Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bath Manor Special Care Centre during CMS and state inspections, most recent first.
A resident with self-care deficits, muscle weakness, and morbid obesity, who required two-person assistance and requested only female staff for personal care, was found heavily soiled with stale-smelling urine that had soaked through two incontinence briefs and bed linens, requiring a full bed change. The resident reported not being changed since the prior evening, and a CNA confirmed the resident had been heavily soiled at the start of the morning shift and that at times no female CNAs were available to provide incontinence care, resulting in a failure to deliver timely incontinence care.
An LPN failed to use a barrier or disinfect a shared glucometer during blood glucose monitoring for a resident with diabetes and impaired cognition. The glucometer was placed on a dirty over-bed tray and not cleaned after use, contrary to facility policy and manufacturer instructions. This practice affected one resident and had the potential to impact several others requiring blood glucose checks.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with undated and unlabeled food items, expired milk, dirty surfaces, food and utensils on the floor, and improper storage practices such as boxes stacked to the ceiling and open food containers. The Food and Nutrition Services Director confirmed these issues, which affected all residents receiving meals, including several who were NPO.
Two rehab staff assisted a resident with complex medical needs and a stage 4 pressure ulcer without donning required PPE, despite posted instructions and a physician's order for Enhanced Barrier Precautions. Both staff acknowledged not following EBP protocol during high-contact care activities.
Surveyors found that the clean linen room and a common shower room were not maintained in a clean and sanitary manner, with floors covered in debris and a non-functional bathtub used for storage of soiled items, affecting multiple residents. Staff interviews revealed confusion about cleaning responsibilities and a lack of specific policies for maintaining these areas.
Quarterly statements for resident fund accounts were not mailed to the designated guardians or primary financial contacts, but instead were sent to the residents at the facility address. This failure was confirmed by interviews with financial contacts and the Business Office Manager, and was not in accordance with signed agreements or facility policy.
The facility did not notify a resident when their personal funds neared the SSI resource limit and failed to timely disperse another resident's funds after death. One resident was not informed about their account balance, and another's funds were not released to the funeral home for over three months, contrary to facility policy.
A resident with multiple medical conditions was found to have alcoholic beverages stored in his room without a physician order or a care plan addressing alcohol consumption. Facility staff confirmed the absence of required documentation and the presence of alcohol, which was against facility policy that mandates provider orders and nurse administration for alcohol use.
A resident receiving oxygen therapy did not have a current physician order or care plan intervention in place, and the oxygen tubing and nasal cannula had not been changed or dated as required. Staff were unable to confirm when the equipment was last changed, and documentation of cleaning and tubing changes was delayed, contrary to facility policy.
A resident with multiple chronic conditions was found self-administering prescribed clotrimazole cream for tinea corporis without an assessment or physician order authorizing self-administration. The medication was left unsecured on the bedside table, and an LPN confirmed that facility policy requiring assessment and orders for self-administration had not been followed.
A resident with multiple medical conditions, who was alert and oriented, was observed being fed breakfast by an RN who stood over the resident instead of sitting as required by facility policy. The RN acknowledged that the resident usually received meal assistance with staff sitting, cueing, and encouraging her, but in this instance, the meal was provided while the RN stood, resulting in a lack of dignified dining experience.
A resident with severe cognitive impairment became unresponsive and was administered Narcan by EMS, but the facility failed to notify the legal guardian until the next morning. The LPN contacted TeleMed, and EMS administered Narcan, reviving the resident. Despite the serious incident, the guardian was not informed promptly, contrary to facility policy.
Two residents in the facility did not receive adequate morning care, as required by their care plans. One resident with multiple sclerosis and cerebral palsy was not provided with face washing or oral care, leaving food particles in their mouth. Another resident with COPD and cancer was not assisted with oral care or hair grooming. The CNA confirmed the lack of care, and the DON stated that comprehensive morning care is expected.
A resident with a history of Alzheimer's and schizophrenia experienced a significant change in condition, including altered mental status and unconsciousness. Despite being difficult to arouse, routine medications were administered without notifying the physician. The physician later requested hospital transport, but the resident was instead given Narcan for a potential overdose and remained at the facility. No labs were obtained, and the pharmacy was not consulted to review medications. The facility failed to communicate timely with the resident's guardian and the DON.
A resident with Alzheimer's and schizophrenia was found unresponsive and administered Narcan, indicating a possible overdose. Despite recent medication changes, the facility failed to consult pharmacy services or conduct a timely drug screen. The resident's medications were improperly administered, and the facility did not involve the pharmacist to assess the situation.
The facility failed to assess blood sugars before meals for two residents, leading to incorrect insulin dosing. Additionally, a resident's medication was improperly crushed, contrary to guidelines. These errors were identified during a complaint investigation, affecting three residents reviewed for medication administration.
