Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Harmony Village Of Warren during CMS and state inspections, most recent first.
Failure to Report Injury of Unknown Origin: The facility did not report a resident’s ankle fracture of unknown origin to the SA. The resident had dementia, was severely cognitively impaired, required 2-person assist for transfers and bed mobility, and was on hospice with OA and DJD. Records showed the fracture was confirmed by x-ray, with no witnessed fall, reported trauma, or environmental hazards identified, and the NHA stated no FRI had been submitted.
Surveyors identified improper food storage and preparation practices, including moldy cardboard on the cooler floor, expired Italian dressing, a soiled ice scoop holder, and oatmeal served below the required hot holding temperature. These actions did not meet professional standards for food service safety.
A resident with cerebral palsy and impaired mobility was observed twice without accessible water in their room, once with the water cup out of reach and another time with no water cup present. The resident reported being unable to access water due to mobility limitations and fear of falling, and also noted that the water cup had been removed. The DON stated that fresh water should be available, but no facility policy on water provision was provided during the survey.
A resident who was discharged from Medicare Part A and remained in the facility did not receive a timely SNF/ABN notice informing them or their representative of potential financial liability for ongoing services. The Business Office Manager acknowledged the oversight, and the Administrator confirmed the expectation for timely notification.
The facility did not ensure that two residents with mental health diagnoses received appropriate PASARR Level II evaluations following a change in condition. One resident was not referred for a Level II evaluation despite a completed Level I screening indicating mental health diagnoses, and another resident's Level I screening was completed inaccurately, omitting relevant mental health information and recent antidepressant use. These actions did not comply with required PASARR procedures.
A resident with cognitive impairment and multiple diagnoses, including PTSD, did not have a care plan addressing PTSD despite documentation in two OBRA evaluations. The omission was acknowledged by both a social worker and the DON, and the facility's policy requires such diagnoses to be included in the care plan.
A resident with mood and depressive disorders was observed exhibiting distressing behaviors, and review of their care plan revealed outdated interventions referencing a psychiatric provider no longer involved in their care. Staff interviews confirmed the care plan had not been updated to reflect current treatment practices, and facility policy did not address updating interventions.
A resident with multiple chronic conditions, including hepatitis C and a history of polysubstance abuse, did not receive ordered gastroenterology and infectious disease consults for colonoscopy and hepatitis C management. Despite physician orders and the resident's agreement to the consults, the facility did not follow through, and the DON confirmed the consults were not completed.
A resident with a suprapubic catheter did not have timely catheter changes as prescribed, with observations of soiled and discolored tubing and no documentation of recent changes. Staff were unable to confirm when the last change occurred, and medical records lacked evidence of compliance with physician orders for catheter care.
The facility did not ensure that monthly medication regimen reviews were completed and documented by a licensed pharmacist for several residents, including those with complex medical conditions such as dysphagia, Alzheimer's, and heart failure. The July reviews were missing, and irregularity reports were not available when requested. The DON confirmed the missing documentation and was uncertain about the handling of irregularity reports, and the facility's pharmacy review policy was not provided during the survey.
An LPN crushed and administered delayed release and extended release medications, as well as an incorrect dosage of a cranberry tablet, to a resident with dysphagia and Alzheimer's, resulting in a medication error rate of 12.12%. The DON was notified, and the NP confirmed these medications should not be crushed, in accordance with facility policy.
The emergency egress path outside the staff entrance was found to be obstructed by construction activities, including broken ground, gravel, and barricades, which could delay or prevent evacuation during an emergency. This was confirmed by the maintenance director during the survey.
A delayed egress emergency exit door in the 300 unit did not activate its release process when pressure was applied, as observed by surveyors and confirmed by the maintenance director. This failure to comply with egress requirements could affect up to 30 occupants during an emergency evacuation.
Fire-rated cross corridor doors between the main lobby and main corridor hallway were found not to fully close, failing to resist the passage of smoke and fire as required. This deficiency, confirmed by the maintenance director, could affect up to 50 occupants by allowing smoke and fire to spread between compartments.
A portable space heater was observed running in the Human Resources Office, in violation of regulations prohibiting such devices in health care occupancies. The facility could not verify that the heater's element did not exceed the allowed temperature, and the maintenance director confirmed the finding.
A resident was not protected from physical abuse by staff, as determined through observation, interview, and record review. This failure resulted in Immediate Jeopardy and demonstrated noncompliance with federal requirements for freedom from abuse.
A resident with intact cognition reported being slapped and verbally abused by an LPN during care, with a CNA witnessing and attempting to intervene before leaving the room. The LPN continued working the remainder of their shift after the incident was reported. In a separate event, a resident with impaired cognition was slapped in the face by another resident in a common area, witnessed by a receptionist. Both incidents involved delays in immediate protective actions and reporting, resulting in substantiated abuse findings.
A resident with severe cognitive impairment and a legally appointed DPOA was discharged to an estranged family member without notifying or obtaining consent from the DPOA. Facility staff accepted a birth certificate and a phone confirmation from the resident's ex-wife, neither of whom were listed as contacts, and did not arrange for home care, physician follow-up, pharmacy, DME, or hospice services after discharge.
