Cridersville Nursing and Rehab

Inspectors wroteBased on medical record review, staff and Guardian interviews, and policy review, the facility failed to ensure residents had access to their medications upon discharge. This affected one resident (#50) of two reviewed for discharge. The facility census was 50.

Inspectors wroteBased on record review, resident interviews, staff interviews, review of facility scheduled medication pass times, and policy review the facility failed to administer medications as ordered. This affected three (Residents #2, #7 and #30) out of six residents reviewed for medication. The facility census was 39.

Inspectors wroteBased on observation, staff interview, and facility policy, the facility failed to ensure accurate and completed crash cart audits. This affected eighteen (#10, #11, #12, #14, #18, #19, #20, #22, #23, #24, #25, #27, #28, #29, #30, #32, #42, and #43) out of thirty-five full code residents. The facility census was 35. Observation and interview of crash cart on 04/27/26 at 3:05 P.M. with the Director of Nursing (DON) revealed April 2026 daily audit documentation did not include verification of expiration dates. Review of the crash cart audit logs further showed an extension cord was in the cart on 04/13/26, 04/17/26 and 04/26/26: however, observation confirmed the extension cord was not present in the crash cart at the time of inspection. [...]

Inspectors wroteBased on medical record review, review of hospital documents, and resident and staff interview, the facility failed to prevent an avoidable fall. Actual harm occurred on 08/10/25 when Resident #33 was in the bathroom leaning on the sink. The sink broke loose from the wall, fell to the floor, and broke into pieces. Resident #33 subsequently fell on top of a sharp piece of the sink and sustained a five millimeter (mm) laceration which hemorrhaged blood and required hospitalization with sutures needed to close the wound. This affected one (Resident #33) of three residents reviewed for accidents. The census was 41.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of invoices and receipts, the facility failed to maintain a homelike environment for its residents. This affected four (#9, #16, #33, and #35) of 25 residents reviewed for physical environment. The census was 41.

Inspectors wroteBased on medical record review and staff interview, the facility failed to initiate a care plan related to anticoagulation medication use. This affected one (#24) of three residents reviewed for care plans. The census was 41.

Inspectors wroteBased on medical record reviews, staff, resident and resident representative interviews, review of Self-Reported Incidents (SRI's), and policy review, the facility failed to ensure a resident was free from sexual abuse. This affected one (#12) out of three residents reviewed for abuse. The facility census was 39.

Inspectors wroteBased on review of a closed medical record, staff interview, policy review, Emergency Medical Services (EMS) run sheet, and review of staff statements, the facility failed to immediately start and continue Cardio-Pulmonary Resuscitation (CPR) until EMS were on scene for one resident (Resident #42) who was identified as a Full Code status and was found unresponsive without vital signs. This resulted in serious life-threatening harm and/or death when Resident #42 did not receive immediate and continuous CPR prior to EMS services arriving at the facility. This affected one (Resident #42) of three residents reviewed for code response. The facility identified 24 residents residing in the facility designated with Full Code status. The facility census was 40. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the outside provider respiratory notes, the facility failed to ensure a Bilevel Positive Airway Pressure (BiPAP) was ordered after a resident returned from the hospital. This resulted in Actual Harm when Resident #34 was admitted to the hospital with an oxygen (O2) level of 38 percent (%) and was admitted to the hospital and placed on a ventilator. This affected one resident (#34) out of three residents reviewed for oxygen. The census was 40.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified of a change in condition when the resident had an elevated blood pressure. This affected one (Resident #34) of three reviewed for change in condition. The facility census was 40.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's care plan had goals and interventions in place for wound care. This affected one (Resident #45) of three residents reviewed for wound care. The facility census was 40.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete weekly wound assessments. This affected one (Resident #43) of three residents reviewed for wounds. Additionally, the facility failed to complete wound treatments as ordered. This affected one (Resident #12) of three residents reviewed for wound care. Lastly, the facility failed to ensure a resident made it to a scheduled outside doctor's appointment. This affected one (Resident #12) of three residents reviewed for appointments. The facility census was 40.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure physician orders were followed during medication administration. This affected one resident (#12) of three reviewed for medication administration. The facility census was 40. .

Inspectors wroteBased on medical record review, staff interview, review of facility policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to timely cohort COVID-19 positive residents. This affected four (Residents #39, #11, #29, and #34) of four residents reviewed for COVID-19 isolation. The facility census was 42.

