Community Skilled Healthcare

Inspectors wroteBased on closed record review, review of an Emergency Medical Services (EMS) Run Report, review of the American Heart Association (AHA) 2025 guidance for adult Cardiopulmonary Resuscitation (CPR), review of the facility CPR policy and interview, the facility failed to promptly and correctly provide basic life support (BLS) including Cardio-Pulmonary Resuscitation (CPR) to Resident #92, (a resident with advance directives for a Full Code status), when the resident was found unresponsive and absent of vital signs. This resulted in Immediate Jeopardy and actual serious life-threatening harm and subsequent death of Resident #92 on 03/07/26 at approximately 9:00 A.M. when Transportation Aide (TA) #873 identified Resident #92 was unresponsive. [...]

Inspectors wroteBased on interview and record review, the facility failed to take reasonable steps to ensure residents were assisted by a designated staff member for conducting resident council meetings and residents were timely informed of meetings in advance. This had the potential to affect all 83 residents residing in the facility. The facility census was 83.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to ensure residents were informed of their rights on an ongoing basis. This had the potential to affect all 83 residents currently residing in the facility.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to inform the residents of their right to file a complaint with the State survey and certification agency. This had the potential to affect all 83 Residents in the facility.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure all residents were informed on the grievance filing process. This had the potential to affect all 83 residents residing in the facility. The facility census was 83.

Inspectors wroteBased on review of records and interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all residents residing in the facility. The facility census was 83.

Inspectors wroteBased on observation, record review, job description review and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all residents who resided in the facility. The facility census was 83.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly conduct a facility-wide assessment with active involvement of all required participants to determine what resources are necessary to care for the residents competently during day-to-day operations. This had the potential to affect all residents residing in the facility. The facility census was 83.

Inspectors wroteBased on record review and interview, the facility failed to have a current transfer agreement with an area hospital. This had the potential to affect all residents residing in the facility. The facility census was 83.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure care plans were revised in response to resident assessments and physician ordered interventions for Resident #10, Resident #49, Resident #71, and Resident #90. This affected four residents (#10, #49, #71,and #90) of 47 residents reviewed for care plans. The facility census was 83.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #78 was provided one-to-one activities to meet personal needs, and failed to ensure all residents residing on the memory care unit (Residents #4, #5, #8, #10, #13 , #14, #16, #17, #23, #30, #40, #42 , #46, #47, #48, #50, #59, #64 , #65, #66, #68, #72, #83, and #84) received a program of therapeutic activities for their highest practical well-being. This affected 25 residents (Residents #4, #5, #8, #10, #13, #14, #16, #17, #23, #30, #40, #42 , #46, #47, #48, #50, #59, #64 , #65, #66, #68, #72, #78, #83, and #84) of 83 residents observed for activities. The facility census was 83.

Inspectors wroteBased on employee personnel file review, review of the facility assessment, review of the facility policy and interview, the facility failed to ensure staff had specialized training for the memory care unit. This had the potential to affect all residents (Residents #4, #5, #8, #10, #13, #14, #16, #17, #23, #30, #40, #42, #46, #47, #48, #50, #59, #64, #65, #66, #68, #72, #83, and #84) residing in the memory care unit The facility census was 83.

Inspectors wroteBased on record review, interview and observation the facility failed to ensure call lights were within reach for Residents #13, #76, and #84. This affected three (Residents #13, #49, and #84) of three residents reviewed for call lights. The facility census was 83.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to provide written notice of room changes to the resident and family representative. This affected one resident (#79) out of one resident reviewed for room change. The facility census was 83.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure residents were free from physical restraints. This affected one resident (Resident #66) of one resident reviewed for physical restraints. The facility census was 83.

Inspectors wroteBased on record review and interview the facility failed to ensure residents were notified of bed hold information prior to discharge to the hospital and failed to notify the Ombudsman of hospitalizations. This affected two residents (Residents #2 and #5) of two residents reviewed for hospitalizations. The facility census was 83.

Inspectors wroteBased on record review and interview the facility failed to ensure a care plan was developed to include discharge planning for Resident #77. This affected one resident (#77) of 47 residents reviewed for care plans. The facility census was 83.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to administer a proper dose of acetaminophen (analgesic) to Resident #60. This affected one (Resident #60) of six residents observed for medication administration. The facility also failed to address x-rays in a timely manner for Resident #10. This affected one (Resident #10) of two residents reviewed for falls. The facility census was 83.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to secure smoking materials for Resident #52. This affected one Resident (#52), who was identified as the facility's only smoker, of one resident reviewed for smoking and had the potential to affect all residents in the facility. The facility's census was 83.

