Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Altercare Of Wadsworth during CMS and state inspections, most recent first.
The facility failed to date insulin pens after opening, affecting three residents with diabetes. During medication administration, an LPN and the DON confirmed that insulin pens for these residents were not dated, contrary to facility policy. The LPN was unsure of the insulin pens' effective duration post-opening.
The facility failed to maintain infection control during medication administration for two residents. An LPN allowed a pill to be ingested after it fell on a comforter, and another LPN mishandled a pill that fell on a cart and failed to disinfect a surface before placing a glucometer on it. Both actions were confirmed as inappropriate by the DON.
The facility failed to have the designated infection control preventionist participate in the QAPI committee and attend required meetings. Despite completing the infection preventionist training, the RN was not listed as a committee member and did not attend meetings from December 2023 through March 2024, as confirmed by interviews and sign-in sheets.
The facility failed to invite a resident's POA to all care plan meetings. The resident, who was severely cognitively impaired and dependent for activities of daily living, had a POA who expressed a preference to attend all care conferences. However, the POA was not invited to the quarterly care plan meetings on two occasions. The LSW confirmed that notifications were mailed out, but no follow-up calls were made, and the resident's name was missing from the invitation list for one of the meetings.
The facility failed to notify two residents and their responsible parties of changes in wound treatment and skin injury. One resident developed wounds due to improper use of incontinence brief tape, and the POA was not informed. Another resident and their responsible party were not notified of new physician orders for wound treatment.
The facility failed to ensure that a resident was ambulated per physician orders to maintain functional abilities. Despite a physician's order for a restorative ambulation program, the resident was not offered or assisted with ambulation on multiple dates. Interviews confirmed that staff were not following the prescribed program, and the resident expressed a desire to maintain his walking ability.
The facility failed to follow physician orders for a resident requiring Tubigrip and arm elevation, resulting in significant swelling. Additionally, improper fitting of incontinence briefs caused skin injuries, with staff failing to take preventive measures or provide proper education.
The facility failed to follow and implement orders for a resting hand splint for a resident who was severely cognitively impaired and dependent for activities of daily living. Observations and interviews revealed that the splint was not applied as ordered due to misunderstandings and forgetfulness. Further investigation showed that a new order for a different splint was not entered into the electronic medical system, resulting in the order not being implemented.
A resident with a neuromuscular dysfunction of the bladder and a suprapubic catheter had their urinary catheter bag repeatedly placed on the bed above the bladder, contrary to physician orders and facility policy. This improper positioning was confirmed by the resident, an LPN, and the DON, highlighting a failure in adhering to proper catheter care protocols.
The facility failed to provide enteral nutrition per the physician's order for a resident with multiple diagnoses, including dysphagia and hemiplegia. Observations revealed the resident's tube feeding was not running as prescribed, and the resident exhibited signs of dehydration. The LPN responsible for the resident confirmed the discrepancy upon reviewing the physician's orders.
The facility failed to monitor oxygen saturation levels for three residents receiving continuous and as-needed oxygen therapy. Despite orders to check oxygen saturation every shift, the required monitoring was not performed, as confirmed by the DON and other staff.
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. Post-dialysis assessments were not conducted on multiple occasions, and there was no documentation received from the dialysis center for nearly a month. The Director of Nursing confirmed that the necessary assessments were not performed, leading to a deficiency in providing safe and appropriate dialysis care.
The facility failed to ensure a physician's order for an as-needed psychotropic medication had a time-frame for usage for a resident with multiple psychiatric diagnoses. The PRN order for Ativan 0.5 mg was issued without an end date, contrary to the facility's policy requiring a 14-day limit unless extended by the prescribing practitioner with documented rationale.
The facility failed to ensure accurate documentation in the medical records for two residents, leading to discrepancies in their treatment. One resident continued to receive a treatment that should have been discontinued, and another had duplicate treatment orders for the same pressure ulcer.
Failure to Date Insulin Pens After Opening
Penalty
Summary
The facility failed to ensure that insulin pens were properly dated and labeled after opening, affecting three residents who were observed during medication administration. Resident #9, who was admitted with a diagnosis of diabetes, had a physician's order for Glargine insulin to be administered twice daily. During an observation, it was noted that the insulin pen for this resident was not dated to indicate when it was opened. Interviews with the LPN and the Director of Nursing confirmed the absence of a date on the insulin pen, and the LPN admitted to being unsure of the duration for which insulin pens remain effective after opening. Similarly, Resident #16, also diagnosed with diabetes, had an order for Basaglar Kwikpen insulin to be administered once daily. The insulin pen for this resident was also found to be undated during the medication administration observation. The same issue was observed with Resident #40, who had an order for Fiasp insulin to be administered with meals. The facility's policy on medication storage, which requires medications to be stored following manufacturers' recommendations and to be dated upon opening, was not adhered to in these cases.
