Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Orchards At Warren during CMS and state inspections, most recent first.
A resident with impaired cognition and existing Stage 3 pressure ulcers to the sacral region and left hip had a physician order for daily-shift wound care, including cleansing with NS, application of Medihoney gel, and a dry dressing. Review of the TAR showed four consecutive days where the ordered treatment was left blank, indicating it was not completed, and there was no documentation explaining the missed care. In interview, the DON could not explain the lack of charting and stated an expectation that all treatments be documented, despite a facility policy committing to prevention of skin breakdown.
A resident with vascular dementia, intact cognition, and independent mobility repeatedly expressed intent to leave, contacted outside parties to assist with discharge, and had previously attempted to move toward an exit, leading staff to apply a wander alert device and mark the resident as an elopement risk, though this device was not documented in the care plan and the resident was still scored as low elopement risk. On a later occasion, the resident removed screws from a window designed to limit its opening, climbed out unnoticed, and was found walking outside by a housekeeping supervisor, who, along with additional staff, spent about 15 minutes coaxing the resident back inside. Staff confirmed they were unaware the resident had left the building, the NHA noted the resident’s preference for a closed door complicated supervision, and the DON acknowledged there was no documentation policy for nurses and CNAs.
Staff failed to provide timely incontinence care, appropriate meal positioning, and regular repositioning for three dependent residents. One resident, cognitively impaired and care-planned for q2h incontinence checks, remained in bed through the morning and was later found soiled with loose stool, with no prior incontinence care observed. Another resident with severe cognitive impairment and multiple comorbidities was left in bed with a breakfast tray positioned at mouth and nose level, a urine odor present, and bed controls out of reach; when care was finally provided, the brief was visibly urine-soiled, and the CNA stated this was the first incontinence care since the start of the shift. A third resident with paralysis, stroke, and malnutrition, care-planned as totally dependent for repositioning at least every two hours, was observed multiple times over several hours with no change in body position, including with the head off the pillow. The DON later acknowledged that aides may prioritize care timing and reported rounds had been done, but the residents’ positions had not changed.
The facility failed to keep AEDs and crash carts in a ready-to-use condition, including during a code blue for a resident with full code status when the nearest AED lacked pads and staff had to retrieve another device from a different unit. Surveyors later found an AED case cracked open with no visible status light, an empty wall-mounted AED box above a crash cart that was documented as checked, and a dining room crash cart with soiled towels on top and no inventory form. On multiple units, AEDs were stored with batteries removed, contrary to the manufacturer’s instructions that they be stored with pads and battery installed to allow daily self-tests. A unit manager was unable to complete the AED self-test as outlined in the manual, and the administrator confirmed there were no facility policies governing AEDs or crash carts.
Pest control program was not maintained when a kitchen drainage pipe was propped up by a water-damaged cardboard box beneath a coffee maker table, and numerous gnats were observed on the box and pipe. The Dietary Manager stated the box was being used to support the pipe, with no explanation for the damaged cardboard or the gnats.
Failure to conduct and document quarterly care conferences for multiple residents. Records showed several residents with significant medical and functional needs had incomplete care conference documentation, and one resident said they had never attended a care conference despite wanting to be included. The SSD stated care conferences should be completed quarterly, and the NHA said the facility had been without a social worker and was trying to catch up.
Failure to maintain a clean, home-like environment was observed in resident rooms and bathrooms. A resident’s bathroom door was damaged and remained unrepaired, one bathroom had brown substance, debris, and urine/feces odor, another had smeared feces with gnats present, and a resident on TF had spilled formula on the pole, base, and floor that remained over repeated observations. Additional issues included a missing closet door, rusted hardware, piled clothing, peeled cove base, and a urine hat left with residual liquid.
Failure to provide an appropriately sized bed: A resident with collapsed vertebra and COPD, intact cognition, and max ADL dependence repeatedly stated the bed was uncomfortable and too small, saying they felt like they were going to fall off it and that they needed a larger bed. Staff observed the resident lying sideways across the bed with their feet against the footboard and the call light on the floor, but no TELS request was entered for a different bed or mattress despite the resident's repeated complaints.
A facility failed to notify the physician about a resident's critical low blood glucose result of 34. The resident had Bipolar Disorder, Epilepsy, and Stroke, and was tube fed and NPO. Progress notes and the MD logbook contained no documentation of physician notification or any action taken, and the DON stated abnormal lab values should be reported and documented.
