Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
Based on medical records review and staff interview, the facility failed to provide a shower after resident
request because it was not a scheduled shower day. This affected one (#289) of one residents reviewed for
choices. Facility census was 89.
Findings include:
Review of Resident #289's medical record revealed he admitted to the facility 02/01/20. Diagnoses included
aftercare following joint replacement surgery, major depressive disorder, and anxiety.
At the time of the survey, Resident #289's Minimum Data Set (MDS) was not due nor completed. Review of
Resident #289's preference care plan, initiated 02/08/20, revealed his preferences for daily life and
person-centered care that were important or somewhat important to him included receiving a shower. The
care plan stated personal preferences would be respected and that resident preferences would be
considered and, to the extent possible, accommodated. Interventions included encouraging resident
choices in regards to activities of daily living.
Review of a nursing progress note 02/09/20 revealed Resident #289 requested to know what his shower
days were and staff informed him his scheduled shower days were Tuesday and Fridays. The note stated
Resident #289 then requested a shower because he got spaghetti on his shirt during dinner. The progress
note revealed a state-tested nursing assistant (STNA) offered to change Resident #289's clothes and
bedding. The note documented Resident #289 refused to allow staff to change his shirt. The note revealed
the nurse on duty went to speak to resident and encouraged him to allow staff to change his shirt and
bedding because they were soiled with spaghetti. The note revealed Resident #289 refused to have his
shirt and bedding changed and stated he would wait until staff could give him a shower and that he did not
want anything else from staff.
Interview on 02/12/20 at 11:38 A.M. with Director of Nursing (DON) revealed the facility used a shower
schedule based on resident preference. He stated residents were typically scheduled for showers two days
a week but could always request additional showers per preference. He stated if a resident requested a
shower, even if it were not on a shower day, staff should accommodate the preference. Upon reading
Resident #289's progress note dated 02/09/19, DON confirmed Resident #289 should have been provided
a shower following his request.
Interview on 02/12/20 at 3:53 P.M. with Regional Director of Clinical Services #119 stated the facility did not
have a policy for providing showers but was based on resident preference.
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 9
Event ID:
366446
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and review of the facility policy, the facility failed to notify Resident #38's family
and physician of a bruising incident while the resident was receiving an anticoagulant. This affected one
(#38) of one residents reviewed for notification of change. Facility census was 89.
Findings include:
Review of Resident #38's medical record revealed an admission date of 07/18/16 with diagnoses including
cerebral infarction, abnormal coagulation profile, paroxysmal atrial fibrillation, chronic kidney disease (stage
three), and anxiety disorder.
Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively
impaired and required the extensive assistance of one person for bed mobility, transfer, dressing, hygiene
and bathing needs. The MDS further revealed that Resident #38 required the extensive assistance of two
people for toileting needs and she utilized a wheelchair device.
Review of Resident #38's care plan dated 08/11/2016 revealed the resident was at risk for bleeding and
bruising related to the utilization of the medication Eliquis (a blood thinner) with interventions to monitor and
report abnormal bruising and monitor for medication side effects of bruising.
Review of a nursing note dated 12/09/19 at 4:53 P.M. that documented a skin assessment was completed
and that Resident #38 had a large bruise to the left knee and scattered bruising to the left lower extremity.
Review of the documentation revealed no evidence of the family or physician being notified regarding the
bruise.
Review of Resident #38's progress notes revealed a social services note dated 02/06/20 at 5:55 P.M.
documented the resident had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 (indicating the
resident was moderately cognitively impaired).
Observation of Resident #38 left knee on 02/11/20 at 2:25 P.M. revealed a large yellow and dark purple
bruise across the lower half of the resident's knee that appeared to not be a fresh bruise due to the noted
coloration.
Interview with the Director of Nursing (DON) and the Corporate Registered Nurse (RN) #119
02/12/20 at 1:08 P.M. revealed the facility was not sure if the family or physician were notified of the large
bruise to Resident #38's knee and confirmed there was no documentation that the family or physician was
notified of the bruising. Further interview with the DON revealed the facility was notifying the family of the
incident at that time, but they should have been notified at the time of the incident.
Review of the facility policy titled Change of Condition dated 04/03 revealed a significant change in
condition includes resident with wound , pressure sore or other skin disorder and the Unit Supervisor or
Charge Nurse will notify the resident, physician and guardian/interested family members of all changes as
stated above.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366446
If continuation sheet
Page 2 of 9
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
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 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
records review and staff interview, the facility failed to provide a Notice of Medicare Non-Coverage
(NOMNC) and Skilled Nursing Facility Beneficiary Protection (SNF/ABN) as required to a resident. This
affected one (#153) of three residents reviewed for appropriate NOMNC and SNF/ABN notices. Facility
census was 89.