Inspectors wroteBased on record review, observation, facility policy review and interview, the facility failed to ensure Resident #9's nasal spray was stored in a safe manner. This affected one (Resident #9) of six residents observed during medication administration. In addition, the facility failed to date a multi-dose vial of Tubersol (a liquid that is used to test if someone has been exposed to tuberculosis) in a manner to preserve efficacy. This had the potential to affect all residents who may require tuberculin skin testing using multi-dose vials. The facility census was 83.

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to ensure dental services were obtained for Resident #4. This affected one resident (Resident #4) of two residents reviewed for dental services. The facility census was 83.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to ensure attractive and palatable pureed food was served to Resident #39. This affected one Resident (#39) of three residents reviewed for food. The facility identified nine residents (#10, #35, #39, #41, #64, #65, #66, #74, #79) as receiving pureed diets. The census was 83. Review of the medical record for Resident #39 revealed an admission date of 04/26/25 with medical diagnoses including diaphragmatic hernia without obstruction or gangrene, other idiopathic peripheral autonomic neuropathy, and moderate protein-calorie malnutrition. The prescribed diet was listed as pureed texture, regular consistency and no added salt. An interview on 04/08/26 at 10:55 A.M. with Resident #39 revealed most days his pureed food was runny and not appealing. Observation on 04/08/26 at 12:39 P.M. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure influenza and pneumococcal vaccines were addressed and administered timely for Resident #66. This affected one Resident (#66) of seven residents investigated for timely vaccination administration. The facility census was 83.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a COVID 19 vaccine was addressed and administered timely for Resident #66. This affected one Resident (#66) of seven residents investigated for timely vaccination administration. The facility census was 83.

Inspectors wroteBased on record review, interview, review of the facility self-reported incident (SRI) and investigation and facility policy review, the facility failed to ensure resident-to-resident abuse did not occur between Resident #52 and Resident #40. This affected two (Residents #40, and #52) of six residents reviewed for abuse. The facility census was 91. Review of the medical record for Resident #40 revealed an admission date of 04/07/16. Diagnoses included autistic disorder, developmental disorder, anxiety, hypertension and scoliosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was severely cognitively impaired. She required substantial assistance for eating and was dependent for oral care, toileting, showering, dressing and personal hygiene. Review of the medical record for Resident #52 revealed an admission date of 03/20/25. [...]

Inspectors wroteBased on interviews, record reviews, review of facility Self-Reported Incidents (SRI), and review of facility policies the facility failed to ensure residents were free from misappropriation. This affected three residents (Residents #2, #26, and #94) of three residents reviewed for misappropriation. The facility census was 91.

Inspectors wroteBased on interview, review of facility Self-Reported Incidents (SRI), and review of facility policy, the facility failed to implement policies related to misappropriation. This affected one Resident (Resident #26) out of three residents reviewed for misappropriation. The facility census was 91.

Inspectors wroteBased on record review, interview, review of the facility self-reported incident (SRI) and investigation and review of the facility policy, the facility failed to thoroughly investigate allegations of resident-to-resident abuse. This affected two (Residents number #40 and #52) of six residents reviewed for abuse. The facility census was 91. Review of the medical record for Resident #40 revealed an admission date of 04/07/16. Diagnoses included autistic disorder, developmental disorder, anxiety, hypertension and scoliosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was severely cognitively impaired. She required substantial assistance for eating and was dependent for oral care, toileting, showering, dressing and personal hygiene. Review of the medical record for Resident #52 revealed an admission date of 03/20/25. [...]

Inspectors wroteBased on interview, medical record review, and review of facility policy the facility failed to ensure Resident #93 received a safe and complete discharge process. This affected one resident (Resident #93) out of four residents reviewed for discharge. The facility census was 91. Review of Resident #93's medical record revealed an admission date of 10/03/25 and a discharge date to home on [DATE]. Diagnosis included Rhabdomyolysis, moderate protein-calorie malnutrition, hypertensive chronic kidney disease stage V, seizures, hypothyroidism, anemia, hyperfunction of pituitary gland, urinary retention, hyperlipidemia, diabetes insipidus, and hypopituitarism. Review of Resident #93's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment and required set up or clean up assistance for Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on record review, interviews and review of the facility policy, the facility failed to ensure sufficient staffing to meet the needs of all residents. This affected three (Residents #35, #67 and #69) of six residents reviewed for showers and had the potential to affect all 75 residents in the facility.

Inspectors wroteBased on review of the facility schedule and interview, the facility failed to ensure a Registered Nurse (RN) was in the facility for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 75 residents in the facility.

