Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Ovid Healthcare Center during CMS and state inspections, most recent first.
Improper food service plumbing and drain line setup was observed in the kitchen and nourishment areas. An overhead spray nozzle was hanging below the flood rim of the garbage disposal, with the DM stating she knew it needed to be above the sink and that maintenance was aware. The ice machine drain line was also observed routed directly into a drain in the nourishment room and sitting inside a drain in the main food storage room.
Lack of active water management for unused fixtures. An unused hose with a spray nozzle was observed in a bathroom near a toilet, and the Maintenance Director stated it was not flushed regularly. Similar unused hoses were observed in multiple rooms, and a hopper in the housekeeping storage room was also found with the Maintenance Director unsure whether it was used or flushed. Record review showed the water mgmt plan addressed stagnation prevention and required regular flushing of infrequently used plumbing fixtures.
A resident with paraplegia and a BIMS of 15 was found to have his smoking status changed from independent to supervised after he obtained a guardian, even though prior smoking evaluations had documented him as independent. The DON said the resident was supervised by default because he had a guardian and could not wheel his wheelchair outside alone, while staff acknowledged the evaluation still said independent and the IDT did not meet to make the decision together as required by policy.
Excessive Room Temperature: A resident with COPD was found in a room that was noticeably hotter than the hallway, with two fans running, the window cracked open, and the wall heater still blowing hot air. The resident said the heat had been reported but remained unresolved for nearly a week, and the room temperature measured 81.6°F, which the Maintenance Director acknowledged exceeded acceptable ranges.
Failure to Implement Fall Prevention Interventions: A resident with multiple diagnoses including dementia, bipolar disorder, and DM had a fall care plan that included a call light reminder sign and a perimeter/concave mattress, but these interventions were not in place during repeated observations. The resident had facial bruising and reported it was from a fall, and the DON confirmed the resident had experienced several falls and that the planned interventions did not appear to be currently in place.
Inconsistent orthostatic BP monitoring was identified for a resident with multiple diagnoses, including dementia and bipolar disorder, who had active orders for orthostatic BP checks. The MAR and vitals documentation showed incomplete and inconsistent recordings, including single BP entries and two seated readings 7 minutes apart, rather than documented orthostatic measurements with position changes. The DON stated orthostatic BP should be obtained by changing positions from lying, sitting, and standing if able, and CDC guidance was referenced for the standard method.
Inadequate pain management for a resident with severe right hip pain was identified after he was observed grimacing, moaning, and rating his pain as 8/10 while trying to reposition for relief. The resident believed his oxycodone was scheduled rather than PRN, and staff reported he had declined therapy related to pain, could not reposition himself, and required extensive assistance with care due to ongoing pain.
The facility failed to maintain safe food temperatures, affecting all 61 residents. Observations revealed that food items on the steam table were below required temperatures, and the pantry refrigerator was operating outside the acceptable range. The Dietary Manager acknowledged the issue, and unsafe food items were discarded.
The facility failed to implement Enhanced Barrier Precautions for a resident and did not adequately mitigate the spread of COVID-19. An RN worked while symptomatic and later tested positive for COVID-19, leading to multiple infections among staff and residents. Additionally, an LPN did not use proper PPE while caring for a resident on Enhanced Barrier Precautions, failing to wear a gown and perform hand hygiene.
The facility failed to provide accurate SNF ABN forms for two residents who had exhausted their Medicare Part A benefits. The forms included costs for OT and PT services but omitted other potential financial liabilities, such as room and board. The Business Office Manager acknowledged the omission but stated it was due to incorrect training.
The facility failed to provide adequate ADL care for two residents, resulting in poor oral hygiene and insufficient showering. A resident with multiple medical conditions was observed with significant oral hygiene issues and improper positioning, while another resident reported receiving only three showers in a month. Additionally, infection control practices were not followed, as an LPN failed to use appropriate PPE during care.
A resident with multiple health issues did not receive daily pressure ulcer care as ordered, leading to potential worsening of the condition. The dressings on the resident's foot were not changed for two days, despite being documented as completed by an LPN. The facility's documentation policy requires timely and accurate record-keeping, which was not adhered to in this case.
A resident's medication was found improperly stored and unlabeled at their bedside, with no physician's order in the EMR. An LPN confirmed its use, and an RN/Unit Manager later entered a new order, but the medication remained improperly labeled and stored.
