Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medina Bsd Opco Llc during CMS and state inspections, most recent first.
Foley catheter insertion and catheter care failures: An LPN changed a resident’s Foley without an order while the resident was moving and verbalizing pain, with no documented assessment, provider notification, or follow-up when hematuria and severe pain developed; the resident later became unstable, was hospitalized, and died with urosepsis after imaging showed the catheter was malpositioned in the urethra. A second resident’s ordered monthly catheter changes and shift-based urine output monitoring were not carried out as ordered, and charting showed catheter tasks were signed off without the catheter actually being changed.
Missed Pre-Meal Blood Sugar Check and Insulin Administration: A resident with DM had orders for pre-meal blood glucose checks and Lispro insulin before meals, but an LPN failed to check the blood sugar and administer insulin before lunch. The blood glucose was later found to be 384 mg/dL, and the resident became lethargic with hypotension and reduced responsiveness, requiring transfer to the ED. The DON confirmed the timing error, and the Administrator stated no investigation was conducted related to the medication error.
Staff failed to follow EBP during care for two residents. One resident with a PICC line, wound care needs, MRSA, and an amputation stump dressing received IV care and incontinence care without proper EBP signage or gown use, and the DON entered without an isolation gown and left without hand hygiene. For another resident with bilateral buttock pressure ulcers, an RN left the room wearing gown and gloves to gather supplies and walked in the hall before returning, despite facility policy requiring PPE removal before leaving the room and hand hygiene before and after glove use.
Delayed Incontinence Care for a Resident Requiring Toileting Assistance: A resident with CHF and frequent bowel and bladder incontinence required partial/moderate assistance with toileting hygiene, and the care plan directed staff to assist with bathroom use and clean the peri area after each incontinent episode. During observation, a CNA stated it was the first time during the shift she had checked the resident for incontinence; the resident was found lying in bed with a urine-saturated brief, pad, and sheet, and the buttocks were red and excoriated. The DON stated incontinent residents should be checked every 2 hours.
Missed Post-Op Follow-Up Appointments: A resident with MS, chronic pain, and intact cognition was hospitalized after coffee ground emesis and surgery for a perforated small intestine/SBO. Discharge instructions called for GI and surgical follow-up visits, but facility records showed no evidence the appointments were scheduled or documented, one follow-up was never scheduled, and transport records did not confirm a pickup for the GI appointment.
An LPN and RN provided wound care to a resident with multiple Stage II pressure ulcers and other open areas, but the LPN did not cleanse each wound before applying treatment and did not wash hands or change gloves between separate wound sites. The resident had wounds on the buttocks, sacrum, and posterior thigh, and the LPN stated she believed cleansing and glove changes were unnecessary because the orders did not specify cleansing. The wound care nurse/ADON stated wounds should always be cleansed before treatment and that staff should wash hands and change gloves between wounds.
Fall prevention interventions were not consistently implemented for two residents at risk for falls. One resident with epilepsy, DM, dysphagia, and severe cognitive impairment was observed without the call light within reach, without nonskid socks, and with the wheelchair not properly set up. Another resident with brain neoplasm, weakness, syncope, spinal stenosis, and back pain was found on the floor after meds and later observed with the bed not in the low position, despite care plan interventions requiring the bed to remain low, the call light within reach, and other fall-prevention measures; an LPN and CNA confirmed the missed interventions.
A resident with anxiety and depression had a PRN Ativan order, and the pharmacy review noted that PRN psychotropic meds are limited to 14 days unless the rationale and estimated duration are documented. The DON confirmed the review form was never completed, and nurses continued giving the medication multiple times over several months.
A resident with multiple documented food allergies, including gluten, dairy, soy, and others, had allergy information that was not accurately reflected on the diet ticket. During a meal observation, the resident received gluten-containing foods, and the SSD confirmed the tray contents. The DM said she had collected preferences but had no documentation that gluten-free needs were allergies rather than preferences, while the DON confirmed the EMR listed gluten as an allergy but the diet ticket did not. The resident stated he only received a standard menu and no alternate options to accommodate his allergies.
