DIVINE REHABILITATION AND NURSING AT SHANE HILL
For profit - Corporation
69 Beds
DIVINE HEALTHCARE MANAGEMENT
Data: November 2025
Trust Grade
55/100
#452 of 913 in OH
Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Divine Rehabilitation and Nursing at Shane Hill has a Trust Grade of C, which means it is average and positioned in the middle of the pack among nursing homes. It ranks #452 out of 913 facilities in Ohio, placing it in the top half of the state, and #3 out of 6 in Mercer County, indicating that there are only two local options that are better. The facility shows an improving trend, having reduced issues from 9 in 2024 to 3 in 2025. However, staffing is a concern with a rating of 2 out of 5 stars and a high turnover rate of 61%, significantly above the state average of 49%. While the facility has not incurred any fines, which is a positive sign, specific incidents raised concerns about resident safety and staff training. For example, staff failed to follow contact precautions during wound care for a resident with MRSA, which could affect other residents. Additionally, state tested nurse aides did not receive the required continuing education, potentially impacting the quality of care for all residents. Overall, while there are some strengths, such as the absence of fines and an improving trend, families should consider the staffing challenges and specific care issues when researching this facility.
- Trust Score
- C
- In Ohio
- #452/913
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Top 49%
No red flags
9 → 3 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 3 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Ohio average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 61%
15pts above Ohio avg (46%)
Frequent staff changes - ask about care continuity
Chain: DIVINE HEALTHCARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Ohio average of 48%
The Ugly 23 deficiencies on record
Jun 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Base...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on record review, review of facility Self-Reported Incident (SRI), staff interview and policy review, the facility failed to ensure residents were free from abuse and neglect. This affected one (#10) of three residents reviewed for abuse. The facility census was 64.
Findings include:
Review of medical record for Resident #10 revealed an admission date of 08/22/22 diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety major depressive disorder, single episode, unspecified, other cerebrovascular disease.
Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental status (BIMS) score of 13 indicating intact cognition. She was independent for eating, was dependent for toileting and required maximum assistance for bed mobility and transfers.
Review of Resident #10's progress note dated 05/04/25 at 7:15 P.M. revealed the resident was heard yelling from her room and found lying beside her bed. There was no further documentation regarding the incident.
Interview on 06/04/25 at 3:10 P.M. with the Administrator and Director of Nursing (DON) revealed it was brought to their attention on 05/08/25 that Certified Nursing Assistant (CNA) #50 had witnessed the abuse of Resident #10 by CNA #51 and Licensed Practical Nurse (LPN) #52 on 05/04/25. CNA #50 had informed management during her training by CNA #51 they entered Resident #10's room and CNA #51 informed Resident #10 she was going to put her in an incontinence product, and she should urinate in it and they would be back to check and change her. The DON explained Resident #10 was able to call staff when needed and ambulate to the bathroom and did not require an incontinence product routinely. The DON explained when she questioned CNA #50, she was informed due to previous experiences at reporting incidents at her previous employer, CNA #50 did not believe her concerns would be addressed and she feared the retribution she experienced there. During the interview, the Administrator shared CNA #50 also informed them after Resident #10 had fallen on 05/04/25, LPN #52 had instructed CNA #50 and #51 to assist her off the floor and onto the bed. CNA #50 stated Resident #10 began to yell when she was moved, and LPN #52 placed her hand on the mouth of Resident #10 and asked her to be quiet. Both staff members were removed from the schedule pending the investigation. The Administrator revealed she reviewed camera footage from 7:00 P.M. to 12:00 A.M. on 05/04/25 which showed LPN #52 went into Resident #10's room for 13 seconds around the time of her fall and then exited the room. The Administrator stated LPN #52 did not return to the room until the 8:00 P.M. with medication pass, when she was in the room for about 36 seconds. The Administrator stated during her investigation she interviewed both CNA #51 and LPN #52 who verified the allegation involving Resident #10 were accurate and each were terminated.
Interview on 06/04/25 at 3:33 P.M. with CNA #50 revealed Resident #10 was able to use her call light, was able to inform staff when she needed to use the bathroom and was able to ambulate with assistance from staff. CNA #50 shared CNA #51 placed an incontinent product on Resident #10 because she did not want to toilet her frequently, and informed Resident #10 she would be in to check and change her later throughout the shift. CNA #50 stated a short time later into the shift, they found Resident #10 on the floor beside her bed. LPN #52 was notified and came into the room when she instructed CNA #50 and #51 to assist Resident #10 up and back into her bed. CNA #50 stated Resident #10 began to yell when they moved her, and LPN #52 put her hand over Resident #10's mouth to quiet her. CNA #50 shared she did not report her concern to management and explained at the facility previously worked at would not investigate concerns she had brought to management's attention, and she felt there was retribution for reporting issues. CNA #50 stated when she reported the concern to the scheduler why she no longer wanted to work at the facility; she was contacted by management and an investigation was initiated. CNA #50 stated she did receive education regarding the timeliness of reporting abuse and denied she had any further concern for the care and or treatment of residents at the facility.
Review of a facility SRI dated 05/09/25 titled Neglect/Mistreatment Abuse revealed it was reported that Resident #10 had a fall and the LPN #52 did not assess her before they got her off the floor. It was also reported that LPN #52 put her hand over Resident #10's mouth because she was yelling out. It was also reported that CNA #51 told Resident #10 she was putting a brief on her stating we are not doing this. The SRI did not indicate the day the allegation occurred. The allegation was investigated by the facility and substantiated.
Review of the typed statement of the DON revealed she interviewed LPN #52 who verified she did not do an assessment of Resident #10 prior to instructing CNA's #50 and #51 to assist her back to bed.
Review of the electronic mail statement from CNA #51 documented on 05/04/25 Resident #10 had fallen and the nurse instructed CNA #50 and #51 to assist Resident #10 back to bed without an assessment or taking vitals.
Review of the facility provided termination document for CNA #51 revealed a violation of putting an incontinence product on Resident #10 in order not to toilet her frequently. This was signed by CNA #51 on 05/12/25.
Review of the electronic mail statement from LPN #52 revealed after Resident #10 had fallen, she began to yell as staff assisted her from the floor. LPN #52 put her hand up to Resident #10's mouth and asked her to please stop yelling.
Review of the facility provided termination document for LPN #52 revealed a violation which included a violation of abuse policy. This was signed by LPN #52 on 05/12/25.
Review of the facilities undated policy titled Abuse, Neglect and Exploitation revealed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further indicated alleged violations would be reported to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
As a result of the incident, the facility took the following actions to correct the deficient practice by 05/12/25:
•
On 05/09/25, the facility submitted an SRI and began an investigation into the allegation involving Resident #10.
•
CNA #51 and LPN #52 were terminated by the facility on 05/12/25.
•
All staff received education on the abuse policy including the timeliness of reporting concerns was completed by 05/12/25. The education was completed by the Administrator or designee.
•
The facility conducted ongoing monitoring and there were no further abuse concerns.
•
Interviews on 06/04/25 with LPN #45, LPN #46, CNA #40, CNA #48, CNA #49 and CNA #50 reported they had received training on abuse and timeliness of reporting.
•
Interview of Resident #10 on 06/04/25 revealed she did not have a concern for her safety at the facility.
This deficiency represents non-compliance investigated under Complaint Number OH00165736.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Base...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on record review, review of facility Self-Reported Incident (SRI), staff interview and policy review, the facility failed to ensure allegations of abuse and neglect were timely reported to the Administrator. This affected one (#10) of three residents reviewed for abuse. The facility census was 64.
Findings include:
Review of medical record for Resident #10 revealed an admission date of 08/22/22 diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety major depressive disorder, single episode, unspecified, other cerebrovascular disease.
Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental status (BIMS) score of 13 indicating intact cognition. She was independent for eating, was dependent for toileting and required maximum assistance for bed mobility and transfers.
Review of Resident #10's progress note dated 05/04/25 at 7:15 P.M. revealed the resident was heard yelling from her room and found lying beside her bed. There was no further documentation regarding the incident.
