The most recent inspection on file for Cityview Healthcare and Rehabilitation took place on July 2, 2025. Across the 21 inspections published by the Ohio Department of Health, surveyors cited 27 deficiencies.
A deficiency is a rule the surveyor found the facility was not meeting. Ohio inspects against two rule books at once, so most findings carry a federal code and an Ohio code for the same problem; each is counted once here, the way the state counts it. Correction dates are the state's confirmation that the issue was fixed.
This report reproduces what Ohio publishes and nothing else. Of the 21 inspections listed, the state publishes the surveyor's written findings for 10; for the other 11 it publishes only the date, the type of visit and the number of deficiencies - 11 of which found none.
Facility Details
Inspections
21 on file · 27 deficienciesJuly 2, 2025Complaint survey4 deficiencies▼
F-0584Safe/Clean/Comfortable/Homelike Environment▼
Based on observation, interview, record review and review of the facility policy, the facility failed to ensure a clean sanitary environment for Resident's #12, #13, #32, #33, #37, #44, #53, #56, #70, #74, #84, #89 and #92 who resided on the third floor nursing unit and failed to ensure phone calls to the facility were answered timely. This had the potential to affect all residents residing in the facility. The facility census was 93.
Findings include:
1. Review of Resident #44's medical record revealed an admission date of 07/19/23 and diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, schizophrenia and unspecified dementia with other behavioral disturbance.
Review of Resident #44's care plan dated 04/18/25 included Resident #44 had an ADL self-care performance deficit related to diagnoses. Resident #44 would maintain current level of function through the review date of 10/27/25. Interventions included Resident #44 was independent for toileting and Resident #44 required setup assistance with personal hygiene and oral care.
Review of Resident #44's Quarterly MDS assessment dated 04/30/25 revealed Resident #44 was unable to complete the Brief Interview for Mental Status. Resident #44 required setup or clean-up assistance for oral hygiene and supervision or touching assistance for personal hygiene.
Observation of the facility work orders open and in progress did not reveal a work order for a dripping ceiling, disconnected sink pipe, sink and counter partially pulled away from wall, paper towel and soap dispenser pulled off wall, no light bulb cover or bathroom door latch needing repaired in Resident #44's room
Observation on 06/26/25 at 9:38 A.M. of Resident #44's room with Housekeeper #217 revealed Resident #44 resided on the secured third floor nursing unit (Connections Community) and there was a puddle of water on the floor. Closer observation revealed the ceiling was leaking and dripping what appeared to be water onto the floor and the sink drain was not connected to the drain pipe and when the water was turned on for the sink it drained from the sink into the pipe and onto the floor. Housekeeper #217 confirmed both the leaking ceiling and the disconnected pipe under the sink and stated he was usually assigned to clean the third floor nursing unit and for the last two to three months there was always water on the floor in this room. Further observation of Resident #44's room revealed the sink had a square counter surrounding it and both the sink and counter were leaning to the left and partially pulled away from the wall. There was no soap dispenser or paper towel holder on the wall by the sink and a damaged wall with a large area of chipped plaster could be seen where they used to be attached. There was a mirror above the sink and above the mirror two bare light bulbs could be seen and there was no cover on them. A thermostat on the wall did not have a cover. Housekeeper #217 stated the paper towel dispenser and soap dispenser were ripped off the wall two to three months ago by another resident and had not been repaired. Housekeeper #217 stated Resident #44 did not do the damage seen in the room. The door to the bathroom was ajar and Resident #44 asked Housekeeper #217 to shut the door and put the trash can in front of it. Resident #44 stated the door to the bathroom shared with a second resident room would not stay shut and a trash can had to be put in front of it to keep it closed. Resident #44 stated he was sick of this [expletive] and did not like the door to the bathroom continually swinging open.
Observation on 06/26/25 at 9:49 A.M. of Resident #44's room with the Director of Nursing (DON) confirmed water was dripping onto the floor from the ceiling, the sink was not connected, the soap dispenser and paper towel holder were ripped off the wall and the wall was damaged with a large area of chipped plasture, the door to the bathroom would not stay shut, there was no thermostat cover and no cover over the light bulbs above the sink. The DON confirmed the sink and counter were partially ripped off the wall and leaning to the left. The DON did not know what the status was of all the broken things in the room.
Interview on 06/26/25 at 9:54 A.M. of Environmental and Laundry Supervisor (ELS) #218 confirmed another resident with a wardobe pushed the wardrobe against Resident #44's sink and caused it to be partially pulled away from the wall. ELS #218 indicated he did not put a work order in or tell Maintenance Supervisor (MS) #219 about Resident #44's damaged sink. ELS #218 stated he was not aware of the other broken and damaged things in Resident #44's room.
Interview on 06/26/25 at 12:17 P.M. of MS #219 revealed work orders were placed in the electronic system and staff could always text him, or tell him in person if something needed fixed. MS #219 stated he had two maintenance assistants to help with the work load. MS #219 stated he was not told about the leaking ceiling and sink drain in Resident #44's room, he only found out about it today and a work order was put in today. MS #219 stated Resident #44's sink and counter was on a list to be replaced, and he was working his way down from the fourth floor. MS #219 indicated the paper towel and soap dispensers were replaced a few minutes ago. Observation of Resident #44's room with MS #219 confirmed the leaking ceiling and disconnected sink drain, the bare light bulbs above the sink, the thermostat without a cover, and the door to the bathroom that would not stay closed. MS #219 stated the bathroom door did not have a latch and he would make sure it was fixed, and the thermostat was not connected and he would make sure it was removed.
Observation on 06/26/25 at 1:00 P.M. of the secured third floor nursing unit (Connections Community) with Licensed Practical Nurse (LPN) #204 revealed widespread ceiling tiles stained light and dark brown in Resident's #12, #13, #32, #33, #37, #53, #70, #74, #84, #89 and #92 rooms. Resident #56's room had a broken light cover at the head of the bed.
Review of Resident #84's medical record revealed an admission date of 03/31/21 and diagnoses included schizoaffective disorder bipolar type, catatonic disorder due to known physiological condition and major depressive disorder.
Review of Resident #84's Annual MDS assessment dated 04/10/25 revealed Resident #84 had moderate cognitive impairment.
Observation on 06/26/25 at 1:00 P.M. of Resident #84's room revealed the bathroom door was open to the shared bathroom with another room and a pungent urine odor was apparent. Resident #84 said the bathroom smelled and to please close the door. Observation of the bathroom revealed it was dirty and had urine stains on the floor and toilet. LPN #204 confirmed the bathroom was dirty, smelled and needed cleaned.
2. Review of the local city Division of Fire Incident Report 2025-501332-000 dated 03/03/25 at 3:33 A.M. included a call was received and the arrival time to the facility was 3:37 A.M. On scene at the same time as EMS. There was a delay entering the building due to no one was at the front desk. Post entry, assisted EMS load an elderly male onto a cot and EMS to transport patient to the local hospital. The apparatus clear date and time was 03/03/25 at 3:57 A.M.
On 06/30/25 at 5:22 A.M. a phone call was made to the facility. The phone rang 18 times without being answered. After 18 rings the phone rolled over to music for four minutes then back to ringing. The phone rang an additional 8 times and was answered by facility staff.
On 07/02/25 at 6:36 A.M. a phone call was placed to the facility. The phone rang 28 times and was not answered by staff. The phone did not roll over to voicemail, but just kept ringing. Unable to talk to staff from facility.
Interview on 06/26/25 at 3:32 P.M. of Registered Nurse (RN) #220 revealed she remembered on 03/03/25 Resident #95 called 911 because he did not want to be in the facility. Resident #95 placed himself on the floor after he called 911 because he wanted EMS to take him to the hospital. Resident #95 was on one-to-one observation and the aide who was watching him saw him put himself on the floor. RN #220 did not remember EMS being delayed getting into the facility or have any knowledge this happened.
Interview on 07/02/25 at 8:35 A.M. of Nurse #221 revealed she worked night shift and there was no receptionist at the front desk to answer the phone. Nurse #221 revealed the phones rolled over to the second floor and she was not sure if they also rang on the third and fourth floor nursing units. When told the phone rang 28 times on 07/02/25 at 6:36 A.M. without being answered Nurse #221 stated it was busy last night and the nurses and aides could have been busy and unable to answer the phone when it rang. Nurse #221 indicated the residents needed to be monitored and they really needed to have a receptionist on night shift on the first floor to answer the phones and allow visitors into the facility. Nurse #221 stated she was sure she was busy with a dressing change at that time and was unable to answer the phone.
Interview on 07/02/25 at 8:41 A.M. of Registered Nurse (RN) #222 revealed she worked night shift and just left the facility. RN #222 thought the phone rang to all the floors when it rang, but sometimes staff was busy and unable to answer the phone. RN #222 stated last night was a busy night, the residents required close monitoring and the phone could not be answered.
