Inspection visit
Inspection
19 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 19 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident interview, staff interview, review of the concern log, and review of facility policy, the facility failed to
ensure concerns were filed, addressed, and resolved in a timely manner. This affected one resident (#6) of
three reviewed for dignity. The facility census was 52.
Findings include:
Review of the medical record for Resident #6 revealed an admission date of 02/22/24 with diagnoses that
included unspecified fracture of left ulna, multiple sclerosis, and essential hypertension.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a
Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of
the MDS assessment revealed Resident #6 was dependent on staff for Activities of Daily Living (ADLs).
Review of the progress note dated 09/11/24 at 2:08 P.M. revealed Resident #6 went to the social service
office and appeared upset, stating Social Service Director (SSD) #466 did not place a grievance for the
staff member who stated they wanted Resident #6 to die. SSD #466 informed Resident #6 this was her first
time hearing of the incident and did not know what happened. Further review of the progress note revealed
SSD #466 informed the Administrator, Assistant Director of Nursing (ADON) #452, and the Director of
Nursing (DON) #507.
Interview on 10/06/24 at 11:19 A.M. with Resident #6 revealed a staff nurse, who she was unable to
identify, stated that she wanted her to die and she reported the incident to SSD #466. Resident #6 revealed
SSD #466 asked her to leave her office because she could not repeat what occurred word for word.
Interview on 10/07/24 at 11:25 A.M. with SSD #466 revealed she was responsible for taking care of
concerns and that she was familiar with Resident #6. SSD #466 revealed Resident #6 spoke with her in her
office a few times over the last 3 months. SSD #466 revealed Resident #6 informed her that one of the staff
nurses (unable to be identified) said she wanted Resident #6 to die. SSD #466 revealed Resident #6 was
visibly upset and became disrespectful, so she asked Resident #6 to exit her office, but she refused. SSD
#466 revealed she left her office. SSD #466 revealed she entered a note into Point Click Care (PCC) and
sent a text to staff.
Interview on 10/07/24 at 3:58 P.M. with the Administrator revealed she was not aware of the incident
regarding staff nurse stating she wanted Resident #6 to die.
(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 10
Event ID:
365774
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Follow-up interview on 10/07/24 at 4:00 P.M. with SSD #466 revealed she did not complete and file a
concern log form for Resident #6, but she informed ADON #452 during the standup morning meeting the
following day.
Interview on 10/08/24 at 9:10 A.M. with ADON #452 revealed she was not aware of the concern regarding
Resident #6 and staff nurse who stated she wanted Resident #6 to die. ADON #452 revealed all concerns
were to be documented on a grievance form and taken to the Administrator.
Review of the concern log dated August, September, and October 2024, revealed no documented incidents
dated 09/11/24 in regard to grievance placed with SSD #466 by Resident #6.
Review of the facility document titled, Grievances/Resident/Family, revised 11/04/16, revealed the facility
had a policy in place to document concerns and resolutions and identifying areas for improvement to
promote customer satisfaction with facility care and services. Further review of the policy revealed the
social services/designee would act as the grievance official and be responsible for overseeing the
grievance process, receiving and tracking grievances through their conclusion and to take immediate action
to prevent further potential violations of any resident right while alleged violation is investigated.
This deficiency represents non-compliance investigated under Complaint Number OH00157038.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 2 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
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 0567
Honor the resident's right to manage his or her financial affairs.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and staff interview the facility failed to ensure authorizations for resident fund
accounts were witnessed by non-facility staff. This affected two residents (#7 and #41) of five residents
reviewed for resident fund accounts. The facility census was 52.
Residents Affected - Few
Findings include:
1. Review of the authorization to manage funds for Resident #7, dated 10/17/23, revealed no non-facility
affiliated witness signature was obtained as required.
2. Review of the authorization to manage funds for Resident #41, dated 03/16/23 and 11/09/23, revealed no
non-facility affiliated witness signature was obtained as required.
Interview on 10/07/24 at approximately 4:00 P.M., Business Office Manager (BOM) #448 verified the
authorization forms were not witnessed for Residents #7 and #41.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 3 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
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 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and staff interview, the facility failed to ensure all required notices of potential
financial obligation were given to residents prior to the discontinuation of skilled services while using their
Medicare Part A benefit. This affected two residents (#17 and #55) of three residents reviewed for
beneficiary notices. The facility census was 52.
