed Resident #42 had oxygen therapy related to congestive heart failure. Interventions included oxygen via nasal prongs at 2-4 liters (L) as needed. Review of a physician order dated 05/22/21 revealed Resident #42 was ordered oxygen 2-4 (L) to keep pulse oxygen above 90%. Observation on 12/27/21 at 11:46 A.M., of Resident #42 revealed the Resident in bed sleeping. Additional observation revealed a running oxygen concentrator set at 4 L. Resident #42 was not wearing the oxygen at the time of the observation. The oxygen tubing was draped over Resident #42's feeding pump. The tubing was undated, and the nasal cannula was uncovered, touching the feeding pump. Interview on 12/27/21 at 11:49 A.M, with Licensed Practical Nurse (LPN) #431 revealed Resident #42 did not always wear her oxygen. LPN #431 verified the oxygen tubing was draped over the feeding pump, was undated, and the nasal cannula was not covered and stored in a sanitary manner. LPN #431 stated she believed oxygen tubing was changed weekly, but she was uncertain on what day and would have to check the physician orders. Interview on 12/28/21 at 12:40 P.M., with the Director of Nursing (DON) revealed oxygen tubing should be changed weekly and the staff changing the oxygen tubing should date and initial the tubing when it was completed. The DON stated the facility did not have a good system in place to ensure oxygen tubing was being changed regularly and there should be physician orders to change oxygen tubing, prompting nursing staff to do it. The DON verified neither Resident #2 or Resident #42 had physician orders to change oxygen tubing and it was unknown when the tubing was last changed. Additionally, the DON stated nasal cannula's should be stored in a bag when not in use to ensure sanitary storage of equipment.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, resident interview, staff interview and policy review, the facility failed to provide pain management to a resident. This affected one (#145) of two residents reviewed for pain management. The facility identified 30 residents that receive pain management. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set (MDS) assessment was not completed at this time. Review of the care plan dated 12/26/21 revealed the resident had pain related to osteoarthritis. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain within a reasonable amount of time after approach through the review date. Administer analgesia as per orders. Give one half hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor pain characteristics. Review of the discharge physician orders from the hospital dated 12/26/21 revealed an order for oxycodone-acetominophen 5-325 milligram (mg) one tablet by mouth every six hours as needed for pain until 01/02/22, and pregabalin 100 mg one tablet every eight hours for muscle pain. Review of the Medication Administration Record (MAR) revealed the first dose of oxycodone-acetaminophen was administered at 12:01 A.M. on 12/27/21. Pregabalin was not administered until 12/28/21 at 10:00 P.M. Observation on 12/27/21 at 10:35 A.M., revealed Resident #145 was observed lying bed and started flinching in pain and stated oh oh, holding his left leg stump. Interview on 12/27/21 at 10:35 A.M., at the time of the observation, with Resident #145 stated he left the hospital at 4:00 P.M. on Sunday. He arrived to the facility and was put in bed by the ambulance staff and didn't see a staff member until two hours later. Resident #145 stated he pushed his call light at 6:00 P.M., requesting pain medication and they told him there was no medicine there for him yet. At 7:00 P.M., he called again asking for pain medication and a girl brought him water in. At 10:00 P.M., he pushed his call light and finally an aide came in and said the nurse had to go somewhere and was at one of the other houses. Resident #145 asked when he would get his pills and she said the nurse would be over at 11:00 P.M. When the nurse came in, Resident #145 told him he hadn't gotten his pills yet, was having terrible pain and he didn't get his pregabalin for his phantom pain. Resident #145 stated the nurse gave him a couple Advil. The nurse left and at midnight and came back with a Percocet. Resident #145 stated the following morning he asked the nurse when he was going to get his pregabalin and she stated that she would have to check. Resident #145 stated he told the nurse he was having a lot of phantom pain in his left stump. Interview on 12/28/21 at 2:10 P.M., with the Director of Nursing (DON) verified Resident #145 didn't receive his pregabalin every eight hours as ordered because the pharmacy did not send the Pregabalin, due to needing a written prescription from the physician. The DON verified the resident didn't receive pregabalin since admission and he was having phantom pain of his left leg. The DON stated she was going to have to investigate and see what happened or where the communication dropped with the pharmacy as to why the pregabalin was not here to administer. Interview on 12/28/21 at 2:34 P.M., with Licensed Practical Nurse (LPN) #431 verified she had not administered pregabalin and it had not been available since Sunday when Resident #145 was admitted . LPN #431 stated she had told the DON yesterday it wasn't at the facility. LPN #431 stated she told the MDS Nurse today that they still needed a prescription sent to the pharmacy and the MDS Nurse called the Nurse Practitioner and she sent a prescription to the pharmacy. They were going to drop ship the pregabalin, so it should arrive later today. LPN #431 verified that Resident #145 has been complaining of phantom pain since he has been admitted . Review of the policy titled Medication Administration, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician. Medications are administered without unnecessary interruptions.