Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 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, facility policy and procedure review and interview the facility failed to ensure the advance
directives/code status for Resident #26 and Resident #281 were consistent between each residents'
electronic health record, the hard chart/paper record on the unit and the sticker on the first page of the hard
chart for quick reference. This affected two residents (#26 and #281) of two residents reviewed for
advanced directives.
Findings include:
1. Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE].
Resident #26 had diagnoses including acute and chronic respiratory failure with hypoxia, history of
COVID-19, essential hypertension, hyperlipidemia, and atherosclerotic heart disease of native coronary
artery without angina pectoris.
A review of Resident #26's physician's orders revealed his advance directives/code status was a Do Not
Resuscitate Comfort Care Arrest (DNR CC-A). The order had been in place since 06/13/19.
A review of Resident #26's hard chart/paper record located on the unit revealed the first page was Resident
#26's face sheet in a plastic sleeve. The plastic sleeve had a green sticker in the lower right corner of the
pate that read Resuscitate. A do not resuscitate form was found in the hard chart that identified the
resident's code status as DNR CC-A. If this box was checked, the DNR Comfort Care Protocol was to be
implemented in the event of a cardiac arrest or a respiratory arrest. The form had been signed by the
physician on 06/11/19.
On 05/02/22 at 1:37 P.M. interview with Registered Nurse (RN) #378 revealed residents advanced
directives/code status were recorded in two different locations. They were identified in the electronic health
record (EHR) and the hard chart/paper record. RN #378 opened Resident #26's EHR and revealed the
advanced directive was DNR CC-A. RN #378 then opened Resident #26's hard chart and indicated the
sticker on the plastic sleeve holding the face sheet read Resuscitate. RN #378 revealed the stickers were
put on the face sheet sleeve for quick reference and verified the sticker was not correct for Resident #26.
RN #378 revealed the paper do not resuscitate form in the physical chart was correct.
2. Review of Resident #281's medical record revealed the resident was admitted to the facility on [DATE].
Resident #281 had diagnoses including atherosclerotic heart disease of native coronary artery without
angina pectoris and essential hypertension, history of COVID-19.
A review of Resident #281's physician's orders revealed his advance directives/code status was a
(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 15
Event ID:
366052
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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
DNR CC-A. The order had been in place since 03/14/22.
Level of Harm - Minimal harm
or potential for actual harm
A review of Resident #281's hard chart located on the unit revealed a do not resuscitate form that identified
the resident's code status as Do Not Resuscitate Comfort Care (DNR CC). If this box was checked, the
DNR Comfort Care Protocol was to be implemented immediately. The form had been signed by the
physician on 01/04/22.
Residents Affected - Few
On 05/02/22 at 1:43 P.M. interview with Registered Nurse (RN) #378 revealed residents advanced
directives/code status were recorded in two different locations. They were identified in the electronic health
record (EHR) and the hard chart/paper record. RN #378 opened Resident #281's EHR and verified the
advanced directive was DNR CC-A. RN #378 then opened Resident #281's hard chart and verified the
paper form identified the resident's code status as DNR CC. RN #378 verified there was a discrepancy
between the EHR and hard chart advanced directive/code status documentation.
A review of the facility policy titled Advance Directives, revised 2022 revealed it was the policy of the facility
to identify a code status consistent with resident wishes to facilitate providing emergency care and services
to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance
with the comprehensive plan of care. Advanced Directives should be reviewed and updated with the
quarterly Minimum Data Set and/or as the resident indicates.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 2 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to ensure Resident #73's physician was notified as ordered
when the resident's blood glucose level (blood sugar) was greater than 400. This affected one resident
(#73) of five residents reviewed for unnecessary medication use.
Findings include:
Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Resident #73
had diagnoses including Parkinson's disease, hypertension, bipolar disorder, gout, polyneuropathy,
long-term use of insulin, anxiety disorder, chronic pain syndrome, chronic kidney disease, cerebral
infarction, protein-calorie malnutrition, osteoarthritis, breast cancer, dementia and inflammatory
spondylopathy.
Review of the May 2022 physician's order revealed Resident #73 had an order for Novolog (insulin) flex pen
per sliding scale subcutaneously before meals and at bedtime. The sliding scale revealed for a blood
glucose level from 0 to 150 give no insulin; for blood glucose level greater than 150- divide by 30 and minus
three and this would be the total units to give. The sliding scale revealed if the blood glucose level was
greater than 400 to call the physician.
