Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure
resident preference and choice for when to get up was honored. This affected two (#37 and #35) of five
residents reviewed for choices. The census was 101.
Findings include:
1. Review of Resident #37's medical record revealed a re-admission date of 03/25/23 with an initial
admission dated of 06/01/22. Diagnoses included Parkinson's disease, heart failure, syncope and collapse,
cirrhosis of liver, major depressive disorder, diabetes mellitus type II, anxiety disorder, dysphagia, and
personal history of COVID-19.
Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview
for Mental Status (BIMS) score of 15 indicating Resident #37 was cognitively intact. Resident #37 required
extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #37
displayed no behaviors during the review period.
Review of Resident #37's care plan revised 02/14/23 revealed supports and interventions for the risk for
impaired skin integrity, risk for pain, risk for discomfort or adverse side effects of anti-Parkinson therapy, and
self-care deficit. Interventions for self-care deficit included assistance of two staff members for transfers and
a preference for morning showers.
Observation on 04/03/23 at 10:20 A.M. of Resident #37 found him wearing a gown and lying in bed.
Interview on 04/03/23 at 10:23 A.M. with Resident #37 found him to be alert and aware. Resident #37
stated he was not happy he was still in bed. Resident #37 stated the staff knew his preference to get up and
ready after breakfast, but it was almost time for lunch and he had not gotten up yet.
Interview on 04/04/23 at 1:18 P.M. with State Tested Nursing Assistant (STNA) #411 stated Resident #37
was able to make his needs known and was cooperative with care. STNA #411 reported Resident #37 was
able to participate in his care but required assistance. STNA #411 reported being aware of Resident #37's
preference to be up and ready for the day before or shortly after breakfast. STNA #411 verified she had not
gotten Resident #37 up and out of bed yesterday when he wanted. She reported she just did not have the
time to get to him.
2. Review of Resident #35's medical record revealed an admission date of 11/09/22. Diagnoses included
chronic obstructive pulmonary disease, diabetes mellitus type II, morbid obesity, major
(continued on next page)
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 16
Event ID:
365389
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0561
depressive disorder, chronic kidney disease, and lymphedema.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #35's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status
(BIMS) score of 15 indicating Resident #35 was cognitively intact. Resident #35 required extensive
assistance with bed mobility, dressing, and toilet use. Resident #35 was totally dependent on staff for
transfers, personal hygiene, and bathing. Resident #35 displayed no behaviors during the review period.
Residents Affected - Few
Review of Resident #35's care plan revised 04/06/23 revealed supports and interventions for risk for decline
in cognition, risk for impaired skin integrity, potential for difficulty breathing, chronic pain, self-care deficit,
and risk for falls.
Observation on 04/03/23 at 10:00 A.M. of Resident #35 found him lying in bed.
Interview on 04/03/23 at 10:01 A.M. with Resident #35 found him to be alert and aware. Resident #35
reported he was very unhappy. He stated the staff knew he wanted to get up around 8:00 A.M. and it was
now 10:00 A.M. and he was still not gotten up. Resident #35 stated BINGO was supposed to be starting
soon in the dining room area, and he was going to miss it because he was still in bed. Resident #35
reported it was his birthday and they were having a party for him in the afternoon. He stated he was really
hoping to be up by then.
Observation on 04/03/23 at 10:32 A.M. found a group of residents in the dining room area participating in
BINGO and Resident #35 was observed to still be in bed.
Observation on 04/03/23 at 1:34 P.M. found Resident #35 dressed, up in his wheelchair, and in the
common area for his birthday celebration. The residents who were at the party were observed participating
again in BINGO.
Interview on 04/04/23 at 1:26 P.M. with State Tested Nursing Assistant (STNA) #411 stated Resident #35
was able to make his needs know, was cooperative with care, and required staff assistance for getting up
and ready in the morning. STNA #411 reported Resident #35 liked to get up out of bed early in the
morning, usually right after breakfast. STNA #411 verified she had not gotten Resident #35 up yesterday
until around 11:00 A.M. STNA #411 reported she was just not able to get to him.
