Schoenbrunn Healthcare
SCHOENBRUNN HEALTHCARE in NEW PHILADELPHIA, OH — inspection on March 26, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
and interviews, the facility failed to ensure the privacy of Resident #3 during incontinence care.
This
Findings include:
Review of the medical record for Resident #3 revealed admission to the facility on [DATE] with diagnoses including lung disease, heart failure, diabetes, anxiety, gastric reflux, high blood pressure, arthritis, and a bleed of the gastric system.
Further review of the medical record revealed a quarterly minimum data set (MDS) assessment was completed on 01/14/26.
The MDS assessment revealed Resident #3 was cognitively intact and was dependent on staff with personal hygiene, toileting, bathing, dressing, transfer and mobility.
The MDS assessment also indicated Resident #3 was always incontinent of both bowel and bladder.Observation on 03/25/26 at 8:58 A.M. of incontinence care of Resident #3 revealed certified nurse's aide (CNA) #137 gathering appropriate supplies and entering the double occupancy room of Resident #3 and closing the door. Resident #3's roommate was present in the room sitting in his wheelchair.
There was an undrawn privacy curtain located in the middle of the room dividing the space. CNA #137 began providing incontinence care of Resident #3 without pulling the privacy curtain to ensure the privacy of Resident #3. Resident #3 was laying in his bed and CNA #137 removed his adult brief exposing his genital area for cleaning then had Resident #3 roll to his left side toward the wall exposing his buttocks to his roommate while she continued to clean Resident #3 buttocks.
The privacy curtain was not used at anytime during the care provided by CNA #137.Interview on 03/25/26 at 9:04 A.M. with Resident #3 revealed sometimes the CNAs forget to pull the curtain during incontinence care and it sometimes bothers him that he is exposed to his roommate when he is in the room. CNA #137 was present for interview with Resident #3 and acknowledged she did not pull the privacy curtain for Resident #3 and immediately apologized to him.
Review of the facility policy undated and titled Resident Rights, revealed residents have the right to privacy and confidentiality.
Further review revealed personal privacy to include personal care.This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2800638.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
365152 03/26/2026
Schoenbrunn Healthcare 2594 East High Avenue New Philadelphia, OH 44663
the food and nutrition service, including a qualified dietician.
director of food and nutrition services (Dietary Manager) and educate dietary aides.
This affected all
9:43 A.M. with the Administrator revealed they have a company called Health Care Services Group (HCSG) that started as a contract company to run the kitchen.
The facility uses their employees and conduct oversight.Review of personnel credentials revealed Dietary Manager #217 did not have the qualifications to be a Dietary Manager.
She was not certified and her degrees were not in the areas to qualify her for the position, despite her years of working in a kitchen.
Interview on 03/23/26 at 11:02 A.M. with Dietary Manager #217 revealed she had been employed by the facility as a cook.
When HSCG was contracted they hired the kitchen employees the facility had employed.Interview on 03/24/26 at 4:13 P.M. with Dietary Manager #217 revealed HCSG took over running the kitchen on 10/20/25.
Dietary Manager #217 was promoted to manage the kitchen on 12/01/25.
She revealed [NAME] #100 was the credentialed Dietary Manager and stepped down when the contract company took over due to the complexity of the computer system. [NAME] #100 informed HCSG she was stepping down as the Dietary Manager at the beginning of November and recommended Dietary Manager #217, who was a Cook, to take over.
She informed HCSG at that time Dietary Manager #217 was not credentialed.
They informed the facility they would pay for Dietary Manager #217 to take the classes to receive credentials as a Certified Dietary Manager.
Dietary Manager #217 verified she had not started classes.
She speculated the new company might be waiting to see if she would be able to handle the position before putting money into her training.This deficiency represents non-compliance investigated under Complaint Number 2701233.
365152 03/26/2026
Schoenbrunn Healthcare 2594 East High Avenue New Philadelphia, OH 44663
Observation and interviews related to the meal appearance and palatability revealed on 03/26/26 at 1:25 P.M. Resident #78 was sitting on the side of the bed eating his lunch.
The resident appeared to have two bowls of pasta salad on his tray that he was eating with a fork.
