Below 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 Arbors At Marietta during CMS and state inspections, most recent first.
Inaccurate MDS ROM Assessment: A resident with severe contractures, ventilator dependence, trach and PEG status, and severely impaired cognition had an MDS that incorrectly indicated no ROM impairments. The physician, PT, OT, and multiple staff confirmed the resident had contractures in both upper and lower extremities, and the Regional Nurse verified the MDS should have reflected ROM impairment to both sides.
A resident with severe contractures, severe cognitive impairment, and total ADL dependence had a care plan that did not include her upper and lower extremity contractures and did not match the documented ROM status. During catheter care, an RN positioned the resident and attempted to separate her legs; a grinding/popping noise was heard and the procedure was stopped. Staff interviews confirmed the resident had longstanding contractures and that the care plan did not reflect the catheterization approach needed for her condition.
Surveyors found that meals were not being served according to the dietitian-approved cycle menus and that menu substitutions were not consistently or accurately documented. On the observed lunch service, the kitchen served a completely different meal than what was listed on the current cycle menu and used an outdated diet guide sheet from a prior year. The Menu Substitution Log showed numerous substitutions over several months but lacked entries for the current month and did not fully capture all items that were changed for the observed meal. Staff reported that many substitutions were made based on the preferences of a small group of residents attending resident council, and acknowledged that some changes were not communicated to all residents. A resident reported frequent unannounced menu changes and inconsistent meal items among residents on the same hall, contrary to the facility’s written policy requiring menus to be served as written and all substitutions to be logged.
A resident with cancer, obesity, and edentulism, who was cognitively intact and on a regular diet with thin liquids, choked while eating a meal that included facility-provided chicken and family-provided blueberries and yogurt. CNAs initially observed no concerns when delivering the tray and bringing in a visitor, but later found the resident with a blue face, pointing and pounding at his throat/chest, and showing signs of choking. Staff immediately initiated back thrusts and the Heimlich maneuver after confirming the resident’s DNRCC-A status, but were unable to dislodge the obstruction, and EMS later pronounced the resident deceased. The facility completed an internal incident report and obtained staff witness statements, but the Administrator did not submit a self-reporting incident to the State survey agency, despite acknowledging that this unusual occurrence resulting in death should have been reported as possible neglect under the facility’s abuse/neglect policy.
Two residents experienced deficiencies in safety and fall prevention, including one who suffered a head injury during transport due to improper wheelchair securement by a transport aide, and another who did not have required fall interventions such as traction strips and accessible call light in place. These failures occurred despite care plans and policies outlining necessary precautions for residents at risk.
A resident reported that shower rooms were not always cleaned well and had a persistent stain on her shower curtain. Observations confirmed a bowel movement on the shower room floor, a used washcloth left on a handrail, and a stain on the resident's shower curtain. Housekeeping and floor staff did not ensure prompt cleaning between uses, resulting in unsanitary conditions.
Surveyors found that MDS assessments were not completed accurately for three residents, including incorrect documentation of catheter use, dental status, and fall injuries. Staff interviews and record reviews confirmed discrepancies between actual resident conditions and what was recorded in the MDS, with failures to follow facility policy for assessment accuracy.
Three residents did not have complete or accurate care plans addressing their specific medical needs, including IV access, indwelling catheter care, and oral/dental status. Staff interviews and record reviews revealed missing or incomplete documentation, lack of clarity about current treatments, and failure to follow facility policy for timely, comprehensive care planning.
A resident with significant hearing loss did not consistently wear prescribed hearing aids due to one device being missing, and the facility failed to report or document the missing hearing aid as required. Staff were unaware of the loss, and the issue was not communicated to the audiology provider or recorded in the missing items log, resulting in the resident not receiving needed assistance with hearing.
A resident with multiple chronic conditions and a risk for skin impairment was observed to have dark blue, cool, and dry, flaky skin on both lower extremities. Despite these findings, the care plan did not include interventions for the discoloration and dry skin, and the issue was not documented in the Minimum Data Set. Staff confirmed the skin condition, but the care plan had not been updated to address these non-pressure skin issues as required by facility policy.
Two residents with indwelling urinary catheters did not receive appropriate care and documentation. One resident's catheter bag was observed improperly positioned both above the bladder and on the floor, while another resident had no care plan, physician orders, or accurate assessment for catheter care. Staff interviews confirmed lapses in awareness and documentation, contrary to facility policy requiring proper catheter management.
