Inspection visit
Health inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of resident personal funds accounts, policy and procedure review and interview the facility failed to
ensure residents who were within $200.00 of the Social Security Income (SSI) resource limit of $2,000.00
were assisted in spending down the money so the resident did not lose their Medicaid eligibility. This
affected two residents (#32 and #60) of five residents reviewed for personal funds.
Residents Affected - Few
Findings include:
1. Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including respiratory failure, chronic obstructive pulmonary disease, diabetes, hypertension and
dysphagia. Record review revealed the resident did not have a financial power of attorney or legal guardian.
Review of Resident #60's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/13/2022 revealed
the resident's speech was impaired and she was severely cognitively impaired.
Review of Resident #60's personal funds account on 07/11/2022 revealed she had $9,179.76 in her
personal funds account. As of 03/25/2022 Resident #60's account exceeded the $2,000.00 SSI resource
limit.
On 07/14/22 at 12:58 P.M. interview with Business Office Manager (BOM) #700 confirmed Resident #60
exceeded the $2,000.00 SSI resource limit. BOM #700 indicated she had notified Resident #60 quarterly
her personal funds account exceeded the SSI resource limit. However, the resident was non-verbal and
was unable to participate in conversations regarding the funds. BOM #700 was unaware of anything
Resident #60 needed. BOM #700 revealed she also had spoken with Resident #60's brother (specific dates
not provided), but stated he had not done anything with her money.
On 07/14/22 at 1:08 P.M. interview with Social Service Designee (SSD) #240 revealed she was not aware
Resident #60's personal funds account exceeded the SSI resource limit. SSD #240 indicated Resident #60
had personal needs the money could be used for.
Review of the undated Resident Trust Fund Accounting and Records policy revealed the provider shall give
written notification to each resident who received Medicaid benefits and whose funds were managed by the
provider, when the amount in the resident's account reached $200.00 or less than the resource limit.
2. Review of Resident #32's medical record revealed the resident was admitted to the facility on
(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:
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
07/18/2022
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 0569
Level of Harm - Minimal harm
or potential for actual harm
[DATE] with diagnoses including COVID-19, chronic obstructive pulmonary disease, diabetes, hemiplegia,
hypertension, dysphagia, seizures and traumatic brain injury.
Review of Resident #32's annual MDS 3.0 assessment, dated 05/16/2022 revealed the resident's speech
was rarely/never understood and he had severely impaired cognition.
Residents Affected - Few
Review of Resident #32's personal funds account revealed on 07/11/2022 Resident #32 had $5,939.31 in
his personal funds account. As of 03/25/2022 Resident #32's account exceeded the $2,000.00 SSI
resource limit.
On 07/14/22 at 12:58 P.M. interview with BOM #700 verified Resident #32 exceeded the $2,000.00 SSI
resource limit. BOM #700 revealed she had spoken with Resident #32's brother (date not provided), and he
was supposed to work on spending the money, but stated he had not had time to do so. BOM #700
revealed she was unaware of anything the resident might need.
On 07/14/22 at 1:08 P.M. interview with Social Service Designee (SSD) #240 revealed she was not aware
Resident #32's personal funds account exceeded the SSI resource limit. SSD #240 indicated Resident #32
had personal needs the money could be used for.
Review of the undated Resident Trust Fund Accounting and Records policy revealed the provider shall give
written notification to each resident who received Medicaid benefits and whose funds were managed by the
provider, when the amount in the resident's account reached $200.00 or less than the resource limit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review medical record review, policy and procedure review and interview the facility failed to ensure
Resident #45's medical record contained evidence of contact information of the practitioner responsible for
the care of the resident, resident representative information including contact information, advance directive
information, all special instructions or precautions for ongoing care, as appropriate, and comprehensive
care plan goals when the resident was discharged to the hospital. This affected one resident (#45) of one
resident reviewed for hospitalization.
Findings include:
Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] and
discharged on 07/05/2022 with diagnoses including acute respiratory failure, type II diabetes, morbid
obesity, anxiety and dysphagia.
Review of Resident #45's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/27/2022 revealed
the resident's speech was clear, he made himself understood, he understands others and his cognition was
moderately impaired.
Review of Resident #45's progress note, dated 07/04/2022 revealed Resident #45's daughter in-law was
contacted, and she informed the nurse Resident #45 had called her and he was talking about hurting
himself. Resident #45 thought he was on a bus in [NAME] Virginia. Resident #45's daughter in-law wanted
the resident sent to the emergency department. Resident #45 was asked if he wanted to go to the
emergency room for evaluation and he said yes. Resident #45 was sent to the emergency department and
was admitted to the hospital.
