Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carecore At Mary Scott during CMS and state inspections, most recent first.
A resident with bipolar disorder, schizoaffective disorder, and schizophrenia, who was legally deemed incompetent and had a guardian over person, was repeatedly allowed to sign out and leave on unsupervised LOAs despite the guardian’s explicit requests to the DON and Administrator to prohibit such leave. Over several months, the resident went out unsupervised 159 times. The care plan identified elopement risk, dissatisfaction with guardian placement, and intent to leave, and called for guardian guidance/consent. The guardian reported seeing the resident in the community punching people and confirmed she had told facility leadership not to allow unsupervised LOAs. The RDCO, Administrator, and DON acknowledged they continued to permit daily unsupervised LOAs based on the resident’s BIMS score of 15 and their view of resident rights, despite the guardian’s objections.
A resident with dementia and multiple comorbidities, who remained largely independent in ADLs, and the resident’s daughter/POA repeatedly requested transfer to another facility with a memory care unit. An LPN documented the resident believed she was supposed to move but there were no discharge or transfer orders, leading to resident agitation. Social services and admissions staff documented that referrals would be sent to several named facilities, but email correspondence and staff interviews showed miscommunication over who was responsible for sending the referrals and confirmed that only one referral was actually sent. This failure to timely and consistently act on the resident and family’s discharge and transfer request did not align with the facility’s discharge planning policy.
A resident with multiple comorbidities, moderate cognitive impairment, and a left heel wound did not receive consistent weekly skin assessments or accurate wound treatment as ordered. Facility records showed only two documented weekly skin assessments over several months, despite policy requiring weekly assessments. The TAR reflected nightly heel wound treatments as completed by various LPNs, but observation revealed a heel dressing that was two days old, with the DON confirming it had been dated ahead and signed on an earlier shift. An LPN acknowledged signing for a heel treatment he did not perform and stated he was unaware the resident had a heel treatment, demonstrating a failure to provide and accurately document ordered wound care.
Staff failed to wear beard restraints during food preparation and used expired chemical test strips to check sanitizing solutions, contrary to facility policy and professional standards. These lapses in food safety and sanitation practices affected all residents receiving meals from the kitchen.
Expired and undated insulin was found in two medication carts during observation. An LPN identified that opened insulin is only good for about 28 days, yet one vial of Lantus and another insulin vial had exceeded that timeframe, and three additional insulin vials were left without open dates. Staff stated the nurse who opened the insulin was responsible for dating it, and the IP, IDON, and Administrator all confirmed that expired or undated insulin should not remain in the carts.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact, repeatedly requested to be transferred to the hospital during episodes of acute symptoms such as chest pain, low blood sugar, and gastrointestinal distress. Despite these requests, nursing staff deferred to the PCP, who typically ordered in-house treatment and monitoring rather than approving a hospital transfer. Staff interviews confirmed that the resident's right to self-determination and participation in care decisions was not honored, in violation of facility policy and resident rights regulations.
A resident with a history of mental health diagnoses and intact cognition was unable to access a private area for telephone use, as facility phones were located in open, public spaces where conversations could be overheard. Staff interviews confirmed the lack of private phone areas, and facility policies requiring privacy for resident communications were not followed.
The facility failed to report multiple allegations of abuse—including physical, verbal, and threatening behavior—by staff and residents to the State Survey Agency as required by policy. In each case, staff and leadership were aware of the allegations but did not ensure timely reporting, despite clear evidence and internal acknowledgment that the incidents met the criteria for mandatory reporting.
Failure to Thoroughly Investigate Abuse Allegations: The facility did not thoroughly investigate abuse allegations involving three residents. One resident with dementia and moderate cognitive impairment alleged an RN shoved a table into the resident’s knee and was rude, but the file lacked immediate resident interviews, assessment, or suspension of the alleged perpetrator. Another resident with schizophrenia and other psychiatric diagnoses reported a CNA told the resident to shut up, yet no abuse report or investigation was completed. A third resident with depression, PTSD, and cerebral palsy was discharged after threats and weapons were reported, but the Administrator stated no investigation was done to determine whether the resident threatened others or to interview staff.
A resident with depression, anxiety, PTSD, ADHD, and cerebral palsy was discharged after the facility reported weapons and a death threat, but the chart did not contain documented behaviors supporting the emergency discharge reason. The physician’s discharge plan included home therapy, DME follow-up, and PCP follow-up, yet the SSD stated she did not help arrange follow-up appointments or other discharge services. The record also showed no documented behavioral issues before the discharge and no active discharge planning in the MDS.
Inaccurate and Incomplete Discharge Documentation: A resident with depression, anxiety, PTSD, ADHD, and cerebral palsy was discharged after threatening another resident and having weapons and other items found in the room. The discharge paperwork was inconsistent about the reason for discharge and the discharge destination, with one record listing home or a homeless shelter and another listing home only, while the chart also lacked a complete recitation of the discharge reason and destination. Progress notes later stated the resident had been given homeless shelter and food bank information, and the SSD said she did not assist with follow-up appointments or other discharge services.
