Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Canal Winchester Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to consistently monitor and document food temperatures for multiple meals over two months, despite a policy requiring temperatures of TCS foods to be taken and recorded for each meal. Review of dietary logs showed numerous missing entries for breakfast, lunch, and dinner, and food committee minutes reflected resident reports of undercooked and overcooked items, as well as cold eggs. During an observed lunch service, the Dietary Manager and dietary staff acknowledged that meal temperature logs contained missing temperatures before meals were served, affecting all residents in the facility.
A resident with multiple serious diagnoses, including multiple myeloma and secondary malignant neoplasm of bone, had a physician order for Pomalyst 2 mg PO each morning, but the MAR showed two missed morning doses. Nursing notes documented that the drug was reportedly not available in the med cart, while an RN later stated the family had supplied the medication, it was placed in the top drawer of the cart, and the MAR reflected that location. The RN confirmed the resident did not receive the ordered doses, and no medication error report was completed despite the missed administrations and the facility’s policy requiring accurate medication administration per physician orders.
The facility failed to document meal intakes for a resident with multiple serious diagnoses, including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not in remission, need for assistance with personal care, and adult failure to thrive. The resident’s MDS indicated a need for supervision or touching assistance with eating, yet review of the record showed only one documented meal intake during the stay, with no entries for all meals on one day and a missing lunch entry on another day. The Regional DON confirmed the missing documentation, which did not align with the facility’s Food and Nutrition Services policy requiring provision and tracking of meals to meet residents’ nutritional needs and preferences. This issue was discovered incidentally during a complaint investigation.
A cook was observed preparing and plating breakfast foods while wearing a hairnet that did not fully cover the hair, leaving the back exposed. The RD confirmed the hairnet was not properly positioned during food service, and facility policy requires all dietary staff to wear hair restraints that cover all hair.
The facility failed to follow pre-op dental instructions and to implement and document physician orders for TED hose. One resident with heart failure and intact cognition had documented care plans for coordinated dental services, but the record lacked evidence of a key dental consult and scheduled surgery, and the dental office reported that pre-op fasting and medication instructions were not followed, causing cancellation of the planned procedure. Two other residents with edema and complex cardiac/vascular conditions had orders for bilateral TED hose or compression hose, yet surveyors repeatedly observed them without the ordered hose in place. In both cases, LPNs acknowledged that the ordered hose were not being used, while the treatment administration records showed the treatments as completed, contrary to observations and interviews.
Surveyors found that staff did not consistently follow transmission-based precautions, enhanced barrier precautions, or hand hygiene requirements. A resident on contact and droplet isolation for COVID-19 was cared for by a CNA who entered the room without required PPE and with a mask pulled down, despite clear isolation signage and available PPE. Another resident on enhanced barrier precautions was served a meal by a housekeeping manager who wore only a gown, touched room surfaces, then walked into the hallway still gowned and discarded the gown in regular trash, while a lab technician drew blood from a different resident on enhanced barrier precautions without donning a gown as indicated. An LPN providing medications and wound care to two residents failed to change soiled gloves or perform hand hygiene between contaminated and clean tasks, and handled personal items and room surfaces with contaminated gloves, contrary to the facility’s hand hygiene and PPE policies.
Failure to maintain dignity during mealtime. A resident with dementia, anxiety, and major depression had severely impaired cognition and required substantial to maximal assistance with eating and total dependence for several ADLs. During dining room observation, a CNA was seen standing while feeding the resident, and the Administrator confirmed the CNA was standing during the feeding.
Failure to provide written bed hold notice for a resident with moderate cognitive impairment and multiple medical diagnoses. The BOM spoke with the resident's representative about the bed hold request, but the facility did not mail the notice because it did not have the representative's address, despite policy calling for written notice by mail or email within 24 hours or the next business day.
Failure to Care Plan CPAP Therapy: A resident with OSA and multiple chronic conditions had a physician order for nightly CPAP, but repeated observations showed the resident asleep without the CPAP in place. A CNA stated she did not think the resident used the CPAP anymore, and the MDS RN verified CPAP was not included in the resident’s care plan even though it should have been.
Failure to provide meaningful activities for two residents. One cognitively intact resident with multiple chronic conditions and another resident with COPD, depression, and HF both wanted more arts and crafts, but the activity logs and calendars showed very limited craft offerings. Staff said craft supplies were limited by the budget, residents often had to bring their own supplies, and activities were sparse, with little variety and limited options later in the day.
Failure to follow wound treatment orders affected two residents with pressure injuries. One resident with impaired cognition and multiple comorbidities had Stage II and Stage III sacral/gluteal pressure ulcers, but the chart lacked wound treatment orders in the MAR/TAR and a later Wound Assessment and Plan order was not transcribed into the record; an LPN and the RD confirmed the missing orders. Another resident with CHF, pulmonary HTN, anemia, and bilateral lower-extremity ulcers had Stage III and unstageable great toe pressure injuries, yet repeated observations showed no dressings on either toe despite active orders, and the resident reported staff were dressing the shins instead.
A resident with COPD, CKD, diabetes, and cognitive impairment lost more than 13% of body weight in less than three months, and ordered nutritional supplements were not active or provided as intended. Another resident with ESRD and diabetes had a fluid restriction in the care plan, but staff were unaware of the order and the resident was observed with multiple drinks available, with nursing staff not following the restriction.
Failure to follow respiratory therapy orders affected two residents. One resident with chronic respiratory failure, CHF, COPD, and intact cognition was observed twice without the ordered continuous O2 at 3 LPM, and an LPN confirmed the oxygen should be worn at all times. Another resident with CHF, AFib, diabetes, and intact cognition returned from the hospital without an active CPAP order, although the Regional Director verified the resident had been wearing CPAP at the facility.
Pharmacy recommendations were not consistently reviewed and documented by the provider, and repeated medication issues were left unclear for two residents. One resident with multiple chronic conditions had recurring insulin-related recommendations that lacked proper signatures, dates, and clear justification, while an A1C ordered for follow-up was not obtained as expected. Another resident with dementia and pain had a morphine order clarification issue that was deferred to hospice, but no documented follow-up was found.
A resident on the 300 hall had a deficiency related to hazardous chemicals being left unsecured. The resident was cognitively impaired and used a walker and wheelchair for mobility. Surveyors observed a container of microdot minute wipes on top of both med carts in the hallway, with labeling stating to keep out of reach of children and warning of hazards to humans and domestic animals. An LPN confirmed the wipes were not secured.
Two residents at risk for falls were not provided with the required two-person assistance during transfers, as specified in their care plans and facility policy. In one case, a resident was transferred with a mechanical lift by only one CNA, resulting in a fall when the lift strap broke. In another case, a resident with impaired cognition and mobility was assisted by only one LPN during a transfer and fell while being weighed. Both incidents occurred due to staff not following established protocols, though no major injuries were reported.
A resident with severe cognitive impairment and a history of falls was left unattended with the bed in a high position and the fall mat not in place when a CNA left the room to get supplies. The resident rolled out of bed and sustained a hip fracture requiring hospitalization and surgery. Staff interviews and records confirmed that required fall interventions were not in place at the time of the incident.
The facility did not provide timely surgical staple removal for two residents following surgery and failed to implement a physician's order for daily weights for another resident. In both wound care cases, there was a lack of documentation and follow-up regarding staple removal, and for the resident requiring daily weights, the order was not entered or carried out by staff.
A resident with significant mobility limitations and a history of pressure ulcer risk was not provided with prescribed off-loading interventions, such as heel boots, despite having a care plan and physician orders in place. Observations and interviews confirmed that staff did not apply the available heel boots, resulting in the resident developing a stage II pressure ulcer that was being treated but not adequately prevented.
A resident with multiple diagnoses and intact cognition experienced lower back pain, prompting an x-ray that revealed compression deformities. The resident was not informed of the x-ray results or new treatment orders until several days later, and documentation of this notification was delayed. There was also no timely documentation that the nurse practitioner was made aware of the x-ray findings, as confirmed by an LPN.
