Inspection Reports for Meadow Grove Transitional Care
5919 Blue Star Dr, Grove City, OH 43123, United States, OH, 43123
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
95 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 3
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to properly monitor resident fluid restrictions and nutritional status, including weight monitoring and documentation.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00163772.
Findings
The facility failed to adequately monitor and document fluid intake for residents with fluid restrictions and failed to notify physicians of significant weight changes or refusals to be weighed. Several residents had missing or inaccurate fluid intake documentation, and nursing staff did not consistently track or follow up on weight monitoring as ordered.
Deficiencies (3)
Failure to properly monitor resident fluid restrictions, including incomplete and inaccurate documentation of fluid intake for Resident #58 and Resident #47.
Failure to adequately monitor and address resident nutritional status, including lack of notification to physicians of significant weight changes and refusals to be weighed for Residents #19 and #29.
Failure to obtain daily weights as ordered for Resident #47 and failure of nursing staff to follow up when weights were missed.
Report Facts
Census: 95
Fluid restriction amount: 2400
Fluid restriction dietary limit: 1080
Fluid restriction nursing limit: 840
Fluid restriction supplements limit: 480
Weight decrease: 10.4
Weight decrease: 11.1
Weight refusals: 16
Weight refusals: 1
Weight refusals: 4
Weight refusals: 3
Weight refusals: 3
Weight refusal: 1
Fluid restriction nursing limit: 1320
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide #199 | Certified Nursing Aide | Interviewed regarding fluid restriction monitoring and documentation. |
| Director of Nursing | Director of Nursing | Confirmed fluid intake documentation practices and weight monitoring procedures. |
| Dietitian #192 | Dietitian | Interviewed about notification of physicians regarding weight changes and refusals. |
| Licensed Practical Nurse #107 | Licensed Practical Nurse | Confirmed procedures for weight monitoring refusals for Resident #19. |
| Regional Nurse #300 | Regional Nurse | Confirmed history of non-compliance with weight monitoring for Resident #19. |
| Licensed Practical Nurse #157 | Licensed Practical Nurse | Interviewed regarding weight documentation and fluid tracking for Resident #47. |
| Registered Nurse #175 | Registered Nurse | Interviewed about fluid restriction tracking responsibilities for Resident #47. |
Inspection Report
Routine
Census: 95
Deficiencies: 6
Date: Mar 24, 2025
Visit Reason
Routine inspection to assess compliance with regulations related to resident care, medication administration, food safety, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate assistance with activities of daily living, improper monitoring of fluid restrictions and nutritional status, inappropriate use of antipsychotic medication, unsafe food storage and serving practices, incomplete hand hygiene during medication administration, inadequate disinfection of glucometers, and failure to use proper personal protective equipment during tracheostomy care.
Deficiencies (6)
Failure to ensure dependent residents received assistance with activities of daily living, affecting Resident #79.
Failure to properly monitor resident fluid restrictions and nutritional status, affecting Residents #58, #47, #29, #19, and others.
Failure to ensure residents receive antipsychotics as clinically indicated; Resident #7 was prescribed Seroquel without appropriate indications or gradual dose reduction attempts.
Failure to store and serve food in a safe and sanitary manner, affecting all 95 residents.
Failure to complete hand hygiene during medication administration for Resident #50 and failure to disinfect glucometer properly for Resident #27.
Failure to use gloves and appropriate PPE during tracheostomy care for Resident #46.