A resident with cognitive impairment was inappropriately touched by another resident in the dining room when no staff were present to supervise. The incident was witnessed by the Activities Director, who intervened immediately. Prior to the event, staff had discussed the perpetrator's sexual behaviors, but no formal reports were made to the DON. Both residents involved had significant care needs, and the lack of supervision enabled the incident.
The facility failed to maintain a clean and repaired environment, affecting all 126 residents. Observations revealed issues such as debris buildup in shower drains, rusted heater registers, soiled bedding, and damaged walls. Flooring was dull and discolored, with soil buildup at room entries. Interviews with the Administrator, DON, and Maintenance Director highlighted concerns about the building's condition, with maintenance staff being understaffed for most of the year.
A resident with diabetes and a history of stroke experienced high blood glucose levels, but the facility failed to notify the physician in a timely manner as required by policy. The resident's glucose levels were recorded as 450 mg/dl and 550 mg/dl, but the physician was only notified after the resident became lethargic and was sent to the hospital. The facility's policy required notifying the physician for readings over 400 mg/dl, which was not followed.
The facility failed to implement care plans for two residents, one with catheter care needs and another with dental pain, despite their intact cognition and specific medical conditions. The Director of Nursing acknowledged the absence of necessary care plans, which is against the facility's policy.
The facility did not maintain a safe environment for its 133 residents due to broken and missing floor tiles in the basement. The Maintenance/Housekeeping/Laundry Director initially claimed the tiles contained asbestos, but later expressed uncertainty. The Director admitted that corporate was not informed about the issue, and the Nursing Home Administrator was unaware of the potential asbestos. The facility also failed to provide an environmental policy on floor tiles.
A resident experienced a lack of clean linen and an unclean bathroom environment due to facility-wide linen shortages and maintenance issues. The resident reported not having their bed linen changed and was observed in a worn gown with a stained pillowcase. The bathroom had water leakage, mold, and dust buildup. The facility faced operational challenges with laundry equipment, and staff shortages in housekeeping, laundry, and maintenance contributed to the deficiency.
The facility failed to maintain accurate medical records and shower documentation for six residents. A nurse documented administering medications to a resident on leave, and there was a lack of shower documentation for seven residents over 14 days. Interviews revealed discrepancies between reported care and documented records.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident, R901, who was reviewed for alleged violations. Documentation submitted to the SA showed that R901 sustained an ankle fracture of unknown origin, but the Nursing Home Administrator did not report it to the SA and stated that it occurred during care. The resident’s medical record showed diagnoses including dementia, metabolic encephalopathy, and anemia, and that the resident was severely cognitively impaired and required two-person assistance for transfers and bed mobility. The medical record also showed x-ray results dated 5/5/26 confirming a left ankle fracture. An IDT review note stated the resident was on hospice services with osteoarthritis and DJD, was alert to self only, and had a confirmed ankle fracture with no observed or reported trauma consistent with a fall. The interdisciplinary team initiated an investigation and reviewed recent documentation, staffing reports, and incident logs, finding no witnessed falls or reported injuries, and no environmental hazards in the resident room or common areas. On 5/12/26, the NHA stated that a Facility Reported Incident had not been submitted and that a Past Non-Compliance had been completed instead; the PNC showed a compliance date of 5/6/26, but there was no documentation that the FRI had been submitted to the SA.
Deficient Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed several deficiencies in food storage and preparation practices within the facility's kitchen. In the walk-in cooler, a large piece of cardboard was found on the floor beneath a rack holding milk crates, and the cardboard's surface was covered with a spotty, black mold-like substance. Additionally, an opened 1-gallon container of Italian dressing with a use-by date that had already passed was present in the cooler. The ice scoop holder in the dining room contained a black, slimy gel on the bottom inside surface, with the tip of the ice scoop resting in the gel. These conditions were not in accordance with professional standards for food service safety as outlined in the 2017 FDA Food Code. Further, during breakfast service, approximately 45 individual covered bowls of oatmeal were observed on a tray next to the steam table, not being held at the required hot holding temperature. At a later time, 6 bowls remained, and the internal temperature of the oatmeal was measured at 125 degrees Fahrenheit, below the required 135 degrees Fahrenheit for hot holding. The Food Service Manager was unable to provide an explanation for the failure to maintain the correct temperature. These findings demonstrate a failure to prepare, store, and serve food in accordance with professional standards, as required by federal regulations.
Failure to Ensure Accessible Water for Dependent Resident
Penalty
Summary
The facility failed to ensure that water was accessible to a resident who required assistance with activities of daily living and was at risk for falls and dehydration. On two separate occasions, the resident was observed in bed without water within reach; once, the water cup was on a dresser out of reach, and another time, the water cup was missing entirely. The resident reported being unable to reach the water and expressed concern about falling if attempting to get it, and later stated that someone had removed the water cup. The resident's medical record indicated diagnoses of cerebral palsy and difficulty walking, with a care plan identifying risks for falls and dehydration. The DON confirmed that fresh water should be available to residents, and the facility was unable to provide a policy regarding water provision before the survey concluded.
