Galion Meadows Skilled Nursing and Rehabilitation

Inspectors wroteBased on observations and interviews, the facility failed to ensure a sanitary kitchen environment, failed to ensure proper food storage and labeling, failed to ensure adequate hand hygiene during meal service, and failed to maintain clean equipment in the food preparation and service areas. This had the potential to affect all residents in the facility. The facility census was 55.

Inspectors wroteBased on observation, medical record review, review of the infection control and surveillance plan, interview, and review of the facility policy, the facility failed to ensure appropriate infection surveillance. This had the potential to affect all residents. Additionally, the facility failed to ensure Personal Protective Equipment (PPE) was worn during care for a resident on Enhanced Barrier Precautions (EBP). This affected one resident (#9) of one resident reviewed for EBP. The facility identified 12 residents on EBP. The facility census was 55. Findings Include: 1. Review of the infection surveillance and control sheets for 01/2026 through 03/2026 revealed the facility did not track each infections bacteria when indicated. Further review of the infection surveillance and control sheets revealed there was no surveillance for the month of 04/2026. Interview on 05/26/26 at 8:32 A.M. [...]

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness and adverse effects. This affected five (#5, #8, #17, #31, and #59) of five residents reviewed for unnecessary medications. The facility identified 43 residents receiving psychotropic medications. The facility census was 55.

Inspectors wroteBased on observation, medical record review, interview, and facility policy review, the facility failed to ensure resident medical records were accurate and complete. This affected six (#3, #9, #18, #26, #43, and #49) of 22 sampled residents reviewed for accuracy of the medical record. The facility census was 55.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure advance directives were consistent throughout the medical record. This affected three (#17, #38, #59) of four residents reviewed for advance directives. The facility census was 55.

Inspectors wroteBased on medical record review, interview, and review of the facility policy, the facility failed to ensure proper assessment and notification to the physician after moving a resident to the secured memory care unit. This affected one (#59) of three residents reviewed for dementia care. The facility census was 55.

Inspectors wroteBased in record review, staff interview, and review of facility policy the facility failed to ensure a bed hold notice and a notice of transfer were given to resident or the resident representative upon discharge to the hospital. This affected one (#56) of one resident reviewed for hospitalization. The facility census was 55.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the state mental health authority for Resident #03 when he was readmitted to the facility with new diagnosis of acute respiratory failure with hypoxia and sepsis after a hospitalization following an incident in which he ingested his own feces and for Resident #16 after a significant change in condition which resulted in a new diagnosed mental health condition. This affected two residents (#03 and #16) of two residents reviewed for preadmission screening and resident review (PASRR). The facility census was 55.

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to timely assess, monitor, and treat a change in skin condition. Additionally, the facility failed to ensure a skin wound treatment was completed per physician orders. This affected two (#18, #42) of two residents reviewed for non-pressure related skin conditions. The facility census was 55.

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure pressure ulcer wound treatments were completed per physician orders. This affected one (#49) of one resident reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 55.

Inspectors wroteBased on record review, resident interview, staff interview, and facility policy review, the facility failed to ensure residents were was free from accident hazards. This affected one (#31) of three residents reviewed for accidents. The facility census was 55.

Inspectors wroteBased on observation, review of the medical record, interview, and policy review, the facility failed to ensure interventions were implemented for significant weight loss, failed to monitor fluid restrictions, and failed to provide nutritional supplements per physician orders. This affected three (#1, #38, #27) of three residents reviewed for nutrition. The facility identified three residents with significant weight loss, two residents with fluid restrictions, and five residents receiving nutritional supplements. The facility census was 55.

