Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aventura At Walton Hills during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including CKD, DM2, Parkinson’s disease, and dementia, exited through an emergency exit door, triggering an alarm and resulting in an unwitnessed fall outside. Staff responded, assessed the resident, and returned him to the unit, and a subsequent investigation confirmed he had been outside briefly and that door alarms functioned properly. However, the resident’s legal guardian reported being informed only of the fall and not that the resident had eloped, and the medical record lacked documentation that the guardian was notified of the elopement, despite facility policy requiring notification of the resident’s representative after accidents or significant incidents.
A resident with multiple chronic conditions, including dementia and Parkinson’s disease, was initially assessed as low risk for wandering but later scored as moderate and then high risk on wander-risk evaluations. Despite these increasing risk scores, the sections of the wander-risk tools designated for care plan interventions were left blank, and no elopement-risk care plan was initiated. The resident began self-propelling in a wheelchair and ultimately exited through an emergency exit door, triggering an alarm and sustaining an unwitnessed fall outside before being promptly found and assessed by staff. Interviews showed that an LPN completing the assessments had never filled out the intervention section, the MDS/RN relied on IDT judgment and did not care plan solely for wandering behavior, and leadership acknowledged that a care plan should have been implemented earlier in accordance with facility policy requiring care plan revisions when resident conditions change.
Failure to use standardized recipes and prepare palatable meals. Residents reported bland, tasteless food, and a cook prepared jerked chicken and rice and beans without the approved recipe and without all required ingredients. A test tray showed the rice and bean side dish was overcooked and bland, and the DM confirmed key ingredients had not been ordered and recipes were not available for staff use.
Kitchen food storage and sanitation were deficient: an open thickener container sat near a mixer with fruit flies, food and supplies were left uncovered or exposed to air, cleaning chemicals were stored next to food, and multiple surfaces had debris, splatter, grease buildup, and stained liners. The freezer door would not close fully because of ice buildup, several food items were undated, and the Dietary Mgr confirmed the findings.
Multiple residents and staff reported that rooms and common areas were not cleaned daily, with observations confirming dirt, grime, damaged furniture, and poor floor conditions throughout the facility. Staff interviews revealed that environmental concerns had been known for months but not addressed, and improper floor maintenance practices contributed to the buildup. Facility policies for cleaning and disinfection were not followed, resulting in unsanitary conditions affecting residents, including those with significant physical limitations.
Call Light Out of Reach for Dependent Resident: A resident with hemiplegia, MDD, and ESRD was observed in a wheelchair with a Hoyer pad beneath him, while his call light was tied to the bed rail and lying on the floor out of reach. The resident said he wanted help getting to bed but could not reach the call light, and a CNA confirmed it was out of reach. The facility policy required all residents to have a means to call staff for assistance through a direct communication system.
Delayed implementation of pharmacy recommendations and physician orders affected two residents. One resident with DM, epilepsy, schizophrenia, and other chronic conditions did not have a recommended valproic acid level obtained and remained on a lower Lantus dose than ordered. Another resident with stroke-related deficits, dysphagia, GERD, HTN, and hyperlipidemia had several PRN meds that were recommended for discontinuation but remained on the MAR, and gabapentin dose reduction and lab monitoring orders were not implemented in a timely manner.
Failure to Follow Hand Hygiene and Infection Control During Incontinence Care: A resident who was always incontinent of bowel and bladder received incontinence care from a HCNA and CNA who did not perform hand hygiene before or after direct resident contact or after assisting with transfers. During care, two feces-soiled briefs and used washcloths were placed on the floor, and the staff later confirmed they did not maintain infection control practices during the task.
A resident at risk for pressure ulcers developed an unstageable ulcer due to the facility's failure to implement and document appropriate interventions. Despite having a care plan, the facility did not consistently perform skin assessments or provide necessary treatments, leading to the deterioration of the resident's condition. Interviews with staff confirmed inaccuracies in weekly skin observations and a lack of investigation into the ulcer's progression.
An LPN failed to perform hand hygiene during medication administration for three residents, despite facility policies requiring handwashing before and after resident contact and glove use. The residents had various medical conditions, and the deficiency was identified during a complaint investigation.
