Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Astoria Place Of Waterville during CMS and state inspections, most recent first.
A resident with bipolar disorder, schizoaffective disorder, major depressive disorder, epilepsy, and other comorbidities experienced a gradual dose reduction of Abilify without timely psychiatric reassessment and with inconsistent behavior documentation. In the weeks before the incident, staff and psychology notes described depression, low energy, poor concentration, anhedonia, and later increased aggression, arguing, medication refusal, and throwing objects, but these behaviors were not consistently charted, and no medication changes were implemented. On an overnight shift, a CNA observed the resident talking to himself, shouting profanities, and becoming highly agitated and unapproachable, while an LPN documented verbal aggression, threatening gestures, and lack of sleep, but hospice was not notified as directed and no effective interventions were implemented. The next morning, the resident was found outside on a snowy hillside about 100 feet from his window, lightly clothed, combative, stating he wanted to die, and showing signs of hypothermia and injury; EMS and hospital records documented altered mental status, psychosis, delusions, hypothermia, frostbite, and placement on an Emergency Application for a suspected suicide attempt. The facility lacked a policy for behavioral or psychological needs and did not follow its change-in-condition policy requiring physician consultation for significant mental or psychosocial changes.
A resident with multiple chronic conditions and moderate cognitive impairment exited the building through a window and was later found outside, prompting staff to call 911 and remain with the resident until EMS arrived. Although internal notifications were documented, review of the state CALS system showed no report of the elopement to the Ohio Department of Health. In an interview, the Administrator confirmed the elopement and acknowledged that ODH was not notified, stating unawareness of the reporting requirement despite a facility policy directing that such incidents be reported to the Administrator and, when applicable, to ODH within required time frames.
A resident with a history of schizophrenia and moderate cognitive impairment, who had no prior documented aggressive behaviors, was found in a room with another resident who was discovered deceased with ligatures tightly wrapped around her neck. Staff had last seen both residents in the hallway earlier in the evening. The facility failed to prevent resident-to-resident abuse, resulting in the death of a resident by strangulation, as confirmed by coroner and police reports.
The facility did not provide food prepared in a form tailored to meet the individual needs of residents, resulting in meals that were not consistently modified for specific dietary or physical requirements.
The facility did not ensure staff consistently followed dietary restrictions and supervision requirements, resulting in a resident's death from choking after receiving unapproved food, and additional incidents where residents with special dietary needs were left unsupervised or accessed inappropriate food items.
Inadequate Legionella Water Monitoring: The facility failed to accurately monitor and document water flushing, water temps, and water quality testing for Legionella prevention. Logs showed missed flushing for multiple months, incomplete flushing details, pH readings below the acceptable drinking water range, and gaps in temp documentation. The RDM stated the facility lacked an assigned maintenance director and that flushing and monitoring practices were being done less frequently than expected, with no guidance available for the optimal chlorine level.
Failure to provide QAPI training was identified after review of employee files showed no evidence of QAPI training for several CNAs, an LPN, and an RN. Staff interviews also confirmed that multiple employees were not aware of QAPI and had not been trained on it, and the HR Manager verified the missing training records.
Surveyors identified multiple environmental deficiencies, including holes in drywall, water accumulation under sinks, missing or broken light cords and covers, and stained ceilings in several resident rooms. The Regional Director of Maintenance confirmed these issues, which affected eight residents and indicated a failure to maintain a homelike environment.
Two residents with self-care deficits did not receive adequate nail care as required by their care plans. One resident was repeatedly observed with dirty fingernails containing a dark brown substance, despite staff awareness of her behaviors and care needs. Another resident had long fingernails and expressed a desire for them to be trimmed, but staff were unclear about responsibility for this task. Facility policy required staff to follow ADL care plans, including nail care, but this was not consistently done.
Two residents experienced deficiencies in supervision and safety: one was not properly assessed after an unwitnessed fall, and another, with a history of taking food from others, was able to access and consume food not permitted in her prescribed pureed diet. Staff were aware of these behaviors but did not implement additional interventions to prevent recurrence.
A facility failed to honor resident choice for medication timing and showers. One resident with severe cognitive impairment and diabetes had morning meds offered by the night nurse at about 3:00 A.M., which the resident refused because it was too early, and an LPN and ADON confirmed the timing was inappropriate. Another resident, dependent on staff for bathing, had no documentation of showers being provided per her choice on scheduled shower days, and the DON verified the missing documentation.
A resident with intact cognition and diagnoses including schizophrenia, COPD, and PVD had a personal funds account balance above the Medicaid resource limit. The CNO RN verified there was no evidence the resident or representative was notified when the account was within $200 of the $2,000 limit, despite facility policy requiring such notification.
The facility failed to notify resident representatives and, in one case, document notification after a resident-to-resident altercation and a hospitalization for acute psychiatric symptoms. One resident with dementia and other psychiatric diagnoses struck another resident who was in her room, and although both residents were assessed and the MD and manager on duty were notified, there was no indication the resident representatives were contacted. Another resident with schizophrenia and depression became acutely psychotic, was sent to the ED for psych eval, and returned with no new orders, but there was no documentation that the representative was notified.
A resident with dementia, Alzheimer's disease, depression, and impaired cognition was ordered olanzapine 2.5 mg at bedtime for antipsychotic use, but the record contained no supporting diagnosis for the medication. An MDS LPN confirmed there was no diagnosis documented to justify the psychotropic, despite facility policy requiring review of psychoactive medication use and physician clarification when diagnoses are missing.
Baseline care plans were not completed within 48 hours of admission for three residents. One resident had dementia, depression, anxiety, HTN, and hemiplegia; another had Parkinson's disease, DM2, paranoid schizophrenia, HTN, and hypothyroidism; and a third had MDD, bipolar disorder, unspecified psychosis, and cognitive communication deficit. The President Clinical Services verified the delay, and the facility policy required a baseline care plan within 48 hours of admission.