Review of the facility policy titled, Guest/Resident Rights, revised 04/28/22, revealed the resident had the
right to a dignified existence and self-determination.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 2 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, review of an incident and accident log, and review of facility policy,
the facility failed to ensure proper notifications were made following resident falls and transfers to the
emergency room. This affected two (#16 and #77) of eight residents reviewed for notification. The census
was 101.
Findings include:
1. Review of Resident #16's medical record revealed an admission date of 03/02/22. Diagnoses included
Parkinson's disease, schizoaffective disorder, muscle weakness, diabetes mellitus type II, anxiety disorder,
major depressive disorder, hoarding disorder, morbid obesity, and osteoarthritis.
Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview
for Mental Status (BIMS) score of 15 indicating Resident #16 was cognitively intact. Resident #16 required
extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #16
was totally dependent on staff for bathing. Resident #16 displayed no behaviors during the review period.
Review of Resident #16's care plan revised 02/18/23 revealed supports and interventions for risk for
changes in mood, grief, self-care deficit, and risk for falls. Interventions for fall risk included anticipate
needs, assess risk level for falls on admission and as needed, bed against the wall to increase functional
space, fall risk protocol, encourage the resident to wear appropriate footwear as needed, keep the
environment safe, keep the call light in reach, provide adequate lighting, keep commonly used item in
reach, lock the wheels on the wheelchair prior to transfers, provide an adaptive wheelchair as needed,
utilize a four wheeled walker, provide side rails, provide activities, and maintain non-skid strips to the floor in
front of the bed.
Review of Resident #16's fall risk assessment completed 02/16/23 revealed Resident #16 was at risk for
falls.
Review of the incident accident log from 11/04/22 through 04/03/23 revealed Resident #16 fell on [DATE],
12/31/22, 01/19/23, and 02/07/23.
Review of Resident #16's fall investigations revealed Resident #16's responsible party was not notified of
Resident #16's fall on 12/31/22, and Resident #16's physician was not notified of Resident #16's fall on
02/07/23.
Interview on 04/04/23 at 1:09 P.M. with Resident #16 state she fell often, and reported sometimes staff
were with her when she fell and sometime she was by herself.
Interview on 04/06/23 at 2:29 P.M. with Director of Nursing (DON) #381 verified Resident #16's responsible
party was not notified of Resident #16's 12/31/22 fall, and Resident #16's physician was not notified of
Resident #16's 02/07/23 fall.
2. Review of the medical record for Resident #77 revealed an admission date of 12/25/22 with diagnoses of
abnormalities of gait and mobility, dementia, and fracture of the neck of the right femur.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 3 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the comprehensive MDS assessment dated [DATE] revealed Resident #77 had intact cognition
and required extensive assistance of one person for transfers and locomotion. Further review revealed
Resident #77 had a fracture related to a fall in the last six months.
Review of the medical record for Resident #77 revealed a fall risk assessment was completed on
admission.
Review of the medical record for Resident #77 revealed he fell on [DATE], was assessed for injuries, and
sent to the emergency room. Review of the progress notes dated 01/31/23 revealed no documentation
Resident #77's family was notified of his transfer to the emergency room.
Review of the fall investigation dated 01/31/23 revealed no documentation family was notified of Resident
#77's transfer to the emergency room.
Interview on 04/06/23 at approximately 4:00 P.M. with the DON #381 confirmed the medical record for
Resident #77 did not include documentation his family was notified on 01/31/23 when he was transferred to
the emergency room.
Review of the facility policy titled Notification of Change, revised 12/19/22, revealed the facility must inform
the resident, resident's physician and the resident's representative when there is a change in status. A
change in status would include an accident involving the resident.
Review of the facility policy titled, Fall Management, revised 08/18/22, revealed residents would be
evaluated for their risk for falls and a plan of care would be developed and implemented based on the
evaluation with ongoing review. Evaluations would be completed for fall risk upon admission, re-admission,
quarterly, annually and with a significant change in condition. The licensed nurse would notify the attending
physician and the responsible party of the fall and document the notification in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 4 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 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
medical record review, observation, staff interview, and facility cleaning schedule, the facility failed to
ensure resident wheelchairs were maintained in a clean and sanitary manner. This affected four (#12, #43,
#48, #63) of four residents reviewed for clean equipment. The census was 101.