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to reassess a resident for continued use of enabler bars according to the facility policy. This affected one (#2) of one resident reviewed for potential restraint. The facility census was 49. Findings include: Review of the medical record for Resident #2 revealed an admission date of 04/21/18. Diagnoses included respiratory failure, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and required extensive two-person assistance with bed mobility and transfers. Review of the plan of care, revised 06/17/19, revealed Resident #2 had an Activities of Daily Living (ADL) mobility performance deficit related to diabetes, contractures to the bilateral lower extremities, and COPD. Interventions included bilateral side enabler bars to the head of the bed to assist with bed mobility and increased independence. Review of a physician order dated 02/25/19 revealed Resident #2 had an order for bilateral side enabler bars to the head of the bed to assist with bed mobility and increased independence. Additional review of the medical record revealed Resident #2 was last reassessed for enabler bar use on 05/14/20. The Electronic Medical Record (EMR) was silent for any assessments after 05/14/20. Interview on 12/28/21 at 12:32 P.M. of the Director of Nursing (DON) revealed enabler bars were not considered restraints or restrictive devices, but the facility followed their policy for restraints and resistive devices for enabler bar use. The DON confirmed enabler bar screenings should be completed prior to implementation and quarterly thereafter and all assessments were completed and stored in the EMR. The DON verified Resident #2 had not been reassessed for the use of enabler bars since 05/14/20. Review of facility policy titled Physical Restraints/Restrictive Devices, revised 07/20/11, revealed an assessment would be completed prior to the application of the device and quarterly thereafter.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation, staff interview, resident interview and policy review, the facility failed to provide an antibiotic and pain medication to a resident. This affected one (#145) of five residents reviewed for medication administration. The facility identified 30 residents that receive pain medications and two residents receive antibiotics. The facility census was 49. Findings include: Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The Minimum Data Set assessment was not completed at this time. Review of the discharge physician orders from the hospital dated 12/26/21 revealed an order for oxycodone-acetaminophen 5-325 milligram (mg) one tablet by mouth every six hours as needed for pain until 01/02/22, pregabalin 100 mg one tablet every eight hours for muscle pain and ceftriaxone sodium solution reconstituted two gram intravenous (IV) one time a day for infection until 01/04/22. The hospital had administered ceftriaxone on 12/26/21 and the facility was to start the antibiotic on 12/27/21. Review of the Medication Administration Record (MAR) revealed Resident #145 did not receive ceftriaxone on 12/27/21 as ordered. The first dose of oxycodone-acetaminophen was administered at 12:01 A.M. on 12/27/21. Pregabalin was not administered until 12/28/21 at 10:00 P.M. Observation on 12/27/21 at 10:35 A.M., revealed Resident #145 was observed lying bed and started flinching in pain and stated oh oh, holding his left leg stump. Interview on 12/27/21 at 10:35 A.M., at the time of the observation, with Resident #145 stated he left the hospital at 4:00 P.M. on Sunday. He arrived to the facility and was put in bed by the ambulance staff and didn't see a staff member until two hours later. Resident #145 stated he pushed his call light at 6:00 P.M., requesting pain medication and they told him there was no medicine there for him yet. At 7:00 P.M., he called again asking for pain medication and a girl brought him water in. At 10:00 P.M., he pushed his call light and finally an aide came in and said the nurse had to go somewhere and was at one of the other houses. Resident #145 asked when he would get his pills and she said the nurse would be over at 11:00 P.M. When the nurse came in, Resident #145 told him he hadn't gotten his pills yet, was having terrible pain and he didn't get his pregabalin for his phantom pain. Resident #145 stated the nurse gave him a couple Advil. The nurse left and at midnight and came back with a Percocet. Resident #145 stated the following morning he asked the nurse when he was going to get his pregabalin and she stated that she would have to check. Resident #145 stated he told the nurse he was having a lot of phantom pain in his left stump. Interview on 12/28/21 at 2:10 P.M., with the Director of Nursing (DON) verified Resident #145 verified Resident #145 didn't receive the ceftriaxone antibiotic yesterday due to it not being at the facility because the pharmacy didn't send it. Also, Resident #145 did not receive his pregabalin every eight hours as ordered because the pharmacy did not send the Pregabalin, due to needing a written prescription from the physician. The DON verified the resident didn't receive pregabalin since admission and he was having phantom pain of his left leg. The DON stated she was going to have to investigate and see what happened or where the communication dropped with the pharmacy as to why the antibiotic and pregabalin was not here to administer. Interview on 12/28/21 at 2:34 P.M., with Licensed Practical Nurse (LPN) #431 verified she had not administered pregabalin and it had not been available since Sunday when Resident #145 was admitted . LPN #431 stated she had told the DON yesterday it wasn't at the facility. LPN #431 stated she told the MDS Nurse today that they still needed a prescription sent to the pharmacy and the MDS Nurse called the Nurse Practitioner and she sent a prescription to the pharmacy. They were going to drop ship the pregabalin, so it should arrive later today. LPN #431 verified that Resident #145 has been complaining of phantom pain since he has been admitted . Review of the policy titled Medication Administration, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician. Medications are administered without unnecessary interruptions.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure a PRN (as needed) order for a psychotropic medication did not exceed 14 days and the facility failed to perform a quarterly Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving psychotropic medication. This affected two (#24 and #36) of five residents reviewed for unnecessary medications. The facility identified 33 residents that receive psychotropic medications. The facility census was 49. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 11/10/21. Diagnoses included weakness, essential hypertension, nonrheumatic mitral valve insufficiency, sick sinus syndrome, atrial flutter, presence of cardiac pacemaker, pulmonary hypertension, type 2 diabetes mellitus with diabetic neuropathy and unspecified dementia without behavioral disturbance. Review of the quarterly Minimum Data Set Assessment revealed Resident #24 had moderate cognitive impairment with a Brief Interview Mental Status score of 10 out of 15. No behaviors were exhibited during the assessment period. Resident received hospice services. Review of the care plan dated 08/24/21 revealed the resident received hospice services. The resident will be free of depression and anxiety through the review date. Interventions included consult with physician and social services to have hospice. Encourage resident to express feelings, listen with non-judgmental acceptance and compassion. Review of the physician orders revealed an order dated 08/24/21 for Ativan 0.5 milligram (mg) one tablet every four hours as needed for anxiety. Interview on 12/29/21 at 8:50 A.M., with Licensed Practical Nurse (LPN) #436 verified that Resident #24 had a PRN Ativan order since 08/24/21, with no stop date, and no documentation or evaluation of Resident #24's need for the continued use of a PRN Ativan. 2. Review of the medical record for Resident #36 revealed an admission date of 12/17/18. Diagnoses included paranoid personality disorder, essential hypertension, gout, unspecified psychosis not due to a substance or known physiological condition, muscle weakness, gastro-esophageal reflux disease without esophagitis, anxiety disorder, major depressive disorder, recurrent, dysphagia, oral phase, and venous insufficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 was rarely/never understood. Resident had verbal behavioral symptoms directed towards others occur four to six days during the assessment period. Resident #36 received antipsychotic, antianxiety, antidepressant and diuretic seven days during the assessment period. Review of the care plan dated 12/17/18 revealed Resident #36 had potential for drug related complications related to antipsychotic medication seroquel for diagnosis of hallucinations. Resident will remain free of complications of antipsychotic therapy daily. Interventions included administer medications as ordered by physician . Monitor for side effects and effectiveness. AIMS test quarterly and as needed. Monitor document report as needed any adverse reactions of antipsychotic medications. Talk to resident in native tongue as able. Provide elder with outside visits, family phone calls and polka music when upset. Review of the physician orders for Resident #36 revealed an order dated 04/08/21, for trazodone 50 mg one tablet by mouth at bedtime for sleep aid, 05/04/21 quetiapine fumarate 25 mg one tablet one time a day and give 50 mg by mouth one time a day for hallucinations, 05/25/21 duloxetine delay release 60 mg one tablet by mouth every day for depression, 08/14/21 buspirone five mg one table by mouth three times a day for anxiety, and 10/29/21, observe for side effects of antipsychotic medications every shift. Review of the most current AIMS assessment dated [DATE] revealed minimal extremity movements of upper extremities. Include movements that are choreic, do not include tremor. Severity of abnormal movements, minimal. Patient awareness of abnormal movements-awareness but no distress. Do movements disappear in sleep-yes. Score one. Interview on 12/28/21 at 3:11 P.M., with the Director of Nursing (DON) verified Resident #36 has not had an AIMS assessment completed since 05/16/20 and the facility policy is to complete an AIMS assessment every quarter. Review of the policy titled Abnormal Involuntary Movement Scale Assessment Procedure, revised 07/20/11, revealed an AIMS assessment is to be completed on admission if on an antipsychotic, or when an antipsychotic is started, then quarterly. Review of the policy titled Gradual Dose Reduction, dated 11/29/17, did not address use of PRN antipsychotic medications.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation of medication supplies, manufacturer instruction reviews and staff interview, the facility failed to ensure open dates were marked on insulin products in use. This affected two (#23 and #17) of two resident's insulin medication observed . The facility identified 13 residents with orders for insulin administration. The census was 49. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 12/19/20. Diagnoses included Type 2 diabetes mellitus. Review of physician orders for Resident #23 revealed they included an order dated 08/18/21, for Lantus (Basaglar) SoloStar 100 units per milliliter insulin solution pen injector, inject 22 units twice daily. Observation on 12/29/21 at 7:30 A.M., revealed the medication storage cart in House #1 contained two Basaglar (Lantus) 100 units per milliliter insulin Kwikpens for Resident #23, with one approximately three-quarters full and the other one approximately two-thirds full. Neither pen was marked with an open date. Interview during this observation with Registered Nurse #434 confirmed the two Basaglar insulin pens were not marked with open dates and were in use. 2. Review of the medical record for Resident #17 revealed an admission date of 09/09/20. Diagnoses included Type 2 diabetes mellitus and Stage 3 chronic kidney disease. Review of physician orders for Resident #17 revealed they included an order dated 10/05/20, for Tresiba FlexTouch insulin solution pen injector 200 units per milliliter, inject 60 units one time per day for Type 2 diabetes mellitus. The record for Resident #17 also included an order dated 10/15/21, for Novolog solution 100 units per milliliter, inject per sliding scale with meals (three times per day). Observation on 12/29/21 at 1:52 P.M., revealed the medication storage cart in House #2 contained two Tresiba insulin pens for Resident #17, one containing approximately 100 units and the other containing approximately 500 units. The manufacturer labels stated the product should be discarded within 56 days after opening. The cart also contained a half-full vial of Novolog insulin for Resident #17. None of the three insulin products were marked with open dates. Interview during this observation with the Director of Nursing (DON), confirmed these three insulin products were not marked with open dates. The DON confirmed nurses are to follow insulin manufacturers' instructions and denied the facility has a written policy that speaks to this. Review of manufacturer instructions for the Basaglar Kwikpen found at www.basaglar.com, confirmed the insulin is to be discarded no later than 28 days after initial use. Review of manufacturer instructions for the Tresiba FlexTouch, found at www.mynovoinsulin.com, confirmed the insulin product is to be discarded no later than 56 days after initial use. Review of manufacturer instructions for the Novolog Flexpen, found at www.novocare.com, confirmed the insulin product is to be discarded no later than 28 days after initial use.