Inspectors wroteBased on review of the Facility Assessment and interview, the facility failed to ensure the facility assessment was updated annually. This had the potential to affect all 75 residents in the facility.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to notify the responsible party, Power of Attorney (POA) or emergency contact of resident transfers to the hospital. This affected two (Residents #10 and #51) of three residents reviewed for notification. The facility census was 75.

Inspectors wroteBased on record review and interview, the facility failed to send information to the hospital regarding resident health status upon transfer. This affected two (Residents #10 and #51) of three residents reviewed for hospitalizations. The facility census was 75.

Inspectors wroteBased on record review, staff interview, resident interview and facility policy review, the facility failed to ensure residents received baths or showers per resident preference. This affected three (Resident #35, Resident #67, and Resident #69) out of six residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure physician orders to prevent skin breakdown were being followed. This affected one resident (Resident #9) out of three residents that were sampled for skin breakdown. The facility census was 75.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to ensure falls were thoroughly investigated. This affected two (Residents #22 and #51) of three residents reviewed for falls. The facility census was 75.

Inspectors wroteBased on observation and interview, the facility failed to ensure staffing information was posted timely and accurately. This had the potential to affect all 75 residents in the facility.

Inspectors wroteBased on medical record review, staff interview, review of the facility Self-Reported Incidents (SRIs), review of the facility investigation, and facility policy review, the facility failed to ensure thorough investigations were completed regarding diversion of narcotics and a resident-to-resident altercation. The facility also failed to ensure preventative and corrective measures were in place. This affected three residents (# 11, #61 and #72) of four residents who were investigated for abuse and misappropriation. The facility census was 82.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure there was a registered nurse (RN) on duty for at least eight consecutive hours, seven days a week as required. This had the potential to affect all 80 residents. The facility census was 80.

Inspectors wroteBased on record review, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) manual, and interview, the facility failed to accurately code MDS assessments for five residents (#5, #11, #51, #71 and #73) of seven residents reviewed for resident assessments. The facility census was 80. Findings Include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, chronic obstructive pulmonary disease (COPD), seizures, heart disease, gastric reflux, generalized anxiety disorder, and vascular dementia without behavioral disturbance. Review of the physician's orders for Resident #5 revealed she was admitted to hospice upon admission [DATE]) with a diagnosis of end stage cerebral atherosclerosis. [...]

Inspectors wroteBased on record review, observation and interview the facility failed to maintain Resident #36's right to a dignified existence. This affected one resident (Resident #36) of the three residents reviewed for dignity. The facility census was 80.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #37 was provided adequate assistance during ambulation to prevent a fall and that fall risk evaluations/assessments were completed at least quarterly. This affected one resident (#37) of three residents reviewed for falls. The facility census was 80.

Inspectors wroteBased on observation, medical record review, review of hospital records, review of information from the National Pressure Injury Advisory Panel (NPIAP), review of facility policy, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the development of, worsening of and promote the healing of a facility acquired pressure ulcer for Resident #44, a resident who was at risk for pressure ulcer development and dependent on staff for all activities of daily living (ADLs) including bed mobility, turning and repositioning, incontinence care for both bowel and bladder, showering, and dressing. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain sufficient nursing services staff to meet the total care needs of residents according to their plan of care. This affected six residents (#4, #10, #32, #44, #72 and #79) and had the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility administration did not ensure proper management of all resources for the highest practicable wellbeing of all residents which included failure to eradicate bed bugs, failure to ensure sufficient nursing staff to meet the resident's acuity needs, and failure to ensure resident rooms were maintained in a manner to protect the resident right to a safe, clean, comfortable environment. This had the potential to affect all 78 residents living in the facility. The facility census was 78.

Inspectors wroteBased on observation, medical record review, shower schedule review, review of facility policy and staff and resident interview, the facility failed to ensure residents received showers per schedule or preference. This affected six Residents (#4, #10, #32, #44, #72 and #79) out of six Residents reviewed for showers. The facility census was 78.

Inspectors wroteBased on observations, maintenance log review, medical record reviews, and staff and resident interviews the facility failed to ensure the walls in the resident rooms for Resident #1 and Resident #79 were in good repair. This affected two residents (Residents #1 and Resident #79) of eleven residents reviewed for physical environment. The facility census was 78.

Inspectors wroteBased on observation, staff and resident interviews, record review and review of exterminator invoices the facility failed to maintain an effective pest control program for bed bugs. This affected one resident (Resident #4) of eleven residents reviewed for physical environment and had the potential to affect the additional 77 residents residing in the facility. The facility census was 78.

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain a sanitary kitchen to prepare food in a manner to prevent contamination and food borne illness. This had the potential to affect 80 residents who receive food from the kitchen. The facility identified zero residents who did not eat by mouth. The facility census was 80.

