Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
Based on medical record review, staff and resident representative interviews, and policy review, the facility
failed to include resident representative in the development of a baseline care plan and failed to provide
resident representative with a copy of the baseline care plan. This affected one (#198) out of five residents
reviewed for baseline care plans. The facility census was 47.
Findings include:
Review of the medical record for Resident #198 revealed an admission date of 08/24/23 with medical
diagnoses of sepsis, nondisplaced fracture of left humerus, hypothyroidism, and dementia.
Review of the medical record for Resident #198 revealed an admission Minimum Data Set (MDS)
assessment, dated 08/30/23, which indicated Resident #198 had severely impaired cognition and required
extensive staff assistance with bed mobility, transfers, dressing, and toileting.
Review of the medical record for Resident #198 revealed an admission Screen and Baseline Care plan
assessment was completed by Director of Nursing (DON) on 08/24/23. Further review of the medical record
revealed a signature sheet signed by Regional MDS nurse #204 which stated the care plan was reviewed
with Resident #198 on 08/25/23 and the resident refused to sign the signature sheet. Review of the
signature sheet and review of the medical record did not reveal any documentation to support the baseline
care plan was developed or reviewed with Resident #198's representative or that a copy of the baseline
care plan was given to the resident representative.
Interview on 09/13/23 at 4:50 P.M. with Resident #198's representative confirmed she did not participate in
the development or review of Resident #198's baseline care plans. Resident #198's representative also
stated she was not given a copy of the baseline care plan.
Interview on 09/13/23 at 5:30 P.M. with DON confirmed the medical record for Resident #198 did not have
documentation to support the resident representative assisted with the development of the baseline care
plan or was given a copy of Resident #198's baseline care plans.
Review of policy titled, Baseline Care Plan dated 11/13/17, stated the facility was to develop and implement
a baseline care plan for each resident that includes the instructions needed to provide effective and
person-centered care of the resident that meet professional standards of quality care. The policy stated the
facility would provide the resident and/or representative with a summary of the baseline care plan.
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:
365953
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
365953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein St Marys Retirement Community
11230 State Route 364
St Marys, OH 45885
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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, observation, staff, physician and resident representative interviews, the facility failed
to follow the physicians orders for treatment of a wound. This affected one (#8) of one reviewed for wound
care. Additionally, the facility failed to provide care and services to treat a resident's constipation. This
affected one (#198) out of one resident reviewed for constipation. The facility census was 47.
Residents Affected - Few
Findings include:
1. Medical record review for Resident #8 revealed an admission on [DATE] with diagnoses including but not
limited to myasthenia gravis with exacerbation, type two diabetes, sleep apnea, morbid obesity, major
depressive disorder and anxiety.
Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed the resident
had impaired cognition. Resident #8 required limited assistance from one staff member for bed mobility,
transfers, and toileting. Resident #8 required application of non surgical dressing and ointments to areas
other than feet.
Review of the plan of care for Resident #8 revealed resident has microbial infection related to venous
ulcers, educate resident on disease management and infection control precautions. Enhanced Barrier
Precautions in place.
Review of the physician orders for Resident #8 revealed an order dated 08/26/2023 for Santyl External
Ointment 250 unit/gram (Collagenase), apply to posterior right calf topically every day shift for wound
healing. Apply Santyl and mix with Medihoney and cover with border gauze.
Review of the skin and wound evaluation dated 08/01/23 revealed medial calf open area 1.1 centimeter
(cm) x 1.4 cm with no depth or undermining documented. Redness of the skin was documented.
Observation on 09/13/23 at 9:20 A.M. with Licensed Practical Nurse (LPN) #43 of Resident #8 wound
dressing change revealed the resident had removed the dressing to right posterior calf prior to the nurse
entering the room. LPN #43 donned gown and gloves and entered bathroom. LPN #43 used a wash cloth
and hand soap from the soap dispenser hanging on the wall of the bathroom. LPN #43 washed the wound
with a section of the soapy washcloth and then rinsed the wound with a separate area of the washcloth.