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure placement of a gastrostomy tube prior to administering a gastrostomy tube flush. This affected one (#9) of one resident reviewed for tube feeding. The facility identified one resident with a feeding tube. The facility census was 55.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received the necessary respiratory care and services to meet their needs. This affected one (#29) out of two residents reviewed for respiratory care. The facility census was 55.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure ongoing communication with the dialysis services provider. This affected one (#27) of one resident reviewed for dialysis services. The facility identified two residents as receiving dialysis services. The facility census was 55.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that residents with post-traumatic stress disorder (PTSD) received necessary care and services to meet the resident's psychosocial needs. This affected two (#31 and #03) of two residents reviewed for trauma informed care. The facility census was 55.

Inspectors wroteBased on observation, interviews, record review, review of hospital records and policy review, the facility failed to facilitate guardianship and appropriate behavioral health services to meet the complex psychosocial needs of a resident with schizoaffective disorder, post-traumatic stress disorder (PTSD), depression, anxiety, and an intellectual disability, which resulted in Resident #03 continuing with behaviors that were detrimental to his psychosocial and physical well-being. This affected one resident (#03) of two residents reviewed for behaviors. The facility census was 55.

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders resulting in a medication error rate exceeding five percent. 26 opportunities were observed with three medication errors, resulting in a medication error rate of 11 percent. This affected two (#27 and #52) of six residents observed for medication administration. The facility census was 55.

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure a mechanical soft diet was provided per physician orders. This affected one resident (#38) of two residents reviewed for food. The facility census was 55.

Inspectors wroteBased on medical record review, interview, and review of the facility policy, the facility failed to ensure residents received the coronavirus (Covid-19) vaccination upon consent. This affected one (#22) of five residents reviewed for vaccinations. The facility census was 55. Findings Include: Review of the medical record for Resident #22 revealed an admission on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic bronchitis, and peripheral vascular disease (PVD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had impaired cognition. Further review of the MDS revealed Resident #22 was not up to date on the Covid-19 vaccination. Review of the care plan dated 06/25/25 revealed Resident #22 had impaired respiratory status related to COPD, and pulmonary disease. [...]

Inspectors wroteBased on personnel file review, staff interview, and facility policy, the facility failed to ensure newly hired employees were screened through the abuse registry upon hire to identify potential findings related to abuse, neglect, exploitation, or misappropriation of property for seven of seven newly hired employees reviewed. This had the potential to affect all residents residing in the facility. The facility census was 55.

Inspectors wroteBased on observation, resident, family, and staff interviews, and record review, the facility failed to ensure a pleasant homelike environment free of frequent strong foul odors of urine on the North and South units of the facility and failed to ensure the resident's wheelchairs were clean. This had the potential to affect 38 residents residing on the North and South units and affected three (Residents #25, #40, and #43) of four residents whose wheelchairs were observed for cleanliness. The facility census was 51.

Inspectors wroteBased on observations, staff interviews, record review, review of manufacturer instructions, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policies, the facility failed to maintain infection control practices while administering medications to the residents, completing hand hygiene when providing care to the residents, donning proper personal protective equipment (PPE) and completing proper hand hygiene for residents on Enhanced Barrier Precautions (EBP) for indwelling devices, and disinfecting a glucometer between use for Residents #4 and #5. This affected six residents (#4, #5, #34, #37, #40, and #47) observed for infection control. The facility census was 51.

Inspectors wroteBased on resident representative interview, staff interviews, record review, and review of the facility policy, the facility failed to inform a resident's resident representative of a incident involving the resident. This affected one (Resident #37) of three residents reviewed for being informed of health condition. The facility census was 51.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to obtain urine outputs as physician ordered for a resident and failed to ensure a resident's new areas of skin breakdown were timely assessed and treated. This affected one (Resident #37) of three residents reviewed for quality of care. The facility census was 51.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure a resident was safely transferred using a mechanical lift (Hoyer). This affected one (Resident #37) of two residents reviewed for transfers. The facility census was 51.

Inspectors wroteBased on observation, staff interviews, record review, review of the facility policy, and review of the insulin pen guidance, the facility failed to ensure their medication error rate did not exceed five percent (%). Two errors occurred within 27 opportunities for an error rate of 7.4%. This affected one (Resident #40) of five residents observed for medication administration. The facility census was 51.

