Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Altercare Zanesville Inc. during CMS and state inspections, most recent first.
A staff member entered the room of a resident on contact precautions for MRSA to deliver a meal without wearing PPE or performing hand hygiene, despite clear signage and facility policy requiring these measures. The staff member acknowledged not following the required infection control protocols.
A resident with diabetes and cardiac history did not receive prescribed blood glucose monitoring or insulin administration as ordered after returning from an endocrinology appointment. Insulin Lispro was discontinued, and blood sugar checks were not performed, except during blood draws, despite orders to continue both insulin and monitoring. The resident also reported her glucose monitoring device was not replaced promptly, and staff interviews confirmed the orders were not clarified or followed.
A resident with Stage 3 chronic kidney disease experienced a decline in condition, including confusion and falls, after the facility failed to timely conduct a urinalysis despite family requests. The delay in testing and treatment led to a urinary tract infection with Escherichia coli, which progressed to sepsis and acute renal failure, resulting in the resident's death. The facility did not notify medical providers of the family's concerns or the resident's symptoms, contributing to the resident's decline.
A resident with multiple health conditions did not receive ordered basic metabolic panel (BMP) tests on specified dates, despite staff indicating collection. The facility lacked a policy on laboratory services, relying solely on physician orders, leading to a deficiency in compliance.
A facility failed to provide proper catheter care for a resident with an indwelling urinary catheter. The resident, with severe medical conditions, was observed receiving care where a CNA did not change gloves between tasks, contrary to facility policy and national guidelines. The catheter tubing was also improperly positioned, increasing infection risk.
Two residents in an LTC facility experienced inadequate pain management, resulting in severe pain for one and potential harm for the other. A resident with multiple diagnoses did not receive scheduled narcotic medication on time, leading to a pain level of 10 out of 10. Another resident on hospice care did not receive PRN morphine, raising concerns about unrecognized pain. Facility policies on medication administration and pain management were not followed, contributing to these deficiencies.
The facility failed to accurately document controlled medications for two residents, leading to discrepancies between the eMAR and Controlled Drug Forms. One resident receiving hospice care had multiple undocumented doses of hydrocodone, while another resident with severe pain had OxyContin administered without immediate documentation. These issues were identified during a complaint investigation, indicating non-compliance with documentation requirements.
A resident with a Stage IV pressure ulcer did not receive proper wound care as per physician orders. The RN failed to cover the wound with a dressing, used contaminated scissors, and did not maintain proper hand hygiene during the dressing change. The resident was also found laying on a drainage collection bag, contrary to care guidelines.
The facility exhibited a medication error rate of 15.15%, affecting three residents. An LPN administered eye drops to a resident without the required waiting period, while an RN followed a resident's instructions instead of the physician's orders for eye drops. Another LPN administered an incorrect dosage of a laxative. These actions were confirmed through observations and interviews.
The facility failed to provide proper pressure ulcer care for two residents. One resident's air mattress was set incorrectly, not matching her weight, while another resident did not receive ordered wound care treatments. A nurse admitted to not completing the treatments due to being busy with other incidents, yet signed off as if they were done.
A resident with a PEG tube experienced multiple dislodgements due to the facility's failure to ensure the use of an abdominal binder as ordered. Despite documentation indicating the binder was in place, interviews revealed it was not used during one incident, and staff were unaware of extra binders available. The resident required emergency room visits for tube replacement.
A resident with a history of traumatic brain injury and hemiplegia did not receive the necessary eating equipment as ordered, affecting his ability to feed himself. Despite orders for built-up foam handled utensils and sip cups with handles, the resident was given regular utensils and cups. An LPN confirmed the oversight and noted that compliance varied depending on kitchen staff.
The facility failed to report a possible neglect incident after staff were found sleeping during a night shift, affecting 27 residents. Despite a silent fire drill revealing staff asleep, the Administrator did not file a self-reported incident, considering it an employee conduct issue. The facility's policy requires reporting such incidents to the Administrator and the ODH.
The facility failed to maintain infection control practices during incontinence care and did not ensure staff wore face masks during a COVID-19 outbreak. Observations showed that two LPNs and an STNA were not wearing masks as required. Additionally, an STNA placed a urine-soaked incontinence product on the floor without a barrier and did not change gloves during care for a resident with diabetes and heart failure.