LPN #43 discarded gloves and completed hand hygiene and new gloves donned. Plurogel was applied to
the bordered dressing along with Medihoney and adhered to the wound on the right posterior calf.
Interview on 09/13/23 at 9:30 A.M. with LPN #43 stated the physician did not order a specific wound
cleanser so she just use the hand soap on the wall and a washcloth. Further interview LPN #43 verified that
Plurogel is the same as Santyl and interchangeable. LPN #43 verified the physicians orders stated Santyl
and not Plurogel.
Interview on 09/13/23 at 9:40 A.M. with Director of Nursing (DON) verified Resident #8's order was for
Santyl and the medical supply company advised her that Plurogel was an equivalent to Santyl and was
significant savings. DON verified the order was not changed to reflect the interchange of ointment and it
should have been. Additionally, the DON stated the wash cloth and hand soap should have
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365953
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
365953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein St Marys Retirement Community
11230 State Route 364
St Marys, OH 45885
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
not been used to clean wound. The wound should have been cleaned with a wound cleanser and gauze
pads.
Interview on 09/13/23 at 10:13 A.M. with Wound Physician #202 verified Plurogel was not an equivalent to
Santyl and did not know the facility had not been using Santyl as ordered. Further interview with Wound
Physician #202 verified that the nurse should not be using the wall hand soap on the wound, but a wound
cleanser and will discuss the incident with the DON. Wound Physician #202 verified the wound did not
increase in size and continued to heal slowly as with any venous ulcer does.
2. Review of the medical record for Resident #198 revealed an admission date of 08/24/23 with medical
diagnoses of sepsis, nondisplaced fracture of left humerus, hypothyroidism, and dementia.
Review of the medical record for Resident #198 revealed an admission Minimum Data Set (MDS)
assessment, dated 08/30/23, which indicated Resident #198 had severely impaired cognition and required
extensive staff assistance with bed mobility, transfers, dressing, and toileting. Review of the MDS revealed
Resident #198 was occasionally incontinent of bowel and had no constipation.
Review of the medical record for Resident #198 revealed a physician order dated 08/24/23 for Colace
(laxative) 100 milligram (mg) by mouth every 24 hours as needed for constipation and 08/28/23 bisacodyl
suppository (laxative) 10 mg rectally every 24 hours as needed for constipation.
Review of the medical record for Resident #198 revealed no documentation to support Resident #198 had
a bowel movement from 08/25/23 through 09/01/23.
Review of the medical record for Resident #198 revealed an August 2023 Medication Administration
Record (MAR) which did not have documentation to support the facility staff administered any medications
for constipation from 08/25/23 to 08/31/23.
Interview on 09/11/23 at 11:57 A.M. with Resident #198's representative stated Resident #198 went seven
days without a bowel movement before the resident was given medication to help treat his constipation.
Resident #198's representative stated she informed staff the resident was having constipation.
Interview on 09/13/23 at 11:30 A.M. with Director of Nursing (DON) stated the facility did not have a policy
for management of constipation but the facility practice was for nursing staff to administer milk of magnesia
when a resident had not had a bowel movement for three days. DON confirmed the medical record for
Resident #198 did not have documentation to support Resident #198 had a bowel movement from 08/25/23
to 09/01/23 nor was medication administered to treat the constipation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365953
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
365953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein St Marys Retirement Community
11230 State Route 364
St Marys, OH 45885
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
Based on medical record review, staff and hospice staff interviews and review of a hospice contract, the
facility failed to collaborate hospice services for the completion of a comprehensive plan of care for a
resident admitted hospice services. This affected one (#13) of one reviewed for Hospice services. The
facility census was 47.
Findings include:
Medical record review for Resident #13 revealed an admission dated on 12/09/22 with diagnoses including
but not limited to sepsis, electrolyte imbalance, hypothyroidism, anemia, lymphedema, acute osteomyelitis,
type two diabetes, obesity, seizures, obstructive sleep apnea, encephalopathy, intracranial abscess and
granuloma.