Review of the quarterly Minimum Data Set 3.0 assessment, dated 04/04/22 revealed Resident #73 had
intact cognition and received insulin seven out of seven days during the assessment reference period.
Review of the medication administration record for March 2022 revealed on 03/25/22 at 4:00 P.M. Resident
#73 had a blood glucose level of 471.
Review of the progress note, dated 03/25/22 revealed no evidence the physician was notified of the blood
glucose level of 471 for Resident #73 as ordered.
Review of the medication administration record for March 2022 revealed on 03/29/22 at 4:00 P.M. Resident
#73 had a blood glucose level of 494.
Review of the progress note, dated 03/29/22 revealed no evidence the physician was notified of the blood
glucose level of 494 for Resident #73 as ordered.
Review of the medication administration record for March 2022 revealed on 03/31/22 at 8:00 P.M. Resident
#73 had a blood glucose level of 471.
Review of the progress note, dated 03/31/22 revealed no evidence the physician was notified of the blood
glucose level of 471 for Resident #73 as ordered.
Review of the medication administration record for April 2022 revealed on 04/01/22 at 4:00 P.M. Resident
#73 had a blood glucose level of 440.
Review of the progress note, dated 04/01/22 revealed no evidence the physician was notified of the blood
glucose level of 440 for Resident #73 as ordered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 3 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Review of the medication administration record for April 2022 revealed on 04/16/22 at 11:00 A.M. Resident
#73 had a blood glucose level of 424.
Review of the progress note, dated 04/16/22 revealed no evidence the physician was notified of the blood
glucose level of 424 for Resident #73 as ordered.
Residents Affected - Few
On 05/04/22 at 4:33 P.M. interview with the Director of Nursing verified there was no evidence the physician
was notified of the blood glucose readings greater than 400 on 03/25/22 at 4:00 P.M., on 03/29/22 at 4:00
P.M., on 03/31/22 at 8:00 P.M., on 04/01/22 at 4:00 P.M. or on 04/16/22 at 11:00 A.M. for Resident #73.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 4 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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
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, facility policy and procedure review and interview the facility failed to provide residents and
resident representatives a written notice indicating the reason for the discharge and appeal rights. This
affected two residents (#45 and #81) of 24 residents interviewed/reviewed for hospitalization.
Findings include:
1. Review of Resident #45's medical record revealed diagnoses including chronic obstructive pulmonary
disease, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead
to blood clots in the heart) and malignant neoplasm of the urethra (a tube that connects the urinary bladder
to the urinary meatus for the removal of urine from the body).
A nursing note, dated [DATE] at 10:41 A.M. indicated the Urology Department at Veterans Affairs was
notified Resident #45's left urostomy drain was leaking at the site on his back and of low drainage output
was noted in the bag. The Urology Department was also notified of Resident #45 having blood from his
penis. Resident #45 had an appointment with nephrology the next day at 11:30 A.M.
A nursing note dated [DATE] at 1:44 P.M. indicated the nephrology department called the facility and
requested Resident #45 be sent to the Emergency Department. Resident #45 was agreeable with the
transfer.
A nursing note dated [DATE] at 2:45 P.M. indicated Resident #45 left the facility via the facility's van en
route to the emergency room for evaluation and treatment. There was no evidence of a transfer/discharge
notice being provided.
A nursing note dated [DATE] at 9:17 P.M. indicated Resident #45 was admitted to the hospital with a
diagnosis of mechanical complications of the nephrostomy catheter.
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified Resident #45 received
no transfer/discharge notice/documentation when he was sent to the hospital [DATE].
2. Review of Resident #81's medical record revealed diagnoses including multiple sclerosis, chronic
obstructive pulmonary disease, type two diabetes mellitus, heart disease, anemia, chronic congestive heart
failure and dementia.
A nursing note dated [DATE] at 8:15 A.M. indicated at 7:55 A.M. Resident #81 was blue and had white froth
at the left corner of his mouth. Cardiopulmonary Resuscitation (CPR) was initiated and Resident #81 was
suctioned. CPR continued until paramedics arrived and took over CPR. Resident #81 was sent to the
emergency room.