Failure to Provide Timely Podiatry Services: A resident with Parkinson's Disease, muscle weakness, and intact cognition reported requesting podiatry for months without being seen and said long toenails were hurting. CNA shower documentation repeatedly noted that the resident needed toenails cut, and observation found thick, curled, yellowish toenails with black areas. The SSD and DON described the process for adding residents to the podiatry list, but the resident's most recent podiatry note was not available during survey.
The facility failed to document physician orders, informed consent, risk-versus-benefit discussions, attempted alternatives, and ongoing monitoring for side rail use for two residents. One resident with CVA, acute respiratory failure with hypoxia, and HF had side rails on the bed without an order or care plan address, and the side rail assessment had blank measurement fields. Another resident with muscle weakness and age-related physical debility had side rails observed on the bed, but the MDS, orders, care plan, and consent did not reflect their use, and multiple side rail assessments also had blank measurement sections.
A resident with seizures, epilepsy, and stroke did not receive ordered lacosamide because the medication was unavailable and on order, with missed doses documented on the MAR and in nursing notes. The resident said the medication was needed for epilepsy, and the DON stated medications should be reordered by the nurse and administered as ordered.
Delayed Oral Surgeon Consultation: A resident with Failure to Thrive, physical debility, stroke, and impaired cognition had poor oral hygiene, missing or broken teeth, and documented oral discomfort. Dental notes recommended extraction of non-restorable teeth by an oral surgeon, but the appointment was cancelled because the resident needed a stretcher and was not followed up for months. Staff and the DON reported the cancelled visit was not tracked to completion.
Failure to use required PPE for residents on EBP: an LPN entered a resident’s room wearing gloves but no gown while administering meds through a PEG tube, and a CNA entered another room with two residents on EBP and provided care without being observed donning PPE. The DON confirmed gown and gloves were required, and the facility policy called for gown and glove use during high-contact care activities for residents with devices such as feeding tubes.
A facility failed to notify a resident's family of a change in condition, despite multiple nursing notes documenting the resident's decline in ability to transfer and toilet independently. The resident, with severe cognitive impairment and multiple diagnoses, was not able to communicate the change, and the family only became aware during a visit. Staff interviews revealed a lack of communication and documentation, and the facility's policy did not address notifying the resident's representative.
A resident with dysphagia, diabetes, and dementia was admitted with a pureed diet order and experienced weight loss. Despite requiring extensive eating assistance and showing decreased oral intake and appetite, the facility failed to complete a comprehensive nutritional assessment in a timely manner. The RD acknowledged the oversight, and the DON could not provide the policy on assessment timeliness.
The facility failed to serve food in a palatable manner and at the preferred temperature, leading to dissatisfaction among residents. Observations showed meals were served cold, with missing items and inadequate portions. A resident with congestive heart failure and type 2 diabetes expressed dissatisfaction with the food quality. A test tray revealed food temperatures below the preferred level, contrary to the facility's policy on food palatability.
The facility failed to maintain an effective pest control program in the kitchen, with standing water and gnats observed in multiple areas. The Dietary Manager was unable to explain the presence of standing water, which was noted as a breeding ground for gnats. Pest control reports indicated ongoing issues with gnats.
The facility failed to ensure proper medication storage, with four residents found with medications at their bedsides without assessments or physician orders for self-administration. This included inhalers and pills, with staff confirming the lack of authorization for bedside storage.
A resident with a history of kidney stones and chronic kidney disease requested a hospital transfer due to severe pain, but the facility failed to honor this request. The resident was informed that they would need to sign out AMA and cover transportation costs, leaving them in pain without the desired medical intervention. This incident highlights a violation of the resident's right to self-determination.
A resident with severe cognitive impairment and a history of stroke was not provided with an assistive communication device, such as a communication board, despite being non-verbal and dependent on staff for most activities of daily living. Staff interviews revealed a lack of awareness about the availability of a communication board, and observations confirmed its absence, contrary to facility policy.
A resident with impaired vision was observed wearing broken glasses, with one lens missing and the other dirty. Despite being seen by an eye doctor, the issue was not resolved, and the resident was told to obtain new glasses independently. Facility staff were unaware of the problem until informed, and the Director of Nursing acknowledged that the situation should have been addressed immediately, as per the facility's policy on emergency services.
A resident with COPD and acute respiratory failure was observed using oxygen without a physician order, contrary to facility policy. Staff interviews confirmed the oversight, acknowledging the necessity of a physician order for oxygen administration.
A resident with cognitive impairment requested their medications to be crushed, and an LPN complied without verifying physician orders. This included Duloxetine, a delayed-release medication that should not be crushed. The facility's DON was informed post-administration, and it was confirmed that the medication was altered inappropriately, violating professional standards.