Interview on 06/11/25 at 3:10 P.M. with the Administrator and Director of Nursing (DON) revealed it was brought to their attention on 05/08/25 that Certified Nursing Assistant (CNA) #50 had reported an allegation of the abuse of Resident #10 by CNA #51 and Licensed Practical Nurse (LPN) #52 which occurred on 05/04/25. CNA #50 had informed management during her training by CNA #51 they entered Resident #10's room and CNA #51 informed Resident #10 she was going to put her in an incontinence product, and she should urinate in it and they would be back to change her later in the shift. The DON explained Resident #10 was able to call staff and ambulate to the bathroom. The DON explained when she questioned CNA #50, she was informed due to previous experiences at reporting incidents at her previous employer, CNA #50 did not believe her concerns would be addressed and she feared the same retribution she experienced there.
Interview on 06/04/25 at 3:33 P.M. with CNA #50 revealed Resident #10 was able to use her call light, was able to inform staff when she needed to use the bathroom and was able to ambulate with assistance from staff. CNA #50 shared CNA #51 placed an incontinent product on Resident #10 because she did not want to toilet her frequently, and informed Resident #10 she would be in to check and change her later throughout the shift. CNA #50 stated a short time later into the shift, they found Resident #10 on the floor beside her bed. LPN #52 was notified and came into the room when she instructed CNA #50 and #51 to assist Resident #10 up and back into her bed. CNA #50 stated Resident #10 began to yell when they moved her, and LPN #52 put her hand over Resident #10's mouth to quiet her. CNA #50 shared she did not report her concern to management and explained at the facility previously worked at would not investigate concerns she had brought to management's attention, and she felt there was retribution for reporting issues. CNA #50 stated when she reported to the scheduler why she no longer wanted to work at the facility; she was contacted by management and an investigation was initiated. CNA #50 stated she did receive education regarding the timeliness of reporting abuse and denied she had any further concern for the care and or treatment of residents at the facility.
Review of a facility SRI dated 05/09/25 titled Neglect/Mistreatment Abuse revealed it was reported that Resident #10 had a fall and the LPN #52 did not assess her before they got her off the floor. It was also reported that LPN #52 put her hand over Resident #10's mouth because she was yelling out. It was also reported that CNA #51 told Resident #10 she was putting a brief on her stating we are not doing this. The SRI did not indicate the day the allegation occurred. The allegation was investigated by the facility and substantiated.
Review of the facilities undated policy titled Abuse, Neglect and Exploitation revealed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further indicated alleged violations would be reported to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
As a result of the incident, the facility took the following actions to correct the deficient practice by 05/12/25:
•
On 05/09/25, the facility submitted an SRI and began an investigation into the allegation involving Resident #10.
•
CNA #51 and LPN #52 were terminated by the facility on 05/12/25.
•
All staff received education on the abuse policy including the timeliness of reporting concerns was completed by 05/12/25. The education was completed by the Administrator or designee.
•
The facility conducted ongoing monitoring and there were no further abuse concerns.
•
Interviews on 06/04/25 with LPN #45, LPN #46, CNA #40, CNA #48, CNA #49 and CNA #50 reported they had received training on abuse and timeliness of reporting.
•
Interview of Resident #10 on 06/04/25 revealed she did not have a concern for her safety at the facility.
This deficiency represents non-compliance investigated under Complaint Number OH00165736.
Mar 2025
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Self-Reported Incidents (SRI), facility investigation documentation, staff interview, and revi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Self-Reported Incidents (SRI), facility investigation documentation, staff interview, and review of facility policy, the facility failed to ensure staff were immediately removed from the floor when allegations of staff to resident verbal abuse occurred. This affected one resident (#5) of four residents reviewed. The facility census was 65.
Findings Include:
Review of Resident #5's medical record revealed an admission date of 02/08/22 and a discharge date of 02/27/25. Diagnoses included major depressive disorder, altered mental status, type II diabetes, anxiety disorder, chronic pain, and insomnia.
Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #5 was cognitively intact. Resident #5 required supervision with toilet use and personal hygiene. Resident #5 was independent with dressing, transfer and mobility. Resident #5 required maximal assistance with bathing. Resident #5 displayed no behaviors at the time of the review.
Review of Resident #5's care plan canceled 02/28/25 revealed supports and interventions for self-care deficit, anemia, pain, diabetes, and depression.
Review of the facility's Self-Reported Incident (SRI) 255532 revealed on 12/27/24 staff witnesses reported Certified Nursing Assistant (CNA) #499 was frustrated and argumentative with Resident #5. Review of the investigation documentation found on 12/27/24 at approximately 5:00 P.M. Resident #5 was seated in the dinning room, got up and went back to her room to get her dentures. Resident #5 was still in her room when her dinner tray came out of the kitchen and CNA #499 took Resident #5's dinner tray down to her room. Resident #5 was reported to have been cussing and yelling at CNA #499. CNA #499 was observed coming out of Resident #5's room with a raised voice saying Resident #5 was not going cuss at her when she was doing what she was told to do. She proceeded to drop Resident #5's dinner tray on the nurses station counter. CNA #499 was directed by Registered Nurse (RN) #572 to place the tray back at Resident #5's seat in the dining room. CNA #499 complied and was overheard continuing to yell and argue with Resident #5. It was noted CNA #499 grabbed her coat and went out to take a smoke break. CNA #499 commented she was getting agitated and it was what she was told to do. CNA #499 was noted to have stayed out of the building for about 20 minutes before returning to the floor. In CNA #499's statement she indicated she came back into the facility and spoke with another unidentified staff about getting through the night and it would get better. At 6:38 P.M. the Director of Nursing (DON) received a phone call about the situation and advised RN #572 to have CNA #499 to go home. At approximately 7:07 P.M. Licensed Practical Nurse (LPN) #548 told CNA #499 the DON wanted her to leave the building that night and to call in on Monday. At 7:15 P.M. CNA #499 clocked out. CNA #499 sent a text on 12/27/24 at 7:19 P.M. to the DON for confirmation she was to leave the building and reported she had already clocked out. The concern for staff to resident verbal abuse began on 12/27/24 at approximately 5:00 P.M. and CNA #499 continued to work in the facility until 7:15 P.M. when she clocked out. CNA #499 remained in the facility for approximately two hours after the concern arose.
Interview on 03/14/25 at 12:54 P.M. with the Director of Nursing (DON) and the Administrator verified the verbal altercation began between CNA #499 and Resident #5 at approximately 5:00 P.M. and CNA #499 remained in the facility until 7:15 P.M. when she clocked out.
Review of the facility policy titled, Abuse, Neglect, and Exploitation, revised August 2024 revealed the facility would make efforts to ensure all residents were protected from physical and psychosocial harm as well as additional abuse during and after the investigation. The staff were to respond immediately to protect the alleged victim.
Nov 2024
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
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Base...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on record review, review of a facility self-reported incident (SRI), staff interview, and review of the facility misappropriation policy, the facility failed to ensure a resident was free from misappropriation of medication. This affected one (Resident #01) out of three residents reviewed for misappropriation. The facility census was 64.
Findings include:
Review of the medical record of Resident #01 revealed an admission date of 11/10/22. Diagnoses include Alzheimer's disease, dementia, moderate protein-calorie malnutrition, anxiety disorder, and supraventricular tachycardia.
Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #01 was severely cognitively impaired. The assessment further indicated Resident #01 was unable to respond to questions related to pain but did exhibit signs of pain to include non-verbal sound, verbal words (ouch, hurts), facial expressions, and protective body movements.
Review of the Resident #01's physician orders reveaeld the resident had an order for Oxycodone (opiate) 5 milligrams (mg) one tablet by mouth two time a day for severe pain dated, dated 06/28/23. The doses were scheduled for 5:00 A.M. and 8:00 P.M. Oxycodone 5 mg give one by mouth every one hour as needed for pain, may give sublingual (SL) or by mouth (PO) dated 11/16/22 and discontinued on 11/04/24.
Review of Resident #01's medication administration record (MAR) reveaeld the scheduled doses of Oxycodone were provided routinely and the resident did not usually take any as needed Oxycodone doses. The November 2024 MAR had four doses of the as needed Oxycodone documented as follows: 11/02/24 at 8:29 A.M. effectiveness unknown, 11/02/24 at 5:05 P.M. effective, 11/03/24 at 8:20 A.M. effectiveness unknown, and 11/03/24 at 3:47 P.M. effective.