A dietary note dated [DATE] at 4:06 P.M. indicated Resident #81 was expected to return.
A nursing note dated [DATE] at 5:45 P.M. indicated Resident #81's son reported Resident #81 expired at
the hospital. There was no evidence of a written notification of the reason for the transfer/discharge notice
being provided at the time of the resident's transfer/discharge.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 5 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified neither Resident #81 or
his responsible party received a transfer/discharge notice when the resident was sent to the hospital on
[DATE].
Review of the facility policy titled, Notice of Transfer or Discharge (revised in 2022) revealed a notification
would be sent to a resident being transferred or discharged from the nursing facility, including if an
immediate transfer or discharge was required based on the resident's urgent medical needs.
Event ID:
Facility ID:
366052
If continuation sheet
Page 6 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, facility policy and procedure review and interview the facility failed to provide residents or
resident representatives a written notice of the bed hold policy. This affected two residents (#45 and #81) of
24 residents interviewed/reviewed for hospitalization.
Findings include:
1. Review of Resident #45's medical record revealed diagnoses including chronic obstructive pulmonary
disease, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead
to blood clots in the heart) and malignant neoplasm of the urethra (a tube that connects the urinary bladder
to the urinary meatus for the removal of urine from the body).
A nursing note dated [DATE] at 10:41 A.M. indicated the Urology Department at Veterans Affairs was
notified Resident #45's left urostomy drain was leaking at the site on his back and of low drainage output
was noted in the bag. The Urology Department was also notified of Resident #45 having blood from his
penis. Resident #45 had an appointment with nephrology the next day at 11:30 A.M.
A nursing note dated [DATE] at 1:44 P.M. indicated the nephrology department called the facility and
requested Resident #45 be sent to the Emergency Department. Resident #45 was agreeable with the
transfer.
A nursing note dated [DATE] at 2:45 P.M. indicated Resident #45 left the facility via the facility's van en
route to the emergency room for evaluation and treatment. There was no evidence of a bed hold notice
being provided.
A nursing note dated [DATE] at 9:17 P.M. indicated Resident #45 was admitted to the hospital with a
diagnosis of mechanical complications of the nephrostomy catheter.
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified Resident #45 received
no bed hold notification when he was sent to the hospital [DATE].
2. Review of Resident #81's medical record revealed diagnoses including multiple sclerosis, chronic
obstructive pulmonary disease, type two diabetes mellitus, heart disease, anemia, chronic congestive heart
failure, and dementia.
A nursing note dated [DATE] at 8:15 A.M. indicated at 7:55 A.M. Resident #81 was blue and had white froth
at the left corner of his mouth. Cardiopulmonary Resuscitation (CPR) was initiated and Resident #81 was
suctioned. CPR continued until paramedics arrived and took over CPR. Resident #81 was sent to the
emergency room.
A dietary note dated [DATE] at 4:06 P.M. indicated Resident #81 was expected to return.
A nursing note dated [DATE] at 5:45 P.M. indicated Resident #81's son reported Resident #81 expired at
the hospital. There was no evidence of a written notification of the bed hold policy.
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified neither Resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 7 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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 0625
#81 or his responsible party received a bed hold when the resident was sent to the hospital [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility Bed Hold Notice Upon Transfer policy (implemented [DATE]) revealed in the event of
an emergency transfer of a resident, the facility would provide a written notice of the facility's bed hold
policies within 24 hours. The facility would keep a signed and dated copy of the bed hold notice information
given to the resident and/or resident representative in the resident's file.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 8 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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, facility policy and procedure review and interview the facility failed to ensure Resident #17
was invited to attend a quarterly care conference to be a part of the care planning process. This affected
one resident (#17) of one resident reviewed for participation in care planning.
Findings include:
A review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE].
Resident #17 had diagnoses including bilateral below the knee amputations, emphysema, mild intellectual
disability, schizophrenia, chronic obstructive pulmonary disease and the need for assistance with personal
care.