The facility failed to develop individualized care plans with measurable objectives for two residents. One resident with stroke, OA, cognitive impairment, and dependence for ADLs had a care plan that did not specify the right hand splint schedule or contracture details, even though OT orders and discharge notes addressed splint use and an observation showed a contracted hand with no protective device in place. Another resident with CHF, COPD, and asthma was observed smoking, but the care plan had no smoking focus area despite a smoking assessment showing the resident smoked independently and could light a cigarette; the DON, IP/unit manager, and Administrator all stated a smoking care plan was expected.
Failure to keep a resident's fingernails clean and trimmed: A resident with MS, DM, severe cognitive impairment, and dependence for personal hygiene had fingernails extending well beyond the fingertips with black matter underneath on repeated observations. CNAs said they were responsible for nail care or for notifying the nurse if the resident had DM, but one CNA did not report the issue and another said she was unaware she needed to report it. An LPN later confirmed the nails needed to be cleaned and trimmed.
Failure to Apply Ordered Splints and Handrolls: Two residents with contracted hands had physician-ordered splints or handrolls that were not applied as directed. One resident with stroke history and severe cognitive impairment had a right-hand splint left off while the splint sat on nearby furniture, and staff did not document donning or doffing. Another resident with MS and severe cognitive impairment had a left palm roll ordered while out of bed, but observations repeatedly found no roll or splint in the hand, and staff were unsure who was responsible for applying it.
Incorrect Low Air Loss Mattress Weight Settings: Two residents with orders for low air loss mattresses had settings that did not match their documented weights. One resident with CHF, severe cognitive impairment, and ADL dependence had a mattress dial set between 240-280 lbs. despite a weight around 173-174 lbs. Another resident with severe cognitive impairment, malnutrition, and ADL dependence had the dial set at 120 lbs. despite a weight dropping from 90.2 lbs. to 74.8 lbs. Staff stated the settings were placed by the mattress company, while the IDON stated nurses were to ensure the dial was correct for the resident’s weight.
The facility failed to keep resident lighters secured as required by the smoking policy. Three residents with intact cognition and smoking assessments showing they could light their own cigarettes were observed retaining lighters in bags or pouches and using them during smoke breaks; one resident even handed a lighter to another resident to light a cigarette. The AD, LPN, UM/IP, and IDON all stated lighters were supposed to be stored by staff in a locked location, but the residents had kept them instead.
Blood glucose monitor not sanitized between resident uses. An LPN checked a resident’s blood sugar, then returned the monitor to the medication cart and placed it in a drawer without cleaning it before moving on to the next resident. The resident had DM and severe cognitive impairment, and facility leaders and the manufacturer’s instructions all indicated the monitor should be cleaned and disinfected between patient use.
A resident's family member reported missing oxycodone, prompting police involvement, but the facility did not report the allegation of misappropriation to the State Agency. Staff failed to verify and document the amount and condition of the controlled substance upon receipt, and facility records showed no self-reported incident was filed, despite policy requirements.
A resident with a tracheostomy and multiple complex medical conditions did not have an extra trach tube available at the bedside as required by their care plan and facility policy. Staff confirmed that necessary trach supplies were not always available, and when a replacement was provided, it did not match the physician's order. This resulted in non-compliance with established care protocols.
The facility was found to have improperly stored food items, including undated and unsealed packages of hot dogs, pepperoni, shredded cheese, bologna, and sliced turkey. The Dietary Manager confirmed these items were not stored according to the facility's policy, which mandates dating of refrigerated and freezer foods.
A resident with multiple health conditions experienced delays in receiving a hip replacement surgery due to inadequate scheduling and transportation arrangements. The surgery was initially postponed for dental clearance, which was delayed, and later canceled due to transportation issues. The facility's failure to document and coordinate these appointments led to significant delays in the resident's care.
The facility failed to maintain complete medical records for residents' outside medical appointments, affecting three residents. A resident with multiple diagnoses had incomplete documentation for orthopedic and dental appointments, while another resident had no record of a radiology appointment. A third resident's dental appointment lacked documentation. Interviews confirmed the lack of documentation and communication from external providers.
A facility failed to administer an antibiotic as ordered for a resident with a history of psychoactive substance abuse, obesity, osteomyelitis, pulmonary embolism, and ADHD. The medication was not documented as administered on several occasions, despite a physician's order for daily intravenous administration. This was confirmed by the DON.