A resident with multiple medical conditions and moderate cognitive impairment, identified as being at risk for pressure ulcers, did not have a care plan in place for pressure ulcer prevention. Staff confirmed the absence of such a care plan and were unaware of any skin issues beyond a surgical incision. This deficiency was found during a complaint investigation.
A facility failed to follow proper infection control and isolation precautions for residents with influenza. PPE carts lacked eye protection, and signs indicating isolation precautions were missing. Staff entered isolation rooms without full PPE, contrary to facility policies.
A resident with multiple medical conditions, including COPD, experienced a lack of dignity and respect during a transfer when a CNA made an inappropriate comment as the resident became short of breath. The facility's investigation confirmed the incident, leading to the CNA's termination.
A facility failed to implement a comprehensive pressure ulcer prevention program for a resident, resulting in the development and deterioration of a pressure ulcer on the resident's foot. Despite hospice staff identifying the ulcer in February, the facility did not address it until August, leading to its classification as a Stage IV ulcer by September. The resident had severe cognitive impairment and multiple health conditions, and the facility's lack of monitoring and treatment contributed to the deficiency.
A resident's call light was left unanswered for over 10 minutes, despite being activated by a family member who needed assistance with the resident's incontinence brief and preparation for an appointment. Staff, including an STNA and an LPN, failed to respond promptly, leading to a delay in care. The incident was investigated under a complaint.
A resident with severe cognitive impairment and multiple medical conditions was found with facial bruising, which was not reported to the state agency as required. The bruising was likely caused by someone holding the resident's mouth to encourage eating. The facility's investigation was delayed, and the deficiency was identified during a complaint investigation.
A resident with severe cognitive impairment and multiple health issues was found with facial bruising, which was not promptly investigated by the LTC facility. Staff members noticed the bruising but failed to report or document it immediately. The facility's investigation was delayed, and it was later determined that the bruising likely occurred due to someone holding the resident's mouth to encourage eating.
A facility failed to implement fall interventions for a resident with a known fall history. Despite a care plan that included keeping the call light within reach, an observation revealed it was out of reach, verified by an LPN. This oversight represents a failure to follow the care plan, crucial for preventing falls in residents with multiple medical conditions.
A resident with COPD and respiratory failure had their oxygen nasal cannula improperly stored, wrapped around the oxygen holder without a protective bag. Observations also noted a nebulizer machine with its delivery system left on the counter outside of a plastic bag. An LPN confirmed the inappropriate storage, which did not comply with the physician's orders for equipment maintenance.
A resident with a complex medical history, including COPD and anxiety disorder, experienced a delay in receiving prescribed Cepacol sore throat lozenges. The lozenges, ordered for administration every two hours as needed, were not delivered until two days after the order was placed. An LPN confirmed the delay in initiation of the medication.
A facility failed to timely obtain a physician-ordered urinalysis and culture for a resident with a complex medical history, due to unavailable lab services over the weekend. The delay led to the resident being treated for a UTI during an ER visit before the test was conducted. An LPN confirmed the untimely collection of the urine sample, resulting in a deficiency finding.
A resident's family member discovered soiled linen and a ripped mattress stained with urine and feces, emitting a strong odor. The facility failed to maintain the mattress in a clean and sanitary manner, as confirmed by the Administrator.
The facility failed to maintain a clean environment in one of its units, affecting several rooms with stained carpeting. A resident reported the stains were present upon admission and even offered to pay for cleaning. An LPN confirmed the issue, which was investigated under multiple complaints.
A facility failed to ensure proper infection control practices, as observed when an STNA delivered meal trays to residents, including those with COVID-19, without changing masks or performing hand hygiene. The STNA wore only a surgical mask, contrary to the facility's policy requiring an N-95 mask, gown, gloves, and face shield for COVID-19 precautions. This noncompliance potentially affected multiple residents and was confirmed by interviews with the STNA and an LPN.
A resident with multiple diagnoses, including diffuse large B-Cell lymphoma and atrial fibrillation, hit her head on the side rail while being assisted with bed mobility. The facility failed to notify the physician, initiate neurological checks, or conduct follow-up assessments. The resident was later hospitalized with a scalp hematoma. Interviews confirmed the lack of incident reporting and follow-up care, contrary to facility policy.
The facility failed to ensure proper date labeling, cleanliness of dishware, and appropriate hot holding temperatures for food, potentially affecting all residents except two who were NPO. Observations revealed expired food items, soiled storage containers, and food temperatures below the required 135 degrees Fahrenheit.
The facility failed to serve food at a palatable and warm temperature, affecting four residents and potentially impacting all residents receiving meals from the kitchen. Observations and interviews confirmed that food temperatures were below the required 135 degrees Fahrenheit, contrary to the facility's policy.
A resident with multiple diagnoses and a moderate cognitive deficit was observed with long, jagged, and dirty fingernails on two occasions, despite the care plan and facility policy requiring staff to provide nail care. The resident expressed her inability to clean her nails and desire for assistance, highlighting the staff's failure to adhere to care guidelines.
A facility failed to identify and document a resident's left great toe injury. Observations showed a bandaged toe with dark red drainage and an untrimmed toenail. The resident's medical record lacked treatment orders, and staff interviews confirmed the absence of documentation. The injury occurred when the resident's toe got caught in bed covers, and the facility's policy on skin and wound care was not followed.
The facility failed to ensure that pressure reducing devices were in place for a resident with multiple medical conditions, including a surgical wound to the left achilles. Despite the care plan's directive to use a heel protector, observations revealed the device was not consistently in place, leaving the resident's left achilles directly on the bed. This deficiency was confirmed through multiple observations and staff interviews.
The facility failed to have a physician's order for the use of oxygen for a resident with COPD and other serious conditions. The resident was observed receiving oxygen without the necessary documentation or care plan interventions, as confirmed by an LPN.
The facility failed to maintain a medication error rate below five percent, resulting in a 10.34 percent error rate. Errors included incorrect dosages of Potassium Chloride and Famotidine for one resident and improper administration of eye drops for another. The errors were confirmed through observation and interviews with the LPN involved.
The facility failed to notify the PCP of elevated blood glucose levels for a resident with diabetes, despite multiple readings exceeding the physician-ordered parameters. An LPN confirmed the lack of notification, which was against the facility's policy on Change in Condition Notification.
The facility failed to ensure individualized fall preventative interventions were in place for two residents. One resident's fall mat was not in place, and another resident's wheelchair lacked the required Dycem for safety. These deficiencies were confirmed by staff and were against the facility's Fall Management Guidelines policy.
Failure to Monitor and Document Food Temperatures for All Meals
Penalty
Summary
The deficiency involves the facility’s failure to consistently monitor and document food temperatures in accordance with its policy and the Ohio Uniform Food Safety Code. Review of dietary food temperature logs for March 2026 showed multiple missing meal temperature entries, including missing breakfast and lunch temperatures on several dates, missing breakfast, lunch, and dinner temperatures on other dates, and missing dinner temperatures on numerous additional dates. Similar review of April 2026 logs revealed missing breakfast and lunch temperatures on multiple days, missing breakfast, lunch, and dinner temperatures on several days, and missing lunch or dinner temperatures on other dates. The facility’s policy required that temperatures of TCS (time/temperature control for safety) foods be taken and properly recorded for each meal. Food committee meeting minutes for March 2026 documented resident reports that fries, baked potatoes, and tenders were undercooked, pork loin was overcooked, and broccoli and other vegetables were sometimes overcooked or undercooked; residents also reported undercooked baked potatoes and eggs served cold. During an observation of lunch meal preparation and temperature checks on 04/20/26, surveyors, along with the Dietary Manager and another dietary staff member, noted that the March and April meal temperature logs contained missing meal temperatures. In an interview at the time of this observation, the Dietary Manager and dietary staff member confirmed the missing documentation prior to serving meals. The facility census at the time was 110 residents, and the deficiency was investigated under Complaint Number 2961159.