Findings include:
1. Review of Resident #48's medical record revealed an admission date of 12/01/20. Diagnoses included
benign neoplasm of the left choroid, hyperlipidemia, major depressive disorder recurrent, difficulty in
walking, muscle weakness, benign prostatic hyperplasia without lower urinary tract symptoms, and
essential primary hypertension.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately
cognitively impaired.
Review of Resident #48's medical record revealed Resident #48 utilized a wheelchair.
Observation on 04/03/23 at 5:00 P.M. of Resident #48's wheelchair revealed the wheelchair had a build up
of grime and dirt along the metal bars along the side and under the wheelchair.
Interview on 04/03/23 at 5:09 P.M. with Licensed Practical Nurse (LPN) #383 verified there was a regular
cleaning scheduled for resident equipment and should be cleaned at least monthly. LPN #383 verified
Resident #48's wheelchair was dirty and had not been cleaned in an unknown amount of time.
2. Review of Resident #63's medical record revealed was admitted on [DATE]. Diagnoses included
cerebrovascular disease, unspecified dementia unspecified severity without behavioral disturbance, benign
prostatic hyperplasia with lower urinary tract symptoms, retention of urine, anxiety disorder.
Review of the MDS assessment, dated 02/11/23, revealed the resident was severely cognitively impaired.
Review of the medical record revealed Resident #63 utilized a wheelchair.
3. Review of the medical record for Resident #12 revealed a readmission date of 08/25/19 with diagnoses
of Alzheimer's disease, dementia, and history of falling.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had severely impaired
cognition and required a wheelchair for mobility.
4. Review of the medical record for Resident #43 revealed an admission date of 04/13/21 with diagnoses of
Parkinson's disease and dementia.
Review of the comprehensive MDS assessment dated [DATE] revealed Resident #43 was rarely
understood and required a wheelchair for mobility.
Observation and interview on 04/03/23 at 5:12 P.M. with LPN #396 confirmed Resident #63's wheelchair
had clumps of dust hanging from the framework under his wheelchair, Resident #12's wheelchair had thick
dust on the frame of her power wheelchair, and Resident #43's wheelchair wheels were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 5 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
splattered with a light brown substance that appeared to be chocolate milk, and the cog at the joint of the
wheel and the spokes were coated in dust and debris. Continued interview with LPN #396 stated
wheelchairs were expected to be cleaned during third shift.
Review of an undated cleaning chore list revealed each hall was listed separately and then each day of the
week up to two rooms were listed each day for a hall.
Interview on 04/04/23 at approximately 11:30 A.M. with Director of Nursing (DON) #381, upon reviewing the
cleaning chore list document, verified resident equipment, including resident wheelchairs, are to be cleaned
by third shift staff on the designated days according to the chart.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 6 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure
residents who required staff assistance with activities of daily living, received adequate and timely care to
maintain good personal hygiene including shaving, nail care, and received timely and adequate assistance
with meals. This affected three (#16, #29, and #71) of five residents reviewed for activities of daily living.
The census was 101.
Residents Affected - Few
Findings include:
1. Review of Resident #16's medical record revealed an admission date of 03/02/22. Diagnoses included
Parkinson's disease, schizoaffective disorder, muscle weakness, diabetes mellitus type II, anxiety disorder,
major depressive disorder, hoarding disorder, morbid obesity, and osteoarthritis.
Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview
for Mental Status (BIMS) score of 15 indicating Resident #16 was cognitively intact. Resident #16 required
extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #16
was totally dependent on staff for bathing. Resident #16 displayed no behaviors during the review period.
Review of Resident #16's care plan revised 02/18/23 revealed supports and interventions for risk for
changes in mood, grief, and self-care deficit. Interventions for bathing included to check nail length and trim
and clean on bath days and as necessary with a bathing type listed as a shower.