A resident with multiple serious diagnoses was nearly given an overdose of Methadone when a nurse misinterpreted a medication order and prepared four bottles instead of one. The error was discovered during a narcotic count, and the resident refused the extra medication, preventing further harm. The incident resulted from incorrect order entry and misunderstanding of the medication supply and documentation.
A resident with complex medical needs was given an incorrect dose of Methadone due to a transcription error and confusion over pharmacy supply. The error was not promptly identified, and documentation did not accurately reflect the administration or proper waste of the controlled substance. The remaining Methadone was improperly disposed of by flushing, without a second nurse witness as required by policy.
Three cognitively intact residents signed binding arbitration agreements without understanding their content, as none recalled being offered or viewing the required explanatory video, nor receiving an adequate explanation. The agreements were presented during admission and signed electronically, typically without a witness, contrary to facility policy requiring clear explanation.
Staff failed to follow infection control protocols when an LPN did not perform hand hygiene between glove changes during medication administration for a resident with a gastrostomy tube, and a CNA entered the room of a resident on contact precautions for C. diff without wearing appropriate PPE. These actions were not consistent with facility policy and affected two residents.
A registered nurse was hired without the facility verifying her residency status or completing the required FBI background check, as only a state BCI check and federal exclusion checks were performed. The facility's process at the time relied on verbal confirmation of residency without documentation, and the responsible HR staff member has since been replaced.
Inaccurate MDS ROM Assessment
Penalty
Summary
The facility failed to ensure that a resident assessment accurately reflected Resident #102’s status at the time of the quarterly MDS assessment. Resident #102 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, dependence on a ventilator, Parkinson’s disease, anemia, tracheostomy status, gastrostomy status, contractures of the right and left lower legs and right and left upper arms, neuromuscular dysfunction of the bladder, and major depressive disorder. The quarterly MDS dated 04/15/26 indicated severely impaired cognition, total dependence on staff for all ADLs, and no ROM impairments. Record review and staff interviews showed the resident had contractures at admission and throughout the stay. The physician’s progress note documented marked contractures of the upper and lower extremities, the PT evaluation documented contractures to all joints of both lower extremities, and the OT evaluation documented contractures to both shoulders, elbows, wrists, and hands. Staff including the NP, Therapy Program Director/COTA, Nursing Restorative Aide, and Regional Nurse confirmed the resident had severe contractures in both arms and legs, and the Regional Nurse verified the MDS was marked incorrectly and should have reflected ROM impairment to both upper and lower extremities. An observation also showed the resident in bed with bilateral arm and leg contractures.
Care plan did not address severe contractures or match ADL care needs
Penalty
Summary
The facility failed to develop a person-centered care plan that addressed Resident #102’s medical and physical care needs related to contractures, and it failed to implement the ADL care plan as written. Resident #102 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, ventilator dependence, Parkinson’s disease, anemia, tracheostomy status, gastrostomy status, neuromuscular bladder dysfunction, major depressive disorder, and contractures of the right and left lower legs and right and left upper arms. The quarterly MDS dated 04/15/26 indicated severely impaired cognition, total dependence on staff for all ADLs, and no ROM impairments, despite the physician’s progress note on 01/15/26 documenting marked contractures of the upper and lower extremities. The ADL care plan dated 01/15/26 identified the resident as dependent for all ADLs and included two-person assistance for bed mobility, toileting hygiene, bathing, and transfers with a mechanical lift, but it did not include a care plan for the resident’s upper and lower extremity contractures. PT evaluation on 01/16/26 documented contractures to all joints of both lower extremities, and OT evaluation on 01/16/26 documented contractures to both shoulders, elbows, wrists, and hands. During an interview, the NP stated the resident was admitted with severe contractures to her arms and legs, and the Therapy Program Director and Nursing Restorative Aide also stated the resident had contractures in both arms and legs since admission. On 05/21/26, RN #278 was changing the resident’s catheter and positioned the resident on her right side at the edge of the bed; when she attempted to separate the resident’s legs, a grinding noise was heard and the procedure was stopped. CNA #202 and CNA #308 were present but did not have their hands on the resident. CNA #202 and CNA #308 both described the nurse trying to spread the resident’s legs to replace the catheter and hearing a popping or grinding noise, after which the nurse stopped and the resident was sent to the hospital. The Regional Nurse stated the care plan should have reflected that the resident would do better with one person performing catheter insertion because the resident would be more uncomfortable and harder to catheterize if a second person was holding her leg in position.