A resident with cerebral infarction and left hemiplegia was not using a prescribed hand splint, which was observed unused in their room. The resident reported occasional pain and acknowledged the need for the splint. Staff were unaware of any instructions to use the splint, and there was no documentation supporting its discontinuation. A new splint was ordered but delayed, and the facility's policy on splints was not provided.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide and document ordered pressure ulcer treatment for a resident with existing Stage 3 pressure ulcers to the sacral region and left hip. The resident was admitted with these wounds, had impaired cognition with a BIMS score of 3/15, and required staff assistance with bed mobility and transfers. The Treatment Administration Record (TAR) contained an order, starting 7/9/2025, to cleanse the coccyx with normal saline, apply Medihoney gel, and cover with a dry dressing every day shift. Review of the July 2025 TAR showed that on four consecutive days (July 10th–13th) the treatment entries were left blank, indicating the ordered wound care was not completed, and there was no additional documentation in the medical record explaining why the treatments were not done. In an interview, the DON stated they were unsure why the treatment was not charted and reported an expectation that all treatments be documented as completed, while facility policy stated a commitment to providing care and services to prevent skin breakdown.
Failure to Adequately Supervise and Prevent Elopement of an Identified Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident identified as an elopement risk. The resident was admitted with vascular dementia and had a BIMS score of 15/15, indicating intact cognition, and was independent with ambulation and most ADLs. In the weeks prior to the incident, the resident repeatedly verbalized plans to leave, including stating they would discharge the next day, calling a moving company and their church for assistance, and telling staff they would call the police. On one occasion, the resident moved quickly toward an exit when discussing discharge and had to be redirected; at that time, a wander alert device was applied, and the care plan was updated to reflect elopement risk, but the care plan did not document that a wander alert device had been applied. An elopement risk assessment subsequently scored the resident as low risk despite the multiple expressed intentions to leave. The incident under review occurred when the resident exited the building without staff knowledge by removing screws from the inside window casing that were intended to limit the window opening to 2–3 inches, allowing the window to open wide enough for the resident to climb out. The resident was later observed outside, walking on the driveway near the building by a housekeeping supervisor, who attempted unsuccessfully to coax the resident back inside while the resident repeatedly stated they were leaving and not returning. Additional staff were called, and after about 15 minutes the resident returned to the building. Staff confirmed they had not been aware the resident was out of the building. The Nursing Home Administrator stated that the resident preferred to keep their door closed at all times, making it difficult to balance privacy with increased supervision. The DON reported there was no policy for documentation for nurses and CNAs when documentation policy was requested.
Failure to Provide Timely Incontinence Care and Repositioning for Dependent Residents
Penalty
Summary
The deficiency involves staff failure to timely provide incontinence care, toileting-related ADL assistance, and repositioning for three dependent residents. One resident, admitted with diagnoses including hypertension and pain and assessed as moderately cognitively impaired, required substantial/maximal assistance with toileting hygiene, personal hygiene, bathing, and meal setup, and had a care plan directing incontinence checks at least every two hours during the day. This resident was observed in bed from early morning through mid-morning without evidence of incontinence checks; at 10:50 AM, staff found the resident soiled with loose stool covering the pubic area. The resident’s fingernails were noted to have soil underneath, and there was no prior observed incontinence care before that time. Another resident, with diagnoses including adult failure to thrive, heart disease, and Alzheimer’s disease, and severely impaired cognition, required substantial/maximal assistance for toileting hygiene and was dependent for bathing, dressing, and personal hygiene, with partial assistance needed for bed mobility and meal setup. This resident was observed in bed with the breakfast tray positioned at mouth and nose level, unable to respond meaningfully, with a urine odor present; the bed controls were out of reach, and the LPN did not adjust the resident’s position when questioned. Later, staff found a visibly urine-soiled brief, and the CNA reported this was the first incontinence care provided to these residents since the start of the 7 AM shift. A third resident, admitted with diagnoses including left-sided paralysis, stroke, and malnutrition, had a care plan indicating incontinence of bowel and bladder, need for assistance with ADLs, and total dependence on staff for repositioning in bed at least every two hours and as necessary. This resident was repeatedly observed supine in bed with the head of the bed elevated 30–45 degrees, eyes closed, and legs elevated with heel boots, from late morning through mid-afternoon. Across multiple observations, the resident’s position did not change, including when the head was noted to be off the right side of the pillow. The DON later stated that aides may prioritize timing of care based on resident needs and reported that rounds had been completed initially and between 9:00 and 9:30 AM, but the observed positions of the residents had not changed. Facility policy on toileting stated that when a resident indicates verbally or non-verbally a need to use the bathroom, staff should promptly assist, but the observations showed delays in incontinence care and lack of timely repositioning for these dependent residents.