Interview on 07/02/25 at 9:06 A.M. of the Director of Nursing (DON) revealed after the receptionist left for the evening around 7:00 P.M. the phones should be forwarded to ring on all three nursing units. The DON stated the phone should be answered within three rings, but on night shift sometimes the staff was busy and unable to answer the phone. The DON indicated if the phone rang 28 times without being answered that was too long and not okay. The DON stated the phones should be answered in case of an emergency.
Review of the facility policy titled Housekeeping included the purpose was to establish standards of cleanliness and consistency in the way in which rooms and common areas were cleaned and maintained. The facility would be cleaned on a regular basis according to Federal and State guidelines. The bathroom was to be clean and free of odors. Porcelain sinks were to be free of cracks, chips, stains. Towel, toilet paper and soap dispensers were to be checked daily and refilled, replaced as needed. The resident's room was to be free of odors. If nursing personnel noticed any sanitary violations occurring in resident rooms housekeeping and, or maintenance should be notified promptly.
This deficiency represents non-compliance investigated under Complaint Number OH00165460 and OH00163250.
F-0677ADL Care Provided for Dependent Residents▼
Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #19 and #43 received appropriate incontinence care timely. This affected two residents (Resident's #19 and #43) out of three residents reviewed for incontinence. The facility census was 93.
Findings include:
1. Review of Resident #43's medical record revealed an admission date of 04/17/12 and a readmission date of 01/06/15. Diagnoses included senile degeneration of the brain, Parkinson's Disease and paranoid schizophrenia.
Review of Resident #43's care plan revised 10/07/24 revealed Resident #43 had bladder and bowel incontinence and was at risk for skin breakdown and urinary tract infections. Resident #43 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included staff would provide assistance with toileting and incontinence care as needed.
Review of Resident #43's Quarterly Minimum Data Set assessment dated 06/28/25 revealed Resident #43 was unable to complete the Brief Interview for Mental Status. Resident #43 did not reject care during the seven-day assessment look-back period. Resident #43 was dependent for all ADL's (Activity of Daily Living's). Resident #43 was always incontinent of urine and bowel.
Observation on 07/01/25 at 7:43 A.M. of Certified Nursing Assistant's (CNA)'s #223 and #224 revealed they were preparing to provide Resident #43's incontinence care. Observation revealed Resident #43 was wearing two incontinence briefs. The two briefs were soaked with dark yellow urine and a moderate amount of somewhat hard brown feces could be seen. CNA #223 stated it looked like Resident #43 had not been changed in awhile. CNA #224 did not have all the supplies she needed and left the room to gather the supplies leaving Resident #43 uncovered from the waist down while she was gone. CNA #223 did not pull the covers over Resident #43 while she waited for CNA #224 to return. CNA #223 stated Resident #43 should not be wearing two incontinence briefs and she never used two incontinence briefs when she was providing care. After a few minutes CNA #224 returned to the room and CNA's #223 and #224 continued Resident #43's incontinence care. Resident #43 cried out in pain when her buttocks were wiped and some redness could be seen on the bilateral inner buttocks. Assistant Director of Nursing (ADON) #225 entered the room and CNA #223 told her Resident #43 was having some pain and her feces were somewhat hard and ADON #225 stated she would check for the last bowel movement and if Resident #43 had anything ordered for constipation. After providing incontinence care CNA #224 placed Resident #43's soiled incontinence briefs in a plastic bag. Using the soiled gloves she used for incontinence care, CNA #224 picked up the clean incontinence brief and placed the clean brief on Resident #43. CNA #224 did not change her soiled gloves or use hand hygiene and covered Resident #43 with a sheet and blanket. CNA #224 confirmed she did not change her soiled gloves before putting a clean incontinence brief on Resident #43 and covering her with a sheet and blanket.
Review of the facility policy titled Incontinence Care updated 01/06/25 included the purpose was to maintain skin integrity, prevent skin breakdown, control odor and provide comfort and self-esteem for the residents. The policy was to be used on residents were were incontinent of bowel and bladder. When providing incontinence care cleanse the area with perineal wash or a mild cleanser, pat dry, remove gloves, perform hand hygiene, don gloves. Provide absorbent under pad and briefs as needed. Remove gloves and perform hand hygiene, then don gloves. Change linens and clothing as needed.
2. Review of Resident #19's medical record revealed an admission date of 07/20/09 and diagnoses included unspecified dementia, anxiety disorder and adult failure to thrive.
Review of Resident #19's care plan revised 10/15/24 revealed Resident #19 had bowel and bladder incontinence related to impaired mobility and diagnoses. Resident #19 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to change disposable briefs as required and needed.
Review of Resident #19's Quarterly MDS assessment dated 04/11/25 revealed a Brief Interview for Mental Status was not conducted due to Resident #19 was rarely or never understood. Resident #19 was dependent for ADL's and was frequently incontinent of urine and always incontinent of bowel.
Observation on 07/01/25 at 7:55 A.M. of CNA's #223 and #226 revealed they were preparing to provide incontinence care for Resident #19. Observation revealed Resident #19's incontinence brief had a large amount of dark yellow urine that appeared to have been there awhile. CNA #223 stated Resident #19 did not look like she had her incontinence brief changed for awhile and pointed to a folded blanket under Resident #19's buttocks. The blanket had dried urine on it. Further observation revealed Resident #19 had a folded blanket under her buttocks and also a reusable chux pad. CNA #223 stated Resident #19 should not have a folded blanket and a reusable chux underneath her and it looked like it was put there for added protection for urine incontinence. CNA #226 left the room to get supplies and Resident #19 was left uncovered from the waist down while she was gone. CNA #223 did not cover Resident #19 while she waited for CNA #226 to return.
Review of the facility policy titled Incontinence Care updated 01/06/25 included the purpose was to maintain skin integrity, prevent skin breakdown, control odor and provide comfort and self-esteem for the residents. The policy was to be used on residents were were incontinent of bowel and bladder. When providing incontinence care cleanse the area with perineal wash or a mild clenser, pat dry, remove gloves, perform hand hygiene, don gloves. Provide absorbent under pad and briefs as needed. Remove gloves and perform hand hygiene, then don gloves. Change linens and clothing as needed.
This deficiency represents non-compliance investigated under Complaint Number OH00165460.
F-0679Activities Meet Interest/Needs of Each Resident▼
Based on observation, interview, record review, review of the facility Activity Calendar and review of facility policy the facility failed to ensure residents were provided activities as scheduled and failed to ensure Resident's #11, #33, #47 #67, and #82's care planned interventions were implemented for activities and activities were offered per their preferences. This had the potential to affect all the residents in the facility. The facility census was 93.
Findings include:
Review of Resident #67's medical record revealed an admission date of 04/05/25 and a readmission date of 06/19/25. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side, type two diabetes mellitus and schizoaffective disorder. Resident #67 resided on the second floor nursing unit.
Review of Resident #67's electronic record from 06/01/25 through 06/26/25 did not reveal evidence Resident #67 had one-to-one activity participation or self-directed activity participation.
Review of Resident #67's Admission Minimum Data Set assessment dated 06/26/25 revealed Resident #67 was cognitively intact. Over the past two weeks Resident #67 stated he felt down, depressed or hopeless on two to six days. Resident #67 did not reject care during the seven-day assessment look-back period. Resident #67 stated it was very important to listen to music he liked, to do his favorite activities, to go outside when the weather was good. Resident #67 stated it was somewhat important to do things with groups of people and to be around animals such as pets. Resident #67 used a wheelchair and was dependent for chair-to-bed-to-chair transfer.
Review of Resident #67's care plan dated 06/26/25 revealed long term stay in the facility was in the best interests of Resident #67. Discharge to the community would not be pursued at this time due to care needs. Interventions included staff would encourage, assist Resident #67 to interact with other residents, attend activities and understand where the bathrooms, dining room, activity areas etcetera were located.
Review of Resident #67's progress notes dated 06/19/25 through 07/01/25 did not reveal evidence Resident #67 attended activities or was encouraged to attend activities.
Observation on 06/26/25 at 12:35 P.M. of Resident #67 revealed he was sitting in a motorized wheelchair in the common area of the main entrance to the facility. Resident #67 waved the surveyor over and stated he felt cooped up in the facility. Resident #67 stated there were no activities provided, they never take us on trips and the residents needed something to do.