Failure to Issue Timely SNF/ABN Notice After Medicare Discharge
Penalty
Summary
The facility failed to provide a timely Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF/ABN) to a resident who had a Medicare Part A discharge and continued to reside in the facility. Record review showed that the resident did not receive the required notice informing them or their representative of potential financial liability for services not covered by Medicare. During interviews, the Business Office Manager acknowledged the oversight, and the Administrator confirmed that the notice should have been issued in a timely manner.
Failure to Complete and Refer PASARR Level II Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required Preadmission Screening and Resident Review (PASARR) procedures were followed for two residents with mental health diagnoses. For one resident with hemiparesis, schizoaffective disorder, anxiety disorder, and major depressive disorder, a Level I PASARR screening was completed as a change of condition, but there was no evidence of a referral for a Level II evaluation or that such an evaluation was completed, despite the resident's mental health diagnoses. The social worker confirmed that the Level II evaluation was not done, and the nursing home administrator stated that PASARRs and Level II evaluations should be completed timely per policy. For another resident with major depressive disorder and generalized anxiety disorder, the PASARR Level I Change in Condition screening form was completed inaccurately, as it failed to document the resident's current mental illness diagnosis and recent use of prescribed antidepressant medication. The social worker acknowledged the form was completed incorrectly. The facility's policy requires that individuals with or suspected of having mental disorders be referred for a Level II PASARR evaluation, but this process was not followed for these residents.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident who had documented diagnoses of PTSD in two separate OBRA evaluations completed in 2024 and 2025. The resident was admitted with multiple diagnoses, including cerebral infarction, heart failure, and major depressive disorder, and was noted to be cognitively impaired and dependent on assistance for bathing and dressing. Despite these findings and the documented PTSD diagnosis, the resident's care plan did not include interventions or goals related to PTSD. Both the social worker and the DON acknowledged the omission when questioned, and the facility's policy requires that changes in a resident's mental or psychosocial functioning be incorporated into the care plan.
Failure to Update Psychiatric Care Plan Interventions
Penalty
Summary
A deficiency was identified when the facility failed to update the interventions on a psychiatric care plan for a resident with a history of mood disorder and major depressive disorder. The resident was observed awake in bed, yelling, screaming, and swearing. The electronic medical record showed the resident was prescribed Remeron for depression, and the most recent MDS assessment indicated moderately impaired cognition with no mood indicators. The psychiatric care plan listed an intervention involving follow-up by a specific psychiatric provider agency, but this agency was no longer involved in the resident's care. During interviews, the social worker confirmed that the care plan interventions had not been updated to reflect the current treatment practices, and the DON agreed that interventions should be updated as needed. A review of the facility's care planning policy did not address the updating of interventions when care planning, contributing to the failure to revise the care plan to match the resident's current psychiatric treatment arrangements.
Failure to Obtain Ordered Gastroenterology and Infectious Disease Consults
Penalty
Summary
The facility failed to obtain required gastroenterology and infectious disease consultations for a resident who was reviewed for consults. The resident was admitted with multiple diagnoses, including dysphagia, peripheral vascular disease, anxiety, hepatitis C, hepatitis B, COPD, severe protein calorie malnutrition, alcoholism, diabetes, insomnia, sinusitis, and thyroid disease. The resident was cognitively intact and independent in transfers and bed mobility. A physician progress note documented the need for chronic disease management, specifically hepatitis C, and discussed the need for a colonoscopy and GI follow-up, to which the resident agreed. Despite active physician orders for a gastroenterology consult for colonoscopy and a consult for evaluation and management of chronic hepatitis C, these consults were not carried out. The Director of Nursing confirmed that the consults had not been followed through. A review of the facility's physician orders and clarification orders did not show any documentation addressing the completion of these physician-ordered consults.
Failure to Ensure Timely Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure timely changing of a suprapubic (SP) urinary catheter for one resident. Observations revealed that the resident's catheter tubing appeared faded, soiled, and had areas of black discoloration, with the drainage tube clouded with sediment. Interviews with staff indicated uncertainty about when the last catheter change occurred, and the resident was unsure of their last urology visit or catheter change. Record review showed the last documented urology appointment was several months prior, with physician instructions for the SP catheter to be changed every six weeks. However, there was no documentation in the facility records of any recent catheter changes, and staff were unable to provide evidence of compliance with the prescribed change schedule. The resident had a history of heart failure, chronic kidney disease, and high blood pressure, and had been readmitted to the facility multiple times. The medical record included inconsistent or outdated orders regarding catheter type and size, and lacked clear documentation of catheter change timing. Despite requests, the Director of Nursing was unable to provide documentation of catheter changes prior to the survey exit. The facility's policy required clarification orders to initiate treatment according to the plan of care, but this was not followed in the case of the resident's catheter care.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly medication regimen reviews (MRRs) and followed up on physician notification of pharmacy recommendations for four out of five residents reviewed for unnecessary medications. Specifically, for one resident with diagnoses including dysphagia, peripheral vascular disease, and anxiety, the July MRR was missing from the medical record, and irregularity reports for several dates were not available upon request. The facility was unable to provide the requested MRRs and irregularity reports during the survey, despite multiple requests. Additionally, three other residents with diagnoses such as schizoaffective disorder, bipolar disorder, insomnia, dysphagia, Alzheimer's disease, heart failure, kidney disease, and hypertension also had missing July MRRs. The Director of Nursing confirmed that the July MRRs were never received and was unsure about the status of the irregularity reports, stating they had been given to unit managers. The facility's policy and procedure for pharmacy services related to pharmacy reviews was requested but not provided before the survey concluded.