Failure to Provide Ordered Thickened Liquids: A resident with dysphagia, COPD, and anxiety disorder had orders for a pureed diet with nectar-thick liquids, but breakfast service included milk that appeared thinner than ordered and later omitted the ordered nectar-thick cranberry juice and milk entirely, substituting nectar-thick water instead. Staff confirmed the inconsistency, and the DM stated the kitchen only had pre-thickened apple juice and water, while the RD noted that milk had to be thickened in-house and the facility had two residents with thickened-liquid orders.
Incomplete wound care documentation and order accuracy: A resident with multiple pressure ulcers had orders for Triad cream and dry dressings to four wound sites, but during observed wound care an LPN did not cleanse the wounds before treatment, did not consistently change gloves or perform hand hygiene between sites, and found one wound without the dressing that should have been in place. The Wound Care Nurse/ADON stated wounds should always be cleansed before treatment and acknowledged the omission of cleansing instructions in the orders, while the TAR had no active wound care orders documented and no signed entries showing the observed treatments were completed.
The facility failed to screen new employees against the State of Ohio Nurse Aide Registry before employment, potentially affecting all 52 residents. Personnel files for several staff members, including a PTA, LPN, RN, DM, DOR, Housekeeper, and DA, showed no evidence of NAR checks. The HR Manager was unaware of this requirement, confirming the oversight.
The facility failed to provide adequate staffing, leading to unmet resident needs and delayed call light responses. Residents and staff reported insufficient aides, particularly during night shifts, resulting in long wait times for assistance. Observations confirmed the inadequacy, with call lights going unanswered. The facility did not implement its assessment to maintain required staffing levels, resulting in non-compliance.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week, due to call-offs and lack of replacements. The staffing tool review showed no RN coverage on two days, despite the facility assessment indicating a need for one to two RNs per shift for an average census of 53 residents. This non-compliance had the potential to affect all 52 residents.
A resident reported a distressing comment from a staff nurse to the Social Service Director (SSD), who failed to document the grievance or inform the necessary administrative staff. The resident, who was cognitively intact and dependent on staff for ADLs, was dismissed by the SSD for not recounting the incident verbatim. The facility's policy to document and address grievances promptly was not followed.
The facility failed to ensure that authorizations for resident fund accounts were witnessed by non-facility staff, affecting two residents. The authorizations for managing funds lacked the required non-facility affiliated witness signatures. This deficiency was confirmed during an interview with the Business Office Manager, who verified the oversight.
The facility failed to provide required SNF ABNs to two residents before discontinuing skilled services under Medicare Part A. The Business Office Manager confirmed the oversight, mistakenly believing the forms were only needed for Medicare Part B beneficiaries.
A resident with hearing loss did not receive timely audiology services despite physician orders and a care plan indicating the need for such services. The facility's scheduling process failed, resulting in the resident experiencing discomfort due to a blocked ear, with no follow-up care provided.
