Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon
observation and interview the facility failed to properly place a catheter bag. This affected one (#33) of one
residents in the facility with a catheter. Census was 25. Records Reviews for Resident #33 revealed
resident was admitted on [DATE] with diagnosis fracture of shaft of humerus and left arm, major depressive
disorder, anxiety, and panic disorder.The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
Resident #33 was cognitively intact and was admitted with suprapubic catheter due to neuromuscular
dysfunction of bladder. Observation of Resident #33 on 09/02/25 at 10:38 A.M. revealed suprapubic
catheter bag laying on the floor folded in half beside Resident #33's bed.Interview with RN #101 verified
suprapubic catheter bag was laying on the floor beside the bed.
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 5
Event ID:
366197
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
366197
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at St Henry The
522 Western Avenue
Saint Henry, OH 45883
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 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and policy review the facility failed to provide care for
peripherally inserted central catheter. This directly affected one resident, #12, of one reviewed for
intravenous catheters. The facility census was 25.Findings Include:Review of the medical record of
Resident #12 revealed an admission date of 03/18/25. Diagnoses include urinary tract infection and
Extended-Spectrum Beta-Lactamase in urine. Review of the quarterly Minimum Data Set assessment
dated [DATE] revealed Resident #12 to be cognitively intact. The assessment indicated no intravenous
catheter. Review of the physician order dated 08/25/25 revealed an order to change the midline dressing
every week. The order indicated this should occur on Mondays. Interview and direct observation of
Resident #12 on 09/02/25 at 8:45 A.M. revealed a peripherally inserted central catheter (PICC) in the right
upper arm. The dressing was loose and dated 08/25/25. Direct observation and interview on 09/02/25 at
9:00 A.M. with Registered Nurse (RN) #110 provided verification the dressing was loose and overdue to be
changed. Review of the policy titled Midline Dressing Changes, dated 01/17/19, revealed the midline
catheter dressings will be changed every five to seven days.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366197
If continuation sheet
Page 2 of 5
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
366197
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at St Henry The
522 Western Avenue
Saint Henry, OH 45883
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, staff interview, and policy review the facility failed to ensure medications were
securely stored. This had the potential to affect two residents, (#18 and #19), identified by the facility as
being confused and independently mobile residents. The facility census was 25. Findings
Include:Observation on 09/02/25 at 8:50 A.M. an antibiotic was noted on the medication cart which was
located in the hallway. The cart was unattended. Registered Nurse (RN) #110 was observed to exited a
resident room and verified the medication had been lying on the medication cart unattended. The
medication was labeled Resident #12 and contained Ertapenem sodium (antibiotic) solution reconstituted 1
gram. Review of the policy titled Medication Storage, undated, revealed medications will be stored in a
manner that ensures the safety of the residents. All medications will be stored in a locked cabinet, cart, or
medication room that is accessible only to authorized personnel.
Event ID:
Facility ID:
366197
If continuation sheet
Page 3 of 5
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
366197
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at St Henry The
522 Western Avenue
Saint Henry, OH 45883
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interview and facility policy review, the facility failed to maintain a safe sanitary
kitchen. This had the possibly to affect 23 out 25 residents who receive food from the kitchen. The facility
identified Resident #1 and #2 did not receive food from the kitchen. The facility census was 25. Findings
Include: Observation of the kitchen on 09/02/25 at 9:48 A.M. revealed the trash can by the food serving
table had a flip lid. The here was observed multiple areas of thick food particles on the can. Observation of
the kitchen freezer revealed the door handles had a red sticky substance on them as did the surface of the
refrigerator behind the door handles. These findings were verified with Dietary Manager #106 at the time of
the observation. Facility policy Cleanliness, undated, revealed purpose to keep the kitchen and servery as
clean as possible during and after operations.
Event ID:
Facility ID:
366197
If continuation sheet
Page 4 of 5
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
366197
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at St Henry The
522 Western Avenue
Saint Henry, OH 45883
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and policy review the facility failed to follow infection
control procedures for residents in isolation. This directly affected one resident, (#12), and had the potential
to affect five residents, #01, #02, #12, #16, and #33, on isolation. The facility census was 25.Findings
Include:Review of the medical record of Resident #12 revealed an admission date of 03/18/25. Diagnoses
include urinary tract infection and Extended-Spectrum Beta-Lactamase in urine. Review of the quarterly
Minimum Data Set assessment dated [DATE] revealed Resident #12 to be cognitively intact. The
assessment indicated no isolation. Review of the physician order dated 08/26/25 revealed an order for
contact isolation. Observation on 09/02/25 at 8:45 A.M. revealed a sign on the door to Resident #12's room
indicating enhanced barrier precautions. Personal protective equipment was available for use. Observation
on 09/02/25 at 9:00 A.M. revealed Registered Nurse (RN) #110 entered the room of Resident #12 along
with this surveyor. RN #12 did not don gloves nor gown and proceeded to touch the midline catheter
dressing on Resident #12's right upper arm, without gloves. RN #110 exited the room and returned with
gloves and a disposable isolation gown. RN #110 donned the items and proceeded to initiate the
administration of an antibiotic intravenously. Observation on 09/02/25 at 1:00 P.M. revealed the signage at
the entrance to Resident #12's room had been changed to indicate contact isolation in place of the
enhanced barrier precautions. Interview on 09/02/25 at 2:00 P.M. with RN #110 provided verification the
signage had been changed to the increased restrictive isolation, and it should have been contact isolation
for a while now. Review of the policy titled Enhanced Barrier Precautions undated revealed gloves and
gowns are to be worn with high contact with residents.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366197
If continuation sheet
Page 5 of 5
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Back to topCitations
5 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.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the September 4, 2025 survey of GARDENS AT ST HENRY THE?
This was a inspection survey of GARDENS AT ST HENRY THE on September 4, 2025. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDENS AT ST HENRY THE on September 4, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide for the safe, appropriate administration of IV fluids for a resident when needed."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.