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 interviews, and facility policy review, the facility failed to notify the physician of a
resident's change in condition. This affected one (#10) of three residents reviewed for change in condition.
The facility census was 81.Findings include:Record review for Resident #10 revealed the resident was
admitted to the facility on [DATE] and expired on [DATE]. Diagnoses included Alzheimer's disease and
memory deficit following cerebral infarction.Review of a Minimum Data Set (MDS) quarterly assessment
dated [DATE] revealed Resident #10 had impaired cognition evidenced by a Brief Interview for Mental
Status (BIMS) score of nine (9). The resident was assessed to require supervision with toileting, bathing,
and dressing, was frequently incontinent of bladder and bowel, and had no skin issues.Review of progress
notes dated [DATE] at 1:20 P.M. revealed Registered Nurse (RN) #131 documented Resident #10 was not
acting like herself, not eating, getting up, or using the restroom. RN #131 contacted Resident #10's
daughter and offered to send her to the emergency room, and the daughter decline at that time. There was
no evidence the facility notified the facility of the resident's change in condition. Further review revealed on
[DATE] at 2:26 P.M., Resident #10 was transferred to emergency room without physician
notification.Interview on [DATE] at 5:50 P.M. with Regional Nurse #128 verified the physician was not
notified of change of condition for Resident #10.Review of facility policy titled, Notification of Change in
Condition, dated [DATE], revealed a significant change in a resident's physical, mental, or psychosocial
status results in reasons to notify the physician immediately.This deficiency represents non-compliance
investigated under Complaint Number 2731910.
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 8
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
02/25/2026
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Based on observation, staff interview, and facility policy review, the facility failed to maintain a clean and
home-like environment. This affected two (#13 and #18) of eight residents review for environment. The
facility census was 81.Findings include:Observation on 02/23/26 at 9:07 A.M. revealed Resident #13's floor
had a large amount of food crumb particles, small pieces of shredded paper, and mud-like substance
throughout the entire carpet in the room. Interview on 02/23/26 at 9:09 A.M. with License Practice Nurse
(LPN) #130 verified all findings in Resident #13's room.Observation on 02/23/26 at 9:50 A.M. revealed
Resident #18's floor had a cover of shredded paper, shredded metallic paper, and food crumb particles
from bed area to the door area. Interview on 02/23/26 at 9:52 A.M. with License Practice Nurse (LPN) #130
verified all findings in Resident #18's room. Interview on 02/23/26 at 11:18 A.M. Regional Nurse #128
revealed rooms should be cleaned daily including over the weekend. Review of the undated facility policy
titled, Standard Operate Procedure (SOP)-Room Cleaning-Health Center, revealed daily cleaning include
organize, trash pickup and dusting, spraying approved disinfectants, wipe surfaces clean, and vacuum
room, and mop bathroom.This deficiency represents non-compliance investigated under Complaint Number
2731910.
Event ID:
Facility ID:
365541
If continuation sheet
Page 2 of 8
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
02/25/2026
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure
timely drainage of urinary catheter bags. This affected one (#12) of four residents reviewed for urinary
catheters.Findings include:Review of the medical record for Resident #12 revealed he was admitted on
[DATE] with diagnoses including hereditary spastic paraplegia, chronic obstructive pulmonary disease,
heart disease, cough, wheezing, shortness of breath, malignant neoplasm of bladder, and suprapubic
urostomy.Review of a functional assessment dated [DATE] revealed Resident #12 required set-up to partial
assistance with activities of daily living, utilized a motorized wheelchair, and was independent with mobility.
Review an admission note dated 02/08/26 for Resident #12 revealed he was alert and oriented.Observation
on 02/25/26 at 9:00 A.M. of Resident #12's urinary catheter bag revealed it was round, taut, and full of
yellow liquid.Interview on 02/25/26 at 9:10 A.M. with Certified Nurse Aide (CNA) #138 confirmed Resident
#12's urinary catheter bag was round, taut, and filled with urine. Subsequent observation of CNA #138
emptying the urinary catheter bag revealed 3,000 milliliters (mL) of urine was emptied from the bag.Review
of the manufacturer's label for Resident #12's urinary catheter bag revealed the capacity of the bag was
2,000 mL.Review of facility policy dated 12/16/24 and titled, Emptying Urinary Bags, revealed the facility
would empty urinary catheter bags each shift or more often if needed to prevent the bag from becoming
full.This deficiency represents non-compliance investigated under Complaint Number 2752534.
Event ID:
Facility ID:
365541
If continuation sheet
Page 3 of 8
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
02/25/2026
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation medical record review, resident and staff interview, and review of facility policies, the facility
failed to ensure respiratory supplies were stored and dated in a safe manner and failed to ensure a
resident's need for supplemental oxygen was provided in a timely and sufficient manner. This affected two
(#13 and #57) of five residents reviewed for oxygen. The facility census was 81.Findings include:1. Record
review for Resident #13 revealed the resident was admitted to the facility on [DATE] with diagnoses
including chronic obstructive pulmonary disease and chronic respiratory failure.