Interview on 06/26/25 at 12:58 P.M. of Licensed Practical Nurse (LPN) #204 and Certified Nursing Assistant (CNA) #203 revealed they were standing near the third floor nurses station. LPN #204 indicated the third floor nursing unit was a secured unit and residents with behavioral and mental health issues resided on it. CNA #203 stated the residents got into fights and broke things because they had no activities to occupy them. LPN #204 and CNA #203 stated emphatically that they had not seen an activity person today, the activity schedule looked good, but there had not been any activities provided so far today from 7:00 A.M. until 12:58 P.M. CNA #203 stated it was worse on the second floor nursing unit, and the second floor did not do any activities at all. Again CNA #203 stated the schedule looks good but there are no activities.
Review of the Second Floor Activities Calendar revealed on 06/26/25 at 1:00 P.M. the scheduled activity was Manicures and Cards.
Review of the Connections Community Activities (third floor secured nursing unit) revealed on 06/26/25 at 1:00 P.M. the activity scheduled was Discussion (Responsibly).
Review of the Blue Sky Community (fourth floor secured memory unit) Activity Calendar revealed on 06/26/25 at 1:00 P.M. Manicures and Cards was the activity scheduled.
Observation on 06/26/25 at 1:11 P.M. of the third floor secured nursing unit did not reveal any activity was provided including Discussion (Responsibly). There was no observation of activity staff. LPN #204 stated no activity person showed up.
Observation on 06/26/25 at 1:20 P.M. of the second floor did not reveal any activities were provided including Manicures and Cards. Registered Nurse (RN) #205 stated there were no activities right now but the residents had church this morning from about 10:15 A.M. until 11:45 A.M. RN #205 stated there were no activities now because the activities staff were responsible to take the residents out for their smoke break at 1:30 P.M.
Observation on 06/26/25 at 1:25 P.M. of the fourth floor secured nursing unit (Blue Sky Community) including the common area did not reveal any activities including Manicures and Cards were provided.
Interview on 06/26/25 at 1:26 P.M. of RN #206 revealed she was sitting at the fourth floor nurses station. RN #206 confirmed there were no activities being provided now or at 1:00 P.M. RN #206 stated if activities were provided they would be held in the common area of the fourth floor.
Review of the fourth floor Blue Sky Community Activities Calendar revealed on 06/26/25 at 2:00 P.M. a Hydration Cart was the activity scheduled. On 06/26/25 at 3:00 P.M. Bingo was the activity scheduled.
Observation on 06/26/25 at 2:42 P.M. of the fourth floor nursing unit (Blue Sky) did not reveal evidence of a Hydration Cart or Bingo being provided for the residents.
Review of the Connections Community Activities (third floor secured behavioral unit) revealed on 06/26/25 at 3:00 P.M. Board Games was the activity scheduled.
Review of the Second Floor Activities Calendar revealed on 06/26/25 at 2:00 P.M. the activity scheduled was Hydration Cart. on 06/26/25 at 3:00 P.M. the activity scheduled was Game Room.
Observation on 06/26/25 at 2:45 P.M. of the second floor nursing unit revealed no evidence activities were provided including a Hydration Cart.
Observation on 06/26/25 at 3:18 P.M. of the fourth floor secured memory unit (Blue Sky Community) including the common area did not reveal evidence activities were provided for the residents including Bingo.
Observation on 06/26/25 at 3:20 P.M. of the second floor nursing unit did not reveal any activities were being provided to the residents including Game Room.
Observation on 06/26/25 at 3:22 P.M. of the third floor secured nursing unit (Connections Community) did not reveal activities were offered to the residents including Board Games.
Interview on 06/26/25 at 3:22 P.M. of LPN #204 confirmed there were no activities currently being provided to the residents on the third floor secured nursing unit.
Interview on 06/26/25 at 3:40 P.M. of Activity Director (AD) #207 revealed he had four Activity Assistant's (AA)'s #208, #209, #210 and #211. AD #207 stated AA #209 called off today, and AA #210 and AA #211 had a scheduled day off. AD #207 stated AA #208 worked today. AD #207 confirmed activities were not provided as scheduled due to three Activity Aides were off today. AD #207 stated each nursing unit had an Activity Aide and activity schedules were different for each nursing unit. AD #207 stated church services was offered this morning from 10:15 A.M. until 11:45 A.M. and many residents enjoyed going to the church service. AD #207 first stated the fourth floor nursing unit had Bingo at 2:15 P.M. or 2:30 P.M. and when told Bingo was not observed on the fourth floor at those times AD #207 stated Bingo was not provided because he had to attend resident care conferences from about 1:45 P.M. until 2:45 P.M. AD #207 confirmed the activity staff supervised smoke breaks at 9:30 A.M., 1:30 P.M. and 4:30 P.M. AD #207 stated the only activity provided on the third floor secured nursing unit (Connections Community) today was a movie at around 1:10 P.M. AD #207 stated he started the movie so residents could watch it while they ate their lunch meal. AD #207 stated he placed cards and puzzles at the far end of the counter of the second floor nurses station and there were also cards located on an activity cart that stayed on the second floor in the common area. AD #207 stated he made an announcement to the residents to let them know where the cards and puzzles were.
Observation on 06/26/25 at 3:50 P.M. with AD #207 of the second floor nursing unit revealed there were no cards or games located on the nurses station counter at the far end. AD #207 stated the residents probably took them to their rooms. Observation of the third floor nursing unit revealed there were papers for word search, coloring etcetera contained in plastic covers and thumb tacked to a bulletin board. There was no observation of pencils or crayons. Further observation with AD #207 of the third floor nursing unit revealed a locked room with a broken video game, a broken air hockey table and a broken table soccer game. There was a basketball game in the common area which was available for resident use. AD #207 stated the games had been broken anywhere from two weeks to a month. Observation of the fourth floor nursing unit (Blue Sky) revealed a couple board games on a ledge in the common area along with some coloring items, a baby doll and a therapeutic stuffed doggie. AD #207 stated there had been no outside trips planned for the residents since about 10/2024 because the bus driver quit and the bus was given to a sister facility. AD #207 stated the only transportation the facility had now was a van which was acquired about three months ago and only had the capacity to hold one wheelchair, two walkers and one aide and the van was mostly used for resident appointments. A van driver was hired about a month ago. AD #207 stated residents asked to go on trips all the time. The residents want to go to the zoo on Mondays because it is free, and want to go to parks, to see Christmas lights, to see the air show but were unable to because the facility did not have a bus big enough to accommodate the residents. AD #207 stated the residents missed their trips and when they returned from the trips they had a better, different mind set, and it was a positive experience for them. AD #207 stated he was going to contact the sister facility to see if they could loan the facility the bus for some trips. AD #207 stated when a resident attended activities it was documented in their electronic record. AD #207 confirmed the activity calendars for the second, third (Connections Community) and fourth floor (Blue Sky) nursing units had zoo trips planned for 10:00 A.M. on 06/09/25, 06/16/25, and 06/30/25 and those trips did not happen.
Interview on 06/30/25 at 12:45 P.M. with Resident's #5 and #60 revealed they resided on the third floor secured nursing unit (Connections Community). Resident #5 stated the residents stayed in the facility and did not go anywhere. Resident #5 stated I wish we could go somewhere. Resident #5 stated the residents were taken outside about a month ago, but the facility did not offer outside too much. Resident #60 stated we used to go places and I want to go places. Resident #60 stated she was not taken outside the facility to the grassy area, and would like to do that.
Review of Resident #82's medical record revealed an admission date of 09/13/12 and diagnoses included other specified injuries of the left wrist, hand, and fingers, spastic hemiplegia affecting the left non-dominant side, and and generalized anxiety disorder.
Review of Resident #82's care plan revised 04/14/21 included Resident #82 was self-directed with leisure pursuits. Resident #82 would try to maintain current level of leisure. Interventions included to encourage participation in group activities of interest, leave of absence with supervision only; offer assistance to and from group activities if needed, preferred activities were cards, games, music, outdoors, outings (parks, picnics, movies), arts and crafts, cooking, religious services, sports, educational, provide Resident #82 with an activities calendar and notify him of any changes to the calendar or activities.
Review of Resident #82's Annual MDS assessment dated 03/31/25 revealed Resident #82 was cognitively intact. Resident #82 did not reject care during the seven-day assessment look-back period. It was very important to Resident #82 to go outside to get fresh air when the weather was good and very important to do his favorite activities. It was very important to be around animals such as pets. Resident #82 used a wheelchair and required partial to moderate assistance for chair-to-bed-to-chair transfers. Resident #82 required substantial to maximal assistance for upper and lower body dressing.