CONCERN (E)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to provide urinary catheter care. This affected four (#3, #45, #48 and #145) of four residents reviewed for urinary catheters. The facility identified four residents with indwelling urinary catheters. The facility census was 49. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/20/15. Diagnoses included unspecified dementia without behavioral disturbance, retention of urine, essential hypertension, major depressive disorder, recurrent, anxiety disorder, neuromuscular dysfunction of bladder and heart failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had moderate cognitive impairment with a Brief Interview Mental Status (BIMS) score of 13 out of 15. Resident #3 had an indwelling catheter and was always continent of bowel. Review of the care plan dated 09/18/17 revealed Resident #3 had a Foley urinary catheter related to neurogenic bladder. The goal was to remain free from catheter related trauma through the review date. There were no catheter care interventions in the care plan. Review of the physician orders revealed there was an order dated 06/18/19 for a 16 French Foley Urinary Catheter in place. Foley care daily and prn (as needed). Further review of the medical record for Resident #3 revealed there was no documented evidence staff provided the urinary catheter care as ordered. 2. Review of the medical record for Resident #145 revealed an admission date of 12/26/21. Diagnoses included obstructive and reflux uropathy, osteoarthritis, malignant neoplasm of prostate, anemia in chronic kidney disease, and hydrocele. The MDS had not yet been completed. Review of the care plan dated 12/26/21 revealed Resident #145 had an urinary tract infection (UTI), goal was to resolve UTI. Administer antibacterial as prescribed, observe for changes in mental status or level of consciences, observe for pain signs, facial grimaces, moaning, holding sides of back and report to nursing immediately. Obtain laboratory work as ordered by physician. Resident had indwelling Foley catheter related to obstructive uropathy. The resident will show no signs and symptoms of UTI through review date. Resident had 16 French indwelling urinary catheter. There were no interventions for catheter care. Review of the physician orders revealed an order dated 12/27/21 provide urinary catheter care every shift. Further review of the medical record for Resident #3 revealed there was no documented evidence staff provided the urinary catheter care every shift. 3. Review of the medical record for Resident #48 revealed the resident was admitted [DATE] and had diagnoses including acute cystitis with hematuria and acute kidney failure. The record indicated Resident #48 had a recent urethral stent placement that necessitated the indwelling urinary catheter. Review of physician orders for Resident #48 revealed an order for an indwelling urinary catheter, to be changed every month and as needed. The record included an additional order to provide urinary catheter care every shift. Review of the care plan for Resident #48 revealed it identified a risk for infection due to the indwelling urinary catheter. Interventions included urinary catheter care as ordered. Further review of the medical record for Resident #48 revealed there was no documented evidence staff provided the urinary catheter care every shift. 4. Review of the medical record for Resident #45 revealed the resident was admitted [DATE] and had diagnoses including acute kidney failure and obstructive reflux uropathy. Review of physician orders for Resident #45 revealed an order for an indwelling urinary catheter for obstructive uropathy, to be changed every month and as needed. The record included an additional order to provide urinary catheter care every shift. Review of the care plan for Resident #45 revealed it identified a risk for infection due to the indwelling catheter for obstructive uropathy. Interventions included catheter care as ordered. Further review of the medical record for Resident #45 revealed there was no documented evidence staff provided the urinary catheter care every shift. Interview on 12/29/21 at 2:47 P.M., with the Director of Nursing verified there was no documentation of catheter care being completed for Resident #3, Resident #145, Resident #45 and Resident #48. Review of the policy titled Indwelling Urinary Catheter Care, reviewed 11/19/21, revealed urinary catheter care is to be performed at least once daily and as needed.