The facility failed to maintain infection control practices during blood glucose assessments for two residents. An LPN and an RN used a shared glucometer without proper cleaning, contrary to facility policy and manufacturer instructions. The glucometer was not stored properly, and cleaning was insufficient, posing a risk of cross-contamination.
A resident with cerebral palsy and cognitive deficits died after an LPN administered another resident's medications, including Methadone and likely Hydromorphone, without reporting the error. The resident was found unresponsive and later pronounced deceased. The LPN initially confessed to the error but later denied it during the facility's investigation.
A facility failed to coordinate dialysis catheter care for a resident with chronic kidney disease, leading to an infection. The resident's son found a soiled dressing over the catheter, dated several days prior. Staff interviews revealed confusion about dressing change protocols, and records showed no recent dressing changes. The resident later died from complications related to the infected catheter.
A facility failed to notify the legal guardian of a resident's death, despite the guardian being responsible for medical and financial decisions. The resident, who had severe medical conditions and was under hospice care, passed away, and the facility only informed the spouse, who was estranged. The legal guardian was not informed until the next day, preventing the resident's daughter from visiting before the body was released.
A resident with a PEG tube for enteral feeding was transferred to the hospital after the facility failed to address repeated concerns about black discoloration and leaking from the tube. Despite reports from STNAs, the facility did not document or act on these issues, resulting in the discovery of maggots in the tube. The resident had a history of multiple health conditions and was dependent on staff for daily living activities.
A resident at an LTC facility, with a history of falls and various medical conditions, fell and sustained a femur fracture due to the facility's failure to conduct a comprehensive fall risk assessment and implement individualized interventions. The incident was not thoroughly assessed, and conflicting accounts of the fall's occurrence were reported. The facility's fall prevention policy was not adequately followed, and the investigation did not determine the cause of the fracture.
A facility failed to thoroughly investigate an allegation of verbal abuse towards a resident during a shower. A family member reported overhearing a staff member speaking meanly to the resident, but the facility's investigation was incomplete, lacking comprehensive witness statements and specific questions about abuse. The resident later expressed feeling uncomfortable and described the staff member as verbally abusive, yet the facility concluded the allegation was unsubstantiated.
A resident left an LTC facility AMA due to dissatisfaction with her meal, leading to inadequate communication and documentation regarding her discharge. Despite being cognitively intact, the resident was found disoriented and cold outside the facility. Staff interviews revealed inconsistencies in notifying the physician and documenting the incident, highlighting a failure to follow the facility's AMA discharge policy.
The facility failed to timely ensure a comprehensive treatment plan for a resident's chest tube, resulting in delayed orders for draining, monitoring, and dressing changes. The resident had multiple diagnoses, including heart failure and end-stage renal disease, and was admitted with a chest tube without specific care orders.
A resident with altered mental status and dementia was found with a saturated incontinence brief and significant skin redness and irritation due to a lack of timely incontinence care. Staff failed to communicate the resident's condition, leading to delayed care and discomfort.
Failure to Provide Timely Incontinence Care Due to Staffing and Gender Preference Constraints
Penalty
Summary
The facility failed to provide adequate and timely incontinence care to a resident who was continent/incontinent of bladder. The resident, admitted with diagnoses including muscle weakness, need for personal care assistance, and morbid obesity, had a care plan indicating self-care deficits and requiring assistance from two staff members for toileting and personal hygiene, with an intervention specifying that only female staff provide personal care per the resident’s request. During an observation of incontinence care at 7:52 A.M., the resident was found incontinent of a large amount of stale-smelling urine that had soaked through two incontinence briefs and linens, necessitating a full bed change. The resident reported not having been changed since approximately 6:00 P.M. the previous evening, and the CNA providing care confirmed that the resident was heavily soiled at the start of her 6:00 A.M. shift and that there had been times when no female CNAs were available to change the resident, resulting in a lack of timely incontinence care. This deficiency was cited for failure to ensure adequate and timely incontinence care for one resident out of three observed for incontinence care, as identified through observation, interview, and record review under a complaint investigation.