Failure to Administer Ordered Anti-Cancer Medication and Report Medication Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a prescribed anti-cancer medication was not administered as ordered. The resident, admitted with diagnoses including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not in remission, need for assistance with personal care, and adult failure to thrive, required staff assistance with multiple activities of daily living. A physician’s order directed that the resident receive Pomalyst 2 mg by mouth in the morning through a specified date. Review of the April Medication Administration Record showed that the resident did not receive the scheduled Pomalyst doses on two consecutive mornings. Nursing documentation indicated that on one of those mornings the nurse was unable to administer Pomalyst because it was not available in the medication cart. However, an RN later stated in interview that on the day of admission the family had brought in the medication, it was placed in the top drawer of the medication cart, and the order in the MAR reflected that location. The RN confirmed that the resident did not receive the ordered medication despite it being available in the cart. Additionally, there was no medication error report completed for the missed doses, contrary to the facility’s medication administration policy, which requires safe and accurate preparation and administration of medications according to physician orders and professional standards of practice.
Failure to Document Meal Intakes for a Resident Requiring Assistance with Eating
Penalty
Summary
The facility failed to ensure complete documentation of meal intakes in the medical record for one resident, resulting in missing records of nutritional intake over most of the resident’s short stay. The resident, admitted with diagnoses including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not in remission, need for assistance with personal care, and adult failure to thrive, had an MDS assessment indicating a need for supervision or touching assistance with eating. Review of the medical record showed that from admission on 04/03/26 through discharge on 04/05/26, only one meal intake was documented, for breakfast on 04/05/26. No meal intakes were recorded for breakfast, lunch, or dinner on 04/04/26, and no intake was documented for lunch on 04/05/26. During an interview, the Regional Director of Nursing confirmed the missing meal intake documentation, which was inconsistent with the facility’s policy requiring provision of meals and attention to residents’ nutritional needs and preferences. This deficiency was identified as an incidental finding during the course of a complaint investigation and was based on closed record review, staff interview, and review of the facility’s Food and Nutrition Services policy dated 09/20/17.
Improper Hair Restraints in Dietary Services
Penalty
Summary
The facility failed to ensure hairnets were worn properly by kitchen staff to protect food from potential contamination. During observation on 02/10/26 at 7:20 A.M., a cook was seen frying eggs and plating breakfast foods while wearing a hairnet that did not adequately cover the hair, leaving the back of the hair exposed at approximately shoulder level. During an interview at 7:30 A.M., the Regional Dietitian confirmed the hairnet was not fully covering the cook's hair while food service tasks were being performed and stated the hairnet could be lowered to cover the hair. Facility policy titled Hair Restraints, approved 09/15/10, states hair shall be restrained to prevent physical contamination of food and that all dietary employees on duty shall wear hair restraints to cover all hair, with two hairnets or a scrub cap required if one hairnet cannot fully cover the hair.
Failure to Follow Dental Pre-Op Instructions and Apply Ordered TED Hose
Penalty
Summary
The deficiency involves the facility’s failure to follow pre- and post-appointment instructions and to implement physician orders for compression (TED) hose. One resident with chronic obstructive sleep apnea, heart failure, and intact cognition had care plans indicating the need for coordinated dental services, including arranging dental care and following pre- and post-operative treatment changes. The resident’s record contained no evidence of a dental appointment on a specified November date or any pre- or post-operative orders for a dental surgery scheduled for a specified December date. A dental office staff member reported that the resident had a consult in early November where preoperative instructions were given to the resident’s daughter, but when the resident arrived for surgery in mid-December, she reported she had eaten and taken medications that morning contrary to the preoperative instructions, resulting in cancellation of the surgery. The DON confirmed the surgery was later completed in late December and acknowledged there was no documentation of the earlier appointment or scheduled surgery in the resident’s record, and that appointment information should be entered on the TAR and after-visit information obtained and followed. The deficiency also includes failure to apply TED hose as ordered for a resident with multiple cardiovascular and circulatory diagnoses, including acute on chronic combined systolic and diastolic heart failure, pulmonary hypertension, chronic venous hypertension with bilateral lower extremity ulcers, localized edema, and other conditions. This resident was cognitively intact and required assistance with several ADLs. A physician order directed that TED hose be applied to both legs every day shift for swelling and circulation. On multiple observations over two days, the resident was seen in bed and in a wheelchair without TED hose in place. During wound care, an LPN applied an ace wrap to the resident’s left shin instead of TED hose, and later confirmed that ace wraps, not TED hose, were being used and that the resident had never worn TED hose, despite the existing physician order. The February treatment administration record showed TED hose as signed off as applied on one of the observation dates by the same LPN. A third resident, admitted with diagnoses including localized edema, major depression, hypertension, and acute respiratory failure, and with intact cognition, also had a physician order for compression hose to both lower extremities to be applied in the morning and removed in the evening each day for edema. Observations on two consecutive days at multiple times showed that the ordered hose were not in place. During a concurrent interview, an LPN verified that the hose were not on as ordered. Review of the February treatment record revealed that on one of the observation dates, the hose had been documented as applied, despite repeated observations that they were not on the resident. The facility’s policy on physician and practitioner orders, last issued and reviewed on specified dates, states that a licensed nurse is responsible for completing care per physician orders. This deficiency was investigated under a specific complaint number.
Failure to Follow Transmission-Based Precautions, Enhanced Barrier Precautions, and Hand Hygiene Requirements
Penalty
Summary
The deficiency involves multiple failures in implementing transmission-based precautions, enhanced barrier precautions, and proper hand hygiene. In one instance, a CNA entered the room of a cognitively intact resident who was on contact and droplet isolation for a newly identified positive COVID-19 test without wearing required PPE, with their mask pulled down to the chin. The resident’s door displayed signs for droplet and contact isolation, and a PPE cart was properly stocked outside the room. The CNA stated they did not think the resident was on isolation precautions, and the resident reported not knowing if she was on contact isolation. A nurse later confirmed the resident was on contact and droplet isolation and that staff should be wearing PPE when entering the room. Another set of deficiencies involved improper use of enhanced barrier precautions and PPE by non-nursing staff. A housekeeping and laundry manager entered the room of a resident on enhanced barrier precautions wearing only a gown and no gloves to deliver a meal tray. While in the room, she touched the bedside table to move items and then exited the room, walked across the hallway still wearing the gown, and discarded it in a regular trash can at the nurse’s station before using hand sanitizer. She acknowledged seeing the enhanced barrier precautions sign and admitted she donned a gown but not gloves because she was unsure of the rules. In a separate incident, a laboratory technician entered the room of another resident on enhanced barrier precautions, who had a PICC line and a JP drain, and drew blood without wearing a gown as required by the posted signage and facility policy. The technician stated she did not see the signage or the PPE available on the back of the door, but indicated she would normally wear a gown and gloves for a blood draw under enhanced barrier precautions. Additional deficiencies were identified in hand hygiene and glove use during medication administration and wound care. During medication administration to a resident with COVID-19 and weeping edema of the lower extremities, an LPN performed hand hygiene and donned PPE before entering the room, then touched the resident’s weeping lower extremities and soiled bed linens with gloved hands, and subsequently handled a blood pressure cuff and administered medications without changing gloves or performing hand hygiene. The LPN later verified that soiled gloves were not removed and hand hygiene was not performed before touching the blood pressure cuff and medications, contrary to the facility’s hand hygiene policy. In another observation, the same LPN performed wound care on a cognitively intact resident with multiple lower extremity wounds. During the procedure, the LPN intermittently performed hand hygiene and changed gloves but also touched her cell phone and the back pocket of her scrubs with gloved hands, then continued wound care, handled dressings, wiped the floor, and moved the resident’s wheelchair before finally removing PPE and performing hand hygiene. The LPN acknowledged that hand hygiene was not consistently performed after handling soiled dressings and linens and before moving from contaminated to clean body sites, and the unit manager confirmed that facility policy required hand hygiene in these situations. Facility policies reviewed by surveyors specified that contact precautions require hand hygiene, gloves, and gown; droplet precautions require gloves, gown, mask, and eye protection; and enhanced barrier precautions require gown and glove use during high-contact resident care activities for residents colonized with MDROs or at increased risk due to indwelling devices. The hand hygiene policy required hand hygiene before moving from a contaminated body site to a clean body site, after handling contaminated objects or equipment, and before and after handling clean or soiled dressings or linens, as well as before handling medications. The observed practices by the CNA, housekeeping and laundry manager, laboratory technician, and LPN did not conform to these written policies, resulting in the cited infection prevention and control deficiency affecting multiple residents. This deficiency represents noncompliance investigated under Complaint Number #2713145.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to maintain dignity during mealtime for one resident. Resident #28 was admitted with diagnoses including dementia, anxiety, and major depression, and his quarterly MDS showed severely impaired cognition with substantial to maximal assistance needed for eating and dependence for oral hygiene, toileting, showering/bathing, dressing, and personal hygiene. During dining room observation on 02/11/2026 at 8:40 A.M., CNA #206 was seen standing while feeding Resident #28 and continued standing to feed him until 8:46 A.M. The Administrator confirmed during interview at 8:46 A.M. that CNA #206 was standing while feeding the resident.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to notify the resident's representative in writing of the bed hold policy for Resident #133. Resident #133 was admitted on 12/03/25 and discharged on 01/12/26. The resident had diagnoses including unspecified protein-calorie malnutrition, Type II Diabetes Mellitus, heart failure, cutaneous abscess of the abdominal wall, colostomy status, and depression. The five-day PPS MDS indicated moderate cognitive impairment and physical, verbal, and other behavioral symptoms. On 01/12/26 at 05:17 P.M., the facility nurse practitioner ordered Resident #133 to be evaluated in the emergency department, and the resident and resident representative were notified of the transfer. The bed hold notice for Resident #133 was dated 01/12/26 and prepared by the BOM, who documented speaking with the resident's representative that day. However, the BOM stated the facility did not have the representative's address and that the representative requested a bed hold during the conversation. The facility did not mail the bed hold notice to the resident's representative, despite the facility policy stating it would attempt to provide or send written notice within 24 hours and/or the next business day via mail and/or email.