Residents Affected - Few
Findings include:
1. Review of the beneficiary notice worksheet provided by facility during the annual survey revealed
Resident #17 was discharged from skilled therapy services while using his Medicare Part A benefit on
05/14/24.
Review of the notices provided to Resident #17 upon discontinuation of skilled services revealed no Skilled
Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) was given to Resident #17 as
required.
2. Review of the beneficiary notice worksheet provided by facility during the annual survey revealed
Resident #55 was discharged from skilled therapy services while using his Medicare Part A benefit on
09/03/24.
Review of the notices provided to Resident #55 upon discontinuation of skilled services revealed no SNF
ABN was given to Resident #55 as required.
Interview 10/07/24 at 2:54 P.M. with Business Office Manager (BOM) #448 verified Residents #17 and #55
did not receive a SNF ABN. BOM #448 stated she thought those forms were only given to residents who
were on Medicare Part B.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 4 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
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 - Minimal harm
or potential for actual harm
Based on personnel record review, staff interview and review of facility policy, the facility failed to ensure all
new employees were screened through the State of Ohio Nurse Aide Registry (NAR) prior to employment
to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents
or misappropriation of resident property. This had the potential to affect all 52 residents residing in the
facility. The facility census was 52.
Residents Affected - Many
Findings include:
Review of the personnel file for Physical Therapist Aide (PTA) #424 revealed a hire date of 11/21/23. There
was no evidence PTA #424 was checked against the NAR prior to employment.
Review of the personnel file for Licensed Practical Nurse (LPN) #531 revealed a hire date of 11/21/23.
There was no evidence LPN #531 was checked against the NAR prior to employment.
Review of the personnel file for Registered Nurse (RN) #421 revealed a hire date of 07/24/24. There was no
evidence RN #421 was checked against the NAR prior to employment.
Review of the personnel file for Dietary Manager (DM) #469 revealed a hire date of 08/02/24. There was no
evidence DM #469 was checked against the NAR prior to employment.
Review of the personnel file for Director of Rehabilitation (DOR) #491 revealed a hire date of 11/14/23.
There was no evidence DOR #491 was checked against the NAR prior to employment.
Review of the personnel file for Housekeeper #537 revealed a hire date of 03/21/24. There was no evidence
Housekeeper #537 was checked against the NAR prior to employment.
Review of the personnel file for Dietary Aide (DA) #493 revealed a hire date of 07/18/24. There was no
evidence DA #537 was checked against the NAR.
The interview on 10/06/24 at 10:01 A.M. with Human Resource Manager (HR) #428 revealed she was not
aware that all new employees were required to be checked against the NAR and confirmed she had not
performed the checks prior to the first day of employment. HR #428 verified PTA #424, LPN #531, RN
#421, DM #469, DOR #491, Housekeeper #537 and DA #493 had not been screened through the NAR
prior to working.
Review of the facility policy titled Resident Right to Freedom from Abuse, Neglect and Exploitation Policy
and Procedure, dated 2022, revealed the facility will not employ or otherwise engage individuals who have
had a finding into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of
residents or misappropriation of resident property.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 5 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident interview, staff interviews, facility policy review, and review of ancillary
documentation, the facility failed to ensure residents received timely ancillary services. This affected one
resident (12) of one resident reviewed for ancillary services. The facility census was 52.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with
diagnoses of low back pain, hearing loss, and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had a
Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of
the MDS assessment revealed Resident #12 had difficulty hearing.
Review of the care plan dated 07/17/24 revealed Resident #12 had a communication problem related to a
hearing deficit with interventions that included monitor and/or record confounding problems such as ear
discharge and cerumen (wax) accumulation and refer to audiology for hearing consult as ordered.
Review of the physician orders dated 07/15/24 revealed an order to see the audiologist as needed.
Review of the physician orders dated 09/26/24 revealed an order for debrox solution (Debrox Otic Solution
6.5 percent) to be given five drops in both ears two times a day, for removal of earwax and to follow-up with
the audiologist to clean ears.
Interview on 10/06/24 at 11:12 A.M. with Resident #12 revealed she needed her ear cleaned out and that
she had drops placed in her ear in preparation to be seen by the audiologist two weeks ago. Resident #12
revealed the audiologist never showed up and her right ear was still blocked. Resident #12 revealed her
right ear was blocked and was uncomfortable. Resident #12 reported no staff had followed-up with her
regarding her ear or the audiologist.