Review of the Controlled Substance Record (CSR) for the Oxycodone five mg for Resident #01 revealed the medication was documented as removed from the medication cart at the following times which were not documented on the MAR or documented in the progress notes as provided to the resident on 11/02/24 at 9:45 A.M., 11:00 A.M., 12:00 P.M., 1:30 P.M., 2:30 P.M., 2:35 P.M., 3:30 P.M., and 5:30 P.M. The Oxycodone five mg was documented as removed from the medication cart at the following times which were not documented on the MAR as administered to the resident or documented in the progress notes as provided to the resident on 11/03/24 at 9:30 A.M., 11:00 A.M., 12:00 P.M., 1:30 P.M., 2:45 P.M., 4:45 P.M., and 5:30 P.M. This is 15 doses of the narcotic pain medication not documented as provided to the resident over these two days.
Review of a facility self-reported incident dated 11/04/24, indicated during review of the Controlled Substance Record (CSR) it was discovered an agency nurse Registered Nurse (RN) #100 administered 19 doses of Oxycodone (opioid) five milligram (mg) on the CSR record for Resident #01 over two days. Only four of those 19 doses were recorded on the medication administration record (MAR) as provided to Resident #01. Resident #01 normally does not receive as needed doses of the medications. While reviewing cameras footage for a period of four hours, this nurse was not observed medicating Resident #01, despite the medication having been documented as having been administered. Attempts to contact RN #100 were unsuccessful as she failed to return any phone calls or calls from the staffing agency, who was her employer. Staff interviews revealed Resident #01 had no behaviors out of his ordinary over the time frame. Staff further stated they had not witnessed RN #100 medicate Resident #01. Staff interviewed further stated RN #100 would not be available at times during the three shifts, but none reported feeling she had been impaired.
Review of the facility investigation revealed five like residents had been interviewed. None had any concerns with not receiving medications. The facility additionally interviewed two nurses and the two Certified Nursing Assistants (CNA) who had worked with RN #100, and all denied any knowledge of misappropriation. The [NAME] County Sheriff's office, the Ohio Board of Nursing, the facility pharmacy, and the staffing agency were all notified on 11/04/24 by the Administrator. Resident #01's physician was notified by the nurse who discovered the concern on 11/04/24.
Review of Licensed Practical Nurse (LPN) #120's typed statement, dated 11/05/24, revealed on 11/02/24, while receiving report from RN #100, RN #100 appeared to be disorganized and unable to focus on anything for more than a few seconds. LPN #120 documented RN #100 kept reporting Resident #01 had been very combative with cares and stated Resident #01 had been hitting and kicking staff. After report the controlled substances were counted and RN #100 stated I hope I can stay awake long enough to drive home. When LPN #120 asked her why, she had stated she had been working a lot, in a defensive tone. LPN #120 reported she had told RN #100 to be careful and she would see her in the morning. LPN #120 reported RN #100 returned on 11/03/24 and during report kept trying to change the subject. LPN #120 reported she returned at 7:00 P.M. and once again RN #100 appeared very disorganized. When RN #100 reported on Resident #01 she stated she had contacted the provider as his medication was getting low and she had not wanted him to be without. RN #100 once again stated Resident #01 had been very combative with care during the day. After RN #100 left, LPN #120 asked the CNA if Resident #01 had been more combative throughout the day and she said, no more than normal. As LPN #120 was reviewing the documentation she noted Resident #01 had received the oxycodone every hour over the last two days. LPN #120 documented Resident #01 was alert and acting his normal behaviors. LPN #120 documented informing the Administrator and Director of Nursing of her concerns on 11/04/24.
Review of the summary of investigation indicated the allegation of misappropriation by RN #100 towards Resident #01 was substantiated.
Review of the Ohio Board of Nursing licensure verification revealed RN #100 held an active license as of 10/24/22. RN #100 was from a contracted staffing agency.
Interview on 11/21/24 at 8:15 A.M. with the Administrator revealed RN #100 was never to return to the facility and no further incidents of misappropriation were discovered. The Administrator confirmed the facility conducted an investigation and substantiated that RN #100 misappropriated Resident #01's medications.
Review of the policy titled Controlled Substance Administration & Accountability, undated, revealed the facility will have safeguards in place in order to prevent loss or diversion. The policy was followed in the events surrounding the misappropriation of Resident #01's narcotic medication by RN #100.
As a result of the incident, the facility took the following actions to correct the deficient practice by 11/21/24:
•
Immediate removal of RN #100 from the schedule on 11/04/24.
•
All resident narcotic records and Narcotic medications were audited on 11/04/24 with no deficient practice noted.
•
Five like residents were interviewed on 11/04/24 and had no concerns related to misappropriation.
•
Three staff members were interviewed on 11/04/24 and one on 11/05/24 and were not aware of any misappropriation occurring while working with RN #100.
•
All staff in the facility were in-serviced by the Administrator and the Director of Clinical Operations on the facility's abuse, neglect, and misappropriation policy by 11/21/24.
•
RN #100 has been placed on a Do Not Return list on 11/04/24.
•
All resident narcotic records continue to be audited weekly by the Director of Nursing and Unit Managers indefinitely.
This deficiency represents non-compliance investigated under Complaint Number OH00159761.
Apr 2024
8 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 F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident authorization form was in place for a resident with a personal fund account. This affected ...
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Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident authorization form was in place for a resident with a personal fund account. This affected one (#15) of the six residents reviewed for personal fund accounts. The facility census was 64.
Findings included:
Review of the medical record for Resident #15 revealed an admission date of 01/11/18, with medical diagnoses of diabetes mellitus, hyperlipidemia, anemia, and dementia.
Review of the medical record for Resident #15 revealed an annual Minimum Data Set (MDS) assessment, dated 01/08/24, which indicated Resident #15 had moderate cognitive impairment and required moderate staff assistance with toilet hygiene and bathing and set-up assistance with transfers and bed mobility.
Review of the medical record for Resident #15 revealed a Resident Fund Statement, dated 12/30/23 through 03/29/24 which indicated Resident #15 had a personal fund account with the facility. Further review of the medical record for Resident #15 revealed no documentation to support the resident or resident representative who had signed a personal fund account authorization form.
Interview on 04/04/24 at 3:31 P.M., with Business Office Manager (BOM) #321 confirmed the medical record for Resident #15 did not contain documentation to support the resident or resident representative had signed an authorization form for a personal fund account.
Review of the undated policy titled, Resident Personal Funds, stated if the resident chooses to deposit personal funds with the facility, upon written authorization of the resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited in the facility.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, revealed the facility failed to maintain a homelike environment in complet...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, revealed the facility failed to maintain a homelike environment in completing repairs. This affected one (#60) of 23 resident rooms observed. The facility census was 64.
Findings include:
Review of medical record for Resident #60 revealed admission date of 08/23/24. The resident was admitted with diagnoses including dementia with sever psychotic disturbances, type two diabetes mellitus, anxiety, bipolar disease, and chronic pain syndrome.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. He was independent or required supervision only for activities of daily living.
Interview on 04/03/24 at 8:34 A.M., with Resident #60, revealed he pointed out the drywall which was damaged from his recliner and his bathroom faucet dripped. He stated he placed paper towels in the sink to muffle the sound of the dripping.
Observation on 04/03/24 at 8:34 A.M., revealed there were four damaged drywall areas approximately four feet from the floor and directly behind the top of the recliner. Three of the areas were approximately one inch () by (x) one eighth (1/8) inch. One of the areas was approximately 3.0 x one quarter (1/4) inch. Observation of the bathroom sink revealed the faucet had a slow, steady drip of water. This was verified with State Tested Nursing Assistant #231.
Interview on 04/03/24 at 11:05 A.M., with Maintenance Director #319 revealed he was unaware Resident #60's faucet was leaking, but it would not be a concern if it was leaking directly into the sink. He also denied knowledge of the drywall damage to the wall behind Resident #60's recliner and stated it would be something fixed after the resident moved out and the room would be redone.
This deficiency represent the noncompliance investigated under Complaint Number OH00151833.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of wound care, record review, resident interview, staff interview, and review of policy, the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of wound care, record review, resident interview, staff interview, and review of policy, the facility failed to ensure residents did not acquire pressure ulcers from medical devices in place. This affected one (#32) of three residents reviewed for pressure ulcers. The current census is 64.
Findings include:
Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #32 include fracture of right femur, transverse fracture of right fibula, acute kidney injury, diabetes type 2, asthma, heart disease, and pressure ulcers of bilateral buttocks. Review of the comprehensive Minimum Data Set (MDS) assessment dated revealed the resident had intact cognition, had pressure ulcer upon admission, and was a 2-person assist for Activities of Daily (ADL).