A facility failed to individualize a care plan for a resident with complex medical needs, including paraplegia and a recent unstageable pressure ulcer. The care plan did not address the pressure ulcer acquired in-house, and this was confirmed by the Regional Director of Clinical Operations. The facility's policy requires comprehensive, person-centered care plans, which was not followed in this instance.
The facility failed to conduct weekly skin observations as ordered for two residents, leading to incomplete documentation and lack of interventions for pressure ulcers. One resident had a history of paraplegia and pressure ulcers, while another was at moderate risk for skin breakdown. The facility's policy required weekly skin audits, but these were not consistently performed, as confirmed by staff interviews.
A facility failed to ensure staff followed enhanced barrier precautions during catheter care for a resident with paraplegia and neuromuscular dysfunction of the bladder. An LPN provided care without wearing a gown, contrary to the facility's policy and the sign on the resident's door, which required gloves and a gown for such procedures.
The facility failed to treat residents with dignity, affecting three individuals. A resident with developmental disorder and another with dementia had their urinary drainage bags visible without privacy covers, contrary to physician orders. Additionally, a resident with stroke and dementia was treated rudely by a CNA who blocked his wheelchair and spoke in an intimidating manner.
A facility failed to include a resident and their POA in the development and implementation of the resident's care plan. Despite the resident having intact cognition and the POA's attempts to arrange a care planning conference, no such conference was scheduled or documented. The facility's policy required resident involvement in care planning, but this was not adhered to, and no explanation was documented.
The facility failed to address grievances in a timely manner, affecting two residents. One resident with a suprapubic catheter had concerns about leakage and lack of catheter flushes, which were not documented or addressed despite attempts by the resident's POA to contact the DON. Another resident reported being left in the bathroom for a long time, but the DON was unaware of the issue. The facility's grievance log showed no entries for two months, indicating a failure to document and address grievances as per policy.
A facility failed to timely report an allegation of staff-to-resident verbal abuse involving a resident with Alzheimer's. The incident was observed by a receptionist who reported it a day later to the Admissions Director. The Administrator and DON were informed two days after the incident, and the self-reported incident was initiated on the same day, contrary to the facility's policy requiring immediate reporting and investigation.
A resident with a chronic indwelling suprapubic catheter did not receive appropriate catheter care, as the facility failed to document necessary catheter flushes and did not secure the catheter tubing properly. The resident reported that the catheter was not flushed despite a physician's order, leading to sediment buildup and leakage. Observation revealed the catheter insertion site was uncovered and not properly anchored, with thick mucus-like drainage and sediment in the tubing.
A resident with intact cognition was exploited by a kitchen aide who engaged in an inappropriate relationship, exchanging flirtatious texts and nude pictures, and soliciting money for sexual activity. The incident was reported after the aide claimed the resident assaulted her, leading to an investigation that confirmed the exploitation. The aide was fired for violating the facility's abuse policy.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive ordered wound care for newly identified open areas on the buttocks. Despite hospice orders for specific wound care, the facility's records lacked evidence of completion on two occasions. The resident's condition was later identified as Kennedy ulcers, and interviews confirmed the deficiency in documentation and care.
A resident with epilepsy and cognitive impairments did not return from a leave of absence as expected, and the facility failed to ensure her safety. The resident left without taking necessary medications, and staff did not follow procedures to sign her out or verify her whereabouts. Despite attempts to locate her, the resident was not found until she was hospitalized two days later.
