Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pinnacle Health & Rehab Canton during CMS and state inspections, most recent first.
Housekeeping and maintenance services were not adequately provided to keep resident rooms, hallways, the shower room, dining room, and laundry room sanitary and orderly. Surveyors observed strong urine and feces odors throughout the facility, a broken picture frame taped together, a strong urine odor at a resident room door, and multiple areas with chipped or missing paint, broken fixtures, stained surfaces, soiled items on the floor, and uncleanable surfaces. An LPN, the laundry aide, and the Maintenance Director confirmed several of the findings.
Failure to Verify Required Training for Contracted Nursing Staff: The facility did not ensure contracted nursing staff obtained required education in abuse and neglect, resident rights, and dementia care before working independently with residents. Surveyors reviewed three CNAs and one LPN who worked multiple shifts through the AllShifts App, and their files lacked evidence of the required training. The DON stated the facility relied on AllShifts for the training records and did not provide the education itself.
A resident's eMAR was left open on an unattended medication cart outside a resident room, making protected health information visible and easily accessible to residents, visitors, or other unauthorized persons. No staff were present in the area when surveyors observed the issue, and a CNA/Medication Technician later acknowledged the unsecured cart and closed the eMAR after coming from the nurses' station.
Failure to Monitor Psychotropic Medication Side Effects: The facility did not develop or implement complete care plans with measurable goals and interventions for psychotropic medication use for three residents. One resident with depression was receiving antidepressant and anti-anxiety meds, another resident with Parkinsons, depression, and delusional disorder was receiving antidepressant, anti-anxiety, and antipsychotic meds, and a third resident with anxiety disorder, dementia with psychotic disturbance, delusional disorders, and major depressive disorder was receiving antipsychotic and anti-anxiety meds. Although the care plans called for Q-shift monitoring of side effects and effectiveness, the clinical records lacked evidence that monitoring was being done, and the DON stated the facility had never monitored anyone for side effects of the medications identified.
The facility failed to have the IDT review and revise care plans within the required timeframe after MDS assessments for several residents. Records showed IDT meetings were held before or after completed MDS assessments, and for one resident there was no evidence of an IDT meeting after the admission assessment. The SW confirmed the timing issues and that some care plans were not reviewed and completed within 7 days of the IDT meetings.
The facility failed to monitor and document side effects and effectiveness for psychotropic and anti-anxiety medications for three residents. One resident with major depressive disorder had orders for Lexapro, Remeron, and PRN lorazepam, another resident with Parkinson's disease, depression, and delusional disorders had orders for duloxetine and risperidone, and a third resident with anxiety disorder, dementia with psychotic disturbance, and delusional disorders received risperidone and buspirone. Although care plans directed Q-shift monitoring, the clinical records lacked evidence that the required side-effect monitoring was completed, and the DON confirmed this during interview.
Kitchen Sanitation and Food Labeling Deficiencies: A surveyor observed a dirty wall fan, heavily soiled air vent, partially dislodged ceiling tiles, and a food mixer with chipped paint and dried residue. The dry storage room and freezer contained multiple unlabeled food items, and the walk-in refrigerator and freezer floors were rusty. The Food Service Supervisor confirmed the findings.
QA Committee failed to ensure the prior POC was effective after an annual LTC recertification survey. On follow-up, surveyors recited F583 for PHI confidentiality, F584 for housekeeping and maintenance services, and F689 for an environment free of accident hazards for the same reasons previously cited, and the findings were discussed with the DON.
The facility failed to maintain infection control practices when staff handled soiled linen unbagged and without gloves, including a CNA and an RN carrying linen against their bodies to the soiled linen hamper. The facility also failed to place a resident with an open, draining wound on EBP; staff observed only gloves being used during linen removal, and the room lacked EBP signage and a PPE cart despite active wound care orders and recent treatment for cellulitis.
Incomplete investigation of alleged injury of unknown origin: A resident reported that a CNA pressed the resident’s forehead and pulled the resident’s ear, but the SW’s investigation was limited to interviews with the resident and the CNA. Required interviews with other staff, residents, and applicable witnesses were not completed, and the investigation was closed with no findings.