Further review of Resident #45's medical record revealed no evidence the emergency department and/or
the hospital was provided with information for Resident #45's including contact information of the resident's
physician, resident representative contact information, advance directive information, and comprehensive
care plan goals as required.
On 07/14/22 at 1:55 P.M. interview with the Director of Nursing (DON) confirmed there was no evidence in
Resident #45's medical record of physician contact information, Resident #45's representative information
including contact information, advance directive information, all special instructions or precautions for
ongoing care, and comprehensive care plan goals when the resident was discharged to the hospital. The
DON revealed she send a copy of the resident's face sheet, history and physical, and physician orders to
the hospital. The DON confirmed there was no evidence of the additional information being sent with
Resident #45 as required.
Review of the facility Transfer to Hospital for admission policy, revised April 2002 revealed a completed
transfer form was to be sent with the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 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
medical record review, facility policy and procedure review and interview the facility failed to ensure bed
hold information was provided to Resident #45 and/or the resident's representative at the time of transfer to
the hospital. This affected one resident (#45) of one resident reviewed for hospitalization.
Finding include:
Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] and
discharged on 07/05/2022 with diagnoses including acute respiratory failure, type II diabetes, morbid
obesity, anxiety and dysphagia.
Review of Resident #45's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/27/2022 revealed
the resident's speech was clear, he made himself understood, he understands others and his cognition was
moderately impaired.
Review of Resident #45's progress note, dated 07/04/2022 revealed Resident #45's daughter in-law was
contacted, and she informed the nurse that Resident #45 had called her and he was talking about hurting
himself. Resident #45 thought he was on a bus in [NAME] Virginia. Resident #45's daughter in-law wanted
the resident sent to the emergency department. Resident #45 was asked if he wanted to go to the
emergency room for evaluation and he said yes. Resident #45 was sent to the emergency department and
was admitted to the hospital.
Further review of Resident #45's medical record revealed no evidence Resident #45 or his responsible
party were provided or notified of the facility bed hold policy/information at the time of his transfer.
On 07/14/22 at 1:55 P.M. interview with the Director of Nursing (DON) confirmed neither Resident #45 or
his responsible party were provided required bed hold information at the time of transfer/discharge.
Review of the facility Bed Hold Policy, revised 11/30/2018, revealed before a nursing facility transferred a
resident to a hospital or the resident goes on a therapeutic leave, the nursing facility must provide written
information to the resident or the resident representative related to bed hold.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of Centers for Medicare and Medicaid (CMS) guidance and interview the
facility failed to timely complete and submit a Minimum Data Set (MDS) assessment for Resident #63, who
had been discharged from the facility. This affected one resident (#63) of 20 residents whose MDS 3.0
assessments were reviewed.
Residents Affected - Few
Findings include:
Review of Resident #63's closed medical record revealed the resident was admitted to the facility on [DATE]
with diagnoses including unspecified dementia, muscle weakness and repeated falls. The resident was
discharged from the facility on 05/13/22.
Review of a nursing progress note, dated 05/13/22, revealed the resident was discharged to a Hospice
house.
Review of the MDS 3.0 assessments completed for Resident #63 revealed there had not been a discharge
MDS assessment completed related to the resident's discharge from the facility as of 07/13/22.
On 07/14/22 at 11:10 A.M. interview with the Director of Nursing (DON) verified there had not been a
discharge MDS assessment completed for Resident #63 since her discharge on [DATE].
Review of the online CMS guidance titled Long Term Care Facility Resident Assessment Instrument 3.0
User's Manual Version 1.17.1
(https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf), dated 10/2019 revealed a
discharge assessment-return not anticipated must be completed when the resident was discharged from
the facility and the resident was not expected to return to the facility within 30 days, must be completed 14
days after the discharge date , and must be submitted within 14 days after the MDS completion date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0641
Ensure each resident receives an accurate assessment.
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, review of Centers for Medicare and Medicaid (CMS) guidance and
interview the facility failed to ensure Resident #14's Minimum Data Set (MDS) 3.0 assessments were
accurate to reflect the resident's limitations in functional mobility/range of motion. This affected one resident
(#14) of 20 residents whose MDS 3.0 assessments were reviewed.
Residents Affected - Few
Findings include:
Record review revealed Resident #14 was admitted to the facility on [DATE] and had diagnoses including
chronic respiratory failure, tracheostomy status, schizophrenia, neuromuscular dysfunction of bladder,
anxiety disorder, major depressive disorder, gastrostomy status, dysphagia, unspecified protein-calorie
malnutrition, functional quadriplegia, anemia, viral hepatitis C, and personal history of traumatic brain injury.