Foley catheter insertion and catheter care failures
Penalty
Summary
The facility failed to ensure safe, clinically indicated, and competent Foley catheter insertion and follow-up monitoring for one resident, and failed to follow physician orders for indwelling catheter care for another resident. One resident had diagnoses including urinary retention and neuromuscular dysfunction of the bladder, severe cognitive impairment, and an indwelling Foley catheter ordered for monthly changes, drainage each shift and as needed, and irrigation PRN for obstruction or increased sediment. The record showed the catheter was last changed by an LPN, and later that day another LPN documented that the resident’s wife was concerned he was still using a bedside drainage bag instead of the ordered leg bag. Later the same day, the LPN removed and replaced the resident’s Foley catheter even though there was no order to change it. The documentation stated the resident attempted to sit up and move during insertion, but there was no documented assessment of difficulty, trauma, or need to escalate care, and no evidence the physician was notified. A later nursing note documented small hematuria and administration of PRN Tramadol for generalized pain rated 10/10, but there was no documented physician notification of the new severe pain or bleeding. By early the next morning, the resident was slow to arouse, incontinent of stool, hypotensive, tachycardic, and had a Foley drainage bag full of dark red blood. Hospital records showed the Foley catheter was malpositioned in the urethra, causing bladder distention, urethral and bladder trauma, and urosepsis. The resident died after hospitalization, and the death certificate listed urosepsis as the immediate cause of death. A second resident had diagnoses including end-stage renal disease and neuromuscular dysfunction of the bladder, with physician orders for Foley output monitoring every shift and catheter changes every 28 days and PRN. Review of the chart and interviews showed the catheter change order was entered incorrectly in the EMR so that nurses electronically signed it nearly every day without an actual catheter change, and the resident’s catheter was not changed monthly as ordered. The resident reported that the facility had not been changing the catheter as ordered and that he had experienced several UTIs and hospitalizations. Hospital records showed a repeat culture after catheter replacement was negative, confirming the prior infection was associated with the old catheter, and the final diagnosis included hypotension and UTI due to an indwelling catheter.
Missed Pre-Meal Blood Sugar Check and Insulin Administration
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and accepted standards of practice, resulting in a significant medication error for Resident #70. The resident was admitted with diagnoses including diabetes mellitus, anxiety, and major depressive disorder and had orders for blood sugar checks before meals and Lispro insulin 4 units subcutaneously before meals. On 11/14/25, the resident’s lunch was served at 11:15 A.M., but the blood glucose check was not performed until 12:33 P.M., when the reading was 384 mg/dL. The DON confirmed this timing during record review, and the MAR supported that the insulin was not administered prior to the meal as ordered. Later that day, LPN #800 was notified by the resident’s family member that the resident was lethargic and not eating lunch. The resident’s blood pressure was 78/55 mmHG, pulse 80, and the resident responded only to name. LPN #800 contacted the nurse practitioner and the resident was sent to the emergency department. The ED discharge summary documented lethargy, decreased intake, and an elevated blood glucose of 271 mg/dL, and family expressed concern that insulin had not been administered timely. The DON confirmed the missed pre-meal blood sugar check and insulin administration, and the Administrator stated no investigation was conducted related to the medication error.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure staff followed required Enhanced Barrier Precautions (EBP) while providing care for two residents. One resident had diagnoses including osteomyelitis of the right femur, MRSA infection, resistant to an unspecified antibiotic, and infection of an amputation stump, with an MDS showing intact short-term memory, frequent incontinence, and need for partial/moderate assistance with toileting hygiene. The care plan and physician orders indicated EBP for a PICC line and wound care, including use of gowns and gloves during high-contact care, but during observation the resident received IV medications with no EBP signage displayed and no gowns available. A CNA entered to provide incontinence care without an isolation gown, despite the resident having a right leg stump dressing in place, and the DON entered to assist with repositioning without wearing an isolation gown and exited the room without performing hand hygiene. The CNA stated she did not wear gowns during personal care unless the resident had an open-air wound, catheter, or C. difficile, and the LPN confirmed the resident had not been on EBP until signage and PPE were placed at the door. For the second resident, record review showed diagnoses including chronic systolic heart failure, acute kidney failure, and weakness, with the MDS indicating dependency for toileting and transfers and three Stage II pressure ulcers present on admission. The care plan identified skin breakdown/open areas/pressure ulcers to the bilateral buttocks related to limited mobility and noncompliance with prevention interventions, with treatment to be completed as ordered. During wound care, two nurses donned gowns and gloves, but when one nurse left the room to gather supplies, she exited wearing the gown and gloves and walked up the hall before returning with the supplies and donning a new gown. The ADON/Wound Care Nurse stated staff should remove PPE before leaving a resident's room, consistent with facility policy. The facility EBP policy required PPE availability outside rooms and appropriate disposal inside rooms, and the hand hygiene policy required hand hygiene before donning and after removing gloves.
