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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, record review, review of facility self-reported incidents (SRIs), and facility policy
review the facility failed to ensure physician's orders were followed to prevent potential resident-to-resident
abuse. This affected three residents (#7, #21, and #37) of 18 residents reviewed for abuse. This had the
potential to affect three other residents (#18, #19, and #67) on the 400-Unit. The facility census was 81.
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 12/15/23 with diagnoses
including schizoaffective disorder bipolar type, mild cognitive impairment, and anxiety.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37
was able to understand staff and was able to be understood. She refused to answer questions on the
cognitive assessment; however, staff stated she had impaired memory. Resident #37 knew she was in a
nursing home, where her room was, staff names and faces, and the season. Staff stated Resident #37 was
independent regarding decision making for tasks of daily life.
Review of the facility SRIs tracking number 247416 dated 05/12/24 revealed at 1:20 P.M. Resident #37
went into Resident #21's room and slapped her in the face. No injuries were noted, and Resident #37 was
placed on 15-minute-checks. Additionally, a door alarm was placed to notify staff of wandering.
Review of the facility SRIs tracking number 247423 dated 05/12/24 revealed at 18:15 P.M. a state tested
nurse aide (STNA) had just left a resident's room after providing care and observed Resident #37 stand,
approach Resident #7 and slap her once on both sides of the face. The STNA immediately responded and
placed Resident #37 on a couch in the lounge area. Resident #7 was taken to her room. Both residents
were assessed, and no injuries were noted. Resident #37 was provided one-on-one supervision until
transported to the hospital for evaluation for escalating behaviors. While at the hospital, Resident #37's labs
and urinalysis were withing normal limits. When she returned to the facility, she continued on one-on-one
observations at all times to monitor behaviors.
Review of the monthly physician's orders for June 2024 revealed Resident #37 had an order dated 05/13/24
for constant one-on-one supervision for prevention and safety.
Review of the medication administration record (MAR) and treatment administration record (TAR) for June
2024 for Resident #37 revealed staff were documenting she was to have one-on-one supervision.
(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 12
Event ID:
365555
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Review of the nursing progress note dated 06/09/24 at 10:20 A.M. revealed Resident #37 had behaviors
with attempting to touch and sit on other residents. Staff had separated her from other residents, and the
physician was updated. A new order was obtained to send the resident to the emergency room to be
evaluated. The nursing progress note on 6/10/24 at 1:49 A.M. stated Resident #37 was back at the facility
and an intervention of one-on-one supervision was initiated as well as 15-minute safety checks.
Residents Affected - Few
Observation with Registered Nurse (RN) #1275 on 06/11/24 at 9:26 A.M. revealed Resident #37 to be in
her room, awake and lying in her bed. There were no staff in her room or in the hallway on the unit. RN
#1275 verified Resident #37 was to have someone with her at all times. RN #1275 was only able to find one
staff member, State Tested Nurse Aide (STNA) #1223 who was in the lounge/common area out of view
from Resident #37's room. STNA #1223 came to Resident #37's room and stated she was the only staff
member on the unit to care for six residents. STNA #1276 went on break which left only her on the unit. On
06/11/24 at 9:30 A.M., STNA #1276 returned to the unit and stated she had been on her 15-minute break.
She stated she left the floor at 9:20 A.M. and was unaware that she was supposed to update staff on other
units that she would need someone to replace her so that STNA #1223 could continue to perform
one-on-one supervision to Resident #37.
Interview on 06/11/24 at 9:47 A.M. with the Director of Nursing (DON) verified Resident #37 had an order
for one-on-one supervision due to escalated behaviors on 06/09/24. She stated staff should stay with the
resident and call staff on other units when they needed a break so they could replace her on the floor.
Review of the facility policy titled, Resident Abuse Prevention Practices, revised October 2022, revealed it
was the policy of the facility to protect all residents from abuse.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 2 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Potential for
minimal harm
Based on record review and interview, the facility failed to ensure all employees had reference checks prior
to hire. This affected seven of sixteen employees reviewed for abuse. This had the potential to affect all 81
residents residing in the facility.
Residents Affected - Many
Findings include:
Review of the employee file for [NAME] #1262 revealed a hire date of 01/12/22. There was no documented
evidence reference checks were completed upon hire.
Review of the employee file for State Tested Nurse Aide (STNA) #1249 revealed a hire date of 01/31/23.
There was no documented evidence reference checks were completed upon hire.
Review of the employee file for Licensed Practical Nurse (LPN) #1229 revealed a hire date of 05/14/23.