Observation on 04/03/23 at 3:24 P.M. of Resident #16 found her hair appeared unclean and she had facial
hair on her chin and upper lip that was approximately one-half inch long.
Interview on 04/03/23 at 3:26 P.M. with Resident #16 revealed she was alert and aware. Resident #16
reported she had not been getting bathed or shaven. She was supposed to be shaved when she got
showers but she was not being showered and was only getting washed up in bed. Resident #16 reported
she was supposed to get showers three times a week. Resident #16 stated she did not like having hair on
her face.
Review of Resident #16's shower schedule revealed she was supposed to receive a shower on first shift on
Mondays, Wednesdays, and Fridays.
Observation on 04/04/23 at 7:13 A.M. of Resident #16 found she still had facial hair and her hair appeared
unclean.
Observation on 04/04/23 at 11:24 A.M. of Resident #16 found her seated in the dining room with 12 other
random residents. Resident #16 had observable facial hair on her upper lip and chin.
Interview on 04/04/23 at 1:12 P.M. with State Tested Nurse Aide (STNA) #411 verified Resident #16 was
supposed to be showered and shaved on 04/03/23 on first shift, and verified she had not showered or
shaved her. STNA #411 reported she ran out of time on 04/03/23, and she would make sure Resident #16
got showered and shaved on Wednesday. STNA #411 was not able to say when the last time Resident #16
was provided an actual shower and was shaven. STNA #411 verified Resident #16 had long facial hair.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 7 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
2. Review of Resident #29's medical record revealed an admission date of 05/10/19. Diagnoses included
cerebral infarction, Parkinson's disease, dysphagia, hemiplegia, major depressive disorder, contracture of
muscle at multiple sites, muscle weakness, and personal history of COVID-19.
Review of Resident #29's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status
(BIMS) score of nine indicating Resident #29 was moderately cognitively impaired. Resident #29 was totally
dependent on staff for bed mobility, transfers, personal hygiene and bathing. Resident #29 required
extensive assistance with dressing, eating, and toilet use. Resident #29 displayed no behaviors during the
review period. Resident #29 was not receiving therapy services at the time of the review. Resident #29 had
limited range of motion impairment on both sides of his lower extremities and impaired on one side of his
upper extremities.
Review of Resident #29's care plan revised 03/12/23 revealed supports and interventions for impaired
communication, risk for complications of left side hemiplegia and hemiparesis, risk for fluctuation in mood
and self-care deficit. Interventions for self-care deficit included oral care after all oral intakes, staff extensive
assistance to eat, between extensive assistance to dependent on staff assistance with personal hygiene,
when bathed staff were to check his nail length and trim and clean his nails on the bath day and as
necessary, and keep fingernails trimmed and clean.
Observation on 04/03/23 at 1:30 P.M. found Resident #29 lying in bed. Resident #29's fingernails were long
and his face was unshaven with about a quarter of an inch of hair growth.
Interview on 04/03/23 at 1:32 P.M. found Resident #29 was alert, aware, and able to answer single word
and yes and no questions. Resident #29 reported he was not able to shave himself or cut his fingernails.
Resident #29 indicated he wanted his nails and facial hair trimmed, and the staff had not done it like he
wanted.
Observation on 04/04/23 at 11:32 A.M. of Resident #29 found him up in his wheelchair. Resident #29
continued to be unshaven and his fingernails were long.
Interview on 04/04/23 at 1:22 P.M. with STNA #411 stated Resident #29 was totally dependent on staff for
all his activities of daily living (ADLs). STNA #411 reported Resident #29 was bathed on third shift on
Mondays, Wednesdays, and Fridays. STNA #411 reported when Resident #29 was bathed he was to be
shaven and have his nails trimmed if needed. STNA #411 verified Resident #29 had not been shaven and
his fingernails were long.
Observation on 04/05/23 at 8:38 A.M. of Resident #29 found him up in his wheelchair in the dining room for
breakfast. Resident #29 continued to not be shaven. His hands were under a blanket and his fingernails
were not able to be observed.