Delayed Incontinence Care for a Resident Requiring Toileting Assistance
Penalty
Summary
Resident #36, admitted on 04/01/22 with diagnoses including CHF and malaise, was assessed as frequently incontinent of bowel and bladder and requiring partial/moderate assistance with toileting hygiene. The care plan directed staff to assist the resident to the bathroom during usual rounds and on demand, and to clean the peri area with each incontinent episode. During observation on 04/27/2026 at 11:03 A.M., CNA #721 entered the room to provide incontinence care and stated this was the first time during the shift that she had time to check the resident for incontinence, despite starting at 6:00 A.M. At the time of the observation, Resident #36 was lying in bed with a brief saturated with urine, and the pad and sheet beneath the resident were also saturated. The resident's buttocks were red and excoriated, and CNA #721 noted the resident had a sore bottom. The DON stated incontinent residents should be checked every two hours and changed if needed. The facility policy on Perineal Care stated incontinent residents are to receive perineal care during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and prevent and assess for skin breakdown.
Missed Post-Op Follow-Up Appointments
Penalty
Summary
The facility failed to ensure that appointments were scheduled, transportation was arranged, and ordered follow-up visits were attended for a resident with Multiple Sclerosis, overactive bladder, chronic pain syndrome, and a history of digestive system disease. The resident had intact cognition with a BIMS of 15 and required set-up for toileting hygiene, with occasional incontinence. After the resident developed nausea and coffee ground emesis, the physician ordered transfer to the ED, and the resident was hospitalized for a perforated small intestine and surgery for small bowel obstruction with drain placement. The hospital discharge instructions included a gastroenterology follow-up to be scheduled for two weeks post-op and a surgical post-op follow-up to be scheduled two weeks after surgery. Facility records from the weeks after discharge showed no evidence that either follow-up appointment was scheduled or documented, and the July and August physician orders, MARs, and TARs contained no documented physician order for the post-operative follow-up appointments. Facility staff confirmed the resident was supposed to have two follow-up appointments, but one receptionist stated the surgical follow-up was never scheduled. Although the facility form listed a gastroenterology appointment with transportation arranged, the transport company confirmed there was no scheduled pickup, and the resident did not attend the appointment.
Improper Wound Cleansing and Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
Failure to provide proper wound care and infection control occurred during treatment of Resident #5, who was admitted with chronic systolic congestive heart failure, acute kidney failure, and weakness. The resident was cognitively intact, dependent on staff for toileting hygiene and chair/bed transfers, and required partial/moderate assistance for bed mobility. The resident had three Stage II pressure ulcers present on admission and additional skin breakdown/open areas to the bilateral buttocks related to limited mobility and noncompliance with prevention interventions. During wound care observation, an LPN and RN provided treatment to multiple wounds on the resident. The LPN removed the dressing from the right buttocks and confirmed there were no dressings on the sacrum, right posterior thigh, or left buttocks wounds. The LPN applied Triad cream and a border foam dressing to the right buttocks without cleansing the wound first. The LPN then moved to the left buttocks wound without washing hands or changing gloves and again applied Triad cream and a border foam dressing without cleansing the wound. The LPN later cleansed the sacral wound with normal saline after requesting saline from the RN, but did so without removing gloves or performing hand hygiene after the prior wound. The LPN then applied Triad cream and a foam dressing to the right posterior thigh wound without cleansing it first. During interview, the LPN stated wound cleansing depended on the orders and said she thought hand hygiene and glove changes were not necessary because she was not removing anything old between wounds. The wound care nurse/ADON stated wounds should always be cleaned before treatment and that staff should wash hands and change gloves between wounds, and also stated the orders should have included cleansing. The facility policy on pressure injury prevention and management required full skin and wound assessments, keeping skin clean, minimizing contamination risk, and following professional standards of practice, including evidence-based interventions to prevent infection and support wound healing.