Residents Affected - Few
Findings include:
Review of Resident #153's medical record revealed she admitted to the facility 06/09/18. Diagnoses
included fusion of the spine and muscle weakness.
Review of Resident #153's Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact.
Review of a form titled Beneficiary Notice-Residents discharged Within the Last Six Months, revealed
Resident #153 was discharged from Medicare A services on 09/04/19, had benefit days remaining, and
remained in the facility. Review of a form titled, SNF Beneficiary Protection Notification Review, revealed
Resident #153's first day of Medicare Part A skilled services began 09/08/19 and her last covered day of
Part A service was 09/20/19. The form stated the facility/provider initiated the discharge from Medicare Part
A services when benefit days were not issues. The form also revealed both the SNF/ABN and NOMNC
forms were not issued and should have been.
Interview on 02/13/20 at 9:36 A.M. with Administrator confirmed Resident #153 was not issued a NOMNC
or SNF/ABN as required. Administrator stated the facility did not have a policy to guide staff on accurate
issuing of NOMNC and SNF/ABN's but they followed Medicare guidelines.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366446
If continuation sheet
Page 3 of 9
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
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** 3. Review of
the medical record for Resident #72 revealed an admission date of 04/12/18 with diagnoses including but
not limited to end stage renal disease, diabetes mellitus, dementia, depression, and hypertension.
Residents Affected - Few
Review of the annual comprehensive MDS assessment dated [DATE] revealed Resident #72 had no
cognitive deficits, and received anticoagulant therapy.
Review of physicians orders dated January 2020 revealed Resident #73 was not on any anticoagulant
medications.
Review of January 2020 Medication Administration Record (MAR) revealed Resident #72 did not receive
any anticoagulant therapy.
Interview was conducted on 02/12/20 at 4:21 P.M. with the MDS Nurse #74 and she verified Resident #72
was not receiving any anticoagulant therapy and the annual MDS dated [DATE] was not coded correctly.
Based on record review, staff interview, review of the Resident Assessment Instrument (RAI) manual and
policy review, the facility failed to accurately code resident's Minimum Data Set (MDS) assessment
regarding hospice services, dental status and anticoagulant. This affected three (#68, #3 and #72) out of 30
residents sampled during the survey. The facility census was 89.
Findings include:
1. Review of Resident #68's medical record revealed an admission date of 05/31/18 with diagnoses
including chronic kidney disease, vascular dementia with behavioral disturbances, celiac disease, personal
history of malignant neoplasm of breast (cancer), personal history of malignant neoplasm of uterus
(cancer), and cerebral infarction (an area of brain tissue that has dead cells from blockage or narrowing in
the arteries supplying blood and oxygen to the brain).
Review of Resident #68's MDS quarterly assessment dated [DATE] revealed the resident was severely
cognitively impaired and was totally dependent on the assistance of one person for bed mobility, dressing,
eating, toileting, transferring and hygiene needs. Further review of the 01/02/20 MDS Section O - Special
Services revealed the Resident #68 utilized oxygen therapy services and was not receiving hospice
services.
Review of Resident #68's physician order dated 06/26/18 revealed to admit the resident to hospice services
with a terminal diagnosis of cerebral arteriosclerosis.
Review of Resident #68's care plan updated on 01/15/20 revealed the resident was admitted to hospice on
06/26/18 with interventions to collaborate care with facility staff, contact hospice for change in resident
conditions, and to monitor break through pain.
Interview with the Hospice Registered Nurse (RN) # 150 02/12/20 at 4:28 P.M. confirmed Resident #68 was
receiving hospice nursing service one time per week at the time of the 01/02/20 MDS assessment and RN
#150 stated she began caring for Resident #68 in 06/2019.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366446
If continuation sheet
Page 4 of 9
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview with the MDS Nurse #74 on 02/12/20 3:57 P.M. verified the quarterly MDS dated [DATE] was
coded incorrectly as MDS did not document Resident #68 utilized hospice services.
Review of the RAI 3.0 manual dated 10/19 revealed a section titled Section O: Special Treatments,
Procedures, and Programs and instruction for the facility to review the resident's medical record to
determine if the resident received services in the last fourteen days and to code residents identified as
being in a hospice program for terminally ill persons where an array of services is provided for the palliation
and management of terminal illness and related conditions.
2. Review of Resident #3's medical record revealed she admitted to the facility 07/26/17. Diagnoses
included diabetes mellitus and cognitive communication deficit.
Review of Resident #3's MDS assessment dated [DATE] revealed she had a moderate cognitive
impairment. The MDS also revealed she did not have loosely fitting full or partial dentures.
Review of Resident #3's dental care plan, last revised 10/14/19, revealed she had impaired dentition and
was at risk for oral problems related to wearing dentures. The care plan stated Resident #3's dentures fit
loosely, and the Power of Attorney (POA) was aware and declined dental services 11/27/18 and 10/14/19.
