Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to notify resident's representatives of transfer to the
hospital. This affected one (#36) resident of two reviewed for hospitalizations. The facility also failed to notify
the Long- Term Care Ombudsman of transfers to the hospital. This affected two (#6 and #36) of two
residents reviewed for hospitalizations. The facility census was 37.
Findings include:
1. Resident #6 was admitted to the facility 10/25/18 with a diagnoses of Alzheimer's disease, chronic
obstructive pulmonary disease, hypertension, anxiety disorder, depression and shortness of breath.
Resident #6 was admitted on [DATE] to a local hospice company after a brief stay in the hospital.
Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had severe cognitive
impairment. Her functional status was listed as supervise one person assist for all activities of daily living.
Review of the progress note dated 05/11/19 revealed the resident was sitting her wheelchair in the common
area and a nurse noticed she was a little shaky. Upon assessment her oxygen saturations were at 77
percent (%) on room air, temperature was 99.9 tympanic, blood pressure was 129/62, respirations were 24
and heart rate was 72. The resident was assisted into her bed and placed on oxygen via nasal cannula.
Once in bed, the nurse attempted to auscultate the resident's heart rate. It was not audible due to wheezing
and labored breathing. The resident's son arrived and the decision was made to send the resident to the
local emergency room.
Interview with the Business Office Manager (BOM) #54 on 05/19/19 at 12:43 P.M. revealed she did not
notify the Long Term Care Ombudsman of the resident's transfer to the hospital.
2. Review of the closed record revealed Resident #36 was admitted to the facility on [DATE] with a
diagnosis of acute and chronic respiratory failure, encephalopathy, epilepsy, anxiety, paralytic syndrome,
hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side with
contractures.
Review of the MDS dated [DATE] revealed Resident #36 was cognitively intact. His functional status is
listed as extensive two person assist for all activities of daily living.
Review of the progress note dated 04/09/19 revealed Resident #36 was sent out to the local hospital for
possible pneumonia.
(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 11
Event ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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 0623
Interview with BOM #54 confirmed no letter of transfer was sent to Resident #36's Power of Attorney or the
Long Term Care Ombudsman.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident and staff interview, and review of facility policy the facility failed to have quarterly
care conferences for residents and failed to have the proper staff attend the care conferences. This affected
three Residents (#7, #13, and #35) of 16 reviewed during the investigative phase of the survey. The facility
census was 37.
Findings include:
1. Resident #7 was admitted to the facility on [DATE] with diagnoses of acute osteomyelitis of right radius
and ulna, type II diabetes mellitus, bipolar disorder, chronic pain syndrome, opioid dependence, chronic
obstructive disease, skin graft infection and Stevens-Johnson Syndrome.
Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was cognitively intact. His
functional status was listed as independent for all transfers and ambulation.
Interview with Resident #7 on 05/19/19 at 2:00 P.M. revealed the facility did not hold quarterly care
conferences and he wished they would. He revealed the facility did not have a social worker in this facility.
Interview with the Administrator on 05/21/19 at 9:00 A.M. confirmed she was behind on her care
conferences and Resident #7's last care conference was held on 10/12/18. She also confirmed the proper
disciplines were not involved. She only had herself, the resident, and a nurse during the care conference on
10/12/18.
2. Resident #13 was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory
failure, cellulitis of bilateral lower extremities, chronic obstructive pulmonary disease, and schizophrenia.
Review of the quarterly MDS dated [DATE] revealed the resident had no cognitive impairment. Her
functional status was listed as extensive two person assist for all activities of daily living. The resident
needed a Hoyer lift for transfers.
Interview with Resident #13 on 05/19/19 at 2:30 P.M. revealed the facility did not hold care conferences on
a quarterly basis. She revealed it was sometime last year when her last conference was completed.
Interview with the Administrator on 05/21/19 at 9:00 A.M. confirmed she was behind in her care
conferences and Resident #13's last care conference was held on 10/11/18. She also confirmed the proper
disciplines were not involved in the care conference.
3. Medical record review for Resident #35 revealed an admission date of 11/02/17. Medical diagnoses
included diabetes, hemiplegia to left side for upper and lower extremities and end stage renal disease.