Infection Control Breaches During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control procedures during medication administration, affecting two residents. For Resident #49, the incident occurred when an LPN administered medications, including Gabapentin, Metoprolol Succinate ER, and Pantoprazole. During the process, one of the pills was dropped onto the resident's comforter. Instead of discarding the contaminated pill, the LPN instructed the resident to ingest it, which was confirmed as inappropriate by both the LPN and the Director of Nursing (DON). For Resident #46, the deficiency involved an LPN who mishandled medication by allowing a Lexapro pill to fall onto the medication cart. The LPN picked up the pill with bare hands and placed it back into the medicine cup, which was then given to the resident. Additionally, the LPN failed to use a barrier or disinfect the overbed tray before placing a glucometer on it. Both actions were confirmed as breaches of infection control protocols by the LPN and the DON.
Infection Control Preventionist Not Participating in QAPI Committee
Penalty
Summary
The facility failed to have the designated infection control preventionist participate in the Quality Assurance Performance Improvement (QAPI) committee and attend meetings as required. Registered Nurse (RN) #596, who completed the infection preventionist training course on 03/01/23, was not listed as a member of the QAPI committee. Additionally, RN #596 did not attend the QAPI monthly committee meetings held from December 2023 through March 2024, despite her claim of attending every meeting to present infection control information. This deficiency was confirmed through interviews and review of meeting sign-in sheets, which showed no evidence of her attendance.
Failure to Invite POA to Care Plan Meetings
Penalty
Summary
The facility failed to invite Resident #60's Power of Attorney (POA) to all care plan meetings. Resident #60, who was admitted with diagnoses including muscle weakness, lack of coordination, hemiplegia, and hemiparesis following a cerebral infarction, was severely cognitively impaired and dependent for activities of daily living. Despite this, the POA was only invited to two care plan meetings, as revealed during an interview on 04/23/24. The POA expressed a preference to attend all care conference meetings, but records showed that the POA was not present at the quarterly care plan meetings on 12/06/24 and 03/10/24. Licensed Social Worker (LSW) #557 confirmed that notifications for care plan meetings were mailed out at the beginning of the previous month, but no follow-up calls or further notifications were made. A review of the lists provided to the receptionist for mailing invitations revealed that Resident #60's name was missing from the list for December 2023 and was the last name on the list for March 2024. LSW #557 was unsure why Resident #60's name was omitted from the December list, confirming that the POA was not properly notified for the care plan meetings on 12/06/24 and 03/10/24.
Failure to Notify Residents and Responsible Parties of Wound Treatment Changes
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were notified of changes in wound treatment and skin injury. This deficiency affected two residents. Resident #60, who was severely cognitively impaired and dependent for activities of daily living, developed wounds on the right upper and anterior thigh due to the tape from an incontinence brief being placed directly on the skin. Despite the presence of a Power of Attorney (POA) for Health Care, the POA was not notified of the wounds. The Assistant Director of Nursing (ADON)/Wound Care Nurse confirmed that the POA had not been informed due to time constraints. Similarly, Resident #26, who had diagnoses including Alzheimer's disease, chronic kidney disease, and diabetes mellitus, was not notified of new physician orders for wound treatment to the buttocks. The resident's responsible party was also not informed. The ADON verified that staff did not notify Resident #26 or the responsible party of the new treatment orders. The Director of Nursing confirmed that notifications should be made within the same shift. The facility's policy required immediate notification of the resident and their authorized representative when there was a new form of treatment.
Failure to Follow Physician's Orders for Restorative Ambulation Program
Penalty
Summary
The facility failed to ensure that Resident #65 was ambulated per physician orders to maintain functional abilities. Resident #65, who had diagnoses including Parkinsonism, muscle weakness, and age-related physical debility, was referred for a restorative ambulation program. The physician's order specified that staff were to assist the resident to ambulate up to 326 feet with his walker for 15 minutes a day, four to seven days a week as tolerated. However, documentation revealed that the resident was not offered or assisted with ambulation on multiple dates in April 2024, and was only assisted three days in one week and two days in another week during that month. Interviews with Resident #65 and the Assistant Director of Nursing (ADON) confirmed that the resident was not receiving the prescribed ambulation assistance. Resident #65 expressed a desire to maintain his walking ability, but stated that staff were not assisting him to ambulate with his walker since he stopped receiving skilled therapy services. The ADON verified that staff were not following the physician's order for the resident's restorative program on the specified dates. The facility's policy on Restorative Nursing Care, updated in April 2024, indicated that the restorative program should be provided to maintain residents' highest level of physical functioning, but this was not adhered to in the case of Resident #65.