Review of Resident #32's care plans dated 02/19/24 revealed a focus for cellulitis of the lower extremities, open area right lower leg. Interventions include on 02/26/24 keep right leg immobile, Unna boot with Profore wraps to bilateral leg, apply every other day using a 2-3 person assist to keep right leg immobile. Further review of the care plans revealed a focus for acute pain related to fracture of right femur. Interventions include pad splint and casting at the top of upper thigh and heel on the right lower leg with gauze pads to protect from skin breakdown. Keep splint on right leg, remove only for pulse and skin checks.
Review of Resident #32's physician orders for the right leg revealed on 02/26/24 at 7:00 A.M., the resident was to have Unna boot with Profore wraps to bilateral legs every other day using a 2-3 person assist to keep right leg immobile, every other shift every other day. The order was discontinued on 03/01/24.
Review of the order dated 03/01/24 the wound dressing order changed to cleanse open areas with Dakin's 0.125%, pat dry, apply Urgotul silver, followed by ABD pad, wrap full leg from toes to bend of knee with gauze/kerlix, then wrap with Ace wrap. Change daily and as needed every night shift for wound care. This order was discontinued on 03/04/24.
Review of the order dated 03/05/23 the wound dressing order changed right lower leg cleanse open areas with Dakin's 0.125% pat dry, apply Urgotul silver, followed by ABD pad, wrap full leg from toes to bed of knee with gauze/kerlix, then wrap with Ace wrap every day shift once a day. This order was discontinued on 03/28/24.
Review of Resident #32's progress notes dated 03/01/24 at 8:30 A.M., revealed the Certified Nurse Practitioner (CNP) #350 documented Resident #32's right posterior leg had a fluid filled blister. The right medial lower leg has an open area. The anterior ankle is noted to have a purple, non-blanchable area and a superficial open area at the center. Per the note the CNP documented her impression as a suspected deep tissue injury to the right anterior ankle related to a medical device and a suspected deep tissue injury and stage two pressure injury to the right upper posterior thigh.
Review of Resident #32's wound assessments dated 03/01/24 to 04/01/24 revealed the upper posterior thigh suspected deep tissue injury was staged at a pressure ulcer stage 2 had healed as of 03/28/24. The right anterior ankle suspected deep tissue injury was staged as a pressure ulcer stage 2 and was improving.
Further review of Resident #32's progress notes revealed on 03/06/24 at 12:52 P.M., Registered Nurse (RN) #411 documented in a progress note the nurse observed and evaluated Resident #32's braces were not applied correctly, the Unna boots were not on correctly, the skin was cool to touch on the left leg and toes. Resident #32's right leg was warm to tough. Pressure ulcers present related to missing placement of the braces. Per the note the nurse updated CNP #350 and the provider ordered to send the resident to the hospital for evaluation and treatment.
Interview on 04/01/24 at 3:40 P.M., with Resident #32 revealed the resident was alert and oriented. Resident #32 stated he has had a lot of issues with his legs and recently he was notified he had some more wounds due to the braces not being applied correctly. Resident #32 stated he did not have any increased pain with the new wounds. Resident #32 did state he had to go to the hospital, at the beginning of 03/2024, to be treated for possible blood clots due to the braces being too tight. Resident #32 stated he returned the same day and stated the hospital staff told him he did not have any blood clots. Resident #32 stated he did not have concerns regarding his wound care at the facility at the time he had the different dressings he understood the nursing staff were unsure of how to apply his braces to prevent new ulcers.
Interview on 04/03/24 at 1:57 P.M., with RN #411 revealed the nurse was caring for Resident #32 prior to and after 03/01/24 when the pressure ulcers to his right leg were discovered. RN #411 stated she believed and notified Certified Nurse Practitioner (CNP) #350 the resident had new skin issues due to the staff not applying the boots and splints to his bilateral legs. RN #411 stated the CNP #350 ordered for Resident #32 to be sent to the hospital for treatment of the new wounds caused by the splints and boots.
Interview on 04/04/24 at 10:20 A.M., with CNP #350 stated when she was assessing Resident #32's legs on 03/01/24 she noted the resident had two suspected deep tissue injuries from improper placements of the splints on the resident's right leg. Per CNP #350, both the wounds she observed did develop into stage two pressure ulcers. CNP #350 stated upon discovery of the Unna boots being applied too tightly on 03/01/24 she ordered new dressings for the resident. CNP #350 stated on 03/06/24 she was notified by the nurse the resident's legs and toes showed decrease signs of circulation so she ordered the resident to be seen at the hospital. CNP #350 verified she felt the pressure ulcers to the right leg on the thigh and the ankle were due to the improper placement and improper wrapping of the dressing.
Observation of 04/04/24 at 10:30 A.M., of Resident #32's wound dressing revealed the right thigh wound appeared to be healed with no open areas. The right ankle wound appeared to be as described in the wound documentation, a stage two pressure ulcer. CNP #350 was observed measuring and documenting the conditions of the resident's wounds. CNP #350 was observed applying the wound dressing as prescribed. Resident #32 denied any issues with his wounds at the time of the observation.
Review of the undated facility policy titled, Pressure Injury Prevention and Management, revealed the facility will assess and revised any interventions which may cause avoidable pressure ulcers.
This deficiency represent the noncompliance investigated under Complaint Number OH00151812 and OH00151833.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews, interview with respiratory care provider, and policy review,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews, interview with respiratory care provider, and policy review, the facility failed to ensure a resident's noninvasive ventilator such as bi-level positive airway pressure (BiPap), average volume-assured pressure support (AVAPS), or continuous positive airway pressure was administered as ordered. This affected one (#25) resident of four residents reviewed for noninvasive ventilators. The facility identified four residents had noninvasive ventilators. The facility census was 64.
Findings include:
Review of the medical record for Resident #25 revealed an admission date of 07/14/22, with medical diagnoses of chronic obstructive pulmonary disease, morbid obesity, chronic kidney disease stage III, and congestive heart failure.
Review of the medical record for Resident #25 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/11/24 which indicated Resident #25 was cognitively intact and required moderate staff assistance for bed mobility, maximum staff assistance for transfers and toilet hygiene, and was dependent for bed mobility. Review of the MDS revealed the use of oxygen and noninvasive mechanical ventilator.
Review of the medical record for Resident #25 revealed a physician order dated 07/19/22, for BiPap mode with setting at eight minimum pressure support, six maximum pressure, 18 target rate, and 14 bleed in three liters of oxygen every night shift.
Review of the medical record for Resident #25 revealed the March and April 2024 Treatment Administration Record (TAR) revealed no documentation to support the Bipap was administered as ordered on 03/25/24 - 03/31/24 and on 04/01/24.
Review of the medical record for Resident #25 revealed a nurse progress note, dated 03/25/24 at 6:03 A.M., which stated the Bipap mask was broken-blue plastic loop that connects the mask straps. The note stated the respiratory company was called but could not reorder parts due to after hours and would pass it on to the dayshift nurse to order.
Review of the order form from the respiratory company dated 03/25/24 revealed the facility ordered the mask for Resident #25.
Interview on 04/03/24 at 9:50 A.M., with Registered Nurse (RN) #106 stated she called the respiratory company and ordered the part for resident on the morning on 03/25/24. RN #106 stated Resident #25 had two Bipap masks in her room and was not sure if either mask worked.
Observation with interview on 04/03/24 at 10:00 A.M., with Resident #25 stated she has not worn her Bipap machine since 03/25/24 because her mask was broken. Resident #25 confirmed she had two Bipap masks sitting on the bedside table but was not sure if either of the masks worked properly. Observation revealed two Bipap masks sitting on her bedside table near the Bipap machine.
Interview on 04/03/24 at 11:05 A.M., with a representative from the respiratory company confirmed the facility ordered Resident #25 a new Bipap mask on 03/25/24 and stated the new mask was delivered to the facility on [DATE].
Interview on 04/03/24 at 4:11 P.M., with Director of Nursing (DON) confirmed the new Bipap mask for Resident #25 arrived on 03/27/24. DON confirmed staff has not administered the Bipap machine as ordered for 03/27/24 through 04/02/24.
