F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to develop and implement a comprehensive and
individualized activity program designed to meet the total care needs of Resident #52. This affected one
resident (#52) of five residents reviewed for activities.
Residents Affected - Few
Findings include:
Review of Resident #52's medical record revealed an admission date of 05/02/18 with diagnoses of
Alzheimer's disease, chronic obstructive pulmonary disease, atrial fibrillation, anxiety and depression.
Review of the resident's plan of care, dated 05/06/18 revealed the resident had the potential for alteration in
activities related to cognitive impairment, impaired decision making and impaired mobility. Interventions
included to engage resident in group activities, familiarize the resident with nursing home environment and
activity program on regular basis, give the resident the opportunity to express opinion of activities attended,
give the resident verbal reminders of activity before commencement of the activity, invite and encourage the
resident's family to attend, offer reality orientation on all possible occasions and contacts, praise all efforts,
provide resident with a monthly calendar, provide assistance with transportation as needed, remove
resident from activity if behavior was unacceptable to others, respect the resident's choice in regard to
limited/no activities.
Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
the resident had clear speech, usually understood others, usually made himself understood and had severe
cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of three. Review of mood
and behavior section of the MDS revealed the resident had physical behaviors directed towards others and
rejected care. Review of the resident's daily preferences revealed the section was not assessed. The
resident was dependent on two staff for activities of daily living.
Review of the resident's quarterly activity assessment dated [DATE] revealed the preferred activity setting
was small groups. The resident enjoyed watching television (westerns, news), music (gospel, blue grass),
religious services, pets, family orientation. The assessment determined the care plan was
appropriate/current.
Review of the resident's activity participation log for October 2019 revealed no one on one activities were
offered to the resident.
On 10/29/19 at 9:38 A.M. Resident #52 was observed sitting in his Broda (specialized) chair with his eyes
closed and head down in front of the television.
(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 8
Event ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concord Health & Rehab Ctr
1242 Crescent Drive
Wheelersburg, OH 45694
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 10/29/19 at 1:00 P.M. interview with Activities Director #111 revealed they have one activity calendar for
the entire facility including the secured unit. She said they have two morning activities on the unit and she
had a schedule for the activity aides to follow. She said it was something different each day.
On 10/30/19 at 10:05 A.M. observation of the scheduled activity revealed the activity staff placed a disc of
music in the CD player that was not of the resident's era of music and asked the residents if they wanted to
dance. The activity staff allowed the 10 songs to play on the disc with minimal interactions with the
residents and left the unit. No snack was provided as scheduled.
On 10/30/19 at 10:10 A.M. observation of Resident #52 revealed he was up in his Broda chair facing the
television that was also playing along with the music. The resident was not engaged in the music or the
television. No observation was made of the staff interacting with the resident.
On 10/31/19 at 10:30 A.M. observation of the morning activity on the secure care unit revealed the beach
ball activity that was scheduled at 10:00 A.M. was not occurring. The residents on the unit were being given
a popsicle. Observation of Resident #52 revealed he was up in his Broda chair in front of the television.
On 10/31/19 01:13 PM interview with AD #111 revealed the ball activity was completed and they had
popsicles. She said they do one activity with them at 10:00 A.M. then invite them to the activities off the
secured unit. She said that was why they mark residents as refused because they don't want to come off
the unit. She said they also have bins with magazines, balls and other things the State Tested Nursing
Assistants (STNA) staff can do with the residents. She said she changes them out every now and then. She
said she understands the facility needs an ongoing program on the dementia unit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
If continuation sheet
Page 2 of 8
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concord Health & Rehab Ctr
1242 Crescent Drive
Wheelersburg, OH 45694
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to prevent Resident #34, who received all of her nutrition via
gastrostomy tube from sustaining a significant weight loss. This affected one resident (#34) of one sampled
resident reviewed for nutrition.
Residents Affected - Few
Findings include:
Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses that included cerebral palsy, adult failure to thrive, seizures, gastroparesis, major depressive
disorder single episode, gastro-esophageal reflux disease, intellectual disability and constipation.
Review of Resident #34's admission nutrition assessment, dated 05/03/19 revealed her current body weight
was 107.2 pounds and her body mass index was 24.1, indicating healthy weight status. Resident #34's diet
order was nothing permitted orally (NPO), she received a tube feeding at 45 milliliters (ml) for 22 hours. The
assessment documented the tube feeding met the resident's estimate need.
Review of Resident #34's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/06/19 revealed
her speech was unclear, she sometimes understands, was sometimes understood, her short-term memory
was ok, her long-term memory was impaired, she recalled her room location, staff names, that she was in a
nursing home, and she had moderately impaired decision making. Resident #34 had no behaviors, did not
reject care, and was dependent on one staff to eat. Resident #34 had no swallowing problems, was 56
inches tall, weighed 107 pounds, had no significant weight changes, and received greater than 51 percent
of nutrition via tube feeding.