Review of Resident #82's electronic record dated 06/01/25 through 06/26/25 revealed there was no evidence Resident #82 participated in one-to-one activities for things like pet visits therapy, and going outside. Group participation activities revealed on 06/04/25 and 06/22/25 Resident #82 played Bingo, on 06/18/25, 06/21/25, 06/22/25 and 06/25/25 he attended coffee, social interaction and news. Resident #82's self-directed activity participation revealed on 06/04/25 he had coffee, social interaction and news. On 06/08/25 music, dancing, and entertainment was documented. On 06/13/25 he was outside in the courtyard. On 06/21/25 at 10:05 A.M. he did exercise and strength. There were no additional activities documented including trips outside the facility .
Interview on 06/30/25 at 12:58 P.M. of Resident #82 revealed he was the Resident Council President. Resident #82 stated the residents could go in the back of the facility by the grass, but did not leave the facility because the facility did not have a bus to take us anywhere. Resident #82 stated the residents were taken outside for Veterans Day last November and if there was enough staff they would be given ice cream outside, but he could not remember the last time this happened. Resident #82 indicated the second floor residents were taken out more often than the residents who resided on the third and fourth floor nursing units. Resident #82 stated residents want to leave the facility and go on trips, and told him they were upset because they wanted to go places like the store and the zoo. A sister facility had the bus that used to be at the facility and used for outings, and when it was taken to the sister facility there were no more outings. Resident #82 stated he was told by staff that we are the projects and can't get the bus.
Review of the Second Floor Activities Calendar revealed on 06/30/25 at 1:00 P.M. the scheduled activity was Cornhole.
Observation on 06/30/25 at 1:16 P.M. of the second floor nursing unit did not reveal Cornhole was provided as scheduled. RN #212 confirmed there was no Cornhole and stated the activities staff rotated floors on days Cornhole was offered, and she thought Cornhole was being offered on the third floor secured nursing unit.
Review of the Connections Community Activities (third floor) Calendar revealed on 06/30/25 at 1:00 P.M. Discussion (Love) was scheduled as an activity.
Observation on 06/30/25 at 1:18 P.M. of the secured third floor nursing unit (Connections Community) did not reveal Cornhole was provided as an activity. Further observation did not reveal Discussion (Love) was conducted.
Review of the Blue Sky Community (fourth floor) Activity Calendar revealed on 06/30/25 at 1:00 P.M. the scheduled activity was Cornhole.
Observation on 06/30/25 at 1:21 P.M. of the secured fourth floor nursing unit (Blue Sky) did not reveal Cornhole was offered as an activity.
Interview on 06/30/25 at 1:30 P.M. of AA #208 confirmed Cornhole was not provided as scheduled on the second and fourth floor nursing unit, and Discussion (Love) or Cornhole was not provided on the third floor nursing unit. AA #208 stated AD #207 and AA #209 were both not working today. AA #208 stated AA #211 was only working until 3:00 P.M. and the activities had to be pushed back. AA #208 stated the resident birthday party scheduled for 3:00 P.M. had to be done now because AA #211 was leaving at 3:00 P.M. AA #208 indicated activities were documented in resident's electronic record, but often the Activity Aides were not able to log into the system to log the activities residents attended. AA #208 tried to log into the electronic record system and showed the surveyor how the system froze and would not let her into the electronic system to record activities. When this happened AA #208 stated the Activity Aides wrote resident names and the activities they attended on a piece of paper and this was given to AD #207 and he documented the activities. AA #208 stated there were no sign in sheets or resident names written down to document when residents attended activities. AA #208 indicated we just know what residents attended. AA #208 revealed the facility had a shaded, grassy area with picnic tables where residents could be taken if the weather permitted, and this would be documented in their electronic record. AA #208 showed the surveyor the outside area which had picnic tables positioned under trees and the surrounding area was grassy. There were no residents in the grassy, shaded area.
Interview on 06/30/25 at 2:18 P.M. of Unit Manager (UM) #213 revealed the third floor nursing unit (Connections Community) residents could be taken outside with supervision.
Interview on 06/30/25 at 2:33 P.M. of Resident #67 revealed the facility had no activities provided to the residents on a regular basis. Resident #67 stated it was boring here and they only had parties sometimes. When asked if the residents were taken to the grassy, shaded outside area with picnic tables Resident #67 stated [expletive] no, they only keep us on the pavement by the smoking area.
Interview on 06/30/25 at 3:44 P.M. with AA #210 revealed she usually provided activities on the second floor nursing unit. Today she was going to play Name That Tune in the morning but she could not get the radio to work. AA #210 confirmed Name That Tune was not a scheduled activity and the scheduled activities of a Zoo Trip at 10:00 A.M., Cornhole at 1:00 P.M., Hydration Cart at 2:00 P.M. were not offered. AA #210 stated the Monthly Resident Birthday Party scheduled for 3:00 P.M. had to be moved up because AA #211 was leaving at 3:00 P.M. AA #210 stated she did not document resident activities because she did not have access to the electronic system, did not have a log in, and a coworker charted for her. AA #210 stated she worked on 06/15/25, it was Fathers Day and the facility cooked hot dogs inside, not outside for the residents. AA #210 indicated that she felt like the residents would like to go outside more, but that did not happen very much due to staffing.
Review of Resident #11's medical record revealed an admission date of 10/14/16 and a readmission date of 11/29/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus and bipolar disorder.
Review of Resident #11's care plan dated 10/18/24 included long term stay in the facility was in the best interests of Resident #11 and discharge to the community would not be pursued. Resident #11 would be long term care with staff attempting to anticipate and meet his needs. Interventions included staff would encourage and assist resident to interact with other residents, attend activities and understand where bathrooms and activity areas were located.
Review of Resident #11's Quarterly MDS assessment dated 04/10/25 revealed Resident #11 was cognitively intact. Resident #11 did not reject care during the seven-day assessment look-back period. Resident #11 used a wheelchair and required supervision or touching assistance for upper and lower dressing and chair-to-bed-to-chair-transfer.
Review of Resident #11's progress notes dated 06/02/25 through 06/30/25 did not reveal evidence Resident #11 was encouraged to attend activities or that he refused to attend activities.
Review of Resident #11's medical record including activity charting dated 06/01/25 through 06/30/25 revealed there was no evidence Resident #11 attended one-to-one activities. On 06/03/25 Resident #11 attended a group activity and played Bingo. On 06/03/25 Resident #11 had a self-directed activity for coffee, social interaction and news. There was no further evidence of activities.
Interview on 06/30/25 at 4:14 A.M. with Resident #11 revealed he resided on the second floor nursing unit and the facility did not have enough activities. Resident #11 revealed they only do one percent of the activities scheduled on the calendar and no one watches over them. Resident #11 revealed there was a resident birthday party today and he was not asked to attend, and he was not asked to attend any activities. Resident #11 revealed trips such as zoo trips were posted on the activity calendar but they did not happen. Resident #11 revealed he would like to go on outside trips, the facility used to take them on trips, and it was very upsetting to him and boring at the facility. He would like to go to the zoo, picnics and to the beach. Resident #11 revealed he had not been taken outside by the activity staff other than for smoke breaks.
Review of Resident #47's medical record revealed an admission date of 11/21/22 and diagnoses included unspecified dementia, moderate with psychotic disturbance, schizoaffective disorder bipolar type and chronic kidney disease.
Review of Resident #47's care plan dated 02/03/23 included Resident #47 needed to reside in the secured Blue Sky Living Community (fourth floor) to meet the physical, mental, spiritual and emotional well-being and safety needs of the resident. Resident #47 would reside safely in the Blue Sky Living Community daily. Interventions included to encourage activities.
Review of Resident #47's Quarterly MDS assessment dated 06/11/25 included Resident #47 was cognitively intact. Resident #47 did not reject care during the seven-day assessment look-back period. Resident #47 used a wheelchair and required supervision or touching assistance for upper and lower body dressing and chair-to-bed-to-chair transfers.
Review of Resident #47's medical record activity charting dated 06/01/25 through 06/30/25 did not reveal evidence Resident #47 attended one-to-one activities. On 06/09/25 and 06/19/25 Resident #47 attended a group activity for coffee, social interaction and news. There was no further evidence Resident #47 attended activities.
Interview on 06/30/25 at 4:30 P.M. with Resident #47 revealed she resided on the fourth floor memory unit (Blue Sky) and all they have is coffee. Resident #47 revealed she was taken outside one time to the smoking area, but there was no one to talk to. Resident #47 revealed there were no zoo trips because the facility did not have a bus and she wished there were outings. Resident #47 revealed she was not invited to the cook out and it was very upsetting not to have outside time and outings.
Interview on 06/30/25 at 4:33 P.M. with Certified Nursing Assistant (CNA) #214 revealed there were no activities scheduled on the second shift and sometimes residents say they were bored and act out. If activities were scheduled it would give the residents something to do other than argue and act out. CNA #214 indicated she only saw the activity staff giving residents coffee, CNA #214 made a face, rolled her eyes, and stated I can think of plenty of activities for the residents.