Review of quarterly MDS dated [DATE] revealed he was cognitively intact. His functional status was
supervision for bed mobility, transfer, and toilet use and he was independent for eating.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of care conference meetings for Resident #35 revealed for the past year he had only one, which
was held on 10/12/18 at 10:00 A.M.
Interview with Resident #35 on 05/19/19 at 2:19 P.M. he had had a care conference recently.
An interview conducted with the Administrator on 05/21/19 at 8:43 A.M. verified she was behind on the care
conferences for the residents.
Review of policy entitled Plan of Care Meeting dated 01/26/17 revealed all residents will have a care
conference meeting scheduled at least every 90 days. The attendees should be, but limited to a therapist,
program nursing, registered nurse, MDS nurse, activity director, aide, physician, dietary manager and
dietician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident
#15 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, macular
degeneration, Alzheimer's disease, overactive bladder, legal blindness and depression.
Residents Affected - Some
Review of the MDS dated [DATE] revealed severe cognitive impairment. Her functional status was listed as
independent to supervise only for all activities of daily living. Resident #15 was occasionally incontinent of
urine and always continent of bowel.
Review of the care plan dated 04/01/19 revealed Resident #15 had feelings of sadness, emptiness, anxiety,
uneasiness, depression characterized by ineffective coping, low self-esteem, tearfulness, motor agitation,
withdrawal from care/activities related to brain deterioration and recent relocation. Interventions included to
monitor/document for changes in hearing ability, and one on one activities.
Observation of Resident #15 on 05/19/19 at approximately 11:00 A.M. revealed Resident #15 in her room
with the door closed.
Interview with the AD #32 on 05/20/19 at 11:28 A.M. revealed Resident #15 does not want to come out of
her room, so the staff go in and do one on one activities with her. When asked what kind of activities were
provided with the resident, she revealed she talks with her. AD #32 also revealed she could not produce
any activity logs to show she had been doing one on one activities.
Observations of the resident on 05/20/19 at 10:00 A.M., and 11:00 A.M., on 05/21/19 at 2:00 P.M., and 3:00
P.M. and on 05/21/19 at 2:00 P.M. revealed no activity staff going into the room to provide one on one.
4. Resident #13 was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory
failure, cellulitis of bilateral lower extremities, chronic obstructive pulmonary disease, and schizophrenia.
Review of the quarterly MDS dated [DATE] revealed the resident had no cognitive impairment. Her
functional status was listed as extensive two person assist for all activities of daily living. The resident
required a Hoyer lift for transfers.
Review of the care plan dated 04/05/19 revealed Resident #13 had feelings of sadness, anxiety,
uneasiness characterized by; tearfulness, motor agitation, withdrawal from care/ activities related to:
relocation. Interventions included to encourage verbalization, encourage loved ones to keep in contact/visit,
encourage resident to attend group activities.
Interview with Resident #13 on 05/19/19 at 2:00 P.M. revealed the activities were lacking. She revealed
there was only two activities and no activities in the evenings.
Interview with the AD #32 on 05/20/19 at 10:00 A.M. revealed she just started her job as activity director,
two weeks ago. She indicated the need to redo the activity calendar and to schedule more and later
activities. AD #32 also revealed she could not produce any activity log to show she had been doing one on
one activities.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observations, resident and staff interviews and review of the activity
calendar the facility failed to ensure an ongoing activity program was provided for the residents, failed to
ensure there were activities provided in the evenings and also failed to ensure participation for activities
were documented. This affected four (#13, #15, #32, and #35) of four residents reviewed during the annual
survey for activities. The census was 37.
Residents Affected - Some
Findings include:
1. Medical record review for Resident #35 revealed an admission date of 11/02/17. Medical diagnoses
included diabetes, hemiplegia to left side for upper and lower extremities and end stage renal disease.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. His
functional status was supervision for bed mobility, transfer, and toilet use and he was independent for
eating.
Review of care plan dated 01/22/19 revealed he had little to no involvement in activities and was at risk for
psychosocial well being decline. Interventions were to assist resident to plan leisure activities, determine
feasibility of offering activities of interest that are not currently offered, engage resident in group activities,
and visit resident at least one time a day with resident to develop or sustain contact using conversation.