A CNA failed to notify the charge nurse before moving a resident after a witnessed fall, contrary to facility accident, incident, and fall policies requiring immediate nurse assessment before moving the resident. The resident's arm became caught in the wheelchair during the move, the charge nurse was not told the resident had fallen, and the provider was not notified of the incident or the resident's arm pain; the resident was later found to have a right humeral head fracture.
Exposed Sharp Metal on Hallway Heater Cover: A surveyor observed a base board heater cover in a hallway partially off and exposing sharp metal fins. The DON confirmed the finding and stated that residents ambulate around the facility and move around in wheelchairs.
A resident with a documented fall risk experienced an unwitnessed fall when their call bell was not within reach, contrary to care plan interventions requiring staff to ensure accessibility and encourage its use.
A facility failed to maintain a resident's dignity by not grooming them properly over three days, despite their dependency on staff for daily living activities. Additionally, an RN incorrectly identified a medication during a pass, telling a resident that a PreserVision ARDES 2 tablet was TUMS. The DON confirmed these practices were unacceptable.
The facility failed to maintain a sanitary and comfortable environment, as observed during a tour. Issues included dirty floors, stained tiles, and uncleanable surfaces on equipment and wheelchairs. These deficiencies were confirmed by the Maintenance Director and Administrator.
The facility failed to update and implement care plans for residents, leading to deficiencies in care. Two residents had call bells out of reach, contrary to their care plans. Another resident with PTSD lacked an updated trauma-informed care plan, and a resident with dementia had no goals or interventions for behaviors in their care plan.
The facility failed to properly label and remove expired medications from a medication cart and did not maintain appropriate storage temperatures for biologicals in two refrigerators. Insulin pens were found expired or without opened dates, and medications like Ozempic and Trulicity were stored at incorrect temperatures due to ice buildup in the refrigerators.
The facility did not conduct PASRR Level II evaluations for two residents with mental health diagnoses whose stays extended beyond 30 days. Both residents were initially admitted for short-term convalescence, but their stays became long-term without the necessary PASRR Level II referrals. This was confirmed by the Social Service Director and discussed with the DON.
A facility failed to implement a baseline care plan within 48 hours for a resident with COPD. Despite having active medication orders for respiratory issues, the care plan lacked goals and interventions for the resident's condition. This deficiency was confirmed during a record review with a surveyor.
A resident with cerebral palsy had a care plan that was not updated to reflect the discontinuation of a wrist brace. Despite observations and staff interviews confirming the resident had not used a brace for over a year, the care plan still included outdated information. The DON confirmed the care plan was incorrect.
A patient lift in the hallway was found missing a sling bar safety clip, posing a potential accident hazard. The DON confirmed the deficiency during the survey.
A facility failed to provide trauma-informed care for a resident with PTSD, who was cognitively intact and distressed by loud noises. The resident's care plan did not include identification of PTSD triggers, as required by facility policy. The LSW admitted that while new residents had trauma-informed care plans, long-term residents like this one had not been updated.
Surveyors found deficiencies in kitchen safety and temperature monitoring, including improper facial hair protection and missing temperature logs for dish machines and refrigeration units.
The facility failed to properly contain garbage, as observed by surveyors during a kitchen tour. Trash was stored in an open-top cart outside the kitchen, leaving it exposed and potentially attracting pests. The Food Service Director confirmed the practice of keeping trash in the open bin before moving it to a larger trash trailer.
The facility's kitchen walk-in freezer was not maintained in good repair, with a significant ice build-up preventing the left fan from running and causing the right fan to make noise. The Food Service Director confirmed these issues, noting that the freezer had been worked on earlier in the year but continued to malfunction.