Report Facts
Facility census: 95
Fluid restriction amount: 2400
Medication dosage: 400
Weight changes: 10.4
Weight changes: 11.1
Wet time for glucometer disinfection: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #175 | Registered Nurse | Observed failing to perform hand hygiene properly during medication administration for Resident #50 and improper glove use. |
| Director of Nursing | Director of Nursing | Confirmed deficiencies related to shaving needs, fluid monitoring, weight monitoring, medication administration, and infection control. |
| CNA #201 | Certified Nursing Assistant | Observed Resident #79 not properly bathed or dressed and unsure about hospice responsibilities. |
| Dietitian #192 | Dietitian | Confirmed fluid restriction monitoring issues and lack of food safety policy. |
| LPN #157 | Licensed Practical Nurse | Confirmed failure to weigh Resident #47 as ordered and lack of fluid tracking. |
| House Nurse Practitioner #301 | Nurse Practitioner | Confirmed Resident #7's antipsychotic medication use without appropriate indications. |
| House Nurse Practitioner #302 | Nurse Practitioner | Confirmed Resident #7's admission medication review and concerns about antipsychotic use. |
| LPN #107 | Licensed Practical Nurse | Observed improper disinfection of glucometer for Resident #27. |
| RN #175 | Registered Nurse | Observed performing tracheostomy care on Resident #46 without mask or gown. |
| CNA #219 | Certified Nursing Assistant | Observed buttering dinner roll with bare hands. |
| CNA #185 | Certified Nursing Assistant | Observed feeding resident with dinner roll held in bare hands. |
| Dietary Supervisor #165 | Dietary Supervisor | Confirmed broken and dirty light cover in food service area. |
| Maintenance Supervisor #138 | Maintenance Supervisor | Confirmed knowledge of broken light cover and plan to replace. |
| Regional Nurse #300 | Regional Nurse | Confirmed weight monitoring deficiencies for Resident #19. |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 3
Date: Jan 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00149838 regarding the facility's failure to timely inform the physician of a resident's change in condition and related nursing care issues.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00149838.
Findings
The facility failed to ensure timely physician notification of a resident's change in condition, failed to ensure an LPN worked within their scope of practice during the change in condition, and failed to maintain complete and accurate documentation of the resident's change in condition. These deficiencies affected one resident (Resident #49) and involved inadequate assessments, delayed communication with medical providers, and incomplete medical record documentation.
Deficiencies (3)
Failed to ensure the physician was informed timely of a resident's change in condition.
Failed to ensure an LPN worked within their scope of practice and nursing standards during a resident's change in condition.
Failed to ensure complete and accurate documentation of a resident's change in condition in the medical record.
Report Facts
Facility census: 93
Resident admission date: Jan 22, 2023
Oxygen saturation levels: 82
Oxygen saturation levels: 93
Oxygen saturation levels: 96
Physician verbal order time: 1800
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #215 | Licensed Practical Nurse | Named in findings related to failure to timely notify physician, incomplete assessments, and documentation issues. |
| STNA #205 | State Tested Nursing Aide | Reported noticing resident's change in condition and informing LPN #215. |
| FNP #220 | Facility Nurse Practitioner | Interviewed regarding on-call provider system and lack of contact records. |
| ISRN #225 | In-House Supervisor Registered Nurse | Instructed LPN #215 to contact on-call provider and discussed expectations for reassessments. |
| DON | Director of Nursing | Provided statements on nursing assessment expectations and documentation processes. |
| RN #201 | Registered Nurse | Interviewed about nursing assessments and documentation requirements. |
| RN #208 | Registered Nurse | Interviewed about oxygen administration and physician contact protocols. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Jan 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint Number OH00149324) regarding the facility's failure to provide appropriate pressure ulcer care and timely implementation of new wound treatment orders.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00149324.
Findings
The facility failed to ensure timely receipt and implementation of new wound treatment orders for Resident #40, who developed a facility-acquired stage four pressure ulcer and other wounds. The resident received incorrect wound treatment for seven days due to lack of timely communication and documentation from the wound clinic.
Deficiencies (1)
Failure to ensure new wound treatment orders were timely obtained and implemented, resulting in incorrect wound care for Resident #40.
Report Facts
Facility census: 86
Days incorrect wound treatment applied: 7
Number of residents reviewed for pressure ulcers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident #40's wound care and facility procedures | |
| in-house wound nurse practitioner | Provided wound care and ordered outside wound clinic consult for Resident #40 |
Inspection Report
Routine
Census: 86
Deficiencies: 4
Date: Dec 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including medication management, activities of daily living assistance, pressure ulcer care, fall prevention, and other care standards at Meadow Grove Transitional Care.