Interview with Resident #35 on 05/19/19 at 2:10 P.M. revealed activities were boring and the facility didn't
have anything on the weekends or evenings. He said he told the activities director, but it didn't get better.
Observation of Resident #35 on 05/19/19 at 2:28 P.M., 05/20/19 at 3:10 P.M. and on 05/21/19 at 1:00 P.M.
revealed he was sitting in his room and there was no encouragement given from staff to participate in
activities during these times.
Review of activity calendar from 05/01/19 through 05/22/19 revealed it was silent for activities scheduled in
the evening.
Review of participation logs for Resident #35 from 01/01/19 through 05/22/19 revealed the facility couldn't
produce any participation in activities for the resident.
Interview with Activities Director (AD) #32 on 05/20/19 at 11:28 A.M. verified there wasn't activities in the
evenings. She said the activity director left about three weeks ago. She verified the participation for the
residents had not been documented.
2. Medical record review for Resident #32 revealed an admission date of 04/07/18. Medical diagnoses
included heart failure, venous insufficiency, chronic lung disease and diabetes.
Review of the quarterly MDS dated [DATE] revealed Resident #32 was cognitively intact. Functional status
was supervision for bed mobility, limited assistance for toilet use and transfer and he was independent for
eating.
Observation of Resident #32 on 05/19/19 at 1:57 P.M., 05/20/19 at 7:32 A.M., on 05/20/19 at 10:27 A.M.,
and on 05/21/19 at 9:22 A.M. revealed he was sitting in his room and there was no staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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 0679
encouragement given to participate in activities during these times.
Level of Harm - Minimal harm
or potential for actual harm
Interview with Resident #32 on 05/19/19 at 1:57 P.M. revealed there wasn't activities offered in the evenings
for the residents.
Residents Affected - Some
Interview with AD #32 on 05/20/19 at 11:28 A.M. verified there wasn't activities in the evenings. She said
the activity director left about three weeks ago. She verified the participation for the residents had not been
documented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and resident and staff interview, the facility failed to follow
recommendations for restorative therapy. This affected one (#35) of one resident for restorative therapy. The
facility identified seven residents who currently receive restorative care. The census was 37 residents.
Findings include:
Medical record review for Resident #35 revealed an admission date of 11/02/17. Medical diagnoses
included diabetes, hemiplegia to left side for upper and lower extremities and end stage renal disease.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.
His functional status was supervision for bed mobility, transfer, and toilet use and he was independent for
eating.
Review of discharge recommendations from Physical therapy (PT) dated 09/12/18 revealed
ROM/strengthening of the left leg.
Review of discharge recommendations from Occupational Therapy (OT) dated 11/01/18 revealed
restorative for Range of Motion (ROM) and splinting for left hand.
Review of progress notes, physician orders and restorative documentation from 09/12/18 through 12/31/18
for Resident #35 revealed the record was silent for restorative care.
Interview with Resident #35 on 05/19/19 revealed he didn't wear his brace anymore on his left hand. He
stated staff did not helping him with applying the brace and he couldn't apply the brace by himself. He
denied exercises were done for his left leg.
Interview with PT #52 on 05/21/19 at 9:41 A.M. revealed Resident #35 was seen for services through
therapy. She stated he was seen for left sided impairment for upper and lower strengthening and provided a
brace for him for his left hand. The recommendations from the therapy department was for him to have
restorative care for his left hand for ROM and strengthening exercises and to utilize a brace. She stated for
his leg he the recommendation was to perform ROM and strengthening exercises. S he stated this should
have been done for 8-12 weeks and then he would go to functional maintenance. She stated this should
have been tasked out to the aides taking care of the resident.
Interview with Corporate Registered Nurse (CRN) #9 on 05/21/19 at 11:12 A.M. verified she couldn't find
any evidence of the recommended therapy orders being implemented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff and resident interview, the facility failed to ensure physicians orders were
followed to hold blood pressure medication for a resident prior to receiving dialysis. This affected one (#35)
of one resident reviewed for dialysis. The facility identified two residents who attending dialysis off grounds.