A facility failed to properly store and label a medication for a resident with complex medical needs. The medication was found at the bedside without a name, date, or physician's order. Despite the resident's dependency on care, the medication was not documented or labeled correctly, indicating a lapse in medication management.
The facility failed to protect residents from abuse and neglect, including inappropriate sexual behaviors between cognitively impaired residents, harassment complaints, and deprivation of food. Incidents were inadequately addressed, not reported to the State Agency, and lacked comprehensive investigation, violating the facility's abuse prohibition policy.
The facility failed to maintain adequate staffing levels, resulting in insufficient supervision of residents with sexual behaviors and increased risk of abuse. With a high number of residents requiring assistance, the staffing schedule often left CNAs overwhelmed, leading to incidents such as resident-to-resident sexual occurrences and a fall due to lack of supervision. Staff interviews confirmed the challenges faced due to understaffing, with some unable to take breaks or properly monitor residents.
The facility failed to operationalize policies to prevent abuse and ensure adequate staffing, leading to incidents of resident abuse and neglect. Multiple residents with cognitive impairments engaged in inappropriate sexual behaviors, with insufficient investigation and reporting. A resident filed a grievance about harassment, and a staff member was reported for being rude and withholding food. Staffing levels were inadequate, contributing to the incidents.
The facility failed to implement its abuse prevention policies, resulting in multiple incidents of inappropriate sexual behavior among residents, unreported grievances, and staff misconduct. Despite documented histories of such behaviors, interventions were not adequately enforced, and incidents were not reported to the State Agency or thoroughly investigated.
The facility failed to report multiple incidents of abuse and inappropriate behavior involving residents, including sexual misconduct and harassment. Despite being aware of these incidents, the facility's staff did not report them to the State Agency. Additionally, there were reports of staff misconduct, including an LPN being rude to residents, which were not investigated or reported.
The facility failed to investigate and report multiple abuse allegations involving residents with cognitive impairments engaging in inappropriate sexual behaviors. Despite recurrent incidents, the facility did not conduct comprehensive interviews or report to the State Agency. Additionally, a resident's grievance about harassment and allegations of staff misconduct were not adequately addressed.
A resident with severe cognitive impairment was involuntarily secluded in his room after engaging in inappropriate sexual behaviors in the dining room. Despite expressing a desire to leave, the resident was confined without guardian consent, and the incident was not reported to the State Agency. The investigation was incomplete, and the involved LPN was not immediately removed from duty.
A resident received Narcan without a physician's order, leading to a medication error. An LPN administered Narcan, intended for another resident, to a resident who was unresponsive and had shallow breathing, despite no history of opioid use. The LPN believed it was necessary due to the resident's use of Gabapentin, although Gabapentin is not an opioid. Emergency services were called after Narcan showed no effect, and the resident was later diagnosed with a UTI.
Improper Food Service Plumbing and Drain Line Setup
Penalty
Summary
Food service practices were not maintained in accordance with professional standards in the kitchen and nourishment areas. On 04/01/2026 at 8:47 AM, an overhead spray nozzle was observed hanging below the flood rim of the garbage disposal, and the Dietary Manager stated she was aware the spray nozzle needed to be above the sink and that maintenance also knew about it; a zip tie was being used in an attempt to hold it up. On 04/01/2026 at 9:36 AM, the drain line to the ice machine was observed routed directly into the drain in the nourishment room, and on 04/01/2026 at 12:29 PM, the drain line to the ice machine was observed sitting inside the drain in the main food storage room. The report cited the 2022 Food Code requirement for an air gap between the water supply inlet and the flood level rim.
Lack of Active Water Management for Unused Fixtures
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During observation, an unused hose with a spray nozzle was seen in the bathroom near the toilet in room [ROOM NUMBER]. When the Maintenance Director was asked whether the hose near the toilet was flushed on a regular basis to prevent water stagnation, he stated that unused fixtures in empty rooms are flushed, but the hose near the toilet is not flushed. Similar unused hoses with spray nozzles were also observed in bathrooms near toilets in multiple rooms at approximately 9:42 a.m., 9:44 a.m., 9:45 a.m., and 9:46 a.m. At 9:49 a.m., a hopper was observed in the housekeeping storage room. When asked whether the hopper is used and flushed regularly, the Maintenance Director stated he was not sure if it is being used and was not sure if it was flushed. Record review showed the facility's water management plan included remediation activities for breaches in control limits and stated that preventing water stagnation is a general principle of an effective water management program. The flushing logs indicated that plumbing fixtures not used regularly were to be run for a minimum of 3 minutes, and the logs were marked completed for January, February, and March 2026 and December 2025.