Failure to Maintain AEDs and Crash Carts in Ready-to-Use Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure essential emergency equipment, specifically AEDs and crash carts, were maintained in a ready-to-use condition. A complaint intake reported that during a code blue for resident R904 on the [NAME] unit, staff could not use the closest AED because it did not have pads, and staff had to obtain another AED from a different unit. R904’s record showed the resident was cognitively intact, required staff assistance with activities of daily living, and had a full code status; after the code and a 911 call, the resident was transferred to a local hospital. During the survey, attempts to contact the nurse involved in the code were unsuccessful. Surveyors observed multiple issues with AEDs and crash carts throughout the facility. An AED in a red case on top of the crash cart outside reception was found cracked open with no visible status light. On the [NAME] unit, the crash cart log showed all items checked, but the wall-mounted AED box above it was empty. In the large dining room, the crash cart had soiled towels on top and no form to monitor its inventory. On the [NAME] unit and the Rose/Lavender unit, AEDs were stored with the batteries removed; the unit manager and the DON stated this was done to prevent beeping and preserve battery life. Review of the manufacturer’s manual, however, showed the AED must be stored with pads and battery installed so it can perform daily self-tests and remain ready for use. When asked to demonstrate the self-test, a unit manager inserted the battery and turned the AED on but did not complete the self-test, stating it would waste pads, and reported being unable to complete it without connecting pads. The administrator reported the facility had no policies addressing AEDs or crash carts.
Pest Control Program and Harborage Conditions
Penalty
Summary
The facility failed to maintain an effective pest control program by eliminating harborage conditions. During an observation of the kitchen, the stainless-steel table holding the coffee maker was seen with a built-in drainage well, and the drainage pipe under the table was propped up by a water-damaged cardboard box. Numerous gnats were observed on the box and drainage pipe. When questioned, the Dietary Manager stated the box was being used to support the pipe, and no explanation was provided for why the water-damaged cardboard had not been discarded or for the observed gnats. The report also cited the 2022 FDA Food Code section 6-501.111 regarding controlling pests and eliminating harborage conditions.
Failure to Conduct and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct and document quarterly care conferences for five reviewed residents. Record review showed that residents with diagnoses including bipolar disorder, epilepsy, stroke, failure to thrive, physical debility, heart disease, quadriplegia, dementia, epilepsy, heart failure, hypertensive urgency, and type 2 diabetes had active care plans with multiple needs identified, such as bowel and bladder incontinence, restorative nursing programs, dependence on staff for emotional, intellectual, physical, and social needs, and assistance with ADLs. For several residents, the electronic record contained only some care conference dates, and additional documentation of quarterly conferences was requested but not provided before survey exit. One resident stated during interview that they had been at the facility for about a year, did not know when discharge would occur, and had never attended any care conference meetings, adding that they wanted to be included. Record review for that resident showed care conferences were documented as attended on two occasions, but there was no documentation of a quarterly care conference during the spring of 2025. The Social Services Director stated that care conferences are completed quarterly and should be documented in the resident record, and the Administrator stated the facility had been without a social worker for a period of time and was trying to catch up with care conferences.
Failure to Maintain Clean, Home-Like Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a home-like environment for two residents and for two resident rooms reviewed. In R108’s room, the bathroom door had a square broken area in the wood approximately one-third of the way from the top of the door. R108 stated they did not like the damage and that it bothered them. The damaged bathroom door remained observed on subsequent days. The Director of Maintenance stated, “We don't inspect the rooms,” and indicated that something should be entered into the electronic maintenance request system to address it. R108’s record showed diagnoses including collapsed vertebra and COPD, and the most recent MDS indicated intact cognition and maximum assistance with all ADLs other than eating and oral care. Additional room conditions were observed that were not maintained in a clean or home-like condition. One bathroom had an unknown brown substance in the toilet bowl and seat, visible debris around the bathroom perimeter, and an odor of urine and feces. Another bathroom had a strong fecal odor, smeared feces on the toilet seat, floor, and inside the garbage can, with gnats flying near the feces. In R11’s room, the tube feeding pole, base, and floor were observed with spilled brown tube feeding liquid that remained present across multiple observations. The room also had a missing bifold closet door, rusted mounting hardware at the floor, clothing piled on the floor, a peeled section of cove base in the shared bathroom, and a urine hat with residual yellow liquid left on the back of the toilet.