Failure to Follow Dietitian-Approved Menus and Accurately Document Menu Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to provide meals as written on the approved cycle menu and to accurately document all menu substitutions. Surveyors reviewed the facility’s Week #1 2025–2026 cycle menu, which listed a specific lunch for a Wednesday: cranberry orange chicken, roasted Brussels sprouts, garlic and rosemary roasted red skin potatoes, a dinner roll, and Mandarin oranges, with an alternate of cheese ravioli with marinara sauce and tossed salad. During an observation of the lunch meal service, the food being prepared and served did not match this menu. Instead, the kitchen was serving smothered chicken thigh with poultry gravy, broccoli florets, mashed potatoes, a dinner roll, and sliced pears, which corresponded to a different menu (a Tuesday meal from a 2023–2024 diet guide sheet) rather than the current 2025–2026 cycle menu. When surveyors requested the spreadsheet for the day’s menu to verify portion sizes and menu compliance, dietary staff produced a spreadsheet from the 2023–2024 Diet Guide Sheet rather than the correct 2025–2026 Week #1 menu. Review of the facility’s Menu Substitution Log for November 2025 through January 2026 showed 27 recorded substitutions deviating from the planned dietitian-approved cycle menu. However, there was no Menu Substitution Log for February, and the Administrator later added the 02/11/26 lunch substitutions onto a previously provided log. Even then, the added entry only noted that chicken thigh was substituted with chicken breast, Brussels sprouts with broccoli, and roasted potatoes with mashed potatoes, and did not document that cranberry orange chicken had been replaced with smothered chicken or that Mandarin oranges had been replaced with pears. Both the Administrator and a Regional Nurse confirmed that the meal served did not match the current cycle menu and that the substitution log did not fully or accurately reflect the substitutions made. Interviews with staff and a resident further described the pattern of unrecorded or inadequately recorded substitutions and deviations from the menu. The cook reported that the planned cranberry orange chicken, Brussels sprouts, and red skin potatoes were not served because residents at resident council had previously expressed dislike for those items, and that many substitutions were based on the preferences of the 15–25 residents who typically attended council meetings. She acknowledged that these preferences might not represent the entire resident population and that some menu changes based on known preferences were not communicated to residents, despite residents receiving a weekly “daily chronicle” listing upcoming meals. A resident reported frustration that the posted menus were often changed without notice, estimating that this occurred two or three times per week, and stated that residents on the same hall sometimes received different food items without explanation. The facility’s own menu policy required menus to be prepared in advance, served as written unless substitutions were made for preference, unavailability, or special meals, and required that a menu substitution log be maintained on file, but the observed practices and documentation did not align with these requirements.
Failure to Report Resident Choking Death as Possible Neglect
Penalty
Summary
The deficiency involves the facility’s failure to report a possible situation of neglect to the State survey agency after a resident choked during a meal and subsequently died. The resident had diagnoses including malignant neoplasm of the prostate and obesity, was cognitively intact, and required only setup or cleanup assistance with eating. He was on a regular diet with regular texture and thin liquids, had no documented history of coughing or choking with meals or medications, and was not receiving speech therapy. His care plans addressed risk for altered nutritional status and noted that he was edentulous, with interventions including providing meals per preference and order and assistance with meals as needed. On the day of the incident, documentation showed that a CNA delivered the resident’s lunch tray while he was sitting upright with no concerns noted. Shortly thereafter, another CNA brought a visitor into the room and again no concerns were noted. When a CNA later returned to the room to pick up trays, the resident was observed sitting upright with his face turning blue, pointing and pounding on his throat/chest area, and showing signs of choking. Staff immediately called for help and initiated back thrusts, followed by the Heimlich maneuver performed by nursing staff after verifying the resident’s DNR Comfort Care Arrest status. Despite continued efforts, the obstruction could not be visualized or dislodged, EMS was called, and the resident was ultimately pronounced deceased. Witness statements indicated the resident had been eating blueberries and yogurt brought by family, in addition to chicken from his lunch tray. The facility completed an internal incident report and collected multiple witness statements, including from the CNAs and nurses involved. The Administrator later acknowledged that no self-reporting incident was submitted to the State survey agency regarding this choking event and resulting death. The Administrator questioned whether reporting was required since the facility’s internal investigation concluded there was no wrongdoing and staff responded appropriately. However, he recognized that the event was an unusual occurrence resulting in a resident’s death that should have been reported as possible neglect, consistent with the facility’s abuse, neglect, and exploitation policy, which requires immediate reporting of alleged violations and events that could indicate noncompliance related to neglect, including those resulting in serious bodily injury.