Failure to Notify Legal Guardian of Resident Elopement Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal guardian of an elopement incident as required by facility policy. The resident, admitted with diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, had a daughter listed as his legal guardian. A discharge, return-anticipated MDS assessment indicated his memory was intact, he did not wander, and he required partial to moderate assistance for ambulation using a wheelchair. On the date of the incident, a progress note by an RN documented that the resident pushed on an exit door, triggering the alarm, and was found on his right side on the ground with his wheelchair beside him after an unwitnessed fall. A head-to-toe and neurological assessment were completed, vital signs were obtained, and the resident was assisted back into his wheelchair and brought to the nursing station for closer monitoring. A facility investigation documented that the resident had exited through an emergency exit door off a hall under construction and not occupied, had been outside less than five minutes, and had last been seen at the nurses’ station five minutes prior. The investigation noted that the alarm and egress doors functioned properly and staff responded immediately, finding the resident on the ground outside. However, the resident’s medical record did not contain evidence that the legal guardian was notified of the elopement. During a telephone interview, the guardian stated she had only been notified of the fall and was not aware the resident had gotten outside until speaking with the surveyor. The DON reported that an incident report in risk documentation (not part of the medical record) showed the family had been notified of an incident and transfer to the hospital, but it was unclear whether this referred to the elopement or the fall. The facility’s policy required nursing staff to notify the resident’s representative when the resident was involved in any accident or incident resulting in injury or a significant change in condition, and this notification specific to the elopement was not documented.
Failure to Timely Care Plan for Resident Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, measurable care plan addressing elopement risk for a resident identified as being at risk for wandering and elopement. The resident was admitted with multiple diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, and had a legal guardian. An initial wander-risk evaluation in late 2025 identified the resident as low risk for wandering, and an annual MDS assessment documented that the resident was cognitively intact, did not wander, and required partial to moderate assistance with ambulation using a wheelchair. A subsequent wander-risk evaluation in early 2026, completed by an LPN, showed the resident had progressed to a moderate risk for wandering, but the section of the form asking what interventions would be care planned was left blank. A discharge, return-anticipated MDS again documented that the resident did not wander and required partial to moderate assistance with ambulation. A later wander-risk evaluation in mid-February 2026, completed by an MDS/RN, identified the resident as high risk for wandering, and again the section for care plan interventions was left blank. On the same date, a progress note documented that the resident pushed on an exit door, activated the door alarm, and was found on his right side outside the emergency exit door with his wheelchair beside him after an unwitnessed fall; he was assessed and brought back to the nursing station for closer monitoring. A facility investigation confirmed that the resident had exited through an emergency exit door on a hall under construction and had been outside for less than five minutes, with alarms and egress doors functioning and staff responding immediately. Interviews with the LPN and MDS/RN revealed that nurses completed wander-risk assessments and the MDS/RN handled care planning, that the LPN had never completed the care plan intervention section of the wander-risk tool, and that the MDS/RN did not initiate an elopement risk care plan when the resident’s risk level increased from low to moderate because the IDT believed the resident was not an elopement risk. The Administrator and DON confirmed that a care plan should have been initiated when the resident began self-propelling around the facility and that this was not done until after the elopement event, despite facility policy stating that assessments are ongoing and care plans are revised as resident conditions change.
Failure to Use Standardized Recipes and Prepare Palatable Meals
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature. The facility was cited after observation, record review, interview, and policy review showed staff prepared menu items without using the dietitian-approved standardized recipes and without having all required ingredients available. The deficiency affected 72 of 75 residents who ate meals in the facility; three residents were identified as receiving no food by mouth. Resident #38 had diagnoses including type II diabetes mellitus, chronic respiratory failure, hearing loss, above-the-right-knee amputation, major depression, diabetic peripheral angiopathy, anxiety, obesity, insomnia, obstructive sleep apnea, and COPD. The resident was ordered a consistent carbohydrate/liberal diabetic diet with regular consistency and thin liquids, and stated the food tasted bland, had no flavor, and repeated the same recipes over and over. Resident #60, who had vascular dementia, atherosclerosis of extremity arteries, high blood pressure, hypertensive heart failure, asthma, anxiety, cerebrovascular