Crushing of Delayed and Extended Release Medications and Incorrect Dosage Administration
Penalty
Summary
During a medication pass observation, an LPN prepared and crushed several medications, including one delayed release and two extended release medications, before administering them to a resident. The medications that were crushed and placed into applesauce included Zunveyl (Benzgalantamine Gluconate) Oral Tablet Delayed Release 10 mg and Metoprolol succinate 100 mg ER, both of which should not be crushed according to facility policy and standard medication guidelines. Additionally, a cranberry tablet was administered at an incorrect dosage (450 mg given instead of the ordered 400 mg). These actions resulted in a medication error rate of 12.12% out of 33 medications observed during the survey. The resident involved had diagnoses of dysphagia and Alzheimer's disease, required a mechanically altered diet, and needed substantial to maximal assistance with eating. The facility's policy on medication crushing, dated June 2019, specifically states that timed release tablets should not be crushed due to their design for sustained release and to reduce stomach irritation. The DON was made aware of the errors at the time of observation, and the Nurse Practitioner confirmed that delayed and extended release medications should not be crushed and was not previously aware that this practice was occurring.
Obstructed Emergency Egress Due to Construction
Penalty
Summary
The facility failed to maintain a clear and unobstructed means of egress as required by regulation. On May 6, 2025, at approximately 11:00 AM, observation revealed that the emergency egress path outside the staff entrance doors was under construction due to underground pipe replacement. The ground in this area was broken, filled with gravel, and barricaded to prevent foot traffic, which could delay or prohibit evacuation through these doors during an emergency. These findings were confirmed through an interview with the maintenance director at the time of observation.
Plan Of Correction
Element 1 On April 11, 2025, maintenance staff immediately cleared items and made a pathway for all cited exit areas, including the northwest exit and exit near Room 411. Signs were temporarily posted indicating caution until the area was verified safe and useable again. Element 2 All residents in units adjacent to and reliant upon the affected exits (northwest hallway and near Room 411) were assessed for potential risk. No residents experienced adverse effects as a result of the obstruction. Element 3 All maintenance and housekeeping staff were in-serviced on May 6, 2025, regarding the revised policy and procedures. Element 4 The Director of Maintenance or designee will audit all exits daily during week x5 days a week for a month, then once weekly for 2 months. Findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee monthly for review and further recommendations. The administrator is responsible for the sustained compliance.
Delayed Egress Door Fails to Release During Emergency Exit Test
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless the door met the special locking arrangements for delayed egress as specified by regulations. Specifically, on May 6, 2025, at approximately 11:30 AM, it was found that the 300 unit delayed egress emergency exit door did not activate the delayed egress release process when pressure was applied to the door. This malfunction was directly observed and confirmed through an interview with the maintenance director at the time of the observation. This deficiency could affect up to 30 occupants in the event of an emergency evacuation, as the door's failure to release could prohibit or delay their exit. The report does not mention any specific residents or their medical conditions at the time of the deficiency, nor does it provide details about any immediate consequences resulting from the malfunction.
Plan Of Correction
Element 1: On May 16, 2025, maintenance staff installed highly visible signage ("Push to Exit" and "Emergency Exit Release") above and beside all magnetically locked egress doors. A staff member was assigned to test each door's emergency function to verify operability. Element 2: All residents were evaluated for reliance on egress doors for safe evacuation. No residents were affected by the magnetic locking system during the time of inspection. Element 3: All emergency exit devices were tested facility-wide for compliance. Staff training was conducted on May 16, 2025, to review emergency door operation, including the use of magnetic locks and identifying signage. Monthly egress drills will now include checks of all egress door systems, including magnetic locks. Element 4: The Maintenance Supervisor will conduct monthly tests of each egress door's emergency release function and verify signage placement and visibility. Audit results will be documented and reviewed in monthly Safety Committee meetings. Trends or failures will be escalated to QAPI for corrective planning. The administrator is responsible for the sustained compliance.