Residents Affected - Few
Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had
intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was
assessed to require oxygen therapy.
Review of the current care plan revealed Resident #13 had potential for complications in functional and
cognitive status related to respiratory disease related to obstructive pulmonary disease and oxygen use.
Observation on 02/23/26 at 9:07 A.M. revealed Resident #13's oxygen concentrator was running at two
liters of oxygen with undated tubing attached to nasal cannula laying on the floor in front of the
concentrator. There was also undated tubing with an oxygen mask laying on the floor beside the
concentrator.
Interview on 02/23/26 at 9:09 A.M. with License Practice Nurse (LPN) #130 verified undated tubing, nasal
cannula, and oxygen mask way laying on the floor.
2. Review of the medical record for Resident #57 revealed she was admitted on [DATE] with diagnoses
including chronic respiratory failure with hypoxia, stage five chronic kidney disease, chronic heart failure,
and obstructive sleep apnea.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #57 was cognitively intact and
did not display any behaviors at the time of the assessment. She utilized a wheelchair, was dependent for
all transfers and mobility, and required partial to maximal assistance with activities of daily living. This
assessment indicated she had cardiorespiratory diagnoses and utilized oxygen therapy.
Review of physician orders for Resident #57 revealed an order dated 11/25/24 for continuous oxygen to be
administered by nasal cannula at 2 liters per minute.
Observation on 02/25/26 at 9:15 A.M. of Resident #57 sitting in the dining room revealed she was wearing
an oxygen nasal cannula and had a portable oxygen tank on the back of her wheelchair set to two liters per
minute. Further observation revealed the nasal cannula was not dated and two gauges on the portable
oxygen tank indicated the tank was empty.
Interview on 02/25/26 at 9:15 A.M. with Resident #57 revealed she had been feeling increased shortness of
breath since she awakened that morning and was still experiencing increased shortness of breath at the
time of the interview.
Interview on 02/25/26 at 9:30 A.M. with Certified Nurse Aide (CNA) #140 confirmed Resident #57's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 4 of 8
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
02/25/2026
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
nasal cannula was not dated and the gauges on the portable oxygen tank on the back of Resident #57's
wheelchair indicated the tank was empty.
Review of facility policy titled, Respiratory Equipment, dated 05/11/16, revealed to change the oxygen
cannula and tubing monthly and as necessary, and keep the oxygen cannula and tubing in a plastic bag
when not used.
Review of facility policy dated 12/13/24 and titled, Administration of Oxygen, revealed the facility would date
oxygen tubing and administer oxygen according to physician orders.
This deficiency represents non-compliance investigated under Complaint Number 2752534 and Complaint
Number 2731910.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 5 of 8
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
02/25/2026
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of a facility policy, the facility failed to ensure
documentation in the electronic health record was complete and accurate. This affected two (#10 and #11)
of eight residents reviewed for documentation. The facility census was 81.Findings include:1. Review of the
medical record for Resident #11 revealed he was admitted on [DATE] with diagnoses including type two
diabetes mellitus, metabolic encephalopathy, cardiomegaly, morbid obesity, and stage two chronic kidney
disease. The resident died at the facility on [DATE].
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was
cognitively intact and did not display any behaviors at the time of the assessment. He utilized a walker with
supervision and a manual wheelchair independently. He required supervision assistance with activities of
daily living and touch assistance with shower transfers. The assessment indicated Resident #11
experienced shortness of breath with exertion, was diagnosed with medically complex conditions including
the above noted diagnoses, and was not enrolled in hospice services.
Review of physician orders for Resident #11 dated [DATE] revealed he was a full code (initiation of
cardiopulmonary resuscitation in the event of cardiac or respiratory failure).
Review of nursing progress notes from [DATE] revealed a note written by Licensed Practical Nurse #129 on
[DATE] at 3:00 P.M. indicating a funeral home arrived at the facility to retrieve Resident #11's remains.
Further review of progress notes and other areas of Resident #11's medical record revealed the absence of
documentation of events that led up to the funeral home arrival at the facility.
Interview on [DATE] at 9:10 A.M. with Regional Registered Nurse #128 confirmed the events leading up to
the death of Resident #11 on [DATE] were not documented in the medical record.
2. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and died on
[DATE]. The resident's diagnoses included Alzheimer's disease and memory deficit following cerebral
infarction.
Review of the MDS assessment dated [DATE] revealed Resident #10 had impaired cognition evidenced by
a Brief Interview for Mental Status (BIMS) score of nine. The resident was assessed to require supervision
with toileting, bathing, and dressing, and was frequently incontinent of bladder and bowel, and assessed
with no skin issues.