Housekeeping and Maintenance Deficiencies
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in resident rooms, hallways, the shower room, dining room, and laundry room over 3 days of survey. During the initial tour, the facility was observed to smell of stale urine and feces throughout. On a later tour, a picture hanging by a resident room had a broken frame held together with scotch tape, and another picture across the hall had a frame coming apart; an LPN confirmed the finding. Surveyors also noted a very strong urine odor at the door of a resident room, with a wet floor sign at the entrance, and the facility again smelled of urine and feces throughout during a subsequent tour. During an environmental tour with the Maintenance Director, surveyors observed multiple areas with chipped, missing, or broken surfaces and uncleanable conditions. Findings included a resident's wheelchair with ripped armrests, clean briefs and clothing on a closet floor, chipped or missing paint on a bathroom door trim, a toilet seat stained yellow in the shower room, numerous commode buckets, soiled gloves and briefs on the floor, a chipped and missing shower transition strip, a dirty and stained toilet bowl in a resident room, chipped or missing paint on hallway heaters, a broken wall light cover, chipped or missing paint on a bathroom doorframe, and black marks with chipped or missing paint on dining room walls. In the laundry room, surveyors observed wooden folding tables and laundry carts with chipped or missing paint, a wooden frame under a dryer with chipped or missing paint, a floor with chipped or missing paint, a drying rack with worn surfaces exposing untreated wood, and a dusty or dirty wall exhaust fan. The laundry aide and Maintenance Director both confirmed the laundry room and environmental findings.
Failure to Verify Required Training for Contracted Nursing Staff
Penalty
Summary
The facility failed to implement and maintain an effective training program for nursing staff contracted through the AllShifts App in the areas of dementia care, resident rights, and abuse and neglect. During a complaint investigation, surveyors reviewed four contracted professionals—three CNAs and one LPN—and found that each had worked multiple shifts at the facility without evidence in their files that they had completed the required education before independently providing services to residents. Review of the facility’s staffing sheets showed that CNA #8, CNA #9, CNA #10, and LPN #3 each began working through AllShifts and completed multiple shifts during the reviewed timeframe. Their employee files lacked evidence of training in Abuse and Neglect, Resident Rights, and dementia. The DON stated that the facility relied on AllShifts’ packet for each contracted professional and did not provide education to staff contracted through the App. When asked for proof of the required training, the DON contacted AllShifts but was unable to provide evidence that the training had been completed prior to the end of the survey.
Unsecured Medication Cart Exposed Resident eMAR
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when surveyors observed an unattended medication cart outside a resident room with a fully open computer monitor displaying Resident #3's electronic Medication Administration Record (eMAR). The eMAR was visible and easily accessible to residents, visitors, or other unauthorized persons, and no staff were observed in the area at the time. One resident was seen in the hall, and about 1 minute later a CNA/Medication Technician came from behind the nurses' station, approached the medication cart, acknowledged that it was unsecured, and closed the eMAR, stating, "I was only over there at the nurses station." The issue was discussed with the DON during an interview.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to develop and implement complete care plans with measurable goals and interventions for psychotropic medication use for 3 residents. For Resident #3, who was admitted with major depressive disorder and was receiving Remeron, Lexapro, and Lorazepam, the care plan stated that antidepressant and psychotropic side effects were to be monitored and documented each shift, including changes in behavior, cognition, gait, appetite, bowel function, and other adverse reactions. However, the clinical record lacked evidence that the resident was being monitored for side effects from antidepressant or psychotropic medication use. For Resident #7, who was admitted with Parkinsons, depression, and delusional disorder and was receiving Risperdal and Duloxetine, the care plan addressed antidepressant and anti-anxiety medication use with instructions to monitor for side effects and effectiveness each shift and to monitor for safety. The record also noted the resident was taking antipsychotic medication Risperdal, but the facility failed to develop goals and interventions for antipsychotic use. The clinical record lacked evidence that the resident was being monitored for side effects from antidepressant and anti-anxiety medication use. For Resident #6, who was admitted with anxiety disorder, dementia with psychotic disturbance, delusional disorders, and major depressive disorder and was receiving Risperdal and Buspirone, the care plan included psychotropic and anti-anxiety medication monitoring with documentation of target behaviors and side effects each shift. Despite these care plan entries, the clinical record lacked evidence that the resident was being monitored for side effects from anti-anxiety or psychotropic medication use. During interview, the DON stated the facility had never monitored anyone for side effects of the medications identified in the report.