Incomplete Comprehensive Care Plans: The facility failed to timely develop comprehensive care plans for two residents. One resident who smoked had admission documentation showing the need for smoking supervision and storage of lighter and cigarettes, but the care plan did not include a smoking care area. Another resident with depression had a psych med order and psych recommendations, but the care plan lacked individualized interventions for depression. The MDS LPN and SSD confirmed the missing care areas, and the facility policy required a comprehensive care plan within 21 days of admission.
A resident with impaired cognition, limited ROM, and left-sided mobility impairment did not receive an ordered cock-up wrist splint and sling as directed. Staff documented that the devices could not be found, and surveyors observed the resident without them on multiple occasions. An RN confirmed the splint and sling were missing, and the resident stated her left arm felt more comfortable when she wore them.
A resident with dysuria and other UTI symptoms had a urine specimen delayed for several days, no documented monitoring or follow-up while symptoms continued, and the culture later showed Klebsiella pneumoniae resistant to the initially ordered antibiotic. Another resident with a suprapubic catheter was observed urinating from the penis while the leg bag was empty, reported the catheter was not working, and staff were unaware the catheter was not functioning or even that the resident had a suprapubic catheter.
Delayed Physician Notification of Abnormal Urine Culture Results: A resident with DM2, depression, schizoaffective disorder, PVD, and HTN had a urine specimen ordered for dysuria, but staff did not document continued attempts to obtain the specimen or notify the MD when it was not obtained. When the urine culture later showed >100,000 Klebsiella pneumoniae with resistance to nitrofurantoin, the MD was not timely notified of the abnormal lab results.
A resident with Parkinson's disease and other diagnoses had orders and a care plan for weighted built-up utensils, a 2-handled cup with lid, and separate bowls at all meals, but the lunch tray was served on a divided plate instead of in bowls. The resident reported a prior meal was also not provided in bowls, and an LPN verified the meal was not served as ordered.
Incomplete documentation of a choking incident and diet change was found for a resident with CVA-related hemiplegia/hemiparesis, Parkinson's disease, vascular dementia, MDD, and dysphagia. An LPN reported the Heimlich maneuver was used after the resident choked on a tater tot, with vitals obtained and the diet changed to mechanical soft pending ST evaluation, but the chart had no record of the event, the assessment, or an order for the diet change.
Inappropriate Antibiotic Use for Suspected UTIs: The facility failed to ensure antibiotics were appropriately prescribed for suspected UTIs for three residents reviewed for antibiotic stewardship. One resident received Macrobid despite a urine culture showing the organism was resistant, another was started on Levaquin without documented UTI signs or symptoms and without urinalysis or culture testing, and a third received Macrobid after an inconclusive urine specimen with no repeat sample ordered. The infection surveillance checklist for the latter two residents indicated UTI criteria was not met.
Failure to provide education before pneumococcal vaccine acceptance or refusal. Two residents were affected: one resident with chronic respiratory failure, heart disease, hyperlipidemia, and dementia received PCV 20 without evidence of prior education, and another resident with Alzheimer's disease, dementia, schizoaffective disorder, COPD, and HTN refused the vaccine without evidence of education on risks and benefits. The VPCS confirmed no documentation was available showing the required education occurred before the vaccine was given or declined.
The facility did not ensure an RN was present for the required eight hours on a specific day, as confirmed by schedule and timesheet reviews and staff interview. This lapse affected all 68 residents, as there was no RN available to provide necessary nursing care and oversight.
A housekeeper used personally purchased household cleaning products instead of facility-approved agents to clean resident rooms and common areas on one unit, with the knowledge and approval of her supervisor. The cleaning products were not intended for industrial or sanitizing use, and the facility lacked a policy specifying required cleaning agents.
A resident with severe cognitive impairment and high fall risk was assisted to the bathroom without his walker by two CNAs, resulting in a fall and a fractured femur. The incident was not reported to the nurse, and the facility's investigation was incomplete, lacking documentation of the resident's use of a walker and environmental conditions. The care plan did not include the use of a walker, and the facility's fall policy was not adequately followed.
A resident with a history of aggressive behavior physically abused two other residents, causing significant injuries. The facility's interventions, such as 15-minute checks and psychological evaluations, were insufficient, and the investigation lacked comprehensive assessments. The facility's policy on abuse prevention was not effectively implemented, contributing to repeated incidents of abuse.
The facility failed to timely report resident-to-resident abuse incidents involving a resident with dementia who caused injuries to two other residents. The incidents were not promptly filed in the Self-Reported Incident (SRI) database, and local law enforcement was not notified as required by the facility's policy. This resulted in non-compliance with state regulations.
