Medina Bsd Opco LLC

Inspectors wroteBased on review of the medical record and interview with staff, the facility failed to ensure laboratory tests were obtained as ordered for Resident #2. This affected one resident (Resident #2) of three residents who were reviewed for physician orders. Findings Include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, bronchiectasis, gastroparesis, dependent on a respirator, neuromuscular dysfunction of the bladder, obstructive sleep apnea, hypertension, osteomyelitis, Acinetobacter Baumannii, pseudomonas, resistant to antibiotics, anxiety disorder, pressure ulcers, acquired absence of right and left legs above the knee, diverticulitis, gastric ulcer, suprapubic catheter, and major depressive disorder. [...]

Inspectors wroteBased on record review, observations, hospital record review, interviews, and policy review, the facility failed to ensure safe, clinically indicated, and competent Foley catheter insertion and follow up monitoring for Resident #64 and failed to follow physician orders for indwelling catheter care for Resident #37. This resulted in Immediate Jeopardy and serious life-threatening harm, negative health outcomes, and/or death for one resident (#64) when Licensed Practical Nurse (LPN) #800 performed a non ordered Foley catheter change on [DATE] while Resident #64 was visibly moving, resisting, and verbalizing pain, without clinical assessment, supervisory involvement, or medical provider notification. There was no documented evidence of assessment of insertion difficulty, trauma, or need for escalation. [...]

Inspectors wroteBased on record review, interviews, review of manufacturer guidelines, and review of facility policies, the facility failed to ensure medications were administered in accordance with physician orders and accepted standards of practice resulting in a significant medication error for Resident #70. Actual Harm occurred on 11/14/25 when Licensed Practical Nurse (LPN) #800 failed to perform the physician ordered pre meal blood glucose check and failed to administer the prescribed Lispro insulin prior to the lunch meal. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure staff followed required Enhanced Barrier Precautions (EBP) while providing care for two residents (#36 and #5) of two residents observed for infection control. This failure to follow EBP has the potential to expose the residents and others to infection risk and had the potential to affect an additional 13 residents (#2, #7, #9, #10, #16, #27, #32, #47, #37, #47, #48, #49, #53 and #68) identified by the facility who also required EBP. The facility census was 52.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure that Resident #36, who required staff assistance with toileting hygiene, received timely incontinence care. This affected one resident (#36) of eight residents reviewed for activities of daily living (ADL) care. The facility census was 52.

Inspectors wroteBased on medical record review, interview, review of facility transportation logs and review of facility policy, the facility failed to ensure appointments were scheduled, transportation was arranged and appointments were attended as ordered by the physician. This affected one resident (#22) of three residents reviewed for appointments outside of the facility. The facility census was 52.

Inspectors wroteBased on record review, observation, interview, and review of the facility policy, the facility failed to perform hand hygiene and change gloves between treating multiple wounds on Resident #5 during wound care observation and did not cleanse each wound prior to treatment. This affected one resident (#5) of two residents observed for wound care. The facility census was 52.

Inspectors wroteBased on record review, observation, facility policy review and staff interview, the facility failed to ensure fall prevention interventions were implemented for Residents #8 and #69. This affected two residents (#8 and #69) of four residents reviewed for accidents. The facility census was 52.

Inspectors wroteBased on record review and interview, the facility failed to implement pharmacy recommendations from its monthly drug regimen review for one resident (#33) of five residents reviewed for unnecessary medications. The facility census was 52.

Inspectors wroteBased on record review, observation, and staff and resident interviews, the facility failed to ensure that clinically diagnosed food allergies were accurately identified, documented, communicated, and honored for Resident #57. This affected one resident (#57) out of three residents reviewed for nutrition. The facility census was 52.

Inspectors wroteBased on record review, observation, interview and facility policy review, the failed to provide liquids at the ordered consistency for Resident #68. This issue affected one resident (#68) of two residents reviewed for thickened liquids. The facility identified two residents (#13 and #68) with orders for thickened liquids. The facility census was 52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete and accurate medical record documentation for one resident (#5) of two residents reviewed for wound care. The facility census was 52.

Inspectors wroteBased on personnel record review, staff interview and review of facility policy, the facility failed to ensure all new employees were screened through the State of Ohio Nurse Aide Registry (NAR) prior to employment 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 52 residents residing in the facility. The facility census was 52.

Inspectors wroteBased on observations, resident interviews, staff interviews, review of staff schedules, review of the staffing tool, review of the concern logs, and review of the facility assessment, revealed the facility failed to ensure adequate staffing to meet the needs of the residents. This had the potential to affect all 52 residents residing in the facility.

Inspectors wroteBased on facility assessment review, staffing tool 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 52 residents residing in the facility.

Inspectors wroteBased on resident interview, staff interview, review of the concern log, and review of facility policy, the facility failed to ensure concerns were filed, addressed, and resolved in a timely manner. This affected one resident (#6) of three reviewed for dignity. The facility census was 52.

Inspectors wroteBased on record review and staff interview the facility failed to ensure authorizations for resident fund accounts were witnessed by non-facility staff. This affected two residents (#7 and #41) of five residents reviewed for resident fund accounts. The facility census was 52.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit. This affected two residents (#17 and #55) of three residents reviewed for beneficiary notices. The facility census was 52.

Inspectors wroteBased on record review, resident interview, staff interviews, facility policy review, and review of ancillary documentation, the facility failed to ensure residents received timely ancillary services. This affected one resident (12) of one resident reviewed for ancillary services. The facility census was 52.