Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on dining observations and staff interview the facility failed to treat 13 residents (#03, #06, #07,#36,
#37, #42, #45, #51,#56, #59, #61, #333, and #434) eating in the restorative dining room with dignity during
the meal. The facility census was 78.
Findings include:
Observation on 07/18/22 at 11:20 A.M. revealed State Tested Nursing Assistant (STNA) #123 was in the
restorative dinning room standing to the right side behind Resident #37 wheelchair attempting to feed her a
spoonful of food. Resident #37 would not open her mouth.
Further observation on 07/18/22 at 11:40 A.M. of dining revealed a small room behind the large main dining
room. There were 12 residents ( #03, #06, #07,#36, #37, #42, #45, #56, #59, #61, #333, and #434) in the
room in wheelchairs sitting at three small square tables. One Resident (#51) was sitting off to the left side of
the room with an over bed table in front of her. STNA #123 stood and fed three different residents ( #03,
#06, and #37) each one bite at the middle table then left the small dining room. She returned to the dining
room and fed Resident #06 one bite of his puree diet. She went to another table and began feeding
Resident #03 while standing.
Resident #51 was sitting at an over bed table to the left of the tables. She was served a regular diet on the
over bed table at 11:50 A.M.
There were nine residents ( #03, #06, #36,#37, #45, #59, #61, #333, and #434) requiring staff to feed them
and four residents ( #07, #42, #51,and #56 ) requiring cues to feed themselves. Three staff members
(STNA #65, #110, #123) were in the dining room feeding nine residents. All three staff members were
moving from table to table standing and feeding the residents.
Interview with Assistant Director of Nursing (ADON) #74 on 07/18/22 at 12:20 P.M. revealed the small
dining room was the restorative dining room. She verified all of the residents currently in the dining room
either required staff to feed them or extensive cueing to ensure the residents would feed themselves. She
verified it was her expectation the staff sit in a chair at eye level with the resident and feed the resident
engaging the residents in the dining process. She stated the restorative dining room was very crowded and
there was little room for the staff to sit. She verified staff should not be moving from table to table to feed
multiple residents at one time. She verified that Resident #51 was seated at the over bed table due to
limited space .
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 11
Event ID:
365541
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review , observation, resident and staff interviews and facility policy review the facility failed
to provide one resident (#36) of one resident reviewed with an adaptive call light. The facility census was
78.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses
including Parkinson's disease, anemia, cervical spine stenosis, hypertension, and contracture of his left
wrist.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive deficits. He
requires extensive assistance with all activities of daily living . He was currently receiving hospice care in
the facility.
Review of the plan of care dated 07/18/22 stated the resident may need adaptations to participate in
activities. The only adaptive intervention was for a bingo board . There was no mention of call light use and
no mention of checking the resident requiring frequent checks.
Observation on 07/18/22 at 10:40 A.M. revealed Resident #36 was in a specialized tilt in space wheelchair
sitting in the center of his room. He asked the Surveyor to get a nursing assistant to help him. The call light
was hooked to the top of his bed. Resident #36 states he can't use his hands so he can't use his call light
even it it was within his reach. The call light is a string attached to a switch and he stated he can't pull it
down.
Observation on 07/19/22 at 3:20 P.M. revealed Resident #36 was in his room in tilt in space wheelchair. The
call light string was attached to the top back of his wheelchair out of the resident's reach. He verified he
could not reach his call light . He stated even if he could reach the string he could not pull it as his hands
did no work well enough to pull down on the string to activate it. He stated he has end stage Parkinson
disease and has really been going down hill physically. He stated staff is to check on him every half hour to
see if he needs anything.
Interview on 07/19/22 at 3:25 P.M. with Assistant Director of Nursing (ADON) #74 verified Resident #36's
call light was out of reach . ADON #74 stated the facility's call light system is not compatible with a soft
touch call light. She stated the facility has bells for residents who can't pull down on the call light.
Review of the policy Guidelines for Answering Call Lights ,dated 05/11/16 stated adaptive call lights are
available if needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 2 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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
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
medical record review, resident and facility staff interviews, the facility failed to honor choices of two of 12
sampled residents (Resident #32 and Resident #75), regarding showers. The facility census was 78.
Findings include:
1. Interview with Resident #32 occurred on 07/18/22 at 12:52 P.M., Resident #32 identified she is getting a
shower about once a month. Resident #32 confirmed she is receiving bed baths, but actually wants
showered. Resident #32 appeared clean and odor free at the time of the interview and observation.