Fire-Rated Corridor Doors Failed to Close Fully
Penalty
Summary
Surveyors observed that the fire-rated cross corridor doors between the main lobby and the main corridor hallway did not fully close, which compromised their ability to resist the passage of smoke and fire. This observation was made during a facility inspection and was confirmed through an interview with the maintenance director at the time of the survey. The doors in question are required by regulation to resist the passage of smoke and, in certain cases, fire, to prevent the spread of hazardous conditions between compartments. The deficiency was specifically noted as affecting the protection of corridor openings, as the doors failed to meet the standards outlined in NFPA 19.3.6.3. The report states that this issue could impact up to 50 occupants in the event of a smoke or fire event, as the compromised doors would allow heat, smoke, and fire to pass into adjacent compartments. No information about individual residents' medical histories or conditions at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1 On May 14, 2025, maintenance personnel adjusted and repaired the door to Room 302 to ensure full closure and smoke resistance. A door sweep was installed on the door near Room 410 to eliminate the excessive gap. Element 2 A facility-wide audit of all corridor doors was completed on May 9, 2025. No other deficiencies in corridor door function were identified. All residents in proximity to the affected rooms were found safe and unaffected. Element 3 All facility doors were checked for compliance with smoke resistance standards on May 14, 2025. Staff were educated on May 16, 2025, on reporting improperly closing doors to the maintenance department immediately. Element 4 The Director of Maintenance or designee will complete monthly corridor door inspections to ensure doors close and latch properly and resist the passage of smoke. Results will be recorded and reviewed during QAPI meetings. Any failure will prompt immediate repair and re-education. The administrator is responsible for the sustained compliance.
Portable Space Heater Found in Prohibited Area
Penalty
Summary
A portable space heater was found running in the Human Resources Office during an observation on May 6, 2025. The facility failed to ensure that portable space heating devices were prohibited in all health care occupancies, as required by regulations. Additionally, it could not be verified that the heating element of the space heater did not exceed 212 degrees Fahrenheit, as specified by code. The maintenance director confirmed these findings during an interview at the time of observation. This deficiency could potentially affect 15 occupants in the event of a space heater related fire, as noted in the report.
Plan Of Correction
Element 1 On May 6, 2025, the portable space heater identified in the Human Resources Office was immediately removed from the facility and placed in secure storage pending disposal. A sweep of all administrative, clinical, and non-clinical areas was conducted the same day to identify and remove any other unauthorized space heaters. None were found. The Maintenance Director confirmed removal and documented the action. Element 2 A full facility audit of all office, administrative, breakroom, and storage areas was completed to ensure no other prohibited portable heating devices were present. All residents were evaluated for potential risk exposure. No resident rooms or care areas contained space heaters, and no resident was adversely affected. Element 3 On May 8, 2025, the facility reviewed its Electrical Equipment and Fire Safety Policy. Education was provided to clearly state that all portable space heaters are prohibited, unless explicitly approved in writing by the Administrator and Maintenance Director and confirmed to not exceed 212°F and only used in nonsleeping staff areas. A mandatory in-service training was conducted on May 16, 2025, for all department heads, including Human Resources, Administration, Maintenance, and Nursing, regarding fire safety compliance and the prohibition of portable space heaters under NFPA 101. Element 4 Beginning May 16, 2025, the Director of Maintenance or designee will perform monthly environmental safety rounds, with documentation confirming no prohibited space heaters are in use. Any unauthorized heating devices found will be immediately removed and reported to the Administrator and Safety Committee. Compliance findings will be reviewed monthly during the facility's QAPI meetings for 6 months and quarterly thereafter. The administrator is responsible for the sustained compliance.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by staff, as identified through observation, interview, and record review. This incident involved one resident out of three reviewed for abuse and resulted in an Immediate Jeopardy situation. The report documents that the facility did not ensure the resident's right to be free from abuse, specifically physical abuse by staff, as required by federal regulations. The deficiency was substantiated by findings from the survey, which included direct evidence of the abuse and the facility's failure to prevent it. No additional details about the resident's medical history or condition at the time of the incident are provided in the report.
Plan Of Correction
F600 - Freedom from Abuse, Neglect, and Exploitation Deficient Practice #1: Failure to Protect Resident (R800) from Staff Abuse Element #1: Resident R800 received immediate emotional support from Social Services on 4/16/2025. Resident was assessed by nursing for physical injury and psychosocial trauma. Ongoing counseling and support have been arranged as requested by resident. Resident's care plan was updated to include Element #2. Element #2: On 4/16/2025, all residents with a BIMS of 8+ were interviewed for abuse concerns. Residents with BIMS <8 were assessed for known history of behavioral challenges, cognitive impairments, or psychiatric diagnoses to determine if any similar incidents or risks were present. No further noncompliance or similar incidents were identified during this audit. Element #3: LPN “E” was immediately suspended on 4/3/2025 and has not returned to the facility. CNA “C” and LPN “D” received 1:1 education.
Failure to Protect Residents from Physical and Verbal Abuse by Staff and Peers
Penalty
Summary
A resident with an intact mental status and a history of dysphagia and weakness reported to the Director of Nursing (DON) that they were slapped on the arm twice by their midnight nurse during care. The resident stated that the nurse was verbally abusive, refused to allow them to use the bathroom, and called them derogatory names. Another staff member, a Certified Nurse Assistant (CNA), was present during the incident and attempted to intervene but was met with aggression from the nurse and subsequently left the room. The CNA reported the incident to another nurse and contacted the facility administration at the end of their shift. The nurse accused of abuse continued to work the remainder of their shift after the incident. The facility's investigation revealed that the incident occurred during the early morning hours while the resident was experiencing acute illness symptoms. The nurse involved was not immediately removed from resident care and continued working until the end of their shift, despite the abuse allegation being reported to staff. The DON and Nursing Home Administrator (NHA) were informed of the incident later in the morning, and the nurse was suspended only after administrative review. The abuse was substantiated, and the resident expressed feeling unsafe and embarrassed as a result of the incident. In a separate event, another resident with impaired cognition was physically abused by a fellow resident in a common area. The incident was witnessed by a receptionist, who observed one resident approach and slap another in the face. The aggressor admitted to the act and expressed intent to repeat it. The incident was reported to the NHA, and the aggressor was subsequently sent for inpatient psychiatric care. Both incidents demonstrate failures in protecting residents from abuse by staff and peers, as well as lapses in immediate response and reporting protocols.