A review of Resident #17's Minimum Data Set (MDS) 3.0 assessments revealed she had a significant
change MDS assessment completed on 01/28/22. The prior MDS assessment was a quarterly MDS
completed on 01/12/22. The significant change MDS indicated the resident had no communication issues
and was cognitively intact. The resident was not known to have displayed any behaviors or reject care
during that seven day assessment period. The assessment revealed the resident required an extensive
assist of one to two staff for most of her activities of daily living.
A review of Resident #17's care plans revealed the resident was admitted for short term placement for
rehabilitation. The resident wanted to be discharged to a group home or an assisted living facility.
Resident #17's electronic health record was absent for any documented evidence of care planning
conferences being held for the resident. The facility provided paper care conference attendance records
that had been held for the resident in the past 12 months. The facility indicated the resident's brother did not
participate in meetings that were scheduled for September 2021 or April 2022. The care conference
attendance records for 06/10/21 and 01/12/22 revealed the resident's brother attended both of those
meetings via phone. The resident was not indicated to have attended either meeting held or part of the two
meetings scheduled in September 2021 and April 2022, when the brother did not participate.
On 05/02/22 at 11:49 A.M. an interview with Resident #17 revealed she had not been invited to attend any
of her care planning conferences. The resident revealed she was not aware of there being any meetings
held on her behalf to discuss her care planning goals.
On 05/03/22 at 2:29 P.M. an interview with Registered Nurse (RN) #358 revealed care conferences were
completed upon admission, quarterly and whenever the family requested to have one. RN #358 revealed
care planning conferences were scheduled around the time of the resident's MDS assessments. The facility
sent out a letter to the family and asked them to RSVP if they wanted to attend. She stated, if the resident's
family did not respond, they still met to review the resident's care plans. The residents were invited to come,
if they were cognitively intact. The care planning conferences were documented on a care conference
attendance record and uploaded into the computer to be a part of the resident's electronic health record.
On 05/03/22 at 2:44 P.M. a follow up interview with RN #358 revealed the care conference attendance
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 9 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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
records for September 2021 and April 2022 were the only two they had documented evidence of care
planning conferences being held for Resident #17. RN #358 confirmed the resident's brother did not attend
the care planning conferences scheduled in September 2021 or April 2022. She reported they still reviewed
the resident's care plans on that date. She denied they had any documented evidence of Resident #17
being invited to attend any of the care conferences held on her behalf. She acknowledged the resident
reported she had not been invited to attend any of her care conferences, in which they had no
documentation to show otherwise.
A review of the facility policy on Participation In Care Conference, revised 2021 revealed the purpose of the
policy was to provide interdisciplinary communication with the resident and/or legal representative for
purposes for review and further development of an individualized comprehensive plan of care. Care
conferences for long term care residents shall occur on a regular basis (i.e., initial, quarterly, annual,
significant change in status, and as needed). A letter informing the resident and/or their responsible party
shall be provided two weeks in advance of the scheduled conference. The resident and/or resident
representative would sign the attendance sheet to indicate attending of meeting. If the care conference was
held via phone or zoom, facility representative would log all participants.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 10 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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
record review, review of physician standing orders and interview the facility failed to recheck Resident 23's
blood glucose level after an initial blood sugar check was below 65 milligrams/ deciliter (mg/dl). This
affected one resident (#23) of five residents reviewed for unnecessary medication use.
Residents Affected - Few
Findings include:
Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE] with a
diagnosis that included adult onset diabetes mellitus.
A review of Resident #23's physician's orders revealed an order to receive Lantus (long acting insulin) 19
units subcutaneously in the afternoon and 15 units at bedtime. The resident also had an order to receive
Humalog (fast acting insulin) before meals and at bedtime as per sliding scale. The sliding scale included a
formula to use dividing the blood sugar by 30 and then subtract 3 units.
A review of Resident #23's medication administration record (MAR) for April 2022 revealed the resident's
blood sugar was recorded as being 57 mg/dl at 5:00 A.M. on 04/23/22, 04/29/22 and 04/30/22. (Normal
blood sugar levels between 70-110 mg/dl). The MAR did not provide documented evidence of the resident's
blood glucose levels being rechecked after her blood sugar levels were found to be low on those days.
A review of Resident #23's nursing progress notes revealed no documented evidence of the resident's
blood glucose level being rechecked an hour after they were found to be low on 04/23/22, 04/29/22 and
04/30/22. The progress notes indicated the resident was provided a snack on two of those days but did not
document the resident's low blood sugar was followed up/re-checked to ensure it came up after a snack
was given.
