Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bath Creek Estates during CMS and state inspections, most recent first.
Surveyors observed two medication administration errors that caused the facility’s medication error rate to exceed 5%. In one case, an LPN administered insulin using a pen device to a resident with diabetes without priming the pen as required by the manufacturer’s instructions. In another case, an LPN measured a resident’s ordered 17 g dose of MiraLAX by filling the product cap only partway instead of to the top rim as specified on the container, then administered the inaccurately measured dose. These actions resulted in a calculated medication error rate of 7.14% during the survey.
A resident with severe cognitive impairment and dementia was physically abused by an LPN, who slapped the resident in response to being spat on. The incident was witnessed by multiple staff, and the resident immediately showed signs of distress. The facility's investigation confirmed the abuse based on staff statements and the resident's reaction.
The facility failed to ensure emergency call devices were within reach for five residents, leading to a deficiency. Residents with cognitive impairments and mobility dependencies were observed with call lights out of reach, despite being at risk for falls. The facility's policy required call lights to be within easy reach, but this was not adhered to, resulting in the deficiency.
The facility failed to ensure proper hand hygiene during medication administration and care for several residents, as LPNs did not sanitize or wash their hands before and after administering medications. Additionally, appropriate PPE was not worn during PEG tube care for a resident, despite the need for enhanced barrier precautions. The facility's policies on transmission-based precautions and hand hygiene were not adhered to, potentially affecting additional residents.
A resident with dementia and other health issues was not provided with adequate incontinence care, resulting in skin damage. The resident was left in a saturated brief for extended periods, leading to a partial thickness abrasion and moisture-associated skin damage. Facility staff failed to follow care protocols and did not report the skin issues as required.
The facility failed to implement ordered fall interventions for three residents, leading to deficiencies in accident prevention. A resident was found without necessary fall interventions like dycem and a floor mat, while another had a floor mat improperly stored. A third resident lacked a visual cue to call for assistance. The DON confirmed that verbal reports were the primary communication method for fall interventions, leading to inconsistencies.
The facility failed to provide sugar-free syrup to residents on a low concentrated sweets (LCS) diet, affecting three residents with diabetes and other health conditions. Despite dietary orders and tray tickets indicating the need for diet syrup, regular syrup was served. Staff interviews confirmed the error, highlighting a lapse in adherence to dietary protocols.
A resident with complex medical conditions had a critically high sodium level, but the LTC facility failed to provide timely treatment. Despite attempts to contact the nephrologist, no new orders were given, and the resident's sister requested a hospital transfer. The resident was admitted to the ICU for hypernatremia and dehydration.
A facility failed to assess a resident's pain upon admission, leading to an ineffective pain management plan. The resident, with a complex medical history, was admitted with a prescription for Oxycodone but did not receive a pain assessment until the following day. Interviews confirmed that pain assessments were required on admission, every shift, and as needed, but this protocol was not followed.
A resident with multiple diagnoses, including sepsis and diabetes, did not receive a scheduled dose of Cefazolin on the day of admission. The medication was available in the Omnicel, but the first dose was administered the following morning. Interviews confirmed the failure to adhere to the facility's medication administration policy.
Medication Administration Errors Result in Exceeding 5% Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 28 medication administration opportunities, resulting in a 7.14% error rate. For one resident with diabetes mellitus who was cognitively intact and received insulin injections daily, the physician’s order directed administration of insulin aspart 23 units SQ with meals. During observation of a medication pass, an LPN removed the insulin aspart pen from the cart, dialed the pen directly to 23 units, attached the needle, and administered the dose without priming the pen. The LPN confirmed she did not prime the pen and acknowledged that her usual practice would be to prime the pen, then dial the required dose, then place the needle on the pen. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection by selecting 2 units, holding the pen needle-up, tapping to move air bubbles, and pushing the dose knob until insulin is seen at the needle tip before dialing the prescribed dose. In a separate incident, another resident with Crohn’s disease, diverticulosis, constipation, severe cognitive impairment, and frequent bowel incontinence had a physician’s order for MiraLAX powder 17 g PO once daily. During an observed medication administration, an LPN measured the MiraLAX powder by filling the product cap only to just under the very bottom line inside the lid, then poured this amount into water for administration. When asked to read the product instructions, the LPN reviewed the MiraLAX container, which stated that the bottle cap is a measuring cup designed to contain 17 g when filled to the top rim. The LPN confirmed that the MiraLAX had not been measured according to the manufacturer’s instructions. These two observed medication administration errors formed the basis of the cited deficiency under the referenced complaint investigation.
