F 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview, the facility failed to notify residents with a Medicaid payor source
and/or their representatives when their resident fund balances reached two hundred dollars ($200.00) less
than the resource limit to prevent the potential loss of eligibility for Medicaid services. This finding affected
three (Residents #10, #15 and #19) of four residents reviewed for resident fund accounts. The facility
census was 48.
Residents Affected - Few
Findings include:
Review of the facility Resident Trust Account Balance form dated 04/26/22 revealed Resident #10 had a
balance of two thousand, four hundred, seventy dollars and twenty-eight cents ($2,470.28); Resident #15
had a balance of two thousand, four hundred, twenty-one dollars and eight-eight cents ($2,421.88); and
Resident #19 had a balance of four thousand, two hundred, forty-one dollars and fifty-one cents
($4,241.51) in their resident fund accounts.
Review of Residents #10, #15 and #19's medical records revealed the payor source was Medicaid.
Interview on 04/26/22 at 10:40 A.M. with Medical Records #810 confirmed Residents #10, #15 and #19 had
a payor source of Medicaid and were not provided notification their resident fund balances reached
$200.00 less than the resource limit to prevent potential loss of eligibility for Medicaid services.
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 2
Event ID:
366329
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
366329
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Woods Nursing Center, Inc
1525 East Western Reserve Road
Poland, OH 44514
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
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, record review and interview, the facility failed to properly store and dispose of loose
or expired medications and expired glucometer control solutions as well as expired disinfectant wipes used
to clean the medication carts and glucometers. This finding affected five residents (Residents #1, #4, #22,
#32, and #147) who received blood glucose testing (BGTs) on the 300 and 400 halls and one resident
(Resident #4) of one resident reviewed for expired glucagon (medication for low blood sugar) who resides
on the 400 hall. The facility census was 48.
Findings include:
Observation on 04/27/22 at 10:50 A.M. on the 300 hall with Registered Nurse (RN) #828 during medication
storage review revealed five loose medications in the medication cart. There was one yellow tablet, three
white tablets, and one pink tablet. There was a bottle of disinfectant wipes with an expiration date of 10/21
stored in the cart and used to clean the glucometers after each use. There was glucometer control solution
with an expiration date of 02/22 stored in the medication cart with the glucometers.
Interview on 04/27/22 at 11:00 A.M. with RN #828 confirmed there were five loosed medications in the cart
as well as the expired disinfectant wipes used to clean the glucometers after each use and expired
glucometer control solution stored in the medication cart.
Observation on 04/27/22 at 11:30 A.M. on the 400 hall Licensed Practical Nurse (LPN) #893 during
medication storage review revealed Resident #4 had an expired glucagon pen in the medication cart with
an expiration date of 03/22. There was a bottle of disinfectant wipes with an expiration date of 10/21 stored
in the cart and used to clean the glucometers after each use. There was glucometer control solution with an
expiration date of 08/18 stored in the medication cart with the glucometers.
Interview on 04/27/22 at 11:40 A.M. with LPN #893 confirmed there were expired disinfectant wipes,
expired glucometer control solutions and an expired glucagon pen for Resident #4 in the medication cart on
the 400 hall.
Record review for Residents #1, #4, #22, #32 and #147 revealed physician orders for BGT daily or before
and after meals due diagnosis of diabetes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366329
If continuation sheet
Page 2 of 2