Review of the undated policy titled, Noninvasive ventilation (CPAP, Bipap, AVAPS, Trilogy), stated the facility was to provide noninvasive ventilation as per physician's order and current standards of practice. The policy stated Bipap or bi-level positive airway pressure was a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth. The policy stated to replace equipment immediately or when equipment is available, when it was broken and malfunctions, or if visible soiling remains after cleaning.
This deficiency represents non-compliance in regards to the allegations for Complaint Number OH00151883.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and review of policy, the facility failed to monitor blood pressure prior to the administer of medications as ordered. This affected for one (#24) of f...
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Based on medical record review, staff interview, and review of policy, the facility failed to monitor blood pressure prior to the administer of medications as ordered. This affected for one (#24) of five residents observed for medication administration. The facility census was 64.
Findings include:
Review of the medical record of Resident #24 revealed an admission date of 11/08/20. Diagnoses include hypertension, diabetes mellitus type II, and schizoaffective disorder.
Review of the physician order dated 07/09/23 revealed metoprolol tartrate 50 milligrams (mg) by mouth two times daily for hypertension, hold in SBP (systolic blood pressure) is less than 110 mm/Hg (milliliters of mercury) or heart rate less than 60 beats per minute. A second order dated 07/11/23 for amlodipine 10 mg once daily for acute kidney injury and hold if SBP less than 110 mm/Hg.
Observation of medication administration on 04/03/24 at 10:20 A.M., revealed Licensed Practical Nurse (LPN) #114 removed a 50 milligram (mg) tablet of metoprolol and a 10 mg tablet of amlodipine (both for hypertension) to administer to Resident #24. Both medications had instructions to hold if the systolic blood pressure was less than 110 milliliters of mercury (mm/Hg) and for the metoprolol hold if the heart rate was less than 60 beats per minute. LPN #114 administered both medications without obtaining a blood pressure or heart rate value. Interview with LPN #114 immediately following the administration provided verification LPN #114 had not obtained a blood pressure or heart rate value prior to administering the medications.
Review of the undated policy titled Medication Administration revealed to obtain and record vitals signs when applicable and or ordered by the physician.
This deficiency represents non-compliance in regards to the allegations for Complaint Number OH00151883 and OH00151405.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and review of the product insert instructions, the facility failed to ensure insulin pen needles were primed after a new needle was applied. This affected one (#2...
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Based on observation, staff interview and review of the product insert instructions, the facility failed to ensure insulin pen needles were primed after a new needle was applied. This affected one (#24) of two residents observed for insulin administration. The facility census was 64.
Findings include:
Review of the medical record of Resident #24 revealed an admission date of 11/08/20. Diagnoses include hypertension, diabetes mellitus type II, and schizoaffective disorder.
Review of the physician order dated 11/20/23 revealed Insulin Aspart (with Niacinamide) eight (8) units routinely and additional units as necessary related to sliding scale to be injected subcutaneously four times daily related to diabetes mellitus type II.
Observation on 04/03/24 at 10:20 A.M., revealed Licensed Practical Nurse (LPN) #114 placed a new needle onto the Aspart insulin pen for Resident #24. LPN #114 dialed the pen to 18 units and injected Resident #24 with the insulin, LPN #114 verified he had not primed the needle stating I thought that was just with a new pen.
Review of the manufacturer's product insert revealed instructions to check the flow of medication through the needle before every injection.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and review of policy, the facility failed to ensure personal protective equipment (PPE) was utilized during a procedure for one resident (#04) of two residents w...
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Based on observation, staff interview, and review of policy, the facility failed to ensure personal protective equipment (PPE) was utilized during a procedure for one resident (#04) of two residents with Enhanced Barrier Protection (EBP) in place. The facility also failed to ensure staff performed proper hand hygiene when performing tracheostomy care for one (#04) resident out of the two residents reviewed for tracheostomy care. Furthermore, the facility failed to ensure a sanitary environment was provided during meal service. This directly affected one resident (#20) and had the possibility to affect five males (#13, #17, #20, #24, and #61) who eat in their rooms. The facility census was 64.
Findings included:
1. Review of the medical record for Resident #04 revealed an admission date of 10/07/22, with medical diagnoses of chronic obstructive pulmonary disease, heart failure, traumatic subarachnoid hemorrhage, and hypertension.
Review of the medical record for Resident #04 revealed a quarter Minimum Data Set (MDS) assessment, dated 02/18/24, which indicated Resident #04 had moderate cognitive impairment and required maximum staff assistance for bathing, bed mobility, and transfers and was dependent upon staff for toilet hygiene. Further review of the MDS revealed Resident #04 had a colostomy, tracheostomy, and indwelling catheter.
Observation on 04/03/24 at 12:45 P.M., of Registered Nurse (RN) #106 providing catheter care for Resident #04 revealed RN #106 pulled down the front of Resident #04's pants and adult incontinence briefs with ungloved hands. RN #106 then donned a plastic isolation gown and gloves. RN #04 obtained a basin of water and two wash cloths. RN #106 wet one wash cloth with soapy water and cleansed the insertion site of the suprapubic catheter using aseptic technique. RN #106 removed her gloves and placed a split four-inch by four-inch gauze around the catheter and taped it in place. Interview with RN #106 immediately after the procedure provided verification, she had not used proper enhanced barrier precautions when providing catheter care for Resident #04.
Observation on 04/04/24 at 10:07 A.M., of RN #109 complete tracheostomy care for Resident #04 revealed RN #109 washed her hands prior to donning gown and gloves. RN #109 removed Resident #04's inner tracheostomy cannula and dressing around the tracheostomy site then removed her gloves. RN #109 then donned new gloves and inserted the new clean inner cannula. RN #109 proceeded to remove her gloves and opened a tracheostomy kit to get the normal saline and cotton tipped applicators from the kit. RN #109 continued to open both bedroom and bathroom drawers with her bare hands looking for additional supplies prior to applying new gloves and using the supplies to clean around Resident #04's tracheostomy site. RN #109 applied new tracheostomy ties and sponge drainage dressing around the tracheostomy site. RN #109 removed her gloves and handed Resident #04 his water pitcher. RN #109 washed her hands prior to leaving Resident #04's room.
Interview on 04/04/24 at 10:25 A.M., with RN #109 confirmed she did not perform hand hygiene after removing her gloves at any time during the tracheostomy care or prior to handing Resident #04 his water pitcher. RN #109 confirmed Resident #04 was under EBP and she did not wear a mask when performing the tracheostomy care.
Review of the policy titled, Enhanced Barrier Precautions dated 03/20/24 revealed personal protective equipment for enhanced barrier precautions is necessary only when performing high-contact activities. The policy stated EBP would be obtained for residents with wounds and/or indwelling devices (central lines, indwelling catheter, tracheostomy/ventilator tubes).
Review of the undated policy titled, Tracheostomy Care stated the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-center care plan and resident goals and preferences. Policy stated tracheostomy care would be provided per physician orders. The policy stated to perform hand hygiene per facility policy, put exam gloves on both hands, masks and eye wear should be work if there is a likelihood of splashes and splattering. The policy state to remove old dressing and remove gloves and discard dressing and gloves. Perform hand hygiene, apply gloves, insert new inner cannula, clean stoma with normal saline moistened cotton-tipped applicators, change trach ties, and replace split dressing. The policy continued to state to dispose of equipment and perform hand hygiene.
2. Observation on 04/03/24 at 12:45 P.M., of Registered Nurse (RN) #106 providing catheter care for Resident #04 revealed RN #106 pulled down the front of Resident #04's pants and adult incontinence briefs with ungloved hands. RN #106 then donned a plastic isolation gown and gloves. RN #04 obtained a basin of water and two wash cloths. RN #106 wet one wash cloth with soapy water and cleansed the insertion site of the suprapubic catheter using aseptic technique. RN #106 removed her gloves and placed a split four-inch by four-inch gauze around the catheter and taped it in place. Interview with RN #106 immediately after the procedure provided verification she had not used proper enhanced barrier precautions when providing catheter care for Resident #04.
3. Observation on 04/01/24 at 11:48 A.M., revealed State Tested Nursing Assistant (STNA) #233 sat a tray of food on the overbed table of Resident #20. A urinal was on one end of the table with approximately 200 milliliters of urine in it. This surveyor interviewed STNA #233 after she exited the room about the urinal placed on the overbed table, near the food. STNA #233 stated That is where he likes it and gets upset if it is not there. STNA #233 verified there was urine in the urinal and then emptied it in the toilet and replaced the urinal on the over bed table.