Failure to Ensure Resident Safety During Transportation and Fall Prevention
Penalty
Summary
The facility failed to ensure resident safety during facility-provided transportation and did not implement required fall interventions for residents at risk for falls. One resident, who was dependent on staff for transportation and had a history of cerebral infarction, generalized weakness, and was on blood thinning medication, was injured during transport when the transport aide did not properly secure the wheelchair straps. As a result, the resident was dislodged from the wheelchair during a bus turn, fell, and sustained a head laceration that required medical treatment, including staples. The resident reported that only one side of the wheelchair was locked, and despite questioning the aide, was assured everything was secure. The incident was confirmed by interviews and documentation, and the resident expressed fear and pain following the event. Another resident, with diagnoses including hypertension, diabetes, and end-stage renal disease, experienced two falls and was identified as being at risk for further falls. The care plan for this resident included specific interventions such as 15-minute checks, traction strips to the floor, and ensuring the call light was within reach. However, during observation, the resident's call light was not accessible, and traction strips were not present as ordered. The resident stated she relied on her roommate to call for assistance, indicating that the prescribed interventions to prevent falls were not in place at the time of review. Policy review indicated that the facility was required to assess each resident's fall risk and implement appropriate interventions, including environmental modifications and care planning. Despite these requirements, the facility did not ensure that interventions were consistently implemented for residents at risk for falls or that transportation safety protocols were followed, resulting in actual harm to at least one resident and placing others at risk.
Failure to Maintain Clean and Sanitary Shower and Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in both the shower room and a resident's room. During an interview, a resident reported that the shower rooms were sometimes not cleaned well and noted a persistent stain on her shower curtain since admission. Observations by the Housekeeping Supervisor and Maintenance Staff confirmed the presence of a quarter-sized, soft bowel movement on the floor next to the drain in the third stall of the first-floor shower room, as well as a used washcloth hanging over the handrail in the second stall. Additionally, a round stain was observed on the resident's shower curtain. The Housekeeping Supervisor stated that while housekeeping staff mop the floors each morning and scrub them weekly, floor staff are responsible for cleaning the shower room between residents. A review of a CNA's statement indicated that after giving the resident a shower, she intended to clean the shower room afterward. However, subsequent observation found no sign of the CNA or the resident in either the room or the shower area. The facility's policy requires maintaining a safe, clean, and homelike environment, ensuring that the building and equipment are kept sanitary. The failure to promptly clean the shower room and address the stain on the resident's shower curtain led to the deficiency.
Inaccurate MDS Assessments for Catheter, Dental, and Fall Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for several residents, specifically regarding falls, dental status, catheter use, and continence status. For one resident admitted with an indwelling urinary catheter, nursing documentation and direct observation confirmed the presence of the catheter, yet the MDS assessment and continence evaluation incorrectly indicated no catheter use and did not rate urinary continence. There were also no documented orders for catheter care, and both MDS nurses and the Director of Nursing confirmed they were unaware the catheter remained in place. Another resident's MDS assessment failed to accurately reflect the presence of broken and missing teeth, despite the resident's report and staff confirmation of this dental status. Additionally, a third resident's MDS assessment incorrectly indicated a fall with major injury, although records and staff interviews confirmed only a minor fall with no major injury had occurred. The facility's policy requires adherence to the MDS Resident Assessment Instrument (RAI) manual for accurate assessment and documentation, which was not followed in these cases.
Failure to Maintain Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to maintain comprehensive, resident-centered care plans for three residents, as evidenced by incomplete or missing documentation and care planning for significant medical needs. For one resident with a PICC line for antibiotic therapy, the care plan did not specify the type of intravenous access or provide complete information regarding the IV status, despite orders and ongoing treatment. The Director of Nursing confirmed the care plan was incomplete in this regard. Another resident was admitted with an indwelling urinary catheter, but there was no care plan addressing catheter care, and staff interviews revealed confusion about whether the catheter had been removed. The resident continued to have the catheter in place, as observed by surveyors, but this was not reflected in the care plan or physician orders, and staff were unaware of the ongoing need for catheter care. A third resident with a history of acute respiratory failure, traumatic brain injury, tracheostomy, and severe malnutrition had broken and missing teeth, but the care plan did not address oral or dental status. Staff confirmed that oral care was provided and that the resident had significant dental issues, but there was no care plan in place to address these needs. The facility's policy requires comprehensive, person-centered care plans to be developed within seven days of the MDS assessment, including measurable objectives and timeframes, but this was not followed for the residents reviewed.