Failure to Assess and Respond to Resident’s Acute Mental Health Decline Leading to Harm
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, document, and address a resident’s mental health decline and behavioral changes, despite the resident’s significant psychiatric history and hospice status. The resident had diagnoses including bipolar disorder, schizoaffective disorder, major depressive disorder, epilepsy, COPD, and CKD, and was receiving hospice services. Antipsychotic medication (Abilify) had been gradually reduced from 10 mg to 5 mg on 11/11/25 and then to 2.5 mg on 12/11/25 as a gradual dose reduction. Psychology notes from 12/10/25 and 12/24/25 documented depression, low energy, poor concentration, and lack of motivation, but no psychosis, hallucinations, or suicidal ideation at those times. Behavior documentation from 12/07/25 through 01/02/26 showed no recorded behaviors, despite later staff reports of aggression and mood changes. On 12/22/25, nursing documentation noted low energy, inability to sleep, quiet and flat affect, and a behavior note described anhedonia and sadness. A PHQ-9 interview on 12/23/25 recorded no mood symptoms and indicated no need for a staff mood interview. On 12/24/25, psychology documented depressed affect, low energy, poor concentration, lack of interest, and sadness, but still no psychosis or suicidal ideation. On 12/30/25, a nursing progress note stated hospice was advised of increased aggression and that a PNP would adjust medications; however, there was no corresponding documentation of the resident’s aggression in the behavior charting, no record that the PNP actually saw the resident that day, and no evidence of any medication changes. A later interview with an RN clarified that the resident had been arguing with a roommate, refusing medications, and throwing things in his room, but these behaviors were not captured in the behavior documentation. During the night shift of 01/01/26–01/02/26, a CNA reported that the resident was “not right” and “actually scary,” lying in bed talking quietly to himself, shouting profanities when staff walked by, and becoming more agitated when approached, acting as if he would get out of bed. The CNA, who had cared for the resident for two to three years, stated this behavior was very out of character and reported her concerns to the LPN. The LPN attempted to give evening medications around 7:30 P.M., which the resident refused, and stated the door was kept open to observe him. The LPN later sent a text to the physician at 6:07 A.M. about the behaviors and lack of sleep but did not contact hospice as instructed by the DON and did not receive a response before leaving at 6:36 A.M. Behavior charting for 01/02/26 at 5:59 A.M. documented that the resident was verbally aggressive, yelling profanities, making threatening gestures, unapproachable, highly agitated, awake all night, and talking loudly with aggressive, profane language to himself; it also stated that the physician and on-call provider were notified, but there was no evidence of interventions implemented throughout the night. On the morning of 01/02/26, the DON reported receiving a call around 6:00 A.M. from the hall nurse about the resident talking to himself and to people who were not there and instructed the nurse to call hospice. The DON arrived at approximately 7:00 A.M., was told the resident was sleeping, and did not check on him. Hospice later confirmed the facility did not contact them about the change in mental status and that hospice only became aware when their nurse arrived for a routine visit and saw EMS assisting the resident. Around 7:50 A.M., a transportation driver arriving at the facility saw something in the snow and discovered the resident outside approximately 100 feet from his window, on his knees in the snow, agitated, stating he wanted to die, with abrasions, bright red skin, and wearing only light clothing. Facility staff and EMS reports indicated the resident was combative, aggressive, and psychotic, with altered mental status, injuries, and signs of hypothermia in temperatures around 21°F. EMS and hospital records documented that the resident was found kneeling in the snow with a cold wet blanket, with drag marks suggesting he had rolled down a hill from a first-floor window approximately 77 inches above the ground. The resident was pale with purple extremities, abrasions, and nonblanchable skin over heels and knees, and required soft restraints and sedative medication due to combative behavior. At the hospital, he was described as cold to the touch, with a core temperature of 95.6°F, delusions (including stating he was pregnant), and paranoia. He was admitted with hypothermia due to exposure, stage one frostbite to the heels, and delusions, and was placed on an Emergency Application for suspected suicide attempt after reportedly jumping from his window and remaining in the snow. Interviews with the PNP and hospice staff revealed discrepancies in Abilify dosing between hospice and facility records, lack of timely psychiatric reassessment after the GDR, and inconsistent or missing documentation of behavioral concerns. The facility’s Administrator and Vice President of Clinical Operations confirmed there was no facility policy related to meeting residents’ behavioral or psychological needs, and the facility’s change-in-condition policy required physician consultation for significant changes in mental or psychosocial status, which was not consistently followed in this case.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to notify the Ohio Department of Health (ODH) of a resident elopement as required. Medical record review showed that Resident #09, who had multiple diagnoses including localization-related symptomatic epilepsy with simple partial seizures, COPD, chronic kidney disease, bipolar disorder, schizoaffective disorder, morbid obesity, and major depressive disorder, was admitted on an identified date and later transferred to the hospital. An MDS assessment indicated the resident was moderately cognitively impaired without documented mood concerns or behaviors. A nursing progress note documented that on a specific date the nurse was notified the resident was outside, 911 was called, and the nurse remained with the resident until emergency services arrived, stating that all parties were notified. Review of the Certification, Licensure, and Survey (CALS) system for the relevant time period revealed no evidence that the facility reported the resident’s elopement to ODH. During an interview, the Administrator confirmed that the resident had exited the building through his window and was found outside the facility, and acknowledged that ODH had not been notified. The Administrator stated that hospice had informed her they were required to report the incident to ODH, but she was not aware that she was also required to do so. Review of the facility’s Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property policy showed that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and all injuries of unknown source must be reported immediately to the Administrator or designee, and that if abuse was alleged or serious bodily injury identified, the Administrator/designee would notify ODH immediately but not later than two hours after the allegation or identification of serious bodily injury.
Failure to Prevent Resident-to-Resident Abuse Resulting in Homicide
Penalty
Summary
A deficiency occurred when the facility failed to prevent resident-to-resident abuse, resulting in the death of one resident. The incident involved a resident with a history of schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder, who was initially admitted to a secured dementia unit, later moved to a behavior unit, and then returned to the dementia unit. This resident had no documented history of aggressive behaviors toward staff or other residents during their stay, and their care plan included interventions for cognitive loss and impaired judgment. Another resident, with diagnoses including major depression, bipolar disorder, severe cognitive impairment, and other medical conditions, resided on the secured dementia unit and was independently ambulatory with severe cognitive impairment noted on assessment. On the evening of the incident, staff were unable to locate the resident with schizophrenia for medication administration. After searching, staff found the resident in a room with the door closed, standing inside and perspiring. Behind a privacy curtain, another resident was found lying supine on the floor with towels and a pillowcase tightly wrapped around her neck, her face purple, and blood in her mouth. The staff immediately called for help, assessed the unresponsive resident, and contacted emergency services and law enforcement. The resident was pronounced deceased at the scene, and the cause of death was determined to be homicide by strangulation, as confirmed by the county coroner and autopsy findings. Interviews and documentation revealed that staff had last seen both residents in the hallway earlier that evening, and there was no indication of prior aggressive behavior from the resident who committed the act. The facility's policy on abuse, mistreatment, and neglect was reviewed, which defines abuse as the willful infliction of injury resulting in physical harm. The incident was investigated by police, and the resident responsible was taken into custody. The deficiency was cited for the facility's failure to protect residents from abuse, resulting in actual harm and death.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures. The report does not provide further details about the residents involved or their medical conditions at the time of the deficiency.