Review of the policy titled Enhanced Barrier Precautions dated 03/20/24, revealed personal protective equipment for enhanced barrier precautions is necessary only when performing high-contact activities.
This deficiency represents non-compliance investigated under Complaint Number OH00151883 and OH00151938.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure residents were free of potential hazards and accident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure residents were free of potential hazards and accidents. This affected one (#60) resident and had the ability to affect 19 additional residents (#7, #8, #11, #14, #28, #29, #30, #34, #36, #39, #40, #41, #48, #50, #51, #53, #56, #58, and #59) in the memory unit who were cognitively impaired and independently mobile. The facility census was 64.
Findings include:
Review of medical record for Resident #60 revealed admission date of 08/23/23. The resident was admitted with diagnoses including dementia with severe psychotic disturbances, type two diabetes mellitus, anxiety, Bipolar Disease, and chronic pain syndrome.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. He was independent or required supervision only for activities of daily living.
Review of the progress note on 03/07/24 at 9:29 P.M., revealed Licensed Practical Nurse (LPN) #104 documented she had been informed by an unidentified State Tested Nursing Assistant, that Resident #60 had gotten into staffs' bag and took a lighter and cigarette. Staff had been able to get the lighter, but Resident #60 refused to give them the cigarette. Attempts to redirect Resident #60 were unsuccessful, and his family was called. Resident #60's son-in-law came to the facility and the incident was deescalated.
Interview on 04/04/24 at 8:42 A.M., with LPN #104 revealed she had gotten in report at shift change Resident #60 had been having increased moodiness. She was alerted by staff around shift change Resident #60 had gotten into a staff members coat which had been hanging in a common area at the end of the unit. Staff had been able to get the lighter from him. However, multiple attempts to get the cigarette were unsuccessful. The family was then called to inform them of the incident and increased behaviors. Resident #60's son in law came to the facility and after walking Resident #60 outside the facility for a bit, he was able to get Resident #60 to turn over the cigarette. LPN #104 then explained, normally the staff's personal items would be locked in the nursing office, however, the area was under construction at the time of the incident.
Apr 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interviews, and policy review, the facility failed to comprehensively assess a resident's activity pursuits on admission. This affected one (#42) of the 16 reside...
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Based on medical record review, staff interviews, and policy review, the facility failed to comprehensively assess a resident's activity pursuits on admission. This affected one (#42) of the 16 residents reviewed for assessments. The facility census was 58.
Findings include:
Review of the medical record for Resident #42 revealed an admission date of 03/12/23 with medical diagnoses of Parkinson's disease, psychotic disorder with delusions, dementia, anxiety, diabetes mellitus and hypertension.
Review of the medical record for Resident #42 revealed an admission Minimum Data Set (MDS) assessment, dated 03/18/23, which indicated Resident #42 had moderately impaired cognition and required extensive assistance with bed mobility, transfers, and toileting. Further review of the MDS revealed interviews for Resident #42's activity preferences were not completed and the activity questions were dashed.
Review of the medical record for Resident #42 revealed no documentation to support Resident #42 or a resident representative was interviewed by facility staff to determine the resident's activity preferences.
Interview on 04/26/23 at 11:04 A.M. with Activity Director #214 confirmed he was responsible for completing resident interviews regarding activity preferences and confirmed he had not completed a comprehensive activity assessment for Resident #42.
Review of the policy titled, Activity, revealed the facility is to provide on-going program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and family and staff interview, the facility failed to conduct a quarterly care plan review meeti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and family and staff interview, the facility failed to conduct a quarterly care plan review meeting. This affected one (#37) of 16 residents reviewed for care planning meetings. The facility census was 58.
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 10/12/22 with medical diagnoses of dementia with other behavioral disturbances, diabetes mellitus, hypertension, depression, and hyperlipidemia.
Review of the medical record for Resident #37 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #37 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, and toileting, and was dependent for bathing.
Review of the medical record for Resident #37 revealed a progress note, dated 11/16/22 at 1:07 P.M., which revealed a care conference was held with staff and family. Review of the medical record for Resident #37 did not contain documentation to support the facility conducted a care plan review meeting since 11/16/22.
Interview on 04/24/23 at 2:46 P.M. with Resident #37's daughter stated the family and resident representative have not been invited to a care plan review meeting for Resident #37 since the fall of 2022.
Interview on 04/26/23 at 12:05 P.M. with Administrator confirmed the facility had not conducted a care plan review meeting for Resident #37 since the meeting on 11/16/22 or after the most recent quarterly assessment dated [DATE]. Administrator stated the facility did not have a care plan review meeting or care conference policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to provide adequate interve...
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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 adequate interventions and supervision to ensure a cognitively impaired resident did not elope from the facility. Additionally, the facility failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to prevent further elopements. This affected one (#37) resident of seven residents reviewed on the secured memory care unit. The facility census was 58.
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 10/12/22 with medical diagnoses of dementia with other behavioral disturbances, diabetes mellitus, hypertension, depression, and hyperlipidemia. Review of the medical record revealed Resident #37 was admitted to a room on the facility's secured memory care unit (MCU).
Review of the medical record for Resident #37 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #37 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing toileting, and supervision with ambulation. The MDS did not have documentation to support Resident #37 had any behaviors or was wandering.
Review of the medical record for Resident #37 revealed a care plan, dated 10/20/22, which revealed the resident was an elopement risk and wanderer related to history of leaving previous facility where he lived. The goal for the care plan indicated Resident #37 would not leave the facility unattended. Review of the elopement risk and wanderer care plan revealed all interventions were added to the care plan on 10/20/22 and included to provide activities, toileting, and to offer pleasant distractions. Further review of the care plans revealed an impaired cognition related to dementia care plan dated 10/21/22. The care plan had an intervention which indicated Resident #37 was to reside on the secured MCU.
Review of the medical record for Resident #37 revealed a wandering scale risk assessment, dated 10/12/22, which revealed Resident #37 was at high risk for wandering.
Review of the medical record for Resident #37 revealed an elopement risk assessment, completed 11/09/22, which revealed Resident #37 was at risk for elopement. Further review of the medical record revealed an elopement risk assessment, completed 01/19/23, revealed Resident #37 was not at risk for elopement.
Review of the medical record for Resident #37 revealed a nursing note dated 11/09/22 at 6:08 A.M. which revealed the [NAME] hall unit nurse observed Resident #37 outside of the facility when she looking through another resident's window. The nursing note further revealed the [NAME] hall unit nurse went into the parking lot and brought Resident #37 back inside the facility. The nursing note revealed Resident #37's representative and nurse practitioner were notified of the elopement and the staff placed a WanderGuard (an electronic device used to prevent independently mobile and cognitively impaired residents from elopement) to Resident #37's left ankle.
Observation on 04/26/23 from 7:18 A.M. to 7:30 A.M. of Resident #37 revealed Resident #37 wandered the halls of the MCU. Resident #37 was observed to push on the secured doors in MCU that go to the [NAME] hall unit. The doors alarmed and Resident #37 moved away from the doors. Staff were observed to walk into the hallway to check the alarming doors.
Interview on 04/26/23 at 10:42 A.M. with Director of Nursing (DON) confirmed Resident #37 was found outside of the facility on 11/09/22 at 5:35 A.M. DON stated Resident #37 exited the MCU through a secured door on the MCU that opened to the outside. DON stated the secured exit door had an alarm that sounds for 15 seconds when staff or residents push on the door prior to the door opening. DON stated Resident #37 did not have any injuries from the incident. DON confirmed the Resident #37 wandered on the MCU and exit seeks at times. DON confirmed no resident-specific interventions were put in place after Resident #37's elopement on 11/09/22 or that the facility conducted a thorough investigation including root cause analysis. DON stated staff education and training was not completed after Resident #37's elopement on 11/09/22.
Review of the facility policy titled, Elopement and Wandering Residents, dated 01/03/2020, stated the facility would ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and resident care in accordance with their person-centered care plan addressing the unique factors contributing to wandering or elopement risk. The policy stated alarms are not a replacement for necessary supervision and staff are to be vigilant in responding to alarms in a timely manner. The policy continued to state the facility staff would implement interventions to reduce hazards and risks and modify interventions when necessary.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policies, the facility staff failed to main...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policies, the facility staff failed to maintain contact precautions during wound care, and failed to have a Legionella water management program in place. This directly affected one (#165) of three residents reviewed for transmission based precautions and had the potential to affect all 58 residents residing in the facility. The census was 58.