CONCERN (F)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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Based on review of staffing schedules and staff interview, the facility failed to provide a Registered Nurse (RN) at least eight hours daily in the facility. This had the potential to affect all 49 of 49 residents in the facility. The facility census was 49. Findings include: Review of the staffing schedules revealed the facility did not have a RN work eight hours on 12/04/21, 12/05/21, 12/19/21 and 12/26/21. Interview on 12/29/21 at 12:15 P.M., with the DON verified the facility did not have a RN on duty eight hours on 12/04/21, 12/05/21, 12/19/21 and 12/26/21. The DON denied having a policy for staffing.

Jun 2019 7 deficiencies

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and staff interview, the facility failed to ensure residents were provided with appropriate written notification when payment services were being changed. This affected two (Resident #13 and #35) of three residents reviewed for beneficiary notices. The facility identified 15 residents who were discharged from Medicare skilled services in the last 90 days. The facility census was 46. Findings include: 1. Review of the medical record for Resident #35 revealed the resident was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation (irregular heart rhythm), depression, coronary artery disease, kidney stones, anorexia, diabetes mellitus type II, acute pain, anxiety, muscle wasting and congested heart failure. Review of a five-day Minimum Data Set 3.0 (MDS) assessment, dated 06/07/19, revealed the resident had no cognitive deficits and required extensive assistance for all activities of daily living except supervision with eating. Review of physician orders revealed the resident was discharged from Occupational Therapy on 06/11/19 Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed Resident #35 began receiving skilled services on 05/31/19. A Notice of Medicare Non-coverage form was provided to the Resident on 06/07/19 to inform of services that would end on 06/11/19. There was no documentation of a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) with an option to continue services during an appeal was provided. Interview with Licensed Practical Nurse (LPN) #175 on 06/19/19 at 3:45 P.M. verified there was no SNF-ABN completed for Resident #35. She revealed she had recently taken over the position and was not aware of the need to complete a SNFABN for resident who had been cut from therapy. She stated there had not been any forms except the Notice of Medicare Non-coverage forms provided to the resident or family member since she had started. 2. Review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, seizures, aphasia, anxiety, hypertension, gastroesophageal reflux disease, depression, coronary artery disease and dysphagia. Review of a quarterly Minimum Data Set 3.0 assessment, dated 04/09/19, revealed the resident had no cognitive deficits and required extensive assistance with her activities of daily living. Speech, Physical and Occupational therapies had been provided. Review of an SNF Beneficiary Protection Notification Review revealed the Resident #13 began receiving skilled services on 02/28/19. A Notice of Medicare Non-coverage form was provided to the Resident on 04/08/19 to inform of services that would end on 04/09/19. It revealed no SNFABN with an option to continue services during an appeal was provided. Review of a Notice of Medicare Non-coverage form for Resident #13 revealed the resident's last covered day of skilled services was 04/09/19. The form was signed by the resident on 04/08/19. Interview with LPN #175 on 06/19/19 at 3:45 P.M. verified there was no SNFABN completed for Resident #13. Further interview with LPN #175 on 06/20/19 at 12:00 P.M. verified Resident #13 was not given the Notice of Medicare Non-Coverage notification at least two days prior to the last covered day.