Staff-to-Resident Abuse Incident Involving LPN
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and other medical conditions was subjected to staff-to-resident abuse. The resident, who required significant assistance with daily activities and had a history of rejecting care and exhibiting physical and verbal behaviors, was involved in an incident where an LPN slapped him in the face. This event was witnessed by multiple staff members, and the resident immediately reacted by holding his cheek and questioning why he was slapped. The incident was further corroborated by staff statements describing the LPN's aggressive response after the resident spat at him, including verbal threats and physical retaliation. The facility's records and staff interviews revealed that the LPN became confrontational after the resident spat at staff, making threatening remarks and ultimately striking the resident with an open hand, causing the resident's head to move and his face to turn red. Other staff present in the room attempted to comfort the resident following the incident. The LPN denied the action, but the investigation substantiated the abuse based on consistent staff accounts and the resident's immediate response. The facility's policy prohibits all forms of abuse, neglect, and mistreatment, and requires immediate reporting and investigation of such incidents. In this case, the abuse was reported to administration, and a full investigation was conducted, including interviews and assessments of other residents. The incident was also reported to the appropriate authorities as required by policy.
Emergency Call Devices Out of Reach for Residents
Penalty
Summary
The facility failed to ensure that emergency call devices were within reach for five residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #20, who was moderately impaired cognitively and dependent on staff for mobility, was observed with her call light out of reach on the bedside table. Despite being at moderate fall risk, the resident was unable to reach the call light, which was confirmed by the Assistant Director of Nursing. Resident #16, who was severely impaired cognitively and required assistance for most activities of daily living, was found with her call light on the floor under her bed. This resident was also at risk for falls, and the Environmental Services Manager confirmed the call light was not accessible. Similarly, Resident #12, who was cognitively intact but dependent on staff for mobility, had his call light on the floor, out of reach, which was confirmed by a Registered Nurse. Resident #64, who was moderately impaired cognitively and at moderate fall risk, was observed with her call light wrapped around the position bar, out of reach while she was in her wheelchair. Lastly, Resident #23, who was severely impaired cognitively and at high fall risk, had his call light on top of a mini refrigerator, inaccessible from his low bed. The facility's policy required call lights to be within easy reach, but this was not adhered to, resulting in the deficiency.
Inadequate Hand Hygiene and PPE Use During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration and care for several residents. Observations revealed that an LPN did not sanitize or wash her hands before and after administering medications to multiple residents. This included preparing medications at the medication cart, entering residents' rooms, and returning to the cart without performing hand hygiene. The LPN confirmed during an interview that she did not use hand sanitizer or wash her hands during these processes. Additionally, the facility did not ensure appropriate personal protective equipment (PPE) was worn during PEG tube care for a resident. The resident's care plan indicated the need for enhanced barrier precautions due to the use of a gastric tube. However, observations showed that the LPN did not don an isolation gown or perform hand hygiene before entering the resident's room to address issues with the tube feeding pump and administer medications via the PEG tube. The LPN confirmed the lack of PPE use during the care process. The facility's policies on transmission-based precautions and hand hygiene were not adhered to, as evidenced by the absence of an Enhanced Barrier Precaution sign and PPE near the resident's room. The Director of Nursing confirmed these deficiencies and acknowledged the lack of compliance with the facility's infection control policies. The failure to follow these protocols had the potential to affect additional residents in the facility.
Inadequate Incontinence Care Leads to Skin Damage
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, leading to skin integrity issues. The resident, who had diagnoses including heart failure, Parkinson's Disease, and dementia, was supposed to be checked and changed every two hours as per physician orders. However, observations revealed that the resident was left in a heavily saturated incontinence brief for over four and a half hours, resulting in a partial thickness abrasion on the left buttock and reddened skin. Further observations on subsequent days showed that the resident continued to sit in a padded wheelchair for extended periods without being checked or changed, leading to additional skin damage. The resident's incontinence brief was found heavily soaked with urine, and the skin on the buttocks and thighs showed signs of moisture-associated skin damage (MASD). The facility's policy required immediate reporting and documentation of such skin issues, but this was not done by the CNAs who identified the problem. Interviews with staff revealed a lack of communication and adherence to care protocols. CNAs did not report the skin issues to the nursing staff, and the resident was not changed as frequently as required. The facility's policies on wound documentation and incontinent resident care were not followed, contributing to the deficiency identified during the survey.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure that fall interventions were in place as ordered for three residents, leading to deficiencies in accident prevention. Resident #23, who was severely impaired cognitively and at high risk for falls, was found without necessary fall interventions such as dycem on the recliner and wheelchair, and a floor mat that was improperly stored. Observations revealed that the resident's call light was not within reach, and staff were not fully aware of the required interventions due to inadequate communication. Resident #72, also severely impaired cognitively and at high risk for falls, was found with a floor mat folded and not in place as required. Despite having a history of falls and specific interventions ordered, the mat was not utilized correctly, and the staff, including the DON, confirmed the oversight. The facility's policy required that preventative measures be implemented for residents identified at risk, but these measures were not consistently applied. Resident #25, who had a history of falls and required substantial assistance, was observed without a posted sign to remind the resident to call for assistance, as ordered. The resident had experienced falls due to attempting to transfer independently, and the lack of visual cues contributed to the risk. The DON acknowledged that verbal reports were the primary method for communicating fall interventions, which led to inconsistencies in the application of necessary safety measures.