Failure to Care Plan CPAP Therapy
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included CPAP therapy for Resident #91. The resident was admitted with diagnoses including acute on chronic combined systolic and diastolic congestive heart failure, pulmonary hypertension, iron deficiency anemia, chronic venous hypertension with bilateral lower extremity ulcers, obstructive sleep apnea, restless leg syndrome, anemia, pain, shortness of breath, and localized edema. The admission MDS indicated the resident was cognitively intact, needed varying levels of assistance with toileting, bathing, dressing, footwear, personal hygiene, eating, and oral hygiene, and used a non-invasive mechanical ventilator. A physician order dated 01/07/26 directed CPAP to be applied every night shift, but observations on 02/09/26, 02/10/26, and 02/11/26 showed the resident asleep in bed without the CPAP in place. During one observation, CNA #479 confirmed the resident was not wearing the CPAP and stated she did not think the resident used it anymore because he had also not been wearing it the last time she worked. Review of the care plan initiated on 01/06/26 showed no CPAP care plan, and the MDS Coordinator RN verified that CPAP was not care planned but should have been included in the plan of care. The facility policy stated the comprehensive, person-centered care plan should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Meaningful Activities
Penalty
Summary
The facility failed to provide meaningful activities to all residents, affecting two of six residents reviewed for activities. One resident was cognitively intact and had interests that included arts and crafts, cards/bingo/puzzles, community outings, computer use, exercise/sports, music, gardening, pet therapy, reading/writing, and watching TV/movies/news. Her care plan directed staff to remind her of ongoing activities and specific locations, but review of activity logs from November 2025 through January 2026 showed no documented arts and crafts activities offered, completed, or refused. She stated activities on the second floor were better than on the first floor, that there were no activities past 4:15 P.M. except one-on-one activities, and that arts and crafts were limited and often required residents to provide their own supplies. A second resident with diagnoses including COPD, depression, and heart failure had an intact BIMS score and a care plan noting she wanted to do crafts in her room, talk on the phone, and watch television, while declining group activities frequently. She stated she used to be a teacher and enjoyed working on all different kinds of crafts, but refused many activities because the facility did not really have crafts to do and she would attend more if there were more crafts. The Activities Director stated the facility did not have multiple craft activities and that offerings were influenced by resident voting and the activities budget. Review of the activity calendars showed only a few arts and crafts activities over several months, and the weekly Knotting Knitters activity required residents to bring their own supplies.
Failure to Follow Wound Treatment Orders for Pressure Injuries
Penalty
Summary
The facility failed to implement and/or follow physician orders for pressure injury treatment for two residents. One resident was admitted with diagnoses including diabetes mellitus, hemiplegia, hemiparesis, and chronic congestive heart failure, and the MDS showed impaired cognition with a BIMS score of 6 and a need for self-care assistance. This resident was coded with a Stage II and a Stage III pressure ulcer on the sacrum. The care plan identified the resident as at risk for skin integrity impairment and included administering treatments per physician orders, but the physician orders in the record did not include treatment orders for the pressure ulcers, and the TAR also did not contain wound treatment orders for those ulcers. Progress notes documented pressure injuries on the resident’s gluteal areas with measurements and treatments such as cleansing with normal saline, applying triad paste, and leaving the wounds open to air. A physician Wound Assessment and Plan later documented a Stage II pressure injury and a Stage III pressure ulcer with specific treatment orders, including cleansing with normal saline, applying triad cream, leaving open to air, and for the Stage III wound, applying a collagen sheet and covering with a dry dressing every day and as needed. Those wound treatment orders were not transcribed into the resident’s medical record. An LPN and the Regional Director both confirmed that the resident did not have wound care orders for either pressure ulcer. A second resident was admitted with diagnoses including acute on chronic combined systolic and diastolic heart failure, pulmonary hypertension, iron deficiency anemia, chronic venous hypertension with ulcer of bilateral lower extremity, obstructive sleep apnea, restless leg syndrome, anemia, pain, shortness of breath, and localized edema. The resident’s MDS showed intact cognition and required varying levels of assistance with toileting, bathing, dressing, footwear, hygiene, eating, and oral hygiene. Physician orders included treatment for the right and left great toes, and the skin issues record identified a Stage III pressure ulcer on the left hallux and an unstageable pressure ulcer on the right hallux. However, observations on multiple occasions showed no dressings on either great toe, and the resident stated staff were applying dressings to the shin area only. The resident also stated a requested Band Aid for the left toe was not applied, and an LPN verified that no dressings were present on either great toe while noting the resident had new orders for the great toes.
Failure to Provide Ordered Nutrition Support and Follow Fluid Restriction
Penalty
Summary
The facility failed to ensure one resident did not experience significant weight loss and failed to ensure another resident’s fluid restriction was followed. Resident #66 had diagnoses including COPD, schizoaffective disorder, stage three chronic kidney disease, type two diabetes, and a history of bowel cancer, and had a BIMS score of 8, indicating moderate cognitive impairment. Review of weights showed the resident lost more than 13% of body weight in less than three months, from 169 pounds to 146 pounds, while not on a prescribed weight loss program. Resident #66 was identified in the care plan as nutritionally at risk, with interventions including monitoring food intake, monitoring weights, providing the ordered diet, and providing nutritional supplements as ordered. However, the physician orders reviewed did not show active supplement orders, and observation during lunch showed the resident appeared thin or underweight with no nutritional supplement on or near the tray. The meal ticket also did not indicate a supplement was to be provided. The Regional Dietitian stated the resident should have been receiving supplements such as med pass 120 mL twice daily and magic cup twice daily, but active supplement orders were not found and had not been reinstated after the resident returned from a brief hospital stay. Resident #92 had diagnoses including hypotension, cardiomegaly, end-stage renal disease, diabetes mellitus type II, major depressive disorder, muscle weakness, and osteoarthritis, and had intact cognition with a BIMS score of 15. The care plan included a fluid restriction of 950 mL per day, with specific amounts allocated for day and night shifts. During observation, the resident had a 500 mL water bottle and a glass of water on the table and confirmed both were hers, while denying staff were monitoring fluid intake. The Regional Dietician confirmed the fluid restriction order, but an LPN and a CNA stated they had no knowledge of the restriction and were not following it; the LPN also could not find active fluid restriction orders for any residents.