Failure to Provide an Appropriately Sized Bed
Penalty
Summary
The facility failed to provide an appropriately sized bed for a resident who stated the bed was uncomfortable and that they felt like they were going to fall off it. The resident, who reported being tall, said they had asked multiple staff members on multiple occasions for a larger bed and had not been told they needed to complete a grievance form. During observations on multiple occasions, the resident was lying perpendicular across the bed with their legs slightly bent and feet pressed against the footboard, and their body positioned close to the side of the bed nearest the room door. The resident's call light was also observed on the floor underneath the left side of the bed. The resident's record showed diagnoses including collapsed vertebra and COPD, intact cognition, and a need for maximum assistance with all ADLs except eating and oral care. The resident weighed 223 pounds as of 11/23/25. The Director of Maintenance stated that if a resident needed a different mattress and/or bed, staff were supposed to enter a request into the TELS maintenance system, but no TELS request had been made for this resident. The resident's CNA also stated the resident had recently commented about wanting a new bed that fit better, and no request had been entered. The Administrator stated the expectation was that staff would notify the appropriate manager so a bed could be provided. The facility policy on Resident Rights stated residents have the right to reasonable accommodation of needs and preferences.
Failure to Notify Physician of Critical Blood Glucose Result
Penalty
Summary
The facility failed to notify the physician regarding an abnormal laboratory result for one resident whose blood glucose level was 34, which was reported as a critical value and below the lab's normal range of 82-115 mg/dl. The resident had been admitted to the facility with diagnoses including Bipolar Disorder, Epilepsy, and Stroke, and the active care plan noted dependence on tube feeding, NPO status, potential for fluid imbalance, ADL deficits requiring assistance, and altered cardiovascular status related to hypertension and hyperlipidemia. Review of the progress notes showed no documentation that the physician was notified or what action was taken, and review of the physician's logbook showed no entries for the resident on or after the date of the abnormal lab result related to the low blood glucose. The DON stated that the nurse should notify the physician of abnormal lab values and document the notification in the progress notes or doctors' logbook.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide podiatry services for one resident who had been requesting to see the podiatrist for months and had not yet been seen. The resident stated that their long toenails hurt. The resident was admitted with Parkinson's Disease and muscle weakness, and the MDS showed a BIMS score of 14/15, indicating intact cognition. The resident also required staff assistance with bed mobility and transfers. Record review and observation showed the resident's toenails were repeatedly identified by CNA documentation as needing to be cut on multiple shower dates in November and December. During observation, the toenails were thick, curled from their length, and yellowish with black on some toenails. The resident's most recent podiatry note was requested but not received by the end of survey. The SSD stated that residents who want podiatry are usually added to the list, and the DON stated that when shower sheets document an issue such as long toenails, staff should notify Social Work so the resident can be placed on the podiatry list as soon as possible.
Failure to Document and Monitor Side Rail Use
Penalty
Summary
The facility failed to document the physician’s order, informed consent, risk-versus-benefit discussion, attempted alternatives, and ongoing monitoring for the use of side rails for two residents. For one resident, who was admitted with diagnoses including cerebral infarction, acute respiratory failure with hypoxia, and heart failure, the record showed the resident was cognitively intact and required 2-person assistance for bed mobility, but the care plan did not address side rails and there were no physician orders in place. A Nursing Side Rail assessment stated the rails were being ordered for positioning and that a trapeze had been tried as an alternative, but the assessment contained blank responses for the measurements section. The resident stated the rails made them feel safe, and later said the rails had been removed and replaced, while also indicating they had not trialed an alternative such as a trapeze. For the second resident, who was admitted with muscle weakness and age-related physical debility and had an intact BIMS score of 15/15, side rails were observed on the bed and the resident stated they helped with pushing up in bed and moving side to side. The medical record did not note side rails in the MDS, physician orders, or care plan, and no consent was found for their use. Nursing Side Rail Assessments dated over several months were present, but the section for measurements was blank on each assessment. Staff interviews indicated the rails were viewed as assist bars or used for mobility/positioning, that risk-versus-benefit discussions were discussed rather than written, and that monthly safety checks were completed without documentation. A request for the facility’s bed rail policy was made but not provided by the end of survey.