Findings
The facility was found deficient in several areas including failure to notify a physician of significant weight gain for a resident, inadequate assistance with activities of daily living such as showers, nail care, and shaving, failure to implement pressure ulcer prevention interventions, and inadequate fall prevention measures including malfunctioning wheelchair anti-rollback devices.
Deficiencies (4)
Failed to ensure a resident's physician was notified when weight gains were noted of greater than 2.5 pounds as ordered.
Failed to ensure residents dependent on staff received assistance with showers, nail care, and shaving of unwanted facial hair.
Failed to ensure skin prevention interventions were implemented for a resident with a history of pressure ulcers.
Failed to ensure a resident's fall prevention interventions were in place as per the plan of care; wheelchair anti-rollback device was missing parts and ineffective.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Facility census: 86
Weight increase: 4.5
Weight increase: 4
Pressure reduction cushion documented: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Verified no documented evidence physician was notified of Resident #88's weight gain; confirmed bathing and shaving issues; acknowledged lack of shower documentation; confirmed pressure ulcer and fall prevention issues |
| Licensed Practical Nurse #110 | Licensed Practical Nurse | Reported Resident #17 was having pain and had given Tylenol; stated pressure reducing cushion was in recliner |
| Licensed Practical Nurse #106 | Licensed Practical Nurse | Reported Resident #33 was at risk for falls and verified anti-rollback device intervention |
| State Tested Nursing Assistant #117 | State Tested Nursing Assistant | Reported on nail care for Resident #49 and compliance with nail trimming |
| State Tested Nursing Assistant #123 | State Tested Nursing Assistant | Reported on shower schedule and bathing assistance for Resident #88 |
| Physical Therapy Assistant #200 | Physical Therapy Assistant | Assisted Resident #33 to standing position and verified wheelchair anti-rollback device malfunction |
| Physical Therapist #205 | Physical Therapist | Assisted Resident #33 to standing position and verified wheelchair anti-rollback device malfunction |
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 7
Date: Feb 13, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, notification of changes, assessment accuracy, care planning, treatment and care, and dental services.
Findings
The facility was found deficient in multiple areas including failure to honor resident shower requests, failure to notify family and physician of bruising incidents, inaccurate Minimum Data Set (MDS) assessments, failure to revise care plans to include new behaviors, failure to monitor and document bruising related to anticoagulant use, failure to provide timely dental services, and failure to provide required Medicare notices.
Deficiencies (7)
Failed to provide a shower after resident request because it was not a scheduled shower day.
Failed to notify resident's family and physician of a bruising incident while resident was receiving an anticoagulant.
Failed to provide Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Beneficiary Protection (SNF/ABN) notices as required.
Failed to accurately code resident's Minimum Data Set (MDS) assessment regarding hospice services, dental status, and anticoagulant therapy.
Failed to revise care plan to include new behaviors such as wandering without pants.
Failed to monitor and document bruising episodes during skin assessments related to anticoagulant use.
Failed to provide dental services in a timely manner after Power-of-Attorney request.
Report Facts
Facility census: 89
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding shower scheduling, notification of bruising, and bruising documentation |
| Regional Director of Clinical Services | Regional Director of Clinical Services #119 | Interviewed regarding shower policy, MDS accuracy, care plan revisions, and bruising documentation |
| MDS Nurse | MDS Nurse #74 | Interviewed regarding inaccurate MDS coding |
| MDS Nurse | MDS Nurse #57 | Interviewed regarding inaccurate MDS coding and dental care plan |
| Social Service Assistant | Social Service Assistant (SSA) #54 | Interviewed regarding care plan revisions and dental services |
| Corporate Registered Nurse | Corporate Registered Nurse (RN) #119 | Interviewed regarding bruising documentation |
| Administrator | Administrator | Interviewed regarding Medicare notices and dental appointment arrangements |
| Hospice Registered Nurse | Hospice Registered Nurse (RN) #150 | Interviewed regarding hospice services for Resident #68 |
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