Failure to Honor Guardian Restrictions on Unsupervised Leave of Absence
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to follow a resident’s legal guardian’s request to prohibit unsupervised Leaves of Absence (LOAs). The resident had been admitted with bipolar disorder, current manic episode with psychotic features, anxiety disorder, and schizoaffective disorder. An Annual MDS showed the resident was cognitively intact with a BIMS score of 15. The resident’s care plan documented risk for injury related to elopement, dissatisfaction with guardian placement, intent to leave the facility, and schizophrenia, with interventions including updating boundaries, mental status, and guardian guidance/consent, and noting that the guardian sometimes gave permission for the resident to sign herself out. Amended Letters of Guardianship from probate court showed the resident was deemed incompetent and had a legal guardian over person only. Record review showed that over a several‑month period the resident signed herself out and went on unsupervised LOAs 159 times. The resident’s guardian reported she had repeatedly asked the DON and Administrator for months not to allow the resident to leave unsupervised because of the resident’s schizophrenia and non‑adherence with medications, and stated she had personally seen the resident downtown at a bus stop punching people and at a bread store. The Regional Director of Clinical Operations confirmed the facility allowed the resident to leave unsupervised on a daily basis because she had a BIMS of 15 and “has rights,” despite knowing the guardian did not want the resident to go on LOAs. The Administrator and DON also confirmed they allowed the resident to leave unsupervised daily, citing resident rights and the resident’s intact cognition, even though the guardian had informed the facility not to let the resident leave.
Failure to Timely Process Resident and Family Request for Transfer to Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with a resident and family-initiated request for discharge and transfer to another facility with a memory care unit. The resident, who had multiple diagnoses including type 2 diabetes, dementia, nutritional deficiency, acute kidney failure, transient ischemic attack, and atherosclerotic heart disease, had a BIMS score of eight indicating cognitive impairment but was largely independent with personal care and ADLs. On one date, an LPN documented that the resident stated she was supposed to move to another facility that day, but there were no transfer or discharge orders, and the resident became agitated and required redirection. A subsequent progress note documented that the social service worker spoke with the resident’s daughter/guardian, who requested a transfer to a facility with a memory care unit and stated that a referral had been sent. Further review showed that on a later date the Admissions Director spoke with the resident’s daughter, who was also power of attorney, and the daughter again requested referrals to facilities with memory care units. The Admissions Director emailed the Senior Social Worker listing five specific facilities and documented that the daughter wanted referrals sent to those facilities; the Senior Social Worker replied that she would take care of the referrals by the end of that business day. A follow-up email from the Admissions Director several days later requested an update, and the Senior Social Worker responded that she would be in the building on Tuesday and referenced having state in three facilities and things being “a little crazy.” Interviews revealed conflicting accounts: the former social service worker stated he sent a referral on the same day he was terminated; the Senior Social Worker stated she told the Admissions Director to send the referrals; and the Admissions Director stated she was told the Senior Social Worker would send them and verified that only one referral had actually been sent. This sequence of miscommunication and lack of follow-through on the resident/family’s transfer request was inconsistent with the facility’s discharge planning policy, which required safe, person-centered, and compliant discharge planning in collaboration with the resident, representative, and interdisciplinary team.
Failure to Complete Ordered Heel Wound Care and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete weekly skin assessments and ordered wound treatments for a bedbound resident with a left heel wound. The resident, admitted with multiple diagnoses including morbid obesity, schizoaffective disorder, chronic pain syndrome, osteoarthritis, and major depression, had moderate cognitive impairment and required staff assistance for ADLs. Facility records showed that from the time the heel wound was identified on 12/18/25 through 03/23/26, only two weekly skin assessments were documented, on 02/03/26 and 03/17/26, despite facility policy requiring weekly assessments with each risk assessment. The resident’s care plan identified her as at risk for skin breakdown due to incontinence, decreased mobility, impaired cognition, and obesity, and noted she was resistive to care and turning and repositioning, with interventions including completion and monitoring of skin treatments per physician orders. Review of the physician’s order dated 03/06/26 showed a nightly and as-needed wound care regimen for the left heel, including cleansing, drying, applying collagen, and covering with a border foam dressing. The TAR from 12/18/25 through 03/24/26 showed the left heel wound treatment documented as completed, including entries by multiple LPNs on 03/21/26, 03/22/26, and 03/23/26. However, on 03/24/26, observation of the resident’s left heel with an LPN and the DON revealed the dressing was dated 03/22/26 and was two days old. The DON confirmed that the night-shift LPN who worked on 03/21/26 had dated the dressing 03/22/26 and signed the TAR on 03/21/26. Another LPN stated he did not know the resident had a heel treatment, verified he had not completed the treatment on 03/22/26, and stated he was not falsifying documentation when signing it off. The DON further verified that only two weekly skin assessments had been completed during the review period, contrary to facility policy and expectations.