Failure to Ensure Use and Reporting of Missing Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident with a history of hearing loss consistently wore hearing aids as recommended and did not properly report or document the loss of a hearing aid. The resident, who had diagnoses including atrial fibrillation, COPD, heart failure, and hearing loss, was assessed by audiology and prescribed bilateral hearing aids to be worn daily with staff assistance. Despite these recommendations, observations revealed that the resident was not wearing the hearing aids, had difficulty understanding conversations, and reported that one hearing aid was missing. Staff interviews confirmed that the hearing aid had been missing for some time, but there was no evidence that this was reported to the appropriate personnel or documented in the facility's missing items log. Further review of the resident's care plan and medical records showed no documentation of refusal to wear the hearing aids or any indication that the aids were being used daily as directed. The social services director was unaware of the missing hearing aid and had not included it in the concern log. Additionally, the facility had not contacted the audiology provider regarding the missing device. These actions and omissions resulted in the resident not receiving the necessary assistance with hearing, as outlined in their care plan and audiology recommendations.
Failure to Develop Comprehensive Care Plan for Non-Pressure Skin Impairment
Penalty
Summary
The facility failed to provide a comprehensive treatment plan for a resident with altered skin integrity. The resident, who had multiple diagnoses including chronic obstructive pulmonary disorder, diabetes mellitus type two, peripheral vascular disease, congestive heart failure, and atrial fibrillation, was identified as being at risk for skin impairment. Although the care plan included interventions to decrease risk, it did not address the resident's bilateral lower extremities discoloration and dry skin, despite these conditions being observed. The Minimum Data Set did not document any skin impairment, and physician orders were in place for daily skin checks by CNAs and weekly skin assessments by nursing staff. During observations, the resident was noted to have dark blue, cool, and dry, flaky skin on both lower extremities. Interviews with the resident, a CNA, and an LPN confirmed the presence of these skin issues. The LPN acknowledged the findings and indicated that documentation and physician notification would occur, as well as an update to the care plan. However, at the time of the survey, the care plan had not been updated to include interventions for the discoloration and dry, flaky skin, which was inconsistent with the facility's policy requiring monitoring, assessment, and treatment of non-pressure skin impairments.
Failure to Provide Comprehensive Catheter Care and Documentation
Penalty
Summary
The facility failed to provide comprehensive and resident-centered care for residents with indwelling urinary catheters, as evidenced by observations, interviews, and record reviews. One resident with a neurogenic bladder and an indwelling catheter was observed with the catheter bag improperly positioned on two occasions: once hanging above the bladder and once on the floor. Both instances were confirmed by nursing staff, and the facility's policy required catheter care to reduce infections and maintain proper gravity drainage. Another resident admitted with an indwelling catheter for urinary retention did not have a care plan, physician orders, or accurate assessment documentation regarding the catheter. The resident's Minimum Data Set (MDS) was incorrectly coded to indicate no catheter use, and staff interviews revealed a lack of awareness about the presence of the catheter. The Director of Nursing and Unit Manager confirmed the absence of necessary documentation and care planning, despite daily interactions with the resident. Facility policy required catheter care in accordance with clinical standards, which was not followed in this case.
Medication Administration Error Due to Order Misinterpretation
Penalty
Summary
Nursing staff failed to ensure the correct administration of Methadone to a resident with complex medical conditions, including acute respiratory failure, subdural and intracerebral hemorrhage, pneumonitis, and tracheostomy status. The resident was cognitively intact, as indicated by a BIMS score of 15. Multiple Methadone orders were entered and discontinued over several days, with the final order specifying Methadone liquid 60 mg/7.5 ml by mouth once daily. On the day of the incident, a nurse administered four bottles (30 ml) of Methadone instead of the prescribed one bottle (7.5 ml), due to a misunderstanding of the order and incorrect transcription in the medication administration record (MAR). The error was not discovered until the following day during a narcotic count, which revealed a discrepancy in the Methadone supply. The nurse involved confirmed preparing the incorrect dose, and the error was only prevented from escalating because the resident refused to take the additional medication, recognizing the correct dose. The facility's investigation found that the order was not entered correctly in the computer system, and the nurse misinterpreted the intended dose due to the way the medication was supplied and documented. The facility's medication reconciliation policy required verification of medication orders, but this process was not effectively followed, leading to the medication error.