Failure to Follow Infection Control Protocols During Blood Glucose Monitoring
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during blood glucose monitoring for a resident with type 2 diabetes mellitus, impaired cognition, and other diagnoses. The LPN placed a shared glucometer directly onto a visibly dirty over-bed tray without using a barrier or disinfecting the surface. The tray contained personal items such as an open bottle of pop, an opened bag of chips, and a tissue. After use, the LPN did not clean the glucometer before returning it to the medication cart, despite it being used for multiple residents requiring blood glucose monitoring. During interviews, the LPN admitted to not using a barrier or disinfecting the glucometer, stating she was unaware of the requirement and was in a hurry. The Director of Nursing confirmed that facility policy requires a barrier to be used and the glucometer to be cleaned before and after each use. Review of facility policy and the glucometer user manual also confirmed these procedures are necessary to prevent the transmission of blood-borne pathogens. The failure to follow these infection control practices was observed to affect one resident and had the potential to affect several others who also required blood glucose monitoring.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
Surveyors observed multiple sanitation and storage deficiencies in the facility's kitchen during an inspection. In the reach-in refrigerator near the steam table, there were two salads and approximately ten bagged sandwiches that were undated and unlabeled. Dried food splatter was found on the preparation table for the food processor, and a container of applesauce with a spoon was located on the floor under the table. The kitchen hood's metal grates and fire suppression system had a coating of built-up dust, and the microwave had dried food splatter on its top panel. A whisk was found on the floor under the steamer. Inside the walk-in refrigerator, a container of milk was found with an expiration date that had already passed, and the floor under the storage racks was dirty with debris and dried milk. Boxes were stacked to the ceiling in both the walk-in refrigerator and freezer, and there was ice buildup on boxes and the ceiling in the freezer. In the dry storage room, a box of powdered thickener was open to air with a measuring cup resting on the product. The Food and Nutrition Services Director confirmed these findings during the kitchen tour. Facility policies required that all refrigerated items be stored at least six inches above the floor and 18 inches from the ceiling and sprinkler heads, and that kitchen sanitation be maintained through compliance with a comprehensive cleaning schedule. The facility census was 112, and six residents were identified as receiving nothing by mouth (NPO) at the time of the survey.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for a resident with multiple complex medical conditions, including Parkinsonism, pulmonary hypertension, protein-calorie malnutrition, acute respiratory failure, rheumatic mitral valve disease, a stage 4 pressure ulcer, a history of prostate cancer, dysphagia, and muscle weakness. The resident had a physician's order for EBP due to these risk factors. A sign was posted outside the resident's room instructing staff to wear gloves and gowns for high-contact care activities, such as dressing, bathing, transferring, changing linens, providing hygiene, toileting assistance, device care, and wound care. Despite these instructions, two rehabilitation staff members entered the resident's room to assist with repositioning without donning the required personal protective equipment (PPE). Both staff members acknowledged during interview that they did not follow the EBP protocol and should have worn PPE before providing care. Review of the facility's policy confirmed that EBP is indicated for residents with chronic wounds and other risk factors, in accordance with CDC guidelines.
Failure to Maintain Cleanliness in Linen and Shower Rooms
Penalty
Summary
The facility failed to maintain the clean linen room and common shower room in a clean and sanitary condition, affecting 25 residents on the 300 hall. During an environmental tour, surveyors observed the floor of the clean linen room covered with old, dried spills, scuff marks, paper scraps, straw covers, large dust bunnies, and food debris. In the 300 hall shower room, a non-functional bathtub was being used as a storage area and contained a variety of items including a tee shirt, a cigarette butt, a pillow without a case, plastic parts of a bedside commode, a wet fitted sheet with a large reddish-brown stain emitting a strong urine odor, a multicolored sweater, wet wash cloths, and bottles of body and peri wash. Loose black debris and dried, unidentifiable liquid spills were also present beneath these items. The shower room floor was not wet, and there was no humidity to indicate recent use. Interviews with staff revealed confusion regarding cleaning responsibilities. A CNA admitted to placing soiled items in the bathtub after showering a resident and leaving them there while going on break, intending to return later. Housekeeping staff reported cleaning the shower room daily, sometimes twice, but were unsure who was responsible for maintaining the non-functional bathtub. The regional RN confirmed there was no specific policy or job description for keeping the shower rooms clean and sanitary. All residents on the 300 unit used the shower room, and the census confirmed the affected residents resided on this hall.
Failure to Mail Resident Fund Statements to Designated Financial Contacts
Penalty
Summary
The facility failed to ensure that quarterly statements for resident funds accounts were mailed to the individuals identified as the guardian or primary financial contact for several residents. Specifically, for three residents reviewed, the statements were instead addressed and sent to the residents at the facility's address, rather than to their designated financial contacts as required by the signed Resident Fund Management Service Authorization Agreements. These agreements, signed by the responsible parties, clearly indicated that the person signing would receive quarterly statements. Interviews with the residents' financial contacts confirmed that they had not received the required statements and were unaware of the account balances. The Business Office Manager confirmed that a third-party service was used to mail out the statements, and that the statements were sent to the address listed at the top of the statement, which was the facility address for all affected residents. Review of facility policy indicated that statement addresses were to be correct, but this was not followed. The deficiency affected three out of six residents reviewed for resident funds, with the facility identifying a total of 50 residents with personal funds accounts.