disease with left-sided hemiplegia and hemiparesis, GERD, high cholesterol, and severe obesity, was on a regular diet and stated the hamburgers were tasteless and the food was generally bland. Resident #65, with multiple sclerosis, paraplegia, morbid obesity, osteoporosis, vitamin D deficiency, constipation, depression, cataracts, cognitive communication deficit, GERD, and lymphedema, was also on a regular diet and stated the food was often very bland with tough dry meat. During observation, the dinner meal included jerked chicken and rice and beans, but the cook stated she did not have a recipe and prepared the items using her own method. The test tray showed the rice and bean side dish was overcooked and bland. The recipe review showed specific ingredients and directions for both the rice and beans and the jerked chicken, but the Dietary Manager stated the needed ingredients such as lime juice and green onions had not been ordered and the recipes were not available for cooks to use. The facility policy required standardized recipes to be readily available and followed during production.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food items were not stored in a safe and clean manner, and the kitchen work areas were not maintained free of debris and grease buildup. During observation of the kitchen, thickener used to puree foods was open and uncovered next to a mixer with fruit flies around the container. New coffee cups and Styrofoam food containers were stored in a cardboard box on a shelf under the coffee machine that had liquid damage and coffee splatter, and the shelf under the tray line had old, stained parchment paper beneath clean plates used for resident service. The walls by the blender had a large amount of puree splatter and food debris, the walk-in freezer had a large ice buildup at the entrance that prevented the door from closing all the way, and open shelving in the freezer had no liners. Several food items in the freezer were open, exposed to air, and undated, including a bag of hashbrowns, chicken tenders, and a box of pork patties. In the walk-in refrigerator, a grilled roast was stored on the bottom shelf on dirty parchment paper with old meat spillage. In dry storage, a box of fettuccini noodles was open to air and undated, and five bottles of Lime Away cleaner were stored next to dry cereal boxes. The stove and grill area had notable grease buildup throughout and in the hood, and a temperature regulator on the wall next to the grill was hanging off with batteries and the motherboard exposed. The flooring throughout the kitchen had staining, crumbs, and old debris. The Dietary Manager confirmed the findings and stated cleaning supplies should not be stored next to food items; the facility also identified residents who received no food by mouth, but the report did not describe any resident-specific food service issue.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for its residents, as evidenced by multiple observations, interviews, and record reviews. Several residents reported that their rooms and common areas were not cleaned daily, and that furniture was worn and damaged, with chipped wood and food debris present. Observations confirmed that hallways and resident rooms had a buildup of dirt, yellowed wax, stains, dried liquids, scuffed and dull floors, cracked or missing tiles, and holes in the walls. Specific rooms were noted to have significant grime, sticky and dirty floors, and furniture in poor condition. The main lobby and handrails were also found to be in disrepair, with chipped paint and worn surfaces. Interviews with facility staff, including the Regional Director of Operations, the Administrator, an LPN, and the Housekeeping Manager, confirmed that the facility had been aware of these environmental concerns for several months but had not addressed them in a timely manner. The Housekeeping Manager revealed that improper floor maintenance practices, such as applying multiple layers of wax without proper stripping, had led to significant dirt and grime buildup. Staff agreed that the facility was in need of deep cleaning, floor stripping, and repairs to maintain a sanitary environment. A review of facility policies indicated that floors and environmental surfaces were to be cleaned and disinfected regularly, with specific procedures for cleaning, disinfection, and maintenance. However, these policies were not followed, as evidenced by the observed conditions and staff admissions. One resident with significant physical limitations and dependence on staff for all activities of daily living was found to have dirt and debris on the floor of their room, further highlighting the facility's failure to provide a clean and safe environment for vulnerable individuals.
Call Light Out of Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure a dependent resident could reach his call light. Resident #37 was admitted with diagnoses including hemiplegia, major depressive disorder, and end stage renal disease. His MDS showed mild or no cognitive impairment and that he was dependent on staff for chair-to-bed transfers and wheelchair mobility. During observation, he was found in his room in a wheelchair in a reclined position with a Hoyer pad beneath him, while the call light was tied to his bed rail and lying on the floor about four feet away from his wheelchair. When interviewed, the resident stated he wanted assistance getting to bed but could not reach the call light. A CNA later confirmed that the call light was out of reach. The facility’s call system policy stated that all residents were to have a means to call staff for assistance through a direct communication system.