Failure to Review and Revise Care Plans After MDS Assessments
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT), including resident and/or representative participation to the extent possible, after each MDS assessment for 5 of 16 residents reviewed for care planning. For one resident, an MDS admission assessment was completed on 8/12/25, but the clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. On 9/23/25, the Social Services Director stated that an IDT meeting was not held following that admission assessment. For other residents, the record showed IDT meetings were held before or after the completed MDS dates rather than within the required timeframe for care plan review and revision. One resident had an annual MDS completed on 1/22/25 with the IDT meeting held on 1/16/25, and a quarterly MDS completed on 10/23/24 with the IDT meeting held on 10/17/24. Another resident had a quarterly MDS completed on 1/22/25 with the IDT meeting held on 1/16/25. Two additional residents had quarterly MDS assessments completed on 11/6/24 and 2/5/25, with IDT meetings held on 10/31/24 and 1/30/25, respectively. One resident had a quarterly MDS completed on 6/18/25 with the IDT meeting held on 6/12/25. During interviews, the Licensed Social Worker confirmed that IDT meetings were scheduled either the week before or the week of the MDS, and also confirmed that two residents' care plans were not reviewed and completed within 7 days of the IDT meetings.
Lack of Monitoring and Documentation for Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor and document targeted side effects to support the use of psychotropic medications for three residents reviewed for unnecessary medications. One resident with major depressive disorder had active orders for Lexapro, Remeron, and PRN lorazepam for anxiety or restlessness, and the care plan directed staff to monitor and document side effects and effectiveness each shift; however, the clinical record lacked evidence that monitoring for side effects of these medications was performed. Another resident with Parkinson's disease, depression, and delusional disorders had active orders for duloxetine and risperidone, and the care plan included detailed monitoring for side effects and effectiveness each shift, but the record again lacked evidence of monitoring for side effects of the antidepressant, antipsychotic, and anti-anxiety medications. A third resident with anxiety disorder, dementia with psychotic disturbance, and delusional disorders was receiving risperidone and buspirone. The care plan and medication orders directed staff to monitor psychotropic and anti-anxiety medications for side effects and effectiveness each shift, but the resident's clinical record lacked evidence of such monitoring. During interviews on 9/23/25, the DON confirmed that the clinical record lacked evidence of monitoring for the side effects of antipsychotic and anti-anxiety medications for the residents reviewed.
Kitchen Sanitation and Food Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure foods were properly labeled. During a kitchen tour with the Food Service Supervisor, a surveyor observed a dusty and dirty wall fan in the dish room, two ceiling tiles partially fallen out of the ceiling grid, and a wall air vent heavily soiled with dust. The food mixer had chipped and missing paint on the mix arm and base, along with dried food particles and dried liquid residue on the base. In the dry storage room, ten large bags of cereal were not labeled. The walk-in refrigerator floor was extremely rusty, and the walk-in freezer floor was rusty. Six large bags of breaded patties in the freezer were also not labeled. The Food Service Supervisor confirmed the findings during interview, and the Food Service Director was later informed of the observations.
QA Committee Failed to Ensure Prior POC Was Effective
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure that the Plan of Correction for deficiencies cited during the annual Long Term Care Recertification Survey on 11/19/25 was effective. On the follow-up survey on 12/30/25, surveyors determined that the same deficiencies would be recited again for the same reasons: F583 for failure to ensure the confidentiality of protected health information, F584 for failure to provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment, and F689 for failure to ensure that the resident's environment was free of accident hazards. These findings were discussed with the DON during an interview on 12/30/25 at 1:45 p.m.
Infection Control Failures With Soiled Linen Handling and EBP
Penalty
Summary
The facility failed to maintain an infection control program related to the handling of soiled linen. On 9/22/25, a CNA was observed leaving a resident room carrying a large armful of unbagged soiled linen against her body without gloves. The CNA confirmed she should have been wearing gloves, the linen should have been bagged, and it should not have been carried next to her body. The DON later confirmed the finding. On 9/24/25, a CNA was observed carrying an armful of unbagged soiled linen against her body to the shower room and placing it in the soiled linen hamper without gloves. The CNA confirmed she carried the linen unbagged and ungloved. Later that morning, an RN was observed carrying unbagged soiled linen to the shower room and placing it in a soiled linen hamper. The RN stated she came from a resident room and knew the soiled linen should have been bagged, and she confirmed the finding during the interview. The facility also failed to follow Enhanced Barrier Precautions for a resident with an open and draining wound. On 9/23/25, a CNA was observed removing bed linens from a resident’s bed using only gloves in a room with EBP. The resident, R35, had diagnoses including cellulitis of the right lower limb and rash and nonspecific skin eruption, had received antibiotics for soft tissue infection and cellulitis in August 2025, and had active orders beginning 9/9/25 for wound care to open, weeping areas on the right lower leg. Survey observations found no EBP signage or PPE cart outside R35’s room, while other LTC rooms had EBP signs and PPE carts. The IP stated residents with wounds requiring care need to be on EBP, and the RN and DON gave differing statements about whether R35 should have been on EBP.