Review of Resident #33's medical record revealed an admission date of 04/04/25 and diagnoses included paraplegia, attention-deficit hyperactivity disorder and bipolar disorder.
Review of Resident #33's care plan dated 04/07/25 included Resident #33 triggered a level II referral to ODMH (Ohio Department of Mental Health) for PASSRR due to diagnoses of bipolar, anxiety and ADHD. Resident #33's needs per ODMH recommendations. Interventions included socialization and recreation activities to decrease isolation, improve mood and increase peer interaction.
Review of Resident #33's Admission MDS assessment dated 04/11/25 included Resident #33 was cognitively intact. Resident #33 stated he sometimes felt lonely or isolated from those around him. Resident #33 did not reject care during the seven-day assessment look-back period. Resident #33 responded it was very important for him to go outside to get fresh air when the weather was good, to do his favorite activities. Resident #33 responded it was somewhat important to do things with groups of people. Resident #33 used a wheelchair and required partial to moderate assistance for upper and lower body dressing and chair-to-bed-to-chair transfer.
Review of Resident #33's progress notes dated 06/02/25 through 06/30/25 did not reveal evidence Resident #33 refused to attend activities or was encourage to attend activities.
Review of Resident #33's medical record including activity charting dated 06/01/25 through 06/30/25 did not reveal evidence Resident #33 attended one-to-one activities. There was no evidence Resident #33 attended group activities. There was no evidence Resident #33 attended self-directed activities.
Interview on 06/30/25 at 4:39 P.M. with Resident #33 revealed he resided on the secured third floor nursing unit (Connections Community). Resident #33 stated the activities were Bingo two times a week, no other activities were offered, and he wished there was more of a variety of activities. Resident #33 indicated the activity staff always offered excuses why there were no activities planned. If something gets lost then we are never able to play games, the video game, table soccer and air hockey games were broken and there was no paddle or ping pong balls for ping pong. Resident #33 stated there were no activities on the weekends, the activity staff brought coffee around about four times a week, he was not asked to attend any activities, and he was very upset there were no outside trips. Resident #33 revealed it does not even cross their minds to take us outside. Resident #33 stated they do not even get the papers with things like word search, crossword puzzles or coloring, there were no pencils, and no board games either. In the month and a half since Resident #33 lived in facility there was only two times where a movie and popcorn were offered.
Interview on 06/30/25 at 4:54 P.M. with Resident #57 revealed the facility did not have much activities. Resident #57 stated sometimes he snagged a coffee.
Interview on 06/30/25 at 5:16 P.M. of Regional Director of Operations (RDO) #201 revealed the facility bus was always shared with the sister facility and when the facility needed the bus they made arrangements with the sister facility. RDO #201 stated she was not aware the residents had not gone on any bus trips since last year, and the bus was shared with a sister facility and should be used for trips. RDO #201 indicated she did not know how long the facility did not have a driver, but AD #207 had a license and could drive the bus.
Observation on 07/01/25 at 10:12 A.M. of the third floor secured nursing unit (Connections Community) with UM #213 revealed behind the nurses station, activity papers for word search, coloring etcetera were observed hanging on a bulletin and contained in plastic sleeves. There were no pencils, colored pencils, crayons, or pens observed. UM #213 confirmed this and stated if the residents ask for the activity papers the nurses could go to the second floor activity room for the pens, crayons, pencils. Residents on the third floor had to be monitored when they were given pens, pencils, and crayons to make sure they were used appropriately.
Observation on 07/01/25 at 10:12 A.M. with UM #213 of the second floor activity room revealed no activity staff were present in the room and no pencils, pens, crayons could be found. UM #213 revealed she could not find pens, pencils or crayons but the activity staff knew where they were. UM #213 stated the activity room was locked when the staff left for the day, but nurses from the nursing units had keys and could access the room.
Interview on 07/01/25 at 10:43 A.M. of AD #207 revealed he did not document resident activities and the Activity Assistants were responsible to use his office laptop computer to document resident activities. AD #207 indicated Activity Assistant's #208, #209, #210 and #211 did not have access to the electronic system to document activities at the nurses station but he was looking into it. AD #207 stated the fourth floor Blue Sky Community was more dementia, hospice and long term care and the activity staff try to have activities to brighten their day. Last week therapy dogs were brought to facility, but AD #207 confirmed it was not documented on the activity calendar or in resident electronic records. It was important for third floor residents to stay active and there were numerous games kept on the floor and a basketball hoop game. Paddles and ping pong balls were kept behind the desk of the second floor nursing unit and he was planning to talk to the management staff about fixing the third floor video game, air hockey and table soccer games. AD #207 stated he sent an email to the management staff about fixing the games and he would provide it to the surveyor, but no email was provided. AD #207 stated the outside, shaded grassy area was difficult for residents in wheelchairs because the ground sloped down, and they were not taken there often.
Observation on 07/01/25 at 11:27 A.M. of the second floor nursing unit with AD #207 and Licensed Practical Nurse (LPN) #215 revealed there was a ping pong table in the common area, but no paddles or ping pong balls could be found. AD #207 and LPN #215 searched the common area and the nurses station and surrounding areas and could not find ping pong paddles or ping pong balls.
Interview on 07/02/25 at 8:05 A.M. of RDO #201 revealed she had no knowledge of AD #207 requesting video game, air hockey and table soccer game to be fixed. RDO #201 stated on 06/26/25 he talked to her about getting them fixed and she was under the impression the games were recently broken.
Interview on 07/02/25 at 11:00 A.M. of CNA #216 revealed she worked on the secured third floor nursing unit. The air hockey, table soccer and video games had been broken for about a month. CNA #216 stated third floor residents could be accompanied to the second floor to play games such as ping pong but they needed to be accompanied by a staff member.
Review of the facility policy titled Activities Policy revised 04/2022 included the center strives to provide meaningful experiences that benefit the resident psychologically, socially, spiritually, and physically through activities across all ages regardless of the resident's cognitive abilities and physical limitations. The activity department function included to provide a calendar of activities posted in the general area for all to see, to encourage residents to choose the activities of their choice, to provide large group, small group, individually motivated and one-to-one activities. Activities might include offering a center outing in the community or a pleasant community drive. Activities might occur in large open areas, in a quiet lobby, outdoor setting or in a resident's room.
F-0880Infection Prevention and Control▼
Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #19's physician orders and care planned interventions for enhanced barrier precautions were followed. This affected one resident (Resident #19) of two residents observed for enhanced barrier precautions. The facility census was 93.
Findings include:
Review of Resident #19's medical record revealed an admission date of 07/20/09 and diagnoses included unspecified dementia, anxiety disorder and adult failure to thrive.
Review of Resident #19's physician orders revealed Enhanced Barrier Precautions related to feeding tube, every shift.
Review of Resident #19's care plan revised 10/15/24 revealed Resident #19 required Enhanced Barrier Precautions related to feeding tube. To reduce the potential of spreading multi-drug resistant organisms daily. Interventions included use of appropriate Enhanced Barrier Precautions when performing the following including personal hygiene, toileting and peri care.
Review of Resident #19's Quarterly MDS assessment dated 04/11/25 revealed a Brief Interview for Mental Status was not conducted due to Resident #19 was rarely or never understood. Resident #19 was dependent for ADL's and was frequently incontinent of urine and always incontinent of bowel. Resident #19 had a PEG (percutaneous endoscopic gastrostomy) feeding tube and received 51 percent or more of total calories through tube feeding.
Observation on 07/01/25 at 7:55 A.M. of Resident #19's room revealed isolation gowns were hanging on the door leading into the room from the hall. An Enhanced Barrier Precautions sign was hung on the wall above Resident #19's bed. The sign included everyone must clean their hands, including before entering and when leaving room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy, and wound care.
Observation on 07/01/25 at 7:55 A.M. of Certified Nursing Assistant's (CNA)'s #223 and #226 revealed they were preparing to provide incontinence care for Resident #19. CNA's #223 and #226 did not don an isolation gown before entering Resident #19's room to provide care. Licensed Practical Nurse (LPN) #227 entered Resident #19's room, did not don an isolation gown and disconnected the tube feeding from Resident #19's PEG tube. LPN #227's clothes brushed against Resident #19, her bed, and the bed linens while she disconnected the tube. Without donning isolation gowns CNA's #223 and #226 provided incontinence care for Resident #19. While they were providing care CNA's #223 and #226 clothes brushed against Resident #19, her bed and the bed linens. When Resident #19's incontinence care was completed LPN #227 reentered her room without donning an isolation gown and reconnected the tube feeding and turned the tube feeding pump on. CNA's #223 and #226 confirmed they did not wear an isolation gown during Resident #19's incontinence care. LPN #227 confirmed she did not wear an isolation gown when she disconnected and reconnected Resident #19's tube feeding. LPN #227 stated she did not realize she had to wear a gown when hooking up and unhooking the tube feeding.