Interview on 04/05/23 at 8:39 A.M. with Physical Therapy Staff (PTS) #460 stated she was assisting
residents with eating and getting them back to their rooms following breakfast on 04/05/23. PTS #460
uncovered Resident #29's hands and opened them. PTS #460 verified Resident #29 was unshaven and his
fingernails were long.
Interview on 04/05/23 at 3:05 P.M. with STNA #444 stated Resident #29 was not resistant to care but at
times he would pull his face away when she was being shaven.
Review of the facility policy titled, Routine Resident Care, revised 03/07/23, revealed residents
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 8 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0677
were to receive the necessary assistance to maintain good grooming and personal hygiene.
Level of Harm - Minimal harm
or potential for actual harm
3. Review of Resident #71's medical record revealed an admission date of 08/23/22. Diagnoses included
Alzheimer's disease with late onset, type two diabetes mellitus without complications, obstructive sleep
apnea, mixed hyperlipidemia, essential (primary) hypertension, muscle weakness, hypokalemia,
hypothyroidism, major depression recurrent mild, dysphagia, and benign prostatic hyperplasia with lower
urinary tract symptoms.
Residents Affected - Few
Review of the MDS assessment dated [DATE] revealed Resident #71 was rarely understood. Resident #71
was assessed to require extensive one person assistance with dressing and eating, extensive two person
assistance with bed mobility, one person total dependence with locomotion on and off the unit, and two
person total dependence with transferring, toileting, personal hygiene, and bathing. Resident #71 received
a mechanically altered diet and was on hospice.
Review of the care plan dated 08/24/22, and updated on 02/01/23, revealed Resident #71 was care
planned for activities of daily living self care performance deficit and required assistance with activities of
daily living and mobility. Interventions included Resident #71 required extensive assistance to eat.
Observation on 04/03/23 at 11:22 A.M. revealed the meal cart arrived to Resident #71's hall and meal trays
were passed. At 11:48 A.M., Resident #71 was observed laying down flat on his back in bed with his meal
tray on the bedside table next to the bed but out of reach. The pureed lunch meal was uncovered.
Subsequent interview with Resident #71 revealed he believed he had not received the lunch meal and
when he saw the tray began to attempt to pull the meal tray from the bedside table to his lap.
Interview on 04/03/23 at 11:51 A.M. with Licensed Practical Nurse (LPN) #383 verified Resident #71
required extensive assistance with eating. LPN #383 verified the meal trays had been passed
approximately 30 minutes ago and other residents' trays in the hall were beginning to be picked up from
residents finishing their meal. LPN #383 stated she could not verify the temperature because she did not
have a thermometer but would guess that Resident #71's meal was no longer warm.
Interview on 04/03/23 at 12:01 P.M. with LPN #383 and STNA #505 stated it was STNA #505's second day
at the facility and when passing out trays she had just sat Resident #71's tray down not knowing he needed
assistance eating.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 9 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, review of an incident and accident log, and review of facility policy,
the facility failed to ensure neurological checks were completed following unwitnessed falls. This affected
one (#16) of five residents reviewed for falls. The census was 101.
Findings include:
Review of Resident #16's medical record revealed an admission date of 03/02/22. Diagnoses included
Parkinson's disease, schizoaffective disorder, muscle weakness, diabetes mellitus type II, anxiety disorder,
major depressive disorder, hoarding disorder, morbid obesity, and osteoarthritis.
Review of Resident #16's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental
Status (BIMS) score of 15 indicating Resident #16 was cognitively intact. Resident #16 required extensive
assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #16 was totally
dependent on staff for bathing. Resident #16 displayed no behaviors during the review period.
Review of Resident #16's care plan revised 02/18/23 revealed supports and interventions for risk for
changes in mood, grief, self-care deficit, and risk for falls. Interventions for fall risk included anticipate
needs, assess risk level for falls on admission and as needed, place the bed against the wall to increase
functional space, fall risk protocol, encourage the resident to wear appropriate footwear as needed, keep
the environment safe, maintained the call light in reach, provide adequate lighting, place commonly used
items in reach, lock the wheels on the wheelchair prior to transfers, provide an adaptive wheelchair as
needed, utilize a four wheeled walker, maintain side rails, provide activities, and place non-skid strips to the
floor in front of the bed.