Interview on 02/12/20 at 8:11 A.M. with MDS Nurse #57 confirmed Resident #3's dental care plan, last
revised 10/14/19, revealed Resident #3's dentures fit loosely. MDS Nurse #57 confirmed the MDS was
completed inaccurately and would submit a modification.
Interview on 02/12/20 at 3:54 P.M. with Regional Director of Clinical Services #119 revealed the policy did
not have a policy on MDS accuracy but followed the (Resident Assessment Instrument) RAI Manual.
Review of a facility policy titled, Dental Services, dated 11/14/17, revealed it was the policy of the facility to
assist residents in obtaining routine and emergency dental care and that dental needs were identified
through the resident assessment process and would be addressed as needed in the resident plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366446
If continuation sheet
Page 5 of 9
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
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 staff interview, the facility failed to revise a care plan to include new behaviors.
This affected one (#13) of one residents reviewed for behaviors. The facility identified 24 residents with
behavioral healthcare needs. Facility census was 89.
Findings include:
Review of Resident #13's medical record revealed she admitted to the facility 01/28/18. Diagnoses included
Alzheimer's disease and bipolar disorder.
Review of Resident #13's Annual Minimum Data Set (MDS), dated [DATE] revealed the resident had severe
cognitive impairment.
Review of Resident #13's care plan, last reviewed 01/23/20, revealed Resident #13 ambulated via
wheelchair and front-wheeled walker (FWW) depending on the day his abilities differed daily. The care plan
also revealed he had behaviors of wandering, as well as verbal and physical aggression.
Review of Resident #13's nursing progress notes revealed on 01/07/20 Resident #13 had been observed
four times ambulating in the hallway only wearing an incontinence brief and house shoes. Resident was
agitated but able to be redirected. A nursing note dated 01/08/20 revealed Resident #13 was observed
ambulating in the hallway wearing only an incontinence brief and house shoes. The note revealed he was
agitated but was able to be redirected to his room. A nursing progress note dated 01/10/20 revealed
Resident #13 came out of his throughout the shift with no pants and yelled at staff. The progress note
stated he was, very hard to redirect and became very angry, but that staff was able to redirect him to his
room after multiple attempts.
Review of a progress note dated 02/02/20 documented Resident #13 was up throughout the night in his
wheelchair without pants and attempted to go into another resident's room. The progress note revealed he
was difficult to redirect. A progress note dated 02/03/20 revealed Resident #13 was in the hallway yelling
and shaking and slamming his walker down without clothes. Review of Resident #13's care plan revealed it
had not been revised to include him wandering in the hallway without pants.
Interview on 02/12/20 at 2:19 P.M. with Social Service Assistant (SSA) #54 stated the interdisciplinary team
was responsible for ensuring behavior care plans were revised as needed. SSA #54 stated she read
progress notes to review for new behaviors. She confirmed Resident #13 had behaviors of wandering in the
hall without clothes. SSA #54 confirmed wandering was in Resident #13's care plan, but that it had never
been revised to include wandering without pants or other clothing. SSA #54 confirmed that Resident #13's
new behavior warranted a revision to the care plan to guide staff on appropriate in interventions and to
accurately reflect the care plan for Resident #13. Further interview with Regional Director of Clinical
Services #119 revealed the facility did not have a policy to guide staff on care plan revisions, but they
followed the RAI manual for care planning.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366446
If continuation sheet
Page 6 of 9
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observations, staff interview and review of the facility policy, the facility failed to
monitor and document bruising episodes during skin assessments as related to Resident #38's
anticoagulant use. This affected one (#38) of two residents reviewed for skin conditions. The facility census
was 89.
Residents Affected - Few
Findings include:
Review of Resident #38's medical record revealed an admission date of 07/18/16 with diagnoses including
cerebral infarction, abnormal coagulation profile, paroxysmal atrial fibrillation, chronic kidney disease (stage
three), and anxiety disorder.
Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively
impaired and required the extensive assistance of one person for bed mobility, transfer, dressing, hygiene
and bathing needs. The MDS further revealed Resident #38 required the extensive assistance of two
people for toileting needs and she utilized a wheelchair device.
Review of Resident #38's care plan dated 08/11/2016 revealed the resident was at risk for bleeding and
bruising related to the utilization of the medication Eliquis (a blood thinner) with interventions to monitor and
report abnormal bruising and monitor for medication side effects of bruising.
Review of Resident #38's December Medication Administration record revealed head to toe skin
assessments were to be completed every shift every Monday effective 11/13/19 and an assessment was
completed on day and night shift on 12/2/19, 12/9/19, 12/16/19, 12/23/19, and 12/30/19.