Failure to Ensure Food Safety Standards in Food Preparation and Sanitation Testing
Penalty
Summary
The facility failed to ensure that food was prepared and served in accordance with professional standards for food service safety. Observations revealed that dietary staff did not wear appropriate beard restraints while preparing various food items, including pork chops and coleslaw. Multiple staff members were seen with uncovered beards and mustaches during food preparation, and both staff and management acknowledged during interviews that beard restraints should have been used to prevent hair from contaminating food. Facility policy required the use of hair restraints, including beard restraints, to prevent hair from contacting food. Additionally, the facility did not ensure that chemical test strips used to check the concentration of sanitizing solutions were within their expiration dates. The Dietary Manager was observed using QT-40 test strips that had expired several years prior, and chlorine test strips that were also reported as ineffective and near or past expiration. Staff interviews confirmed that expired test strips were in use and that staff should have checked expiration dates to ensure accurate testing of sanitizing solutions. Facility policy required that chemical sanitizing solutions be maintained at correct concentrations, verified by periodic testing with appropriate test strips. These deficiencies affected all residents who consumed food prepared in the facility's kitchen, as the lapses in food safety practices and sanitation testing could impact the overall safety and quality of food service. The findings were based on direct observations, staff interviews, and review of facility policies and documentation.
Expired and Undated Insulin Left in Medication Carts
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when the facility failed to date opened insulin vials and failed to remove expired insulin from two medication carts. On 12/12/25, an observation of the 100 Hall medication cart found a vial of Lantus with an open date of 11/13/25. During the same observation, an LPN stated Lantus was good for 28 days after opening, meaning the vial was expired and should have been removed from the cart. The LPN stated medication carts were checked weekly during cart audits and that nurses were expected to check medication labels for expiration dates before administration. A second observation of the 200 Hall medication cart found one vial of insulin with an open date of 10/31/25 and three additional insulin vials that had been opened and used but were left undated. An LPN stated the insulins were good for a month after opening and that the nurse who opened the vial or pen was responsible for placing the open date on the container. The IP, IDON, and Administrator all stated that opened insulin should be dated and expired or undated insulin should be removed from use; the IDON also stated she had last checked those carts two weeks prior. A facility policy titled Medication Labeling and Storage stated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a different date.
Failure to Honor Resident's Right to Hospital Transfer
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding treatment options, specifically the right to request transfer to a hospital. The resident, who had a history of type II diabetes, hypertension, heart disease, schizophrenia, and other mental health conditions, was cognitively intact as evidenced by a BIMS score of 15. Multiple progress notes documented that the resident experienced various acute symptoms, including pallor, clamminess, twitching, incontinence, difficulty breathing, sweating, shaking, diarrhea, nausea, and chest pain radiating to the left arm. On several occasions, the resident explicitly requested to be transferred to the hospital due to these symptoms. Despite these requests, the nursing staff contacted the primary care provider (PCP), who typically ordered laboratory tests and monitoring rather than approving a hospital transfer. In some instances, the PCP did not return calls, and when contacted, often instructed staff to treat the resident in the facility, stating that hospital care would not differ from what could be provided on-site. The resident's care plan did not document repeated requests for hospital transfer, and staff interviews confirmed that the resident's wishes were not honored, with the PCP's refusal cited as the reason. The Social Services Director and the Interim Director of Nursing both acknowledged that the resident had the right to seek care elsewhere, and the Administrator stated that the resident should have been allowed to go to the hospital if requested. The facility's policy on resident rights, which includes self-determination and participation in care decisions, was not followed in these instances. Interviews with staff and the resident confirmed that the resident's repeated requests to be transferred to the hospital were not granted, and the staff deferred to the PCP's decision rather than honoring the resident's right to choose their treatment options. This resulted in a failure to comply with federal and state regulations regarding resident rights.
Failure to Provide Private Telephone Access for Resident
Penalty
Summary
The facility failed to provide a resident with reasonable access to a telephone in a private setting, as required by both facility policy and resident rights. Observations revealed that the designated telephone stations were located in open areas without doors or walls, allowing conversations to be overheard by staff, residents, and visitors. One resident, who had a history of paranoid schizophrenia, psychosis, anxiety disorder, and personality disorder, and who was cognitively intact and independent with ADLs, was observed making phone calls in these open areas. The resident expressed concerns about the lack of privacy, stating a preference for one phone location over another due to less foot traffic, but still noted there was no privacy available. Interviews with staff, including CNAs, an LPN, the Infection Preventionist, the Interim DON, and the Administrator, confirmed that the facility's phones were not portable and were situated in open, non-private locations. Staff acknowledged the lack of designated private areas for resident phone calls, and the Infection Preventionist reported occasionally offering his office for private calls. Facility policies reviewed indicated that residents were guaranteed the right to private communication, and that telephones should be located in areas offering privacy, but these policies were not being followed in practice.