Missed Anticonvulsant Doses Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure a prescribed medication, lacosamide oral solution 100 mg/10 ml, was available for administration for one resident with diagnoses of seizures, epilepsy, and stroke. The resident’s care plan documented a seizure disorder and directed staff to give medications as ordered and observe for effectiveness and side effects. The medication order required lacosamide 20 ml twice daily for generalized idiopathic epilepsy and epileptic syndrome, but the December 2025 MAR showed the medication was not documented as given twice daily on 12/01 and 12/02, with the morning dose missed on 12/03. Nursing progress notes for those dates stated the medication was unavailable and on order. When the missed doses were reviewed with the DON, the DON reported medications should be reordered by the nurse and administered as ordered. The resident stated, “I need that for my Epilepsy” when asked about the missed doses.
Delayed Oral Surgeon Consultation
Penalty
Summary
The facility failed to ensure an oral surgeon consultation was completed timely for one resident who was reviewed for ancillary services. The resident was observed in bed in a hospital-style gown, reported not receiving daily mouth care, and showed missing or broken upper teeth with white debris between the lower teeth. The resident had a left hand contracture, limited arm movement, tube feeding, and also received a meal tray. The resident’s record showed diagnoses of Failure to Thrive, Physical Debility, and Stroke, along with moderately impaired cognition and dependence on staff for activities of daily living and other needs. The dental record documented oral discomfort and recommended extraction of non-restorable teeth with an oral surgeon, along with follow-up for dentures and assistance with toothbrushing and flossing. Subsequent dental notes stated the resident had not yet seen the oral surgeon, and a later note documented that the facility was working on scheduling the appointment. Social services later confirmed an appointment had been scheduled but was cancelled because the resident needed to go on a stretcher, and the cancelled visit was not followed up for several months. Staff reported they did not know why the appointment had not been completed, and the DON stated staff should have followed up the cancelled appointment and notified social services or the unit manager.
Failure to Use Required PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to don appropriate personal protective equipment (PPE) when providing care to two residents who were on Enhanced Barrier Precautions (EBP). One resident had a sign on the door indicating EBP, and an LPN entered the room wearing gloves but not a gown while administering medications separately through a PEG tube. Another room had a sign indicating both residents were on EBP, and a CNA entered with a bag of wash towels, re-entered the room, and closed the door without being observed putting on PPE. The resident in that room had tube feeding via a PEG tube and pump, and the EBP sign stated that gloves and a gown were required for high-contact care activities including dressing, bathing, transferring, changing linens, hygiene, changing briefs, and toileting assistance. During interview, the CNA reported repositioning the resident while providing care and acknowledged that PPE should have been donned before entering the room. The DON reported that staff should have worn a gown and gloves for the care provided to both residents. The facility policy stated that EBP requires the use of gown and gloves for certain residents during specific high-contact resident care activities, and that residents with devices such as feeding tubes may be placed on EBP empirically while awaiting physician orders.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, which was identified during an interview and record review. The resident, who was admitted with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Diabetes, Dementia, and Heart Failure, was severely cognitively impaired and required limited assistance for transfers and bed mobility. On multiple occasions, nursing notes documented a decline in the resident's ability to transfer and toilet independently, indicating a significant change in condition. Despite these observations, the resident's family was not informed of the change until a family member noticed the decline during a visit. Interviews with facility staff revealed that there was a lack of communication and documentation regarding the notification of the resident's family. A Licensed Practical Nurse (LPN) was informed of the change in condition but was not familiar with the resident and relied on the Unit Manager to contact the family. The Unit Manager claimed to have contacted the family but did not document the attempt. The Director of Nursing acknowledged that the family should have been notified. Additionally, the facility's Acute Change in Condition policy did not address the requirement to notify the resident's representative, contributing to the deficiency.