Failure to Provide Sugar-Free Syrup to Residents on LCS Diet
Penalty
Summary
The facility failed to provide sugar-free pancake syrup to residents on a low concentrated sweets (LCS) diet, as per their dietary orders. This deficiency affected three residents who were observed to have received regular syrup instead of the prescribed diet syrup. The residents involved had pertinent diagnoses such as type two diabetes mellitus, chronic kidney disease, and cognitive impairments, which necessitated adherence to their therapeutic diet orders. Resident #74, who was cognitively intact and required setup for eating, was observed to have an empty container of regular syrup on their breakfast tray, despite the tray ticket indicating a requirement for diet syrup. Similarly, Resident #25, who was severely cognitively impaired but independent in eating, was also found to have consumed regular syrup instead of diet syrup. Resident #26, with a history of diabetes and chronic kidney disease, was observed with regular syrup on their tray, contrary to their LCS diet order. Interviews with staff, including the Regional Director of Dietary Services and CNAs, confirmed that regular syrup was mistakenly provided on LCS diet trays. The facility's dietary staff had been educated on providing meal items per tray ticket, yet the issue persisted. The facility's policy required the use of a tray card identification system to ensure residents received their diets as ordered, but this system failed to prevent the error, leading to non-compliance with dietary orders.
Failure to Address Critically High Sodium Level
Penalty
Summary
The facility failed to provide timely and necessary treatment for a resident following laboratory testing that revealed a critically high sodium level. The resident, who had a complex medical history including end-stage renal disease, dementia, and severe protein-calorie malnutrition, was at increased risk for nutritional issues and dehydration. Despite these risks, the facility did not adequately monitor or address the resident's condition after receiving the lab results. On the day the lab results were received, the resident's sodium level was critically high, but no new orders were given by the on-call nurse practitioner. The facility staff attempted to contact the resident's nephrologist but were unsuccessful in reaching them by phone and only faxed the lab results. The resident's sister was informed of the situation and ultimately requested the resident be transferred to the hospital due to concerns about the high sodium level and poor oral intake. The resident was eventually admitted to the ICU for hypernatremia and was found to be profoundly dehydrated. The facility's policy required staff to recognize and intervene in the event of a significant change in a resident's condition, but this was not adequately done in this case. The lack of timely intervention and communication with the nephrologist contributed to the resident's hospitalization.
Failure to Assess Pain on Admission
Penalty
Summary
The facility failed to properly assess a resident's pain upon admission, which led to an ineffective pain management plan. The resident, who had a complex medical history including sepsis, lumbar epidural abscess, and type 2 diabetes mellitus, was admitted with a prescription for Oxycodone 5 mg to be taken as needed for pain. However, there was no documentation of a pain assessment on the evening of admission, despite the resident reporting a pain level of 9 out of 10. The first pain assessment was documented the following day, indicating a lapse in the facility's protocol for pain management. Interviews with nursing staff and the Director of Nursing confirmed that pain assessments were required to be completed on admission, every shift, and as needed, but this was not done for the resident on the day of admission. The facility's policy on pain management, which mandates an assessment to ensure residents reach their highest practicable level of well-being, was not followed. This deficiency was identified during a complaint investigation and affected the resident's pain management plan.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication to Resident #89 as per physician orders, resulting in a deficiency. Resident #89, who was admitted with multiple diagnoses including sepsis, lumbar epidural abscess, and type 2 diabetes mellitus, was prescribed Cefazolin to be administered intravenously three times a day. However, upon review, it was found that the resident did not receive the 8:00 P.M. dose of Cefazolin on the day of admission, as the first dose was administered the following morning at 8:00 A.M. Interviews with nursing staff and the Director of Nursing confirmed that the medication was available in the Omnicel and should have been administered as ordered. The Director of Nursing also verified that the medication was last given at 1:31 P.M. prior to admission and acknowledged the failure to administer the medication on time. The facility's policy on medication administration times was not adhered to, as medications should be administered within a 60-minute window before or after the scheduled time. This deficiency was investigated under a specific complaint number.
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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 Cuyahoga Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Healthcare Of Cuyahoga Falls | 0.8 mi | — | 75 | 0 |
| Altercare Of Cuyahoga Falls Ctr For Rehab & Nursin | 2.1 mi | ★★★★★ | 0 | 0 |
| Wayside Farm Inc | 2.6 mi | ★★★★★ | 1 | 0 |
| Falls Village Skilled Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| The Pavilion At Stow For Nursing And Rehabilitatio | 3.4 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.