Delayed Implementation of Pharmacy Recommendations and Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were implemented in a timely manner for two residents reviewed for unnecessary medications. One resident had diagnoses including type II diabetes mellitus, neuropathy, chronic respiratory failure with hypoxia, above-the-knee amputation, major depressive disorder, diabetic angiopathy, anxiety, asthma, epilepsy, and schizophrenia. The pharmacist’s medication regimen review recommended a valproic acid level based on the resident’s medication list and an increase in Lantus to 30 units subcutaneously twice daily because blood sugars had routinely been greater than 250 mg/dl; the physician agreed with these recommendations, but the record showed no valproic acid level had been obtained and the Lantus dose remained at 25 units subcutaneously twice daily. The second resident had diagnoses including cerebral infarction with left-sided hemiparesis and hemiplegia, dysphagia, dysarthria, anxiety, insomnia, GERD, hyperlipidemia, hypertension, chronic pain, mild cognitive impairment, and depression. The pharmacist recommended discontinuing several PRN medications, including Colace, ibuprofen, Cepacol, Flonase, ipratropium-albuterol inhalation solution, and polyethylene glycol powder, because they had not been administered; the physician agreed, but the medications remained on the MAR and were not discontinued. Additional pharmacist reviews recommended reducing gabapentin for renal dosing and obtaining routine lipid panel and liver function testing; the physician agreed, but gabapentin remained at 1600 mg/day until a later order changed it, and the lipid panel and liver function test orders were not entered until later. The administrator verified that staff failed to ensure the pharmacy recommendations and physician orders were implemented in a timely manner.
Failure to Follow Hand Hygiene and Infection Control During Incontinence Care
Penalty
Summary
The facility failed to ensure staff followed infection control practices during incontinence care for a resident who was always incontinent of bowel and bladder and was not on a toileting program. The resident’s record showed diagnoses including breast cancer, lumbago with sciatica, depression, osteoarthritis of both knees, Alzheimer’s disease, cervical spondylosis with myelopathy, right knee contracture, spinal fusion of the lumbar region, atherosclerotic heart disease, high blood pressure, hearing loss, glaucoma with cataracts, and high cholesterol. The care plan directed staff to assist the resident with bowel and bladder incontinence care and to help her to the toilet as needed. During an observation, a HCNA and a CNA assisted the resident with incontinence care and transfer. The CNA did not perform hand hygiene before or after assisting the resident to the toilet or before exiting the room, and did not perform hand hygiene before or after assisting the resident back to her wheelchair. The resident was unable to stand and pivot to use the toilet, so both staff assisted her back to her wheelchair and then to bed for brief change. During the incontinence care, the HCNA removed two feces-soiled briefs and placed both directly on the floor. The HCNA then cleaned the resident’s perineal area with two washcloths and placed the soiled washcloths on the floor next to the bed. The HCNA and CNA later confirmed during interview that they did not maintain infection control practices during the task. The facility policy stated that hand hygiene is required before and after direct resident contact, after contact with bodily fluids, after handling used or contaminated items, and after removing gloves.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of an in-house pressure ulcer for Resident #58, who was at risk due to conditions such as type II diabetes mellitus, schizophrenia, and secondary Parkinsonism. Despite having a care plan in place since 2018 that included interventions like turning and repositioning, pressure-reducing mattresses, and skin assessments, there was no documented evidence that these interventions were consistently implemented. The resident's medical record showed a lack of timely identification and treatment of a pressure ulcer that developed on the left buttock, which eventually became unstageable. The facility's records revealed inconsistencies in weekly skin assessments, with several instances where no skin issues were documented despite the presence of a pressure ulcer. The Braden Scale, which assesses the risk of pressure ulcer development, was not completed until after the ulcer was identified. Furthermore, there was a lack of documentation regarding the administration of pain medication and the specific treatments applied to the wound, indicating a failure in comprehensive care and record-keeping. Interviews with facility staff, including the Regional Director of Clinical Operations and the Wound Nurse/Assistant Director of Nursing, confirmed that weekly skin observations were not completed accurately. The facility did not conduct an investigation to determine how the abrasion deteriorated into an unstageable pressure ulcer without staff knowledge. This deficiency represents a significant lapse in the facility's responsibility to provide necessary treatment and services to prevent and manage pressure ulcers, as outlined in their policies.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control measures during medication administration, specifically regarding hand hygiene. An LPN was observed preparing and administering medications to three residents without performing hand hygiene before or after the process. This included not washing hands before entering residents' rooms, after administering medications, and after removing gloves used for administering eye drops. The residents involved had various medical conditions, including hemiplegia, diabetes, vascular dementia, hypertensive heart disease, chronic kidney disease, Alzheimer's disease, and dementia. The facility's policies on infection prevention and control, hand hygiene, and medication administration clearly outlined the requirement for handwashing before and after resident contact and glove use. However, these protocols were not followed by the LPN, as confirmed by interviews with the LPN and the Regional Director of Clinical Operations. This deficiency was identified during a complaint investigation and was a repeat finding from a previous complaint survey.