Failure to Follow Respiratory Therapy Orders
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for Resident #06. The resident was admitted with diagnoses including cerebral infarction, diabetes mellitus, chronic respiratory failure with hypoxia, anxiety, depression, congestive heart failure, and chronic obstructive pulmonary disorder. The care plan and physician orders directed oxygen via nasal cannula continuously at 3 LPM, and the resident’s MDS showed intact cognition with a BIMS score of 15. During observations on 02/10/26 and 02/12/26, Resident #06 was not wearing the ordered oxygen, and an LPN later verified that the resident was not wearing oxygen as ordered and confirmed it should be worn at all times. The facility also failed to have a current CPAP order for Resident #36 after the resident returned from the hospital. Resident #36 had diagnoses including displaced intertrochanter fracture of the left femur, mild protein calorie malnutrition, congestive heart failure, atrial fibrillation, and diabetes, and the quarterly MDS showed intact cognition. The record showed an inactive CPAP order dated 09/22/25 for BiPAP support during the night for sleep apnea, but after the resident returned to the facility on 02/05/2026 there was no active CPAP order. The Regional Director verified there was not a current order for CPAP, although the resident had been wearing the CPAP at the facility.
Pharmacy Recommendations Not Timely or Thoroughly Addressed
Penalty
Summary
The facility failed to ensure a licensed pharmacist’s monthly drug regimen review was timely and thoroughly addressed according to its policies and procedures for irregularity reporting. This involved two residents reviewed for pharmacy recommendations. The report states that the facility did not consistently obtain provider signatures or dates on pharmacy recommendation forms, did not clearly document whether recommendations were accepted or rejected, and did not fully clarify repeated recommendations related to insulin therapy for one resident. For one resident with multiple diagnoses including acute respiratory failure, cardiomyopathy, chronic kidney disease stage IV, congestive heart failure, atrial fibrillation, diabetes, and other chronic conditions, pharmacy recommendations repeatedly questioned the use of insulin products and the need for both long-acting and rapid-acting insulin. One recommendation was marked as disagreed with, but the justification was only noted as duplicate and lacked an actual explanation, and there was no provider signature or date. Another recommendation stated that an A1C would be repeated in July 2025, but the laboratory result review showed no A1C was obtained in July. A later recommendation was signed and agreed to, and another was marked disagree/other with a typed justification that BG/A1C were at goal for age and to repeat A1C in three months. The final recommendation in this series was not addressed on the form, although a later provider progress note documented agreement to discontinue insulin aspart. The DON confirmed the facility never clarified whether the repeated recommendation to stop insulin aspart was a clerical error, since the resident had never been ordered insulin aspart and had instead been ordered insulin lispro sliding scale during the period reviewed. For another resident with dementia, depression, anxiety, insomnia, hypertension, and pain, the pharmacy recommendation identified a mismatch between the ordered morphine dose and the dose documented in the hospital record, and asked that the order be clarified with the prescriber and updated. The record showed that the issue was deferred to hospice, but there was no documented evidence that it was addressed. A regional director later confirmed there was no follow-up by hospice after the physician referral.
Unsecured Hazardous Wipes on Medication Carts
Penalty
Summary
The facility failed to maintain a safe environment free of hazardous chemicals for one resident on the 300 hallway. Resident #97 was admitted with diagnoses including hypertension, hyperlipidemia, and atrial fibrillation, and the MDS assessment showed the resident was cognitively impaired, used a walker and wheelchair for mobility, and had no behaviors. The facility identified the resident as cognitively impaired, independent with ambulation and mobility, and residing on the 300 hallway. During observation of the 300 hallway, residents were up and about the hallways and a container of microdot minute wipes, labeled "keep out of reach of children" and "Hazards to humans and domestic animals," was observed on top of both medication carts stored on the hallway. An LPN confirmed the wipes were on top of the medication cart and not secured.
Failure to Provide Adequate Supervision and Follow Transfer Protocols Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate care and services to prevent falls for two residents who were identified as being at risk. One resident, with diagnoses including pulmonary hypertension, dementia, and spondylosis, was assessed as needing two-person assistance for bed mobility and touch assistance for transfers. Despite this, the resident was transferred using a mechanical lift by only one CNA, contrary to both the resident's care plan and facility policy, which required two trained staff for such transfers. During the transfer, the mechanical lift strap broke, causing the resident to fall backwards onto the bed, though no injuries were noted. Another resident, with a history of heart failure, hypertension, multiple cancers, muscle weakness, and impaired cognition, was care planned for two-person physical assistance with transfers and did not ambulate at baseline. This resident experienced a fall while being re-weighed at the weight station. The resident was being assisted by only one LPN, who was using a gait belt, when the resident lost balance and was eased to the floor. The care plan specified two-person assistance for transfers, but only one staff member was present at the time of the incident. In both cases, staff actions did not align with the residents' care plans or facility policies regarding the required number of staff for transfers and use of mechanical lifts. These failures resulted in falls, though neither resident sustained major injuries. The facility's policies and care plans were not followed, leading to deficiencies in accident prevention and supervision.
Failure to Maintain Fall Interventions Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that fall risk and safety interventions were in place for a resident with a known history of falls from bed. The resident had severe cognitive impairment, required extensive assistance from two staff for bed mobility, and was identified as being at high risk for falls due to multiple medical conditions, including a cerebrovascular accident with left-sided hemiplegia, muscle contractures, and confusion. The resident's care plan included specific interventions such as keeping the bed in the lowest position and ensuring a fall mat was in place. On the day of the incident, a CNA left the resident's room to retrieve personal care supplies, leaving the bed in a high position and the fall mat leaned against the wall instead of being properly placed. During this time, the resident rolled out of bed and sustained a fall, resulting in a nondisplaced intertrochanteric fracture of the left femur. The resident was found on the floor by her bed, complained of hip pain, and was subsequently hospitalized for surgical repair of the fracture. The investigation confirmed that the required fall interventions were not in place at the time of the fall. Prior to this incident, the resident had a documented history of falls, including a recent fall from bed without injury. The care plan and fall risk assessments had identified the need for consistent implementation of fall prevention measures. However, staff failed to follow these interventions, directly leading to the resident's injury. Interviews with staff confirmed that the fall precautions were not maintained when the CNA left the room, and the incident was immediately reported to management.
Failure to Provide Timely Wound Care and Implement Physician Orders
Penalty
Summary
The facility failed to provide timely care for surgical incision staple removal for two residents and did not obtain physician-ordered daily weights for another resident. For one resident with a history of fractured femur, mood disorder, and other significant medical conditions, staples from a surgical incision were not removed in a timely manner. The resident's follow-up appointment for staple removal was canceled by the trauma clinic, and although the spouse, who is the POA, requested that the removal be done in the facility to avoid confusion for the resident, there was no documentation of any plan or action to remove the staples until two weeks later. During this period, the resident continued to have the staples in place, and the spouse reported ongoing concerns to the facility. Another resident, admitted with diagnoses including diverticulitis, acute respiratory failure, and recent abdominal surgery, had a surgical incision with staples present on admission. The medical record indicated that the staples remained in place throughout the resident's stay, and there was no documentation of any discussion or order regarding staple removal during the entire admission. Wound assessments noted the presence of the staples, but no further action was documented regarding their removal. A third resident, with a history of myocardial infarction, acute respiratory failure, and pressure ulcers, had a physician's order for daily weights following a cardiology appointment. Although medication changes from the after-visit summary were implemented, the order for daily weights was not entered into the system, and the resident was not weighed daily as ordered. Interviews with staff confirmed that the process for entering new orders from after-visit summaries was not followed, resulting in the omission of the daily weight order.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with multiple comorbidities, including a history of cerebrovascular accident with hemiplegia, contractures, and decreased mobility, was not provided with appropriate pressure ulcer prevention interventions. The resident was assessed as being at risk for pressure ulcer formation and had a care plan in place that included interventions such as floating heels, use of heel boots, frequent turning and repositioning, and daily skin monitoring. Despite these documented interventions and physician orders, observations revealed that the resident was lying in bed with a dressing on her right ankle/foot and no off-loading devices, such as heel boots, in use. Further investigation through interviews confirmed that heel boots were available but not being applied by staff, as noted by a family member who found the boots in the resident's closet. An LPN also verified that no off-loading was provided to the pressure ulcer on the resident's right ankle. The lack of implementation of prescribed interventions for pressure ulcer prevention and care led to the deficiency, as the resident developed a stage II pressure ulcer that was being monitored and treated, but preventive measures were not consistently followed.