A resident with a significant risk for obstructive sleep apnea did not receive a CPAP machine until nearly two weeks after admission, despite hospital discharge orders. The delay was due to communication issues between the hospital, corporate staff, and the facility's DON. The resident's family had informed an LPN about the need for the CPAP, but their request to bring a personal device was declined due to infection control concerns.
A facility failed to follow proper infection control techniques during wound care for a resident with a Stage IV pressure ulcer. An LPN did not wash hands between glove changes, contrary to the facility's policy, during a dressing change. The resident had multiple diagnoses, including Parkinson's Disease and diabetes.
The facility did not serve the correct portion size of teriyaki pork to residents, as required by their meal plan. Observations showed that the pork slices were smaller than the specified three ounces, with weights ranging from one to 2.5 ounces. This affected all residents receiving meals, except those on specific diets. The facility's policy on therapeutic diets was not adhered to, resulting in this deficiency.
A nurse in an LTC facility misappropriated medication from a resident with multiple health conditions, including dementia and migraines. The nurse took sumatriptan, prescribed to the resident, to relieve her own headache, believing it was not misappropriation since it was not a narcotic. The incident was reported to the Ohio Board of Nursing and the police.
A facility failed to change a wound vacuum as ordered for a resident with multiple health issues, leading to dissatisfaction and a decision to leave the facility. Another resident experienced repeated delays in receiving scheduled pain medication, as confirmed by the DON. These deficiencies were investigated under specific complaint numbers.
Failure to Use PPE and Hand Hygiene During Contact Precautions
Penalty
Summary
A deficiency occurred when the Director of Nutrition Services entered the room of a resident on contact transmission-based precautions for MRSA without donning personal protective equipment (PPE) or performing hand hygiene before entering or after exiting the room. The resident had a medical history that included an infection following a procedure, acquired absence of the right leg above the knee, muscle weakness, and a current MRSA infection. Physician orders required contact precautions for this resident, and signage indicating these precautions, along with a PPE cart, was present outside the room. During the evening meal delivery, the Director of Nutrition Services obtained a Styrofoam cup from another area, poured hot water for tea, and delivered it to the resident without following the required PPE and hand hygiene protocols. The Director later confirmed in an interview that he did not adhere to the contact isolation guidance. Facility policy required staff to wear gloves and gowns and perform hand hygiene when entering and exiting rooms under contact precautions, but these procedures were not followed in this instance.
Failure to Follow Insulin and Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to follow physician orders for insulin administration and blood glucose monitoring for a resident with type 2 diabetes and a history of atherosclerotic heart disease and coronary bypass graft. The resident had orders for Lantus insulin once daily, Insulin Lispro before meals and as needed per sliding scale, and blood glucose monitoring, including the use of a Freestyle Libre sensor. After returning from an endocrinology appointment, the resident's orders were updated to continue insulin and initiate the glucose monitoring device. However, Insulin Lispro was discontinued, and blood glucose monitoring was not performed as ordered. Review of the medication administration records showed that the resident stopped receiving Insulin Lispro and did not have blood glucose checks from the time the new orders were received until the time of the survey, except during blood draws. The resident reported that staff had not been monitoring her blood sugars and that her glucose monitoring device had come off, requiring a two-week wait for replacement. Interviews with facility staff and the endocrinologist's office confirmed that the orders were not clarified or followed, resulting in a lack of appropriate blood glucose monitoring and insulin administration.
Failure to Timely Address UTI Leads to Resident's Death
Penalty
Summary
The facility failed to ensure comprehensive monitoring and timely identification of a change in condition for a resident who was incontinent of bladder and had a diagnosis of Stage 3 chronic kidney disease. The resident's daughter requested a urinalysis due to changes in the resident's cognition, which was not completed by the facility. Despite repeated requests from the family, the urinalysis was delayed, and the resident's condition worsened, including increased confusion, visual hallucinations, and falls. The nurse practitioner ordered a urinalysis with culture and sensitivity, but the order was not entered into the computer system promptly, and the urine specimen was not collected until several days later. The delay in testing and treatment resulted in the resident developing a urinary tract infection with Escherichia coli, which was sensitive to Trimethoprim/Sulfa. The resident was eventually started on Bactrim, an antibiotic, but the treatment was delayed due to the facility's failure to act on the family's concerns and the resident's symptoms. The resident was transferred to the hospital at the family's request due to increased confusion and was diagnosed with sepsis secondary to a urinary tract infection. The resident's condition deteriorated, leading to acute renal failure and death. The facility's inaction and failure to notify medical providers of the family's concerns and the resident's change in condition contributed to the resident's decline and eventual death.