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, the facility failed to provide the resident's responsible party with a written notice of transfer when the resident was transferred to the hospital on two occasions. Additionally the facility failed to notify the Ombudsman of the resident's transfers out of the facility. This affected two (Resident #40 and #46) of three residents reviewed for hospitalization. The facility identified 13 residents who were transferred to the hospital in the last 60 days. The facility census was 46. Findings include: 1. Review of the medical record for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses include urinary tract infection, congested heart failure, schizophrenia, Parkinson's disease, atrial fibrillation, irritable bowel syndrome, repeated falls, muscle weakness and dementia with Lewy bodies. Review of a significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/24/19, revealed the resident was rarely understood, had short and long term memory loss and delusions. Review of the progress notes, dated 04/17/19 and 05/12/19, revealed the resident was sent to the hospital for changes in condition. No documentation was present of a notice of transfer being provided to the resident, responsible party or Ombudsman. Interview with Quality of Life Coordinator #200 on 06/19/19 at 10:00 A.M. verified the facility did not send a notice of transfer to the family when the resident was transferred to the hospital on [DATE] or 05/12/19. She further verified the Ombudsman was not notified of either transfer. Interview with the Administrator on 06/20/19 at 1:15 P.M. verified there was no notice of transfer sent to the Ombudsman for the discharge to the hospital on [DATE] or 05/12/19. She stated she used the notice of transfer forms that had been completed to know who to inform the Ombudsman. She stated there was no notice of transfer form given to her so there was no notification to the Ombudsman. Review of an undated facility policy titled Discharge/Transfer revealed the facility must notify the resident and resident representative of the transfer or discharge an the reasons for the moving in writing and in a language and manner they understand. A copy of the notice of transfer must be sent to the Ombudsman. The medical record must contain evidence that the notice was sent to the Ombudsman. If the transfer was on an emergent basis, a notice of transfer must be provided to the resident, representative and Ombudsman and can be done in a monthly list. 2. Review of the closed medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included respiratory failure, muscle weakness, diabetes mellitus type II, chronic pain, glaucoma and end stage renal disease. Review of a 30-day MDS 3.0 assessment revealed the resident had no cognitive deficits. Review of the progress notes, dated 04/27/1,9 revealed the resident developed a change in mental status and was transferred to the emergency room. Further review of the medical record revealed there was no notification to the Ombudsman of the transfer to the hospital. Interview with Quality of Life Coordinator #200 on 06/20/19 at 12:35 P.M. revealed the resident was sent out on emergency basis. She verified she did not notify the Ombudsman of the transfer.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview and resident interview, the facility failed to provide adequate monitoring of the fistula access site for a resident receiving dialysis. This affected one (Resident #5) of one resident reviewed for dialysis services. The facility identified one resident receiving dialysis services. The facility census was 46. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/11/18 with diagnoses including hypertensive chronic kidney disease - stage five and unspecified kidney failure. Review of the resident's care plan dated 08/01/18 revealed the bruit and thrill were to be monitored as directed. Review of Resident #5's physician orders, dated 09/18/18, revealed the resident was ordered dialysis on Mondays, Wednesdays and Fridays at an outside hemodialysis center. Continued review of the physician orders revealed they were silent pertaining to monitoring the hemodialysis access site for bruit and thrill. Subsequently, after surveyor intervention, an order, dated 06/19/19, was obtained to monitor the left upper extremity dialysis port every shift and as needed for redness, swelling, pain and to auscultate for bruit and palpate for thrill three times a day. Review of the medication administration records (MARs) from August 2018 through May 2019 for Resident #5 revealed they were to be silent for documentation that nursing staff were monitoring the bruit and thrill, nor was there any monitoring of the site for redness, swelling or pain. Nursing notes were also silent to any documentation regarding the fistula site. Interview and observation on 06/17/19 at 4:05 P.M. with Resident #5 confirmed he had a dialysis port in the left upper arm. Resident #5 reported that nursing staff sometimes look at the port. Interview with Licensed Practical Nurse (LPN) #176 on 06/19/19 at 8:15 A.M. revealed nursing staff check for bruit and thrill every shift and document completion on the medication administration record (MAR). Interview on 06/19/19 at 3:40 P.M. with the Director of Nursing (DON) revealed monitoring of the bruit and thrill were completed on pre-dialysis and post-dialysis on dialysis days, Monday, Wednesday and Fridays. The DON confirmed the record to be silent for documentation of monitoring the access site on days Resident #5 was not receiving dialysis (Sundays, Tuesdays, Thursdays and Saturdays). The DON also confirmed a physician order was obtained 06/19/19 to monitor the dialysis port every shift and as needed.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #23 revealed an original admission date of 11/13/17. Diagnoses included neuromuscular bladder dysfunction. Review of the MDS assessment, dated 04/17/19, revealed Resident #23 to have short- and long-term memory problems. Review of the physician's order, dated 05/14/19, revealed the resident was to receive Rocephin (antibiotic) intramuscular injection of one gram every day with an ending date of 05/24/19. Another physician's order, dated 06/13/19, revealed the resident was to Rocephin intramuscular injection of one gram every day for ten days. Review of the Medication Administration Records (MARs) for May 2019 and June 2019 revealed the medication was administered as ordered. Review of the McGeer's criteria forms, dated 05/14/19 and 06/19/19, revealed Resident #23 did not meet both criterion for a urinary tract infection and no urine cultures were completed. Review of the facility's antibiotic logs for May 2019 and June 2019 revealed they were silent for any identified organism related to the Rocephin treatments for Resident #23. Interview on 06/19/19 at 1:30 P.M. with the Director of Nursing (DON) confirmed the facility recently initiated the utilization of McGeers criterion effective in April 2019. The DON stated that prior to this, the McGeers criterion was not consistently completed. The DON further confirmed Resident #23 did not meet the McGeers criterion for the physician ordered Rocephin medication in May 2019 and June 2019 and confirmed the record to be silent for urine cultures. Additionally, the DON confirmed training had been provided to the facility physician and nurse practitioner, dated 01/10/19, regarding antibiotic stewardship. Review of the facility policy titled, Stewardship Plan, with an effective date of 11/29/17, revealed the DON, Infection Prevention Coordinator, medical director and consulting pharmacist are responsible for promoting and overseeing antibiotic stewardship activities. McGeers criterion is used to qualify and confirm infections. Each case will be reviewed for details and logged for tracking surveillance purposes. The log will include the date of onset of symptoms, location within the facility, infection type, organism, where acquired, treatment, antibiotic duration, and effectiveness. 