Findings include:
1. Review of Resident #165's medical record revealed an admission dated of 12/22/22. Diagnoses included type two diabetes mellitus, right lower cellulitis, chronic foot ulcer, venous insufficiency, morbid obesity, methicillin-resistant staphylococcus aureus (MRSA), anxiety, and hallucinations.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #165 was assessed as cognitively intact.
Review of physician orders revealed an order dated 01/16/23 for contact isolation related to (MRSA) in a right foot wound.
Review of wound care physician office notes dated 03/01/23 revealed Resident #165's right foot wound was recently cultured and was still positive for MRSA.
Observation of wound care for Resident #165 on 04/26/23 at 12:50 P.M. revealed Licensed Practical Nurse (LPN) #208 entered Resident #165's room and prepared wound care items. A sign posted on Resident #165's door frame read to, See nurse before entering. Further observation revealed personal protective equipment (PPE), including gowns, were hanging on the back of a closet door in the room. LPN #208 did not put on a gown. LPN #208 proceeded to provide wound care to Resident #165's right foot. LPN #208 helped reposition Resident #165's legs in bed and elevated his legs on pillows. LPN #165 then removed the old wound dressing and applied a new dressing. LPN #208 did not put on a gown at any time during Resident #165's wound care.
During an interview on 04/26/23 at 1:07 P.M., LPN #208 confirmed Resident #165 was ordered to be on contact precautions for MRSA in his right foot. LPN #208 confirmed she did not put on a gown while providing wound care to Resident #165's right foot.
Review of the facility's policy dated 12/01/20 revealed contact precaution refers to actions designed to reduce/prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. Healthcare personnel caring for residents in contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.
2. Interview with Maintenance Director #254 on 04/26/23 at 11:50 A.M. stated he did not have proof of the facility assessment or surveillance plan for Legionella, and he was not able to find a program on his electronic maintenance system to follow.
Interview with the Administrator on 04/26/23 at 11:56 A.M. verified there was no evidence of a facility assessment or surveillance plan for Legionella, and the facility did not have any knowledge it was not being completed.
Review of the facility policy dated 12/01/22 revealed it is the the policy to establish primary and secondary strategies for the prevention and control of Legionella infections. The guidelines included Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on review of employee files, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNAs) who worked the in the facility for more than one year ...
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Based on review of employee files, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNAs) who worked the in the facility for more than one year received 12 hours of continuing education for the previous year, and failed to ensure STNAs received specific education related to providing care and services to residents on the special care unit. This affected eight (STNA #212, #213, #218, #226, #243, #244, #246, and #278) of eight employee files reviewed. The deficient practice had the potential to affect all 58 residents residing in the facility. The census was 58.
Findings include:
1. Review of STNA #212's employee file revealed a hire date of 05/18/08. The file indicated STNA #212 received only two hours of continuing education for the past year. The file was absent for any documentation STNA #212 completed any special training for the special care unit.
2. Review of STNA #213's employee file revealed a hire date of 09/19/96. The file indicated STNA #213 received only three hours of continuing education for the past year. The file was absent for any documentation STNA #213 completed any special training for the special care unit.
3. Review of STNA #218's employee file revealed a hire date of 04/21/23. The file was absent for any documentation STNA #218 completed any special training for the special care unit.
4. Review of STNA #226's employee file revealed a hire date of 09/11/03. The file indicated STNA #226 received only five hours of continuing education for the past year. The file was absent for any documentation STNA #226 completed any special training for the special care unit.
5. Review of STNA #243's employee file revealed a hire date of 02/20/23. The file was absent for any documentation STNA #243 completed any special training for the special care unit.
6. Review of STNA #244's employee file revealed a hire date of 01/22/19. The file indicated STNA #244 received only seven hours of continuing education for the past year. The file was absent for any documentation STNA #244 completed any special training for the special care unit.
7. Review of STNA #246's employee file revealed a hire date of 12/01/22. The file was absent for any documentation STNA #246 completed any special training for the special care unit.
8. Review of STNA #278's employee file revealed a hire date of 01/01/23. The file was absent for any documentation STNA #278 completed any special training for the special care unit.
Interview on 04/25/23 at 5:30 P.M. with Director of Nursing verified four (#212, #213, #226, and #244) STNAs did not receive the required 12 hours of continuing education for the past year, and eight (#212, #213, #218, #226, #243, #244, #246, and #278) STNAs did not receive specialty care education.
The facility identified 23 (#01, #06, #09, #14, #24, #27, #28, #30, #34, #35, #37, #39, #40, #41, #42, #48, #50, #52, #53, #56, #58, #60, and #61) residents who resided on the special care unit.
Review of the facility policy titled, Dementia Care, dated 12/01/20, revealed all staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Feb 2020
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of policy and procedures, the facility failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of policy and procedures, the facility failed to ensure a splint device was implemented as recommended by occupation therapy. This affected one (#34) out of one resident reviewed for limited range of motion. The facility census was 67.
Findings include:
Review of medical record for Resident #34 revealed an admission dated of 07/23/15 with diagnosis including cerebral infarction, dysarthia, muscle weakness, pain in right hand, major depression, dysphagia, hypertension, diabetes type two, heart failure and Lupus.
Review of Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review of the MDS revealed the resident required extensive assistance of one person for dressing and had impaired functional limitation on one side of the body for the upper and lower extremities.
Review of Occupational Therapy (OT) Discharge summary dated [DATE] documented resident goal to have right hand splint to improve positioning and allow for ease of hand hygiene. Upon discharge resident right palm based splint was being worn at night with no complaints. She was discharged with the right hand splint for functional maintenance program for splinting.
Review of physicians orders from 05/09/19 through 02/18/20 lacked any documentation of the splint device being ordered to ensure proper implementation.
Review of comprehensive care plan from 05/09/19 through 02/18/20 lacked any care plan for Resident #34 right palm based splint device for implementation.
Review of nursing notes from 05/09/19 through 02/18/20 lacked any documentation related to Resident #34 use of the right palm based splint devices to ensure proper implementation.
On 02/18/20 at 10:26 A.M. an observation was made of Resident #34. During the observation her right hand was noted to be contracted. A splint device was observed on the dresser and was not in place.
On 02/19/20 at 2:33 P.M. an observation was made of Resident #34. During the observation her right hand was contracted and the splint device was noted to be on the dresser. The splint device was not in place.
On 02/19/20 at 2:35 P.M. interview with State tested Nurses Aide (STNA) #306 verified Resident #34 right hand is contracted. She also verified she has never seen a split in place and has not seen a schedule for the device. During the interview STNA #306 went to the computer to check on a splint schedule and verified Resident #34 did not have a order or plan in place for placing the splint on her right hand.
On 02/19/20 at 4:31 P.M. Director of Nursing (DON) verified the facility had no documented to ensure the splint device was implemented as recommended per OT. She also verified the Resident #34 revealed to her she hasn't worn it in approximately six months. The DON also verified she is not sure why it wasn't implemented properly. She also verified the Resident #34 right hand has always been contracted since her stroke and is no additional loss of mobility related to the splint device note being implemented.
Review of policy and procure for brace and splint program dated December 2018 documented the purpose of the brace and splint device is to achieve the highest level of independence possible. Further review documented if a resident has a splint device recommended by a specialized therapist the nurse will obtain a physician order for the splint, create a care plan for proper implementation and use and documented in the electronic medical record effective ness of care plan interventions and progress towards goals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and facility policy review, the facility failed to properly store Tuberculin Purified Protein Derivative in two of the three medication storage rooms. Facility ce...
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Based on observation, staff interview and facility policy review, the facility failed to properly store Tuberculin Purified Protein Derivative in two of the three medication storage rooms. Facility census was 67.
Findings include:
Observation on 02/19/20 at 9:25 A.M. of the medication storage in the memory care unit medication room refrigerator revealed an opened vial of Tuberculin Purified Protein Derivative with no date of opening. The box indicated once entered the vial should be discarded after 30 days.
Observation on 02/19/20 at 9:35 A.M. of the medication storage in the west nurses station medication room refrigerator revealed an opened vial of Tuberculin Purified Protein Derivative with no date of opening. The box indicated once entered the vial should be discarded after 30 days.