Removal Plan
- All current in-house residents' medical records were reviewed for any significant change in conditions and documented signs and symptoms of urinary tract infections, and appropriate notifications have been made to obtain appropriate treatment for significant change in condition if needed.
- The facility laboratory testing practice of completing labs per physician's orders unless a STAT lab was ordered by a physician was reviewed with Medical Director and approved.
- The facility was in contact with a local hospital regarding the possibility of initiating a contract with them for labs, to increase available lab days.
- Nurses were educated on proper notification of significant changes in residents' conditions, signs and symptoms of UTIs per McGeer's criteria, and the facility's plan for family requests for medical intervention.
- An Ad hoc Quality Assessment Performance Improvement (QAPI) meeting was held to review proper notification of significant changes in residents' conditions and signs and symptoms of UTIs per McGeer's criteria.
- The DON or designee would conduct audits of all in-house resident records to ensure any significant change of condition has been reported to the appropriate personnel and treatment was obtained if deemed necessary by physician/CNP/On-Call service.
- The DON or designee would conduct audits of all in-house resident records to ensure documented signs and symptoms of urinary tract infections and the appropriate notifications have been made to obtain appropriate treatment if ordered.
Failure to Provide Ordered Laboratory Services
Penalty
Summary
The facility failed to ensure that a resident received laboratory services as per physician orders. The resident, who was admitted with multiple diagnoses including encephalopathy, atrial fibrillation, sleep apnea, hypertension, chronic kidney disease Stage 4, bradycardia, transient cerebral ischemic attack, and bladder-neck obstruction, was ordered to have a basic metabolic panel (BMP) every Friday until a specified date. However, there was no evidence in the medical records that the BMP was obtained on the specified dates, despite staff signing off that it was collected. Interviews with the Director of Nursing, Administrator, and Corporate Nurse confirmed the absence of documentation for the BMP collection on the specified dates. The facility did not have a policy on laboratory services and relied on following physician orders. The deficiency was identified during an investigation under a specific complaint number, highlighting a lapse in compliance with the ordered laboratory services for the resident.
Inadequate Catheter Care and Glove Use
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, which was observed during a survey. The resident, who had a history of severe medical conditions including dementia, urinary tract infection, and use of an indwelling urinary catheter, was dependent on staff for self-care. During the catheter care procedure, a CNA did not change gloves between tasks, despite handling potentially contaminated materials. The CNA used the same gloves to clean, rinse, and dry the catheter tubing, which is against the facility's policy and national guidelines for glove use. The observation revealed that the catheter tubing was improperly positioned under the resident's leg, pressed against the mattress, which could contribute to infection risk. The CNA's actions were verified by an RN and the CNA herself, confirming the failure to change gloves during the procedure. The facility's policy aimed to prevent urinary tract infections, but the observed practice did not align with these guidelines, potentially compromising the resident's care.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide an individualized and comprehensive pain management program for two residents, resulting in actual harm to one of them. Resident #87, who had multiple diagnoses including end-stage renal disease and diabetic ulcers, was observed in severe pain due to not receiving his scheduled narcotic pain medication on time. Despite having a care plan that included administering pain medications as ordered and observing for breakthrough pain, the resident did not receive his scheduled OxyContin dose at 10:00 A.M., leading to a pain level of 10 out of 10. The delay in medication administration was confirmed by RN #201, who was attending to other residents and did not provide any non-pharmacological interventions to alleviate the resident's pain. Resident #74, who was on hospice care for end-stage congestive heart failure and other conditions, also experienced inadequate pain management. The resident was noted to be in pain during hospice visits, with signs such as grimacing and moaning. Despite receiving scheduled morphine, the resident did not receive any PRN morphine since the previous hospice visit, raising concerns about unreported or unrecognized pain by the staff. The resident's morphine dose was not administered as ordered at 8:00 P.M. on a specific date, and the resident was found deceased later that night. LPN #204, responsible for the medication administration, was involved in other duties and did not administer the morphine on time. The facility's policies on medication administration and pain management were not adhered to, as medications were not administered within the required time frame, and comprehensive pain assessments were not completed. The facility's policy required pain assessments to be conducted prior to administering analgesics and to evaluate the effectiveness of non-pharmacologic interventions. However, these procedures were not followed, leading to severe pain for Resident #87 and potentially contributing to the inadequate pain management for Resident #74.