Failure to Follow Physician Orders and Ensure Proper Incontinence Care
Penalty
Summary
The facility failed to follow physician orders for Resident #60, who had diagnoses including muscle weakness, hemiplegia, and hemiparesis following a cerebral infarction. The orders required the application of Tubigrip to the right upper extremity and elevation of the right arm. Observations on multiple occasions revealed that the resident's right arm was not elevated, and the Tubigrip was not applied, resulting in significant swelling of the right hand. Staff members, including the ADON/Wound Care Nurse, LPN, and STNAs, confirmed the lack of compliance with the physician's orders. The LPN mentioned that the resident did not like the Tubigrip, but upon asking, the resident agreed to have the arm elevated, indicating a lack of consistent care and communication among staff members. Additionally, the facility failed to ensure that Resident #60's incontinence briefs fit appropriately, leading to skin injuries. The resident, who was severely cognitively impaired and always incontinent of bowel and bladder, had wounds on the right thigh caused by the tape on the incontinence briefs being placed directly on the skin. Observations revealed multiple scarred areas and open wounds on the resident's thigh. The ADON/Wound Care Nurse confirmed that the injuries were due to the tape on the briefs and that no measures had been taken to prevent further injury. The DON confirmed that there had been no staff education on proper brief application and that the resident was wearing the wrong size brief according to the facility's sizing chart. The deficiencies highlight a lack of adherence to physician orders and inadequate staff training and communication, resulting in preventable injuries and discomfort for Resident #60. The facility's failure to follow care plans and physician orders, along with improper incontinence care, directly contributed to the resident's deteriorating condition and skin injuries.
Failure to Implement Resting Hand Splint Orders
Penalty
Summary
The facility failed to follow and implement orders for a resting hand splint for Resident #60, who was severely cognitively impaired and dependent for activities of daily living. The resident had a physician's order dated 05/23/23 for a resting hand splint to be applied to the right hand during hours of sleep for four to six hours every shift. However, observations on 04/23/24 and 04/24/24 revealed that the splint was not applied as ordered. Interviews with staff confirmed that the splint was not applied due to misunderstandings and forgetfulness. The Assistant Director of Nursing (ADON) and a State Tested Nursing Assistant (STNA) both confirmed the resident did not have the splint on during their respective observations and interviews. Further investigation revealed that the original order for the resting hand splint was discontinued on 04/10/24, and a new order was written for a different splint. This new order required the use of a right volar inflatable resting hand splint at night for up to six hours, with specific instructions for its application and monitoring. However, the new order was not entered into the electronic medical system by the nursing staff, resulting in the order not being implemented. The Director of Nursing (DON) and the Certified Occupational Therapy Assistant (COTA) confirmed that the new order was not followed due to the failure of the nursing staff to complete the necessary documentation and implementation steps.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter bag was consistently placed below the bladder, as required to prevent complications such as urinary tract infections. The resident, who had a neuromuscular dysfunction of the bladder and a suprapubic catheter, was observed on multiple occasions with the catheter drainage bag lying on the bed above the bladder. This was contrary to the physician's orders and the facility's policy, which specified that the drainage bag should be kept below the bladder and off the floor. Interviews with the resident, an LPN, and the Director of Nursing confirmed that the drainage bag was not positioned correctly and acknowledged the potential for urine to back up into the bladder, increasing the risk of infection. The resident, who had a Foley catheter for several years and a newly created suprapubic catheter, reported that the drainage bag had always been positioned on the bed since the suprapubic catheter was placed. The LPN and the Director of Nursing both verified that the drainage bag should be hanging below the bladder to prevent complications. The facility's undated catheter care policy also supported this requirement. Despite these guidelines, the resident's catheter bag was repeatedly found in an incorrect position, indicating a failure in adhering to proper catheter care protocols.
Failure to Provide Enteral Nutrition Per Physician's Order
Penalty
Summary
The facility failed to provide enteral nutrition per the physician's order for Resident #60. Resident #60, who was admitted with diagnoses including esophagitis, gastroparesis, dysphagia, and hemiplegia following a cerebral infarction, was dependent on tube feeding for nutrition and hydration. The care plan indicated that Resident #60 was to receive enteral feeding formula Peptamen 1.5 at 65 milliliters per hour from 6:00 A.M. to 12:00 A.M., with a six-hour break from 12:00 A.M. to 6:00 A.M. However, observations on 04/25/24 at 7:30 A.M. and 9:11 A.M. revealed that the tube feeding was not running, and the resident's lips and mouth had a thick, dry, pasty film. LPN #515, who was responsible for Resident #60, initially stated that the tube feeding was only to run from 12:00 A.M. to 6:00 A.M., but upon reviewing the physician's orders, confirmed the correct schedule was from 6:00 A.M. to 12:00 A.M. The facility's undated policy on Enteral Nutrition stated that adequate nutrition support through enteral feeding would be provided to residents unable to consume adequate nutritional intake by mouth, and that enteral feeding orders would be written to ensure consistent volume infusion. The failure to adhere to the physician's order for Resident #60's enteral feeding schedule resulted in the resident not receiving the prescribed nutrition and hydration, as evidenced by the observations and interviews conducted during the survey.