A review of the physician's standing orders for hypoglycemia revealed if a resident's blood glucose level
was below 65 mg/dl, the resident was to be given a house supplement orally, if able to consume. Staff were
then to recheck the blood glucose level in one hour. If the blood glucose level remained low or the resident
had adverse symptoms, staff were to then notify the physician.
On 05/04/22 at 9:41 A.M. an interview with Registered Nurse (RN) #379 revealed Resident #23's blood
sugars were known to fluctuate between being low and being high. RN #379 revealed the resident was not
always compliant with her diet and the family was known to bring her in snacks. That was when her blood
sugars tended to go up. RN #379 revealed if a blood sugar was less than 50 mg/dl staff would give (the
medication) Glucagon. If the blood sugar was between 50 and 60 mg/dl, staff gave a snack with sugar and
re-checked the blood sugar in 15 minutes. The repeat blood glucose levels would be documented in the
progress notes and show up under the electronic medication administration record (eMAR) progress notes.
On 05/04/22 at 10:10 A.M. an interview with the Director of Nursing (DON) confirmed, per their
hypoglycemia standing orders, the nurse was to recheck a residents blood sugar an hour after a
supplement had been given for a blood glucose level less than 65 mg/dl. The DON also confirmed if the
blood glucose level remained low, after the supplement was given, the nurse would then have to notify the
physician of the low blood sugar. The DON was unable to find documented evidence of Resident #23's
blood sugar being re-checked on 04/23/22, 04/29/22 or 04/30/22, when the blood sugar was noted to be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 11 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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
57 mg/dl and a supplement had to be given.
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:
366052
If continuation sheet
Page 12 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, facility policy and procedure review and interview the facility failed to complete
accurate assessments and failed to update the physician regarding failure to heal and/or decline in a
pressure ulcer for Resident #72 to determine if a change in treatment was indicated. This affected one
resident (#72) of one resident reviewed for pressure ulcers.
Residents Affected - Few
Findings include:
Review of Resident #72's medical record revealed an admission date of 03/29/22. Resident #72 had
diagnoses including generalized muscle weakness, obesity, chronic congestive heart failure, chronic atrial
fibrillation, post-surgical malabsorption and iron deficiency anemia.
A wound assessment, dated 03/29/22 (admission) indicated Resident #72 had a pressure ulcer on the right
heel which was assessed as a suspected deep tissue injury (SDTI) (a persistent non-blanchable deep red,
maroon or purple discoloration). The wound bed had 100% necrosis (dead tissue). The ulcer measured
three centimeters (cm) in length by three cm width with no depth noted. The physician was notified of the
SDTI. Skin prep was applied to the heel and heel guards were applied.
A baseline care plan dated 03/29/22 indicated interventions to address skin impairment included
observing/documenting the location, size and treatment. Report abnormalities, failure to heal, and signs of
infection to the physician.
A wound assessment, dated 03/31/22 revealed Resident #72 had a SDTI caused by pressure to the right
heel. The assessment also indicated the ulcer was a Stage I (non-blanchable erythema of intact skin) on
admission and was a Stage I at the time of the assessment. The instructions on the form indicated not to
down-stage as a wound healed. The assessment indicated the overall impression was unchanged but did
not indicate the presence of necrotic tissue. Measurements remained three cm by three cm with no depth.
The treatment remained the same.
A comprehensive care plan, created 04/07/22 indicated Resident #72 had impaired skin integrity related to
a suspected deep tissue pressure ulcer to the right heel. Interventions included measuring the area every
week. Record the size, color, presence and characteristics of drainage. Observe for signs of improvement
or decline in healing. Consult with the physician as needed regarding improvement or decline in condition,
effectiveness of treatment and/or need for treatment order change. Monitor/document location, size and
treatment. Report abnormalities, failure to heal and signs of infection to the physician.
A wound assessment, dated 04/07/22 indicated the physician and family/power of attorney (POA) were last
updated about the condition of the SDTI on 03/29/22. Although the assessment indicated the ulcer was a
SDTI present on admission it continued to indicate it was a Stage I ulcer originally and at the time of the
assessment. The assessment indicated the SDTI was unchanged. No necrosis was documented. Wound
measurements continued to be recorded as three cm by three cm with no depth. The treatment remained
the same.