Plan Of Correction
On mandatory reporting, all staff, including nursing, activities, and ancillary services, were re-educated on the "Abuse, Neglect, and Exploitation" policy by 4/17/2025. No staff are permitted to work without re-education. Abuse training emphasized staff must ensure immediate removal of alleged abusers from said areas and make immediate notification to the Abuse coordinator. The Medical Director was notified of the event and involved in QAPI review. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4: The Administrator or designee will conduct weekly rounds for four weeks then 1 x a month for 3 months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance. Deficient Practice #2: Failure to Protect Resident (R801) from Resident-to-Resident Abuse Element #1: R801 was physically assessed and found to have no visible injuries. Resident was offered and received psychosocial support by Social Services. Resident's safety plan and care plan were updated. Element #2: Review conducted of all residents residing in common areas with a history of aggressive behaviors. Resident R802 was identified and sent for psychiatric evaluation and inpatient treatment on 4/16/2025. All interactions between cognitively impaired residents are being monitored. Element #3: Lobby/common area supervision increased during peak resident usage hours. Behavioral Care Plans reviewed for all residents with cognitive impairment and aggression history. Staff re-educated all staff, including nursing, activities, and ancillary services, on the "Abuse, Neglect, and Exploitation" policy by 4/17/2025 and monitoring of resident interactions. No staff are permitted to work without re-education. Abuse training emphasized staff must ensure immediate removal of alleged abusers from said areas and make immediate notification to Abuse coordinator. Reception staff received 1:1 education on mandatory reporting. The Medical Director was notified of the event and involved in QAPI review. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4: The Administrator or designee will conduct weekly rounds for four weeks then 1 x a month for 3 months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance.
Removal Plan
- The DON and designee(s) interviewed/assessed residents with BIMS scores of 8 and above for potential abuse. Residents with BIMS below 8 were assessed by a licensed nurse for an acute change in condition. Concerns were/were not identified.
- Social Services completed a supportive visit with R800.
- LPN E was suspended pending investigation and has not returned to the facility.
- The Abuse, Neglect and Exploitation policy was reviewed by the Administrator and deemed appropriate.
- The Administrator/designee re-educated all staff on the Abuse, Neglect and Exploitation policy, highlighting the requirement to notify the Abuse Coordinator (Administrator) immediately with all abuse allegations. No staff member will be permitted to work until re-education is received.
- The facility Medical Director was notified of this event.
- Facility IDT Team held an ADHOC QAPI meeting.
- From the abuse policy all staff were educated on: Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protection from retaliation; Providing emotional support and counseling.
- CENA that left the room was provided 1:1 education regarding not to leave resident alone with abuser and the LPN assigned to the resident was provided 1:1 education to immediately report allegations of abuse and remove abuser as well and the educations received will be added to both their employee files.
- Facility IDT Team conducted an audit on all residents for their Safety/Abuse. Any negative findings will be immediately corrected.
- All findings will be taken to QAPI to follow up/track for any systematic changes that may be needed.
Failure to Honor DPOA and Arrange Post-Discharge Care
Penalty
Summary
The facility failed to honor the rights of a resident with severe cognitive impairment by not notifying or obtaining consent from the legally appointed Durable Power of Attorney (DPOA) prior to discharging the resident. The resident, who had diagnoses including cervical disc disorder, type 2 diabetes mellitus, and prostate carcinoma, was assessed with a Brief Interview for Mental Status (BIMS) score of 6/15, indicating severe cognitive impairment. The resident required substantial to maximal assistance with activities of daily living and was frequently incontinent. Despite the presence of legal documents designating a stepson as the DPOA and Patient Advocate, the facility discharged the resident to an estranged family member who was not listed in the contact records. On the day of discharge, the facility released the resident to the birth son, who presented a birth certificate as proof of relationship, and whose identity was confirmed over the phone by the resident's ex-wife. The DPOA was not contacted for consent, and the facility staff did not verify the ex-wife's identity. The Social Services Director and DON made the decision to release the resident without arranging for home care, physician follow-up, pharmacy, durable medical equipment, or hospice services. The facility's records indicated that attempts to contact the DPOA were made, but when there was no response, the discharge proceeded without further effort to obtain proper authorization. The facility staff maintained that the resident was their own responsible party and had not experienced a change in cognition, despite documentation of severe cognitive impairment and the existence of a signed DPOA and Patient Advocate form. The discharge was executed without honoring the legal authority of the DPOA, and no arrangements were made for the resident's continued care after leaving the facility.