Failure to Notify and Timely Disperse Resident Funds
Penalty
Summary
The facility failed to notify a resident when their personal funds account approached the Supplemental Security Income (SSI) resource limit and did not timely disperse another resident's funds after their death. For one resident, who was cognitively intact and the primary financial contact, record review showed that their account balance exceeded the notification threshold, but there was no documented evidence that a spend down notification was provided. The resident was unaware of the account or its balance, and the Business Office Manager confirmed that no notification had been sent, citing workload issues as the reason. In a separate case, another resident's account was not closed and funds were not dispersed in a timely manner following their death. Documentation showed that a check for the remaining account balance was issued to the funeral home more than three months after the resident's passing. Both deficiencies were confirmed through interviews and review of facility policy, which required timely notification and disbursement of resident funds.
Failure to Develop Care Plan for Alcohol Use
Penalty
Summary
A deficiency occurred when the facility failed to develop a person-centered care plan addressing alcohol consumption for a resident. The resident, who was alert and oriented with a BIMS score of 14, had diagnoses including chronic diastolic congestive heart failure, cellulitis of the left lower limb, and acute kidney failure. Despite requiring some assistance with ADLs, there were no physician orders or care plan interventions related to alcohol use documented in the resident's medical record. Observations revealed that the resident had two bottles of alcoholic beverages stored in his compact refrigerator, which were purchased by a friend for his consumption. The facility's policy required that alcoholic beverages be prescribed by a provider, obtained by family, and administered only by a licensed nurse, with residents not permitted to keep alcohol in their rooms. The Administrator and Regional Registered Nurse confirmed the presence and removal of the alcohol, and acknowledged the absence of appropriate orders or a care plan for alcohol use.
Failure to Ensure Proper Orders and Equipment Changes for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a history of peripheral vascular disease, type 2 diabetes, and congestive heart failure was observed receiving oxygen therapy without a corresponding physician order or care plan intervention. The resident, who was alert and oriented, reported that the oxygen tubing and nasal cannula had not been changed. Observation confirmed the tubing and cannula were undated, and staff were unable to verify when they were last changed. Review of the resident's medical record and care plan revealed no current orders or interventions for oxygen administration, despite documentation that oxygen was established in the home. Further review of facility records showed that the first documentation of cleaning the oxygen concentrator and changing the tubing occurred several days after the resident's admission. Facility policy required verification of provider orders prior to oxygen administration and mandated weekly changes and documentation of tubing, mask, and cannula. Staff interviews confirmed a lack of knowledge regarding the last change of equipment and the absence of a current order for oxygen, indicating noncompliance with facility policy and standard respiratory care procedures.
Failure to Secure Medications and Assess Resident for Self-Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly secured and that only authorized personnel had access to them. A resident with diagnoses including peripheral vascular disease, type 2 diabetes, and congestive heart failure was observed with two tubes of clotrimazole one percent cream on his bedside table, which he self-applied for tinea corporis on his forearms. There was no assessment in the resident's medical record indicating that he was safe to self-administer medication, nor was there an order permitting self-administration of the antifungal cream. Staff interviews confirmed that the resident did not have authorization or an assessment for self-administration, and the prescribed medication was accessible at the bedside. Facility policy required an interdisciplinary assessment and a specific order for self-administration, which were not present in this case. The LPN removed the medication from the resident's room after observing the resident applying the cream himself.
Failure to Provide Dignified Dining Experience
Penalty
Summary
A deficiency was identified when a resident with diagnoses including congestive heart failure, mild protein-calorie malnutrition, and dysphagia was not provided with a dignified dining experience. The resident, who was alert and oriented according to her most recent assessment, was observed lying in bed with her breakfast meal placed on an over-the-bed table. A registered nurse was seen standing over the resident and feeding her while standing, rather than sitting as required by facility policy. The nurse stated she noticed the resident needed to eat and that the resident typically had someone sitting, cueing, and encouraging her during meals. The nurse confirmed she was standing while feeding the resident, which was not in accordance with the facility's policy for meal assistance.
Failure to Notify Guardian of Significant Change in Condition
Penalty
Summary
The facility failed to timely notify the legal guardian of a significant change in condition for a resident diagnosed with Alzheimer's disease, schizophrenia, and other disorders. The resident, who was severely cognitively impaired and dependent on staff for mobility, became unresponsive during a medication pass. The LPN on duty contacted TeleMed, and the resident was administered Narcan by EMS, which temporarily revived him. Despite the serious nature of the incident, the guardian was not informed until the following morning. The LPN documented that the resident appeared asleep and unresponsive during the medication pass, prompting her to contact TeleMed, who advised sending the resident to the hospital. EMS arrived and administered Narcan, which revived the resident. However, the EMS report indicated that the staff refused transport to the hospital, opting instead to monitor the resident. The refusal form was signed with the resident's signature, despite the resident having a legal guardian. The guardian expressed upset upon learning of the incident the next morning, stating she would have preferred the resident be sent to the hospital for further evaluation. The facility's policy requires notifying the provider, family, or responsible party as soon as practicably possible, which was not adhered to in this case. The Director of Nursing acknowledged that the guardian should have been notified immediately.