Failure to Individualize Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that care plans were individualized for a resident, specifically Resident #33, who was affected by this deficiency. The resident had a medical history that included paraplegia, neuromuscular dysfunction of the bladder, neurogenic bowel, a history of COVID-19, a colostomy, and cannabis dependence. Despite these complex medical needs, the care plan for Resident #33, dated 10/23/24, did not include a plan for a recent unstageable pressure ulcer acquired in-house on 12/05/24. This omission was confirmed during an interview with the Regional Director of Clinical Operations, who acknowledged the absence of a care plan for the pressure ulcer and the lack of updated interventions. The facility's policy, revised in December 2016, requires comprehensive, person-centered care plans that include identified problem areas, measurable objectives, and timeframes, which were not adhered to in this case.
Failure to Conduct Weekly Skin Observations
Penalty
Summary
The facility failed to ensure that weekly skin observations were accurately completed as ordered for two residents, Resident #33 and Resident #72. Resident #33, who had a history of paraplegia and other medical conditions, had orders for wound care on a Stage 3 pressure ulcer on the right lateral ankle and a deep tissue injury on the right heel. However, the care plan did not include these pressure ulcers, and there were no interventions or revisions noted for them. Weekly skin observations were not consistently documented, with missing entries and lack of measurements for the pressure ulcers. Interviews with the Regional Director of Clinical Operations and the Wound Nurse confirmed these deficiencies. Resident #72, who had diagnoses including acute duodenal ulcer and morbid obesity, was at moderate risk for skin breakdown. Despite this, only one weekly skin assessment was completed during her stay, which did not identify any skin issues. The facility's policy required weekly skin audits for all residents, but this was not adhered to for Resident #72, as confirmed by interviews with facility staff. The lack of consistent weekly skin observations for both residents represents a failure to comply with the facility's policy and physician orders. The deficiency was identified during a survey, and it was noted that the facility's policy on Pressure Ulcer/Injury Care and Management, revised in August 2022, required weekly skin audits for all residents. The failure to conduct these audits as required led to the non-compliance finding, which was investigated under a specific complaint number. The report highlights the facility's inability to maintain accurate and timely documentation of skin observations, which is crucial for the management and treatment of pressure ulcers and other skin conditions.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to ensure that staff adhered to enhanced barrier precautions during catheter care for a resident. The resident, who was admitted with paraplegia and neuromuscular dysfunction of the bladder, had physician's orders for catheter care every shift and enhanced barrier precautions. During an observation of catheter care, an LPN provided care to the resident without donning a gown, despite a sign on the door indicating that gloves and a gown were required for such procedures. The facility's policy on enhanced barrier precautions, updated in March, specifies that personal protective equipment, including gloves and a gown, must be used when performing care such as hygiene, changing briefs, assisting with toileting, and urinary catheter care. The LPN acknowledged not wearing a gown as instructed by the sign, which was a requirement under the enhanced barrier precautions. This deficiency was identified during an investigation under Complaint Number OH00161853.