Review of the quarterly MDS 3.0 assessments, dated 01/08/22 and 04/07/22 revealed Resident #14 had
intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15.
The resident was assessed to be dependent on two staff members for bed mobility, transfers and toileting
and was dependent on one staff member for eating. Section G0400 of the assessment was marked as not
assessed for functional limitation in range of motion to upper extremities and lower extremities.
Review of the Physical Function Observation form, dated 03/30/22 revealed the resident had functional
limitation in range of motion to the bilateral upper and lower extremities.
On 07/12/22 at 9:25 A.M. Resident #14 was observed in bed with obvious contractures of both the upper
and lower extremities present.
On 07/12/22 at 4:07 P.M. interview with MDS Nurse #370 verified the MDS assessments, dated 01/08/22
and 04/07/22 had been marked as the resident not being assessed for limited range in motion. MDS Nurse
#370 revealed this was due to nursing staff not having documented an assessment of the limited range of
motion during the seven day lookback period for the MDS assessment. MDS Nurse #370 verified Resident
#14 had limited range of motion present to both upper and lower extremities since being admitted to the
facility which should have been coded on both of the above MDS assessments.
On 07/13/22 at 8:40 A.M. interview with Certified Occupational Therapy Assistant #470 verified Resident
#14 had contractures present to both upper and both lower extremities since being admitted to the facility.
Review of the online CMS guidance titled Long Term Care Facility Resident Assessment Instrument 3.0
User's Manual Version 1.17.1
(https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf), dated 10/2019 revealed
coding for functional Range of Motion (ROM) was a three step process which included testing the resident's
upper and lower extremity ROM. If the resident was noted to have limitation of upper and/or lower ROM,
review G0110 and/or directly observe the resident to determine if the limitation interfered with function or
placed the resident at risk for injury. Code G0400 A/B as appropriate based on the assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview the facility failed to ensure a Preadmission Screening and
Resident Review (PASARR) assessment for Resident #23 was accurately completed upon admission to the
facility. This affected one resident (#23) of three residents reviewed for timely and accurate PASARR
assessments.
Residents Affected - Few
Findings include:
Record review revealed Resident #23 was admitted to the facility on [DATE] and had diagnoses including
bipolar disorder and schizophrenia upon admission.
Review of the PASARR, dated 09/06/21 revealed the assessment was not accurate as it did not include the
resident's diagnoses of bipolar disorder and schizophrenia.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/21/22 revealed the resident
had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of
15. The assessment revealed the resident required extensive assistance from two staff members for bed
mobility and toileting and extensive assistance from one staff member for eating.
On 07/13/22 at 3:30 P.M. interview with the social service designee verified the PASARR assessment
completed for Resident #23 on 09/06/21 had not been filled out accurately as it did not include the resident
had diagnoses of bipolar disorder and schizophrenia and the error had been missed by the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure comprehensive care plans were
developed and implemented for Resident #14 and Resident #29 related to functional mobility/contractures.
This affected two residents (#14 and #29) of three residents reviewed for range of motion.
Findings include:
1. Record review revealed Resident #29 had an initial admission date of 04/29/22 and re-admission on
[DATE]. Resident #29 had diagnoses including quadriplegia, traumatic brain injury, seizures, depression,
mood disorder, constipation, urinary incontinence, chronic cough, and gastrostomy.
Review of Physical Function Assessments, dated 05/11/22 and 06/15/22 revealed the resident had
impairment to both upper extremities and hands.
Record review revealed no comprehensive care plan had been developed for Resident #29 to identify and
provide an individualized plan to address the resident's impairments (range of motion needs) to the bilateral
upper extremities and hands.
On 07/14/22 at 9:28 A.M. observation of Resident #29 with the Director of Nursing (DON) verified the
resident had limitations in range of motion and bilateral hand contractures. The DON also verified the facility
had not developed a comprehensive and individualized plan of care to address and provide interventions
related to range of motion/contractures.
2. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including
chronic respiratory failure, tracheostomy status, schizophrenia, neuromuscular dysfunction of bladder,
anxiety disorder, major depressive disorder, gastrostomy status, dysphagia, unspecified protein-calorie
malnutrition, functional quadriplegia, anemia, viral hepatitis C and personal history of traumatic brain injury.
Review of the Physical Function Observation form, dated 03/30/22 revealed the resident had functional
limitation in range of motion to the bilateral upper and lower extremities.
Review of the quarterly MDS 3.0 assessment, dated 04/07/22 revealed the resident had intact cognition
evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The assessment
revealed the resident was dependent on two staff members for bed mobility, transfers and toileting and
dependent on one staff member for eating.