Smoking status changed without interdisciplinary review
Penalty
Summary
The facility failed to maintain a resident’s dignity related to smoking by changing the resident’s smoking status after the resident obtained a new guardian, despite prior smoking evaluations showing the resident was independent. The resident was admitted with diagnoses including paraplegia, migraines, bipolar disorder, contractures of the left hip, right hip, right knee, and left knee, muscle spasms, osteoarthritis, and PTSD. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and the resident required maximal assistance with several ADLs but was independent with eating. Record review and interviews showed the resident had multiple smoking evaluations that had documented him as independent, including the most recent evaluation that still stated he was independent, with a DON-added comment that he was a supervised smoker by default due to inability to make consistent safe choices and because he had a guardian/DPOA/RP. The smoking policy stated the interdisciplinary team was to make the decision together, but the DON stated the management team made the decision and no IDT meeting was held. The DON also stated the resident was supervised because he could not wheel his wheelchair outside by himself, while staff acknowledged the wording of the evaluation said independent even when they believed he should be supervised. The guardian stated the facility told her the resident became supervised after another guardian left the facility, but she had not seen the smoking policy.
Excessive Room Temperature
Penalty
Summary
The facility failed to ensure comfortable room temperatures for one resident, with the potential to affect 60 residents. Resident #13 was observed seated on the side of her bed and stated that her room felt very hot. The room was noticeably warmer than the hallway, with two fans running, the window cracked open, and the wall heater still operating and blowing hot air. The resident reported that she has COPD and that the high temperature in her room was making her uncomfortable and more difficult to breathe, causing increased discomfort. She stated that the heat issue had been reported to the facility but had not been addressed for nearly a week. When Maintenance Director C checked the room temperature, it measured 81.6 degrees Fahrenheit, and he acknowledged that this exceeded acceptable temperature ranges.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care planned interventions to prevent falls for Resident #56. The resident was admitted and later readmitted with diagnoses including kidney disease, anxiety disorder, restless leg syndrome, dementia, bipolar disorder, fracture of the nasal bones, and type 2 diabetes. The MDS with an ARD of 1/15/2026 reflected a BIMS score of 14 out of 15, indicating the resident was cognitively intact. On 4/01/2026, the resident was observed lying in bed with bruising on the face that was mostly resolved, and during conversation stated the bruising occurred from a fight but later said it occurred from a fall. Review of the fall care plan showed interventions in place except for a sign placed in view to remind the resident to use the call light for assistance with transfers and a perimeter/concave mattress, both initiated in November 2025. However, on 4/01/2026, 4/02/2026, and 4/03/2026, the resident did not have a perimeter mattress or a sign posted on the wall in the room. The DON confirmed the resident had sustained a few falls during the admission and stated the interdisciplinary team discusses interventions and rounds to ensure fall interventions are in place, but also stated she did not think the concave mattress and call light reminder sign were currently in place.
Inconsistent Orthostatic BP Monitoring
Penalty
Summary
The facility failed to ensure orthostatic blood pressures were monitored correctly for a resident with diagnoses including kidney disease, anxiety disorder, restless leg syndrome, dementia, bipolar disorder, fracture of the nasal bones, and type 2 diabetes. The resident’s MDS ARD of 1/15/2026 reflected a BIMS score of 14 out of 15, and on 4/01/2026 the resident was observed lying in bed, alert but not answering questions appropriately. The resident’s electronic medical record also reflected a long history of prescribed antipsychotics for the resident’s medical diagnosis. Physician orders included an order to check orthostatic BP from 3/19/26 to 3/20/26 and another order to take orthostatic BP every shift for 3 days from 3/21/26 to 3/23/26. Review of the MAR and Vitals section showed inconsistent methods for obtaining the orthostatic blood pressures, and in some instances no documentation that the blood pressures were obtained. The MAR for 3/19/26 showed a “y” for yes in the check ortho BP section, 3/20/26 showed a single recorded blood pressure, the Vitals tab for 3/21/26 and 3/22/26 showed single blood pressure records, and 3/23/26 showed two blood pressure recordings 7 minutes apart, both in a seated position. The DON stated that orthostatic blood pressures should be obtained with position changes from lying, sitting, and standing if able, and CDC guidance was cited as lying down for 5 minutes, then measuring blood pressure and pulse, followed by repeat measurements after standing 1 and 3 minutes.