Review of Resident #16's fall risk assessment completed 02/16/23 revealed Resident #16 was at risk for
falls.
Review of an incident and accident log from 11/04/22 through 04/03/23 revealed Resident #16 had falls on
11/13/22, 12/31/22, 01/19/23, and 02/07/23.
Review of Resident #16's fall investigations revealed on 11/13/22 and 12/31/22 Resident #16 had
unwitnessed falls in her room. No neurological checks were found as completed.
Interview on 04/04/23 at 1:09 P.M. with Resident #16 stated she fell often, and reported sometimes staff
were with her when she fell and sometimes she was by herself.
Interview on 04/06/23 at 2:29 P.M. with Director of Nursing (DON) #381 verified Resident #16 did not have
neurological checks completed following her unwitnessed falls on 11/13/22 and 12/31/22.
Review of the facility policy titled, Fall Management, revised 08/18/22, revealed residents would be
evaluated for their risk for falls and a plan of care would be developed and implemented based on the
evaluation with ongoing review. Evaluations would be completed for fall risk upon admission, re-admission,
quarterly, annually and with a significant change in condition. If a potential head injury was present
complete the neurological record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 10 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on medical record review and staff interview, the facility failed to ensure an as-needed anti-anxiety
medication order had an end date. This affected one (#50) of five residents reviewed for unnecessary
medications. The census was 101.
Findings include:
Review of the medical record for Resident #50 revealed an admission date of 02/16/21 with medical
diagnoses of anxiety and depression.
Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #50 had intact cognition
and was independent with setup help only for eating. Further review revealed Resident #50 received an
anti-anxiety medication daily.
Review of the current physician order dated 12/20/22 revealed Resident #50 received Xanax (an
anti-anxiety medication) 0.25 milligrams (mg) up to three times daily as needed for 30 days. The end date
on the order was marked indefinite.
Review of a nursing note dated 12/20/22 revealed the order noted for no stop date on Xanax.
Review of the physician progress notes dated 12/20/22 through 04/05/23 revealed no evaluation was
completed to justify the continued use of the as-needed anti-anxiety medication.
Review of the psychiatric notes completed on 02/01/23 and 03/08/23 revealed no evaluation was completed
to justify the continued use of the as-needed anti-anxiety medication.
Interview on 04/06/23 at 3:02 P.M., with the Director of Nursing (DON) #381 confirmed the as-needed order
for Xanax did not have an end date and the facility could not provide documentation to verify a physician
had evaluated Resident #50 for continued use of an as-needed order for an anti-anxiety medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 11 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, and facility policy review, the facility failed to properly store and secure
medications. This affected one (#97) of one residents reviewed for medication storage. The census was
101.
Findings include:
Review of the medical record revealed Resident #97 was admitted on [DATE]. Diagnoses included
hypo-osmolality and hyponatremia and delirium due to known physiological condition, encephalopathy, end
stage renal disease, type two diabetes mellitus without complications, muscle weakness, hyperlipidemia,
essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina
pectoris.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively
intact.
Review of Resident #97's physician order dated 03/14/23 revealed an order for the anti-nausea medication
Zofran oral tablet four (4) milligrams (mg) give one tablet by mouth every eight hours as needed for nausea
and vomiting and send to dialysis.
Observation on 04/05/23 at 5:04 P.M. of the hemodialysis communication book revealed a hemodialysis
communication document, dated 03/31/23, with a packaged Zofran tablet stapled to the top of the page.
The hemodialysis book was maintained at the 100 and 200 hall nurse's station and was unsecured.
Interview on 04/05/23 at 5:15 P.M. with Director of Nursing (DON) #381 verified the unsecure medication.
Review of the medication administration policy, dated 10/14/22, revealed to ensure the medication cart is
locked at all times when it is not in use or not within your contact vision. Store the locked medication cart in
the appropriate storage area between medication passes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 12 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, and review of the facility policy, the facility failed to ensure residents received
appropriately thickened liquids. This affected one (#46) of two residents reviewed for thickened liquids. The
census was 101.