Interview on 02/19/20 at 9:25 A.M. with Assistant Director of Nursing #106 provided verification of lack of an opened date on the bottle or the box of Tuberculin Purified Protein Derivative
Review of the facility policy titled Medication Management dated 10/19 revealed medications will be dated per manufactures guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident and staff interview, the facility failed to provide routine dental services for a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident and staff interview, the facility failed to provide routine dental services for a resident. This affected one (#11) of four sampled for dental care services. The facility census was 67.
Findings include:
Review of the clinical record revealed Resident #11 was admitted [DATE] with diagnoses of type-two diabetes, hypertension, hyperlipidemia and hypothyroidism.
Review of the care plan dated 08/14/19 revealed Resident #11 was edentulous, had full dentures, and preferred not but prefers not to wear them.
Review of physician note dated 05/09/2018 revealed Resident #11 was seen in facility by the facility contracted dentist for routine oral exam. The findings stated the resident's dentures did not fit well, and the next visit was recommended in 12 months.
Review of physician note dated 11/21/18 revealed Resident #11 was seen at the facility by the facility contracted dentist for a focused exam regarding concerns with dentures. Suggested treatment included to adjust as needed.
Review of Resident #11's annual Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review of the MDS revealed the resident had broken or loosely fitting full or partial dentures and had no natural teeth or tooth fragment(s) (edentulous).
Interview conducted 02/18/20 at 10:47 A.M., Resident #11 revealed she did not wear her dentures due to them not fitting properly. She further stated she had not seen a dentist in over a year.
Interview 02/19/20 at 2:30 P.M., Social Worker #153 verified Resident #11 had not received dental services since 11/21/18.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on medical record review, observation, staff and resident interview, review of the facility smoker list, review of mobile cognitively impaired resident list and review of policy and procedures, ...
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Based on medical record review, observation, staff and resident interview, review of the facility smoker list, review of mobile cognitively impaired resident list and review of policy and procedures, the facility failed to secure tobacco products were stored in a safe manner. The affected one (#17) out of five residents identified as smokers. This had the potential to affect 27 mobile cognitively impaired residents (#1, #3, #4, #6, #13, #18, #19, #21, #22, #23, #25, #27, #29, #30, #35, #36, #38, #45, #46, #48, #58, #62, #64, #67, #70, #71 and #172) were mobile and cognitively impaired with high risk for accident hazards related unsecured tobacco products. Facility census was 67.
Findings include:
Review of medical record for Resident #17 revealed an admission dated of 03/18/19 with diagnosis including type two diabetes, anoxic brain injury, left lower below the knee amputee, hypertension and vitamin D deficiency.
Review of guest who smoke list undated documented Resident #17 was a smoker.
On 02/18/20 at 11:28 A.M. an observation was made of Resident #17 room. During the observation he was observed to have a tray with tobacco with empty filtered cigarettes to roll his own cigarettes. During the observation Resident #17 revealed he was a smoker and always kept his tobacco in his room to roll his own cigarettes.
On 02/18/20 at 4:21 P.M. an interview with the Director of Nursing (DON) verified Resident #17 is not suppose to have his tobacco and tobacco products in his room. She then verified these items should be kept secure at the nurses station. She also verified she would have it removed from the room and secure it at the nurses station.
Review of mobile cognitively impaired resident list undated provided by the facility revealed residents (#1, #3, #4, #6, #13, #18, #19, #21, #22, #23, #25, #27, #29, #30, #35, #36, #38, #45, #46, #48, #58, #62, #64, #67, #70, #71 and #172) were mobile and cognitively impaired with high risk for accident hazards related unsecured tobacco products. The facility confirmed the resident listed on this form could potentially access unsecured smoking material.
Review of policy and procedure titled Resident Smokers Policy revised June 2016 documented all lighters, matches, cigarettes, and tobacco must be kept secure at the nurses station. The policy is to provide and maintain smoking practices to ensure the safety and comfort of all residents, staff and visitors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, review of pureed pork recipe, and review of facility list of residents on pureed diets, the facility failed to prepare pureed food in a manner that retained its ...
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Based on observation, staff interview, review of pureed pork recipe, and review of facility list of residents on pureed diets, the facility failed to prepare pureed food in a manner that retained its nutritive content. This had the potential to affect eight residents (#14, #21, #26, #35, #54, #56, #63, and #68) on pureed diets. Facility census was 67.
Findings include:
Observation 02/19/20 at 9:50 A.M., [NAME] #512 add on half quart of water to eight pork riblets to make eight servings of pureed pork riblets.
Interview 02/19/20 at 9:50 A.M., [NAME] #512 stated she added water to the eight servings of meat until the the consistency was like pudding.
Interview 02/19/20 at 9:55 A.M., Dietary Manager #150 verified she was unaware the pureed pork recipe called for barbeque sauce not water for thinning meat consistency.
Review of policy titles Pureed Pork Riblet dated 2019 revealed barbeque sauce is to be added to the pureed meat if the consistency needs to be thinned.
Review of facility list of residents on pureed diets revealed eight residents (#14, #21, #26, #35, #54, #56, #63, and #68) in the facility received pureed diets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, review of policies and procedures, and review of list provided by facility of residents who do not eat by mouth (NPO), the facility failed to prepare food in a s...
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Based on observation, staff interview, review of policies and procedures, and review of list provided by facility of residents who do not eat by mouth (NPO), the facility failed to prepare food in a sanitary manner. This had the potential to affect all but two residents (#8 and #58) of 67 residents who received meals from the kitchen. Facility census was 67.
Findings include:
Observation on 02/19/20 from 10:40 A.M. to 10: 50 A.M revealed [NAME] #512 stopped plating food to write on resident dining tickets, reheat pureed food in the microwave, and flip through a binder on the kitchen counter. [NAME] #512 began plating food again placing pickles on the plate with her gloved hands, without removing her gloves and performing hand hygiene between tasks.
Interview 02/19/20 at 10:50 A.M. [NAME] #512 verified she did not change her gloves or perform hand hygiene between tasks during.
Review of policy titled Disposable Gloves dated 04/10 revealed gloves are to be changed between tasks and hands washed each time gloves are removed to prevent cross-contamination.
Review of facility list of NPO residents, Resident #8 and resident #58 are the only residents who did not receive meals from the kitchen.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Ohio facilities.
Concerns
- • 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (55/100). Below average facility with significant concerns.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Divine Rehabilitation And Nursing At Shane Hill's CMS Rating?
CMS assigns DIVINE REHABILITATION AND NURSING AT SHANE HILL an overall rating of 3 out of 5 stars, which is considered average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Divine Rehabilitation And Nursing At Shane Hill Staffed?
CMS rates DIVINE REHABILITATION AND NURSING AT SHANE HILL's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Divine Rehabilitation And Nursing At Shane Hill?
State health inspectors documented 23 deficiencies at DIVINE REHABILITATION AND NURSING AT SHANE HILL during 2020 to 2025. These included: 23 with potential for harm.
Who Owns and Operates Divine Rehabilitation And Nursing At Shane Hill?
DIVINE REHABILITATION AND NURSING AT SHANE HILL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by DIVINE HEALTHCARE MANAGEMENT, a chain that manages multiple nursing homes. With 69 certified beds and approximately 64 residents (about 93% occupancy), it is a smaller facility located in ROCKFORD, Ohio.
How Does Divine Rehabilitation And Nursing At Shane Hill Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, DIVINE REHABILITATION AND NURSING AT SHANE HILL's overall rating (3 stars) is below the state average of 3.2, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Divine Rehabilitation And Nursing At Shane Hill?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Divine Rehabilitation And Nursing At Shane Hill Safe?
Based on CMS inspection data, DIVINE REHABILITATION AND NURSING AT SHANE HILL 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 3-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Divine Rehabilitation And Nursing At Shane Hill Stick Around?
Staff turnover at DIVINE REHABILITATION AND NURSING AT SHANE HILL is high. At 61%, the facility is 15 percentage points above the Ohio average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Divine Rehabilitation And Nursing At Shane Hill Ever Fined?
DIVINE REHABILITATION AND NURSING AT SHANE HILL 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 Divine Rehabilitation And Nursing At Shane Hill on Any Federal Watch List?
DIVINE REHABILITATION AND NURSING AT SHANE HILL 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.