Failure to Enforce Dietary Restrictions and Supervision Leading to Choking Incidents
Penalty
Summary
The facility failed to provide adequate administrative oversight, resulting in a resident's death due to choking after being given food items that were not approved for their diet. Despite a requirement for staff to use diet order cards on snack trays to ensure residents received appropriate food, observations revealed that staff were not consistently utilizing these cards during snack distribution. Additionally, a resident who required supervision while eating was observed eating alone and subsequently began choking, with staff intervention needed to resolve the incident. Another resident on a pureed diet was seen taking bacon from another resident's meal tray left unattended in the hallway, despite staff being aware of this resident's tendency to take food from others and the need for close monitoring. Medical record reviews confirmed that the residents involved had specific dietary restrictions and supervision requirements that were not followed. Staff interviews corroborated that the required practices, such as using diet order cards and supervising residents during meals, were not consistently implemented. The facility's policies and job descriptions outlined the responsibility of administration to ensure proper procedures and quality of care, but these were not effectively enforced, leading to multiple incidents where residents received inappropriate food or were left unsupervised during meals.
Inadequate Legionella Water Monitoring
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program related to Legionella monitoring. Review of water flushing logs from January 2025 through August 2025 showed no water lines were flushed in January, February, and March 2025. The log for March 2025 included a note that all rooms were in use on 03/14/25. Further review showed room [ROOM NUMBER] was flushed on 05/06/25, marked late for April 2025, room [ROOM NUMBER] was flushed on 05/16/25 and 06/05/25 and 07/22/25, and room [ROOM NUMBER] was flushed on 08/04/25. The records did not identify which faucet was flushed or how long the flush lasted. Review of water monitoring records showed pH levels of 5 in A-hall and C-hall and 4 in B-hall on 04/11/25, and pH levels of 4.0 with chlorine levels of 1.0 in A-hall, B-hall, and C-hall on 06/06/25 and 06/18/25. Review of water temperature logs from 05/01/25 through 08/12/25 showed no temperatures were documented between 06/21/25 and 07/17/25 and between 07/19/25 and 08/04/25. During interview, the Regional Director of Maintenance stated the facility had no assigned maintenance director and that he was covering the facility. He stated unused water sources were flushed once monthly for 10 minutes and that pH and chlorine were tested once monthly. He later confirmed unused faucets should be flushed once weekly, water temperatures should be checked daily, and a pH of 4.0 or 5 was not appropriate for drinking water; he also verified the facility had no guidance regarding the optimal chlorine level in drinking water.
Failure to Provide QAPI Training
Penalty
Summary
Mandatory QAPI training was not completed for facility staff, as shown by review of the employee files for CNA #320, CNA #306, CNA #305, LPN #383, and RN #365, none of which contained evidence of QAPI training. During interviews, CNA #371, LPN #381, and CNA #219 stated they were not aware of what QAPI was and had not been trained on it. The Human Resource Manager confirmed that employees should receive QAPI training upon hire and verified that CNA #320, CNA #305, CNA #306, LPN #383, and RN #365 had no evidence of QAPI training in their files.
Environmental Deficiencies and Lack of Homelike Environment
Penalty
Summary
Surveyors observed multiple environmental deficiencies affecting eight residents in the facility. In one resident's bedroom, there was a large hole in the drywall at door handle height and a smaller hole near the ceiling behind the door. The shared bathroom for two residents had a waste basket under the sink that was approximately one-quarter full of water. In another resident's bedroom, the light above the bed was missing a cord to turn it on, and the same shared bathroom had the water-filled waste basket. Two residents' room ceilings had large brown-colored areas of an unidentified substance throughout, and another resident's bedroom had a light above the bed with no pull cord. Additionally, another room's ceiling had similar brown-colored areas, and a different resident's light had a broken cover hanging from it. The Regional Director of Maintenance confirmed these findings during an interview and stated that the water under the sink was due to a part needed for repair. The director also confirmed the absence of pull cords for the lights above the beds and acknowledged that while water pipes had burst and been fixed in some rooms, the brown-colored spots on the ceilings had not been addressed. The broken light cover was also confirmed. These observations and confirmations indicate the facility failed to maintain a homelike environment as required.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for dependent residents, as evidenced by observations and interviews involving two residents with self-care deficits. One resident with dementia, Alzheimer's disease, and behavioral issues, including playing in her own feces, was observed on multiple occasions with dirty fingernails containing a dark brown substance. Despite care plan interventions specifying that nail length should be checked, trimmed, and cleaned on bath days and as necessary, the resident's nails remained soiled over several days, even while eating meals with her hands. Staff interviews confirmed the resident's behaviors and the ongoing issue with dirty nails. Another resident with multiple chronic conditions, including bipolar disorder and diabetes, was found to have long fingernails on repeated observations, although the nails were clean and not jagged. The resident expressed dissatisfaction with the length of his nails and requested they be trimmed, but staff were unaware of who was responsible for this task. The facility's policy required staff to follow the ADL care plan, which included nail care, but this was not consistently implemented for the residents reviewed.