Incomplete Investigation of Alleged Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury of unknown origin involving one resident. The resident reported to the Social Worker that a CNA pressed the resident’s forehead and pulled the resident’s ear. Facility policy required all reports of resident abuse, neglect, and related concerns to be promptly and thoroughly investigated, including review of the complaint, interviews with the resident, witnesses, staff with contact with the resident, and other applicable individuals, with witness reports written and signed. The Social Worker confirmed she conducted the investigation, but stated there were no findings. Review of the 5-day follow-up showed the investigation was closed with no findings, yet the Social Worker later stated she only interviewed the resident and the CNA. She confirmed she did not interview any other residents or staff and did not review other potential sources of information because she did not know she needed to. During the interview with the DON, the issue was discussed.
Failure to Follow Fall and Incident Reporting Procedures
Penalty
Summary
The facility failed to ensure treatment and care were provided in accordance with professional standards and its own Accident and Incident and Falls policies when a CNA did not notify the charge nurse before moving a resident after a witnessed fall. Facility policy stated that all accidents or incidents must be reported to the charge nurse immediately, that the victim should not be moved until examined for possible injuries, and that all falls require assessment by a licensed nurse prior to moving the resident. In this case, the resident was being wheeled in a wheelchair when the resident fell forward out of the chair and onto the floor in the hall, and the CNA then assisted the resident back into the wheelchair before notifying nursing staff. The resident later reported that the right arm and shoulder were injured during the event, and the clinical record documented that the arm was caught between the wheelchair wheel and chair while the CNA pulled the resident back up. Nursing documentation noted that the charge nurse was not told the resident had been on the floor at the time, and the incident report reflected that the resident complained of arm pain after the arm was caught in the chair. The provider was not notified at the time of the accident/incident or of the resident's complaint of arm pain, and the next day the resident was seen for shoulder pain and was found to have swelling, faint bruising, tenderness, and a right humeral head fracture.
Exposed Sharp Metal on Hallway Heater Cover
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards when a base board heater cover in the hallway across from a resident room was observed partially off and exposing sharp metal fins. On 9/22/25 at 9:53 a.m., a surveyor observed the heating unit with the front cover not secure and not fully in place. During an interview at 9:58 a.m. with two surveyors present, the DON confirmed the finding and stated that the facility has residents who ambulate around the facility and move around in wheelchairs.
Failure to Ensure Call Bell Accessibility for Resident at Risk for Falls
Penalty
Summary
A resident who was identified as being at risk for falls experienced an unwitnessed fall and was found in front of their wheelchair next to their bed. Review of the resident's care plan indicated that staff were required to ensure the call light was within reach and to encourage the resident to use it for assistance as needed. However, documentation from the post-fall assessment confirmed that the call bell was not within the resident's reach at the time of the incident. This failure to follow the care plan intervention contributed to the resident's fall.