Interview on 10/03/24 at 9:03 A.M. with Business Office Manager (BOM) #448 revealed Social Service
Director (SSD) #466 was responsible for scheduling the ancillary services including the audiology
appointments. BOM #448 revealed after SSD #466 adds residents to the list, the audiology team sends
over an email of who they will see and the date. BOM #448 revealed the schedule is then placed at the
nursing station the day of the appointment to prepare scheduled residents for the audiologist's arrival. BOM
#448 revealed all ancillary services were provided in-house unless outpatient services were required. BOM
#448 revealed, after all procedures were completed, all notes were uploaded into Point Click Care (PCC)
under the miscellaneous tab.
Interview on 10/08/24 at 9:05 A.M. with Licensed Practical Nurse (LPN) #408 revealed audiology
appointments were scheduled monthly, and SSD #466 was responsible for coordinating the authorization
and appointments. LPN #408 revealed Resident #12 had a hearing deficit due to ear wax buildup in her ear
and required services by audiology.
Interview on 10/08/24 at 3:40 P.M. with the Director of Nursing (DON) revealed she was unaware of
Resident #12 was still in need of being seen by the audiologist. The DON confirmed and verified
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 6 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0685
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
physician orders for debrox with no follow-up with the audiologist or added to the list to be seen on the
upcoming visit.
Interview on 10/09/24 at 10:13 A.M. with Resident #12 revealed she was not experiencing minor pain in her
right ear and now it was aggravating. Resident #12 said she received the initial ear drops but no follow-up
occurred.
Interview on 10/09/24 at 10:15 A.M. with LPN #501 revealed Resident #12 informed her that her right ear
was clogged with wax. LPN #501 revealed Resident #12 received an order to debrox and informed the
DON and Assistant Director of Nursing (ADON) #452.
Review of the medical record for Resident #12 revealed no documented physician orders, uploaded
progress notes, or no indication that she was scheduled, seen, and provided audiology services.
Review of the audiology ancillary visit history, since Resident #12's admission, revealed the audiology
services were provided in the facility on 08/30/24 and 10/04/24. Review of the visit history revealed
Resident #12 was not seen for either visit or not added to the list.
Review of the facility document titled, Hearing and Vision Services, undated, revealed the facility had a
policy in place to ensure all residents had access to hearing and vision services and receive adequate
adaptive equipment as indicated. Further review of the policy revealed the social worker/social service
designee would be responsible for assisting residents in locating and utilizing available resources for the
provision of hearing services the resident needs, making appointments, and arranging transportation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 7 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident interviews, staff interviews, review of staff schedules, review of the staffing tool,
review of the concern logs, and review of the facility assessment, revealed the facility failed to ensure
adequate staffing to meet the needs of the residents. This had the potential to affect all 52 residents
residing in the facility.
Findings include:
An interview on 10/06/24 at 10:51 A.M. with Receptionist (RCT) #414 revealed the daily staffing sheets
were completed daily, but residents complained about not enough aides to assist with call lights and
bathroom needs. RCT #414 revealed residents called the receptionist desk phone more on the weekends.
An interview on 10/06/24 at 11:14 A.M. with Resident #5 revealed there was never enough staff due to staff
calling off, especially during the night shift.
An interview on 10/06/24 at 11:19 A.M. with Resident #6 revealed she had to wait over 15 minutes for her
call light to be answered and when they answered the call light, staff turned it off and never returned.
An interview on 10/06/24 at 11:29 A.M. with State Tested Nursing Assistant (STNA) #431 revealed
sometimes the facility was short on aides and operated the facility with only one to two aides on the floor.
An interview on 10/07/24 at 6:20 A.M. with Registered Nurse (RN) #432 revealed there were only two aides
for the overnight shift. RN #432 revealed the two aides were not enough staff to meet the needs of the
residents. RN #432 revealed the night shift was responsible for getting 22 residents up for the morning and
it would not be completed.
Observation on 10/07/24 at 6:25 A.M. revealed Resident #6, #7, and #12 call lights were activated.
Resident #6 revealed she needed incontinence care, Resident #12 revealed she needed to get up for the
day as requested, and Resident #7 revealed he requested water and never received it. Observation
revealed call lights were still unanswered as of 6:45 A.M.