Failure to Prevent Accidents and Ensure Dietary Supervision
Penalty
Summary
The facility failed to adequately assess a resident following an unwitnessed fall and did not provide sufficient supervision to prevent another resident from consuming food not included in their prescribed diet. In the first incident, a resident with diagnoses including paranoid schizophrenia, major depressive disorder, and pseudobulbar affect, who was cognitively intact and required supervision for ADLs, was found lying on the ground near the nurse’s station with her walker beside her. A housekeeper assisted the resident off the floor without notifying nursing staff, and the LPN on duty was unaware of the incident until informed by the surveyor. The required post-fall assessment and reporting procedures were not initiated immediately following the event. In the second incident, a resident with Alzheimer’s disease, dementia, oropharyngeal dysphagia, and schizoaffective disorder, who was on a pureed diet, was observed taking and consuming regular texture food from other residents’ trays on multiple occasions. Despite documentation of repeated incidents where the resident took food from trays or the trash and consumed it, staff interventions were limited to verbal redirection and education. During an observation, the resident was able to access the tray cart, remove bacon from another resident’s tray, and begin eating it before being stopped by a staff member. Interviews confirmed that staff were aware of the resident’s behavior but had not implemented additional interventions to prevent access to inappropriate foods. Both incidents demonstrate a lack of adequate supervision and failure to follow established protocols for resident safety and dietary management. The facility did not ensure that staff were consistently monitoring residents at risk for falls or for consuming foods not aligned with their prescribed diets, resulting in deficiencies affecting two residents reviewed for accidents.
Resident choice not honored for medication timing and showers
Penalty
Summary
The facility failed to ensure residents had the right to choose when they received medications and when they showered. For Resident #47, who was admitted with schizoaffective disorder, type 2 diabetes mellitus, major depressive disorder, severe cognitive impairment, and COPD, the record showed multiple morning medications ordered to be given in the morning, including insulin, psychotropic medications, and other routine medications. On 08/04/25, all morning medications were marked refused after the night shift nurse offered them at about 3:00 A.M. The resident stated he did not take the medications because they were offered too early. An LPN stated the MAR allowed early medication administration beginning at 6:00 A.M., and the ADON confirmed 3:00 A.M. was too early and that the resident could receive medications when requested. For Resident #50, who had diagnoses including generalized anxiety disorder, major depressive disorder, and paranoid schizophrenia and was dependent on staff for bathing and showering, the shower schedule listed showers on Wednesdays and Saturdays on the 12-hour evening shift. Review of shower task documentation, shower sheets, and nurses' notes showed no documentation that the resident received showers per her choice on multiple scheduled shower days, and there was no documentation that she refused showers. The resident stated she had not been receiving showers per her choice on the scheduled shower days, and the DON verified there was no documentation that the showers had been provided as scheduled.
Failure to Notify Resident of Personal Funds Spend Down
Penalty
Summary
The facility failed to ensure a resident was notified of spend down when personal funds were within $200.00 of the $2,000.00 resource limit. Resident #51 was admitted on 05/17/22 with diagnoses including schizophrenia, chronic obstructive pulmonary disease, and peripheral vascular disease, and the annual MDS assessment indicated intact cognition. Review of the resident’s trial balance fund dated 08/11/25 showed a personal funds account balance of $2,293.28. During interview on 08/11/25 at 4:42 P.M., the Chief Nursing Officer RN verified there was no evidence that Resident #51 or the resident representative had been provided notification of spend down when the account was within $200.00 of the state limit. The facility policy stated that residents would be notified when their personal funds were within $200.00 of the $2,000.00 limit.
Failure to Notify Resident Representatives and Physicians of Incidents and Hospitalization
Penalty
Summary
The facility failed to ensure appropriate notifications were made to residents, resident representatives, and physicians for three residents reviewed for resident-to-resident interactions and change in condition. For one resident with anoxic brain damage, dementia, bipolar disorder, and schizoaffective disorder, the record showed an incident on the unit in which another resident was found lying on the floor in her room after she stated she hit the other resident because the other resident was in her room. Both residents were assessed and found to have no injuries, and the physician and manager on duty were notified, but there was no indication that either resident representative was notified. The nurse on duty confirmed she did not notify the resident representative for that resident, stating she believed the resident had a guardian who was not very involved and also stated she did not notify the representative because the resident was her own person. For another resident with neurocognitive disorder with Lewy bodies, stroke, pseudobulbar affect, dysarthria, and anarthria, the facility initiated a self-reported incident after the resident was found on the ground in the other resident's room during the altercation. For a third resident with paranoid schizophrenia, major depressive disorder, and pseudobulbar affect, staff observed the resident running in the hallway, hallucinating, and stating the FBI was watching her through the walls; the physician was notified, EMS was called, and the resident was sent to the hospital for psychiatric evaluation and later returned with no new orders. The CNO confirmed there was no documentation that the resident's representative was notified of the hospitalization and return, and stated the nurse should have contacted the representative when the resident was sent out and upon return.
Lack of Supporting Diagnosis for Antipsychotic Use
Penalty
Summary
The facility failed to ensure an appropriate diagnosis supported the use of an antipsychotic medication for Resident #6, who was admitted on 04/02/25 with diagnoses including conversion disorder with seizures or convulsions, dementia, Alzheimer's disease, and depression. The significant change MDS assessment showed impaired cognition, and a physician order dated 04/02/25 included olanzapine 2.5 mg by mouth at bedtime for antipsychotic use. Review of the medical record found no documentation of a supporting diagnosis for olanzapine, and the MDS LPN confirmed that Resident #6 had no supporting diagnosis for the medication. The facility policy stated that residents receiving psychoactive medication should be evaluated for necessity and that the nurse should contact the physician if appropriate diagnoses to support psychotropic drug use were not on the cumulative diagnosis list.