Failure to Timely Report Allegations of Abuse to State Survey Agency
Penalty
Summary
The facility failed to report multiple allegations of abuse to the State Survey Agency (SSA) as required by both facility policy and federal regulations. In the case of one resident with moderate cognitive impairment and a history of dementia, the resident alleged that a registered nurse shoved a bedside table into their knee and spilled water on them. Multiple staff members, including two CNAs and the RN involved, became aware of the allegation and reported it to the Interim Director of Nursing (IDON). However, the IDON did not report the incident to the SSA, stating she did not believe the CNA and did not consider the behavior to be abuse. The Administrator was not made aware of the full details of the incident and confirmed that the allegation should have been reported to the SSA within two hours, as per facility policy. Another incident involved a resident with intact cognition who reported that a CNA told them to "shut up" and was rude. This allegation was reported to the Administrator, but there was no evidence that it was reported to the SSA. The Social Services Director confirmed that such language constituted verbal abuse, and both the IDON and Administrator acknowledged that the incident should have been reported to the SSA. The Administrator admitted to forgetting to document and report the allegation. A third incident involved a resident with a history of mental health diagnoses who was discharged after allegedly making a death threat to another resident and possessing weapons and pills in their room. The discharge notice cited the threat and the presence of weapons as reasons for the emergency discharge, but there was no evidence that the threat was reported to the SSA. Staff interviews confirmed that the threat and the presence of weapons were known to facility leadership, and the Administrator acknowledged that the incident should have been reported. Facility policy required immediate reporting of all alleged violations to the SSA, but this was not followed in these cases.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving three residents. For Resident #69, who was admitted with dementia and had a quarterly MDS showing a BIMS score of 8 and moderate cognitive impairment, the record and interviews showed that on 12/06/25 the resident reported that RN #10 shoved a bedside table into the resident’s knee and was rough and disrespectful. The facility’s investigation file did not show that Resident #69 or other residents were immediately interviewed, that RN #10 was suspended pending investigation, or that the resident was immediately assessed after the allegation. Although the IDON later stated she interviewed the resident, she described the interview as asking how the resident’s day was and did not document it or ask specifically about the incident. For Resident #43, who had diagnoses including schizophrenia, psychosis, depression, and other chronic conditions and had intact cognition on the quarterly MDS, the resident stated that CNA #18 told them to shut up and was rude when the resident removed sugar from a coffee cart. The allegation was reported to the Administrator, but there was no report or facility investigation for the verbal abuse allegation. The SSD stated the allegation was not discussed with her at the time, and the IDON and RDCS stated they were unaware of it. The Administrator later stated she had not reported the allegation to the SSA and said she may have gotten distracted and forgotten the incident. For Resident #78, who had diagnoses including severe recurrent major depression, anxiety disorder, ADHD, PTSD, and cerebral palsy and had intact cognition on the annual MDS, the facility issued an emergency discharge notice stating the resident endangered others and listing threats and weapons found in the room. The SSD stated the resident showed air soft rifles and handguns to another resident and threatened to harm that resident, causing fear. The Administrator stated there had not been an investigation to determine whether Resident #78 threatened other residents and that she did not interview staff to see if anyone had information about threats. The facility policy required immediate investigation, interviewing involved persons and witnesses, and complete documentation, but the report showed those steps were not thoroughly completed for these allegations.
Emergency discharge lacked documented behavior support and discharge coordination
Penalty
Summary
The facility failed to document in the medical record any behaviors to support the stated reason for an emergency discharge and failed to assist with coordinating after-discharge care as outlined in the physician’s Discharge Summary. The deficiency involved one resident who had been admitted with diagnoses including severe recurrent major depression without psychotic features, anxiety disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, and cerebral palsy. The resident’s annual MDS showed intact cognition with a BIMS score of 15, mild depressive symptoms, no behavioral symptoms during the lookback period, wheelchair use for ambulation, and assistance needs for several ADLs, while also indicating no active discharge planning was occurring. The resident’s care plan included goals related to returning to the community, follow-up with a PCP after discharge, and interventions for a history of polysubstance abuse and emotional, mental, and physical distress related to traumatic life experiences. The physician’s progress note documented anxiety and depression and advised monitoring by staff and reporting to the provider as needed. The Emergency Discharge Notice stated the resident was being discharged because the health of other individuals in the facility was endangered, listing a death threat to another resident and firearms, a knife, pills, and police badge items found in the resident’s room, with discharge to home or a homeless shelter. However, the resident’s medical record contained no other documented information supporting threats to other residents or weapons in the room. The physician’s Discharge Summary stated the resident was discharging home, had been a long-term care resident for assistance with ADLs, and was being discharged because firearms were found. It also stated the discharge plan included home therapy, social services follow-up for DME needs, and PCP follow-up. The Social Services Director stated she was responsible for arranging discharges but did not assist with making follow-up appointments or providing other services after discharge. The Administrator stated no other ideas or alternatives were discussed before the emergency discharge, that the homeless shelter was called before the resident arrived, and that the resident was transported by a family member, with uncertainty about whether the resident went to a shelter or not.