The surveyor commented related to the pasta salad and Resident #78 revealed the bowls were chicken noodle soup not pasta salad.
There was not any broth in either bowl of chicken noodle soup.
The resident was eating it with a spoon.
The resident indicated he requested two bowls of chicken noodle soup daily for lunch.
When asked if they ever have broth he indicated sometimes, they do but usually he has to eat the soup with a fork.
Interview and observations on 03/23/26 at 1:40 P.M. with Certified Nurse Aide (CNA) #111 verified Resident #78 received two bowls of chicken noodle soup that did not contain broth.2.Observation of the dinner tray line on 03/23/26 at 5:28 P.M. revealed broccoli was being served in a bowl.
The broccoli appeared to not be holding it's shape. At 5:54 P.M. the broccoli was served into a bowl to be tested.
The broccoli did not hold shape.
The texture was mushy and watery.Interview on 03/23/26 at 6:04 P.M. with [NAME] #106 verified the broccoli always gets mushy. He indicated he cooks it on the stovetop in a tin on low. 3.
Observation on 03/24/26 at 1:16 P.M. of Resident #78's lunch meal revealed he had two bowls of pasta on his tray. He was eating them with a fork.
Interview on 03/24/26 at 1:16 P.M. with the resident verified the bowls were supposed to contain his chicken noodle soup.
One bowl had no visible broth, and the second bowl had a small amount of liquid on the bottom.
Dietary Manager #217 was present during the observation and interview.
She asked the resident if he would rather have a flat noodle verses the spring noodle and he said yes.
She included the spring noodles must be soaking up the broth.
Observation of the tin of soup in the kitchen on 03/24/26 at 1:18 P.M. revealed it was dry at the bottom when the noodles were pushed aside.
There was no broth in the soup at all.
The tin appeared as a tin of noodles with carrots.Dietary Manager #217 was present during the observation.
She verified there was not broth in the tin of soup in the kitchen.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, Complaint Numbers 2701233, 2661187.
365152 03/26/2026
Schoenbrunn Healthcare 2594 East High Avenue New Philadelphia, OH 44663
intolerances, and preferences, as well as appealing options.
value were available to residents who chose not to eat food that was initially served or who
facility census was 86.Findings include:Interview on 03/23/26 at 11:02 A.M. with Dietary Manager #217 revealed the kitchen needed major plumbing work where the cement floor was removed in areas to access broken pipes in the kitchen and dry storage.
They had no use of the kitchen during 19 days of replacing the pipes and re-cementing the floor. An alternative menu was approved by corporate to be able to serve meals from the dining room using roasters, crockpots, microwave, griddle, and a waffle maker.
Between 02/26/26 and 03/16/26 meals were made out of the dining room and were not cooked in the kitchen.
There was only one choice for each meal.
There were no second option and the only substitutes available were a peanut butter and jelly sandwich and a deli sandwich.
Interview on 03/23/26 at 1:28 P.M. with Resident #72 revealed there are no second options or substitute items. He does not get to order.
They just give him what they want and he doesn't like the peas and carrots and rice he had on his plate.Interview and observation on 03/23/26 at 1:33 P.M. with Resident #78 revealed his meal ticket included he wanted chocolate milk, which was not served on his tray,Interview and observation on 03/23/26 at 1:35 P.M. with Resident #48 revealed she does not order.
She is just served whatever they give her.
Her preference was to get two percent milk, cranberry juice and fruit punch on her tray.
She only was served the fruit punch.Interview and observation on 03/23/26 at 1:42 P.M. with Resident #71 during the lunch meal revealed when the kitchen was down, she was served burnt pizza with no other option.
She indicated even when she tells them what she wants she doesn't usually get it.
Her ticket indicated she was to receive ice for every meal which was not delivered on her tray.
She was also to receive fruit punch per her lunch ticket which was not delivered on her lunch tray.Interview on 03/25/26 at 2:36 P.M. with Dietary Manager #217 verified they did not have a second meal of similar nutritional value available during the kitchen shut down.