Interview on 07/01/25 at 9:00 A.M. of Regional Director of Operations (RDO) #201 revealed she was so disappointed to hear the aides and nurses did not don appropriate PPE (Personal Protective Equipment) when providing Resident #19's incontinence care and tube feeding care. RDO #201 revealed they have provided so much staff education on Enhanced Barrier Precautions.
Review of the facility policy titled Enhanced Barrier Precautions Policy updated 01/2025 included EBP was used in conjunction with standard precautions and expands the use of PPE to donning gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP was indicated for residents including indwelling medical devices even if the resident was not known to be infected or colonized with a MDRO. Indwelling medical devices included feeding tubes. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy, and wound care.
This deficiency represents non-compliance investigated under Complaint Number OH00165460.
February 13, 2025Complaint survey1 deficiency▼
F-0609Reporting of Alleged Violations▼
Based on closed record review, facility policy review, and interview, the facility failed to report an incident of potential neglect involving Resident #93 to the State Agency as required. This affected one resident (#93) of nine residents reviewed for abuse and neglect. The facility census was 91.
Findings include:
Review of Resident #93's closed medical record revealed an original admission date of 08/22/14 with diagnoses of schizoaffective disorder, bipolar, dementia, anxiety, antisocial personality disorder, hallucinations and body dysmorphic order, and right leg above the knee amputation. Resident #93 had elected to be a full code (requiring full resuscitation efforts including cardiopulmonary resuscitation in the event of cardiac or respiratory arrest). Resident #93 was transported to a local hospital where he was pronounced deceased on 08/06/24.
Review of Resident #93's care plan dated 09/21/14 revealed the resident had a self-care performance deficit for activities of daily living related to diagnoses of dementia, paranoid schizophrenia, and limited mobility. Listed interventions included for the resident to be supervised at all times while shaving.
A care plan focus dated 03/12/15 revealed the resident had a mood problem related to paranoid schizophrenia, dementia with behaviors, history of self-harm, antisocial personality disorder, manic episodes, adjustment disorder, psychotic disorder, major depressive disorder, generalized anxiety disorder, and history of suicidal ideations. Interventions included administering medications as ordered and educating residents, family and caregivers regarding expectation of treatment, concerns with side effects, and potential adverse effects.
An additional care plan focus dated 09/08/23 revealed Resident #93 had an identified traumatic event listed as suicide behavior and self-harm with a single listed trigger of being housed on the secured memory care unit. Listed interventions included allowing the resident to express feelings, develop strategies with the resident and/or family to avoid or decrease trauma triggers, discus coping mechanisms, gain as much additional background from family/friends and other healthcare professions as possible, monitor for anxiety, and refer to psych services as needed.
Review of the quarterly Minimum Data Set (MDS) Assessment dated 07/24/24 revealed the resident had intact cognition with noted inattention and disorganized thinking. There were no additional behaviors identified. The assessment revealed the resident required (staff) supervision with showers and was independent with personal hygiene. The assessment also noted the resident received anticoagulant and antipsychotic medications.
Review of a progress noted dated 08/06/25 at 5:00 P.M. authored by the DON revealed the note was created on 08/07/24 at 1:33 P.M. and included on 08/06/24 at approximately 3:10 P.M., the nurse was notified by the activity assistant that there was an emergency on the second floor. Upon arriving on the floor, Resident #93 was observed seated in a wheelchair with his back towards the door. The resident was pale, clammy cool to touch. There was a large amount of saliva coming from the resident's mouth and large among of blood on the floor. There were copious amounts of blood coming from the resident's groin area. A second nurse assessed the resident for a pulse and could not identify one. The resident was lowered to the floor and CPR was initiated. The second nurse applied pressure to the bleeding leg. EMS arrived and continued to work on the resident. Resident #93 was transported to the hospital. According to EMS, the resident had a pulse before leaving the facility.
Review of the facility's investigation dated 08/06/24 revealed statements were obtained from staff members working that day. All staff interviewed reported no concern or indication that the resident was suicidal. There were no reported behaviors or statements that Resident #93 had wanted to harm himself. The facility completed a root cause analysis which concluded the cause of the incident was the Charge Nurse (LPN #500) provided Resident #93 with a sharp object.
Interview on 02/06/25 at 10:40 A.M. with Licensed Practical Nurse (LPN) #500 revealed she was not assigned to care for Resident #93 on 08/06/24. LPN #500 stated at approximately 2:40 P.M., Resident #93 asked her for a pair of scissors to cut his bangs (hair). LPN #500 stated initially she could not find her scissors and went searching for another pair. LPN #500 asked another nurse for a pair of scissors who did not have one. LPN #500 continued to look and found a pair of scissors in her bag and handed them to Resident #93. The scissors were described as safety scissors with a rounded blunted end. LPN #500 provided the scissors to Resident #93 due to her belief the resident was fairly independent with his activities of daily living and had no aggressive behaviors. LPN #500 verified she never looked at the resident's Kardex or care plan prior to giving the resident her scissors. In addition, the resident was not provided any level of supervision while having the scissors.
Interview on 02/11/25 at 12:10 P.M. with the Administrator confirmed the incident with Resident #93's self-harm and suicide was not reported to the State Agency. The Administrator stated the incident was an accident and was not reportable. The Administrator did confirm, following the incident, he completed an investigation but stated he did not believe he needed to report the incident to the State Agency.
Review of the policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/2022 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, and misappropriation of resident property, including injuries of unknown source. The policy defined an alleged violation as a situation or occurrence that was observed or reported but had not yet been investigated and, if verified, could be noncompliance with federal requirements. The policy defined an injury of unknown source as an injury which occurs when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent or location of the injury. The policy defined neglect as the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress.
This deficiency represents an incidental finding of non-compliance identified during the complaint investigation.
December 6, 2024Complaint survey1 deficiency▼
F-0600Freedom from Abuse, Neglect, and Exploitation▼
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on medical record review, staff interview, review of facility self-reported incidents (SRIs), policy review, and review of facility corrective action, the facility failed to ensure residents were free from resident-to-resident physical abuse. This affected five (#2, #20, #21, #22, and #23) of five residents reviewed for abuse. The facility census as 98.
Findings Include:
1. Review of the medical record revealed Resident #2 was admitted to the facility on 09/26/24 with diagnoses that included schizoaffective disorder, dementia, and dysphagia.
Review of the most recent comprehensive Minimum Data Set (MDS) 3.0 assessment dated 10/03/24 revealed Resident #2 was severely cognitively impaired and required extensive assistant for completing his activities of daily living (ADLs).
2. Review of the medical record revealed Resident #20 was admitted to the facility on 03/22/24 with diagnoses that included schizophrenia, dementia, and type two diabetes.
Review of the most recent quarterly MDS 3.0 assessment dated 09/09/24 revealed Resident #20 was severely cognitively impaired and required extensive assistance of one staff person for completing his ADLs.
3. Review of the medical record revealed Resident #21 was admitted to the facility on 12/28/21 with diagnoses that included alcohol dependence, dementia, and gout.
Review of the most recent quarterly MDS 3.0 assessment dated 10/20/24 revealed Resident #21 was severely cognitively impaired and required extensive assistance of one staff person for completing his ADLs.
4. Review of the medical record revealed Resident #22 was admitted to the facility on 08/11/21 with diagnoses that included schizoaffective disorder, cocaine abuse, and brief psychotic disorder.
Review of the most recent quarterly MDS 3.0 assessment dated 09/19/24 revealed Resident #22 was cognitively intact and required the supervision of one staff person for completing his ADLs.
5. Review of the medical record revealed Resident #23 was admitted to the facility on 05/05/16 with diagnoses that included paranoid schizophrenia, bipolar two disorder, and psychotic disorder.
Review of the most recent quarterly MDS 3.0 assessment dated 10/14/24 revealed Resident #23 was cognitively intact and required the supervision of one staff person for completing her ADLs.
Review of the SRI dated 11/15/24 and timed 11:41 A.M. revealed staff reported to the Administrator that Resident #2 kicked Resident #23 in the leg. The staff intervened and separated both residents. A nurse assessed Resident #23 with no injuries noted and the facility initiated every 15-minute checks for Resident #2 and Resident #23. There were no further incidents between Residents #2 and Resident #23.
Review of the SRI dated 11/17/24 and timed 4:59 P.M. revealed staff reported to the Administrator that Resident #2 hit Resident #21 in the face because, according to Resident #2, Resident #21 had Resident #2's television remote in the drawer. Upon the approval of Resident #21 and his responsible party, Resident #21 was moved to a room down the hall away from Resident #2 to prevent any further incidents. Both residents were assessed after the incident with no negative findings.