Inspectors wroteBased on interviews, policy review, and review of the facility's investigation notes, the facility failed to ensure resident medications were not misappropriated. This affected two current residents (Residents #20 and #33) and two former residents (Residents #234 and #332) who resided on the one-hundred hall and had the potential to affect seven additional residents ( #26, #50, #54, #59, #67, #68, and #79) the facility identified as receiving controlled substances from the one hundred medication cart. The facility census was 80.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Ohio Department of Health (ODH) facility self-reported incidents (SRIs), the facility failed to file an SRI report related to allegations of misappropriation affecting four residents (Residents #20 and #33 and Former Residents #234, and #332) out of five residents reviewed for misappropriation. The facility census was 80.

Inspectors wroteBased on observation, interviews, record reviews, review of the memorandum from the Department of Health & Human Services and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to ensure proper infection control practices were followed for Resident #14, #27, #41, #53, #69 and #78 who required enhanced barrier precautions (EBP) and Resident #55 who required blood glucose monitoring. This affected seven residents (#14, #27, #53,#69, #55 and #78) out of 80 residents observed for infection control. The facility census was 80.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure the resident's right to self-administer medications was clinically appropriate. This affected one Resident (#78) of eight residents reviewed for medication administration. The facility census was 80.

Inspectors wroteBased on interview, medical record review, and policy review the facility failed to ensure resident choices related to advanced directives were honored. This affected one resident (Resident #78) of two reviewed for advanced directives. The facility census was 80.

Inspectors wroteBased on observation, interview, and record review the facility failed to change nasal cannula oxygen tubing in a timely manner. This affected one resident (#39) of one resident reviewed for oxygen use. The facility identified 18 residents (#2, #14, #21, #22, #24, #27, #30, #33, #39, #41, #50, #51, #52, #60, #63, #67, #76 and #132) utilizing oxygen. The facility census was 80.

Inspectors wroteBased on staff interview, review of personnel files and policy review, the facility failed develop and implement policies and procedures to include checking references of three employees to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This had the potential to affect all 80 residents residing in the facility. The facility census was 80.

Inspectors wroteBased on record review, interview, review of Authorization for Release of Specialized Privileged Information and facility policy review, the facility failed to provide copies of the medical record to Resident #8's representative. This affected one resident (#8) of one resident reviewed for medical record requests. The facility census was 89.

Inspectors wroteBased on record review, interview, review of self-reported incident (SRI) and facility policy review, the facility failed to thoroughly investigate an allegation of sexual abuse as required. This affected one resident (#47) of three residents reviewed for abuse. The facility census was 89.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #64 was provided showers according to his needs and preferences. This affected one resident (Resident #64) out of eight residents reviewed for showers. The facility census was 89.

Inspectors wroteBased on interview, record review, Self-Reported Incident (SRI) tracking number (#)240778 review, facility investigation review, Police Report #23-23497 review, and review of the abuse policy the facility failed to ensure Resident #6 was free from staff to resident abuse. This affected one resident (#6) out of six residents reviewed for abuse. The facility census was 86.

Inspectors wroteBased on record review, personnel file review, interview, and review of the Ohio Board of Nursing website the facility failed to ensure medications were administered by a licensed nurse. This affected 42 residents (#2, #6, #10, #12, #13, #14, #15, #16, #17, #18, #20, #23, #25, #27, #30, #31, #35, #36, #37, #40, #42, #44, #45, #46, #47, #51, #53, #55, #57, #58, #60, #63, #64, #65, #69, #70, #73, #74, #75, #76, #77, and #78). The facility census was 82.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #41's physician was notified timely on radiographic findings. This affected one (Resident #41) of four residents reviewed for notification. The facility census was 85.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff properly transferred Resident #41 with a mechanical hoyer lift and failed to ensure a thorough investigation was completed following Resident #41's fall from the mechanical hoyer lift. This affected one (Resident #41) of three residents reviewed for falls and mechanical lift transfers. The facility census was 85.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #86 had oxygen orders from the physician corresponding to the oxygen she was utilizing. This affected one (Resident #86) of three residents reviewed for respiratory care. The facility census was 85.

Inspectors wroteBased on record review, facility policy and procedure review, and interview the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property as required. This had the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure Resident #5's guardian was notified when she was sent to the hospital. This affected one (Resident #5) of three residents reviewed for hospitalizations (Residents #5, #55 and #70). The facility census was 76.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #71 was free of staff to resident verbal abuse. This affected one (Resident #71) of three residents (Residents #4, #17, and #71) reviewed for abuse. The facility census was 76.