Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to ensure an advanced directive was signed by the physician
on the hard chart. This affected one resident (#34) out of 18 residents reviewed for advanced directives.
The facility census was 45.
Findings include:
Review of the medical record for Resident #34 revealed an admission date of 04/09/22. Diagnoses included
cognitive communication deficit, type II diabetes, atrial fibrillation, congenital myopathy, cirrhosis of the liver
and emphysema.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 revealed a Brief
Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #34
required extensive assistance of two people for transfers, bed mobility, dressing, toileting, and bathing.
Review of the Care Plan dated 04/11/22 revealed Resident #34 had a Do Not Resuscitate Comfort Care
Arrest (DNRCCA) in place. Interventions included the facility would review code status annual and as
needed (PRN).
Review of the hard chart revealed the DNRCCA form only contained Resident #34's name at the top of the
form. The DNRCCA form was missing Resident #34's address, date of birth , and the physicians signature.
Interview on 05/23/22 at 2:17 P.M. Licensed Practical Nurse (LPN) #351 verified the DNRCCA paperwork
was not filled out for Resident #34.
Interview on 05/24/22 at 11:38 A.M. Regional Nurse #361 verified once the DNR form was filled out it was
placed in a folder for the physician to sign. The DNR form was then sent to Medical Records to be filed in
the chart. Regional Nurse #361 stated the facility would try to find the signed form to present to the
surveyor.
Review of DNRCCA Form on 05/24/22 at 1:55 P.M. provided by the facility revealed the DNRCCA form for
Resident #34 was signed by the physician on 05/23/22. Resident #34 was admitted on [DATE].
Review of facility policy titled, DNR Policy, dated 02/02/17, revealed the DNRCC/DNRCCA form or Full
Code form would be signed by the resident and/or resident representative and the physician. The
(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 7
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
05/26/2022
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 0578
Level of Harm - Minimal harm
or potential for actual harm
resident would be considered a Full Code until the physician could sign the form. The completed DNRCC
form would be uploaded to the electronic medical record and a paper copy would be placed in the front of
the hard chart.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
If continuation sheet
Page 2 of 7
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
05/26/2022
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
2. Observation on 05/23/22 at 10:26 A.M. of Resident #20's room revealed paper scraps, and debris on the
floor of the kitchen, common area, bathroom and under the bed. There appeared to be food on the floor
along the edge of the bed.
Interview on 05/23/22 at 10:26 A.M. Resident #20 stated she had not seen anyone clean her room since
she moved in.
Interview on 05/24/22 at 2:27 P.M. Licensed Practical Nurse (LPN) #312 verified the paper scraps and
debris on the floor of the kitchen, common area, bathroom, and under the bed in Resident #20's room.
Interview on 05/24/22 at 2:27 P.M. Housekeeping Supervisor #361 stated resident rooms were cleaned
everyday by the end of the day.
Review of facility undated policy titled, Monarch Skilled Nursing and Rehabilitation Policies and Procedures
Manual, Daily Housekeeping, revealed purpose keeping rooms clean and orderly. Daily room cleaning
protocol: sweep and mop under bed, furniture, and registers.
Based on observation, and resident and staff interviews, the facility failed to maintain a clean and sanitary
environment. This affected two residents (#38 and #20) out of five residents reviewed for environment. The
census was 45.
Findings include:
1. Observation on 05/23/22 at 3:06 P.M. of Resident #38's room revealed the bed linens were visibly soiled.
The fitted sheet covering the resident's mattress had areas of brown discoloration starting at the middle of
the bed which continued to the foot of the bed. The spots appeared as fingerprints and smears. There were
also brown particles, appearing as dirt, located on the fitted sheet.
Observation on 05/24/22 at 1:28 P.M. of Resident #38's bed linens revealed the bed linens were unchanged
from the previous observation on 05/23/22. The same brown discolorations spots were visible.
Interview on 05/24/22 at 1:29 P.M. State Tested Nurse Aide (STNA) #304 reported bed linens were
changed when linens were dirty or on resident's scheduled shower days. STNA #304 verified Resident
#38's bed linens were dirty and needed to be changed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
If continuation sheet
Page 3 of 7
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
05/26/2022
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
medical record review, staff interview, and review of facility policy, the facility failed to update a care plan for
one resident (#15) out of four residents reviewed for care planning. The facility census was 45.