Review of Resident #34's nutrition assessment dated [DATE] revealed the resident's current body weight
was 108.8 pounds, her body mass index was 24.5, indicating a healthy weight. Resident #34 had a
significant weight gain of 7.5 pounds (24.5%) in 30 days that was desirable.
Review of Resident #34's quarterly MDS 3.0 assessment revealed the resident weighed 109 pounds and
she had significant weight gain that was not planned.
Review of Resident #34's nutrition note dated 09/03/19 revealed her current body weight was 106.6 pounds
and she had no significant weight change. Nursing reported Resident #34 had requested the tube feeding
be turned off for extended periods of time. The assessment revealed Resident #34 may benefit from bolus
tube feedings. The bolus provided the same calories as the feeding provided using the pump. The
recommendation was to change the tube feeding to four times daily. The feeding would meet the resident's
estimated needs.
Review of Resident #34's physician orders revealed a bolus tube feeding four times a day ordered on
09/05/19.
Review of Resident #34's September 2019 medication administration records revealed no evidence the
resident refused her tube feeding. The records revealed Resident #34 her tube feedings as ordered.
Review of Resident #34's weights revealed on 09/05/19 she weighed 106.4 pounds. On 10/16/19 she
weighed 99.9, representing a significant unplanned weight loss of 6.57% in one month.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
If continuation sheet
Page 3 of 8
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concord Health & Rehab Ctr
1242 Crescent Drive
Wheelersburg, OH 45694
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #34's nutrition note dated 10/06/19 revealed a recommendation to change the tube
feeding formula to a more caloric dense formula that provided the same number of calories in a smaller
volume of feeding.
Interview with State Tested Nursing Assistant (STNA) #116 on 10/29/19 at 2:58 P.M. revealed Resident #34
had no behaviors and did not refuse care, including her tube feeding. This STNA stated Resident #34 did
not like oral care, but she did not refuse it.
Interview with Licensed Practical Nurse (LPN) #168 on 10/29/19 at 3:13 P.M. revealed Resident #34 did not
reject care and had no behaviors. LPN #168 had a continuous tube feeding but due to belly pain the
feeding was changed to a bolus tube feeding and the resident was tolerating the bolus feeding better. LPN
#168 stated there had been times the night shift nurse reported Resident #34 had refused a few times.
Interview with the Manager of Clinical Services Registered Nurse #122 on 10/30/19 at 9:08 A.M. confirmed
there was no evidence Resident #34 refused her tube feeding in August or September 2019. There were
three times in September 2019 Resident #34's feeding was held.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
If continuation sheet
Page 4 of 8
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concord Health & Rehab Ctr
1242 Crescent Drive
Wheelersburg, OH 45694
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to ensure an adequate indication for the use of an antianxiety
and antidepressant medication for Resident #8 and failed to ensure target behaviors were identified and
monitored to ensure the medications were justified. This affected one resident (#8) of five sampled
residents reviewed for unnecessary medication use.
Findings include:
Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses that included polyarthritis, cognitive communication deficit, Alzheimer's disease, chronic
obstructive pulmonary disease, type two diabetes, major depressive disorder, restless leg syndrome,
asthma, anxiety disorder, essential hypertension, atrial fibrillation, asthma. hypothyroidism, anxiety disorder,
Parkinson's disease, and chronic pain.
Review of Resident #34's plan of care, dated 11/07/16 revealed the resident was at risk for adverse effects
due to the use of antianxiety and antidepressant medications. No target behaviors were identified on the
care plan.
Review of Resident #8's behavior tracking from May 2019 to October 2019 revealed staff documented on
09/02/19 the resident had behaviors of frequent crying, expressing false beliefs and no behavior.
Review of Resident #8's progress notes from May 2019 to October 2019 revealed one note, dated 07/24/19
which indicated the resident felt sad.
Review of Resident #8's medication management note dated 07/24/19 revealed the resident was very
upset today when she was not allowed to keep her sewing machine in her room and now had to use it the
activity room with supervision.
Review of Resident #8's behavior tracking for 07/24/19 revealed the resident had no behaviors on this date.
Review of Resident #8's progress notes for 07/24/19 revealed the resident reported she was sad for her
children because their father had just passed away.
Review of resident/family/staff concern form (form not dated) revealed on 07/30/19 the Ombudsman met
with the Administrator regarding Resident #8 being upset regarding her sewing machine not being allowed
in her room. The form documented the concern was due to safety as the resident had a diagnosis of
Alzheimer's disease. There was no assessment to determine if the resident was safe or unsafe to have a
sewing machine in her room.