Inaccurate and Incomplete Discharge Documentation
Penalty
Summary
The facility failed to ensure a resident’s discharge was accurately and thoroughly documented in the medical record. Resident #78 was admitted with diagnoses including severe recurrent major depression without psychotic features, anxiety disorder, ADHD, PTSD, and cerebral palsy. The resident’s annual MDS showed intact cognition with a BIMS score of 15, mild depressive symptoms, no behavioral symptoms during the lookback period, and use of a wheelchair. The resident required varying levels of assistance with ADLs, participated in assessment and goal setting, and had care plan focus areas related to returning to the community, a history of polysubstance abuse, and risk for emotional, mental, and physical distress due to traumatic life experiences. The discharge documentation was inconsistent across records. An Emergency Discharge Notice stated the resident was being discharged because the health of other individuals in the facility was endangered, citing a death threat made to another resident and firearms, a knife, a vial of pills, and fake and real-looking police badges found in the resident’s room. That notice stated the resident was being discharged to either home or a homeless shelter. However, the physician’s Discharge Summary stated the resident was discharging home, listed the reason as being found with firearms, and included a discharge plan for home therapy, social services follow-up for DME needs, and PCP follow-up. The Discharge Summary did not include the homeless shelter as a possible discharge location and did not list the full reason for discharge as stated in the discharge notice. Progress notes documented that the resident had been discharged the prior day and had been given information about homeless shelters and food banks. The Social Services Director stated she was primarily responsible for arranging discharges and said the resident was discharged because they had brought air soft rifles and handguns into the facility and threatened another resident, causing fear. She also stated she did not assist with follow-up appointments or other discharge services. The Administrator stated the resident was discharged to a local homeless shelter and transported by a family member, but also stated the resident left with a family member and it was unclear whether the resident actually went to a homeless shelter. The facility policy required a discharge summary to include a recapitulation of care and services, the resident’s status at discharge, and post-discharge care instructions.
Incomplete resident-centered care plans for contracture management and smoking
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans with measurable objectives for two residents whose care plans were reviewed. Resident #3 was admitted with diagnoses including cerebral infarction (stroke) and osteoarthritis, and a quarterly MDS showed severe impairment in cognitive skills for daily decision-making, short- and long-term memory problems, functional limitation in range of motion, and dependence on staff for all ADLs except eating and for all mobility. The resident’s care plan addressed osteoarthritis and scoliosis and directed staff to monitor and report contracture formation and joint changes and to use supportive devices such as splints as recommended by OT, but it did not specify when the resident was to wear the splint or identify the contracture location. An OT discharge summary indicated the resident would tolerate a right hand splint with a schedule based on tolerance, and an order summary listed a trial of a right hand splint for 2 hours. During observation, the resident’s right hand was contracted with the fingers resting on the palm, and no device was seen in the hand to protect the palm. Resident #61 was admitted with diagnoses including acute chronic diastolic CHF, COPD, and asthma. The admission MDS showed a BIMS score of 14 and indicated intact cognition, and it also indicated the resident was not a current tobacco user. The resident’s care plan did not include a smoking focus area, although a smoking assessment later showed the resident was independent, smoked five to ten times a day, and could light their own cigarette. An observation showed the resident lighting a cigarette in the smoking courtyard. Interviews with the IP/unit manager, IDON, and Administrator confirmed that a smoking care plan was expected for residents who smoked and that Resident #61 did not have one.
Failure to Keep a Resident's Fingernails Clean and Trimmed
Penalty
Summary
The facility failed to trim and clean the fingernails for one resident who was unable to perform activities of daily living independently. The resident had a history of multiple sclerosis, type II diabetes mellitus, needed assistance with personal care, and had a contracture of the left hand. The quarterly MDS indicated severe cognitive impairment with a BIMS score of 3 and dependence on staff for personal hygiene. The care plan included an intervention to keep the resident's fingernails short and clean. During multiple observations, the resident's fingernails were noted to extend beyond the fingertips, with black matter underneath the nails. The resident stated staff had not offered to trim the nails and said they needed to be trimmed. CNAs stated they were responsible for cleaning nails, but if a resident had DM, the nurse was responsible for trimming them. One CNA said he saw the resident's nails needed to be cut but did not report it to the nurse, and another CNA stated she noticed the long nails but did not report them and was unaware she was supposed to. An LPN later observed the nails and stated they needed to be cleaned and trimmed. The IDON and Administrator stated staff were expected to keep fingernails clean and trimmed, and that if a CNA could not trim nails because of DM, the CNA was expected to notify the nurse.