Review of the SRI dated 11/17/24 and timed 6:37 P.M. revealed facility staff informed the Administrator that Resident #2 hit Resident #20 in the head and made him fall to the floor. Staff immediately separated the residents and assisted Resident #20 up from the floor. Resident #20 was immediately assessed with no injuries noted. Resident #2 was immediately transferred to the secured behavior unit to increase behavior monitoring.
Review of the SRI dated 11/18/24 and timed 1:23 P.M. revealed staff notified the Administrator that Resident #22 scratched Resident #2 in the face because Resident #2 was attempting to punch Resident #22. Resident #22 stated he scratched Resident #2 in the face while trying not to get hit and intended no harm from incident and simply was trying to engage in self defense. A nurse on the floor assessed Resident #2 and noted superficial scratches to the face. Resident #22 did not sustain any injuries as a result of the incident. Resident #2's primary care physician was contacted and ordered for Resident #2 to be sent to a local psychiatric hospital for evaluation.
Interview with the Administrator on 12/06/24 at 1:11 P.M. verified Resident #2 kicked Resident #23 in the leg on 11/15/24, verified Resident #2 hit Resident #21 in the face on 11/17/24, verified Resident #2 hit Resident #20 in the head causing the resident to fall on 11/17/24, and verified Resident #22 scratched Resident #2's face while Resident #2 was attempting to hit Resident #22. The Administrator confirmed none of the residents involved in the incidents was significantly hurt and immediate interventions were implemented.
Review of the policy titled, Abuse , Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property
November 19, 2024Complaint surveyImmediate jeopardy4 deficiencies▼
F-0689Free of Accident Hazards/Supervision/DevicesImmediate jeopardy▼
Based on observation, medical record review, facility policy review and interviews, the facility failed to ensure a safe environment free from a potential accident hazard when smoking materials were not secured to prevent unsafe smoking in resident rooms. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on 11/12/24 at 1:03 P.M. when Resident #38, who was assessed to require staff supervision and the use of a smoking apron (device worn to protect from burns caused by hot ashes or lit cigarettes) was observed alone in his room with a strong cigarette odor and visible cigarette smoke in the air. Certified Nursing Assistant (CNA) #300 verified the odor and presence of smoke in Resident #38's room and further stated Resident #37, who was Resident #38's roommate and away from the facility at the time of the observation, had been seen previously smoking in the room. Additionally, Resident #37 and Resident #38's bathroom had cigarette ashes on the floor, burn marks on the toilet seat and toilet paper holder and two cigarette butts were found in the plastic trash can located next to Resident #38's bed. Resident #37 and Resident #38 resided in a room located across the hall from Resident #32, who was identified to utilize oxygen. This affected two residents (#37 and #38) of seven residents reviewed for smoking with the potential to affect all residents residing in the facility. The facility census was 101.
On 11/13/24 at 1:08 P.M., the Administrator, Regional Registered Nurse (RRN) #333 and Regional Director of Operations (RDO) #334 were notified Immediate Jeopardy began on 11/12/24 at 1:03 P.M. when a strong cigarette odor and visible smoke was observed in Resident #37 and Resident #38's room. Additionally, there were cigarette ashes on the bathroom floor, burn marks on the toilet seat and toilet paper holder and two cigarette butts located in the plastic trash can next to Resident #38's bed. While Resident #37 was away from the facility at the time of the observation, Resident #38 was in the room and identified to be a smoker who required supervision and the use of a smoking apron while smoking.
The Immediate Jeopardy was removed on 11/13/24 when the facility implemented the following corrective actions:
On 11/12/24 at 3:00 P.M., the Interdisciplinary Team (IDT), including Housekeeping Manager (HM) #283, Medical Records Coordinator (MRC) #322, Activities Director (AD) #202, Maintenance Director (MD) #271, the Administrator, Human Resources (HR) #262, Scheduler #261, Licensed Social Worker (LSW) #301, Social Services Designee (SSD) #260, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #273, Unit Manager Registered Nurse (UM/RN) #256 and UM/RN #302, conducted room sweeps on all resident rooms for the presence of smoking materials.
On 11/12/24 at 3:15 P.M., UM/RN #302 searched Resident #37's room and any smoking materials identified were secured.
On 11/12/24 at 3:15 P.M., the DON searched Resident #38's room and person and any smoking material identified were secured.
On 11/12/24 at 3:25 P.M., the DON assessed Resident #32, Resident #37 and Resident #38 for injuries, with no adverse effects noted.
On 11/12/24, at 5:00 P.M., the Administrator re-educated all staff on the facility smoking policy and procedure related to supervision of residents who smoke. The education was provided electronically via On-Shift software messaging and texting to staff. The education was completed by all staff by 6:00 P.M.
On 11/12/24, at 5:00 P.M., LSW #301 re-educated all 64 residents who smoke (#2, #3, #4, #5, #6, #8, #10, #12, #15, #18, #19, #20, #21, #22, #24, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #40, #41, #47, #48, #51, #52, #60, #61, #62, #63, #64, #65, #67, #70, #71, #72, #73, #74, #77, #79, #80, #81, #82, #83, #84, #86, #88, #90, #91, #92, #93, #96, #97, #98, #99, #100 and #101) on the smoking policy, which included residents smoking only in designated areas, securing smoking materials and other applicable policies. Failure to follow the facility smoking policy would result in a discharge notice.
On 11/12/24 at approximately 5:00 P.M., a root cause analysis was performed by the Administrator, the DON, ADON #273, HM #283, MRC #322, AD #202, MD #271, HR #262, Scheduler #261, LSW #301 and SSD #260. It was determined residents who had left the facility for appointments or other leave of absences (LOA) may have purchased and brought back smoking materials without staff knowledge and policies and procedures for securing smoking materials had not been adhered to.
On 11/13/24 by 5:00 P.M., the IDT, including RRN #333, the DON, ADON #273, UM/RN #302 and UM/RN #256 completed an audit of the smoking assessments for all 64 residents who smoke to ensure accuracy and updated care plans as needed.
On 11/13/24 by 5:00 P.M., the DON, ADON #273, UM/RN #256 and UM/RN #302 completed a skin assessment on all residents who smoke.
On 11/13/24 at 5:00 P.M., the Administrator provided all staff two questionnaires to ensure education from 11/12/24 was effective.
On 11/13/24 at 7:00 P.M., the Administrator updated the procedure for securing smoking materials when a resident leaves and returns to the facility, to include signing out smoking materials and signing them back in. The Administrator educated all staff and residents on the procedure. Staff would contact the Administrator or designee if smoking materials were not returned.
Beginning on 11/13/24, the Administrator or designee would audit smoking material sign out/sign in sheets one time daily to ensure smoking materials were returned.
Beginning on 11/13/24, the Administrator or designee would complete room audits on all residents who smoke, and throughout the facility, two times per day for eight weeks to ensure residents have no smoking materials in their rooms and were adhering to the facility's smoking policy.
On 11/13/24, an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the root cause analysis and corrective action plan. Those in attendance included the Administrator, the DON and Medical Director (MD) #355.
Review of five (#6, #15, #71, #80 and #98) additional open resident records revealed no concerns.
Interviews on 11/14/24 from 7:37 A.M. through 2:09 P.M. with Dietary Aide (DA) #226, DA #285, CNA #203, CNA #211, CNA #328, CNA #329, CNA #357, Licensed Practical Nurse (LPN) #241, LPN #257, LPN #318, Activities Assistant (AA) #236, Housekeeping #321 and Receptionist #279 confirmed the facility provided education on the smoking policies and procedures, including signing smoking materials in and out.
Although the Immediate Jeopardy was removed on 11/13/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance.
Findings include:
Review of Resident #37's medical record revealed an admission date of 12/22/23 with diagnoses including nicotine dependence, end stage renal disease and muscle weakness.
Review of the Minimum Data Set (MDS) assessment, dated 09/30/24, revealed Resident #37 had impaired cognition.
Review of the care plan dated 09/30/24 revealed Resident #37 was a smoker. Interventions included assess resident for smoking safety, educate resident on where smoking may occur, not giving or trading cigarettes with other residents, encourage safe smoking practices at all times, explain the consequences for smoking including removal of all smoking materials and only being allowed to smoke when supervised, provide a copy of the facility safe-smoking policy and explain so resident is aware of all obligations and consequences of violating the rules, smoking may not occur in residents rooms, bathrooms, hallways or other non-designated areas.
Review of the Smoking Assessment, dated 07/10/24, revealed Resident #37 was assessed by the facility to require supervision while smoking.