There was no documented evidence reference checks were completed upon hire.
Review of the employee file for STNA #1217 revealed a hire date of 10/17/23. There was no documented
evidence reference checks were completed upon hire.
Review of the employee file for LPN #1257 revealed a hire date of 03/26/24. There was no documented
evidence reference checks were completed upon hire.
Review of the employee file for Housekeeper #1256 revealed a hire date of 03/26/24. There was no
documented evidence reference checks were completed upon hire.
Review of the employee file for Dietary Supervisor #1243 revealed a hire date of 04/10/24. There was no
documented evidence reference checks were completed upon hire.
Interview on 06/12/24 at 10:38 A.M. with the Administrator confirmed there was no documented evidence
reference checks were completed for the above employees.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 3 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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
observation, interview, record review, and facility policy review the facility failed to maintain a functioning
alarm for Resident #38 as ordered by the physician. This affected one resident (#38) out of four residents
reviewed for alarms. The facility census was 81.
Findings include:
Review of the medical record for Resident #38 revealed an admission date of 03/16/22 with diagnosis of
dementia.
Review of the physician's order dated 03/20/24 revealed Resident #38 had an order for a door alarm to the
bathroom door that exited into room [ROOM NUMBER] to alert staff if he attempted to enter room [ROOM
NUMBER]. Every shift was to check the function of this alarm.
Review of the medication administration record (MAR) and treatment administration record (TAR) for March
2024 through June 2024 revealed staff had not documented they had ensured the alarm was functioning on
afternoons on 03/23/24, 03/24/24, 03/26/24, 03/29/24, 04/18/24, 04/20/24, 04/24/24, 05/23/24, 05/28/24,
and on nights on 03/22/24 and 04/23/24.
Observation and interview on 06/06/24 at 10:22 A.M. with Resident #38 revealed there was an alarm on the
bathroom door because women were in the adjacent room. He stated the alarm helped so he did not get
confused going out the wrong bathroom door. Observation revealed the alarm was not on and functioning
when the door was opened and entering the adjacent room out of the bathroom.
Observation and interview on 06/10/24 at 10:29 A.M. with Licensed Practical Nurse (LPN) #1216 revealed
Resident #38's bathroom door alarm, which lead to the adjacent room (female resident room), did not have
a functioning alarm. LPN #1216 turned on the alarm and stated staff would turn the alarm off and forget to
turn it back on.
Review of the facility policy titled, Alarms: Bed, Chair, Door, Floor Alarms, Motion Detection, revised
February 2024, revealed staff would check that alarms were functioning properly when assisting residents
with care. Residents were not to be left unattended when alarms were removed or shut off.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 4 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Potential for
minimal harm
Based on employee personnel file review and interview, the facility failed to ensure State Tested Nurse Aide
(STNA) evaluations were completed within 90 days of hire and annually. This affected six STNA's of six
reviewed for performance. This had the potential to affect all 81 residents residing in the facility.
Residents Affected - Many
Findings include:
Review of the employee file for STNA #1219 revealed a hire date of 06/14/21. There was no documented
evidence of an annual evaluation.
Review of the employee file for STNA #1212 revealed a hire date of 01/24/21. There was no documented
evidence of an annual evaluation.
Review of the employee file for STNA #1200 revealed a hire date of 11/19/21. There was no documented
evidence of an annual evaluation.
Review of the employee file for STNA #1249 revealed a hire date of 01/31/23. There was no documented
evidence of an annual evaluation.
Review of the employee file for STNA #1233 revealed a hire date of 04/21/23. There was no documented
evidence of an annual evaluation.
Review of the employee file for STNA #1217 revealed a hire date of 10/17/23. There was no documented
evidence a 90-day evaluation was completed.
Interview on 06/12/24 at 10:38 A.M. with the Administrator confirmed there was no evidence 90-day
evaluation for STNA #1217or annual evaluations for STNAs #1219, #1212, #1200, #1249, and #1233.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 5 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interviews, and facility policy review the facility failed to ensure Resident #2 was free of
significant medication errors. This affected one resident (#2) of 33 residents reviewed during the annual
survey. The facility census was 81.
Residents Affected - Few
Findings include:
Review of medical record for Resident #2 revealed an admission date of 01/25/24 with diagnosis including
leukemia (blood cancer that affects the production and function of blood cells) not having achieved
remission.