Failure to Timely Notify Resident and Practitioner of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to both a resident and the medical practitioner regarding a change in the resident's condition and the need to alter the treatment plan. The resident, who had diagnoses including cerebral infarction, neuropathy, anxiety, and major depression, was cognitively intact at the time of the incident. On one occasion, the resident experienced lower back pain, and staff notified the nurse practitioner, who ordered an x-ray and Tylenol for pain management. The x-ray, completed and reported on the same day, revealed L2 and L3 compression deformities of undetermined age. Despite these findings, the resident was not informed of the x-ray results or subsequent new orders for lab work and Prednisone until several days later. Documentation showed that the resident was only notified of these results and new orders days after the x-ray was performed, and this notification was entered as a late entry in the medical record. Additionally, there was no documentation that the nurse practitioner was made aware of the x-ray results until several days after the test, as confirmed by the unit manager LPN, who could not provide a reason for the delay.
Failure to Develop Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for the prevention of pressure ulcers for one resident who was identified as being at risk. Medical record review showed that the resident had multiple diagnoses, including diverticulitis with perforation and abscess, influenza, colostomy status, bladder disorder, rheumatoid arthritis, anxiety, and intellectual disabilities. The resident's admission MDS indicated moderate cognitive impairment and a risk for pressure ulcers, as well as the use of a pressure-reducing mattress and receipt of surgical wound care. Despite these risk factors, there was no care plan in place to address pressure ulcer prevention. This was confirmed by the MDS Coordinator RN, who acknowledged the absence of a care plan, and by a CNA who was unaware of any skin impairments other than the resident's surgical incision. This deficiency was identified during a complaint investigation and was based on both interview and medical record review.
Infection Control and Isolation Precaution Deficiency
Penalty
Summary
The facility failed to adhere to proper infection control and isolation precaution procedures, affecting four residents diagnosed with influenza. Observations revealed that personal protective equipment (PPE) carts were placed outside the rooms of two residents, but there were no signs indicating the type of isolation precautions in place. Interviews with licensed practical nurses confirmed that these residents were on contact/droplet isolation precautions, and signs should have been posted as a safety measure for staff and visitors. Further observations showed that six resident rooms had PPE carts, but none contained eye protection, which is required for droplet isolation precautions. Interviews with two licensed practical nurses confirmed the absence of eye protection in the PPE carts for four residents on droplet isolation precautions. Additionally, a certified nursing aide was observed entering a resident's room on droplet/contact isolation precautions wearing only a mask, without the required gown, gloves, and eye/face protection. The residents involved had various medical conditions, including influenza, respiratory failure, and chronic diseases. Their care plans indicated that they were to be in contact/droplet isolation in single-occupant rooms, with all services provided in-room and staff observing all PPE precautions. The facility's policies on influenza management and infection control outlined the necessary precautions, including the use of PPE and proper signage, which were not followed in these instances.
Resident Dignity Compromised During Transfer
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, affecting a resident who was cognitively intact and had multiple medical conditions, including chronic respiratory failure and COPD. During a transfer involving a mechanical lift, the resident became short of breath after her oxygen was removed for safety reasons. At this time, a Certified Nursing Aide (CNA) made an inappropriate comment, suggesting that the resident should go to her 'happy place' if she couldn't hold on. This comment was reported by the resident, who felt upset and discouraged by the interaction. The facility conducted an investigation into the incident, which confirmed the inappropriate comment was made by the CNA. The CNA involved admitted to joking around with residents but did not recall making the specific comment. Another CNA present during the incident corroborated the resident's account of the event. The investigation findings supported the resident's allegation, leading to the termination of the CNA involved. The deficiency was identified during the course of a complaint investigation.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident, leading to the development and deterioration of a pressure ulcer on the resident's left lateral foot. The resident, who was cognitively impaired and dependent on staff for daily living activities, was first identified by hospice staff to have an unstageable pressure ulcer in February 2024. However, the facility did not identify or address this pressure ulcer until August 2024, despite having a care plan in place that included interventions for pressure injury prevention. The resident's medical history included severe cognitive impairment, cerebrovascular accident with left-sided hemiplegia, severe protein-calorie malnutrition, and Parkinson's disease, among other conditions. The facility had physician orders for weekly skin evaluations, but there was no documented evidence of assessments or interventions for the pressure ulcer from February to August 2024. The facility's failure to monitor and treat the ulcer resulted in its deterioration, with the ulcer being classified as a Stage IV pressure ulcer by September 2024. Interviews with hospice staff revealed communication issues with the facility's management, and the facility's documentation did not reflect the ongoing assessments and treatments provided by hospice. The facility's policy required weekly evaluations of skin alterations, but this was not adhered to, contributing to the deficiency. The facility's inaction and lack of comprehensive assessments and monitoring led to actual harm to the resident, as the pressure ulcer worsened over several months.
Failure to Respond to Resident's Call Light in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident's call light was answered in a timely manner, affecting one resident out of seven sampled. The resident, who had a moderate cognitive deficit and required substantial assistance with daily activities, had a call light activated for over 10 minutes without any staff response. The resident's family member had activated the call light at 9:25 A.M. due to difficulty in applying the resident's incontinence brief and the need to prepare the resident for a scheduled appointment. Despite the call light being activated, staff members, including a State Tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN), did not respond promptly. The STNA left the unit after finishing with another resident, and the LPN, when informed of the situation, did not take action to assist. It was only after more than 10 minutes that another LPN acknowledged the need to address the call light and mentioned the need to educate staff on timely responses. This incident was investigated under Complaint Number OH00158259.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with facial bruising to the required state agency. The resident, who had a severe cognitive impairment and was dependent on staff for assistance, was found with bruising on both sides of the jaw. The bruising was first noticed by an LPN and later confirmed by other staff members, but it was not reported to the state agency as required by the facility's policy. The facility's investigation determined that the bruising likely occurred when someone was holding the resident's mouth to encourage eating, as the resident had a history of pocketing food and being difficult to feed. The resident's medical history included multiple diagnoses such as cerebrovascular accident with left-sided hemiplegia, severe protein-calorie malnutrition, and major depressive disorder, among others. Despite the facility's policy requiring immediate reporting of injuries of unknown origin, the incident was not reported to the state agency. The facility's investigation into the incident was delayed, with skin sweeps not conducted until several days after the bruising was first observed. The deficiency was identified during a complaint investigation.
Delayed Investigation of Resident's Facial Bruising
Penalty
Summary
The facility failed to timely investigate an injury of unknown origin for a resident with facial bruising who was dependent on staff. The resident, who had a severe cognitive impairment and required extensive assistance for eating, was found with discoloration on the jaw by an LPN. Despite the observation, the incident was not immediately reported or investigated. Several staff members, including an STNA and an RN, noticed the bruising but did not take immediate action to report or document the incident properly. The facility's investigation into the bruising was delayed, with skin sweeps not conducted until several days after the bruising was first observed. The investigation determined that the probable cause of the bruising was related to someone holding the resident's mouth to encourage eating, as the resident had a history of pocketing food. The facility's policy on abuse requires a timely and thorough investigation of any allegations, which was not adhered to in this case, leading to a deficiency being cited.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident with a known history of falls. The resident, identified as having multiple medical conditions including aphasia, chronic kidney disease, and dementia, was at risk for falls due to factors such as deconditioning, incontinence, and muscle weakness. The care plan for the resident included various interventions to mitigate fall risks, such as keeping the bed in the lowest position, using non-skid footwear, and ensuring the call light was within reach. However, during an observation, it was noted that the resident's call light was out of reach, which was verified by an LPN. This oversight represents a failure to implement the planned interventions, specifically the accessibility of the call light, which is crucial for the resident's ability to request assistance and prevent falls. This deficiency was investigated under multiple complaint numbers, indicating a pattern of non-compliance in ensuring a safe environment for residents at risk of falls.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of a resident's oxygen nasal cannula, affecting one resident out of a sample of seven. The resident, who was dependent on supplemental oxygen due to chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypoxia, had a care plan that included providing oxygen at six liters per nasal cannula. Observations on multiple occasions revealed that the nasal cannula was wrapped around the oxygen holder and not stored in a protective bag. Additionally, a nebulizer machine was observed with its medication delivery system laying on the counter outside of a plastic bag. The resident's medical record indicated a moderate cognitive deficit and a range of diagnoses, including anxiety disorder, major depressive disorder, and peripheral vascular disease, among others. The physician's orders required the change of oxygen tubing and related equipment weekly and as needed, and to check the placement and positioning of the nasal cannula every shift. However, the observations made on consecutive days showed non-compliance with these orders, as confirmed by an interview with an LPN who verified the inappropriate storage of the oxygen nasal cannula and nebulizer delivery system.