Findings include:
Medical record review for Resident #15 revealed an admission date of 06/30/21 with diagnoses including
but not limited to, dementia without behavioral disturbance, Parkinson's disease, obstructive and reflux
uropathy, and repeated falls.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental
Status (BIMS) score of nine, indicating Resident #15 was cognitively impaired. Resident #15 required
extensive assistance of two people for Activities of Daily Living (ADLs).
Review of the care plan dated 01/19/22 revealed Resident #15 was at risk for falls. Interventions included
side rails to assist with bed mobility and positioning, perimeter mattress, non-skid footwear to be worn at all
times, physical therapy to evaluate and treat, ensure walker was within reach, wheelchair seat tilted back,
and wheelchair assessment.
Observation on 05/23/22 at 3:06 P.M. revealed Resident #15 had a floor mat on the left side of the bed and
the bed was against the wall. No side rails were observed on the bed. Resident #15 was sitting in a Broda
chair watching television.
Observation on 05/25/22 at 9:48 A.M. revealed Resident #15 was sitting in a reclined Broda chair in the
common area. Resident #15 was wearing regular socks with no shoes. Resident #15 was not wearing
non-slip footwear. A mechanical lift sling was observed underneath Resident #15.
Interview on 05/25/22 at 12:53 P.M. The Director of MDS #366 verified Resident #15 no longer needed side
rails on the bed, non-skid footwear, therapy evaluation (as this was in the past), wheelchair seat tilted back
or wheelchair assessment, because the resident was changed to a Broda chair. The resident no longer
used a walker because the resident no longer ambulated. The Director of MDS #366 verified the floor mat
or having Resident #15's bed against the wall were not included in the care plan.
Interview on 05/25/22 at 2:47 P.M. Regional Nurse #364 verified the facility did not have a policy regarding
care plans. The facility followed the RAI (MDS) manual guidelines.
Review of facility policy titled, Falls Policy and Procedures, revised 5/21/18, revealed the facility would
develop interventions based upon the residents fall risk factors and individual needs and implement a falls
care plan. The falls care plan would be reviewed quarterly and as needed and updated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
If continuation sheet
Page 4 of 7
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
05/26/2022
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to ensure fall interventions were utilized as
identified in the plan of care. This affected one (#13) of four resident reviewed for falls. The census was 45.
Findings include:
Review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE].
Diagnoses include hemiplegia, diabetes mellitus type two, chronic obstructive pulmonary disease, bipolar,
anxiety, depression, chronic kidney disease, and end stage renal disease.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident
#13 was rarely to never understood. The resident was totally dependent of two people for bed mobility and
transfers.
Review of the fall risk assessment dated [DATE] revealed Resident #13 was at moderate risk for falls.
Review of the plan of care, date initiated 10/05/20, revealed Resident #13 was at risk for falls and potential
injury, related to incontinence, lack of coordination, a history of falls, poor balance, weakness, and right
ankle fracture. The goal was to minimize potential risk factors related to falls. Interventions included fall mat
in front of bed while resident is in bed, scoop mattress, mat on floor next to bed, and bed to be in the low
position.
Observation on 05/23/22 at approximately 3:00 P.M. revealed Resident #13 was in bed. Non-skid strips
were observed on the floor next to the resident's bed. The bed was not in the low position and there was no
floor mat next to or in front of the bed. Continued observation revealed the mattress was a regular mattress.
Observation on 05/25/22 at 8:42 A.M. of Resident #13 revealed the resident was in bed, on a regular
mattress with the call light in reach. Further observation revealed there was no fall matt next to or in front of
the bed and the bed was not in the low position. The bed frame was observed to be approximately two and
a half feet from ground level.
Interview on 05/25/22 at 8:49 A.M. during an observation of Resident #13 with the Assistant Director of
Nursing (ADON), revealed the resident was at risk for falls. The ADON verified Resident #13 had no floor
mat next to or in front of the bed, the bed was not in the lowest position, and the mattress was not a scoop
mattress. The ADON verified fall interventions for Resident #13 were not being utilized as documented in
the plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
If continuation sheet
Page 5 of 7
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
05/26/2022
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
medical record review, observation, and staff interview, the facility failed to ensure an indwelling urinary
catheter was stabilized. This affected one resident (#4) out of of two residents reviewed for urinary catheter.
The census was 45.
Findings include:
Review of the medical record for Resident #4 revealed an admission date of 08/10/21. Diagnoses included
sepsis, methicillin resistant staphylococcus bacteremia (MRSA), obstructive reflux uropathy, chronic
osteomyelitis to right ankle and foot, paroxysmal atrial fibrillation, hypertension, systolic congestive and
diastolic congestive heart failure, coronary artery disease, obstructive uropathy, and chronic obstructive
pulmonary disease (COPD).