Failure to Apply Ordered Splints and Handrolls
Penalty
Summary
The facility failed to place a splint or handroll into two residents’ contracted hands as ordered. Resident #3 had a history of cerebral infarction and osteoarthritis, severe cognitive impairment, dependence for all ADLs except eating, and dependence for all mobility. Resident #8 had multiple sclerosis, type II diabetes mellitus, severe cognitive impairment, dependence for personal hygiene, and a contracture of the left hand. Both residents had physician orders and care plan interventions related to splinting or hand rolls, but the records reviewed did not show documentation that the devices were applied as ordered. For Resident #3, the record showed an OT discharge summary indicating the resident tolerated a right-hand splint for two hours per day, with staff and resident compliance at 50% at discharge. The active order summary included an order for trialing a right-hand splint with therapy for two hours. The MARs reviewed did not document when the splint was donned or doffed. Observations showed the resident’s right hand contracted with fingers resting on the palm, the splint lying on a bookcase or overbed table, and at another observation the splint was not on the resident’s hand and no rolled cloths had been placed in the clenched fists. Staff interviews showed CNA staff were unsure of the splint instructions, stated they had not received instruction for this resident, or said they had not placed the splint because the resident had been in bed. For Resident #8, the order summary included an order for a left palm roll to be placed in the morning while out of bed and removed at night when in bed. The MARs did not document donning or doffing of the palm roll, and the Kardex directed staff to use a left-hand towel roll or hand splint. Observations showed the left hand contracted with nothing in the palm, no washcloth or splint in the hand while in bed, no towel roll during church service, and no rolled washcloth, towel, or splint while seated in a wheelchair. Staff interviews showed CNA staff were uncertain about the order, believed therapy had to place the handroll, or stated they had forgotten to apply it. The RM stated the splint or handroll was important to prevent skin breakdown or decline of the contracture, and the MD, IDON, and Administrator stated they expected staff to follow the orders.
Incorrect Low Air Loss Mattress Weight Settings
Penalty
Summary
The facility failed to ensure that the weight settings on low air loss mattresses were correct for two residents who were receiving pressure ulcer prevention support. Resident #2 had diagnoses including congestive heart failure and an unspecified head injury, severe cognitive impairment, dependence with ADLs, and was identified as at risk for pressure ulcers with a pressure-reducing device ordered for the bed. Resident #57 had diagnoses including acute respiratory failure, severe protein-calorie malnutrition, muscle wasting and atrophy, and adult failure to thrive, with severe cognitive impairment, dependence with ADLs, and a pressure-reducing device ordered for the bed. For Resident #2, the physician ordered a low air loss mattress, the care plan included use of a pressure reducing perimeter mattress, and the TAR showed the resident was on a low air loss mattress every shift. The resident’s weight was documented as 173.4 lbs. in September 2025 and 174.2 lbs. in December 2025, but observations showed the mattress dial set at 280 lbs. on one occasion and between 240-280 lbs. on multiple later observations. Staff stated the mattress setting was set up by the mattress company and that nursing staff ensured the pump was on and secured, while one LPN stated she did not touch the setting because the delivery staff had placed it. For Resident #57, the physician ordered a low air loss mattress, the care plan identified risk for skin breakdown related to decreased mobility, malnutrition, pain, and incontinence, and the TAR showed the resident was on a low air loss mattress every shift. The resident’s weight was documented as 90.2 lbs. in September 2025 and 74.8 lbs. in December 2025, but observations showed the mattress dial remained set at 120 lbs. on several occasions. Staff stated the mattress was set by the mattress company technician based on the resident’s weight, the facility only changed it if there were airflow issues, and the IDON stated nurses were to ensure the dial was set correctly for the resident’s weight to reduce the risk of pressure ulcer development and skin damage.
Residents Kept Personal Lighters During Smoking
Penalty
Summary
The facility failed to ensure residents did not retain their own lighters according to the smoking policy. Resident #61 had diagnoses including chronic diastolic congestive heart failure, COPD, and unspecified asthma, and had intact cognition with a BIMS score of 14. Resident #5 had a diagnosis of nicotine dependence and intact cognition with a BIMS score of 15. Both residents had smoking assessments indicating they did not have cognitive loss, visual deficits, or dexterity problems, that they smoked multiple times per day, and that they could light their own cigarettes. During observation, Resident #5 pulled a lighter from a bag/pouch, went into the smoke area, and lit a cigarette. Resident #61 lit a cigarette in the smoking courtyard during a smoke break. The Activity Director stated she did not light either resident’s cigarette and did not know what lighter they used. Resident #5 later provided a lighter to the AD and stated the resident kept lighters because they did not get them back when given to staff. Resident #61 stated the resident used a lighter kept in a pouch/bag. Resident #58 had a diagnosis of peripheral vascular disease and intact cognition with a BIMS score of 14. The resident’s smoking assessment indicated the resident required supervision and could light their own cigarette. During observation, Resident #58 handed a lighter to another resident so that resident could light a cigarette, then placed the lighter in the resident’s bag. LPN #19 observed the other resident use Resident #58’s lighter. The AD stated Resident #58 had a lighter and refused to give it to staff. Staff interviews confirmed the facility expected lighters to be stored in a locked cart or bin, but Residents #61, #5, and #58 had not given their lighters to staff for storage.