Deficiency in Morning Care for Residents
Penalty
Summary
The facility failed to provide adequate morning care to two residents, resulting in a deficiency in the provision of activities of daily living (ADL). Resident #76, who has diagnoses including spastic hemiplegic cerebral palsy, multiple sclerosis, and muscle weakness, was observed not receiving proper A.M. care. Despite requiring substantial assistance with oral hygiene, bathing, and personal hygiene, the Certified Nursing Assistant (CNA) did not wash or offer to wash the resident's face or hands, nor did they provide oral care. The resident was left with visible food particles in their mouth and an oily face, confirming the lack of care provided. Similarly, Resident #106, who has chronic obstructive pulmonary disease (COPD), muscle weakness, and cancer, was also not provided with adequate morning care. The resident, who requires partial assistance with oral hygiene and is dependent on staff for personal hygiene, was found with disheveled hair and confirmed that oral care was not provided. The CNA admitted to not brushing the resident's hair or offering oral care. The Director of Nursing confirmed that CNAs are expected to perform comprehensive morning care, including washing the face, cleaning the body, and providing oral care, as per the facility's policy.
Failure to Provide Appropriate Care for Resident with Altered Mental Status
Penalty
Summary
The facility failed to provide appropriate care and services to a resident who experienced a significant change in condition, including altered mental status and periods of unconsciousness. Despite the resident being difficult to arouse, routine medications, including psychotropic medications, were administered without notifying the physician of the change in condition. When the physician was eventually contacted, they requested the resident be transported to the emergency room, but this directive was not followed. Instead, the resident was administered Narcan for a potential drug overdose and remained at the facility without further investigation into the cause of the condition. The resident, who had a history of Alzheimer's disease, schizophrenia, and mood disorder, among other diagnoses, was severely cognitively impaired and dependent on staff for most activities of daily living. The resident's medication regimen had been adjusted in the weeks leading up to the incident, with increases in Risperidone and Ativan. On the evening of the incident, the resident was found unresponsive, and despite the physician's order to send the resident to the hospital, the facility staff administered Narcan, which temporarily revived the resident. However, no labs were obtained to determine the cause of the potential overdose, and the pharmacy was not consulted to review the medications. The facility's handling of the situation was further complicated by the lack of timely communication and documentation. The resident's guardian and the Director of Nursing were not notified until the following morning, and there was confusion among the staff regarding the administration of medications and the decision not to transport the resident to the hospital. The facility also failed to conduct a timely drug screen to determine if an overdose had occurred, and the pharmacy consultant was not asked to review the medications in light of the resident's change in condition.
Failure to Involve Pharmacy Services in Overdose Incident
Penalty
Summary
The facility failed to involve pharmacy services in a potential overdose incident involving Resident #18, who was administered Narcan. Resident #18, diagnosed with Alzheimer's disease, schizophrenia, and other disorders, was found unresponsive on the evening of 12/26/24. Despite being administered Narcan by EMS, which revived the resident, the facility did not consult with pharmacy services to review the medications for a possible overdose. The facility also did not conduct a timely drug screen to determine if an overdose had occurred. Resident #18 had recent medication changes, including increased doses of Risperidone and Ativan, which were not reviewed by the facility's pharmacist in relation to the unresponsive episode. The resident's medications were crushed and administered in a manner not consistent with the medication guidelines, specifically the Divalproex DR capsules, which should not be crushed. Despite these changes and the administration of Narcan, the facility did not seek the pharmacist's input to assess the situation. Interviews with facility staff, including the DON and the facility pharmacist, confirmed that the pharmacy was not consulted following the incident. The pharmacist indicated that the Narcan administration suggested an overdose, yet no review of the medications was requested by the facility. The lack of timely drug screening and pharmacy consultation contributed to the deficiency identified during the complaint investigation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that blood sugars were assessed prior to meals for two residents, which is crucial for determining the correct dosage of sliding scale insulin. Resident #82, who has type two diabetes mellitus, had his blood sugar checked after consuming breakfast, resulting in the administration of insulin based on a postprandial blood sugar level. The Licensed Practical Nurse (LPN) acknowledged the error, citing time constraints as the reason for the oversight. Similarly, Resident #112, who also has diabetes, had her blood sugar checked after eating breakfast, leading to the administration of insulin based on an elevated blood sugar level. The Registered Nurse (RN) admitted to checking the blood sugar late due to being behind schedule. Additionally, the facility failed to administer medication correctly to Resident #18, who has Alzheimer's disease and other mental health diagnoses. The resident's medication, Divalproex delayed-release capsules, was crushed and mixed with other medications, contrary to the guidelines that specify the capsules should be opened and sprinkled on food without crushing. The LPN responsible for administering the medication confirmed the error, and the facility's pharmacist consultant verified that there were no orders to crush the medication, which could affect its intended absorption and efficacy. These deficiencies were identified during a complaint investigation and affected three residents out of four reviewed for medication administration. The facility's policy on medication administration was not adhered to, resulting in significant medication errors that could potentially impact the residents' health outcomes.