Failure to Complete Timely Nutritional Assessment
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment in a timely manner for a resident admitted with nutritional at-risk indicators. The resident, who had diagnoses including dysphagia, diabetes mellitus, and dementia, was admitted with a hospital transfer order for a pureed diet. The resident's weight decreased from 140 pounds to 131.7 pounds over a period of time, and the care plan indicated the need for extensive assistance with eating. Despite these indicators, a comprehensive nutritional assessment by the Registered Dietician (RD) was not completed. The RD confirmed during an interview that the assessment was missed, although a Minimum Data Set (MDS) nutrition assessment was completed, which is not a comprehensive dietary evaluation. The Director of Nursing (DON) was unable to provide the facility's policy on the timeliness of a full RD assessment, and the policy provided only addressed MDS assessments. The lack of a comprehensive assessment potentially delayed necessary care interventions for the resident, who exhibited multiple dietary-related indicators such as decreased oral intake, decreased appetite, and weight loss.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for one resident and a group of ten residents, leading to dissatisfaction during meals. Observations and interviews revealed that a resident's breakfast consisted of items like biscuits, pancakes, and cereal, with the only protein being a small carton of milk. The resident expressed dissatisfaction with the food, describing it negatively. A review of the resident's electronic medical record showed they had diagnoses including congestive heart failure and type 2 diabetes, with moderately impaired cognition. Notes from a Food Council Meeting indicated widespread dissatisfaction with the food, describing it as unseasoned, soggy, and cold. Further observations included a food cart with trays lacking plate warmers and open doors while meals were being served. A temperature test of a meal showed the food was below the preferred temperature, with items missing from the plate. The Dietary Manager confirmed the preferred temperature should be 100 degrees Fahrenheit or above. A test tray revealed a pork chop at 107 degrees Fahrenheit, which was lukewarm and fatty. The facility's policy on food palatability and temperature was reviewed, indicating that food should be palatable, attractive, and served at appetizing temperatures.
Ineffective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program by not eliminating harborage conditions in the kitchen, which has the potential to affect all residents. During an observation, standing, stagnant, slimy water was found on the floor underneath the garbage grinder at the three-compartment sink, accompanied by cobwebs and numerous gnats. The Dietary Manager (DM) stated that the pipe for the garbage grinder was small and sometimes overflowed but did not explain why the standing water was not cleaned up to prevent a breeding ground for gnats. Additionally, standing water was observed between the coffee maker and the juice dispenser, with gnats flying in the area, and the DM was unsure of the water's source. Pest control service reports from previous dates noted the presence of gnats, indicating ongoing issues with pest control.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for four residents, leading to a deficiency in medication storage and administration. Resident 71 was observed with an inhaler on their bedside table on multiple occasions, without an assessment for self-administration of medications. The resident, who was moderately cognitively impaired, confirmed using the inhaler but there was no documentation supporting their ability to self-administer. Resident 63 was found with a medication cup containing pills on their bedside table, which they ingested upon inquiry, stating they were from the previous night. The resident was cognitively intact, yet there was no indication of an assessment or order for self-administration. A Licensed Practical Nurse (LPN) confirmed that the medications were not administered by them and identified the pills as Gabapentin and Buspar. Residents 22 and 44 were also observed with medications at their bedsides without proper authorization. Resident 22 had an albuterol inhaler on the dresser, and Resident 44 had nasal sprays, including a discontinued medication. Both residents did not have physician orders or assessments for self-administration. The facility's policy requires an interdisciplinary team assessment and a physician's order for residents to self-administer medications, which was not followed in these cases.
Failure to Honor Resident's Request for Hospital Transfer
Penalty
Summary
The facility failed to honor a resident's request for a higher level of care, specifically a transfer to the hospital, which is a violation of the resident's right to self-determination. The resident, identified as R33, reported experiencing severe pain due to a suspected kidney stone and requested to be transferred to the hospital. Despite this request, the resident was informed that the physician did not order a transfer and that they would need to sign out Against Medical Advice (AMA) and be responsible for the transportation costs if they chose to leave. This left the resident in excruciating pain without the desired medical intervention. The resident's medical record indicated a history of kidney stones, chronic kidney disease, and acute pyelonephritis, which substantiates their concern for needing hospital care. The nursing staff documented the resident's request and pain but did not facilitate the transfer. Interviews with the nursing staff and the Director of Nursing revealed a lack of communication and misunderstanding regarding the resident's rights to self-determination and hospital transfer. The facility's policy on resident rights supports the resident's ability to make significant choices about their care, which was not upheld in this instance.
Failure to Provide Assistive Communication Device
Penalty
Summary
The facility failed to provide an assistive communication device for a resident, resulting in limited communication between the resident and staff. The resident, who was admitted with diagnoses including a cerebral infarction and type 2 diabetes, was observed to have severely impaired cognition and was dependent on staff for all activities of daily living except eating. During observations and interviews, it was noted that the resident communicated primarily through gestures, such as giving a thumbs up, and did not have a communication board available, despite the facility's policy to provide such devices to non-verbal residents. Interviews with staff, including a CNA and an LPN, revealed that they were unaware of any communication board being used by the resident. The Rehabilitation Director initially stated that the resident had a communication board by their bed, but subsequent observations did not confirm its presence. The facility's administrator acknowledged the expectation for providing communication boards to non-verbal residents and indicated that alternative communication methods should be explored if a board is not usable. The lack of a communication board was not addressed in the resident's care plan, contributing to the deficiency.