Inspectors wroteBased on observation, staff interviews, record review, review of the facility policy, and review of the insulin pen guidance, the facility failed to ensure a resident was free from significant medication errors when nursing failed to prime insulin pens prior to insulin administration. This affected one (Resident #40) of five residents observed for medication administration. The facility census was 51.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to timely complete nutritional assessments and requests to obtain resident weights to monitor and provide intervention for continued weight increases. This affected one (#28) of three residents reviewed for nutrition and weights. The census was 48. Findings Include:Review of the medical record for Resident #28 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, unspecified convulsions, hypothyroidism, morbid obesity, type II diabetes, chronic obstructive pulmonary disease, dysphagia, muscle weakness, anxiety disorder, and major depressive disorder. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. [...]

Inspectors wroteBased on medical record review, and resident and staff interview, the facility failed to obtain ordered medications to administer to residents. This affected one (#28) of three residents reviewed for medication administration. The facility census was 48.

Inspectors wroteBased on medical record review, resident and staff interviews, review of hospital records, and review of the facility policy, the facility failed to ensure Resident #10 was safely secured while in his electric wheelchair and failed to ensure his wheelchair was properly secured to the floor of the facility's transport van. Actual Harm occurred on 08/25/25 when, during transit, Resident #10's electric wheelchair tipped and moved forward. Resident #10 landed on the right side of his body while still in the wheelchair and hit his head on the transport van's floor. Resident #10 was admitted to the hospital for three days for treatment and monitoring before being discharged back to the facility. This affected one (Resident #10) of three residents reviewed for accidents. The facility census was 54.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #44 ' s guardian was informed about the potential charges for therapy and the beginning of services, which affected one (#44) of three residents reviewed for therapy, and the facility failed to ensure informed consent was obtained prior to initiating dental services for Resident #44. This affected one resident (#44) of three residents reviewed for ancillary services. The facility census was 51. Findings Include:1.) Review of the Resident #44's medical record revealed an admission date of 03/09/17 with diagnoses including Parkinson's disease, dysphagia, dementia, moderate protein calorie malnutrition, anxiety, depression, heart failure, adult antisocial behavior, adult failure to thrive, and liver disease. [...]

Inspectors wroteBased on record review, family interview, and staff interview, the facility failed to complete physician ordered laboratory work required prior to an appointment for Resident #17, resulting in the appointment needing to be rescheduled. The facility failed to complete neurological assessments for Resident #1, after a fall with a head injury. This affected two (#1 and #17) of three residents reviewed for quality of care and treatment. The facility census was 51.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure parameters for Resident #1's midodrine (to treat low blood pressure) were entered correctly into the medical record and midodrine was administered according to the parameters ordered. This affected one (#1) of three residents reviewed for medications being administered correctly. The facility census was 51.

Inspectors wroteBased on medical record review, family interview, and staff interview, the faciltiy failed to obtain physician ordered laboratory tests for one resident. This affected one (#17) of three residents reviewed for physician orders. the faciltiy census was 51.

Inspectors wroteBased on observation, staff interview, record review, and review of wound care policy, the facility failed to follow the appropriate infection control guidelines when changing dressing for Resident #28's wound. This affected one (#28) of two residents observed for infection control practices. The facility census was 51.

Inspectors wroteBased on observation, staff interview, record review, and review of manufacturer guidelines, the facility failed to ensure the dishwasher reach the minimum temperature to sanitize dishware properly. This had the potential to affect all residents who receive food from the kitchen. The facility identified only one resident who did not receive food from the kitchen. The facility census was 46.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to provide activities of daily living care (ADL) for dependent residents who required assistance from staff with bathing/showers. This affected three of three residents (#38, #41, and #52) reviewed for showers. The facility identified all residents required assistance with showers and bathes. The facility census was 42.