The census was 37.
Findings include:
Medical record review for Resident #35 revealed an admission date of 11/02/17. Medical diagnoses
included diabetes, hemiplegia to left side for upper and lower extremities and end stage renal disease.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.
His functional status was supervision for bed mobility, transfer, and toilet use and he was independent for
eating.
Review of the care plan dated 11/08/17 revealed the resident needed dialysis due to renal failure. The
intervention was to hold blood pressure medication on dialysis days.
Review of progress note dated 03/27/19 at 10:10 P.M. revealed Resident #35 returned from dialysis with a
new order from the nephrologist to hold all blood pressure medication on dialysis days.
Review of physician orders dated 03/27/19 revealed Norvasc give 10 milligram (mg) by mouth one time a
day. Further review revealed Metoprolol 50 mg give one tablet by mouth two times a day for hypertension
dated 03/27/19.
Review of physician orders dated 04/09/19 revealed to hold all blood pressure medications on days the
resident went to dialysis.
Review of the Medication Administration Record (MAR) from 05/01/19 through 05/22/19 revealed dialysis
participation was documented on 05/01/19, 05/03/19, 05/06/19, 05/08/19, 05/10/19, 05/13/19, 05/15/19,and
05/17/19. Further review of the MAR for revealed Resident #35 received Novasc 10 mg on 05/01/19,
05/06/19, 05/13/19, and 05/20/19. Further review of MAR revealed Metoprolol 50 mg was given on
05/01/19, 05/06/19, 05/08/19, 05/10/19, 05/13/19, 05/15/19, 05/17/19 and 05/22/19.
Interview was conducted on 05/20/19 at 1:55 P.M. with the Director of Nursing (DON) who revealed
sometimes Resident #35 wanted to take his medications before he went to dialysis. She verified Norvasc
and Metoprolol were given to the resident on dialysis days even though the physician order indicated to not
give them.
An interview with Resident #35 was conducted on 05/20/19 at 3:10 P.M., the resident denied he requested
to take his blood pressure medications on dialysis days.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff and resident interview and policy review the facility failed to ensure food was
served at appropriate temperatures. This had the potential to affect all 37 residents. The census was 37.
Residents Affected - Many
Findings include:
Interview with Resident #35 on 05/19/19 at 2:20 P.M. revealed his meal is never hot and he has been told
there was not a microwave to heat up his meal.
Observation of the breakfast meal on 05/20/19 at 8:07 A.M. with Dietary Manager (DM) #34 revealed the
temperature of the fired eggs was 95 degrees and the sausage links were 106 degrees. DM #34 utilized a
facility thermometer to check the temperatures.
Interview with DM #34 on 05/20/19 at 8:10 A.M. verified the meal was cold.
Review of policy entitled Food Preparation dated 06/20/17 revealed all dietary staff will ensure all foods are
held at appropriate temperature for hot foods at greater than 135 degrees.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
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
365605
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Milcrest Nursing Center
730 Milcrest Drive
Marysville, OH 43040
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
Based on facility policy review and staff interview the facility failed to monitor and test for Legionella in the
facility. This had the potential to affect all 37 residents.
Residents Affected - Many
Findings include:
Review of the Legionella Policy and Procedure, revision dated 05/16/19 revealed the facility was expected
to implement a water management program that included control measures such as physical controls,
temperature management, disinfectant level control, visual inspections, and environmental testing for
pathogens. Testing protocols and acceptable ranges for control measures, and document the results of
testing and corrective actions taken when control limits are not maintained
Interview with the Administrator on 05/21/19 at 4:00 P.M. confirmed the facility had not been monitoring
water temperatures, chemical levels, flushing the lines, or monitoring for pathogens.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
If continuation sheet
Page 11 of 11
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Back to topCitations
10 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.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F679 - Activities
Provide activities to meet all resident's needs.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the May 22, 2019 survey of MILCREST NURSING CENTER?
This was a inspection survey of MILCREST NURSING CENTER on May 22, 2019. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MILCREST NURSING CENTER on May 22, 2019?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.