Failure to Ensure Dignified Treatment of Residents
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, affecting three residents. Resident #31, who had developmental disorder, bladder dysfunction, and Parkinson's, required maximum assistance with personal care and had a urinary catheter. Observations revealed that Resident #31's urinary drainage bag was visible from the doorway without a privacy cover, contrary to physician orders. CNA #317 confirmed the lack of privacy bags and was unaware of their availability in the facility. Similarly, Resident #68, diagnosed with dementia and requiring assistance with personal care, also had a urinary catheter. Observations showed that Resident #68's urinary drainage bag was visible without a privacy cover, and CNA #317 confirmed the absence of privacy bags. Additionally, Resident #70, who had a stroke, aphasia, and dementia, was observed being treated rudely by CNA #313, who blocked the resident's wheelchair and spoke in an intimidating manner. CNA #313 admitted to being instructed to prevent Resident #70 from entering his room but was unsure if the situation had been explained to the resident.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their responsible parties were included in the development and implementation of the plan of care, affecting one resident out of three reviewed for care planning. The resident in question, who had intact cognition, was admitted with diagnoses including paraplegia and bladder dysfunction. Despite multiple attempts by the resident's Power of Attorney (POA) to arrange a care planning conference, no such conference was scheduled or documented in the resident's medical records. Interviews with the Social Services Designee (SSD) revealed that care planning conferences were supposed to occur upon admission and quarterly thereafter, with documentation in the resident's electronic medical records. However, there was no documented evidence of a care planning conference for the resident, and the SSD could not recall specific details of any discussions with the POA. The facility's policy required that a comprehensive, person-centered care plan be developed with the involvement of the resident and their family or legal representative, and any impracticality in involving them should be documented, which was not done in this case.
Failure to Address Resident Grievances Timely
Penalty
Summary
The facility failed to address grievances in a timely manner, affecting two residents. Resident #11, who has paraplegia and bladder dysfunction, had a chronic indwelling suprapubic catheter upon admission. Despite physician orders to flush the catheter with normal saline as needed, there were no documented flushes in December 2024 and January 2025. Resident #11 expressed concerns about his catheter to the nursing staff, but was unaware of who the Director of Nursing (DON) was. His Power of Attorney (POA) attempted to contact the DON multiple times regarding the catheter leaking issue, but received no response. The DON and Administrator later acknowledged the concerns but had not addressed them promptly. Resident #67, who has a right below-knee amputation and vision loss, reported being left in the bathroom for an extended period. A Licensed Practical Nurse (LPN) informed the DON about the incident via text, but the DON claimed to be unaware of the issue. The facility's grievance log showed no entries for December 2024 or January 2025, indicating a failure to document and address grievances as per the facility's policy. The policy requires grievances to be logged and addressed within 72 hours, but this was not adhered to in these cases.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident verbal abuse to the State Agency as required. This incident involved a resident with Alzheimer's and impaired cognition, who required maximum assistance with daily tasks. The incident occurred when a receptionist observed a CNA yelling at the resident near the nurse's station. The receptionist, unsure of the proper procedure, reported the incident the following day to the Admissions Director. The Administrator and Director of Nursing were informed two days after the incident, and the self-reported incident was initiated on the same day, which was not in compliance with the facility's policy. The facility's policy mandates that any supervisor who receives information about potential abuse must notify the Administrator or Director of Nursing immediately and begin an investigation within 24 hours. However, in this case, the report to the State Agency was delayed, as the incident was not reported until two days after it occurred. This deficiency was identified during an investigation of a master complaint and another complaint, highlighting a lapse in the facility's adherence to its abuse reporting policy.
Inadequate Urinary Catheter Care for Resident
Penalty
Summary
The facility failed to ensure appropriate urinary catheter care for Resident #11, who had a chronic indwelling suprapubic catheter. The resident, diagnosed with paraplegia and bladder dysfunction, was dependent on staff for toileting and required maximum assistance with personal hygiene tasks. Despite having a physician's order to flush the urinary catheter with 60 mL of normal saline every 24 hours as needed for possible blockages, there was no documented evidence of catheter flushes in the Treatment Administration Record for December 2024 and January 2025. The resident reported that the evening shift nurse did not flush the catheter or perform any care of the catheter site, only emptying the urinary drainage bag. On observation, the resident's catheter insertion site was uncovered, with a soiled dressing hanging from the catheter tubing. Thick, white mucus-like drainage with a slight foul odor was noted around the insertion site, and large amounts of thick sediment were observed in the catheter tubing and collection bag. The catheter tubing was not properly anchored to the resident's leg, which was confirmed by LPN #237 during an interview. The LPN acknowledged the physician's order for catheter flushing and confirmed that the catheter should have been anchored to prevent movement. The facility's policy on urinary catheter care, revised in September 2014, emphasized the importance of securing the catheter to reduce friction and movement at the insertion site.