Baseline Care Plans Not Completed Within 48 Hours
Penalty
Summary
The facility failed to ensure baseline care plans were developed within 48 hours of admission for three residents, including Resident #52, Resident #15, and Resident #53. Review of Resident #52's record showed an admission date of 01/10/25, diagnoses of dementia, depression, anxiety, hypertension, and hemiplegia affecting the left non-dominant side, and a quarterly MDS indicating intact cognition; however, no baseline care plan was initiated within the first 48 hours of admission. Resident #15 was admitted with diagnoses including Parkinson's disease with dyskinesia with fluctuations, type two diabetes mellitus, paranoid schizophrenia, essential hypertension, and hypothyroidism, and the MDS dated 06/28/25 showed the resident was cognitively intact. The medical record showed the care plan was not developed until 03/24/25. Resident #53 was admitted with major depressive disorder recurrent, bipolar disorder, unspecified psychosis, and cognitive communication deficit, and the MDS dated 05/26/25 showed severe cognitive impairment; the baseline care plan was not completed within 48 hours. On 08/12/25 at 9:22 A.M., the President Clinical Services verified that baseline care plans were not completed timely for these three residents, and the facility policy stated a baseline care plan is to be developed within 48 hours of admission.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to timely develop comprehensive care plans for two residents. For one resident admitted with schizoaffective disorder, COPD, and unspecified psychosis, the admission packet documented that the resident smoked, required supervision during smoking, and needed the facility to store his lighter and cigarettes. The comprehensive admission MDS dated 07/16/25 showed intact cognition and tobacco use, and the facility’s smoker list included the resident. However, the comprehensive care plan reviewed on 08/06/25 did not include a smoking care area, and the Social Services Designee confirmed that the smoking care area had not yet been added because the resident was a relatively new admission. For another resident admitted with conversion disorder with seizures or convulsions, dementia, Alzheimer’s disease, and depression, the record showed a physician order for Lexapro for depression and a psychiatry note recommending increased physical activity, good sleep hygiene, a balanced diet, sunlight exposure, and relaxation techniques. The resident’s care plan, last revised 06/20/25, addressed psychoactive medication use related to mood and behavior disturbance and depression, but it did not include a care plan for the depression diagnosis with individualized interventions. The MDS LPN verified that no depression care plan with individualized interventions was in place. The facility policy stated that a comprehensive care plan would be developed within 21 days after admission after completion of the appropriate assessments by the interdisciplinary team.
Missing Ordered Splint and Sling
Penalty
Summary
The facility failed to ensure a resident received splints and immobilizer devices as ordered by the physician. The resident was admitted with diagnoses including anoxic brain damage, dementia, bipolar disorder, and schizoaffective disorder, and the admission MDS showed impaired cognition, impairment to one upper extremity and one lower extremity, and wheelchair use for mobility. The care plan identified limited physical mobility due to decreased ROM and included interventions to keep the resident's left arm in a sling except at bedtime and bathing. Physician orders required a cock-up wrist splint to the left wrist with removal each shift for skin checks and a sling to the left upper extremity every shift. Nursing progress notes documented that on multiple days the resident's splint and sling were not in place because staff could not find them. Surveyor observations showed the resident without the splint or sling while in the hallway and later while seated in a wheelchair in the common area. An RN confirmed the devices were not being worn because she could not locate them and had been searching for them since the prior week. The resident stated her left arm felt more comfortable when she wore the splint and sling. Later, staff found a splint and sling in the basement, and the OT stated the splint was intended to prevent worsening of left-hand contractures and the sling was ordered due to a prior fractured collar bone.
Delayed UTI Treatment and Nonfunctioning Suprapubic Catheter
Penalty
Summary
The facility failed to ensure a resident’s urinary tract infection was timely and appropriately treated. Resident #69 had diagnoses including type 2 diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension, and was occasionally incontinent of bowel and bladder with substantial to maximal staff assistance needed for toileting. A physician order on 07/22/25 directed staff to obtain a urinalysis with culture if indicated for dysuria, collect the urine, place it in the laboratory refrigerator, and follow up with results in three days. On 07/24/25, nursing documented that a urine specimen could not be collected because the resident could not produce enough urine, but there was no documentation of further attempts to obtain the specimen from 07/24/25 through 07/29/25 and no documentation that the resident was monitored for continued or worsening signs of infection. On 07/30/25, nursing documented that a urinalysis was ordered and a clean-catch specimen was placed in the refrigerator. The laboratory report showed the specimen was collected on 07/30/25, received on 07/31/25, and the facility was notified on 08/02/25 that the culture grew greater than 100,000 Klebsiella pneumoniae. The organism was resistant to nitrofurantoin (Macrobid) and susceptible to multiple other antibiotics, including ciprofloxacin. The physician was not notified of the results until 08/04/25, and the resident reported ongoing weakness, burning, lethargy, dysuria, and lower back pain without having received an antibiotic. Nursing notes showed no follow-up with the physician or resident until after surveyor intervention, and Macrobid was later ordered despite the culture showing resistance to that medication. The facility also failed to ensure a suprapubic catheter was patent and functioning properly for Resident #81, who had diagnoses including unspecified dementia, retention of urine, and diabetes insipidus. The resident’s care plan identified an indwelling suprapubic catheter and directed staff to assist with toileting and provide catheter care per physician orders, with monitoring for pain, discomfort, and abnormalities. Physician orders required a suprapubic catheter to straight drain and catheter care every shift. During observation, the resident was seen ambulating from the bathroom with his pants off and urinating on the floor from his penis while the suprapubic catheter leg bag was empty. The resident stated he had reported the catheter was not working, but the nurse said there was nothing that could be done. An LPN stated she was unaware the catheter was not functioning and did not know the resident had a suprapubic catheter. The ADON later stated the catheter should have been monitored and that the resident had pulled on it while dressing, and a new suprapubic catheter was placed because the prior one was not draining properly.