Record review revealed no comprehensive care plan had been developed for Resident #14 to identify and
provide an individualized plan to address the resident's impairments (range of motion needs) to the bilateral
upper and lower extremities.
On 07/12/22 at 9:25 A.M. Resident #14 was observed in bed. The resident as observed with obvious
contractures to both the upper and lower extremities present.
On 07/12/22 at 4:07 P.M. interview with MDS Nurse #370 verified Resident #14 had contractures present to
both the upper and lower extremities. MDS Nurse #370 also verified the facility had not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0656
developed and implemented a comprehensive plan of care to address and provide intervention for the
contractures/limitations in range of motion.
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:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 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
medical record review and interview the facility failed to ensure residents and/or their responsible party
were invited and participated in quarterly care conferences/interdisciplinary team meetings. This affected
two residents (#20 and #25) of three residents reviewed for care conferences.
Findings include:
1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including low
back pain, binge eating disorder, major depressive disorder, anxiety, hypertension, obstructive sleep apnea,
morbid obesity due to excess calories, history of falling, muscle weakness and difficulty in walking.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/29/22 revealed Resident #20
had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 our of
15. The assessment revealed the resident required extensive assistance from one staff member for bed
mobility and toileting, limited assistance from one staff member for transfers and was independent with no
setup or physical help from staff for eating.
Review of the social service progress notes, dated 01/01/22 through 07/11/22 revealed no evidence of care
conferences being conducted for the resident.
On 07/12/22 at 9:35 A.M. interview with Resident #20 revealed the resident denied being invited to or
attending care conferences with facility staff to discuss his care.
On 07/12/22 at 4:05 P.M. interview with Regional Director of Clinical Operations (RDCO) #990 verified there
was no evidence of care conferences being held for Resident #20 in 2022.
2. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including
schizophrenia, dementia in other diseases classified elsewhere with behavioral disturbance, history of
falling, insomnia, hyperlipidemia, anxiety disorder and need for assistance with personal care.
Review of the quarterly MDS 3.0 assessment, dated 04/29/22 revealed the resident had moderately
impaired cognition evidenced by a BIMS assessment score of 02 out of 15. This assessment revealed the
resident was assessed to exhibit rejection of care one to three days, required extensive assistance from two
staff members for bed mobility, toileting, and transfers and required supervision with setup help only for
eating.
Review of the social service progress notes, dated 07/17/21 through 07/05/22 revealed no documentation
of care conferences being conducted for the resident to include the resident's responsible party.
On 07/12/22 at 4:05 P.M. interview with Regional Director of Clinical Operations (RDCO) #990 verified there
was no evidence of care conferences being held for Resident #20 between 07/2022 and 07/05/22.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0657
This deficiency substantiates Complaint Number OH00131505.
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:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to develop and implement comprehensive and
individualized range of motion treatment and services for Resident #29 to address contractures/limitations
in range in motion to the resident's bilateral upper extremities/hands. This affected one resident (#29) of
three residents reviewed for range of motion.
Findings include:
Record review revealed Resident #29 had an initial admission date of 04/29/22 and re-admission on
[DATE]. Resident #29 had diagnoses including quadriplegia, traumatic brain injury, seizures, depression,
mood disorder, constipation, urinary incontinence, chronic cough, and gastrostomy.
Review of Physical Function Assessments, dated 05/11/22 and 06/15/22 revealed the resident had
impairment to both upper extremities and hands.
Record review revealed no comprehensive care plan had been developed for Resident #29 to identify and
provide an individualized plan to address the resident's impairments (range of motion needs) to the bilateral
upper extremities and hands.
Review of daily task documentation for Resident #29 revealed no evidence the resident was provided range
of motion exercises or use of splinting devices to address the bilateral upper extremity impairments.
On 07/13/22 at 11:30 A.M. observation of Resident #29 revealed the resident's hands were contracted into
closed fists. When asked if he could open his hands, the resident was unable to do so.
On 07/13/22 at 2:45 P.M. interview with Regional Director of Clinical Services #990 verified the resident had
bilateral contractures to both upper extremities with no splint devices or services in place.
On 07/14/22 at 9:28 A.M. observation of Resident #29 with the Director of Nursing (DON) verified the
resident had limitations in range of motion and bilateral hand contractures. The DON also verified the facility
had not developed a comprehensive and individualized plan of care to address and provide interventions
related to range of motion/contractures.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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
medical record review and interview the facility failed to ensure appropriate diagnoses/justification for the
use of psychoactive medications for Resident #16. This affected one resident (#16) of five residents
reviewed for unnecessary medication use.