Review of the significant Minimum Data Set (MDS) assessment for Resident #13 dated 08/28/23 revealed
the resident had intact cognition. Resident #13 required limited assist for bed mobility, extensive assist for
transfers and toileting. Resident #13 required supervision for eating. Resident #13 was coded as receiving
hospice care in the past 14 days.
Review of the hospice plan of care dated 08/21/23 for Resident #13 revealed a focus for facility
coordination. Interventions include establish upon admission the care and services to meet the personal
care, nutritional, mobility, durable medical equipment, elimination and integrity needs, hospice plan of care
to outline services, and collaborate and educate the facility staff on patient/family needs and current
interdisciplinary interventions.
Review of the plan of care for Resident #13 dated 08/23/23 revealed the resident had an acute plan of care
titled end of life care. Interventions included apply skin prep as directed, approach in calm manner, assist
with toileting needs, campus staff and hospice staff to coordinate care for resident, comfort foods and
liquids as tolerated, comfort measure: music of choice, repositioning, massage and hospice services.
Review of the plan of care for Resident #13 dated 08/23/23 revealed resident receives hospice services.
Interventions include provision of Activities of Daily Living (ADL's) to compensate for resident's changing
abilities, encourage participation to the extent the resident wishes to participate, assess resident coping
strategies and respect resident wishes, encourage resident to express feelings, listen with non-judgmental
acceptance, compassion, encourage support system of family and friends, keep the environment quiet and
calm, keep linens clean, dry and wrinkle free keep lighting low and familiar objects near, observe resident
closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there
is breakthrough pain, review resident's living will and ensure it is followed, involve family in discussion,
hospice nurse will provide services, hospice state tested Nursing Assistant (STNA) will provide services.
Review of the physician orders for the month of September 2023 for Resident #13 revealed an order dated
08/22/23 to admit to Hospice.
Review of the hospice visit notes dated 08/21/23 through 09/14/23 was silent for any collaboration between
the hospice staff and the facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365953
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
365953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein St Marys Retirement Community
11230 State Route 364
St Marys, OH 45885
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 09/13/23 at 9:35 A.M. with Licensed Practical Nurse (LPN) #43 stated hospice will provide a
visit schedule to the facility and it is kept at the nursing station. LPN #43 states the nurse comes once a
week and not sure of the STNA's visits. Additionally, stated the Hospice provider has a book at the nursing
station and may have a schedule there as well.
Interview via phone on 09/13/23 at 12:20 P.M. with Hospice Staff #210 stated Resident #13 plan of care
was completed and printed on 08/24/23 and sent to the physician for his signature. Hospice Staff #210
verified the physician has not returned the document at this time.
Interview on 09/13/23 at 1:10 P.M. with facility Social Worker (SW) #108 verified a care conference did not
occur when Resident #13 was admitted to the hospice program. SW #108 verified a significant change
assessment was completed at that time. SW #108 stated the facility does not have a MDS nurse at the time
and corporate is filling in.
Interview on 09/13/23 at 1:52 P.M. with Hospice Registered Nurse (RN) #211 verified there has not been a
care conference with the facility to collaborate care services. Further interview with Hospice RN #211
stated the plan of care for hospice care was completed on 08/24/23.
Interview on 09/13/23 at 10:20 A.M. with Hospice RN #210 verified the facility binder did not contain the
hospice plan of care and provided surveyor a copy for review.
Interview on 09/14/23 at 11:30 A.M. with the Director of Nursing (DON) verified a care conference was not
conducted to collaborate a plan of care for the Resident #13 and there should have been one.
Review of the hospice contract signed 07/23/28 revealed under letter B, hospice will place a copy of the
physicians plan of treatment and a copy of the interdisciplinary plan of care in the facilities chart.
Additionally, letter G stated the hospice plan of care will be written and maintained at specific intervals for
the hospice patient.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365953
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
365953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein St Marys Retirement Community
11230 State Route 364
St Marys, OH 45885
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and policy review, the facility failed to provide each resident or representatives
with education regarding the risk and benefits of influenza immunization yearly when influenza vaccines
were offered. This affected four (#2, #27, #31 and #36) out of five residents reviewed for immunizations. The
facility census was 47.