Fall Prevention Interventions Not Implemented
Penalty
Summary
The facility failed to ensure fall prevention interventions were implemented for two residents who were identified as being at risk for falls. Resident #8 had diagnoses including epilepsy, diabetes mellitus, and dysphagia, and was assessed as severely cognitively impaired and dependent on staff for all ADLs except eating. The care plan identified fall risk related to poor safety awareness, unsteady gait, medication side effects, and incontinence, with interventions including keeping the call light within reach and using nonskid footwear when out of bed. During observation, Resident #8’s call light was not within reach, the resident was sitting in a wheelchair away from the bed, the call light was lying on the bed, nonskid socks were not on, and the wheelchair legs were not in place; an LPN verified these findings. Resident #69 had diagnoses including benign neoplasm of brain, weakness, syncope and collapse, spinal stenosis, and dorsalgia, and the baseline care plan identified multiple fall-risk interventions, including keeping the bed in the low position, assisting with ADLs, ensuring proper footwear, keeping pathways free of clutter, and keeping the call light within reach. The resident was found on the floor after morning medication administration, and later was observed in bed with the bed not in the low position, contrary to the documented intervention. An LPN confirmed the bed was not low, and a CNA stated she had assisted the resident back to bed and did not know the bed should be in the low position, indicating the intervention was not being followed. The facility policy required universal fall-prevention measures, including keeping the call light and frequently used items within reach and lowering the bed, and stated that interventions identified on the fall-risk assessment must be incorporated into the baseline care plan and implemented by staff.
Failure to Implement Pharmacy Review for PRN Psychotropic Medication
Penalty
Summary
The facility failed to implement pharmacy recommendations from the monthly drug regimen review for one resident who was cognitively intact and had diagnoses of generalized anxiety disorder and depression. The resident’s record showed a PRN order for Ativan 0.5 mg by mouth every 12 hours as needed for anxiety, and the care plan addressed psychosocial wellbeing related to anxiety, depression, recent admission, repeat hospitalizations, and recent bilateral below-the-knee amputation. The pharmacy recommendation dated 09/22/25 identified that the resident had a PRN psychotropic order for lorazepam (Ativan) and noted that PRN psychotropic medications are limited to 14 days unless the rationale and estimated duration are documented. The recommendation offered options to discontinue the PRN medication or add a day stop date, but the DON confirmed the form was never completed. Review of the MAR showed the resident received Ativan 14 times in September 2025, 26 times in October 2025, and 2 times in November 2025, and the DON confirmed the pharmacy review was not completed while nurses continued administering the medication during those months.
Food Allergy Information Not Accurately Communicated
Penalty
Summary
The facility failed to ensure that clinically diagnosed food allergies were accurately identified, documented, communicated, and honored for Resident #57. The resident was admitted with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and anxiety disorder, and his electronic medical record listed allergies to banana, dairy products, fish, gluten, lactose, peanuts, pork-derived products, soy, and tomatoes. However, the diet ticket for the resident’s low-concentrated-sweets diet incorrectly listed only shellfish and peanuts, omitting multiple documented allergies including gluten, lactose, soy, and others. During lunch tray observation, Resident #57 received beef tips, noodles, a breadstick, and cake items that were inconsistent with his documented allergies, including gluten-containing foods. The SSD verified the tray contents, and the resident stated he did not request or consume chocolate milk and was reluctant to raise concerns. The DM stated she had collected preferences from the resident and had no documentation that gluten-free requirements were allergies rather than preferences. The DON confirmed the electronic record listed gluten as an allergy while the diet ticket did not reflect it, and the RD stated allergy information had been reviewed but the diet ticket still did not show the full allergy list. The resident also stated he only received a standard menu and no alternate options to accommodate his allergies, and the DON later stated the facility had no policy differentiating allergies from preferences.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide liquids at the ordered consistency for Resident #68, who was admitted with diagnoses including dysphagia, chronic obstructive pulmonary disease, and anxiety disorder. Physician orders for April 2026 specified a no added salt diet with pureed texture and nectar-thick liquids, and the diet ticket reflected nectar-thick cranberry juice and milk along with a divided plate. During breakfast observation on 04/27/26, the cranberry juice was nectar thick, but the milk appeared thinner than ordered; the Assistant Director of Nursing confirmed the issue and thickened the milk to nectar consistency. On 04/29/26, the resident’s breakfast tray did not include the ordered milk or cranberry juice and instead contained two eight-ounce glasses of nectar-thick water. The resident stated he liked cranberry juice. The Transportation Scheduler confirmed the resident did not receive his preferred thickened liquids and said she would contact the kitchen. The Dietary Manager stated the kitchen only had pre-thickened apple juice and water and that, because no pre-thickened cranberry juice was available, dietary did not provide cranberry juice to the resident. She also stated he was the only resident receiving nectar-thick liquids, although the facility identified two residents with thickened-liquid orders. The Registered Dietitian stated that pre-thickened juices were available, but milk had to be thickened in-house. The facility policy stated that any liquid requiring thickening must be prepared to the correct consistency if not provided as such.