Inadequate Pain Management for Resident with Severe Hip Pain
Penalty
Summary
The facility failed to provide adequate pain management for Resident #31, who had significant right hip pain after a fall and was observed grimacing, jerking in place, moaning, and stating that the pain was unbearable. On 03/31/2026, the resident had an order for oxycodone HCl 5 mg, 2 tablets by mouth every 4 hours as needed for pain management. On 04/02/2026, the resident was observed moaning in pain, talking in his sleep, and stated his pain was an 8 out of 10. He also tried to reposition himself for relief in his right hip and stated he needed something for pain. The resident believed his pain medication was scheduled rather than PRN and was reminded to use the call light. During interviews, staff described that the resident had a lot of pain, especially in his right hip, and that he had declined therapy related to pain. RN T stated the resident had previously been more independent but now required much more assistance, and CNA U stated he could not reposition himself and that staff were doing most care for him because he yelled out in pain. The resident was receiving scheduled Tylenol ES 1000 mg three times daily and PRN oxycodone 5 mg, and later the DON reported new orders for oxycodone 10 mg every 6 hours scheduled and Flexeril 5 mg every 8 hours for muscle pain.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures, affecting all 61 residents, with the potential for causing food-related illnesses. During a kitchen inspection, it was observed that the temperatures of various food items on the steam table were below the required levels. The cook acknowledged the low readings and indicated that the issue would be addressed with the administration. The temperatures recorded were as follows: Cream of Potato Casserole at 128°F, Peas at 90°F, Fish at 120°F, Green Beans at 140°F, Mashed Potatoes at 130°F, Gravy at 135°F, and Garlic Bread at 80°F. According to the facility's policy, hot foods should be held at temperatures greater than 130°F. Additionally, the pantry refrigerator was found to be operating outside the acceptable temperature range. The refrigerator's temperature gauge showed a reading of 44°F, while the acceptable range is 32°F to 41°F. The Dietary Manager (DM) explained that the temperature is monitored daily, and actions are taken if readings are out of range. However, during a subsequent observation, the refrigerator registered at 60°F, and food items such as turkey and cheese sandwiches were found to be at unsafe temperatures and were discarded. The facility's policy requires cold foods to be held at temperatures below 41°F to prevent foodborne illness.
Inadequate Infection Control and COVID-19 Mitigation
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident and did not take adequate measures to mitigate the spread of COVID-19 among staff and residents. A Registered Nurse (RN) worked while experiencing symptoms consistent with COVID-19, such as a stuffy nose, dry cough, and body aches, without notifying the facility. The RN tested positive for COVID-19 on 12/30/24, after working multiple shifts across the facility, potentially exposing others. Following this, 31 residents and 23 staff members tested positive for COVID-19. The facility's protocol required symptomatic staff to notify the facility and refrain from working, which was not adhered to in this case. Additionally, a resident with multiple medical conditions, including anoxic brain damage and dysphagia, was not provided with proper infection control measures. During an observation, an LPN failed to use appropriate personal protective equipment (PPE) while providing care to the resident, who was on Enhanced Barrier Precautions. The LPN did not wear a gown while handling the resident's gastrostomy tube and did not perform hand hygiene after glove removal. These actions were contrary to the infection control protocols indicated by the signage on the resident's door, which required gown and gloves for any care provided.
Inaccurate SNF ABN Forms for Residents
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) accurately reflected the estimated cost of items and services for which residents may be charged. This deficiency was identified for two residents who had exhausted their Medicare Part A benefit days. For one resident, the ABN form included the cost per 15 minutes of Occupational Therapy (OT) and Physical Therapy (PT) services but did not include other potential financial liabilities, such as room and board. Similarly, for another resident, the ABN form reflected the cost per 15 minutes of services but omitted other potential financial liabilities, including room and board. The Business Office Manager acknowledged that room and board charges should be included on an ABN, but indicated that this was not how they had been taught.