Inspectors wroteBased on observation, staff interviews, record review, and policy review, the facility failed to implement their infection control policies ensuring staff wore the proper personal protective equipment (PPE) and have PPE readily available outside the residents' rooms. This affected one (#22) of two residents reviewed for contact precautions, This had the potential to affect all 52 residents residing in the facility. The facility census was 52.

Inspectors wroteBased on record review and staff interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 50 residents residing in the facility. Facility census was 50.

Inspectors wroteBased on observations, review of activities calendars, review of resident council minutes, review of activities director job description, review of policy, family member interview, and staff interviews, the facility failed to ensure a variety of ongoing resident centered activities were offered over various times throughout the day and staff were available to implement the scheduled activities. The deficient practice had the potential to affect all 54 residents in the facility. The facility census was 54.

Inspectors wroteBased on observation, staff interviews, review of cleaning procedure log and review of cleaning schedule, the facility failed to ensure that the kitchen ice machine is kept clean. The deficient practice had the potential to affect 53 residents who receive ice from the machine, excluding Resident #7 (who receives nothing by mouth). The facility census was 54.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure physician visits were completed as required. This affected 10 (#01, #08, #15, #16, #19, #24, #34, #39, #41, and #46) of 10 residents reviewed for physician visits. The facility census was 54.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure residents were provided clear communication on what an arbitration agreement proposes and how to accept or decline the arbitration agreement. This affected four (#46, #203, #201, and #302) of four residents reviewed for binding arbitration. The facility census was 54.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were administered in a manner that a reasonable person would consider dignified. This affected two residents (#07 and #32) of five residents reviewed for medication administration and 19 residents reviewed for dignity. The facility census was 54.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure a resident's choice for showers was honored. This affected one (#22) of two residents reviewed for choices. The facility census was 54.

Inspectors wroteBased on observation, staff interview, family interview, record review, and review of facility incident reports, the facility failed to ensure a resident's responsible party was notified of a fall and subsequent transfer to the emergency department. This affected one (#46) of two residents reviewed for notification of change in condition. The facility census was 54.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was accurately completed. This affected one (#8) of one resident reviewed for PASRR. The facility census was 54.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident was included in quarterly care planning and invited to a quarterly care plan conference. This affected one (#41) of one resident reviewed for care planning. The facility census was 54.

Inspectors wroteBased on observation, staff interview, family interview, record review, and policy review, the facility failed to ensure treatment was provided to address a resident's bilateral lower extremity edema. This affected one (#15) of 19 residents reviewed for quality of care. The facility census was 54.

Inspectors wroteBased on review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure incontinence care was completed timely. This affected one (#8) of one resident reviewed for incontinence care. The facility census was 54.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident's pain was timely treated and physician ordered pain medications were available. This affected one (#24) of three residents reviewed for pain management. The facility census was 54.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to provide an appropriate and timely response to a resident with suicidal ideation. This affected one (#8) of two residents reviewed for behavioral/emotional care. The facility census was 54.

Inspectors wroteBased on medical record review, staff interview, consultant pharmacist interview, and policy review, the facility failed to ensure a resident was free from unnecessary psychotropic medication and failed to ensure behavior monitoring was implemented. This affected one (#46) of five residents reviewed for unnecessary medications. The facility census was 54.

Inspectors wroteBased on observation, staff interview, hospice staff interviews, physician interview, family interview, record review, and policy review, the facility failed to ensure the medical records were complete and accurate. This affected three (#46, #34, and #19) of 20 residents reviewed for accurate medical records. The facility census was 54.

Inspectors wroteBased on medical record review, hospice staff interview and staff interview, and policy review, the facility failed to designate a member of the facility's interdisciplinary team to coordinate and communicate with the outside hospice provider and failed to ensure necessary hospice records were obtained by the facility and recorded in the resident's medical record. This affected one (#34) of one resident reviewed for hospice services. The facility identified 5 residents in the facility who received hospice services. The facility census was 54.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure appropriate infection control practices were maintained during medication administration. This affected one (#32) of five residents reviewed for medication administration. The facility census was 54.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to perform annual performance review for State Tested Nurse Aides (STNA). This affected three STNAs (#258, #207, and #204) reviewed for personnel records. This had the potential to affect all 54 residents. The facility census was 54.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure State Tested Nurse Aides (STNAs) completed the minimum required 12 hours of in-servicing a year. This affected one (STNA #258) of three STNAs reviewed for required in-services. This had the potential to affect all residents in the facility. The facility census was 54.