Inadequate Infection Control During Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain proper infection control practices during blood glucose level assessments for Residents #82 and #112. For Resident #82, an LPN used a glucometer that was not covered or stored in a pouch and did not clean it before or after use. The LPN wiped the glucometer for approximately five seconds, which did not comply with the cleaning instructions that required the surface to remain wet for two minutes. The LPN confirmed that the glucometer was used for all residents requiring fingerstick blood sugars in her hall and that she worked in all areas of the facility. For Resident #112, an RN also used a glucometer that was not covered or stored in a pouch and did not clean it before or after use. The RN placed the soiled glucometer directly on top of an opened box of lancets, which were used to obtain blood from residents' fingers. The RN then cleaned the glucometer with an alcohol wipe for approximately five seconds, which was not an approved method for cleaning glucometers. The facility's policy required glucometers to be disinfected between each use according to manufacturer instructions and infection prevention guidelines.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the death of the resident. On the morning of the incident, an LPN administered another resident's medications, including Methadone and likely Hydromorphone, to a resident who was not prescribed these medications. The LPN did not report the medication error, and as a result, no medical intervention was initiated. The resident was later found unresponsive in a common area and was pronounced deceased after resuscitative measures were unsuccessful. The resident involved had a medical history that included cerebral palsy, developmental disorder of speech and language, and cognitive deficits. The resident was dependent on staff for various activities and had a care plan that included administering medications as ordered. The resident's medication administration record indicated that the prescribed medications were documented as administered, but the error involving the administration of another resident's medications was not reported or documented. The incident was compounded by the LPN's failure to report the error immediately, which delayed any potential medical intervention. The facility's investigation revealed that the LPN initially confessed to the error to another nurse but later denied it during the facility's investigation. The resident's postmortem blood work confirmed the presence of Methadone and opiates, which were not prescribed to the resident, indicating the occurrence of the medication error.
Removal Plan
- LPN #381 was suspended pending investigation and subsequently terminated for failure to cooperate with the facility investigation.
- All staff who were working at the time of the alleged incident and the following shift were interviewed by the Administrator and RRN #408.
- UM #332 and UM #400 were suspended pending further investigation and provided with one-on-one education on reporting medication errors, medication administration, abuse/neglect procedures, and immediate reporting protocol to the abuse coordinator.
- An in-house audit was completed by the DON, ADON, and RRN #408 for all residents receiving narcotics to ensure that medication was being received as ordered.
- Audits of all narcotics on each medication cart were completed to ensure all narcotics were accounted for.
- A new protocol was implemented for all zeroed narcotic sheets to stay in the narcotic book until removed by unit manager and/or DON, and all empty narcotic cards were to stay in narcotic drawer until removed by unit manager and/or DON.
- Nurses were in-serviced on medication administration, abuse and neglect-with protocol to report allegations directly to abuse coordinator, shift to shift count of narcotics, destruction of narcotics, change of condition with notification to physician and family, discontinued home medications would be verified by manager and nurse, medication errors and reporting.
- Nurses completed a medication administration competency.
- Alert signs with reporting requirements including the telephone number for the Administrator were placed at nurse's stations, time clock, and break room.
- A Self-Reported Incident was submitted to the State agency involving Resident #117.
- The facility implemented a plan for the DON/designee to audit narcotic medications to ensure the narcotic counts were correct.
- The facility implemented a plan for the DON/designee to ensure medication administration compliance by observing medication administration with two nurses.
- The facility implemented a plan to ensure compliance with the zeroed narcotic control sheets by collecting empty narcotic cards with narcotic sheets from the medication carts.
- The facility implemented a plan for the DON/Designee to ensure compliance of reporting medication errors by interviewing two nurses.
- All negative findings to be reviewed during Quality Assurance Performance Improvement (QAPI) meetings to determine if additional audits were necessary.