Failure to Investigate Medication Error and Improper Controlled Substance Disposal
Penalty
Summary
The facility failed to thoroughly investigate a potential medication error and the disposition of controlled medications for a resident with multiple complex diagnoses, including acute respiratory failure, subdural and intracerebral hemorrhages, and tracheostomy status. The resident was prescribed Methadone, but due to incorrect transcription of the order and confusion regarding the supply from the pharmacy, a nurse administered four bottles (30 ml) of Methadone instead of the prescribed one bottle (7.5 ml). The error was not discovered until the following day during the scheduled morning dose, and documentation on the medication administration record did not match the narcotic sheet, which showed four bottles signed out. There was no documentation of the wasted Methadone. Further investigation revealed that the narcotic count was not completed correctly during shift changes, and the narcotic log did not include the required documentation of a second nurse witnessing the medication waste. The nurse involved confirmed she flushed the remaining Methadone down the toilet, which was against facility policy and Environmental Protection Agency regulations. The facility's investigation did not identify the lack of a second nurse as a witness to the medication waste, and the nurse could not recall who, if anyone, witnessed the destruction of the medication.
Failure to Ensure Resident Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the binding arbitration agreements they signed upon admission. Three residents with intact cognition, as indicated by their BIMS scores of 15, were reviewed and each had electronically signed the facility's Alternative Dispute Resolution Agreement. The agreement stated that residents had been offered or were able to view an audio/visual video explaining the agreement. However, interviews with all three residents revealed that none remembered signing the agreement, none recalled being offered or watching the explanatory video, and none understood the purpose of the agreement at the time of signing. The admissions process involved the Admissions Director presenting the arbitration agreement as part of the admission packet and asking residents to sign electronically, typically without a witness present. The facility's policy required that the agreement be explained in a manner understandable to the resident or their representative. Despite this, the residents interviewed did not recall receiving an explanation or being made aware of their right to refuse the agreement, and one resident expressed a desire to revoke the agreement after learning more about it.
Failure to Follow Infection Control Protocols During Medication Administration and Contact Precautions
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during medication administration and while maintaining contact isolation precautions. In one instance, an LPN administered medications via a gastrostomy tube to a resident with multiple complex medical conditions, including a tracheostomy and enteral feeding, who was on enhanced barrier precautions. The LPN changed gloves between medication tasks but did not perform hand hygiene as required by facility policy before proceeding to administer a nasal inhaler. In another instance, a CNA entered the room of a resident on contact precautions for Clostridium difficile to deliver a lunch tray but did not wear the appropriate personal protective equipment (PPE) as indicated by signage and facility policy. Both failures were confirmed by staff interviews and were not in accordance with the facility's infection prevention and control policies, which reference CDC guidelines for transmission-based precautions.
Failure to Complete Required FBI Background Check Prior to RN Hire
Penalty
Summary
The facility failed to implement its criminal background check policy for a registered nurse who was hired without proper verification of residency or completion of a required FBI background check. The personnel file for the nurse did not contain evidence that the facility determined whether she had resided in the state for the past five years, as required. Only a state Bureau of Criminal Investigation (BCI) check was completed, along with checks through the Office of Inspector General (OIG) and the System for Award Management (SAM), all with no findings. However, the necessary FBI background check was not performed prior to employment, despite the nurse not having lived in the state during the required period. The administrator confirmed that, at the time of hire, the facility's process only involved verbally asking the employee about their residency status, with no written documentation. The administrator also acknowledged that the human resources employee responsible for background checks at the time no longer holds that position. The facility's policy required all employees to undergo a criminal background check before an employment offer was finalized and to follow state regulations regarding such checks, but this was not followed in this instance.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Marietta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marietta Heights Post Acute | 0.7 mi | — | 63 | 2 |
| Harmar Place Nursing And Rehabilitation | 0.8 mi | ★★★★★ | 1 | 0 |
| Waterview Pointe Nursing & Rehabilitation | 0.9 mi | ★★★★★ | 0 | 0 |
| Worthington Healthcare Center | 10 mi | ★★★★★ | 0 | 0 |
| Belmont Healthcare Center | 10.4 mi | ★★★★★ | 10 | 0 |
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