Ohio Veterans Home

Inspectors wroteBased on observation, staff interview, resident interview, medical record review, review of an incident and accident log, and facility policy review, the facility failed to ensure a thorough assessment was completed for use of and residents were free from unnecessary physical restraints. This affected one (#91) of one residents reviewed for physical restraints. The facility census was 233.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure meal intake strategies were followed in accordance with physician orders and failed to ensure residents were adequately supervised and smoking safety interventions were properly utilized during resident smoking. This affected two (#3 and #109) of six residents reviewed for accidents and hazards. The census was 233.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to ensure pain monitoring and pain relief interventions were effectively implemented. This affected one (#195) of three residents reviewed for effective pain control and monitoring in a facility census of 233.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure infection control practices were followed for residents on enhanced barrier precautions and during medication administration. This affected three (#2, #33, and #192) of three residents directly observed for infection control practices. The facility census was 233.

Inspectors wroteBased on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to implement their abuse policy to provide timely interventions and further failed to provide notification to the appropriate medical and support staff for follow-up services. This affected one (#193) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242.

Inspectors wroteBased on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to report allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242.

Inspectors wroteBased on observation, review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to thoroughly investigate allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242.

Inspectors wroteBased on review of the medical record, review of staff statements, staff interview, and policy review, the facility failed to ensure food items were provided per physician orders. This affected one (#93) of three residents reviewed for dietary services and had the potential to affect 14 residents identified by the facility with physician orders for mechanically altered diet textures. The facility census was 242.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on review of the medical record, review of a facility Self-Reported Incident (SRI), review of an SRI investigation, review of staff statements, review of the staffing schedule, review of employee time records, review of a police report, review of video surveillance, review of an incident report, staff interviews, resident interview, family interview, and review of facility policy, the facility staff failed to ensure Resident #241 was free from staff to resident verbal and physical abuse. This resulted in Immediate Jeopardy when Resident #241 was thrown from his wheelchair on 09/16/25 at approximately 7:50 P.M. [...]

Inspectors wroteBased on medical record review, review of a self-reported incident (SRI) and related investigation documents, review of a hospital record, review of an employee skills checklist, and policy review, the facility failed to complete resident transfers using a mechanical lift with appropriate assistance as care planned and as ordered. Actual Harm occurred on 04/29/25 when Resident #2, who was care planned for two-person assistance with all personal care and had a physician order to always be transferred using two people, was transferred in her room by one staff member using a mechanical lift without assistance. Resident #2 sustained a right femur fracture as a result of the improper transfer. This affected one (#2) of three residents reviewed for accidents. The facility census was 223. Findings Include: [...]

Inspectors wroteBased on medical record review, review of facility self-reported incidents (SRIs) and investigation documents, staff and resident interview, and review a facility policy, the facility failed to ensure residents were free from verbal and physical abuse. This affected three (#3, #4, and #5) of five residents reviewed for abuse. The facility census was 223. Findings Include: 1. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs). [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility self-reported incidents (SRI) and related investigation documents, staff and resident interview, review of local new reports, and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (#1) of five residents reviewed for misappropriation. The facility census was 223. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes, chronic kidney disease, and gout. [...]

Inspectors wroteBased on medical record review, review of a self-reported incident (SRI) and related investigation documents, staff interview, and review of a facility policy, the facility failed to timely report an allegation of abuse to the State Survey Agency in a timely manner. This affected one (#3) of five residents reviewed for abuse. The facility census was 223. Findings Include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs). [...]

Inspectors wroteBased on review of the medical record, review of a police report, review of an incident report, observation, staff interview, and policy review, the facility failed to ensure a resident was adequately assessed for unsupervised smoking and failed to follow the smoking policy. This affected one (#84) of three residents reviewed for smoking safety. The facility identified 38 residents who smoked. The facility census was 223.

Inspectors wroteBased on observations, medical record review and staff interviews, the facility failed to provide the resident with a table of appropriate height to ensure proper eating for one (#139) of 40 sampled residents. The facility census was 186.

Inspectors wroteBased on review of medical records, resident and staff interviews, the facility failed to ensure residents were included in their care plan meetings. This affected two (#17 and #95) of 40 sampled residents. The facility census was 186.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to ensure residents receive proper treatment and assistive devices to maintain their hearing abilities. This affected one (#79) of one resident identified with hearing issues. The facility census was 186.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review, the facility failed to ensure safe smoking. This affected two residents (#43 and #171) of two residents reviewed for smoking. The facility census was 186.

Inspectors wroteBased on observations, medical record review, review of facility policy, and resident and staff interviews, the facility failed to provide adequate pain management which resulted in actual harm to Resident #111 who continued to have uncontrolled pain at a level of 8 out of 10 (with 10 being the highest level). This affected one (#111) of two residents reviewed for pain management. The facility census was 186.

Inspectors wroteBased on medical record review, staff interview, resident interview, review of hospital documentation, review of mechanical lift manufacturer instructions, review of facility mechanical lift policy, and review of facility incident investigation documentation, the facility failed to ensure residents were provided with appropriate supervision during a transfer using a mechanical lift. This resulted in actual harm when Resident #433 sustained a 5.0 centimeter (cm) laceration to the right anterior shin which required suturing. The resident was being transferred with a mechanical lift with only one staff person. This affected one (Resident #433) of three residents reviewed for use of mechanical lift for transferring. Facility census was 390.

Inspectors wroteBased on observation, staff interview and review of a facility policy, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents who resided in the facility except Resident #150 who was identified by the facility to not receive meals from the kitchen. The facility census was 390.

Inspectors wroteBased on observation and staff interview, the facility failed to provide staff recipes for pureed diets. This directly affected 14 residents (#3, 21, 89, 114, 164, 200, 232, 250, 300, 364, 377, 381, 383 and 384) who the food was prepared for. The facility identified 19 residents who received a pureed diet. The facility census was 390.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents' dignity was respected during the dining experience. This affected one (Resident #26) of two residents reviewed for dignity. The facility census was 390. Finding Include: Review of Resident #26's medical record revealed an admission date of 02/03/10. Diagnoses included dementia with behavioral disturbance, major depressive disorder, Alzheimer's disease, osteoarthritis, peripheral vascular disease, hypertension, diverticulitis, anemia, heart failure and chronic kidney disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was moderately cognitively impaired. Resident #26 required supervision for bed mobility, transfer, walking and eating. Resident #26 required extensive assistance with with dressing, toilet use, and personal hygiene. [...]

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure residents were properly positioning with positioning devices while in wheelchairs. This affected two (Residents #239 and #354) of three residents reviewed for positioning. The facility census was 390. Findings Include: 1. Review of Resident #239's medical record revealed an admission date of 07/08/19. Diagnoses included mood disorder, anxiety disorder, depressive disorder, dementia, history of falling, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment listed the resident as requiring extensive to total assistance for locomotion on and off the unit. Review of Resident #239's care plan dated 08/15/19 revealed the resident utilized a tilt in space wheelchair. [...]