Plan Of Correction
Element #1 Although R504 is no longer a resident, the facility made post-discharge contact with the legally designated DPOA (Stepson) & the resident is at home with no ill effects related to this occurrence. Re-education was immediately provided to all Social Services and Nursing leadership on interpreting and honoring DPOA and Patient Advocate documentation. Element #2 The facility conducted a comprehensive review of all current residents with a designated Durable Power of Attorney (DPOA) or Patient Advocate. This audit was completed by the Social Services Director and the Interdisciplinary Team. No additional instances of failure to honor a resident's DPOA or Patient Advocate authority were identified. Element #3 Policies regarding resident rights, discharge procedures, and DPOA/legal representative documentation have been reviewed and deemed appropriate. The Social Services Director completed a facility-wide audit of all residents with a listed DPOA or Patient Advocate to ensure documentation is accurate, activated properly, and reflected in the medical record. The IDT was re-educated on the role and authority of a DPOA/Patient Advocate. Legal definitions and proper activation (based on cognitive assessment and advance directive terms). Proper documentation and communication procedures. Audits will be repeated monthly for the next three months, then quarterly thereafter. Element #4 Ongoing Monitoring and QAPI Review: The DON and Administrator will review all discharges weekly during clinical stand-up to verify compliance with discharge and legal representative requirements. The QAPI committee will review audit results monthly and ensure any issues are corrected with retraining and process reinforcement. The Facility Administrator will be responsible for maintaining compliance.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident was inappropriately touched by another resident in the dining room without staff supervision. The incident was witnessed by the Activities Director, who observed one resident touching another's breast. At the time, there were three to four residents present in the dining room, but no staff were supervising. The Activities Director intervened immediately upon witnessing the event. Prior to the incident, staff had discussed the resident who committed the inappropriate act as having exhibited sexual behaviors, and some staff had warned others to be cautious when providing care to this resident. However, no formal reports of inappropriate or sexual behavior had been made to the Director of Nursing before the incident. The resident who was touched had a history of cognitive impairment, with a BIMS score indicating moderate impairment, and required assistance with activities of daily living, including bowel and bladder incontinence. The resident who committed the act also had significant physical and cognitive care needs, including hemiplegia, reduced mobility, and incontinence. The lack of staff supervision in the dining room allowed the incident to occur, despite prior informal awareness among staff of the perpetrator's inappropriate behaviors.
Plan Of Correction
Element #1 On March 3, 2025, immediately following the incident, the Activities Director separated residents R504 and R505 and reported the incident to the facility's Abuse Coordinator and Administrator in accordance with the facility's abuse policy. A full investigation was initiated within the required timeframe, including interviews with involved staff and residents, and findings were documented per regulation. Resident R504 was assessed for physical and emotional well-being by nursing and social services and monitored closely for psychosocial distress. Resident R505's care plan was immediately updated to reflect the behavior, with interventions including 1:1 supervision during group activities, increased monitoring, and review of the need for behavioral health support. R505 was moved to a different unit with staff trained to supervise higher-risk behaviors and reduce the risk of future interactions with R504. Element #2 The facility conducted a full audit of all residents with a known history of behavioral challenges, cognitive impairments, or psychiatric diagnoses to determine if any similar incidents or risks were present. No further noncompliance or similar incidents were identified during this audit. Element #3 Revised supervision in the dining room from the Activities department was implemented requiring an increased presence in dining/activity rooms when residents are present. No additional cases of resident-to-resident inappropriate behavior were identified during the audit. All staff, including nursing, activities, and ancillary services, were re-educated on the Abuse Policy and procedures, how to identify and document inappropriate behaviors, immediate response steps to peer-to-peer abuse, and enhanced supervision strategies. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4 The Director of Nursing or designee will conduct weekly rounds for four weeks then once a month for three months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance.