Failure to Monitor Oxygen Saturation Levels
Penalty
Summary
The facility failed to monitor oxygen saturation levels for residents receiving continuous and as-needed oxygen therapy. This deficiency affected three residents. Resident #60 had an order for oxygen at two liters per nasal cannula as needed to keep SP02 greater than 92 percent, but only two oxygen saturation levels were assessed in April 2024. The Director of Nursing (DON) confirmed that oxygen saturation levels should be assessed every shift for residents with such orders. An observation revealed Resident #60's SPO2 level was 90 percent on room air, indicating inadequate monitoring. The Certified Nurse Practitioner (CNP) also confirmed that saturation levels should be checked every shift for residents with as-needed oxygen orders. Resident #31 had an order for continuous oxygen at two to four liters per nasal cannula, with instructions to check placement and record oxygen saturation every shift. However, the last documented oxygen saturation was on 04/05/24, and the Treatment Administration Record (TAR) did not include a record of oxygen saturation every shift. Interviews with the DON and a Licensed Practical Nurse (LPN) confirmed that the required monitoring was not being done. Similarly, Resident #26 had an order for oxygen one to four liters nasal cannula as needed if pulse oximeter was below 92 percent or shortness of breath, but no pulse oximeter readings were documented since 04/03/24. The DON verified that oxygen saturation should be assessed every shift for residents with such orders, but this was not being done for Resident #26.
Failure to Monitor and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease, had physician orders for dialysis on specific days. However, the medical record review revealed that post-dialysis assessments were not conducted on multiple occasions, and there was no documentation received from the dialysis center for nearly a month. Interviews with the dialysis nurse and the Director of Nursing confirmed that the facility did not consistently send or require communication from the dialysis center, and the necessary post-dialysis assessments were not performed as per the facility's policy. The Director of Nursing verified that the nursing staff were supposed to perform comprehensive assessments, including mental status, vital signs, skin assessment, dialysis access site assessment, lung sounds, edema, pain presence, and any new orders from the dialysis center. Despite this requirement, the assessments were not completed on several specified dates, and no documentation was received from the dialysis center until the day of the survey. This lack of monitoring and communication led to a deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Ensure Time-Frame for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure the physician's order for an as-needed psychotropic medication had a time-frame for usage for Resident #13. Resident #13, who was admitted with diagnoses including schizoaffective disorder, dementia with anxiety, major depressive disorder, and psychotic disorder with delusions, had a new order for Ativan 0.5 mg as needed (PRN) with no stop date. This order was identified during a review of the physician's orders for April 2024, which showed that the PRN Ativan was ordered on 03/04/24 without an end date. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the PRN order for Ativan did not have an end date. The RN stated that she had never administered the PRN dose of Ativan for Resident #13. The DON verified the absence of an end date and mentioned that the physician had discontinued the order on 04/24/24. The facility's Behavior Management Policy indicated that PRN orders for psychotropic medications should be limited to 14 days unless extended by the prescribing practitioner with documented rationale, which was not followed in this case.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for two residents, leading to discrepancies in their treatment. For Resident #26, the medical record showed an order for Medihoney treatment to the left buttock, which was supposed to be discontinued one week after an assessment on 12/14/23. However, the treatment continued until 01/16/24 without any documentation explaining why. Additionally, there were no nursing assessments or progress notes from 03/21/24 to 04/22/24 to justify a new order for Medihoney treatment dated 03/23/24. Interviews with the Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed the discrepancies and lack of documentation in the resident's medical record, including a stage two pressure ulcer identified on 04/19/24 that was not documented in the medical record due to time constraints by the ADON. For Resident #40, the medical record revealed orders for treatments to both the left buttock and sacrum. However, an observation on 04/23/24 showed only one pressure ulcer on the sacrum, and no ulcer on the left buttock. An interview with an RN revealed that the left buttock ulcer had been renamed as a sacrum ulcer, but the treatment order for the left buttock was not discontinued. This resulted in two different orders for the same area, and staff were marking both treatments as completed. The RN confirmed that the medical record was not accurate due to the oversight in discontinuing the left buttock order.
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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 Wadsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sanctuary Wadsworth | 1.9 mi | ★★★★★ | 1 | 0 |
| Wadsworth Pointe | 2.1 mi | ★★★★★ | 0 | 0 |
| Autumnwood Nursing & Rehab Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Doylestown Health Care Center | 4.2 mi | ★★★★★ | 3 | 0 |
| Apostolic Christian Home Inc | 6.8 mi | ★★★★★ | 0 | 0 |
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