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were properly stored until the time of administration. This had the potential to affected 19 (#16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) of 19 residents who received medications from the North medication cart which was observed with pre-pulled medications in the cart. The facility census was 50.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility self-reported incident (SRI) and investigation review, staff interview, facility policy review, and review of facility corrective action, the facility failed to ensure residents were free from physical and verbal abuse from staff. This affected one (#61) of three residents reviewed for abuse. The census was 50.

Inspectors wroteBased on medical record review, resident, family member, and staff interview, review of facility self-reported incidents, and review of a facility policy, the facility failed to ensure an allegation of physical abuse was reported to the State Survey Agency as required. This affected one (#43) of three residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on medical record review, resident, family member, and staff interview, review of facility self-reported incidents, and review of a facility policy, the facility failed to investigate allegations of physical abuse in a timely manner. This affected one (#43) of three residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, review of the facility's Self-Reported Incident, and review of the facility's policy, the facility failed to safely transfer a resident. This resulted in Actual Harm to Resident #55 when State Tested Nursing Aide (STNA) #985 improperly transferred Resident #55 utilizing a 'bear hug' technique and the resident subsequently dislocated her right shoulder and had to be sent to the emergency room for evaluation and treatment. This affected one (Resident #55) of four residents reviewed for accidents. The facility census was 59. Findings Include: Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, difficulty in walking, abnormalities of gait and mobility, dementia, and osteoarthritis. [...]

Inspectors wroteBased on record review, observation, family and resident interview, staff interview and policy review, the facility failed to have an effective activities program for the residents. This affected six (#7, #31, #36, #41, #44 and #56) of 24 residents reviewed for activities. The facility census was 24.

Inspectors wroteBased on record review, observation, staff interview, policy review, and review of the Center of Disease Control (CDC) guidance, the facility failed to provide care and services to reasonably prevent the spread of SARS-CoV-2 virus (COVID-19), when staff did not appropriately use Personal Protective Equipment (PPE). This had the potential to affect 11 residents (#1, #7, #15, #31, #35, #43, #44, #45, #47, #52, and #53) who resided on the north hall and were not in isolation or quarantine for COVID-19. The facility also failed to appropriately handle soiled linen and clothing for one (Resident #49) of one resident reviewed for urinary tract infection. The facility census was 59.

Inspectors wroteBased on medical record review, and resident and staff interviews, the facility failed to allow a resident to decline laboratory testing. This affected one (Resident #55) of six residents reviewed for choices. The facility census was 59.

Inspectors wroteBased on observations, medical record review, review of kitchen meal tickets, and staff interviews, the facility failed to provide nutritional supplements to a resident with a history of significant weight loss. This affected one (Resident #56) of three residents reviewed for nutrition. The facility identified three residents with significant weight loss. The facility census was 59.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure Resident #41 did not have a significant medication error related to insulin administration when the facility held Resident #41's insulin without a physician order or physician notification. This affected one (Resident #41) of six residents reviewed for medication administration. Resident The facility census was 59.

Inspectors wroteBased on observations, medical record review, review of kitchen meal tickets and staff interviews, the facility failed to ensure a resident with food allergies was implemented on the resident's meal ticket. This affected one (Resident #56) of three residents reviewed with food allergies. The facility census was 59.

Inspectors wroteBased on record review and staff interview, the facility failed to inform residents who remained in the facility, of the cost of skilled services This affected two (Residents #14 and #600) of three residents reviewed for beneficiary notification. The facility census was 59.