Deficiencies in ADL Care and Infection Control
Penalty
Summary
The facility failed to provide necessary care for two residents, R31 and R22, in relation to their activities of daily living (ADLs). Resident R31, who was dependent on all care due to multiple medical conditions including anoxic brain damage and neuromuscular dysfunction of the bladder, was observed with significant oral hygiene issues. His family reported and observations confirmed a buildup of plaque and a white substance on his tongue, indicating inadequate oral care. Additionally, R31's care plan required the use of a rolled washcloth or palm protector to prevent his contracted fingers from digging into his palm, which was not observed during multiple checks. Furthermore, R31 was left in the same position for extended periods, with his feet rubbing against the footboard, contrary to his care plan that required repositioning every two hours. The report also highlighted deficiencies in infection control practices. During oral care and handling of R31's gastrostomy tube, LPN B failed to use appropriate personal protective equipment (PPE) despite the resident being on enhanced barrier precautions. This included not wearing a gown and not performing hand hygiene after glove removal. Additionally, there was a medication at R31's bedside without a proper order or labeling, which was later rectified with a new order, but the medication remained improperly labeled. Resident R22, who required substantial assistance with ADLs, reported receiving only three showers since admission, contrary to the facility's policy of offering showers twice weekly. Observations confirmed R22's hair was greasy and uncombed, and the shower task log showed only one documented shower in a 30-day period. The Unit Manager acknowledged the discrepancies in documentation and the lack of audits on shower tasks, indicating a systemic issue in ensuring residents receive the care outlined in their care plans.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for a resident, resulting in the potential for a worsened pressure ulcer. The resident, who was admitted with multiple diagnoses including a periprosthetic fracture, morbid obesity, Parkinson's disease, heart failure, and muscle weakness, was observed with a soiled pillowcase at the foot of her bed, which she believed was due to drainage from her right heel dressing. The resident reported that staff were not consistent in changing her dressing daily as ordered. Upon further investigation, it was found that the dressings on the resident's right foot were dated two days prior, indicating they had not been changed as per the physician's orders. The Treatment Administration Record showed that the wound care was documented as completed by an LPN, but the LPN was not available for comment. The Director of Nursing and Nursing Home Administrator confirmed the discrepancy and noted that the LPN had been educated on proper documentation practices, emphasizing that tasks should be documented immediately after completion. The facility's policy on documentation requires that events be charted as they occur and in chronological order, with reasons for any omissions clearly documented.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper and safe storage and labeling of medications for one resident, identified as Resident #31. This resident was admitted with multiple diagnoses, including Anoxic Brain Damage, Major Depression, and Dysphagia, and was dependent on all care. During an observation, a medication was found at the bedside of the resident without a name, date, or physician's order in the electronic medical record. An LPN acknowledged the medication's presence and indicated that it had been used, but there was no corresponding order in the system. Further investigation by the RN/Unit Manager confirmed the absence of an order for the medication, identified as Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution. A new order was subsequently entered into the system, but the medication remained improperly labeled and stored at the resident's bedside. This oversight highlights a failure in the facility's medication management and documentation processes, potentially affecting the safety and care of the resident.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications for one resident were properly stored and labeled according to professional standards. During an observation, a medication was found at the bedside of a resident without a name, date, or physician's order in the electronic medical record. The LPN acknowledged the medication's presence and indicated that there should be an order for it, but upon further investigation by the RN/Unit Manager, no such order was found in the system. This indicates a lapse in the facility's medication management and documentation processes. The resident involved had multiple medical conditions, including anoxic brain damage, major depression, and neuromuscular dysfunction of the bladder, and was dependent on all care. Despite the resident's complex medical needs, the medication in question, Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution, was not properly documented or labeled, which could potentially impact the resident's care. The RN/Unit Manager later entered a new order for the medication, but the bottle remained unlabeled and without instructions, highlighting a deficiency in the facility's medication handling procedures.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including mental, verbal, and sexual abuse, as well as deprivation of goods and services. Several incidents were reported involving inappropriate sexual behaviors between residents, which were not adequately addressed or reported to the State Agency. For instance, two residents with cognitive impairments were found engaging in sexual behaviors in the dining room, and despite having care plans that included interventions to prevent such interactions, the facility did not effectively implement these measures. Additionally, there was a lack of comprehensive investigation and reporting of these incidents, as evidenced by the absence of interviews with involved staff and the failure to notify the State Agency. Another incident involved a resident filing a grievance against another resident for harassment and unwanted physical contact. Despite the resident's cognitive intactness and clear expression of discomfort, the facility's response was insufficient, as the incident was not reported to the State Agency. The resident's care plan and behavior monitoring tasks did not reflect the ongoing issues, and there was a lack of consistent documentation and intervention to address the resident's complaints. Furthermore, a resident was subjected to deprivation of goods and services, specifically food, by a staff member who was reported to be rude and gruff. The staff member refused to provide additional food to the resident, who was under hospice care, and made derogatory comments about the resident's weight. This incident was reported by hospice staff, but the facility failed to investigate or address the allegations adequately. The facility's abuse prohibition policy was not followed, as the incident was not reported to the State Agency, and there was no investigation into the allegations of abuse.