Review of a Last Chance Agreement, dated 08/19/24, revealed Resident #37 had agreed to not smoke without proper supervision.
Review of Resident #38's medical record revealed an admission date of 04/20/23 with diagnoses including nicotine dependence, bilateral amputations, muscles weakness and muscle weakness.
Review of the MDS assessment, dated 09/27/24, revealed Resident #38 had intact cognition.
Review of the care plan dated 09/27/24 revealed Resident #38 was a smoker. Interventions included monitor for compliance with smoking policy, smoking apron and supervision while smoking.
Review of the Smoking Assessment, dated 10/10/24, revealed Resident #38 was assessed by the facility to require a smoking apron and supervision while smoking.
Observation on 11/12/24 at 1:03 P.M. revealed a strong odor of cigarette smoke outside of Resident #37 and Resident #38's room. Further observation of the residents' room confirmed the presence of cigarette smoke odor and further revealed visible smoke in the air. Concurrent interview with Certified Nursing Assistant (CNA) #300 verified the odor and presence of smoke in the residents' room. CNA #300 stated Resident #37 had previously been observed smoking in the room (date(s) not provided). At the time of the observation, Resident #37 had been out of the facility for approximately one and one-half hours. Resident #38, who also smoked, was lying in bed with a blanket pulled up over his head. An attempted interview with Resident #38 at the time of the observation revealed the resident denied smoking in the room.
At the time of the observation, UM/RN #302 entered the room and opened Resident #37 and Resident #38's bathroom door and revealed cigarette ashes on the floor and burn marks on the toilet seat and toilet paper holder. LSW #301 was also present and discovered two cigarette butts in the plastic trash can, which had some paper waste, located next to Resident #38's bed.
An interview with UM/RN #302 at the time of the observation verified the findings and further confirmed Resident #38 was to be supervised by staff while smoking and required a smoking apron to prevent burns.
A continuous observation at this time revealed Resident #32 resided in the room across the hall from Resident #37 and Resident #38 and had a sign posted outside of the room indicating the resident had oxygen in use. Interview with LSW #301 and UM/RN #302 verified Resident #32 was on oxygen and smoking was not permitted in the area.
An interview on 11/14/24 at 3:48 P.M. with the Administrator revealed staff and residents had been educated on the facility process for signing out smoking materials and signing them back in upon re-entry to the facility. No additional information was provided to determine or support the facility had effective systems in place to ensure smoking materials were actually being signed out and then back in or to prevent residents from engaging in unsafe smoking practices and smoking in their rooms.
Review of the facility policy titled Resident Smoking, revised 05/30/24, revealed smoking was only permitted in designated smoking areas, all resident smoking materials were to be kept locked at all times and non-compliance with the smoking policy could result in a thirty-day discharge notice.
This was an incidental finding discovered during the complaint investigation.
F-0804Nutritive Value/Appear, Palatable/Prefer Temp▼
Based on observation, resident and staff interview and review of Resident Council meeting minutes, the facility failed to ensure meals were served at an appropriate temperature and were palatable. This had the potential to affect all residents, except Resident #50 was what identified by the facility as receiving no food from the kitchen. The facility census was 101.
Findings include:
Observation on 11/12/24 at 12:35 P.M. of the lunch meal service with Licensed Practical Nurse (LPN) #241 revealed a lunch tray that contained of a plate of a red watery substance, a mixture of meat and beans and a bag of chips. LPN #241 stated she was unsure what the meal was and stated this is the slop they are often served. Further observation revealed a container of ice cream on the tray. LPN #241 removed the lid from the ice cream and revealed the ice cream was melted. LPN #241 verified the ice cream was melted and stated the residents often complained about the food and the small portions they received. Concurrent interview with Resident #71 and Resident #73 revealed the food was awful and the portions were not usually enough.
Interview on 11/13/24 at 11:37 A.M. with Regional Dietary Manager (RDM) #336 revealed she observed the lunch meal served on 11/12/24 and stated she spoke with the Administrator about placing an order for bowls to serve those type of meals in to make them more appealing.
Observation of a meal test tray on 11/14/24 revealed the test tray left the kitchen on a meal cart at 9:22 A.M. and the test tray was received at 9:43 A.M. Further observation, with Assistant Director of Nursing (ADON) #273, revealed the meal consisted of scrambled eggs, bacon, toast and grits. The food temperature was cold and lacked flavor. Concurrent interview with ADON #273 verified the findings.
Review of Resident Council meeting minutes revealed food concerns were voiced in August 2024 related to meat being too hard and in September 2024 concerns were voiced related to food not being done.
This deficiency represents non-compliance investigated under Complaint Number OH00158177.
F-0919Resident Call System▼
Based on observation and staff interview, the facility failed to ensure resident call lights were in working order and able to be reached by residents. This affected 14 residents (#41, #42, #43, #44, #63, #64, #80, #81, #83, #84, #89, #90, #91 and #92) of 14 residents observed for call lights. The facility census was 101.
Findings include:
Interview on 11/12/24 at 11:46 A.M. with Activities Aide (AA) #236 revealed she had observed short call light cords in some resident rooms. AA #236 stated she was unsure why the call light cords were shorter than others. Observation with AA #236 revealed call light cords, approximately two to three inches in length, were in Resident #89, Resident #90, Resident #91 and Resident #92's rooms. AA #236 verified the call light cords were not long enough to reach the residents if they were in bed. Continued observations with AA #236 revealed call lights were not functioning in Resident #80, Resident #81, Resident #83, Resident #84, Resident #89, Resident #90, Resident #91 and Resident #92's rooms and there was no evidence an alternative call light system had been implemented. AA #236 stated the call lights had not been functioning for quite a few weeks.
Interview on 11/12/24 at 12:26 P.M. with Certified Nursing Assistant (CNA) #203 revealed she was aware of several non-functioning resident calls lights. Concurrent observation with CNA #203 verified Resident #41, Resident #42, Resident #43, Resident #44, Resident #63 and Resident #64 did not have a functioning call light and there was no evidence an alternative call light system had been implemented.
Interview on 11/14/24 at 2:09 P.M. with Maintenance Director (MD) #271 revealed he became aware approximately two to three weeks prior that the call light system was no functioning properly. MD #271 stated he received an estimate for replacement of the system on 11/07/24 and further stated he received parts to begin repairs on 11/14/24. MD #271 stated he was unsure why some of the resident rooms had short call light cords and confirmed residents would not be able to reach the call lights if they were in bed.
This deficiency represents non-compliance investigated under Complaint Number OH00158177.
F-0921Safe/Functional/Sanitary/Comfortable Environment▼
Based on resident interview, observation and staff interview, the facility failed to ensure a clean and sanitary environment. This affected two residents (#39 and #46) of three residents reviewed for environment. The facility census was 101.
Findings include:
1. Interview on 11/12/24 at 8:59 A.M. with Resident #39 revealed there was water coming into his room from the ceiling and wall. The resident stated the leak had been going on for a few weeks. Resident #39 stated he he informed the Administrator and maintenance of the situation; however, it had not been fixed. Resident #39 stated staff placed towels and sheets down to soak up the water. Concurrent observation revealed a large puddle of water, with multiple sheets placed on the floor near the baseboard, in Resident #39's room. Additionally, Resident #39's sheets were odorous and had several brown and black stains. Resident #39 stated he could not recall the last time the sheets were changed.
During the observation of Resident #39's room, Housekeeper (HSK) #321 entered and stated she had seen the water in the room for several weeks and was unaware of what was being done to fix the leak. HSK #321 stated Certified Nursing Assistants (CNA) were responsible for changing bed linens.
Continuous observation with CNA #216 confirmed Resident #39's linens were odorous and had brown and black stains. CNA #216 stated he would change the sheets.
Observation on 11/13/24 at 10:48 A.M. revealed Resident #39's room had wet towels and sheets on the floor and the bed sheets continued to have an odor and brown and black stains.
Interview on 11/13/24 at 11:00 A.M. with CNA #254 verified Resident #39's bed linens were soiled and further stated they should have been changed following the previous observation of them being soiled.
Interview on 11/14/24 at 2:09 P.M. with Maintenance Director (MD) #271 revealed he had been attempting to find the leak in Resident #39's room for about two to three weeks and just identified the source today.
2. Observation on 11/12/24 at 12:15 P.M. revealed a strong, pungent odor of stool and urine outside of Resident #46's room. Further observation revealed Resident #46's toilet had a large amount of stool and dark colored urine inside the toilet and dried stool inside the toilet bowl and on the toilet seat.
Coinciding interview with CNA #203 verified the findings and further stated she did not want to flush the toilet because she was unsure if the toilet would overflow. CNA #203 stated she would inform the nurse to call maintenance.
This deficiency represents non-compliance investigated under Complaint Number OH00158177.