Controlled Medication Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medications, affecting two residents reviewed for pain management. Resident #74, who was admitted with multiple diagnoses including congestive heart failure and a wedge compression fracture, was receiving hospice care and had a life expectancy of less than six months. The review of Resident #74's records revealed discrepancies between the electronic Medication Administration Record (eMAR) and the Controlled Drug Forms, indicating that doses of hydrocodone were administered but not documented as removed from the controlled drug card. This inconsistency was noted on multiple occasions, with the drug count remaining unchanged despite recorded administrations. Resident #87, admitted with conditions such as end-stage renal disease and Hodgkin lymphoma, was also affected by documentation issues. The resident, who reported severe pain, was prescribed OxyContin for pain management. During an observation, a registered nurse dispensed and administered the medication but failed to document the removal and administration on the Controlled Drug Form at the time of dispensing. This lapse was confirmed by another nurse who verified the omission and acknowledged the requirement for immediate documentation of controlled substances. The report highlights the facility's failure to maintain accurate records of controlled drug administration, as evidenced by the discrepancies in documentation for both residents. These deficiencies were identified during a complaint investigation, indicating non-compliance with the requirement to document controlled medications accurately to account for all drugs administered.
Failure in Pressure Ulcer Care and Hygiene Practices
Penalty
Summary
The facility failed to maintain proper care and services for pressure ulcers, specifically affecting a resident with a Stage IV pressure ulcer on the left ischium. The resident, who was cognitively intact and had paraplegia, was observed during a dressing change where several deficiencies were noted. The registered nurse (RN) responsible for the dressing change did not find a dressing covering the wound, which was against the physician's orders to cover the wound to absorb drainage and protect it. Additionally, the resident was found laying on a drainage collection bag, which was not appropriate. During the dressing change, the RN used contaminated bandage scissors that were stored in his scrub pocket without proper cleaning before use. The RN also failed to change gloves after touching potentially contaminated surfaces, such as his scrub pocket, before continuing with the wound care. These actions were in violation of the facility's wound care policy, which required maintaining a clean field and proper hand hygiene throughout the procedure. The Assistant Director of Nursing confirmed these observations, verifying the non-compliance with the established wound care procedures.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 15.15%, which is significantly higher than the acceptable threshold of 5%. This deficiency affected three residents. For Resident #30, the LPN administered two different eye drops consecutively without waiting the recommended five to ten minutes between applications, as per the manufacturer's guidelines. This oversight was confirmed during an interview with the LPN. Resident #64's medication administration was also flawed, as the RN followed the resident's instructions instead of the physician's orders, administering the wrong eye drops and failing to apply pressure to the inner tear duct as required by the facility's procedures. Additionally, Resident #270 was affected when the LPN administered only one tablet of Senna-S instead of the prescribed two tablets. This error was verified through an interview with the LPN. These incidents highlight a pattern of non-compliance with medication administration protocols, as evidenced by the observations and interviews conducted during the survey. The facility's failure to adhere to prescribed medication orders and administration procedures directly contributed to the identified deficiencies.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for two residents, leading to deficiencies in their treatment. Resident #26, who had multiple diagnoses including Parkinson's disease, COPD, and a stage four pressure ulcer, was found to have an air mattress set incorrectly at 300 pounds, despite her actual weight being 118.6 pounds. This discrepancy was confirmed by a registered nurse during an observation. The care plan for Resident #26 included the use of an air mattress, and the physician's order required checking the placement and function of the mattress every shift, which was not adhered to. Resident #55, with diagnoses including encephalopathy, dementia, and chronic kidney disease, did not receive wound care treatments as ordered. The treatments included cleansing and applying ointments and dressings to various areas. A family complaint revealed that the treatments were not completed on a specific date, and an investigation confirmed that RN #520 had not performed the treatments but had signed off on them as completed. The nurse admitted to being busy with other incidents and running out of time, leading to the oversight.