Failure to Address Resident's Broken Glasses
Penalty
Summary
The facility failed to address the issue of broken glasses for a resident, identified as R109, who was observed wearing glasses missing a section of the frame and the entire lens on the right side. The left lens was dirty and smeared with a greasy substance. R109 reported that the glasses had been broken for quite some time and that the facility had not assisted in obtaining new ones. Despite being seen by an eye doctor in August, the issue was not resolved, and the resident was told to get their own glasses. The resident's medical record indicated a diagnosis of sequelae of cerebral infarction and ataxia, with a care plan noting impaired visual function and the need for assistance with visual devices. Interviews with facility staff revealed a lack of awareness and action regarding the resident's broken glasses. The Unit Manager was unaware of the issue until informed and stated that social work would be notified. The Social Worker confirmed they had contacted the eye doctor but were awaiting a response. The Director of Nursing acknowledged that the situation was emergent and should have been addressed immediately, with optometry fixing or replacing the glasses during the resident's last visit. The facility's policy on appointments indicated that emergency services should be contacted immediately, but this was not followed in R109's case.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician order for oxygen for a resident, identified as R76, who was observed multiple times wearing oxygen at four liters per minute via nasal cannula. R76 was admitted with diagnoses including cerebral infarction, chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. Despite these conditions, a review of R76's medical records revealed no physician order for oxygen, although the care plan indicated oxygen settings of 2-3 liters via nasal cannula. Interviews with facility staff, including an LPN, the Unit Manager, the Director of Nursing, and the Nursing Home Administrator, confirmed the absence of a physician order for oxygen. The staff acknowledged that a physician order is required for residents on oxygen. The facility's policy on oxygen administration also stipulates that oxygen should be administered per physician orders and facility protocol, which was not adhered to in this case.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration when an LPN crushed an extended-release medication for a resident without a physician's order. The incident involved a resident with a history of paraplegia, schizophrenia, and seizure disorder, who was dependent on self-care and had moderate cognitive impairment. The resident requested their medications to be crushed, and the LPN complied without verifying the physician's orders, which did not include instructions to crush the medications. During the medication administration, the LPN crushed several medications, including Duloxetine, which is a delayed-release medication that should not be crushed. The facility's Director of Nursing (DON) was informed of the incident after the medications were administered. Upon review, it was confirmed that Duloxetine should not have been crushed as it is designed to release the active ingredient after ingestion. The facility's policy requires medications to be administered according to the physician's written orders, which was not followed in this case. The DON contacted the facility pharmacist to verify if any of the medications were on the 'DO NOT CRUSH' list. Although the pharmacist initially reported that none of the medications were on the list, further review of the drug manufacturer's literature confirmed that Duloxetine should not be crushed. The facility's failure to follow proper medication administration procedures led to the inappropriate alteration of a resident's medication without a physician's directive.
Failure to Maintain Splinting Program for Resident
Penalty
Summary
The facility failed to maintain a splinting program for a resident, identified as R68, who was observed not using a prescribed hand splint. The splint was repeatedly seen laying on the heat register in the resident's room over several days. R68, who has a history of cerebral infarction with left hemiplegia and muscle wasting, reported that the splint was for their left hand but stated it was never put on anymore. The resident expressed occasional pain in the left hand and acknowledged that the splint should probably be used. Despite the resident's condition and the previous recommendation for a splint to prevent further contracture and pain, there was no recent occupational therapy evaluation or documentation supporting the discontinuation of the current splint. Interviews with staff, including CNAs and the Director of Rehab (DOR), revealed a lack of awareness and documentation regarding the use of the splint. The DOR mentioned that a new splint was ordered but delayed due to the resident's payor source and authorization process. However, no documentation was provided to indicate that the current splint was contraindicated or deemed inappropriate. The facility's policy on splints and orthotics was requested but not provided by the conclusion of the survey, and there was no clear documentation expectation from the facility's administration regarding the discontinuation of the splint.
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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) |
|---|---|---|---|---|
| Autumn Woods Residential Health | 0.4 mi | ★★★★★ | 28 | 0 |
| Windemere Park Health And Rehabilitation Center | 2 mi | ★★★★★ | 2 | 0 |
| Father Murray, A Villa Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Harmony Village Of Warren | 2.1 mi | ★★★★★ | 1 | 0 |
| The Villa At City Center | 2.1 mi | ★★★★★ | 7 | 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.