Interview with Resident #32 occurred again on 07/19/22 at 9:58 A.M. Resident #32 confirmed there is an
issue with residents not getting showers and getting bed baths. Resident #32 identified she is the resident
council president and wants to speak for other residents whom can not speak for themselves.
Review of Resident #32's medical record identified admission to the facility occurred on 08/04/16 with
medical diagnoses including; COPD (Chronic obstructive pulmonary disease), diabetes mellitus with
diabetic neuropathy, chronic kidney disease, ;major depressive disorder, anemia, hypothyroidism, gout,
anxiety disorder, hypertension, gastro-esophageal reflux disease without esophagitis, nausea with
vomiting; constipation, presence of urogenital implants; tachycardia and personal history of COVID-19.
Review of Resident #32 most recent annual Minimum Date Assessment (MDS) assessment, dated
04/26/22 identified Resident #32 is cognitively intact. The assessment identified Resident #32 is dependent
on one staff member for personal care.
Review of the facilities grievance logs identified Resident #32 had voiced concerns on 04/27/22, 05/05/22,
05/16/22, 06/17/22 and 07/07/22 for lack of getting showers. The notes identified when the resident
complains then she is noted to have received on that date; however then has to voice another concern to
get a shower.
Interview with the facility Administrator on 07/19/22 at 1:21 P.M. confirmed Resident #32 had filed grievance
on 04/27/22, 05/05/22, 05/16/22, 017/22 and 07/07/22 for lack of getting showers. The notes identified
when Resident #32 voices her concerns a shower is given at that time, but the same thing is continuing to
occur.
Review of Resident #32 point of care history (where staff document showers/bed bathing) was completed
from 06/20/22 through 07/19/22. The forms identified Resident #32 is schedule for showers on twice a week
on Mondays and Fridays. The information confirmed Resident #32's most recent shower occurred on
07/03/22 and bed baths occurred on 07/19, 07/18, 07/15, 07/13, 07/12, 07/10, 07/07 and 07/05/22.
2. Interview with Resident #75 occurred on 07/18/22 at 1:08 P.M. Resident #75 identified he has not been
getting showers three times a week as scheduled. Resident #75 identified most of the time he is getting a
bed bath instead and prefers a shower. Resident #75 identified he is scheduled on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 3 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Monday, Wednesday and Friday's which are the days he attends Dialysis. Resident #75 was observed
during the interview to be clean and odor free and was shaven.
Review of Resident #75's medical record identified admission to the facility occurred on 06/17/13, with
medical diagnoses including; fracture of the right fibula/tibia, end stage renal disease, diabetes, morbid
obesity, anxiety, major depression, anemia and poor circulation.
Review of the most recent MDS assessment dated [DATE] identified he is cognitively intact. Resident #75 is
legally blind, dependent on staff for bathing, and required dialysis treatment three time a week.
Review of the facility Point of Care history from 06/20/22 through 07/19/22 was completed. The history
identified Resident #75 received bed bathing on 07/19, 07/13, 07/06, 07/01, 06/27, 06/25, 06/21 and
06/20/22.
Interview with Registered Nurse (RN) #74 was completed on 07/20/22 at 10:44 A.M. and confirmed
Resident #75 is not getting showers, as he desires three times a week and instead has been receiving bed
baths.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 4 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record reviews, therapy, family and staff interviews, the facility failed to maintain
ambulation for one (Resident #55) of one residents reviewed for activities of daily living (ADL) decline, in a
total sample of 18 residents. The facility census was 78.
Residents Affected - Few
Findings include:
Review of Resident #55's medical record identified she was admitted to the facility on [DATE]. Resident #55
has medical diagnoses that include: dementia, atrial-fibrillation, anxiety and chronic pain.
Review of Resident #55's admission assessment dated [DATE] identified severe impairment with cognition
and under section G- requires extensive assistant of one, for ambulation, in the room and corridor. The
quarterly assessment dated [DATE] identified continued severe cognitive impairment and ambulation in
room with supervision only. The assessment identified Resident #55 was not walking in the corridor.
Interview with Resident #55's husband occurred on 07/19/22 09:29 A.M. The interview identified two weeks
prior to Resident #55's admission she was walking without any assistance. The interview confirmed she
received therapy at the facility and since that has stopped they are not walking her very much.
Observations of Resident #55 occurred on 07/18/22 at 10:12 A.M.; 11:25 A.M.; and on 07/19/22 at 12:07
P.M. Resident #55 was observed to be an in wheelchair at each observation. Observations on 07/20/22 at
8:30 A.M. and 11:06 A.M. of Resident #55's room and the secured unit identified no evidence Resident #55
had a walker for the staff to ambulate the resident.