2. Record review of Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included c-diff. Review of the quarterly MDS assessment, dated 04/04/19, revealed the resident has impaired cognition. Review of the physician orders, dated 01/09/19, revealed the resident was ordered to receive Augmentin (antibiotic) 875-125 milligram (mg.) orally twice a day for seven days for a 'tooth pain'. On 04/18/19, Resident #10 was ordered to receive Amoxicillin (antibiotic) 500 mg. orally two times a day for seven days for 'tooth ache'. On 05/08/19, Resident #10 was ordered to receive Augmentin 875-125 mg. orally twice a day for seven days for 'tooth decay'. Review of the McGeer's Criteria-Infection Data Collection assessment, dated 01/09/19, revealed Resident #10 was suspected to have an infection marked as 'other' on the assessment form. In the description section of the form, it was noted the resident has complained of tooth pain and the physician ordered Augmentin orally twice a day for seven days for prophylactic. Per the assessment, the infection was acquired in the facility. Review of McGeer's Criteria-Infection Data Collection tool, dated 04/18/19, revealed Resident #10 was suspected to have an infection marked as 'other' on the assessment form, 'tooth' was charted in the description. At the bottom of the form in the description section of the form it was noted the resident has complained of tooth pain and antibiotic therapy has been initiated. Per the assessment, the infection was acquired in the facility. Review of McGeer's Criteria-Infection Data Collection tool, dated 05/09/19, revealed Resident #10 was suspected to have an infection marked as 'other' on the assessment form. In the description section of the form, it was noted the resident has been seen by the Nurse Practioner, (NP), and complained of tooth pain and the area was swollen. Antibiotic therapy has been initiated until resident could be seen by the dentist. Per the assessment, the infection was acquired in the facility. Review of the Medication Administration Record, (MAR), dated 01/2019, 04/2019, and 05/2019, revealed Resident #10 received all the scheduled antibiotics per physician order. Further review of Resident #10's medical record revealed the resident had no evidence of an elevated temperature, increased pain documented, or any laboratory results indicating any active infections for the months of 01/2019, 04/2019, and 05/2019. Review of the facility's infection control log revealed Resident #10 was listed on the log as receiving antibiotics in the months of 01/2019, 04/2019, and 05/2019. For the months of 01/2019 and 04/2019, it was noted the resident had not met the criteria for antibiotics use. Interview on 06/20/19 at 10:38 A.M. with the Director of Nursing (DON) verified Resident #10 has been on antibiotics for the tooth pain in 01/2019, 04/2019, and 05/2019. Per the DON, the resident's physician was educated on the antibiotic stewardship program in 01/2019 but the resident was still ordered to receive the antibiotics. The DON verified Resident #10's NP did prescribe antibiotics in 04/2019 and 05/2019 despite the only symptom for the antibiotic was tooth pain. Based on medical record review, staff interview and review of facility policy, the facility failed to ensure prescribed antibiotics were in accordance with the antibiotic stewardship program. This affected three residents (#10, #14 and #23) of three residents reviewed for infections. The facility census was 46. Findings include: 1. Review of the medical record for Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses include neuromuscular dysfunction of bladder and kidney stone. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment, dated 04/11/19, revealed the resident was rarely understood, had modified independence with decision making, and no rejection of care. Review of a laboratory test for a stool sample ,dated 05/25/19, revealed the stool was positive for Clostridium-difficile (C-diff). There was no remarks for the organism being colonized. Review of the physician orders, dated 05/26/19, revealed the resident was ordered Vancomycin suspension (antibiotic) 50 milligrams per milliliter, give 2.5 milliliter per gastric tube four times a day for 10 days for c-diff. The order was discontinued on 06/03/19. Review of the Medication Administration Records, dated 05/2019 and 06/2019, revealed the Vancomycin was given as ordered. Review of a McGeer's Criteria-Infection Data Collection form, dated 05/28/19, revealed the resident was admitted with an antibiotic order. No symptoms were documented and no criteria were marked. The form did not indicate what the organism was present or what antibiotic was used. Interview with the Director of Nursing on 06/20/19 at 11:15 A.M. verified the McGeer's form did not include the reason for the antibiotic and did not indicate if the antibiotic was appropriate.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, staff interview, and review of a facility policy, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect 45 residents the facility identified as eating from the facility kitchens. Resident #14 did not eat from the facility kitchens. The facility census was 46. Findings include: 1. During the initial tour of House #3527's kitchen on 06/17/19 at 9:38 A.M., an observation of the kitchenette freezer revealed a small plastic re-sealable bag of unlabeled and undated waffles. Interview with State Tested Nurse Aide (STNA) #154 on 06/17/19 at 9:38 A.M. confirmed the above item had been opened and did not contain a label and/or date on the plastic re-sealable bag. 2. During initial tour of House #3525's kitchen on 06/17/19 at 10:40 A.M., an observation of the kitchenette freezer revealed a bag half full of opened undated french fries and a box of waffles that were unsealed. Interview with STNA #151 on 06/17/19 at 10:40 A.M. confirmed the above items had been opened and did not contain a date or were unsealed. 3. During initial tour of House #3529's kitchen on 06/17/19 at 11:20 A.M., an observation of the kitchenette freezer revealed a bag one half full of peas and carrots that were not dated. Observation of the freezer in the dry storage room revealed one box of hash brown patties that had been opened, unsealed and without a date. Interview with STNA #152 on 06/17/19 at 11:20 A.M. confirmed the above items had been opened and were not dated. 4. During initial tour of House #3531's kitchen on 06/17/19 at 11:25 A.M., an observation of the dry storage room refrigerator revealed a gallon of white milk one half full which had an expiration date of 06/16/19. Observation of the kitchenette freezer revealed an opened unsealed and undated bag of hash browns and a bag one quarter full of California vegetables that had been opened and undated. Interview with STNA #153 on 06/17/19 at 11:25 A.M. confirmed the above items had been opened, unsealed and/or did not contain dates on the bags. 5. During initial tour of House #3533's kitchen on 06/17/19 at 11:35 A.M., an observation of the kitchenette freezer revealed two bags half full of frozen vegetables that had been opened and were undated. Observation of the freezer in the dry storage area revealed a bag of chicken breasts half full that had been opened and were undated. Interview with Dietitian #300 on 06/17/19 at 11:35 A.M. confirmed the above items were not dated and/or labeled. Review of a facility provided policy titled, Food Storage Policy & Procedure, with a revision date of 05/2013, revealed its purpose is to assure that all food is to be stored, labeled and dated properly to assure stock rotation and prevent food illnesses.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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Based on record review and staff interview, the facility failed to establish and follow an infection control program to prevent the spread of Legionella disease. This has the potential to affect all 46 residents residing in the facility. Findings include: Record review of the facility's Legionella Prevention Program revealed no testing of the water supply, no tracking of testing, or any mapping of the facility's water supply was conducted by the facility's staff. Interview on 06/20/19 at 1:55 P.M. with the Administrator verified the facility's maintenance director had not conducted any testing on the facility's water system for Legionella. Interview on 06/20/19 at 2:30 P.M. with the Maintenance Director #200 verified he had not conducted any testing on the facility's water supply for Legionella or any other water-born pathogens. He also verified the facility had not conducted a risk plan for the detection of water-born pathogens.