Facility Fails to Maintain Clean and Repaired Environment
Penalty
Summary
The facility failed to maintain a clean and repaired environment, affecting all 126 residents. Observations revealed various issues, including debris buildup in shower drains, rusted and damaged heater registers, and soiled and improperly fitted bedding. Additionally, there were significant damages to walls, such as dents and holes, and widespread marring and scratches on resident room furniture. Flooring throughout the facility was dull and discolored, with significant soil buildup at room entry thresholds and door jambs. Further observations noted consistent issues across the facility's three resident wings. The flooring in resident rooms appeared dull and discolored, with greater discoloration at room entries. Door thresholds and jambs had significant soil buildup, and handrails in hallways were scratched and worn. The main transition hallway had worn paint, cracked tiles, and crumbling sheetrock. Additional issues included broken tiles, peeling wallpaper, and rusted door jambs and exit doors. Interviews with the Administrator, DON, and Maintenance Director revealed concerns about the building's condition. The Maintenance Director reported being the sole maintenance staff for most of the year, focusing on urgent tasks like unclogging toilets. A layoff of housekeeping, floor care, and maintenance staff the previous year had left the facility understaffed until September 2024. Although a process to address the environmental conditions had been initiated, a formal written plan or quality assurance project had not been completed.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding abnormal blood glucose levels for a resident with diabetes and a history of stroke with paralysis. The resident had a sliding scale insulin order that required physician notification for blood glucose levels greater than 450 mg/dl. On a specific day, the resident's blood glucose levels were recorded as 450 mg/dl at 9:56 AM, 550 mg/dl at 11:57 AM, and 550 mg/dl at 3:53 PM, all documented by an LPN. However, there was no notification to the physician for the abnormal glucose levels at 9:56 AM and 11:57 AM. It was only after the resident became lethargic with an unreadable blood sugar and an oxygen saturation of 66% that the physician was notified, and the resident was sent to the hospital. The facility's policy required notifying the physician for blood sugar readings over 400 mg/dl or the threshold established by the physician. Despite this, the LPN did not contact the physician after the initial high readings, and the Director of Nursing indicated that nurses should use their judgment to notify providers. The physician was unaware of the earlier high glucose readings and questioned the rapid elevation of the resident's blood sugar, which was over 1200 mg/dl at the hospital. The facility's failure to follow its policy for timely physician notification contributed to the resident's condition worsening and subsequent hospitalization.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement a care plan for two residents, leading to a deficiency in meeting their care needs. Resident R700, who has diagnoses including paraplegia, opioid independence, major depressive disorder, and anxiety disorder, expressed concerns about the care of their indwelling catheter. Despite having intact cognition as indicated by a Brief Interview for Mental Status assessment score of 15, there was no care plan with goals or interventions for the catheter care in R700's medical record. Similarly, Resident R701, diagnosed with encephalopathy, atherosclerotic heart disease, hemiplegia, and schizophrenia, reported recurring teeth pain. R701 also had intact cognition with a Brief Interview for Mental Status assessment score of 14. However, their medical record lacked an oral or dental care plan with goals and interventions for managing their pain. The Director of Nursing confirmed that each resident should have care plans addressing their specific needs, as per the facility's policy on care planning.
Facility Fails to Address Potential Asbestos in Basement Tiles
Penalty
Summary
The facility failed to maintain a safe and functional environment for its 133 residents, as evidenced by broken and missing floor tiles in the basement. During an observation, the Maintenance/Housekeeping/Laundry Director initially stated that the tiles contained asbestos and that corporate had instructed not to touch them. However, upon further questioning, the Director admitted uncertainty about the presence of asbestos, attributing the assumption to the appearance and size of the tiles. The Director also revealed that corporate was not informed about the tile issue but promised to report it. The Nursing Home Administrator was unaware of the potential asbestos in the floor tiles. Additionally, the facility failed to provide an environmental policy addressing floor tiles by the end of the survey.
Failure to Maintain a Homelike Environment Due to Linen Shortage
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, identified as R803, who was observed lying in bed with a worn, see-through gown and a stained pillowcase. The resident reported not having their bed linen changed since moving to a new room and mentioned a lack of linen at the facility. Observations of the resident's bathroom revealed water dripping from the toilet onto the floor, mold along the wall crease, and a thick layer of dust and debris on the bathroom vent. Additionally, linen closets were found to be lacking essential items such as towels, washcloths, fitted sheets, and gowns. The facility's laundry operations were compromised, with only one of two washers and two of three dryers functioning. The laundry aide reported a significant shortage of linen, with minimal supplies available in the laundry room. The Maintenance/Housekeeping/Laundry Director was unaware of the bathroom issues and acknowledged the need to restock linen due to staff requests. The Director of Nursing attributed the linen shortage to cuts in housekeeping, laundry, and maintenance departments. The Nursing Home Administrator mentioned purchasing a larger washer that could not fit into the building and ongoing education regarding linen storage. The facility's policy on handling clean linen did not specify restocking frequency or ensure sufficient linen availability for residents.
Failure to Maintain Accurate Medical Records and Shower Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for six residents. Specifically, a nurse documented administering 13 medications to a resident who was on a leave of absence from the facility. Additionally, there was a lack of documentation for showers for seven residents over a 14-day period. The Director of Nursing was unaware of the medication documentation error and indicated that shower documentation should be recorded in the twice-weekly Skin Sweep Assessment by the nurse, based on shower sheets provided by CNAs. Interviews with residents revealed discrepancies between their reported care and the documented records. One resident reported receiving a shower on a specific date, while another stated they did not receive any showers or bed baths despite documentation indicating daily showers. Another resident expressed a preference for showers over bed baths, which was not reflected in the records. The MDS assessments indicated varying levels of cognitive function among the residents, with some having intact cognition and others being moderately impaired.
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What surveyors actually found near you
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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.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At City Center | 0 mi | ★★★★★ | 7 | 0 |
| Father Murray, A Villa Center | 1.1 mi | ★★★★★ | 6 | 0 |
| Autumn Woods Residential Health | 2 mi | ★★★★★ | 28 | 0 |
| The Orchards At Warren | 2.1 mi | ★★★★★ | 22 | 0 |
| Windemere Park Health And Rehabilitation Center | 2.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.