Incomplete Wound Care Documentation and Order Accuracy
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for one resident with multiple pressure ulcers present on admission. Physician orders dated 04/28/26 directed Triad cream and dry dressings to four wound sites, but during observed wound care on 04/29/26 at 11:11 A.M., an LPN did not cleanse multiple wounds before applying new treatments, did not consistently change gloves or perform hand hygiene between wound sites, and identified a wound that should have had a dressing in place but did not. The LPN also stated that none of the wound care orders included instructions to cleanse wounds prior to treatment. During interview, the Wound Care Nurse/ADON stated that all wounds should always be cleansed prior to treatment and acknowledged that the omission of cleansing instructions in the orders was an input error. Record review showed the Wound Care Nurse/ADON discontinued all four wound care orders later that morning after the incorrect wound care procedures were observed and discussed, and the April 2026 TAR showed no active orders documented for the wound care performed and no signed entries indicating the observed treatments were completed.
Failure to Screen New Employees Against State Nurse Aide Registry
Penalty
Summary
The facility failed to ensure that all new employees were screened through the State of Ohio Nurse Aide Registry (NAR) prior to employment. This screening is crucial to identify if an employee has any findings related to abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. The personnel files of several staff members, including a Physical Therapist Aide, Licensed Practical Nurse, Registered Nurse, Dietary Manager, Director of Rehabilitation, Housekeeper, and Dietary Aide, revealed that none of these individuals were checked against the NAR before their hire dates. An interview with the Human Resource Manager revealed a lack of awareness regarding the requirement to check all new employees against the NAR. The HR Manager confirmed that the necessary checks were not performed prior to the first day of employment for the mentioned staff members. This oversight had the potential to affect all 52 residents residing in the facility, as the facility's policy clearly states that individuals with findings in the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment, or misappropriation should not be employed.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its 52 residents, as evidenced by multiple interviews and observations. Residents and staff reported insufficient staffing, particularly during night shifts and weekends, leading to delayed responses to call lights and unmet care needs. Interviews with residents revealed complaints about long wait times for assistance, with one resident waiting over 15 minutes for a call light to be answered, only for it to be turned off without follow-up. Staff interviews corroborated these issues, with reports of operating with only one to two aides on the floor, which was insufficient to meet the residents' needs. Observations confirmed the inadequacy of staffing, with call lights going unanswered for extended periods. The staffing tool review indicated that the facility did not have registered nursing coverage for two days and was operating below the required staffing levels. The facility assessment, which was supposed to guide staffing levels, was not implemented effectively, resulting in non-compliance with the required staffing standards. This deficiency was investigated under Complaint Number OH00157038.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as mandated by regulations. This deficiency was identified during a review of the staffing tool with the Staffing Coordinator, which revealed that there was no RN coverage on two specific days due to call-offs, and no replacement RNs were arranged. The facility assessment, which was intended to determine the necessary resources for resident care and daily operations, indicated a need for one to two RNs per shift based on an average census of 53 residents. However, the facility did not adhere to this assessment in maintaining RN coverage, leading to non-compliance with the staffing requirements. This issue had the potential to affect all 52 residents residing in the facility and was investigated under Complaint Number OH00157038.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to ensure that concerns were filed, addressed, and resolved in a timely manner, affecting a resident who was cognitively intact and dependent on staff for Activities of Daily Living (ADLs). The resident reported to the Social Service Director (SSD) that a staff nurse had made a distressing comment wishing for the resident's death. However, the SSD did not document the grievance or inform the necessary administrative staff, including the Administrator and Assistant Director of Nursing (ADON), about the incident. The SSD claimed to have entered a note into the system and sent a text to staff but did not complete the required grievance form. Interviews with the resident and staff revealed discrepancies in the handling of the grievance. The resident expressed that the SSD dismissed her concerns because she could not recount the incident verbatim. The SSD admitted to not filing a concern log form and only verbally informing the ADON during a meeting. The ADON, however, was unaware of the grievance, and the concern log showed no record of the incident. The facility's policy required grievances to be documented and addressed promptly, which was not followed in this case.