Failure to Ensure Abdominal Binder Use for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident with a history of multiple dislodgements of his Percutaneous Endoscopic Gastrostomy (PEG) tube had an abdominal binder in place as ordered to prevent accidental dislodgements. The resident, who had a traumatic brain injury, cognitive communication deficit, hemiplegia, hemiparesis, dysphagia, and gastrostomy status, was admitted to the facility with a care plan that included the use of an abdominal binder due to frequent tube displacements. Despite this, the resident experienced multiple incidents where the PEG tube was dislodged, requiring emergency room visits for replacement. On several occasions, the nursing staff documented that the abdominal binder was in place, yet the PEG tube was found dislodged. Interviews with the resident's representative and a Licensed Practical Nurse (LPN) revealed that the abdominal binder was not in place during one of the incidents, and the staff was unaware of the availability of extra binders in the central supply room. The LPN noted that the PEG tube likely became dislodged due to the resident's movements in bed, and it was not intentional. This deficiency was investigated under Master Complaint Number OH00158726.
Failure to Provide Appropriate Eating Equipment
Penalty
Summary
The facility failed to provide a resident with the appropriate eating equipment and utensils as ordered, which affected the resident's ability to feed himself. The resident, who had a history of traumatic brain injury, hemiplegia, dysphagia, and cognitive communication deficits, was observed during a meal without the necessary built-up foam handled utensils and sip cups with handles. Instead, he was given regular eating utensils and cups, contrary to the physician's orders and the specifications on his meal ticket. An LPN confirmed that the resident was supposed to receive a pureed diet with honey thickened liquids and required built-up utensils and a two-handed sip cup for meals. The LPN acknowledged that the resident sometimes did not receive the correct utensils and cups, depending on the kitchen staff working at the time. The LPN also verified that the meal ticket clearly specified the need for these items and that staff should review the meal ticket when delivering trays to ensure compliance with dietary orders.
Failure to Report Staff Sleeping Incident as Possible Neglect
Penalty
Summary
The facility failed to submit a self-reported incident (SRI) for possible neglect after staff were observed sleeping on the night shift, affecting 27 residents on Unit 3. The facility's Self-Reported Incidents (SRIs) log showed no allegations of abuse, neglect, or misappropriation reported to the Ohio Department of Health since a specified date. Interviews with staff revealed that a Licensed Practical Nurse (LPN) had discovered a State Tested Nurse Aide (STNA) sleeping but did not report it to the nursing supervisor or Administrator, considering it a minor issue. Another STNA reported observing a colleague asleep, which was also not escalated. The Administrator acknowledged that staff should not be sleeping while on duty and mentioned a recent incident of reported staff sleeping. However, the Director of Nursing (DON) and other nurses did not find anyone asleep upon checking. A Facility Investigation Packet included an all-staff meeting addressing sleeping on shift and statements from LPNs who did not observe sleeping staff. A silent fire drill conducted by Maintenance Assistant #205 revealed that several staff members were asleep and had to be awakened to sign the fire drill form. Despite this, there were no written statements from the involved staff, and no documentation regarding potential neglect of residents on Unit 3. The Administrator did not file an SRI, considering the incident an employee conduct issue rather than neglect, as there were no complaints from residents' families. The facility's policy mandates investigating all allegations and suspicions of abuse, neglect, and other issues, with immediate reporting to the Administrator and the ODH. The deficiency was noted as incidental findings of non-compliance during a complaint investigation.
Infection Control Lapses During COVID-19 Outbreak and Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinence care and did not ensure staff wore face masks during a COVID-19 outbreak. Observations revealed that two LPNs and an STNA on Unit 1 were not wearing face masks as required during the outbreak, despite a sign at the facility entrance indicating the need for masks. The staff members acknowledged the requirement to wear masks, and the Administrator confirmed that masks should have been worn. Additionally, during incontinence care for a resident with diabetes mellitus and heart failure, an STNA placed a urine-soaked incontinence product directly on the floor without a barrier and did not change gloves during the process. The STNA also left the resident's room with soiled gloves to dispose of the trash. The Administrator verified that soiled products should not be placed on the floor without a barrier. The facility's hand hygiene policy emphasized the importance of hand washing after contact with body fluids, which was not adhered to in this instance.
Failure to Provide Timely Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary respiratory equipment for a resident, identified as having a significant risk for obstructive sleep apnea, upon admission. The resident was admitted with diagnoses including congestive heart failure and pulmonary fibrosis, and hospital discharge orders included the use of a CPAP machine while sleeping. Despite these orders, the resident did not receive the CPAP machine until nearly two weeks after admission, just before being discharged home. This delay in providing the CPAP machine was due to a lack of communication and coordination between the hospital, corporate level staff, and the facility's Director of Nursing (DON). The resident's family had informed an LPN about the need for a CPAP machine early in the resident's stay, but their request to bring a personal CPAP from home was declined due to infection control concerns. The LPN assured the family that the issue would be addressed, but the equipment was not provided in a timely manner. The DON stated that the hospital referral information did not include a request for a CPAP machine, and although the hospital's after visit summary did contain such an order, the DON was unable to locate the correct document. This deficiency was investigated under multiple complaint numbers.