Review of the discharge instructions from the hospital on [DATE] revealed Resident #2 was ordered
Bosutinib (medication used to treat types of blood cancers such as leukemia) 500 milligrams (mg) one
tablet a day for leukemia and Nilotinib HCl (medication used to treat leukemia) 200 mg one capsule two
times a day related to leukemia. Both of these medications were considered oral chemotherapy drugs.
Review of the care plan dated 01/26/24 for Resident #2 revealed she had leukemia and was on an oral
chemotherapy drug. Interventions included administering medications as ordered.
Review of the monthly physician's orders for January 2024 through April 2024 for Resident #2 revealed she
had an order for Bosutinib 500 mg one tablet a day for leukemia dated 01/25/24. This medication was
discontinued on 02/05/24. Resident #2 also had an order for Nilotinib HCl 200 mg one capsule two times a
day for leukemia dated 01/25/24.
Review of the Medication Administration Record (MAR) for January 2024 through April 2024 for Resident
#2 revealed the following:
Bosutinib 500 mg was not given on 01/26/24, 01/27/24, 01/28/24, 01/29/24, 01/30/24 and 01/31/24 due to
the medication not being available.
Nioltinib 200 mg was not given in the morning on 01/26/24, 01/27/24, 01/28/24, 02/26/24, 02/27/24,
02/28/24, 02/29/24, 03/29/24, 03/30/24, 04/01/24, 04/02/24, 04/03/24, 04/06/24, 04/07/24, 04/08/24,
04/09/24, 04/10/24, 04/11/24, 04/12/24, 04/13/24, 04/16/24, 04/17/24, 04/18/24, 04/19/24, 04/21/24,
04/22/24, 04/23/24, 04/24/24, 04/25/24, 04/26/24, and at night on 01/26/24, 01/27/24, 02/26/24, 02/27/24,
02/28/24, 03/28/24, 03/29/24, 04/01/24, 04/02/24, 04/03/24, 04/04/24, 04/05/24, 04/06/24, 04/07/24,
04/08/24, 04/09/24, 04/10/24, 04/11/24, 04/12/24, 04/14/24, 04/15/24, 04/17/24, 04/18/24, 04/20/24,
04/21/24, 04/22/24, 04/23/24 and 04/24/24, due to the medication being on order, not available, or awaiting
delivery from the pharmacy.
Review of the nursing progress notes dated 01/26/24 through 04/24/24 revealed Resident #2's oncologist
was not notified of the oral chemotherapy medications being unavailable.
Interview on 06/12/24 at 10:25 A.M. with Pharmacist #1297 verified the pharmacy had not sent Resident
#2's oral chemotherapy medication to the facility until 04/24/24. She stated prior to that time, the pharmacy
was unable to provide this medication due to insurance not covering the medication and cost.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 6 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 06/12/24 at 10:32 A.M. with Registered Nurse (RN) #1232 revealed she was aware there was
an issue with getting Resident #2's oral chemotherapy medications as the insurance would not cover it, so
the pharmacy would not send the medication. She stated Resident #2's oncologist was aware and stated to
hold the medication until the facility received it. She did verify before the facility admitted someone, the
admissions office reviewed the resident's medications to ensure they could provide the care and services to
the resident. She was unable to state why the medications were not available on admission if the facility
had followed this process. RN #1232 stated she was also not aware Resident #2 had any further
appointments with her oncologist, Physician #1296.
Interview on 06/12/24 at 11:10 A.M. with Physician #1296 revealed he saw Resident #2 on 06/12/24 in his
office. He stated her previous appointment was on 02/28/24. Physician #1296 stated he only provided
prescriptions for oral chemotherapy medications monthly and needed to see the resident in the office every
month to assess her. At the office visit he would provide the prescription for the oral chemotherapy
medication. He verified the facility had not called his office after 02/28/24 to update him that Resident #2
was not taking her medications due to unavailability. He was unable to confirm or deny if this delay in
medication hindered her treatment course.
Review of the facility policy titled, Medication Administration, revised May 2024, revealed nursing staff were
to review the electronic medication administration record for medication administration orders and
instructions and to provide the medication within one hour prior to or after the time ordered. There was
nothing in the facility procedure to advise nursing staff on what to do if the medication was unavailable
except that a pharmacy policy and procedure manual was available for additional guidance.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 7 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 - Some
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, interview, record review, and facility policy review the facility failed to ensure medications were
disposed of when they had expired. This affected 12 residents (#15, #32, #53, #72, #78, #177, #178, #180,
#226, #227, #228, and #276) who had received expired tuberculin tests (medication to test for tuberculosis)
with the potential to affect all residents in the facility. The facility census was 81.