Delayed Physician Notification of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to timely notify the physician of abnormal laboratory results for one resident reviewed for bowel and bladder concerns. The resident had diagnoses including type 2 diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension, and had intact cognition on the quarterly MDS assessment. A physician order dated 07/22/25 directed staff to obtain a urinalysis with culture if indicated for dysuria, collect the urine, place it in the laboratory refrigerator, and follow up with results in three days. On 07/24/25, a nurse documented that a urine specimen could not be obtained because the resident was unable to produce enough urine, and the nurse would continue trying to collect a specimen. The record showed no documentation from 07/24/25 through 07/29/25 of further attempts to obtain the specimen or that the physician was notified that the urine had not been obtained. A later nurse note on 07/30/25 documented a new urinalysis order and that a specimen was obtained. The laboratory report showed the specimen was collected on 07/30/25, received by the lab on 07/31/25, and the facility was notified on 08/02/25 that the culture grew greater than 100,000 Klebsiella pneumoniae, resistant to nitrofurantoin and susceptible to nine other antibiotics including ciprofloxacin. There was no documentation that the physician was timely notified of the urinalysis results on 08/02/25 or 08/03/25, and the physician was not documented as notified until 08/04/25. The facility's policy on notification of change in condition stated the nurse would consult the physician for significant changes in health status, including abnormal laboratory results.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure a resident received adaptive eating equipment with meals as ordered. Resident #15, who was cognitively intact and had diagnoses including Parkinson's disease with dyskinesia with fluctuations, type 2 diabetes mellitus, paranoid schizophrenia, essential hypertension, and hypothyroidism, had a care plan and physician order for weighted built-up utensils, a two-handled cup with lid, and separate bowls at all meals. The resident told the surveyor that meals were to be provided in bowls and stated that a meal had not been provided in bowls the prior Thursday. During observation, the resident's lunch tray was served on a divided plate instead of in bowls, and an LPN verified that the lunch meal was not served in bowls as ordered. The facility policy for adaptive devices stated that assistive devices shall be provided to residents who need them.
Incomplete Documentation of Choking Incident and Diet Change
Penalty
Summary
The facility failed to maintain complete and accurate resident medical records for one resident reviewed for medical record content. Resident #20 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right side, Parkinson's disease, vascular dementia, major depressive disorder, and dysphagia. The MDS dated 06/27/25 showed the resident had unclear speech, was not oriented to time, used a wheelchair, required setup assistance for eating, toileting, and personal hygiene, and needed substantial assistance with showering, dressing, and transfers. The care plan dated 06/09/25 identified the resident as at possible nutritional risk due to comorbidities and hemiplegia and hemiparesis to the right dominant side related to stroke. During interview on 08/06/25, an LPN stated the resident had an incident about a month earlier in which the Heimlich maneuver was performed successfully to dislodge a tater tot the resident was choking on. The LPN stated an assessment was completed, including vital signs, and the resident's diet was changed to mechanical soft until speech therapy could evaluate the resident. However, the medical record contained no documentation of the choking incident, the post-incident assessment, or any order for a mechanical soft diet. The facility policy on Documentation Guidelines stated that observations or interactions relevant to resident care and services should be recorded in the medical record, including the date and time, relevant information, physician orders or communication, and signature.
Inappropriate Antibiotic Use for Suspected UTIs
Penalty
Summary
The facility failed to ensure antibiotics were appropriately prescribed for urinary tract infections for three residents reviewed for antibiotic stewardship. The facility identified seven residents as receiving antibiotics, and the census was 74. Review of the facility policy showed it was to promote appropriate antibiotic use by evaluating clinical signs and symptoms when infection was first suspected and by using diagnostic testing to optimize tracking and treatment of infections. For Resident #69, who had diagnoses including type 2 diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension, a urine culture collected after the specimen was received by the laboratory showed greater than 100,000 Klebsiella pneumoniae. The organism was resistant to nitrofurantoin (Macrobid) and susceptible to other antibiotics, including ciprofloxacin. The physician was notified of the results, but an order for Macrobid 100 mg twice daily for seven days was entered later, and the resident received Macrobid before the antibiotic was changed to ciprofloxacin. The physician stated he was notified of the laboratory results and should have followed up to ensure the resident was ordered the right antibiotic. For Resident #5, who had diagnoses including neuromuscular dysfunction of the bladder, dementia, and Crohn's disease, the resident had an indwelling catheter and impaired cognition. The resident was seen after pulling out an IV line used for fluids for dehydration, and the physician ordered Levaquin 500 mg daily for seven days. The facility's McGeer Criteria for Infection Surveillance Checklist documented that the resident was evaluated for a UTI, but no signs or symptoms of a UTI were documented and the checklist indicated UTI criteria was not met. The VPCS confirmed there was no indication for initiating antibiotics and no urinalysis or culture and sensitivity was obtained around the time the antibiotic was ordered. For Resident #24, who had diagnoses including benign prostatic hyperplasia, hematuria, obstructive and reflux uropathy, and retention of urine, the resident had impaired cognition and an indwelling catheter. A urine specimen collected for testing was reported as probable contamination because three or more organisms were isolated. Despite the inconclusive urinalysis, the physician ordered Macrobid 100 mg twice daily for UTI. The facility's infection surveillance checklist documented that the resident was evaluated for a UTI, noted discolored urine with odor and visible mucus, and indicated that UTI criteria was not met. The VPCS confirmed the urinalysis was inconclusive and no new urine sample was ordered before the antibiotic was prescribed.