A wound assessment, dated 04/14/22 indicated the physician and family were last updated about the
wound on 03/29/22. The assessment continued to indicate the right heel present on admission was SDTI
but indicated the original and current stage was listed as Stage I. The assessment indicated the overall
impression was that the SDTI was worsening. The wound bed was documented as 100% necrosis. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 13 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
wound continued to be measured as three cm by three cm with no depth. The treatment remained the
same. Documentation indicated the area appeared darker in color.
A wound assessment, dated 04/21/22 indicated the family and physician were last updated about the SDTI
on 03/29/22. The assessment continued to indicate there was a SDTI to the right heel with the original and
current stage listed as a Stage I. The assessment indicated the SDTI was unchanged. The wound bed was
described as 95% necrosis, 5% necrosis. The wound was measured as three cm by three cm with no
depth. Another area of the assessment indicated there was a small area that looked like healthy tissue.
Some of the heel had hardened. The back of the heel was still soft to touch.
A wound assessment, dated 04/28/22 indicated the family and physician were last updated 03/29/22. The
assessment continued to indicate the ulcer was a SDTI but pressure ulcer stage was listed as (Stage) I.
The assessment indicated the SDTI was improving. The wound bed was described as 95% necrosis and
5% epithelial.
On 05/04/22 at 7:45 A.M. interview with Licensed Practical Nurse (LPN) #382 revealed the SDTI never
really deteriorated.
On 05/04/22 at 11:54 A.M. interview with LPN #382 revealed the SDTI was necrotic since admission even
though she did not note it on all assessments. LPN #382 verified with the necrotic tissue she was unable to
know for sure the depth of the wound but stated she was taught to record the depth as 0. LPN #382 verified
although the assessments from 03/29/22 to 04/21/22 indicated the ulcer was either unchanged or
deteriorated she did not notify the physician during that time frame to determine if a treatment change was
indicated. LPN #382 revealed after reviewing the assessments, she should have indicated the wound
remained unchanged on 04/14/22 as the area had always been necrotic (although it was not indicated on
the prior week assessment). LPN #382 revealed the assessment on 04/21/22 which indicated the wound
was 95% necrosis, 5% necrosis was incorrect as it was 95% necrosis and 5% epithelial which would have
been an improvement instead of being unchanged. LPN #382 revealed she did not know why any of the
assessments indicated the ulcer was a Stage I as it had never been a Stage I.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 14 of 15
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
366052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gables Care Center Inc
351 Lahm Drive
Hopedale, OH 43976
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure fall interventions were in place for
Resident #70, who had a history of falls to decrease the risk of additional falls. This affected one resident
(#70) of two residents reviewed for falls.
Findings include:
Review of the medical record revealed Resident #70 was admitted to the facility on [DATE]. Resident #70
had diagnoses including edema, history of transient ischemic attack, cerebral infarction, protein-calorie
malnutrition, cognitive communication deficit, polymyalgia rheumatica, bladder cancer, dementia, anxiety
disorder, schizoaffective disorder and Alzheimer's disease.
Review of the May 2022 physician's orders revealed Resident #70 had an order (dated 03/16/22) to wear
gripper socks when she was not wearing her shoes.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/22 revealed Resident #70
had severely impaired cognition and required extensive assistance of two staff members for transfers.
Further review of the assessment revealed the resident had two or three falls with no injuries since her
admission.
On 05/04/22 at 8:25 A.M. and 9:09 A.M. Resident #70 was observed without any type of shoe or gripper
sock to her left foot. The resident had a dressing in place to her right foot at the time of both observations.
On 05/04/22 at 9:09 A.M. interview with Registered Nurse (RN) #379 revealed Resident #70 was ordered to
have gripper socks on when not wearing shoes. At the time of the interview, observation of Resident #70
with RN #379 verified the resident was not wearing shoes or gripper socks as ordered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366052
If continuation sheet
Page 15 of 15
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 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.
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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the May 5, 2022 survey of GABLES CARE CENTER INC?
This was a inspection survey of GABLES CARE CENTER INC on May 5, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GABLES CARE CENTER INC on May 5, 2022?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
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.