F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike
environment. This affected seven rooms (room [ROOM NUMBER], #13, #15, #20, #23, #26 and activity
rooms) of 38 resident rooms in the facility. The facility census was 41.
Findings include:
1. Observation on 02/19/19 at 10:35 A.M., of room [ROOM NUMBER] revealed a brown water stain in the
corner of the room, a cracked window pane, dried and broken caulking around the window, and a sheet
thumb tacked to the wall as a curtain. The bedsheet/curtain was tied in a knot at the bottom, allowing a view
into the room from the courtyard. The resident was visible from room windows across the courtyard.
Interview on 02/19/19 with Maintenance Director (MD) #184 and Regional Clinical Consultant (RCC) #169
verified the leak in the ceiling, the cracked window, and the sheet for a curtain. Both verified the resident
was visible from the courtyard and the windows across the courtyard.
2. Observation on 02/19/19 at 11:00 A.M., revealed a cracked window in room [ROOM NUMBER] and a
broken window handle lying on the window sill.
3. Observation on 02/19/19 at 5:00 P.M., revealed sheets as curtains were held in place by thumbtacks in
Rooms #20, #23, and #26. In room [ROOM NUMBER], a valance was held above the window by
thumbtacks. A towel was thumb tacked over the window in the memory care unit dining room. In room
[ROOM NUMBER], the bottom window pane had a large crack in it.
Observation on 02/20/19 at 7:10 A.M., revealed a bucket in the corner of the activity room with four inches
of water from a drip in the ceiling with a brownish mark noted on the ceiling tiles.
Observation on 02/20/19 at 8:00 A.M., revealed MD #184 changing stained ceiling tiles in room [ROOM
NUMBER].
Interview on 02/21/19 at 9:30 A.M., with RCC #169 verified the environmental issues of sheets hung as
curtains, cracked and broken windows, and leaks from the ceiling in room [ROOM NUMBER] and the
activity room.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
365336
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/21/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Locust Ridge Healthcare LLC
12745 Elm Corner Road
Williamsburg, OH 45176
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations, and staff interviews, the facility failed to accurately assess a resident's status
on the Minimum Data Set (MDS) for physical restraints. This affected one resident (#32) of twelve residents
reviewed. The facility census was 41.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #32 revealed an admission date of 06/23/16 with diagnoses of
major depressive disorder (MDD) without psychotic features, generalized anxiety disorder, ureter stent
placement, coronary angioplasty with stent placement, cardiac surgery, vascular surgery, pacemaker,
insulin dependent diabetes mellitus (IDDM), urinary tract infection (UTI), hypothyroidism, hyperlipidemia,
bipolar affective disorder, cerebral vascular accident (CVA), coronary artery disease (CAD), congestive
heart failure (CHF), acute/chronic renal failure, and encephalopathy.
Review of the resident baseline care plan dated 01/27/19 revealed no focus for physical restraints.
Review of Resident #32's quarterly MDS assessment dated [DATE] revealed the resident had a Brief
Interview for Mental Status (BIMS) score of three, indicating significant cognitive impairment with
inattention, disorganized thinking, delusions, and verbal and physical behaviors directed at others and self.
The resident required extensive one to two person physical assistance with most activities of daily living
(ADLs). The resident was coded for physical restraints.
Review of the facility matrix on 02/20/19 revealed Resident #32 was positively identified as having physical
restraints.
Observation on 02/21/19 at 7:20 A.M., revealed Resident #32 lying in bed sleeping without any physical
restraints.
Interview on 02/21/19 10:34 A.M., with Licensed Practical Nurse (LPN) #160 revealed Resident #32 had no
physical restraints and had never been physically restrained.
Interview on 02/21/19 at 1:12 P.M., with the Director of Nursing (DON) revealed she was unaware of any
resident requiring physical restraints and verified Resident #32 did not have physical restraints.
Interview on 02/21/19 at 1:21 P.M., with Regional Clinical Coordinator (RCC) #169 verified the MDS was
coded incorrectly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365336
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/21/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Locust Ridge Healthcare LLC
12745 Elm Corner Road
Williamsburg, OH 45176
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on medical record review, interview, and review of and review of the Minimum Data Set (MDS) 3.0
Resident Assessment Instrument (RAI) guidelines, the facility failed to timely develop and implement
comprehensive care plans within the required time frame. This affected one resident (Resident #42) of 12
residents reviewed for care plan accuracy and timeliness. The facility census was 41.
Findings include:
Review of the medical record for Resident #42 revealed an admission date of 11/29/18 with diagnoses
including repeated falls, anemia, and alcohol dependence with withdrawal. She was discharged to the
community on 12/22/18.
Review of the admission MDS 3.0 revealed an assessment reference date of 11/29/18 and was signed as
completed on 12/06/18. Care plan signature date was 12/06/18 and review of the care area assessment
revealed activities of daily living, incontinence, activities, and falls was to be care planned on 12/06/18.
Review of the medical record was silent of any comprehensive care plans. There was a baseline care plan
in place upon admission dated 11/29/18 and did not include any interventions for falls, incontinence, or
activities.
Interview was conducted on 02/21/19 at 12:35 P.M. with Registered Nurse #180 verified there was no
comprehensive care plans completed for Resident #42 and that they should have been completed on
12/06/18 and no later than 12/12/18.
Review of the MDS 3.0 RAI guidelines revealed care plans must be developed within seven days of
completion of the comprehensive assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365336
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/21/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Locust Ridge Healthcare LLC
12745 Elm Corner Road
Williamsburg, OH 45176
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to conduct monthly medication regimen reviews for
residents. This affected one (Resident #38) of five residents reviewed for unnecessary medications. The
facility census was 41.
Findings include:
Review of the medical record review of Resident #38 revealed was admitted on [DATE] with diagnoses
including severe cognitive decline, congestive heart failure, severe protein malnutrition, mood disorder,
insomnia, coronary artery disease.
Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 01/02/19, revealed the resident
had severe cognitive impairment. Resident #38 exhibited no behaviors or rejection of care. Resident #38
received antianxiety and antidepressant medications.
Review of Pharmacy Consultation Reports for November 2018, December 2018 and February 2019
revealed there were no monthly medication regimen review conducted by the pharmacist for Resident #38
for the months of October 2018, September 2018, August 2018 and January 2019.
Interview on 02/21/19 at 2:16 P.M. with Director of Nursing (DON) verified no monthly medication reviews
had been completed for Resident #38 for the months of October 2018, September 2018, August 2018 and
January 2019.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365336
If continuation sheet
Page 4 of 4