Inadequate Staffing Leads to Supervision Failures
Penalty
Summary
The facility failed to ensure adequate staffing levels to supervise and report residents with sexual behaviors, thereby failing to protect vulnerable residents. The facility had a census of 61 residents, with a significant number requiring assistance for daily activities such as dressing, bathing, and toileting. On specific dates, the staffing schedule showed insufficient numbers of Certified Nurse Assistants (CNAs) to meet the needs of the residents, with some shifts having as few as four CNAs to care for 58 residents. This inadequate staffing led to multiple resident-to-resident sexual occurrences that were not properly supervised or documented, increasing the likelihood of abuse allegations not being identified or reported. Interviews with staff during the survey revealed consistent concerns about inadequate staffing levels. Staff members reported being unable to take breaks or adequately supervise residents due to the high workload. On one occasion, a resident fell while attempting to use the bathroom, highlighting the impact of insufficient staffing on resident safety. The facility's scheduling practices, which involved sending staff home when the census dropped, further exacerbated the staffing issues. The Interim Director of Nursing acknowledged the lack of a morning meeting following a particularly understaffed day, as most of the management team was on vacation.
Deficiency in Abuse Prevention and Staffing
Penalty
Summary
The facility administration failed to operationalize its policies and procedures to effectively use its resources and ensure the protection of residents from various forms of abuse, including mental, verbal, and sexual abuse, as well as deprivation of goods and services. This deficiency was identified in 7 out of 10 residents reviewed for abuse. The facility also failed to ensure sufficient nursing staff to meet residents' needs, which increased the likelihood of continued abuse and unmet resident needs. Specific incidents involved residents engaging in inappropriate sexual behaviors, with inadequate investigation and reporting to the State Agency. One incident involved two residents found in the dining room engaging in sexual behaviors. Both residents had cognitive impairments, with one having severe impairment and the other moderate impairment. Despite multiple occurrences of inappropriate behavior, there was only one incident report generated, and the facility did not report the incident to the State Agency. The facility's response included providing education to residents and staff on redirection when sexual behaviors were exhibited, but there was no comprehensive investigation or additional interviews conducted. Another incident involved a resident filing a grievance about being harassed and receiving unwanted touching from another resident. The facility's response was to provide a sitter for the resident, but the incident was not reported to the State Agency. Additionally, there were reports of a staff member being rude and gruff to a resident, refusing to provide additional food as requested, and making derogatory comments about the resident's weight. The facility did not investigate these allegations of abuse. The facility's staffing levels were also inadequate, with multiple staff members reporting insufficient staffing to meet residents' needs, which contributed to the incidents of abuse and neglect.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its abuse policy and procedures effectively, as evidenced by multiple incidents involving residents engaging in inappropriate sexual behaviors. Two residents, one with severe cognitive impairment and another with moderate impairment, were found participating in sexual behaviors in the dining room. Despite documented histories of such behaviors, interventions to prevent these interactions were not adequately enforced, leading to repeated incidents. The facility did not report these incidents to the State Agency, and there was a lack of comprehensive investigation, as additional interviews were deemed unnecessary. Another incident involved a resident filing a grievance against another resident for harassment and unwanted physical contact. The resident with severe cognitive impairment had a history of making inappropriate comments and gestures, yet the facility's behavior monitoring report did not reflect any recent behaviors. The grievance was addressed by providing a sitter for the resident, but the incident was not documented in an incident report or reported to the State Agency. Additional incidents included a resident exposing himself in the hallway and attempting to engage another resident in inappropriate behavior. Despite being reported to the Nursing Home Administrator, there was no documentation or investigation into the incident. Furthermore, a hospice staff member raised concerns about an LPN's behavior towards a resident, including refusal to provide requested food and making derogatory comments. The LPN was not removed from the schedule during the investigation, and no incident report was filed.