Failure to Coordinate Dialysis Catheter Care
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis center regarding the care of a resident's dialysis catheter. The resident, who had chronic kidney disease and was dialysis-dependent, was admitted to the hospital's Intensive Care Unit with an infection from the dialysis catheter that spread to the heart valves. The resident's son observed a soiled dressing over the dialysis catheter, which was dated several days prior, indicating a lack of timely dressing changes. Interviews with facility staff revealed a lack of clarity and adherence to protocols regarding the frequency of dialysis dressing changes. A Licensed Practical Nurse was unsure of the schedule for changing dialysis dressings, while a Dialysis Registered Nurse confirmed that the dressing had not been changed for several days, as there was no documentation of such in the resident's treatment record. The facility's policy required dressings to be changed every seven days and as needed, but this was not followed. The facility's failure to monitor and change the dialysis catheter dressing as needed contributed to the resident's infection and subsequent death. The death certificate listed septic shock, bacteremia, endocarditis, and an infected dialysis catheter as causes of death. The facility's policies and CDC guidelines emphasize the importance of changing dressings when they become soiled, but these were not adhered to in this case.
Failure to Notify Legal Guardian of Resident's Death
Penalty
Summary
The facility failed to ensure timely notification of the legal guardian regarding the death of a resident, identified as Resident #119. The resident had a range of serious medical conditions, including acute and chronic respiratory failure, end-stage renal disease, and was receiving hospice care. Upon the resident's passing, the facility notified the Director of Nursing, the hospice provider, and the emergency contact listed as the spouse, but failed to notify the legal guardian. The legal guardian was responsible for all medical and financial decisions and was not informed until the following day when she called the facility for information. The oversight occurred despite the legal guardian being clearly listed on the resident's face sheet and having been appointed by court documents. The LPN involved in the notification process was unaware of the legal guardian's role and mistakenly contacted the spouse, who was estranged from the resident. This resulted in the resident's daughter, who was actively involved in her care, not being informed in time to visit before the body was released to the funeral home. The facility's policy required notification of the physician, family, and responsible party in the event of a significant change, which was not adhered to in this case.
Failure to Address PEG Tube Concerns Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate ongoing care and services for Resident #82, who had a percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding. Despite repeated concerns voiced by state-tested nurse aides (STNAs) about a black discoloration in the PEG tube, the facility did not address these issues, resulting in the resident being transferred to the hospital with a clogged PEG tube and maggots noted in the tube. The resident had a history of acute respiratory failure, type two diabetes mellitus, aphasia, cognitive communication deficit, cerebral aneurysm, and obesity, and was dependent on staff for activities of daily living. The medical record review revealed that the resident's PEG tube site care included cleansing with wound cleanser, applying triamcinolone 0.1% cream, and covering with calcium alginate and split gauze dressing each shift. However, there was no documented evidence of attempts to schedule a PEG tube replacement despite the tube malfunctioning and the resident refusing replacement multiple times. Progress notes from May to August showed no signs of infection or attempts to address the black discoloration reported by STNAs. Interviews with staff indicated a lack of communication and follow-up on the concerns raised by STNAs. The Unit Manager and Director of Nursing were unaware of the black discoloration or maggots, and the Nurse Practitioner confirmed attempts to schedule a replacement were unsuccessful. Despite reports of leaking and discoloration, there was no documentation of these findings in the progress notes, and the resident was eventually sent to the hospital after maggots were found at the PEG tube site.
Failure to Implement Fall Risk Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a comprehensive fall risk assessment with individualized interventions for a resident, leading to an incident where the resident fell and sustained a severe injury. The resident, who had a history of falls and was at risk due to various medical conditions, did not have specific interventions in place to mitigate the risk of falling. The preadmission fall review and therapy-to-nursing communication forms were incomplete, and the care plan lacked detailed interventions to address the resident's fall risk. On the day of the incident, the resident complained of pain in the right lower extremity, but there was no immediate and thorough assessment of the cause of the pain. The resident was eventually found to have a femur fracture, which required surgical intervention. The facility's investigation into the incident was inconclusive, with conflicting accounts of whether the fall occurred at the facility or prior to admission. Staff interviews did not provide clarity on the incident, and there was no documentation of a fall risk evaluation being completed for the resident. The facility's policy on fall prevention and management was not adequately followed, as evidenced by the lack of a fall risk assessment upon admission and the absence of preventative measures in the care plan. The facility's investigation into the incident did not determine the cause of the fracture, and there was no evidence of abuse or neglect. The resident's account of the fall and subsequent handling by a staff member was not corroborated by staff interviews, and the facility's documentation did not reflect a comprehensive assessment or intervention plan for the resident's fall risk.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse towards a resident, identified as Resident #23. The incident was initially reported by a family member of another resident, who claimed to have overheard a staff member, STNA #281, speaking in a mean manner to Resident #23 during a shower. The family member reported that the staff member left the resident alone in the shower room and was taking selfies. Despite the family member's report, the facility's investigation did not include statements from all staff involved, and the questions asked during the investigation were not specific to abuse. Resident #23, who was cognitively intact, initially denied any abuse when interviewed by the facility. However, further interviews revealed that Resident #23 felt uncomfortable and described the staff member as mean and verbally abusive during the shower. The resident's roommate corroborated this, stating that Resident #23 was almost in tears after the incident and expressed a desire not to be assisted by the staff member again. Despite these accounts, the facility's investigation concluded that the allegation was unsubstantiated. The facility's policy requires immediate reporting and thorough investigation of all abuse allegations, including interviews with all witnesses and involved parties. However, the investigation into this incident lacked comprehensive witness statements and did not document the incident in the resident's progress notes. The facility's failure to follow its policy and conduct a thorough investigation represents a deficiency in ensuring resident safety and addressing allegations of abuse.