Findings include:
Observation on [DATE] at 7:44 A.M. of the medication storage room located on the 600-hall with Registered
Nurse (RN) #1293 revealed a bottle of Tuberculin, Purified Protein Derivative, Diluted Aplisol five milliliters
(mL) that contained 50 tests, lot #68154. The date opened on the bottle stated [DATE].
Interview with RN #1293 at the time of the observation verified the medication was expired, and she
discarded the medication.
Review of the list provided by the facility of residents that were given tuberculosis (TB) tests for lot #68154
after the medication had expired on [DATE] included Residents #15, #32, #53, #72, #78, #177, #178, #180,
#226, #227, #228, and #276.
Review of the facility policy titled, Medication Administration, revised [DATE], revealed the facility should
follow manufacturer instructions for expiration dates of medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 8 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and facility policy review the facility failed to ensure foods were stored in a
manner to prevent contamination and foodborne illness. This had the potential to affect all residents who
received food from the kitchen. The facility identified two residents (#27 and #36) who received no food by
mouth. The facility census was 81.
Findings include:
Observation on 06/10/24 at 8:04 A.M. of the kitchen revealed the following items open and undated in the
dry storage area: one bag of potatoes, one bag of cornflakes, one bag of Cheerios, one box of pancake
batter, three bags of pasta, and one jar of syrup. There were also three bags of hoagie buns that expired on
05/28/24. The cooler contained the following open and undated items: nine packs of strawberries, two bags
of lettuce, one container of salad mix, one tomato, half of an onion, one bag of cucumbers, and 13
prepared cups of juice. The refrigerator contained the following items open and undated: three hard boiled
eggs, two boxes of chicken breasts, three packs of lunch meat, two bags of shredded cheese, one-half full
container identified by [NAME] #1262 as chicken noodle soup, one bag of cooked bratwurst, and one-half
full container of applesauce as identified by [NAME] #1262. There was also one bucket of pickles open and
undated on the floor and one three-fourths full gallon of milk with no cap. The freezer contained the
following open and undated items: one box of mixed vegetables, one bag of sausage links, one bag of
green beans, one bag of chicken tenders, and one frozen pizza. There was also one box of French fries,
one box of chicken filets, one box of frozen pizza, and one box of beef stew directly on the freezer floor.
Interview at the time of the above observation with [NAME] #1262 confirmed food should be labeled with
both an open and use by date, and no boxes should be stored on the floor. He also confirmed the expired
hoagie buns and other items identified during the tour as open and undated.
Review of the facility policy titled Covering, Labeling and Dating Food, dated March 2023, revealed all food
stored would be covered, labeled, and dated, fresh fruits should contain a received on date, and food would
be discarded by the manufacturer's use by or sell by date.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 9 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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 0839
Employ staff that are licensed, certified, or registered in accordance with state laws.
Level of Harm - Potential for
minimal harm
Based on personnel file review and interview, the facility failed to ensure Licensed Practical Nurse (LPN)
#1229 had an active and unrestricted nursing license prior to hire. This affected one of three personnel files
reviewed for staff qualifications. This had the potential to affect all residents residing in the facility. The
facility census was 81.
Residents Affected - Many
Findings include:
Review of the personnel file for LPN #1229 revealed a hire date of 05/14/24. There was no documented
evidence LPN #1229's license was verified prior to starting work.
Interview on 06/12/24 at 12:57 P.M. with the Administrator confirmed there was no documented evidence of
licensure verification in LPN #1229's file.
Review of the document titled License Look Up dated 06/21/24 and timed 1:13 P.M. confirmed LPN #1229
had an active and unrestricted nursing license.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 10 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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** 3. Review of
medical record for Resident #15 revealed an admission date of 05/30/24 with diagnoses including
non-pressure chronic ulcer of the right foot, cellulitis (skin infection) of the left lower limb, diabetes mellitus,
and peripheral vascular disease.
Residents Affected - Many
Observation on 06/12/24 at 11:30 A.M. with RN #1275 of intravenous (IV) medication administration to
Resident #15 revealed he had a central line venous catheter (a line that is inserted into a vein that leads to
the heart). On Resident #15's door leading into the room there was a sign that stated he was on EBP that
instructed staff to wear gown and gloves if there was device care including the use of central lines. During
observation, RN #1275 performed hand hygiene, put gloves on, cleaned Resident #15's bedside table,
removed her gloves, washed her hands, put gloves on, cleaned Resident #15's central line venous catheter
tubing end and then flushed the central with 10 milliliters (mL) of normal saline. RN #1275 then hooked the
central line venous catheter to the IV tubing that was attached to the antibiotics. At 11:45 A.M. RN #1275
verified she was aware Resident #15 was on EBP but thought it was for wound care only. She verified she
had not followed the EBP for the device care.