Review of Resident #8's annual Minimum Data Set (MDS) 3.0 assessment, dated 10/10/19 revealed her
speech was clear, she understands, was understood, and her cognition was intact. She had mild
depression, had delusions, had no behaviors, and did not reject care. The assessment revealed Resident
#8 received a daily antianxiety and antidepressant medication.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
If continuation sheet
Page 5 of 8
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concord Health & Rehab Ctr
1242 Crescent Drive
Wheelersburg, OH 45694
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #8's October 2019 physician orders revealed she received the antidepressant,
Cymbalta 60 milligrams (mg) twice daily, and the antianxiety, Buspar 7.5 mg daily.
Interview with Licensed Practical Nurse (LPN) #197 on 10/31/19 at 2:13 P.M. revealed Resident #8 was a
little depressed sometimes but had no other behaviors.
Residents Affected - Few
Interview with State Tested Nursing Assistant (STNA) #177 on 10/31/19 at 2:16 P.M. revealed Resident #8
had no behaviors and she did not refused care. STNA #177 revealed Resident #8 was not anxious and she
stated sometimes she was depressed, and she cried sometimes.
Interview with Manager of Clinical Services Registered Nurse (RN) #122 on 10/31/19 at 3:50 P.M.
confirmed there were target behaviors identified for Resident #8. RN #122 confirmed the only evidence of
behaviors was on 07/24/19 and 09/02/19.
Interview with the Administrator on 10/31/19 at 3:51 P.M. confirmed Resident #8's sewing machine was
removed from her room due to safety concerns as Resident #8 had a diagnosis of Alzheimer's disease. The
Administrator confirmed there was no policy regarding keeping a sewing machine in a resident's room and
Resident #8 was not assessed to determine if she was unsafe to keep a sewing machine in her room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
If continuation sheet
Page 6 of 8
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concord Health & Rehab Ctr
1242 Crescent Drive
Wheelersburg, OH 45694
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, record review and staff interview the facility failed to ensure contact precautions were followed
for Resident #325, including the use of personal protective equipment to prevent the potential spread of
infection. This affected one resident (#325) and had the potential to affect all 70 residents residing in the
facility.
Residents Affected - Many
Findings include:
Review of Resident #325's medical record revealed an original admission date of 10/07/19 with the latest
readmission of 10/25/19 and admitting diagnoses of Clostridium Difficile (C Diff), dementia, convulsions
and mixed incontinence.
Review of the resident's acute care hospital discharge records dated 10/07/19 revealed the resident was
discharged with orders for contact precautions due to C Diff. Review of the teaching regarding isolation sent
with the discharge instructions revealed all staff and visitors should wear gloves and a gown before entering
the room. They should remove the gown and gloves before leaving the room and must always wash their
hands with soap and water before leaving the room.
Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
the resident had clear speech, understood others, made herself understood and had moderate cognitive
deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The resident required
extensive assistance of two staff for bed mobility, transfers and toileting. The resident was determined to be
frequently incontinent of both bowel and bladder.
Review of the plan of care, dated 10/25/19 revealed the resident had an infection related to C Diff.
Interventions included to provide one on one supervision, contact isolation, give antibiotic therapy as
ordered, the resident was to use a beside commode for for toileting needs, empty bedside commode basket
in hopper room due to shared toilet, assess for signs and symptoms of infection and report to the physician,
notify the physician if treatment was ineffective, encourage fluids, educate resident/family/legal
representative on the importance of compliance and monitor for adverse reactions/side effects.
Review of the resident's admission physician orders, dated 10/25/19 revealed an order for contact isolation
secondary to C Diff. An order dated 10/26/19 was also noted for Vancomycin (an antibiotic used to treat
infection) 25 milligrams (mg)/milliliter (ml) with the special instructions to administer 5 ml by mouth every six
hours until 11/03/19.
On 10/28/19 at 2:48 P.M. observation of Physical Therapist Assistant (PTA) #132 revealed the PTA was
actively providing exercises to the resident's legs with no personal protection equipment (PPE) in place.
On 10/30/19 at 10:05 A.M. interview with Housekeeper #178 revealed she does not wear PPE unless she
makes contact with the resident.
On 10/30/19 at 11:00 A.M. observation of Licensed Practical Nurse (LPN) #126 revealed she had the
facility's portable phone in the resident's room for the resident to make a phone call. Further observation
revealed the LPN did not have PPE on while in the room.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
If continuation sheet
Page 7 of 8
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Concord Health & Rehab Ctr
1242 Crescent Drive
Wheelersburg, OH 45694
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 10/30/19 at 11:06 A.M. interview with LPN #126 revealed the staff does not wear the PPE unless they
come into contact with the resident. She verified she did not have PPE on while in the resident's room and
the also verified the resident was in contact isolation.
Review of the facility policy titled, Standard and Transmission Based Precautions, dated 11/28/17 revealed
transmission-based precautions referred to the precautions implemented in addition to standard
precautions, that were based upon the means of transmission in order to prevent or control infections.
Transmission-based precautions would be maintained as long as necessary to prevent the transmission of
infection.
Event ID:
Facility ID:
366381
If continuation sheet
Page 8 of 8