Ovid Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteThrough observation, interview and record review the facility failed to maintain the resident's dignity related to smoking for one resident (R2) of one evaluated for independent smoking based on unchanged smoking evaluations before and after appointed guardianship. Findings IncludeResident #2 (R2)Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of paraplegia, migraines, bi-polar, contractors on left hip, right hip, right knee, left knee, muscles spasms, osteoarthritis and PTSD.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026 revealed R2 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comfortable room temperatures for one (R13) with the potential to effect 60 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care planned interventions to prevent falls for one (Resident #56) out of 14 residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure orthostatic blood pressures were being monitored correctly (Resident #56) following professional standards. Findings Include Review of the medical record reflected R56 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included kidney disease anxiety disorder, restless leg syndrome, dementia, bipolar disorder, fracture of the nasal bones, and type two diabetes. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/15/2026, reflected R56 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/01/2026 at 11:29 AM, R56 was observed in his room lying in bed. R56 was alert but did not answer questions appropriately. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate pain management to one resident (R31) of one resident resulting in decline in activities of daily living related to uncontrolled pain. Findings IncludeResident #31 (R31)Record review on 03/31/2026 at 2:07 PM oxycodone HCl Oral Tablet 5 MG Give 2 tablet by mouth every 4 hours as needed for pain management. Observation on 03/31/2026 at 2:07 PM, R31 grimaced and jerked in place trying to explain his illness and the pain was unbearable. Observation on 04/02/2026 at11:05 AM from R31's door, R31 moaning out in pain, talking in his sleep. Writer asked R31 if he was in pain, he stated yes. Writer asked R31 if his pain medication was scheduled or he needed to ask for it. R31 stated he thought it was scheduled, rated it as #8 on scale of 0-10. [...]

Inspectors wroteBased on observation and intrview the facility failed to maintain safe food temperatures affecting all 61 residents with the potential for causing food-related illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) implement Enhanced Barrier Precautions for one (Resident #31); and 2) implement measures to mitigate the spread of COVID-19 infection to facility staff and residents. During an interview on 01/08/25 at 8:50 AM, with the Director of Nursing (DON) and Infection Preventionist (IP) I (in attendance via phone), it was reported that the facility's COVID-19 outbreak was believed to have started after Registered Nurse (RN) K tested positive for COVID-19 (on 12/30/24). It was reported that facility-wide COVID-19 testing was initiated for all residents and staff, as RN K had worked all over the facility, and they were unable to determine close contacts. It was reported the first residents tested positive for COVID-19 on 12/31/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) accurately reflected the estimated cost of items and services for which the resident may be charged for two (Resident #13 and #14) of three reviewed for Beneficiary Notification.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care to two of five residents (R22 and R31) reviewed for activities of daily living (ADLs), resulting in these residents not receiving the care needed to maintain their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pressure ulcer treatments as ordered for one (Resident 54) of three reviewed, resulting in the potential of a worsened pressure ulcer.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration.

Inspectors wroteThis citation pertains to intake MI00145732. Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from mental abuse/verbal abuse (Resident #5), sexual abuse (Resident #1 and Resident #2) and deprivation of goods and services (Resident #6 and Resident #7) by staff and protect Resident #6, Resident #3, and Resident #4. Findings Include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). [...]

Inspectors wroteThis citation pertains to intake MI00145732. Based on interview and record review, the facility failed to ensure adequate staff were scheduled to supervise and report residents with sexual behaviors and protect vulnerable residents in a census of 61 residents, resulting in the likelihood of allegations of abuse not identified, reported or documented.

Inspectors wroteThis citation pertains to intake MI00145732. Based on interview and record review, the facility administration failed to operationalize its policy and procedures to manintain effective use its resources and ensure identification, investigation, and protection of residents from mental abuse, verbal abuse, sexual abuse and deprivation of goods and services in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), and failed to ensure sufficient nursing staff to meet residents needs and the likelihood for continued abuse and unmet resident needs in a current facility census of 61 residents.

Inspectors wroteThis citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to implement their abuse policy and procedures in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in continued allegations of abuse.

Inspectors wroteThis citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to immediately report allegations of abuse in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in likelihood of continued abuse.

Inspectors wroteThis citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse, in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and #7), resulting in the likelihood of continued abuse.

Inspectors wroteThis citation pertains to intake MI00145732. Based on interview and record review, the facility failed to prevent involuntary seclusion in one of 10 residents reviewed for abuse (Resident #6), resulting in verbal behaviors and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received appropriate assessment and treatment for a change of condition in one of 10 residents reviewed for abuse (Resident #8), resulting in delayed treatment and a medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) maintain a sanitary kitchen, 2) properly date mark potentially hazardous foods, 3) properly cool cooked food, and 3) clean food contact surfaces, resulting in the potential biological contamination of food, increasing the risk of foodborne illness. These deficient practices affecting 65 residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment, maintain bathroom floors in good repair (room #'s 107, 110, and 306), and provide backflow protection at the salon hair sink, resulting in the potential for a non-homelike environment and contamination of the domestic water supply, affecting 65 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to address and resolve grievances brought forth by the Resident Council resulting in unmet needs, missing items, and not getting their basic needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise care plans for four (Resident #6, #48, #60, #61) of 16 reviewed, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow acceptable professional practice for maintaining controlled medication for three out of four medication carts resulting in the potential for controlled medication diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for adverse side effects of antipsychotic medications for four (Resident #12, #31, #34, and #37) of five reviewed, resulting in the potential of adverse medication side effects.

Inspectors wroteBased on observation interview and record review the facility failed to monitor medication refrigerators for three of three medication refrigerators resulting in the potential for residents to receive medication that is not providing its effective efficiency.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain laboratory draws on four (Resident #11, #34, #37 and #47) of seven reviewed for laboratory monitoring, resulting in the potential for unrecognized and/or untreated abnormal laboratory results.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the use of a full lap tray as a potential chair restraint for one (Resident #60) of one reviewed for restraints, resulting in the potential for residents not having the least restrictive devices.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to the hospital for one (Resident #68) of three reviewed for transfer/discharge, resulting in the potential for residents and/or family being uninformed of the reason for transfer.

Inspectors wroteResident #12 (R12): Review of the medical record reflected R12 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), delusional disorders, major depressive disorder and anxiety disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/19/23, reflected R12 was coded for routine antipsychotic use. The MDS reflected a gradual dose reduction (GDR) had not been attempted and was not documented by a physician as clinically contraindicated. A Physician's Order, with a start date of 6/21/23, reflected Zyprexa (antipsychotic medication) 15 milligrams (mg) was to be given daily, at bedtime. R12's Zyprexa order history reflected a prior dose of 20 mg daily with a start date of 5/12/23 and a stop date of 6/20/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan summary was provided for one (Resident #68) of 12 reviewed for care plans, resulting in the potential for care preferences not being honored and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion/restorative services for one (Resident #61) of two reviewed, resulting in the potential for a decrease in range of motion and worsening contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician ordered parameters upon administration of blood pressure medications for one (Resident #31) of 5 reviewed for unnecessary medications, resulting in the potential for adverse drug consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain radiology services for one (Resident #11) of one reviewed, resulting in the potential for misdiagnosed medical conditions and ineffective treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate transmission-based precautions (TBP) and disposal of personal protective equipment (PPE) for one (Resident #12) of one reviewed for TBP, resulting in the potential for the spread of infection to other facility residents.