Exploitation of Resident by Employee
Penalty
Summary
The facility failed to prevent the exploitation of a resident by an employee, which was substantiated through a self-reported incident, police report, and interviews. The resident, who had intact cognition and was independent in certain activities, was involved in an inappropriate relationship with a kitchen aide. The resident had exchanged personal text messages with the aide, which included flirtatious content and requests for money via a cash app. The aide sent the resident nude pictures and suggested that for a sum of money, they could engage in sexual activity. The incident came to light when the kitchen aide reported that the resident had assaulted her with his wheelchair. Upon investigation, it was discovered that the resident had the aide's phone number and had received nude pictures from her. The resident admitted to giving the aide money and stated that they were planning to have sex after he moved to an assisted living facility. The facility's Director of Nursing (DON) was informed, and an investigation was initiated, which included contacting the police. The police report confirmed the resident's account of the events, including the exchange of money and the solicitation for sexual activity. The facility's policy on abuse, which prohibits taking advantage of residents for personal gain, was violated. The kitchen aide was subsequently fired, although she did not attend a scheduled meeting to discuss disciplinary action. The deficiency was investigated under a specific control number, indicating non-compliance with regulatory standards.
Failure to Complete Ordered Wound Care for Resident
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer wound care was completed as ordered, affecting one of the three residents reviewed for pressure ulcers. The resident, who was admitted with severe cognitive impairment and other medical conditions, was identified as high risk for developing pressure ulcers. Upon admission, the resident had bruising and later developed bilateral buttocks dermatitis. On a subsequent date, three open areas on the buttocks were observed by a nursing assistant and the resident's daughter, leading to new orders for wound care from hospice services. Despite these orders, the facility's records did not show evidence that the wound care was ordered or completed on two specific dates. The resident's condition was later documented as having Kennedy ulcers, with specific treatment instructions provided. Interviews with the DON and ADON confirmed the lack of documentation and completion of the ordered wound care. The facility's Wound Care Management policy was intended to ensure assessments and interventions for skin integrity, but this was not adhered to in this case.
Failure to Ensure Resident Safety During Leave of Absence
Penalty
Summary
The facility failed to ensure the safety of a resident who did not return from a leave of absence (LOA). The resident, who had a history of epilepsy, diabetes mellitus, and cognitive impairments, was allowed to leave the facility with the expectation of returning the same day. However, the resident did not return as planned, and there was no evidence that the resident had taken a supply of her medications during the LOA. The facility's policy required residents to be signed out when leaving the premises, but this procedure was not followed. The Director of Nursing (DON) and other staff members were aware of the resident's absence but did not take immediate action to locate the resident or ensure her safety. The DON was notified late in the evening when the resident did not return, but attempts to contact the resident's mother were unsuccessful. The following day, the DON and other staff members made efforts to locate the resident, including contacting the police for a welfare check. Despite these efforts, the resident was not found until she was transported to a hospital two days later, after being reported missing. Interviews with facility staff revealed a lack of communication and adherence to procedures regarding the resident's LOA. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) involved did not ensure the resident was signed out or verify her whereabouts. The facility's failure to follow its own policies and ensure the resident's safety during the LOA resulted in the resident being without necessary medications and medical supervision for an extended period.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Walton Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Health Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Grande Oaks | 1.3 mi | ★★★★★ | 44 | 0 |
| Northfield Village Retirement Community | 1.4 mi | ★★★★★ | 0 | 0 |
| Avenue At Macedonia | 3.4 mi | ★★★★★ | 0 | 0 |
| Brentwood Health Care Center | 3.9 mi | ★★★★★ | 0 | 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.