Interview with Licensed Practical Nurse (LPN) #340 was completed on 07/19/22 at 12:17 P.M. LPN #340
confirmed Resident #55 could ambulate with contact guard assistance when she was discharged from
therapy and is almost non-ambulatory at this time. The interview confirmed there is not a walker in Resident
#55's room for her to use with the staff.
Review of the physical therapy Discharge summary dated [DATE]; identified Resident #55 was discharged
because she has reached highest practical level achievement. The discharge notes identified Resident #55
can ambulate 120 feet with a front wheeled walker (FWW) with contact guard minimal assistance. The
summary identified Resident #55 transfers with contact guard minimal assistance. The discharged therapy
recommendation was for Resident #55 patient complete functional transfers and ambulation with FWW.
Observation and interview with STNA (State Tested Nursing Assistant) #109 on 07/20/22 at 8:53 A.M.
identified the resident leans forward and does not have a walker on the unit. STNA #109 confirmed she has
not been instructed Resident #55 should walk and or has a walker.
Review of the point of care forms (utilized by STNA for ambulation times) identified the following days;
05/28/22, 05/31/22, 06/02/22, 06/09/22, 06/11/22, 06/20/22, 07/15/22, and on 07/17/22, Resident #55 was
ambulated since 05/24/22, when she was discharged from therapy. The documentation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 5 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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 0676
identified staff walked Resident #55 in her room with extensive assistance of one person.
Level of Harm - Minimal harm
or potential for actual harm
Interview with Occupational Therapist (OT) #320 occurred on 07/21/22 at 9:46 A.M. The interview
confirmed the therapy department can not recommend restorative programs when residents are discharged
from therapy as this facility does not have a program. The interview confirmed there was no written program
to ambulate Resident #55 upon discharge from therapy. The interview confirmed there is no plan of care to
ambulate Resident #55. OT #320 confirmed she had worked with Resident #55 when she was in services
through them. The interview confirmed Resident #55 was able to ambulate with contact guard assistance
only.
Residents Affected - Few
Observation on 07/21/22 at 10:10 A.M. with OT #320 working with Resident #55 was completed. The
observation identified OT #320 was able to ambulate with a walker approximately 120 feet. The interview
confirmed she was contacted yesterday to look at Resident #55 for a decline in ambulation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 6 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record review and staff interviews, the facility failed to prevent a delay in treatment of
surgical wound and suture (stitches) removal for one (Resident #75) of two residents reviewed for
hospitalization. The facility census was 78.
Residents Affected - Few
Findings include:
Observation and Interview with Resident #75 occurred on 07/18/22 01:19 P.M. Resident #75 was observed
with an ace wrap and bandage on the right calf, stopping below the knee. Resident #75 was observed with
sutures (stitches) located on the top of the knee and just below the knee. Resident #75 was asked about
the stitches and confirmed they should have been out weeks ago; however he missed his appointment on
06/30/22 and it has never been rescheduled.
Review of Resident #75's medical record identified admission to the facility occurred on 06/17/13, with
medical diagnoses including; fracture of the right fibula/tibia, end stage renal disease, diabetes, morbid
obesity, anxiety, major depression, anemia and poor circulation.
The most recent Minimum Data Set (MDS) assessment dated [DATE] identified he is cognitively intact.
Resident #75 is legally blind and required dialysis treatment three time a week.
Review of Resident #75's progress notes identified on 06/05/22 revealed Resident #75 had a fall and
suffered a fractured right leg, which required surgical repair on 06/07/22.
Review of Resident #75's hospital discharge records dated 06/09/22 identified Resident #75 should return
to the orthopedic physician office in 3 weeks for a check up and suture removal. Review of the facilities
records identified an appointment was for 06/30/22, but Resident #75 did not make the appointment for
transportation issues. Review of the progress notes dated 06/30/22 identified no entries were made
regarding the missed appointment, rescheduling or suture removal.
Interview with Licensed Practical Nurse (LPN) #181 occurred on 07/19/22 at 12:35 P.M., confirmed
Resident #75 should have had an appointment with the orthopedic surgeon on 06/30/22 and missed the
appointment, for lack of facility transport. The interview confirmed Resident #75's stitches were still in place
and she is going to call the Orthopedic surgeon or Medical Director and ask them about what to do. The
interview confirmed Resident #75 has had the sutures in for the past 6 weeks; and should have had them
removed after 3 weeks, on 06/30/22.