Inspectors wroteBased on review of facility submitted Self-Reported Incidents (SRIs), medical record review, staff interview, review of the facility investigation and review of facility policy, the facility failed to report an allegation of resident abuse to the Ohio Department of Health (ODH). This affected one (#03) of three residents reviewed for abuse. The facility census was 43.

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure one resident reviewed assistance to maintain regular bowel movements. This affected one (#81) of one resident reviewed for bowel movements. The facility census was 29.

Inspectors wroteBased on medical record review, staff interview, and review of the policy, the facility failed to complete skin assessments and document skin alterations for a resident. This affected one (#81) of three resident reviewed for pressure ulcers. The facility census was 29.

Inspectors wroteBased on medical record review, observations, staff interviews, and resident interview, the faciliy failed to ensure a resident experiencing pain was provided pain management. This affected one (#11) of one residents reviewed for pain management. The faciliy census was 29.

Inspectors wroteBased on record review, review of the infection control logs, resident interview, and staff interview, the facility failed to ensure a resident did not receive unnecessary medications. This affected one (#11) of six residents reviewed for unnecessary medications. The current census is 29.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure narcotic medication administration was documented in the medical records for residents. This affected one (#11) of five residents reviewed for medication administration documentation. The current census is 29.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to place one resident in Enhanced Barrier Precautions (EBP) to prevent the spread of infection. This affected one (#81) of one resident reviewed for infection control. The facility census was 29.

Inspectors wroteBased on review of a closed medical record, review of hospital documentation, review of an emergency medical services (EMS) run detail report, review of a facsimile (fax) document, staff interviews, and review of facility policy, the facility failed to ensure a resident (#30) was provided appropriate and timely treatment, care, and services when the resident was assessed with changes in condition. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #30 was ordered supplemental oxygen and a non-invasive ventilator (NIV) for use to aid the resident's respiratory status. [...]

Inspectors wroteBased on review of medical records, resident and staff interview, and policy review, the facility failed to ensure the physician was notified when residents were not using non-invasive ventilators (NIVs) as ordered and notify the physician of abnormal vital signs. This affected three (#20, #25, and #30) of three residents reviewed who used NIVs in a facility census of 30.

Inspectors wroteBased on resident record reviews, staff interviews, and review of facility policy, the facility failed to conduct thorough root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury, resulting in actual harm when a resident experienced repeated falls resulting in fractures. This affected one resident (#30) of three residents reviewed for falls. The census was 30.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure food was prepared and stored in a safe and sanitary manner. This had the potential to affect all 31 residents residing in the facility. The census was 30.

Inspectors wroteBased on review of facility records, staff interview, and review of facility policy, the facility failed to hold Quality Assessment and Assurance meetings at least quarterly. This had the potential to affect all 31 residents in the facility. The facility census was 30. Findings Include: Review of the Quality Assurance (QA) sign in sheets revealed a QA meeting was held on 01/27/22. No other meetings were documented as being completed. There were no meetings documented taking place from March 2021 to October 2021. Interview on 04/14/22 at 1:42 P.M. the Administrator verified there were no QA meetings held from March 2021 through October 2021. Review of the undated facility policy titled, Quality Assurance Committee, revealed the QA committee shall meet at least quarterly and as needed.

Inspectors wroteBased on record review and interview with the Director of Nursing, the facility failed to offer vaccination for pneumonia to residents. This affected four residents (#1, #8, #19, and #24) of five residents reviewed for pneumonia vaccination. The census was 30.

Inspectors wroteBased on resident record review, resident and staff interviews, and policy review, the facility failed ensure residents/resident representatives were given the opportunity to participate in the care planning process. This affected one (#2) of one resident reviewed for care planning. The census was 30.

Inspectors wroteBased on observation, resident record review, and staff interview, the facility failed to ensure pressure reduction interventions were utilized as ordered by the physician. This affected one (#8) of three resident reviewed for pressure ulcers. The census was 30.

Inspectors wroteBased on medical record review, facility staff interview, and facility policy review the facility failed to timely revise care plans. This affected two (#29 and #8) of 13 residents reviewed for care plans. The total facility census was 30.

Inspectors wroteBased on resident record review, observation, review of the activities calendar, and staff interview; the facility failed to provide an individualized activities program designed to meet the interests and needs of a resident who resided on the memory care unit. This affected one (#30) of one resident reviewed for activities. The census was 30.