Deficiencies in Resident Grooming and Medication Identification
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident #31, who was dependent on staff for all activities of daily living due to a diagnosis of dementia. Over three consecutive survey days, the resident was observed with long facial and chin hair, indicating a lack of grooming. Despite the facility's policy that residents should be shaved daily, interviews with CNAs revealed that if a resident refuses grooming, it should be documented, and the resident should be re-approached. However, the observations and interviews confirmed that Resident #31 was not groomed appropriately, as confirmed by the Director of Nursing. Additionally, the facility failed to correctly identify a medication for a resident, identified as Resident #242, during a medication pass. An RN incorrectly informed the resident that a PreserVision ARDES 2 chewable tablet was TUMS. The RN later admitted to the error, stating that the resident was particular about taking medications. The Director of Nursing confirmed with surveyors that providing incorrect information about medication was unacceptable practice.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an unsanitary and uncomfortable environment. During a facility environment tour, several deficiencies were observed. The bathroom across from the nurse's station had a dirty floor and stained tiles. A ceiling tile in the hallway had a large brown stain. A sit-to-stand patient lift had chipped paint and dirt, making it uncleanable. In various resident rooms, there were issues such as dust and debris in bathroom lights, dirty floors around toilets, and soiled wheelchairs with food debris. Additionally, a resident's reclining wheelchair had a torn footrest, creating an uncleanable surface. These findings were confirmed by the Maintenance Director and the Administrator during the tour.
Deficiencies in Care Plan Implementation and Updates
Penalty
Summary
The facility failed to update and implement care plans for several residents, leading to deficiencies in care. Resident #30 was observed in a wheelchair with the call bell out of reach, despite the care plan instructing that the call light should be within reach. Similarly, Resident #8, who requires a hoyer lift for transfers, had the call bell coiled up and out of reach, contrary to the care plan's instructions. These observations were confirmed by CNA #4, indicating a failure to adhere to the care plans designed to prevent falls and ensure prompt assistance. Additionally, the facility did not update the care plan for Resident #9, who was admitted with PTSD, to include trauma-informed care as required. The Licensed Social Worker acknowledged that while new residents had updated care plans, long-term residents like Resident #9 did not. Furthermore, Resident #31, who has dementia and exhibits physical and verbal behaviors, lacked a care plan with goals and interventions for mood and behaviors. This was confirmed during interviews with staff, highlighting a gap in addressing the resident's behavioral needs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and removal of expired medications from the medication cart, as well as maintaining appropriate storage temperatures for biologicals in the medication room refrigerators. During an observation, surveyors found several insulin pens, including Aspart, Basaglar, Lantus, and Lispro, that were either expired or lacked an opened date, contrary to the manufacturer's instructions. The Registered Nurse confirmed the expiration and removed the medications from availability. Additionally, the facility did not maintain the required temperature range for storing medications in two of the three refrigerators observed. The top refrigerator had excessive ice buildup, preventing the freezer door from closing, and contained medications like Ozempic, Trulicity, and Lorazepam, which were stored at incorrect temperatures. Similarly, the bottom refrigerator also had ice buildup and contained insulin pens, COVID-19 vaccines, and an unlabeled vial of Tuberculin, all stored at inappropriate temperatures. The temperature logs for both refrigerators showed that only two days in July had temperatures within the recommended range.
Failure to Conduct PASRR Level II Evaluations for Long-Term Residents
Penalty
Summary
The facility failed to ensure that two residents with specialized mental health diagnoses, whose stays extended beyond the expected 30 days, were referred for a PASRR Level II evaluation and determination. Resident #10 was admitted with a diagnosis of Schizophrenia and initially received a PASRR Level I determination indicating no further evaluation was needed due to a short-term convalescence admission. However, when Resident #10's stay transitioned to long-term, the facility did not forward the PASRR Level I to the State Mental Health Authority for a Level II evaluation. Similarly, Resident #15, admitted with Schizophrenia and Bipolar Disorder, also had a PASRR Level I determination that did not require further evaluation for a short-term stay. Like Resident #10, Resident #15's stay extended beyond the short-term period, and the facility failed to initiate a PASRR Level II evaluation. These findings were confirmed during interviews with the Social Service Director and discussed with the Director of Nursing.
Failure to Implement Baseline Care Plan for COPD Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted with active orders for medications including Advair, Ipratropium-Albuterol, Prednisone, and ProAir, all related to their COPD diagnosis. Despite these orders, the care plan initiated did not include necessary goals and interventions for the resident's respiratory concerns. This deficiency was confirmed during a review of the resident's clinical record with a surveyor, where it was noted that the care plan lacked evidence of addressing the resident's respiratory diagnoses within the required timeframe.