Observation of LPN #181 on 07/19/22 at 3:16 P.M. identified she had a physician order from the facility
Medical Director to remove Resident #75's stitches. LPN #181 entered Resident #75's room and started the
removal of the stitches. Resident #75's right leg was observed with two sutures above the knee, three
sutures just below the knee, had skin growing over the sutures and were difficult to remove. LPN #181
confirmed Resident #75 sutures were difficult to remove due to the extended time they were in place. LPN
#181 continued the suture removal with approximately seven sutures removed from Resident #75's right
ankle, some of which were observed with crusty skin growing over the sutures. Resident #75 expressed
slight discomfort at the time of removal but no pain.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 7 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, staff and resident interview, and observations the facility failed to ensure one
resident ( #43) of 18 sampled residents received her hearing aids on a consistent basis. The facility census
is 78.
Residents Affected - Few
Findings Include:
Review of the medical record for Resident #43 revealed an admission date of 12/01/21. Diagnoses
included, unspecified dementia without behavioral disturbance, anxiety disorder, hypokalemia, essential
hypertension, and insomnia.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/22, revealed she was
moderate cognitive impairment. The assessment, section B (Hearing) revealed moderate difficulty - speaker
has to increase volume and speak distinctly, and indicated hearing appliance used. There were no
behaviors indicated.
Review of the Plan of Care dated 05/21/22 revealed interventions included putting hearing aids in
medication cart each night.
Review of the progress notes dated 05/18/22 revealed Resident #43 had hearing aid on. Review of notes
dated 06/08/22 revealed daughter, came in today and brought in left hearing aid, and placed in Resident
#43's ear. Review of the progress notes dated 06/08/22 through 07/17/22 revealed no further mention of
hearing aid.
Interview on 07/19/22 at 1:45 P.M. with Licensed Practical Nurse (LPN) #157, indicated Resident #43 states
she doesn't want the hearing aids and throws them when she does have them.
Interview on 07/20/22 at 9:43 A.M. with Registered Nurse (RN) #300 stated there is no record used for
nurses to sign off that hearing aids are put in place, we only record hearing aids placed in med cart each
night.
Interview on 07/21/22 at 10:31 A.M. with Resident #43 stated, Yes, I would like to have my hearing aides in
everyday.
Interview on 07/21/22 at 11:22 A.M. with Executive Director (ED) stated a staff education was given about
two months ago because Resident # 43's daughter asked to have hearing aids placed every day.
Observation on 07/18/22 at 11:29 A.M. and 1:02 P.M. revealed Resident #43 in room awake no hearing aids
in place.
Observation on 07/19/22 at 12:27 P.M. revealed Resident #43 sitting up in recliner, in her room eating
lunch. Resident #43 stated she doesn't know where her hearing aids are. Resident #43 pointed to her ears
and shook her head.
Observation on 7/19/22 at 1:50 P.M. revealed LPN #57 removed the hearing aids from her medication cart
and placed then in Resident #43's ears. Resident #43 did not object to having the hearing aids in place.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 8 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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
medical record review, review of pharmacy recommendations and interview the facility failed to timely
respond to pharmacy recommendations. This affected one resident (#05) of five residents reviewed for
unnecessary medications. The facility census was 78.
Findings include:
Review of the medical record for Resident #05 revealed an admission date of 03/25/22. Diagnoses included
Parkinson's Disease, Alzheimer's Disease, dementia, unspecified psychosis not due to a substance or
known physiological condition, major depressive disorder, single episode, and anxiety.
Review of the pharmacy recommendations dated 03/29/22 revealed resident has an order for Celexa 40
milligrams (mg) daily. Food and Drug Administration (FDA) says citalopram doses should not exceed 20
mg/day for most patients over age [AGE]. Higher doses of citalopram (Celexa, etc.) increases risk of QT
prolongation (a heart rhythm that can potentially cause fast, chaotic heartbeats) and torsades (a specific
type of ventricular tachycardia, or fast heart rhythm that begins in your heart ventricles). Please review to
determine if patient would benefit from a decrease to Celexa 20 mg daily, or alternative therapy. If no
change is to be made, please comment. There was no documentation to indicate the physician had
addressed the recommendation.
Review of the pharmacy recommendation dated 04/25/22 revealed a repeat recommendation related to
Celexa 40 mg daily. Review of physician response dated 05/03/22 revealed discontinue Celexa 40 mg, start
Celexa 20 mg daily.
Interview on 07/21/22 at 9:05 A.M. with Registered Nurse (RN) #300 verified the physician did not
document a response to the recommendation dated 03/29/22.
Review of facility policy titled, Medication Regimen Review, revised date 11/2018, revealed
recommendations are acted upon and documented by the facility personnel and/or the prescriber.
Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 9 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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 0920
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size,
with good lighting, air flow and furniture.
Based on dining observations and staff interview the facility failed to ensure there was adequate space in
the restorative dining room for 13 residents (#03, #06, #07,#36, #37, #42, #45, #51, #56, #59, #61,#333,
and #434) requiring extensive assistance with eating. The facility census was 78.
Findings include:
Observation on 07/18/22 at 11:20 A.M. revealed State Tested Nursing Assistant (STNA) #123 was in the
restorative dinning room standing to the right side behind Resident #37 wheelchair attempting to feed her a
spoonful of food. Resident #37 would not open her mouth.
Further observation on 07/18/22 at 11:40 A.M. revealed a small room behind the large main dining room.
There were 12 residents ( #03, #06, #07,#36, #37, #42, #45, #56, #59, #61,#333, and #434) in the room in
wheelchairs sitting at three small square tables. One resident (#51) was sitting off to the left side of the
room with an over bed table in front of her. STNA #123 stood and fed three different residents ( #03, #06,
#37) each one bite at the middle table then left the small dining room. In order to leave the middle table
STNA # 123 had to move two resident's ( #03 and #59) wheelchairs away from two different tables to exit
the dining room. She returned to the dining room and fed Resident #06 one bite of his puree diet. She went
to another table moving Resident #59 wheelchair out of the way and began feeding Resident #03 while
standing.
There were nine residents ( #03, #06, #36,#37, #45, #59, #61, #333, and #434) requiring staff to feed them
and four residents ( #07, #42, #51,and #56 ) requiring cues to feed themselves. Three staff members
(STNA #65, #110, #123) were in the dining room feeding nine residents. All three staff members were
moving from table to table standing and feeding the residents. As staff moved throughout the restorative
dining room they would move resident's wheelchairs so they could to get to a different table.
Interview with Assistant Director of Nursing (ADON) #74 on 07/18/22 at 12:20 P.M. verified the small dining
room was the restorative dining room. She verified all of the residents currently in the dining room were in
wheelchairs and either required staff to feed them or extensive cueing to ensure the residents would feed
themselves. She verified all of the residents currently in the restorative dining room were dependent on staff
for mobility in a wheelchair. She stated the restorative dining room was very crowded and there was little
room for the staff to sit. She verified Resident # 51 was seated off to the left side of the tables and was
eating off an over bed table due to limited space in the restorative dining room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 10 of 11
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
365541
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage The
2820 Greenacre Dr
Findlay, OH 45840
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review,observations, family and staff interviews the facility failed to ensure a clean sanitary
environment was maintained for one resident (#07) in a total sample of 18 residents. The facility census
was 78.
Findings include:
Review of the medical record revealed Resident #07 was admitted to the facility on [DATE] with diagnoses
including Alzheimer's dementia and generalized anxiety.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had
short and long term memory deficits and was unable to complete the Brief Interview for Mental Status. She
requires extensive assistance of one staff member for all activities of daily living including toileting. She was
assessed as always incontinent of bowel and bladder.
Review of the plan of care dated 05/25/22 revealed the resident is incontinent of bowel and bladder.
Interventions included providing incontinent care following incontinence.
Observation on 07/18/22 at 10:30 A.M. revealed the trash in Resident 's #07 bathroom was overflowing with
two wet incontinent briefs. There was a strong smell of urine in the bathroom.
Observation on 07/19/22 at 8:30 A.M. revealed one wet incontinent brief in Resident #07 bathroom trash.
Interview with Resident #07's family member on 07/19/22 at 9:20 A.M. revealed she stated she usually
visits Resident #07 on Saturday evenings and does not leave until she is in bed for the night. She stated
generally there is an wet incontinent brief in the waste basket when she visits which she feels if left from the
last time the resident was changed.
Observation on 07/19/22 at 5:30 P.M. revealed a wet incontinent brief was in the resident's bathroom trash .
Assistant Director of Nursing (ADON) #74 verified there was a wet incontinent brief in the trash can in
Resident #07's bathroom. She stated it is the expectation for staff is to take the soiled briefs in a sealed
trash liner to the dirty utility room and dispose of them immediately. She verified soiled incontinent briefs
are never to be left in a trash can in resident's rooms or bathrooms.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
9 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.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F920 - Dining and Resident Activities
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
FAQ · About this visit
Common questions about this visit
What happened during the July 21, 2022 survey of HERITAGE THE?
This was a inspection survey of HERITAGE THE on July 21, 2022. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HERITAGE THE on July 21, 2022?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.