Inadequate Communication and Documentation in AMA Discharge
Penalty
Summary
The facility failed to ensure that a resident's physician was provided with accurate information regarding a discharge Against Medical Advice (AMA), which compromised the safety of the discharge process. The resident, who was cognitively intact and had a history of anxiety disorder, depression, and a brain disorder, left the facility due to dissatisfaction with her meal. Despite staff efforts to offer alternative meals and persuade her to stay, the resident exited the facility without signing the AMA form initially. The police were involved, and it was determined that the resident, being her own power of attorney, had the right to leave. The documentation and communication regarding the incident were inadequate. The progress notes did not specify which physician was notified, whether the physician was informed before or after the resident signed the AMA form, or what the physician's recommendations were. Additionally, the notes lacked details about the resident's condition and circumstances after leaving the facility, such as her attire, the weather conditions, and whether she was picked up by a friend. Interviews with staff revealed inconsistencies in who contacted the physician and the sequence of events, indicating a lack of clear communication and documentation. The resident was later found disoriented and cold in the woods near the facility, having been exposed to the elements. Emergency Medical Services (EMS) were called, and the resident was returned to the facility. Interviews with the Director of Nursing (DON), Nurse Practitioner (NP), and the resident's physician highlighted a lack of clarity and communication regarding the resident's discharge and subsequent return. The facility's policy on AMA discharges was not adequately followed, as the necessary notifications and documentation were incomplete or unclear.
Failure to Ensure Comprehensive Treatment Plan for Chest Tube
Penalty
Summary
The facility failed to timely ensure a comprehensive treatment plan was in place to properly drain, monitor, and dress a resident's chest tube. The resident, who had diagnoses including acute and chronic diastolic heart failure, end-stage renal disease, and cardiomyopathy, was admitted with a chest tube. However, the hospital discharge orders did not specify how to care for the chest tube, and the facility did not have orders to drain, monitor, or care for the chest tube until three days after admission. The chest tube was initially drained on 03/19/24, and subsequent orders were put in place to drain the chest tube three times a week and record the volume. However, the facility did not order a dressing change for the chest tube until 03/26/24, and the order did not specify the type of dressing required. Interviews with the Director of Nursing and a Certified Nurse Practitioner revealed that the facility was aware of the chest tube prior to admission but did not have specific care orders. The CNP confirmed that there were no orders to care for the chest tube upon admission and that the hospital did not know the proper diagnosis for the chest tube, which was used due to fluid build-up and was meant to be temporary. This deficiency represents non-compliance investigated under Complaint Number OH00152477.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for Resident #121, who was diagnosed with altered mental status, unspecified dementia with agitation, and type two diabetes mellitus with diabetic chronic kidney disease. The resident's care plan indicated that she was incontinent of bladder and bowel and required assistance with toileting to remain clean, dry, and free from skin breakdown. On the day of the incident, the resident was observed sitting in a wheelchair with a large puddle of liquid underneath, and her pants and incontinence brief were saturated with urine. Additionally, the brief contained a moderate to large greenish-brown semi-formed bowel movement, and the resident's buttocks, inner buttocks, upper posterior thighs, and perineal area were reddened. The resident cried out in pain during the cleansing process, and a large reddened, irritated area was observed on her right leg crease, right thigh, and abdomen. Interviews with the staff revealed that the incontinence brief had not been changed for a while, and there was a lack of communication between the staff members regarding the resident's condition. The STNA who took over the care of the resident in the afternoon stated that the previous STNA did not mention the need to change the incontinence brief. The LPN was also unaware of the resident's condition, as no STNA had reported the redness and irritation. The Nurse Practitioner was later informed and provided instructions for treatment. The deficiency was identified during an investigation under Master Complaint Number OH00152597 and Complaint Number OH00152477.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,199 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyant Woods Healthcare Center | 1.4 mi | ★★★★★ | 8 | 0 |
| Village At St Edward Nrsg Care | 1.5 mi | ★★★★★ | 9 | 0 |
| Phoenix Of Fairlawn | 2.4 mi | ★★★★★ | 0 | 0 |
| Arbors At Fairlawn The | 2.6 mi | ★★★★★ | 0 | 0 |
| Timberland Ridge Nursing & Rehabilitation | 3.2 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bath Manor Special Care Centre.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.