Findings include:
Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including
COVID-19, muscle weakness, dysphagia, dementia, congestive heart failure, depression, anxiety,
hypothyroidism and disorders of the bladder.
Review of physician's medication orders revealed the resident had orders for psychoactive medications,
including the anti-psychotic medication, Olanzapine (Zyprexa) 10 milligrams by mouth daily and the
anti-convulsant medication, Depakote 125 mg twice daily.
Review of the resident's current diagnoses revealed no evidence the resident had a diagnosis of psychosis
or other appropriate diagnosis to ensure the justified use of the Zyprexa or Depakote.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/11/22 revealed the resident had severe
cognitive impairment.
On 07/13/22 at 10:01 A.M. interview with Regional Director of Clinical Services #990 verified the lack of
evidence to support the justified use of Olanzapine (Zyprexa) or Depakote for Resident #16.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Potential for
minimal harm
Based on record review and interview, the facility failed to ensure the Medical Director (MD) and/or MD
representative attended quarterly QAA meetings. This had the potential to affect all 60 residents residing in
the facility.
Residents Affected - Many
Findings include:
Review of the QAA sign in sheets revealed the Medical Director (MD) and/or MD representative had not
attended the quarterly QAA meetings held in the facility between October 2021 and June 2022 - Quarter 4
(October to December) 2021, Quarter 1 (January to March) 2022 and Quarter 2 (April to June) 2022.
On 07/18/22 at 2:20 P.M. interview with the Administrator verified the Medical Director (and/or MD
representative) had not been present during the last three quarterly QAA committee meetings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
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
366381
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2022
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 0888
Ensure staff are vaccinated for COVID-19
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, facility policy and procedure review, Centers for Medicare and Medicaid (CMS)
Quality Safety and Oversight (QSO) 22-09-ALL review and interview the facility failed to implemented their
COVID-19 vaccination plan and failed to ensure 100 percent of staff were fully vaccinated against
COVID-19, were temporarily delayed or had been granted a medical or religious exemption as required.
This had the potential to affect all 60 residents residing in the facility.
Residents Affected - Few
Findings include:
On 01/14/22 CMS issued QSO Memo 22-09-ALL requiring all providers ' and suppliers ' staff to have
received the appropriate number of (COVID-19 vaccine) doses by the timeframes specified unless
exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). CMS
provided guidance effective 90 days after the issuing of the QSO memo (April 2022), facility staff
vaccination rates under 100% constituted non-compliance under the rule.
On 07/11/22 review of the facility undated COVID Vaccine Matrix Log revealed two of 95 employees, State
Tested Nursing Assistant (STNA) #650 and STNA #850 were not fully vaccinated against COVID-19. Both
employees were noted to be partially vaccinated against COVID-19. Neither STNA had documented
evidence of having a granted medical or religious exemption or as being temporarily delayed in receiving
the COVID-19 vaccination. This resulted in the staff vaccination rate being 97.9 percent.
Review of the COVID-19 Vaccination Record Card for State Tested Nursing Assistant (STNA) #650
revealed documentation the STNA had received the first dose of the Pfizer COVID-19 vaccine on 12/22/21.
There was no documentation of the second dose of the vaccine being administered.
Review of the COVID-19 Vaccination Record Card for STNA #850 revealed documentation the STNA had
received the first dose of the Moderna COVID-19 vaccine on 01/27/22. There was no documentation of the
second dose of the vaccine being administered.
Review of the facility daily staffing schedules for nursing staff, dated 06/14/22 through 07/14/22 revealed
STNA #650 and STNA #850 worked multiple shifts in a position which required providing direct care to
residents.
On 07/14/22 at 2:52 P.M. interview with the Director of Nursing (DON) verified STNA #650 and STNA #850
were not fully vaccinated, newly hired and did not have a granted medical or religious exemption.
Review of the facility policy titled COVID-19 Vaccine Plan, Exemptions/Accommodations/Temporary Delays
& Tracking, most recently revised on 02/15/22 revealed all employees were required to be considered fully
vaccinated by the deadline as stated in the provided regulations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366381
If continuation sheet
Page 15 of 15
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Back to topCitations
12 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.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F758 - Medication Errors
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.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- 0888GeneralS&S Dpotential for harm
Ensure staff are vaccinated for COVID-19
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
FAQ · About this visit
Common questions about this visit
What happened during the July 18, 2022 survey of CONCORD HEALTH & REHAB CTR?
This was a inspection survey of CONCORD HEALTH & REHAB CTR on July 18, 2022. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CONCORD HEALTH & REHAB CTR on July 18, 2022?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death."
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.