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had
impaired cognition. The resident required extensive assistance of two plus persons for bed mobility and
transfers. The resident required one-person extensive assistance for dressing, toilet use, and personal
hygiene. The resident had an indwelling Foley catheter.
Review of the Plan of Care dated 05/03/22 revealed the resident had alteration in elimination and had an
indwelling Foley catheter due to a diagnosis of obstructive uropathy. Interventions included assess for
abdominal distention, medications as ordered, monitor for signs/symptoms of urinary tract infection (UTI):
elevated temperature, dysuria, flank pain, hematuria, foul smelling urine, report to physician to seek
diagnosis and treatment promptly. Provide incontinence care as needed, change Foley catheter as ordered
and as needed, Foley catheter care every shift and as needed, keep Foley catheter bag below the level of
bladder, and provide hydration as prescribed.
Review of physician orders dated 10/20/21 revealed an order for Foley catheter, continuous drainage 22
French with 30 milliliter (ml) balloon, due to a diagnosis of obstructive uropathy. Irrigate Foley catheter with
60 cubic centimeters (cc) normal saline as needed for possible blockage. Change 22 French urethral
catheter every four weeks starting 12/14/21.
Observation on 05/25/22 at 1:04 P.M. of Foley catheter care for Resident #4 provided by State Tested Nurse
Aide (STNA) #365 revealed the resident did not have a stabilizer (strap hold the catheter tubing around the
resident's leg) for the Foley tubing. The STNA stated he usually had a stabilizer in place.
Interview on 05/25/22 at 1:20 P.M. the Assistant Director of Nursing (ADON) #317 stated the Foley bag was
changed 05/25/22 and she would look into it.
Review of facility policy titled, Catheter Care, Urinary, revised date 09/14 revealed the facility would ensure
catheters remained secure with a leg strap to reduce friction and movement at the insertion site. (Note:
Catheter tubing should be strapped to the resident's inner thigh).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
If continuation sheet
Page 6 of 7
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
05/26/2022
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to assess a resident upon return from dialysis.
This affected one resident (#38) out of one resident reviewed for dialysis. The census was 45.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #38 revealed the resident was admitted to the facility on [DATE].
Diagnoses included chronic kidney disease stage four, noncompliance with medication regime, weakness,
peripheral vascular disease, and diabetes mellitus type two
Review of an the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact
cognition. Resident #38 received dialysis at the facility within the last 14 days.
Review of the plan of care dated 04/20/22, revealed Resident #38 received dialysis at a contracted dialysis
center located in the community on Tuesday, Thursday, and Saturday.
Review of a document titled, Hemodialysis Communication Form, dated 05/10/22, 05/11/22, 05/13/22,
05/16/22, 05/18/22, and 05/20/22, revealed the facility utilized a document to communicate resident
information with the dialysis center. The document included an assessment to be completed by the facility
prior to dialysis, an assessment to be completed by the dialysis center pre and post dialysis, and an
assessment to be completed by the facility upon return from dialysis. Continued review of the
communication form revealed the assessment to be completed by the facility nurse upon return from
dialysis included the resident's vital signs, and an assessment of the resident's status including cognition,
pain, lung congestion, shortness of breath, and edema. Review of the communication forms revealed there
was no assessment completed by a facility nurse upon Resident #38's return from dialysis.
Further review of the medical record for Resident #38 revealed no evidence of a post dialysis assessment
being completed by a facility nurse completed 05/10/22 through 05/20/22.
Interview on 05/24/22 at 9:53 A.M. with the Assistant Director of Nursing (ADON) revealed when a resident
returned to the facility from dialysis, a nurse was to complete a post dialysis assessment. The ADON
revealed the post dialysis assessment would be documented on the hemodialysis communication form and
on the treatment record or medication administration record. The ADON verified the medical record for
Resident #38 contained no evidence of a post dialysis assessment completed on 05/10/22, 05/11/22,
05/13/22, 05/16/22, 05/18/22, and 05/20/22 for Resident #38.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365605
If continuation sheet
Page 7 of 7
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Back to topCitations
6 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.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
FAQ · About this visit
Common questions about this visit
What happened during the May 26, 2022 survey of MILCREST NURSING CENTER?
This was a inspection survey of MILCREST NURSING CENTER on May 26, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MILCREST NURSING CENTER on May 26, 2022?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe, appropriate dialysis care/services for a resident who requires such services."
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.