Findings include:
Review of the medical record for Resident #46 revealed an admission date of 10/27/20 with diagnoses of
multiple sclerosis, morbid obesity, and dysphagia (difficulty swallowing).
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had
moderately impaired cognition and was independent with setup help only for eating.
Review of the physician order dated 03/10/23 revealed Resident #46 received a mechanical soft diet with
nectar thickened liquids.
Observation on 04/05/23 at approximately 10:23 A.M. revealed Resident #46 in a wheelchair in her room
with an overbed table within reach. Further observation of the overbed table revealed a large plastic cup
with clear liquid and ice cubes in it. Interview at that time with Resident #46 verified she was able to reach
her drink and could drink independently.
Interview and observation on 04/05/23 at 10:39 A.M. with Licensed Practical Nurse (LPN) #395 confirmed
Resident #46 had ice cubes in her water. Further interview with LPN #395 confirmed Resident #46 was on
thickened liquids and should not have ice in her drinks. LPN #395 could not identify who provided the water
to Resident #46. LPN #395 confirmed Resident #46 was on thickened liquids.
Interview on 04/05/23 at 10:42 A.M. with LPN #383 stated she did not fill Resident #46's cup, but did
ensure it was within reach when she repositioned Resident #46 prior to the observation on 04/05/23 at
approximately 10:23 A.M. LPN #383 was unaware Resident #46 had a physician order for thickened liquids.
Review of the facility policy titled, Diet Orders, reviewed 11/12/21, revealed the facility would adhere to
therapeutic diet parameters.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 13 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, review of facility policy, and review of the Centers for Disease Control
and Prevention (CDC) guidance for Coronavirus 2019 (COVID-19) vaccination and boosters, the facility
failed to ensure residents were offered the COVID-19 vaccine booster in a timely manner. This affected six
(#4, #11, #19, #20, #26, and #43) of nine residents reviewed for the COVID-19 vaccine. The census was
101.
Findings include:
1. Review of Resident #4's medical record revealed an admission date of 10/01/17. Diagnoses included
cutaneous abscess of the buttock, generalized idiopathic epilepsy and epileptic syndromes intractable,
chronic obstructive pulmonary disease, dysphasia, muscle weakness, schizoaffective disorder, bipolar
disorder, unspecified dementia, hypothyroidism, anxiety disorder, and insomnia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was moderately
cognitively impaired.
Review of the immunization record revealed Resident #4 last received a two-dose COVID-19 primary
vaccine series on 06/07/22 with no documentation of a booster.
Review of a Consent/Declination of COVID-19 Vaccination document dated 10/25/22 revealed Resident
#4's guardian provided consent for Resident #4 to receive the vaccine booster.
2. Review of Resident #11's medical record revealed an admission date of 02/04/22. Diagnoses included
heart failure, type two diabetes mellitus with diabetic chronic kidney disease, unspecified atrial fibrillation,
hyperlipidemia, chronic kidney disease stage four, hypoxemia, and age related osteoporosis.
Review of the MDS assessment dated [DATE] revealed Resident #4 was cognitively intact.
Review of the immunization record revealed Resident #11 last received a two-dose COVID-19 primary
vaccine series on 06/07/22 with no documentation of a booster.
Further review of the medical record revealed no additional documentation showing Resident #4 was
offered a COVID-19 booster from 06/07/22 to April 2023.
3. Review of Resident #19's medical record revealed an admission date of 06/05/10. Diagnoses included
persistent vegetative state, type two diabetes mellitus, chronic conjunctivitis, filamentary keratitis,
gastronomy status, and contracture unspecified joint.
Review of the immunization record revealed Resident #19 last received a two-dose COVID-19 primary
vaccine series on 06/07/22 with no documentation of a booster.