Review of the physician's orders for Resident #15 revealed an order for contact isolation every shift dated
05/31/24. There was no order for EBP.
Review of the care plan dated 05/31/24 for Resident #15 revealed he had an infection of a wound requiring
isolation. Interventions included to provide contact isolation.
Review of the medication administration record (MAR) and treatment administration record (TAR) for
Resident #15 for June 2024 revealed nursing staff had been signing off on each shift that Resident #15
should be in contact isolation.
Review of the Resident #15's wound care progress note dated 06/03/24 revealed he had
Methicillin-Resistant Staphylococcus Aureus (MRSA) (bacteria that is resistant to commonly used
antibiotics) in the left medical lower leg wound and was on IV antibiotics for four weeks.
Interview and observation on 06/12/24 at 1:27 P.M. with RN #1232 verified there was no sign on Resident
#15's room alerting staff and visitors that he was in contact isolation. RN #1232 stated Resident #15 had
MRSA in his wound that was covered by a wound vac. She stated he was a picker and she believed he had
disconnected his wound vac at times as he is non-compliant.
Review of the facility policy titled, Contact Precautions, revised March 2020, revealed gown and gloves
should be worn when staff entered the room and removed before leaving the room when a resident was in
contact isolation.
Based on observation, interview, record review, and facility policy review the facility failed to initiate and use
transmission-based precautions (TBP) and enhanced barrier precautions (EBP) when appropriate for
Residents #15, #56, and #179. This affected three residents (#15, #56 and #179) and had the potential to
affect all 81 residents residing in the facility.
Findings include:
1. Observation and interview on 06/10/24 at 9:18 A.M. with Resident #179 revealed a tracheostomy
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 11 of 12
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
365555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
O'Brien Memorial Health Care C
563 Brookfield Ave SE
Masury, OH 44438
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
was in place. There was no EBP posted and no PPE (personal protective equipment) available near the
room entrance.
Review of the medical record for Resident #179 revealed an admission date of 05/29/24. Diagnoses
included acute and chronic respiratory failure and tracheostomy status. The physician orders effective June
2024 and care plan dated 05/29/24 indicated tracheostomy care was required at least every shift and more
often as needed.
Observation on 06/12/24 at 10:43 A.M. with Registered Nurse (RN) #1266 and Licensed Practical Nurse
(LPN) #1268 of tracheostomy care for Resident #179 revealed both nurses entered the room. There were
no EBP posted and no PPE available near the room entrance. Gloves were donned after appropriate hand
washing, and tracheostomy care was provided. No gowns were worn by either nurse. Interview at the time
of the observation with RN #1266 and LPN #1268 verified no EBP were in place, and gowns were not worn
during tracheostomy care as required.
Review of the facility policy, Enhanced Barrier Precautions (EBP), dated March 2024, revealed EBP were
used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves
during high-contact resident care activities. EBP was indicated for residents with indwelling medical devices
including tracheostomies.
2. Resident #56 was admitted on [DATE] with diagnoses that included Alzheimer's disease, osteomyelitis,
kidney disease, frontotemporal neurocognitive disorder, anemia, anxiety, and depression.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was alert and
oriented to person, place, and time. He had an unstageable wound (full thickness tissue loss in which the
base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or
black) in the wound bed) on the outside of his left heel.
Observation on 06/11/24 at 1:15 P.M. of a dressing change for Resident #56 revealed he was not ordered
to be under EBP due to his pressure wound.
Interview on 06/11/24 at 1:15 P.M. with LPN #1268 revealed his wound was not considered chronic, so
there was no EBP needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365555
If continuation sheet
Page 12 of 12
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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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
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.
F839 - Staff qualifications
Employ staff that are licensed, certified, or registered in accordance with state laws.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0361GeneralS&S Epotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0500GeneralS&S Epotential for harm
Meet other general requirements that are deficient.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the June 13, 2024 survey of O'BRIEN MEMORIAL HEALTH CARE C?
This was a inspection survey of O'BRIEN MEMORIAL HEALTH CARE C on June 13, 2024. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at O'BRIEN MEMORIAL HEALTH CARE C on June 13, 2024?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
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.