Failure to Report Abuse and Inappropriate Behavior
Penalty
Summary
The facility failed to immediately report allegations of abuse involving seven residents, leading to the likelihood of continued abuse. The incidents involved inappropriate sexual behaviors between residents, which were not promptly reported to the State Agency. For instance, two residents were found engaging in sexual behaviors in the dining room, and despite multiple occurrences, the incident was not reported. The facility's interim Director of Nursing and Nursing Home Administrator were aware of the situation but did not take the necessary steps to report it. Additionally, there were grievances filed by residents regarding harassment and inappropriate touching by other residents. One resident filed a grievance about being harassed and kissed by another resident, which was an ongoing issue. Despite the grievance, the incident was not documented in an incident report or reported to the State Agency. The facility's staff were aware of the resident's history of inappropriate behavior, yet failed to take appropriate action to prevent further incidents. There were also reports of staff misconduct, including an LPN being rude and gruff towards residents, and refusing to provide additional food to a resident as requested. This behavior was reported by hospice staff, but the facility did not investigate the allegations or report them to the State Agency. The interim Director of Nursing and Nursing Home Administrator were aware of the staff misconduct but did not take the necessary steps to address the issue.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving multiple residents, leading to the likelihood of continued abuse. Several incidents were documented where residents with cognitive impairments engaged in inappropriate sexual behaviors with each other. Despite these occurrences, the facility did not conduct comprehensive interviews or report the incidents to the State Agency. The investigation was limited, and the facility's response was inadequate, as it only involved providing education to staff and residents without further protective measures. In one case, two residents with cognitive impairments were found engaging in sexual behaviors in the dining room. The facility's records indicated that these behaviors were recurrent, yet only one incident report was generated. The facility did not perform additional interviews or take sufficient action to prevent future occurrences. Furthermore, the facility failed to report these incidents to the State Agency, as required by their abuse prohibition policy. Another incident involved a resident filing a grievance about being harassed by another resident. Despite the grievance, the facility did not report the incident to the State Agency. Additionally, there were allegations of a staff member being rude and denying food to a resident, which were not investigated. The facility's lack of thorough investigation and reporting of these incidents highlights significant deficiencies in handling abuse allegations and ensuring resident safety.
Failure to Prevent Involuntary Seclusion of a Resident
Penalty
Summary
The facility failed to prevent involuntary seclusion of a resident with severe cognitive impairment, who was involved in inappropriate sexual behaviors. The resident, who has a neurodevelopmental disorder and a history of stroke, was found engaging in sexual behaviors in the dining room. Despite interventions in place to redirect the resident to other activities, the resident was told to stay in his room for his meal due to his inability to follow directions and inappropriate behavior. The resident expressed frustration and attempted to leave his room, but was instructed to remain there without the consent of his guardian. The incident was not reported to the State Agency, and the investigation was incomplete as additional interviews were not conducted. The Interim DON confirmed that the resident was forced to eat dinner in his room and stay there for approximately two hours. The LPN involved was not removed from the schedule during the investigation and was later terminated. The facility's abuse prohibition policy defines involuntary seclusion as confinement against the resident's will, which was not adhered to in this case.
Medication Error Due to Unauthorized Narcan Administration
Penalty
Summary
The facility failed to ensure appropriate assessment and treatment for a change of condition in a resident, leading to a medication error. A Licensed Practical Nurse (LPN) administered Narcan to a resident without a physician's order, despite the resident not having a history of opioid use or any indication for Narcan administration. The resident's vital signs were stable, and there was no prescription for Narcan or opioids. The LPN used Narcan intended for another resident, believing it was necessary due to the resident's use of Gabapentin, although Gabapentin is not an opioid. The incident occurred when the resident was found unresponsive with shallow breathing and low respiration rate. Despite the administration of Narcan, there was no change in the resident's condition, prompting the LPN to call emergency services. The resident was transferred to the hospital and later diagnosed with a urinary tract infection. The facility's records confirmed that Narcan was not ordered for the resident, and the physician was notified after the medication was administered.
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 186 citations issued within 25 miles in the last 12 months — including the 1 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ovid
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hazel I Findlay Country Manor | 8.4 mi | ★★★★★ | 12 | 0 |
| Memorial Healthcare Center | 10 mi | ★★★★★ | 1 | 0 |
| Pleasant View Shiawassee County Medical Care Facil | 11.5 mi | ★★★★★ | 0 | 0 |
| Ashley Healthcare Center | 13.5 mi | ★★★★★ | 20 | 0 |
| The Willows At East Lansing | 17.1 mi | ★★★★★ | 11 | 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.