Medication Availability Delay for Resident
Penalty
Summary
The facility failed to ensure the timely availability of medication for a resident, identified as Resident #31, who was affected by this deficiency. The resident had a complex medical history, including chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, and several other conditions. The resident was admitted with a moderate cognitive deficit, as noted in their comprehensive Minimum Data Set (MDS) assessment. A physician's order dated September 21, 2024, prescribed Cepacol sore throat lozenges to be administered every two hours as needed for a sore throat. However, the review of the resident's Medication Administration Record (MAR) for September 2024 showed that the lozenges were not administered until September 23, 2024, at 6:04 A.M. The pharmacy delivery invoice confirmed that the lozenges were not delivered until September 23, 2024. An interview with an LPN on October 3, 2024, verified that the Cepacol throat lozenge was not initiated in a timely manner. This deficiency was investigated under Complaint Number OH00158259.
Failure to Timely Obtain Physician-Ordered Lab Test
Penalty
Summary
The facility failed to timely obtain a physician-ordered laboratory test for a resident, which was identified as a deficiency. The resident, who had a complex medical history including chronic obstructive pulmonary disease, anxiety disorder, and other conditions, was admitted with a moderate cognitive deficit. The resident's care plan included monitoring for changes in elimination and obtaining a urinalysis and culture and sensitivity (UA/C&S) as ordered by the physician. However, the laboratory test was not conducted in a timely manner due to the unavailability of laboratory services over the weekend. The delay in obtaining the UA/C&S resulted in the resident being placed on an antibiotic for a urinary tract infection during an emergency room visit before the test could be conducted. The resident's daughter was informed of the delay, and the deficiency was confirmed through an interview with an LPN, who acknowledged that the urine sample was not collected as required. This incident was investigated under a specific complaint number, indicating noncompliance with the facility's obligation to provide timely laboratory services.
Unsanitary Mattress and Linen Found in Resident's Bed
Penalty
Summary
The facility failed to maintain resident equipment in a clean and sanitary manner, specifically affecting a resident with multiple medical conditions including COPD, anxiety disorder, and dependence on supplemental oxygen. The resident's family member discovered that the bed was made with soiled linen, and upon further inspection, found a rip in the mattress. The foam mattress underneath was stained yellow and brown with dried urine and feces, emitting a strong odor of urine. This indicates that the mattress had not been properly cleaned or maintained, posing a potential health risk to the resident. Interviews with the resident and her family member confirmed the unsanitary condition of the mattress. The family member reported assisting the resident back into bed and noticing the strong odor of urine from the cloth incontinence pad and the mattress. Photographs taken by the family member showed the stained mattress, corroborating the unsanitary conditions. The facility's Administrator verified that the mattress was not maintained in good repair or a clean and sanitary manner, confirming the deficiency.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, specifically affecting one of its four units, the 500 unit, with a census of 72 residents. Observations on September 30, 2024, revealed that the carpeting in Resident #31's room was stained with black and white spots, which had been present since her admission. The resident had even offered to pay for the carpet to be shampooed. Further observations of unoccupied and occupied rooms in the same unit showed similar black stains on the carpeting. On October 3, 2024, an LPN confirmed the presence of stained carpeting in multiple rooms, including rooms 506, 511, and Resident #31's room. This deficiency was investigated under several complaint numbers, indicating ongoing issues with maintaining cleanliness in the facility.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed, specifically regarding hand hygiene and the use of personal protective equipment (PPE) to prevent the spread of COVID-19. This deficiency was observed during the delivery of meal trays by a State tested Nursing Assistant (STNA) who did not adhere to the required protocols. The STNA was seen delivering meal trays to residents, including those with active COVID-19 infections, without changing masks or performing hand hygiene between rooms. The STNA wore only a surgical mask and no additional PPE, despite the facility's policy requiring an N-95 respirator mask, gown, gloves, and face shield for staff entering rooms of residents with COVID-19. The report highlights that two residents were identified with active COVID-19 infections and were under contact and droplet precautions. Despite this, the STNA continued to enter multiple residents' rooms without changing PPE or performing hand hygiene, potentially affecting 16 residents in the hall. Interviews with the STNA and a Licensed Practical Nurse (LPN) confirmed the lack of adherence to the facility's infection control policy, which was revised to include specific PPE requirements for COVID-19 precautions. This deficiency was investigated under multiple complaint numbers, indicating a pattern of noncompliance.
Failure to Provide Appropriate Care After Resident Accident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident following an accident with injury. Resident #99, who had diagnoses including diffuse large B-Cell lymphoma, muscle weakness, viral hepatitis B, and atrial fibrillation, was admitted to the facility with mildly impaired cognition and required partial/moderate assistance with bed mobility. On a specific date, while being assisted with bed mobility, the resident hit her head on the side rail. Despite this incident, the facility did not notify the physician, initiate neurological checks, or conduct follow-up assessments. The resident was later transferred to the hospital due to concerns from the resident's representative about changes in the resident's behavior. Hospital records revealed a mid-left parietal scalp hematoma without skull fracture. Interviews with the resident's representative and a Licensed Practical Nurse confirmed that the facility staff did not complete an incident report, initiate neurological checks, notify the physician, or conduct follow-up assessments after the incident. The facility's policy required reporting, investigating, and reviewing any accidents or incidents involving residents, including initiating neurological checks in the event of head trauma.
Deficiencies in Food Handling and Sanitation
Penalty
Summary
The facility failed to ensure proper date labeling, cleanliness of dishware, and appropriate hot holding temperatures for food, potentially affecting all residents except two who were NPO. Observations revealed that iced tea, lemonade, and punch were incorrectly dated, and a tub of chocolate pudding had an extended date. Hard-boiled eggs and wedge tomatoes were also found with expired dates. The Dietary Manager and Corporate Nutrition Services Coordinator confirmed the discrepancies and discarded the expired items. The facility's policy stated a seven-day use-by date for refrigerated items, but the staff did not adhere to this guideline. Additionally, clear plastic food storage containers on the air-dry rack were found soiled with sticky residue and food debris. The Dietary Manager confirmed the contamination and rewashed the containers. During a tray line observation, the temperatures of carrots, mashed potatoes, and a fish sandwich were below the required 135 degrees Fahrenheit, while French fries were at 172 degrees Fahrenheit. The Dietary Manager and Corporate Nutrition Services Coordinator acknowledged the issue, noting that hot foods should be held at 140 degrees Fahrenheit or above. The facility's policy required TCS foods to be maintained at 135 degrees Fahrenheit or above, which was not followed in this instance.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure food was served at a palatable and warm temperature, affecting four residents and potentially impacting all residents receiving meals from the kitchen. Resident #9, diagnosed with diverticulosis, dysphagia, and irritable bowel syndrome, reported that the food was served cold. Resident #10, with congestive heart failure, type II diabetes, and morbid obesity, also reported that the food was cold and lukewarm. Resident #29, diagnosed with type II diabetes, acute kidney failure, and morbid obesity, stated that the food was sometimes undercooked, overcooked, and cold. Resident #49, with legal blindness, cerebral infarction, and heart failure, described the food as terrible, too cold, and too salty to eat. These observations were confirmed through interviews and medical record reviews for each resident involved. The facility census was 80, with two residents identified as NPO and not affected by the food temperature issue. Observation of the tray line and test tray on 04/17/24 revealed that the food temperatures were below the required 135 degrees Fahrenheit. The Dietary Manager confirmed that the carrots were 124 degrees F, mashed potatoes were 121 degrees F, the fish sandwich was 124 degrees F, and the French fries were 172 degrees F when placed on the test tray. Upon arrival at the 200 Hall and subsequent serving, the food temperatures had further decreased to 113 degrees F for the carrots, 111 degrees F for the mashed potatoes, and 118 degrees F for the French fries. The facility's Food Temperature Monitoring and Recording Policy mandates that all TCS hot food items must be served at a temperature of at least 135 degrees F, which was not adhered to in this instance. The Dietary Manager acknowledged the issue and noted that test trays had not been conducted since her tenure at the facility.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure nail care was provided for a resident who was dependent on staff. Resident #22, who had multiple diagnoses including cerebral infarction, chronic kidney disease, and diabetes mellitus, was observed on two separate occasions with long, jagged, and dirty fingernails containing a brown substance. The resident's care plan indicated that staff should check nail length and trim and clean nails on bath day and as necessary. However, these interventions were not followed, as evidenced by the observations and the resident's own admission that she was unable to clean her nails herself and desired assistance. The deficiency was confirmed through medical record review, observations, and interviews. The resident's quarterly Minimum Data Set (MDS) assessment indicated a moderate cognitive deficit, further emphasizing her dependence on staff for personal hygiene. Despite the facility's policy on nail care, which mandates that RNs, LPNs, and STNAs provide appropriate nail care to prevent infections, the staff failed to adhere to these guidelines, resulting in the resident's neglected nail care.
