Medina BSD Opco LLC

In the surveyor’s words

From the most serious findings on record at Medina BSD Opco LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690May 11, 2026

  Based on record review, observations, hospital record review, interviews, and policy review, the facility failed to ensure safe, clinically indicated, and competent Foley catheter insertion and follow up monitoring for Resident #64 and failed to follow physician orders for indwelling catheter care for Resident #37. This resulted in Immediate Jeopardy and serious life-threatening harm, negative health outcomes, and/or death for one resident (#64) when Licensed Practical Nurse (LPN) #800 performed a non ordered Foley catheter change on [DATE] while Resident #64 was visibly moving, resisting, and verbalizing pain, without clinical assessment, supervisory involvement, or medical provider notification. […]

• Actual harm, isolatedF760May 11, 2026

  Based on record review, interviews, review of manufacturer guidelines, and review of facility policies, the facility failed to ensure medications were administered in accordance with physician orders and accepted standards of practice resulting in a significant medication error for Resident #70. Actual Harm occurred on 11/14/25 when Licensed Practical Nurse (LPN) #800 failed to perform the physician ordered pre meal blood glucose check and failed to administer the prescribed Lispro insulin prior to the lunch meal. […]

• Actual harm, isolatedF686Apr 4, 2022

  Based on medical record review, interview, and policy review the facility failed to ensure a comprehensive assessment of a wound and initiation of a treatment when a wound was identified. Actual harm occurred to Resident #7 on 02/07/22 after the facility failed to comprehensively assess and initiate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #7) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #7's medical record revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated 01/11/22 indicated a potential for skin breakdown related to immobility, incontinence, decreased sensation, history of skin tears, and varied oral intakes. […]

• No harm, potential for more than minimal, widespreadF607Oct 15, 2024

  Based on personnel record review, staff interview and review of facility policy, the facility failed to ensure all new employees were screened through the State of Ohio Nurse Aide Registry (NAR) prior to employment to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This had the potential to affect all 52 residents residing in the facility. The facility census was 52. Findings include: Review of the personnel file for Physical Therapist Aide (PTA) #424 revealed a hire date of 11/21/23. There was no evidence PTA #424 was checked against the NAR prior to employment. Review of the personnel file for Licensed Practical Nurse (LPN) #531 revealed a hire date of 11/21/23. […]

• No harm, potential for more than minimal, widespreadF725Oct 15, 2024

  Based on observations, resident interviews, staff interviews, review of staff schedules, review of the staffing tool, review of the concern logs, and review of the facility assessment, revealed the facility failed to ensure adequate staffing to meet the needs of the residents. This had the potential to affect all 52 residents residing in the facility. Findings include: An interview on 10/06/24 at 10:51 A.M. with Receptionist (RCT) #414 revealed the daily staffing sheets were completed daily, but residents complained about not enough aides to assist with call lights and bathroom needs. RCT #414 revealed residents called the receptionist desk phone more on the weekends. An interview on 10/06/24 at 11:14 A.M. […]