Infection Control Lapse in Wound Care
Penalty
Summary
The facility failed to ensure proper infection control techniques during pressure ulcer wound care for a resident. The resident, who was admitted with multiple diagnoses including Parkinson's Disease, COPD, CHF, high blood pressure, and diabetes, had an intact cognition and was identified with a Stage IV pressure ulcer. The physician's orders required specific wound care procedures, including cleansing with 1/4 strength Dakin's solution and applying hydrofiber with silver, followed by a clean dressing. During an observation of a dressing change, an LPN was noted to have removed gloves and put on new ones without washing hands in between, which is against the facility's wound care policy. The LPN confirmed this lapse in hand hygiene during an interview. The facility's policy mandates washing hands after cleansing the wound and before applying a new dressing, which was not adhered to in this instance. This deficiency was part of incidental findings investigated under multiple complaint numbers.
Improper Portion Sizes Served to Residents
Penalty
Summary
The facility failed to provide residents with the proper portion size of meat, specifically teriyaki pork, during meal service. Observations and a review of the facility's meal spreadsheet revealed that residents were supposed to receive a three-ounce slice of teriyaki pork. However, during the meal service, it was observed that the slices served were smaller than the required three ounces. The Dietary Coordinator weighed a piece of pork and confirmed it was only 1.5 ounces. Further checks on the meal trays showed that the pork slices weighed between one ounce to 2.5 ounces. This issue affected all residents receiving meals from the kitchen, except for nine residents who were on nothing by mouth, mechanical soft, or pureed diets. The facility's policy, titled 'Therapeutic Diet Spreadsheet,' was not followed, leading to this deficiency.
Misappropriation of Resident Medication by Staff
Penalty
Summary
The facility failed to prevent the misappropriation of medication for a resident by a staff member. Resident #66, who had a range of medical conditions including dementia and migraines, was prescribed sumatriptan for migraine relief. An incident was reported where a nurse, RN #311, took sumatriptan from the resident's medication supply without consent. This action was identified as misappropriation of resident property. The incident came to light when RN #311 mentioned to Staff Coordinator #310 that she had taken a sumatriptan pill from a resident's supply to relieve her own headache. RN #311 admitted to taking the medication after being unable to alleviate her headache with other methods. She was aware that the medication belonged to a resident but did not consider it misappropriation because it was not a narcotic. The nurse who provided the medication, LPN #312, did not verify the intended use of the medication. The facility's investigation included interviews with involved staff members. RN #311 expressed remorse for her actions, and it was confirmed that she took the medication from Resident #66. The facility's policy clearly states that misappropriation of resident property is not tolerated, and this incident was reported to the Ohio Board of Nursing and the police.
Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to ensure proper wound care and timely medication administration for two residents. Resident #58, who had multiple diagnoses including acute osteomyelitis and diabetes, did not receive a scheduled wound vacuum change on 08/01/24. The wound vacuum was supposed to be changed on specific days, but due to time constraints and miscommunication between shifts, it was not done as ordered. Resident #58 expressed dissatisfaction with the care received, noting that this was not the first time the wound vacuum change was missed. The Registered Nurse responsible for the shift admitted to running out of time due to other duties and confirmed the lack of documentation for the wound vacuum change. Resident #96, with diagnoses including a left femur fracture and heart failure, experienced delays in receiving scheduled pain medication, oxycodone-acetaminophen, on multiple occasions. The medication was administered late several times over a period from May to June 2024, as documented in the Medication Administration Record. The Director of Nursing confirmed these delays, which were investigated under specific complaint numbers. These deficiencies highlight issues in adherence to care schedules and communication among staff.
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 271 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 Zanesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks Rehabilitation And Healthcare Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Oaks At Bethesda The | 2.1 mi | ★★★★★ | 4 | 0 |
| Continuing Healthcare At Willow Haven | 2.7 mi | ★★★★★ | 58 | 0 |
| Adams Lane Healthcare And Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Continuing Healthcare At Cedar Hill | 3.6 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Altercare Zanesville Inc..
100% money-back within 48 hours.
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.