Review of nursing progress notes revealed Resident #10 was sent to the emergency room on [DATE] due
to a change of condition. On [DATE] at 5:45 P.M., the hospital contacted the facility with an update
regarding the resident having a wound on the coccyx. There was no previous notes for Resident #10
regarding any skin breakdown.
Interview on [DATE] at 5:50 P.M. with Regional Nurse #130 revealed an internal investigation was
completed on Resident #10. Regional Nurse #130 findings revealed on [DATE] at 6:00 A.M. during shift
change, Resident #10 was found to have a bruised like area on the coccyx area. A foam pad was placed on
area. Regional Nurse #130 stated there was no documentation of skin breakdown or placement of a foam
pad placement entered in the resident's electronic health record. Regional Nurse #130 revealed the facility's
policy was to open a wound event, assess the wound and document, notify the physician,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 6 of 8
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
02/25/2026
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 0842
notify the family, initiate treatment, enter order, and complete treatment.
Level of Harm - Minimal harm
or potential for actual harm
Review of facility policy dated [DATE] and titled, Guideline for Late Entry and Corrections to the Medical
Record, revealed the facility would record information and events as soon as they occurred. Further review
of this policy revealed the facility would maintain accurately documented clinical records.
Residents Affected - Few
This deficiency represents non-compliance investigated under Complaint Number 2731910.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 7 of 8
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
02/25/2026
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure
proper signage was in place for a resident on enhanced barrier precautions and failed to ensure urinary
catheter bags were maintained in a manner to prevent infection. This affected two (#58 and #59) of four
residents reviewed for infection control practices.Findings include:1. Record review for Resident #58
revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease,
dementia, bipolar, and cholecystectomy.Review of a Minimum Data Set (MDS) assessment dated [DATE]
revealed Resident #58 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS)
score of seven (07). The resident was assessed to have a surgical wound.Review of the care plan dated
02/05/26 revealed Resident #58 had a surgical incision with indication the resident required enhanced
barrier precautions during high-contact care related to presence of surgical wounds.Observation on
02/25/26 at 9:41 A.M. revealed Resident #58 had bins containing personal protective equipment (PPE) for
infection control precautions in Resident #58's room but there was no signage outside the door.Interview on
02/25/26 at time of finding with Resident #58 revealed the resident was unsure why the bins were in her
room. Interview on 02/25/26 at 9:43 A.M. with Licensed Practical Nurse (LPN) #141 revealed the nurse was
unaware Resident #58 was in isolation. LPN #141 reviewed the resident's orders and stated Resident #58
was not in any isolation. After reviewing the orders with the Surveyor, LPN #141 verified Resident #58 was
in enhanced barrier precautions and confirmed there was no signage was in place to identify the
isolation.Interview on 02/25/26 at 10:20 A.M. with Regional Nurse #128 verified enhanced barrier
precaution orders were in place for Resident #58, however, no signage was in place.2. Review of the
medical record for Resident #59 revealed she was admitted on [DATE] with diagnoses including type two
diabetes mellitus, metabolic encephalopathy, urogenital implants, and hydronephrosis.Review of the
quarterly MDS assessment dated [DATE] revealed Resident #59 was cognitively impaired and did not
display any behaviors at the time of the assessment. She utilized a wheelchair independently, was
dependent for transfers, and required substantial assistance with activities of daily living. The assessment
indicated Resident #59 utilized a urinary catheter for management of neurogenic bladder.Observation on
02/23/26 at 3:00 P.M. of Resident #59 in her wheelchair in the dining room while participating in activities
revealed her urinary catheter bag was on the floor lodged under the small front right wheel of her
wheelchair.Interview on 02/23/26 at 3:02 P.M. with LPN #142 confirmed Resident #59's urinary catheter
bag was on the floor lodged under the small front right wheel of her wheelchair. Subsequent observation
revealed LPN #142 removed the urinary catheter bag from under the wheel and placed the urinary catheter
bag under Resident #59's wheelchair, with half of the urinary catheter bag touching the floor. LPN #142
verbally confirmed Resident #59's wheelchair was low, the urinary catheter bag was on the floor, and there
was currently no feasible option to hang the urinary catheter bag on the chair to provide placement both
below the bladder and off the floor.Observation on 02/23/26 at 3:20 P.M. of Resident #59 in her wheelchair
at the nurses' desk in the back of the facility revealed her urinary catheter bag was lying on the floor under
her wheelchair.Review of the manufacturer's label for Resident #59's urinary catheter bag revealed the bag
should not be on the floor.Review of facility policy dated 12/16/26 and titled, Emptying Urinary Bags,
revealed the facility would keep urinary catheter bags off the floor to prevent damage and
contamination.This deficiency represents an incidental finding discovered during the complaint survey.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365541
If continuation sheet
Page 8 of 8