Failure to Provide Education Before Pneumococcal Vaccine Acceptance or Refusal
Penalty
Summary
The facility failed to ensure residents received education before accepting or refusing a pneumococcal vaccination. Review of the medical record for Resident #3 showed an admission date of 08/28/13 with diagnoses of chronic respiratory failure, heart disease, hyperlipidemia, and dementia. The quarterly MDS dated 08/03/25 indicated intact cognition, and the immunization history showed the resident received PCV 20 on 12/15/23. However, during interview on 08/12/25, the VPCS confirmed the facility could provide no evidence that Resident #3 received education about the risks and benefits of the pneumococcal vaccine before receiving it. Review of the medical record for Resident #38 showed an admission date of 12/28/23 with diagnoses of Alzheimer's disease, dementia, schizoaffective disorder, COPD, and hypertension. The quarterly MDS dated 07/07/25 indicated mildly impaired cognition, and the immunization history showed the resident refused the pneumococcal vaccine on 04/15/24. The VPCS confirmed the facility could provide no evidence that Resident #38 received education about the risks and benefits of the pneumococcal vaccine before declining it. The facility policy titled Pneumococcal Vaccine Policy, dated 09/25/24, stated the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine prior to receiving the vaccine.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight hours daily, as required. Review of staff schedules and timesheets for May 2015 showed there was no RN coverage on one specific day. This was confirmed during an interview with Regional Clinical Support, who acknowledged the absence of documentation indicating an RN worked in the facility on that day. This deficiency affected all 68 residents in the facility, as there was no RN present to provide required nursing oversight and care during the identified period.
Inappropriate Use of Non-Approved Cleaning Agents in Resident Areas
Penalty
Summary
The facility failed to ensure that appropriate cleaning agents were used for cleaning resident rooms and common areas, affecting 32 residents on the upstairs unit. Housekeeper #302, assigned to the second floor, used cleaning products she personally purchased rather than facility-approved chemicals. She did this for convenience, as the facility's chemical supplies were located on the first floor. The housekeeper used two Pinalen brand products, one for floors and one for surfaces and toilets, and did not measure the cleaning solution, instead estimating the amount used. Her supervisor was aware of and approved the use of these products. The facility did not have a policy regarding the types of cleaning products required to meet its cleaning needs. Review of the Safety Data Sheet for Pinalen revealed it is a household multipurpose cleaner not intended for industrial use or as a sanitizing agent. The deficiency was identified through staff interviews, observation, and review of product instructions and documentation, and was confirmed by the facility administrator.
Failure to Ensure Safe Ambulation and Report Fall
Penalty
Summary
The facility failed to ensure the safety and proper supervision of a resident, leading to a fall and subsequent injury. The resident, who had severe cognitive impairment and was at high risk for falls, was assisted to the bathroom by two CNAs without the use of his prescribed walker. During this process, the resident's legs buckled, and he was lowered to the floor by the CNAs. The CNAs then assisted the resident onto the toilet and back to bed without reporting the incident to the nurse, as they did not recognize it as a fall. The resident was later found by the oncoming shift with bruising and swelling, and an x-ray revealed a displaced intertrochanteric fracture of the left femur. The resident required surgical repair and hospitalization. The facility's investigation into the incident was incomplete, lacking documentation of the resident's use of a walker, footwear, and environmental conditions at the time of the fall. Additionally, there was no evidence of a thorough investigation or assessment of the resident's injuries prior to moving him after the fall. The facility's care plan for the resident did not include the use of a walker, despite recommendations from physical therapy. The CNAs involved were unaware that lowering a resident to the floor constituted a fall and did not report the incident. The facility's fall policy was not adequately followed, as the incident was not documented or reported in a timely manner, and the care plan was not updated with appropriate interventions to prevent future falls.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in actual harm to residents. Resident #01, with a known history of aggressive behavior, struck Resident #02 in the face, causing a hematoma and a closed fracture of the right orbital floor. Despite Resident #01's history of aggression, the facility's interventions, such as 15-minute checks and psychological evaluations, were insufficient to prevent the incident. The facility's investigation lacked comprehensive interviews and assessments to understand the factors leading to the incident. In another incident, Resident #01 struck Resident #03 multiple times in the back while Resident #03 was asleep. The facility's response included separating the residents and placing Resident #01 on one-to-one monitoring, but the monitoring was not documented. The facility's investigation into this incident also lacked thorough assessments and documentation of Resident #01's behaviors prior to the incident. The facility's policy on abuse prevention was not effectively implemented, as ongoing assessments and appropriate interventions were not adequately documented or executed. Resident #01's medical records revealed a history of physical aggression, yet there was a delay in psychiatric evaluation and insufficient documentation of behavior assessments. The facility's failure to implement effective monitoring and intervention strategies contributed to the repeated incidents of resident-to-resident abuse. The Director of Nursing acknowledged the lack of documentation and assessments, indicating a gap in the facility's approach to managing residents with aggressive behaviors.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report allegations of resident-to-resident abuse, affecting three residents. On 08/09/24, Resident #01 was observed grabbing Resident #02's hair and punching her in the face, resulting in facial swelling and an orbital fracture. Although the incident was reported to the Director of Nursing (DON) on the same day, there was no evidence that it was filed in the Self-Reported Incident (SRI) database until 08/14/24. The facility's investigation lacked interviews with other staff or residents and did not include any resident interviews. The police were notified, but no report was made due to Resident #01's dementia diagnosis. Another incident occurred on 08/13/24, where Resident #01 struck Resident #03 multiple times in the back, causing a bruise. This incident was not reported to the SRI database until 08/14/24, and local law enforcement was not notified. The facility's policy requires that all allegations of abuse involving bodily injury be reported to the Ohio Department of Health (ODH) database immediately or within two hours. The facility's failure to adhere to this policy resulted in non-compliance with control numbers OH00156980 and OH0015690.
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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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ayden Healthcare Of Waterville | 1.6 mi | ★★★★★ | 34 | 0 |
| Otterbein Monclova | 4 mi | ★★★★★ | 4 | 0 |
| Whitehouse Country Manor | 4.7 mi | ★★★★★ | 0 | 0 |
| St Clare Commons | 4.9 mi | ★★★★★ | 14 | 0 |
| Lakes Of Monclova Health Campus The | 5 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.