Failure to Obtain Non-Facility Witness Signatures for Resident Fund Authorizations
Penalty
Summary
The facility failed to ensure that authorizations for resident fund accounts were witnessed by non-facility staff, affecting two residents out of five reviewed. For Resident #7, the authorization to manage funds dated 10/17/23 lacked a non-facility affiliated witness signature as required. Similarly, for Resident #41, the authorizations dated 03/16/23 and 11/09/23 also did not have the necessary non-facility affiliated witness signatures. This deficiency was confirmed during an interview with the Business Office Manager on 10/07/24, who verified that the authorization forms for these residents were not properly witnessed.
Failure to Provide Required SNF ABNs to Residents
Penalty
Summary
The facility failed to provide required notices of potential financial obligation to residents before discontinuing skilled services under Medicare Part A. This deficiency affected two residents out of three reviewed for beneficiary notices. Resident #17 was discharged from skilled therapy services on May 14, 2024, without receiving a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) as required. Similarly, Resident #55 was discharged from skilled therapy services on September 3, 2024, without receiving the necessary SNF ABN. During an interview on October 7, 2024, the Business Office Manager (BOM) confirmed that the SNF ABNs were not provided to these residents. The BOM mistakenly believed that these forms were only necessary for residents on Medicare Part B, indicating a misunderstanding of the requirements for Medicare Part A beneficiaries.
Failure to Provide Timely Audiology Services
Penalty
Summary
The facility failed to ensure timely access to ancillary services for a resident with hearing difficulties. The resident, who was cognitively intact and had a history of hearing loss, was admitted with a care plan that included monitoring ear conditions and referring to audiology as needed. Despite physician orders for earwax removal and a follow-up with an audiologist, the resident did not receive the necessary audiology services. Interviews revealed that the resident had been experiencing discomfort due to a blocked ear and had not been followed up with after initial ear drop treatment. The facility's process for scheduling and coordinating audiology appointments was not effectively executed. The Social Service Director was responsible for scheduling these services, but the resident was not added to the list for audiology visits on two occasions. The Director of Nursing was unaware of the resident's unmet needs, and there was no documentation of the resident being scheduled or seen by the audiologist. The facility's policy required the social worker to assist residents in accessing hearing services, but this was not adequately fulfilled for the resident in question.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Medina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medina Center For Rehabilitation And Nursing | 1.2 mi | ★★★★★ | 1 | 0 |
| Avenue At Medina | 1.3 mi | ★★★★★ | 11 | 0 |
| Samaritan Care Center And Villa | 1.4 mi | ★★★★★ | 4 | 0 |
| Champion Creek Health And Rehabilitation | 2.6 mi | — | 0 | 0 |
| Western Reserve Masonic Comm | 3.7 mi | ★★★★★ | 0 | 0 |
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