Further verified, they are training new kitchen dietary aides and with the kitchen in the dining room and just moving back to the kitchen on 03/18/26 she had not given them the time they need for training for their duties including the tray line.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, Complaint Numbers 2789794,
- 365152 03/26/2026
Schoenbrunn Healthcare 2594 East High Avenue New Philadelphia, OH 44663
assistance.
was available as ordered.
This affected one resident (#49) of six residents reviewed who were
Resident #49's medical record revealed a 09/20/23 admission with diagnoses including hypertensive urgency, renal dialysis, glaucoma, and legally blind.
Review of the quarterly 01/13/26 Minimum Data Set (MDS) Assessment revealed he was independent for daily decision making and required set up for meals.
Physician orders included a renal diet, regular texture, thin consistency, double protein no orange juice, no bananas, no potatoes, 1800 milliliter fluid restriction with blue scoop bowl and plate guard for renal failure.Observation of the supper tray line on 03/23/26 at 5:28 P.M. revealed the meal was cheeseburger on a bun, broccoli, tater tots, and pineapple tidbits.The ticket for Resident #49 included he was to have a blue scoop bowl and a plate guard.
The tray only had a plate guard.Interview on 03/23/26 at 5:40 P.M. with Dietary Aide #107 revealed she did not have any blue scoop plates.
She included there used to be about 10 and now they can not find any.
Dietary Manager #217 included she went to the room and floor and could not find any.
She included she is having the Administrator buy some.Observation of the lunch tray line on 03/24/26 revealed the first tray was plated at 11:36 A.M. At 11:58 A.M. it was revealed there were no scoop bowls for Resident #49's meal.
The lunch meal was smothered chicken thigh, whole kernel corn, oven brown potatoes, cornbread and sliced pears.
Interview on 03/24/26 at 11:58 A.M. with [NAME] #104 revealed they had three of them (scoop bowls) and now they can not find any.Interview on 03/25/26 at 9:35 A.M. with [NAME] #104 revealed they still had not found or obtained any blue scoop bowls.Interview on 03/25/26 at 9:43 A.M. with Dietary Manager #217 revealed scoop bowls were ordered 03/23/26 and were due to be delivered 03/26/26.This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2800638.
365152 03/26/2026
Schoenbrunn Healthcare 2594 East High Avenue New Philadelphia, OH 44663
Observation of the supper tray line on 03/23/26 at 5:12 P.M. revealed tray line temperatures were taken.
There was no observation of the temperature of the milk being obtained. At 5:46 P.M. the surveyor asked for the milk to be tested when placed on a tray.
The milk was 40 degrees Fahrenheit.Observation of the kitchen on 03/24/26 at 11:08 A.M. revealed there were five cups of milk poured and dated 03/24/26 on the three compartment sink with the milk gallon next to them. At 11:29 A.M. when the tray line began the glasses of milk were placed on a tray in the milk chest by Dietary Manager #217.At 11:50 A.M. a glass of milk was removed from the milk chest and placed on a tray.
The surveyor asked for a temperature reading of the milk.
The temperature was 46.9 degrees Fahrenheit. On 03/24/26 at 11:52 A.M. [NAME] # 104 verified the temperature of the milk was not obtained before the tray line started.
The milk was above the 41 degree guideline for refrigeration.
Review of the food temperature logs for March 2026 revealed there were 71 meals served.
There was not a milk temperature reading for 47 of the 71 meals.
Interview on 03/24/26 at 1:22 P.M. with Dietary Manager #217 verified the milk temperatures were not consistently monitored.
Review of the facility's Record of Food Temperatures policy revised 2022 included potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit.
Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy.3.
Observation of the kitchen milk chest on 03/23/26 at 2:53 P.M. revealed the thermometer read 40 degrees.
There were eight cartons of 1% milk with a use by date of 03/23/26 in the milk chest.Observation of the milk chest on 03/24/26 at 1:22 P.M. revealed there were six cartons of 1 percent milk in the milk chest.Interview on 03/24/26 at 1:22 P.M. with [NAME] #104 revealed she used two of the milk cartons for trays on 03/24/26 not realizing the use by date was 03/23/26.
The milk was served to Resident #21.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, and Complaint Numbers 2789794, 2701233, and 2661187.