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

• 36 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.

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About This Facility

What is Avalon By Otterbein At Perrysburg's CMS Rating?

CMS assigns AVALON BY OTTERBEIN AT PERRYSBURG 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 Avalon By Otterbein At Perrysburg Staffed?

CMS rates AVALON BY OTTERBEIN AT PERRYSBURG's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 50%, compared to the Ohio average of 46%. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Avalon By Otterbein At Perrysburg?

State health inspectors documented 36 deficiencies at AVALON BY OTTERBEIN AT PERRYSBURG during 2019 to 2024. These included: 36 with potential for harm.

Who Owns and Operates Avalon By Otterbein At Perrysburg?

AVALON BY OTTERBEIN AT PERRYSBURG is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by OTTERBEIN SENIORLIFE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 57 residents (about 95% occupancy), it is a smaller facility located in PERRYSBURG, Ohio.

How Does Avalon By Otterbein At Perrysburg Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, AVALON BY OTTERBEIN AT PERRYSBURG's overall rating (4 stars) is above the state average of 3.2, staff turnover (50%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Avalon By Otterbein At Perrysburg?

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 Avalon By Otterbein At Perrysburg Safe?

Based on CMS inspection data, AVALON BY OTTERBEIN AT PERRYSBURG 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 Avalon By Otterbein At Perrysburg Stick Around?

AVALON BY OTTERBEIN AT PERRYSBURG has a staff turnover rate of 50%, 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 Avalon By Otterbein At Perrysburg Ever Fined?

AVALON BY OTTERBEIN AT PERRYSBURG 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 Avalon By Otterbein At Perrysburg on Any Federal Watch List?

AVALON BY OTTERBEIN AT PERRYSBURG is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 60
Avg. Residents: 57
Occupancy: 95.8%
Ownership: Non profit - Church related
Chain: OTTERBEIN SENIORLIFE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
36 Deficiencies: -10
Final Score: 70/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 366354