An interview on 10/07/24 at 6:27 A.M. with STNA #495 revealed there were not enough staff for the night
shift. STNA #495 revealed there were only two aides currently and that was not enough to complete tasks
such as check and change, answer call lights timely, and get them up for the morning.
Observation on 10/07/24 at 6:30 A.M. revealed two nurses, #401 and #432, and two aides, #495 and #603.
Observation revealed floor staff did not match the required daily needed to meet the needs of the residents.
An interview on 10/07/24 at 6:32 A.M. with RN #401 revealed the night shift needed at least 3 aides to
provide sufficient care to the residents that resided in the facility. RN #401 also revealed call lights went
unanswered for long period of time and there were 22 residents to get up for the first shift and they were
running behind schedule.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 8 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Review of the staffing tool with Staffing Coordinator (SC) #526, on 10/07/24 at 11:00 A.M., for coverage
from 09/22/24 through 09/28/24 revealed the facility did not have registered nursing coverage for two days,
09/23/24 and 09/24/24. SC #526 revealed staffing was based on the census and required two to three
nurses and four to five aides during the day shift and two nurses and four aides on the night shift to
adequately and sufficiently provide care to residents.
Residents Affected - Many
Review of the staffing schedules dated 10/06/24 revealed the facility scheduled two registered nurses, RN
#401 and #432, from 6:30 P.M. to 7:00 A.M., one Licensed Practical Nurse (LPN) #417, and three STNAs
#413, #495, and #459.
Interview with SC #526 on 10/07/24 at 11:00 A.M. revealed two aides (#413 and #459) had called off for
their night shift on 10/06/24. SC #526 confirmed and verified the facility lacked adequate staffing as
indicated in the above findings.
An interview on 10/09/24 at 1:30 P.M. with Resident #6's daughter, revealed there were never enough aides
and she had to provide care for Resident #6 when staff was not available.
Review of the concern logs dated September 2023 through August 2024 revealed concerns regarding call
light response times, getting up on time as requested, and staffing issues.
Review of the facility assessment dated [DATE], revealed the facility assessment was in place and utilized,
to determine the resources necessary to care for the facility residents and meet the needs for day-to-day
operations including nights and weekends. Review of the assessment revealed the facility based the
staffing levels on an average census of 53 residents with a need of one to two registered nurses per shift,
one to two licensed practical nurses per shift (12 hour shifts) and three to four state tested nurse assistants
for days and three to four state tested nurse assistants per nights (12 hour shifts). Review of the facility
assessment revealed the facility did not implement the facility assessment in regard to maintain adequate
staffing levels.
This deficiency represents non-compliance investigated under Complaint Number OH00157038.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 9 of 10
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
365774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Medina Bsd Opco LLC
550 Miner Dr
Medina, OH 44256
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 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility assessment review, staffing tool review, and staff interview, the facility failed to use the services of a
Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had
the potential to affect all 52 residents residing in the facility.
Findings include:
Review of the staffing tool with Staffing Coordinator (SC) #526 on 10/07/24 at 11:00 A.M., for coverage
from 09/22/24 through 09/28/24, revealed the facility did not have RN coverage for two days, 09/23/24 and
09/24/24. SC #526 verified there was no RN coverage for those two days due to call-offs and no
replacement RNs were put in place.
Review of the facility assessment dated [DATE], revealed the facility assessment was in place and utilized
to determine the resources necessary to care for the facility residents and meet the needs for day-to-day
operations including nights and weekends. Review of the assessment revealed the facility based staffing
levels of an average census of 53 residents, with a need of one to two registered nurses per shift. Review of
the facility assessment revealed the facility did not implement the facility assessment in regard to
maintaining RN coverage.
This deficiency represents non-compliance investigated under Complaint Number OH00157038.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365774
If continuation sheet
Page 10 of 10
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Back to topCitations
19 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.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0222GeneralS&S Fpotential 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.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
FAQ · About this visit
Common questions about this visit
What happened during the October 15, 2024 survey of MEDINA BSD OPCO LLC?
This was a inspection survey of MEDINA BSD OPCO LLC on October 15, 2024. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MEDINA BSD OPCO LLC on October 15, 2024?
Yes, 19 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to manage his or her financial affairs."
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.