Residents Affected - Some
Findings include
1. Medical record review for Resident #2 revealed an admission date of major depressive disorder, syncope
and collapse, cerebral infarction, poly osteoarthritis, vitamin D, hyperlipidemia, seasonal allergic rhinitis,
chronic obstructive pulmonary disease (COPD), anemia, hypertension, chronic bronchitis, dementia without
behaviors, chronic kidney disease stage three.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed the
resident had impaired cognition. Resident #2 required extensive assist for bed mobility, transfers, and
toileting. Resident #13 required supervision for eating.
Review of the Resident #2 influenza immunization information revealed resident immunization was
administered on 11/09/22. Further record review for Resident #2 revealed there was no documentation
regarding the education provided for risk and/or benefits regarding the influenza immunization.
2. Review of the medical record for Resident #27 revealed an admission on [DATE] with diagnoses to
include but not limited to dementia without behavioral disturbances, anxiety, major depression, and
Alzheimer's disease.
Review of the annual MDS assessment dated [DATE] for Resident #27 revealed the resident had impaired
cognition. Resident #27 required extensive assist for bed mobility, transfers, and toileting. Resident #27
required supervision for eating.
Review of the Resident #27 influenza immunization information revealed resident immunization was
administered on 11/09/22. Further record review for Resident #27 revealed there was no documentation
regarding the education provided for risk and/or benefits regarding the influenza immunization.
3. Review of the medical record for Resident #31 revealed an admission on [DATE] with diagnoses
including but not limited to anemia, atrial fibrillation, arthritis, dementia, anxiety and depression.
Review of the significant change MDS assessment for Resident #31 revealed the resident had severe
cognitive impairment and resident rarely/never understood. Resident #31 required extensive assistance for
bed mobility, transfers, eating and toileting.
Review of the Resident #31 influenza immunization information revealed resident immunization was
administered on 11/04/22. Further record review for Resident #31 revealed there was no documentation
regarding the education provided for risk and/or benefits regarding the influenza immunization.
4. Review of the medical record for Resident #36 revealed an admission on [DATE] with diagnoses
including but not limited to congestive obstructive pulmonary disease, hypertension, peripheral vascular
disease, anxiety, depression, respiratory failure.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365953
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
365953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein St Marys Retirement Community
11230 State Route 364
St Marys, OH 45885
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the quarterly MDS assessment dated [DATE] for Resident #36 revealed the resident had intact
cognition. Resident #36 required extensive assist for bed mobility, transfers, and toileting. Resident #36
required supervision for eating.
Review of the Resident #36 influenza immunization information revealed resident immunization was
administered on 11/09/22. Further record review for Resident #36 revealed there was no documentation
regarding the education provided for risk and/or benefits regarding the influenza immunization.
Interview on 09/14/23 at 2:19 P.M. with the Director of Nursing (DON) revealed the nurse administering the
immunization should have checked the box in the immunization section of the electronic health record when
education of the risk and benefits of the injections were provided. Additionally, the DON stated the consent
for the immunization would be scanned into the medical record and could be found in the miscellaneous
tab.
Interview on 09/14/23 at 3:20 P.M. with the DON verified the progress notes, the check box in the electronic
health record and the miscellaneous tab contained no documentation for any education provided for risks
and benefits for Resident #2, #27, #31, and #36.
Review of the facility policy titled Influenza and Pneumococcal Immunization dated 06/19/2019 revealed the
resident or the resident representative will receive education regarding the benefits and potential side effect
of the immunization prior to the administration and annually.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365953
If continuation sheet
Page 7 of 7
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Back to topCitations
4 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.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the September 14, 2023 survey of OTTERBEIN ST MARYS RETIREMENT COMMUNITY?
This was a inspection survey of OTTERBEIN ST MARYS RETIREMENT COMMUNITY on September 14, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OTTERBEIN ST MARYS RETIREMENT COMMUNITY on September 14, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for..."
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.