Review of Resident #38's documented weekly skin assessments dated 12/02/19, 12/09/19, 12/16/19,
12/23/19 and 12/30/19 revealed no information related to the resident's bruising incidents.
Further review of a nursing note dated 12/09/19 at 4:53 P.M. documented a skin assessment was
completed and that Resident #38 had a large bruise to the left knee and scattered bruising to the left lower
extremity. Further review of Resident #38's progress notes revealed no documentation of the left knee
bruise or any other bruise monitoring.
Review of Resident #38's progress notes revealed a social services note dated 02/06/20 at 5:55 P.M.
documented the resident had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 (indicating the
resident was cognitively impaired).
Observation of Resident #38 left knee on 02/11/20 at 2:25 P.M. revealed a large yellow and dark purple
bruise across the lower half of the resident's knee that appeared to not be a fresh bruise due to the noted
coloration.
Interview with the Director of Nursing (DON) and the Corporate Registered Nurse (RN) # 119
02/12/20 at 1:08 P.M. revealed the facility did not document bruising incidents during skin assessments and
they only documented wounds or pressure ulcers. The interview further revealed staff just placed a check
mark on the MAR to indicate a skin assessment was completed and no detail regarding bruising were
documented.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366446
If continuation sheet
Page 7 of 9
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of the facility policy titled Skin Assessment dated 12/02/15 revealed at the time of
admission/re-admission residents were evaluated for special needs related to skin care and weekly skin
integrity checks are completed by licensed personnel and daily skin is checked during Activity of Daily
Living (ADL) care. The policy further revealed areas of alteration in skin that are present, or which develop
subsequently to admission are monitored on a weekly basis and an assessment of the area is performed
and recorded in the resident's medical record.
Event ID:
Facility ID:
366446
If continuation sheet
Page 8 of 9
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
366446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Grove Transitional Care
5919 Blue Star Drive
Grove City, OH 43123
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 0790
Provide routine and 24-hour emergency dental care for each resident.
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, observation, staff and resident interview and policy review, the facility failed to
provide dental services in a timely manner after Power-of-Attorney (POA) request the service. This affected
one (#3) of one residents reviewed for dental services. Facility census was 89.
Residents Affected - Few
Findings include:
Review of Resident #3's medical record revealed she admitted to the facility 07/26/17. Diagnoses included
diabetes mellitus and cognitive communication deficit.
Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed she had a moderate cognitive
impairment. Review of Resident #3's dental care plan, last revised 10/14/19, revealed she had impaired
dentition and was at risk for oral problems related to wearing dentures.
The care plan stated Resident #3's dentures fit loosely, and that POA was aware and declined dental
services 11/27/18 and 10/14/19. Interventions included making arrangements to get dentures examined for
repairs as needed. A form titled, IDT Advance and Careplan Conference Sheet, dated 11/21/19, revealed
Resident #3's POA did not want to attend the care conference via phone but did request a dental
appointment be scheduled for new dentures. The record review revealed no evidence of Resident #3 being
seen by the dentist.
Observation and subsequent interview on 02/10/20 at 1:55 P.M. revealed Resident #3's top dentures were
loose and became misplaced when Resident #3 talked. When inquired about the fit of her dentures,
Resident #3 stated the fit, could be better.
Interview on 02/11/20 at 12:36 P.M. with Social Service Assistant (SSA) #54 confirmed Resident #3's
dentures fit her loosely. SSA #54 confirmed Resident #3's POA was aware of Resident #3's dental status
and had denied dental services 11/27/18 and 10/14/19. SSA #54 confirmed on 11/21/19, via telephone,
Resident #3's POA had requested her to see the dentist to get fitted for new dentures as her current
appliance no longer fit. SSA #54 stated she added Resident #3 to the dental list for the visiting dentist for
the January 2020 visit. She stated the dentist did visit the facility January 2020, but that he had 56 residents
to see, and did not have time to see all the residents on the list, including Resident #3. SSA #54 revealed
the dentist would not be back until, March or April, of 2020. SSA #54 confirmed the facility did not timely
respond to Resident #3's POA's dental service request.
Interview on 02/11/20 at 1:41 P.M. with Administrator stated a dental appointment was being arranged for
Resident #3.
Review of a facility policy titled, Dental Services, dated 11/14/17, revealed it was the policy of the facility to
assist residents in obtaining routine and emergency dental care and that referrals to a dental provider
would be made as appropriate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366446
If continuation sheet
Page 9 of 9
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Back to topCitations
7 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.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 February 13, 2020 survey of MEADOW GROVE TRANSITIONAL CARE?
This was a inspection survey of MEADOW GROVE TRANSITIONAL CARE on February 13, 2020. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MEADOW GROVE TRANSITIONAL CARE on February 13, 2020?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."
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.