Failure to Update Care Plan for Discontinued Brace
Penalty
Summary
The facility failed to update the care plan for a resident with cerebral palsy, who was admitted with muscle wasting and atrophy, to reflect the discontinuation of a wrist brace. Observations revealed that the resident had bilateral hand/arm contractures and did not have a hand brace, nor did they want one. The clinical record showed an order for a brace to be worn as needed for positioning, which was discontinued, but the care plan was not updated to reflect this change. Care plan meetings were held on several occasions, yet the care plan still included outdated information about the use of braces and splints. Interviews with facility staff, including an occupational therapist, a certified nursing assistant, and a registered nurse, confirmed that the resident had not used a brace for at least a year, and the care plan was incorrect. The Director of Nursing also confirmed these findings, indicating a lapse in ensuring the care plan accurately reflected the resident's current needs and the discontinuation of the wrist brace.
Patient Lift Safety Deficiency
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to a deficiency related to a patient lift. On July 29, 2024, at 9:35 a.m., two surveyors observed a patient lift in the hallway near a resident room that was missing a sling bar safety clip. This missing safety clip posed a risk as it could potentially allow the sling strap to come off during a lift or transfer. At 10:15 a.m., the Director of Nursing confirmed the absence of the safety clip on the patient lift during the surveyor's observation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a current diagnosis of Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, paranoid schizophrenia, anxiety disorder, bipolar disorder, and major depressive disorder, was found to be cognitively intact with a mental status score of 15 out of 15. Despite this, the facility did not identify the resident's PTSD triggers or incorporate them into a care plan, as required by their policy on Trauma Informed Care. During interviews, the resident expressed that loud noises were particularly distressing, yet no staff had inquired about their triggers or how to assist them. The Licensed Social Worker (LSW) acknowledged that the resident's care plan lacked necessary measures for trauma-informed care, admitting that while new residents had these considerations included, long-term residents had not been updated accordingly. This oversight was confirmed during a review of the resident's care plan with a surveyor.
Deficiencies in Kitchen Safety and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to its Refrigeration Policy and Dish Machine Temperature Log procedures during a kitchen tour conducted by surveyors. Observations revealed that a kitchen worker with facial hair was not wearing proper facial hair protection, as it was pulled down below the mouth while working. Additionally, another kitchen worker was observed without any facial hair protection. These observations were confirmed by the Food Service Director during an interview. Furthermore, the facility did not consistently monitor and record temperatures for the dish machine and refrigeration units. The Dish Machine Temperature Log was missing entries for several dates in April 2024, specifically for breakfast on the 5th, 19th, and 24th. Similarly, the Refrigerator/Freezer Temperature Log was missing entries for various times in July 2024, including the 4th, 24th, and 25th. These lapses in documentation were discussed with the Food Service Director by a surveyor.
Improper Garbage Containment
Penalty
Summary
The facility failed to ensure that garbage was properly contained, as observed during a survey. On July 29, 2024, from 9:40 a.m. to 10:10 a.m., two surveyors conducted an initial kitchen tour with the Food Service Director. During this tour, they observed trash being stored in an open-top cart outside the facility next to the kitchen area. This lack of proper containment left the garbage exposed, creating the potential for the harborage and feeding of pests. The Food Service Director confirmed that the trash is kept in the open bin and then wheeled to the large trash trailer later in the day.
Walk-in Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen walk-in freezer in good repair and safe operating condition. During a kitchen tour conducted by two surveyors, it was observed that the walk-in freezer had a significant ice build-up, which prevented the left fan of the freezing unit from running. Additionally, the right fan was making a loud noise as it spun and hit the ice build-up nearby. The Food Service Director confirmed these observations and stated that the freezer had been worked on in February 2024 but had not functioned properly since then. Despite multiple repair attempts, the freezer continued to experience ice build-up issues.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rumford Community Home | 13.2 mi | ★★★★★ | 0 | 0 |
| Sandy River Center | 14.8 mi | ★★★★★ | 21 | 0 |
| Maine Veterans Home - So Paris | 16.8 mi | ★★★★★ | 5 | 0 |
| Market Square Health Care Center, Llc | 17.9 mi | ★★★★★ | 4 | 0 |
| Orchard Park Rehab & Living Center | 18.1 mi | ★★★★★ | 18 | 0 |
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