Ohio Living Mount Pleasant

Based on observation, staff interviews, and policy review, the facility failed to assess residents for risk of entrapment and failed to obtain informed consent prior to installation of assist bars on resident beds. This affected all 28 residents identified by the facility with assist bars attached to their bed. The census was 28.Findings include:Observations of resident rooms on 01/21/26 between 4:26 P.M. and 4:53 P.M. revealed assist bars were attached to all beds in occupied resident rooms.Interview on 01/21/26 at 12:13 P.M. with Registered Nurse (RN) #212 stated the facility did not assess residents for risk of entrapment from assist bars on resident beds.Interview on 01/21/26 at 2:06 PM with the Director of Nursing (DON) confirmed assist bars were applied to all resident beds within in the facility. The DON also reported staff did not assess residents for risk of entrapment related to the use of assist bars on resident beds.Interview on 01/22/26 9:10 A.M. with Occupational Therapist (OT) #252 revealed occupation therapy initial evaluations of residents did not include assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and policy review, the facility failed to ensure staff with facial hair wore appropriate beard covers during meal preparation. This had the potential to affect all 28 residents the facility identified as receiving food from the kitchen. The census was 28. Findings Include: Observation of the kitchen on 01/20/26 from 11:45 A.M. to 12:00 P.M. revealed Sous Chef #177, Dietary Technician (DT) #245, and [NAME] #228 each had varying lengths of facial hair and assisted with meal preparation without wearing beard covers. During an interview on 01/20/26 at 12:28 P.M., Corporate Culinary Director #251 verified male kitchen staff were preparing food without wearing appropriate beard covers. Additionally, he stated every male with facial hair was required to wear a beard cover during food preparation or tray line.During an interview on 01/20/26 at 12:29 P.M. Culinary Director #206 verified Sous Chef #177 and DT #245 both had visible facial hair and were not wearing beard covers while preparing lunch meal trays. During an interview on 01/20/26 at 12:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure medications ordered for residents had adequate indications for use. This affected two (#6 and #24) of eight residents reviewed for unnecessary medications. The facility census was 28.Findings include:1. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction; hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side; unspecified dementia, unspecified severity, with mood disturbance; and type II diabetes.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of two indicating severe cognitive impairment. The resident was assessed to require substantial/maximal assistance for eating, and was dependent on staff for oral hygiene, toileting, shower/bathing, dressing, and personal hygiene. Review of Resident #6's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to ensure insulin and over-the-counter medications were not stored beyond their expiration date. This affected Resident #71 and potentially all residents. The facility census was 73. Findings include: 1. Observation on 07/27/22 at 1:52 P.M. revealed the Skilled Care Unit (SCU) had two opened bottles of insulin that were stored beyond their expiration date. Resident #71 had one bottle of Humalog (aspart insulin) opened 06/19/22 and Lantus (glargine insulin) dated 06/18/22. During an interview at 1:55 P.M. Licensed Practical Nurse (LPN) # 120 verified the SCU med cart held two bottles of insulin for Resident #71 that were stored beyond their expiration date. LPN #120 stated insulin was good for 28 days after opened. 2. During observation on 07/27/22 at 1:39 P.M., revealed the main storage room located in the basement contained multiple bottles of expired medications including four boxes Tagamet 200 milligrams (mg) expired 04/22; five bottles of fish oil 500 mg softgels dated 06/22 and one bottle dated 03/21; one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to provide food portions and prepare foods as planned by a Registered Dietitian. This directly affected one (Resident #33) but had the potential to affect all 73 residents who received food from the kitchen. The facility census was 73. Findings include: 1. Record review revealed Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses included protein-calorie malnutrition, dementia and cerebral infarction. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was receiving eight ounces of supplement twice a day and pureed diet. Resident #33 was receiving hospice care and had 14 percent weight loss in past 90 days. Review of the breakfast menu spreadsheet, dated 07/26/22, revealed the pureed diet meal consisted of one slice of french toast. Review of the recipe for bread slurry revealed a bread slice is saturated with a food thickener.