Failure to Identify and Document Toe Injury
Penalty
Summary
The facility failed to identify and appropriately document an injury to a resident's left great toe and toenail. Observations revealed the resident's toe was covered with a gauze bandage that lacked proper labeling. Further examination showed dark red drainage on the bandage and a thick, long toenail with dried dark red drainage, indicating it had not been trimmed or filed recently. The resident's medical record did not contain any treatment orders for the toe injury, and weekly skin assessments and progress notes did not document the injury or the need for a bandage. Interviews with the resident's spouse and facility staff confirmed the presence of the bandage and the lack of documentation or treatment orders. The resident had refused podiatry services earlier in the month, and the Director of Nursing revealed that the injury occurred when the resident's toe got caught in the bed covers, causing the toenail to bleed. The facility's policy on skin and wound care requires evaluation and documentation of skin alterations by a licensed nurse, which was not followed in this case.
Failure to Ensure Pressure Reducing Devices for Resident
Penalty
Summary
The facility failed to ensure that pressure reducing devices were in place for Resident #17, who had a history of multiple medical conditions including osteomyelitis, dementia, diabetes mellitus, and chronic kidney disease. The resident's care plan included specific interventions to prevent skin injury and manage existing wounds, such as the use of a heel protector to reduce pressure on the left heel. However, observations on multiple occasions revealed that the heel protector was not in place, leaving the resident's left achilles directly on the bed, contrary to the care plan requirements. The resident's medical record indicated a history of a surgical wound to the left achilles, which was present on admission and required ongoing treatment. Weekly skin and wound evaluations documented the wound's measurements and condition, noting moderate amounts of drainage and the presence of slough. Despite the documented need for pressure relief and the care plan's directive to use a heel protector, staff failed to ensure the device was consistently in place, as observed on 04/16/24 and verified by a State tested Nursing Assistant (STNA). Further observations on 04/17/24 during a wound treatment procedure confirmed the absence of the heel protector, with the resident's left achilles laying directly on the bed. The facility's policy on skin and wound care emphasized the importance of individualized care plans to address specific risk factors and prevent skin injury. The failure to adhere to the care plan and ensure the use of pressure reducing devices contributed to the deficiency identified in the report.
Lack of Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to have a physician's order for the use of oxygen for Resident #35. An observation revealed that Resident #35 was receiving oxygen via nasal cannula with the oxygen concentrator set at four liters. However, a review of Resident #35's medical record showed no physician orders for oxygen use. Additionally, the resident's care plan for COPD did not include any interventions for oxygen use, and there was no documentation of oxygen use in the progress notes from 04/01/24 to 04/16/24. Resident #35 was admitted to the facility with diagnoses including Lewy Bodies disorder, Alzheimer's disease, high blood pressure, and COPD. The resident was also admitted to hospice services for neurocognitive disorder with Lewy Bodies disease. Despite these conditions, the facility did not have the necessary physician orders for oxygen use, which was confirmed by the LPN Unit Manager. The facility's policy requires managing residents utilizing oxygen per physician orders, which was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 10.34 percent error rate. This was observed during medication administration for two residents. For Resident #19, the LPN administered 40 mEq of Potassium Chloride instead of the physician-ordered 20 mEq and 10 mg of Famotidine instead of the prescribed 20 mg. The resident had multiple diagnoses, including cerebrovascular accident, dysphagia, and chronic kidney disease, and was noted to have a moderate cognitive deficit. The errors were confirmed through interviews with the LPN involved in the administration. For Resident #17, the LPN administered Cyclosporine Ophthalmic Emulsion 0.05% in both eyes, despite the physician's order specifying administration only in the right eye. The resident had a history of osteomyelitis, asthma, dementia, and other conditions, and also had a moderate cognitive deficit. The LPN's actions were observed and verified through an interview. The facility's policies on medication administration and eye drop administration were reviewed, revealing that the procedures were not followed as required.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to ensure the primary care physician (PCP) was notified of elevated blood glucose levels outside of the physician-ordered parameters for Resident #16. The resident, who had multiple diagnoses including diabetes mellitus, had a care plan that required blood glucose monitoring and physician notification for levels less than 60 or greater than 200. Despite this, the resident's medical record showed multiple instances in April 2024 where blood glucose levels exceeded 200, with no documented evidence that the PCP was notified. Specifically, blood glucose levels of 218, 225, 237, 248, 208, and 215 were recorded without corresponding notifications to the physician. An interview with an LPN confirmed that the physician was not notified of these elevated blood glucose levels. The facility's policy on Change in Condition Notification, dated 08/09/23, mandates notifying the resident, their attending physician, and the resident's designated representative of changes in the resident's medical or mental condition. This deficiency was identified during an investigation under Complaint Number OH00152459.
Failure to Implement Individualized Fall Preventative Interventions
Penalty
Summary
The facility failed to ensure individualized fall preventative interventions were in place for two residents. Resident #16, who had multiple diagnoses including osteomyelitis, dysphagia, and chronic obstructive pulmonary disease, was identified as being at risk for falls. Despite having a care plan that included interventions such as keeping the bed in a low position and using a fall mat, an observation revealed that the fall mat was folded up and not in place. This was verified by a State tested Nursing Assistant (STNA) and was contrary to the facility's Fall Management Guidelines policy, which emphasizes individualized interventions to minimize fall risks. Similarly, Resident #68, who had a history of breast cancer, dementia, and chronic obstructive pulmonary disease, was also at risk for falls. The care plan for this resident included the use of Dycem on the wheelchair seat for safety. However, an observation revealed that the Dycem was not in place, and instead, the wheelchair seat had a waffle air cushion and other items like playing cards and a magazine. The Director of Nursing (DON) confirmed the absence of Dycem, which should have been on top of the foam pressure-reducing cushion. This was also against the facility's Fall Management Guidelines policy.
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.
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What surveyors actually found near you
We read the 931 citations issued within 25 miles in the last 12 months — including the 10 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 Canal Winchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Of Canal Winchester Post-acute Rc | 0.4 mi | ★★★★★ | 36 | 1 |
| Embassy Of Winchester | 0.8 mi | ★★★★★ | 5 | 0 |
| Pickerington Care And Rehabilitation | 4 mi | ★★★★★ | 28 | 0 |
| Violet Springs Health Campus | 4.8 mi | ★★★★★ | 19 | 0 |
| Eastland Rehabilitation And Nursing Center | 6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.