Review of a Consent/Declination of COVID-19 Vaccination document dated 10/27/22 revealed Resident
#19's guardian provided consent for Resident #19 to receive the vaccine booster.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 14 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0887
Level of Harm - Minimal harm
or potential for actual harm
4. Review of Resident #20's medical record revealed an admission date of 10/05/17. Diagnoses included
hemiplegia and hemiparesis following cerebral infarction affecting the right dominate side, type two
diabetes mellitus without complications, cerebral palsy, hereditary and idiopathic neuropathy, essential
(primary) hypertension, moderate intellectual disabilities, anxiety disorder, and muscle weakness.
Residents Affected - Some
Review of the MDS assessment dated [DATE] revealed Resident #20 was cognitively intact.
Review of the immunization record revealed Resident #20 last received a two-dose COVID-19 primary
vaccine series on 06/07/22 with no documentation of a booster.
Review of a Consent/Declination of COVID-19 Vaccination document dated 10/25/22 revealed Resident
#20 provided consent to receive the vaccine booster.
5. Review of Resident #26's medical record revealed an admission date of 07/31/19. Diagnoses included
hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified
sequelae of cerebral infarction, anxiety disorder, major depressive disorder recurrent, essential (primary)
hypertension, unspecified osteoarthritis, dysphasia oropharyngeal phase, muscle weakness, and
hyperlipidemia.
Review of the MDS assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired.
Review of the immunization record revealed Resident #26 last received a two-dose COVID-19 primary
vaccine series on 06/07/22 with no documentation of a booster.
Further review of the medical record revealed no additional documentation showing Resident #26 was
offered an updated COVID-19 booster from 06/07/22 to April 2023.
6. Review of Resident #43's medical record revealed an admission date of 04/13/21. Diagnoses included
Parkinson's disease, other neuromuscular dysfunction of bladder, dementia in other diseases classified
elsewhere unspecified severity without behavioral disturbance psychotic disturbance, Alzheimer's disease
with late onset, paroxysmal atrial fibrillation, hypertensive chronic kidney disease with stage five chronic
kidney disease or end stage renal disease, hypertensive heart disease with heart failure, and essential
primary hypertension.
Review of the MDS assessment dated [DATE] revealed Resident #43 was rarely understood.
Review of the immunization record revealed Resident #43 last received a two-dose COVID-19 primary
vaccine series on 05/26/22 with no documentation of a booster.
Review of a Consent/Declination of COVID-19 Vaccination document dated 10/25/22 revealed Resident
#43 provided consent to receive the vaccine.
Interview on 04/04/23 at 11:44 A.M. with the Director of Nursing #380 verified COVID-19 boosters were not
offered timely for Resident #4, #11, #19, #20, #26, and #43.
Review of facility policy titled, COVID Today Guidelines, effective 03/13/23, verified maintenance vaccine
clinics must be scheduled weekly for current and new guests and residents who have not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365389
If continuation sheet
Page 15 of 16
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
365389
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurels of Defiance The
1701 S Jefferson Ave
Defiance, OH 43512
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
received the vaccine yet and would like to receive it. Facilities should administer the booster doses at the
maintenance clinics.
Review of the CDC guidance titled, Stay Up to Date with COVID-19 Vaccines Including Boosters, dated
03/02/23, revealed the CDC recommended people stay up to date with the COVID-19 vaccine for their age
group. The CDC recommends one updated vaccine for everyone five years and older. Updated boosters are
called updated because they protect against both the original virus that causes COVID-19 and the Omicron
variant. Two COVID-19 vaccine manufacturers, Pfizer and Moderna, have developed updated COVID-19
boosters. Updated COVID-19 boosters became available on 09/22/22 for people aged 12 years and older.
Event ID:
Facility ID:
365389
If continuation sheet
Page 16 of 16
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Back to topCitations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F584 - Safe Environment
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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0241GeneralS&S Epotential for harm
Have correct number of accessible exits for each story.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
FAQ · About this visit
Common questions about this visit
What happened during the April 6, 2023 survey of LAURELS OF DEFIANCE THE?
This was a inspection survey of LAURELS OF DEFIANCE THE on April 6, 2023. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LAURELS OF DEFIANCE THE on April 6, 2023?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.