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and policy review, the facility failed to deliver food to residents in a sanitary manner. The facility identified all residents received food from the kitchen. The facility census was 73. Findings include: 1. During observations on 07/25/22 from 12:03 P.M. to 12:26 P.M., Dietary Aides (DA) #173 and #176 passed lunch trays to residents located on the [NAME] Unit. DA #173 wheeled cart to the [NAME] dining room and delivered lunch trays to Residents #7, #11, #12, #21, #52, #66, and #73. DA #173 did not sanitize her hands or perform hand hygiene. DA #176 delivered a tray to Resident #25 and did not sanitize his hands or perform hand hygiene. DA #173 removed a breakfast tray from Resident #63's room and placed the dirty tray in the top row of the lunch cart above clean lunch trays, asked if that was ok, then handed the dirty tray to DA #176 to return to kitchen. DA #173 delivered a food tray to Resident #41, placed the tray on the bedside table, and moved table in front of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure adequate staffing on the Special Care Unit (SCU). This had the potential to affect all nine residents on the SCU. The facility census was 73. Findings include: Review of the medical record of Resident #44 revealed an admission date of 12/29/18. Diagnoses included dementia with lewy bodies, parkinson's disease, type two diabetes mellitus, dysuria, difficulty in walking, generalized anxiety disorder, unspecified pain, orthostatic hypotension, insomnia, and chronic atrial fibrillation. Review of the plan of care, dated 06/21/19, revealed the resident was at risk for pain due to a history of multilevel spondylosis and osteoarthritis. Interventions included to administer medications as ordered/monitor for effectiveness and notify the physician if pain increases in severity/frequency or is not relieved with ordered medications. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/10/22, revealed the resident had a severe cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food preferences and food items listed on the meal tray for three (Residents #19, # 38 and #37) of five residents reviewed for meal accuracy and food preferences. The facility census was 73. Findings include: 1. During interview on 07/25/22 at 10:37 A.M., Resident #38 stated she selects food preferences for each meal and writes the preferences on the meal ticket because she had intolerances to many foods. She stated she does not get the foods she selects. Review of the spreadsheet dated 07/25/22 revealed the No Added Salt diet included peanut butter sandwich, perfection salad and orange wedges. Review of the meal ticket for Resident #38 on 07/25/22 revealed the resident selected foods of a peanut butter sandwich with mayonnaise, perfection salad and orange wedges. During observation on 07/2522 at 12:40 P.M. Resident #38 received a peanut butter sandwich with no mayonnaise, no perfection salad and no orange wedges. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a dignified dining service for residents. This affected four (Residents #66, #64, #14 and #37) of seven resident reviewed for dining service dignity. The census was 73. Findings include: During observation on 07/25/22 at 12:22 P.M., State Tested Nursing Assistant (STNA) # 22 was standing over Resident #64 in the [NAME]/[NAME] dining room, feeding the resident the lunch meal. During interview on 07/25/22 at 12:25 P.M., STNA #22 verified she was standing and feeding the resident. She stated she was to sit beside the resident when feeding the resident. During observation on 07/25/22 at 12:35 P. M., STNA #129 was standing over Resident #14 while the resident was sitting upright in bed. During interview on 07/25/22 at 12:40 P.M., STNA #129 verified she stood beside the bed and fed Resident #14. She stated there was no chair in the room. During observation on 07/27/22 at 8:49 A.M., STNA #165 was looking at her phone while standing and feeding Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and policy review, the facility failed to ensure the medication error rate was less than five percent. 33 medications were ordered with two errors, for a medication error rate of 6.06 percent. This affected two (Residents # 59 and #64) of four residents reviewed for medications. The facility census was 73. Findings include: During observation on 07/27/22 at 9:47 A.M, Registered Nurse (RN) #137 held Resident #64's scheduled polysaccharide-iron complex 150 mg capsule because she was unable to locate the medication in the medication cart. During observation of medication administration on 07/27/22 at 10:34 A.M., RN #137 held Resident #59's scheduled Lisinopril 20 mg because she was unable to locate the medication in the medication cart. Review of the medical record revealed Resident #59 had physician orders for lisinopril 20 mg by mouth once daily. Resident #64 had physician orders for polysaccharide complex 150 mg by mouth twice daily. During interview on 07/27/22 at 9:58 A.M. and 10:34 A.M. RN #137 verified medications were not given to Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.