Blood Glucose Monitor Not Sanitized Between Resident Uses
Penalty
Summary
The facility failed to ensure staff sanitized a blood glucose monitor after checking a resident’s blood sugar and before placing the monitor back into the medication cart for further use. Resident #8 had been admitted to the facility with a diagnosis of type II diabetes mellitus and had severe cognitive impairment, with a BIMS score of three on the most recent MDS. The resident’s care plan identified a focus related to potential complications from diabetes mellitus, and the active physician order required blood sugar checks every six hours. During observation of morning medication administration, an LPN removed a blood sugar monitor from the medication cart, took it into the resident’s room, and used it to check the resident’s blood sugar. After the test, the LPN returned the monitor to the medication cart and placed it into a drawer without sanitizing it before preparing to test the next resident. During interview, the LPN stated there was no reason she did not sanitize the monitor before returning it to the cart. The UM/IP, PCP, IDON, and Administrator all stated that the blood glucose monitor was expected to be cleaned or sanitized between residents, and the manufacturer’s instructions indicated the monitor should be cleaned and disinfected between patient use.
Failure to Report Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication to the State Agency after a resident's family member reported missing oxycodone. The resident, who was cognitively intact and had multiple medical diagnoses including osteomyelitis, diabetes, and a tracheostomy, was admitted with an order for liquid oxycodone to be administered via G-tube. On the day the medication was brought in by the resident's daughter, staff did not verify the amount of oxycodone remaining in the bottle with the daughter, nor did they document the condition of the medication seal as required by facility policy. The Narcotic Administration Sheet indicated the medication was signed in, but there was no documentation of the seal's condition or any doses administered. Subsequently, concerns were raised by nursing staff about the appearance and integrity of the medication, and the resident's daughter reported the medication as stolen to the police. Despite this allegation and the involvement of law enforcement, the facility did not report the incident to the State Agency, as the DON believed the medication was accounted for. Review of facility records and the ODH Gateway Application confirmed that no self-reported incident was filed regarding this allegation of misappropriation.
Failure to Maintain Required Tracheostomy Supplies at Bedside
Penalty
Summary
The facility failed to ensure that appropriate tracheostomy (trach) supplies were available for a resident in accordance with the care plan and facility policy. Medical record review showed that the resident had significant medical conditions, including anoxic brain damage, epilepsy, chronic obstructive pulmonary disease, and congestive heart failure, and was dependent on staff for all activities of daily living. The care plan required an extra trach tube and obturator to be kept at the bedside, and physician orders specified daily trach care and regular changes of the inner cannula. However, during observation and staff interviews, it was confirmed that there was not an extra trach tube available at the bedside if the current trach became dislodged. Further interviews revealed that the facility did not always have the necessary trach supplies for the resident. When a replacement trach was brought to the bedside by a unit manager, it was found to be a cuffed trach, which did not match the resident's needs and was not ordered by the physician. Review of the facility's tracheostomy care policy confirmed that a replacement trach tube must be available at the bedside at all times, indicating non-compliance with both the care plan and facility policy.
Improper Food Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of food items, as observed during a survey. In the walk-in freezer, an opened and undated package of hot dogs was found on the top shelf, with the packaging not sealed, leaving the hot dogs exposed to the freezer elements. Additionally, a package of pepperoni was found not in its original packaging, unlabeled, and undated. In the walk-in refrigerator, an opened package of shredded cheese, two opened packages of bologna, and sliced turkey wrapped in pan liner paper were observed, all undated. The Dietary Manager confirmed these observations and acknowledged that the storage practices did not comply with the facility's policy, which requires refrigerated food to be dated when opened and freezer food to have the date received and the date opened.
Failure to Provide Timely Care and Transportation for Surgery
Penalty
Summary
The facility failed to provide proper and timely care for a resident requiring a hip replacement surgery, which was affected by multiple scheduling and transportation issues. The resident, who had a history of rhabdomyolysis, congestive heart failure, and other conditions, was initially scheduled for an orthopedic appointment and subsequent hip surgery. However, the surgery was delayed due to the need for dental clearance, which was not obtained until after the original surgery date. There was a lack of documentation in the resident's medical records regarding the scheduling and rescheduling of appointments, as well as the reasons for these changes. Further complications arose when the resident's surgery was rescheduled for a later date, but transportation issues prevented the resident from arriving on time, resulting in another cancellation. The facility's transportation policy was not effectively followed, as the resident was left waiting for transportation that did not arrive, leading to a missed surgery appointment. Interviews with the resident and facility staff confirmed these events, highlighting a breakdown in communication and coordination of care for the resident's medical needs.
Incomplete Medical Records for Outside Appointments
Penalty
Summary
The facility failed to maintain complete medical records for residents regarding their outside medical appointments, affecting three residents. Resident #9, who had multiple diagnoses including rhabdomyolysis and congestive heart failure, had incomplete documentation regarding his orthopedic and dental appointments. There was no record of when his orthopedic appointment was rescheduled, nor was there documentation of his hip surgery being completed or rescheduled. Additionally, there was a lack of documentation for his dental clearance and subsequent appointments, leading to confusion about his medical care timeline. Resident #20, diagnosed with paraplegia and other serious conditions, had no documentation in his medical records to confirm whether a scheduled radiology appointment was completed. Similarly, Resident #35, with a complex medical history including respiratory disorders and immunodeficiency, had no documentation regarding the completion of a dental appointment. Interviews with the Director of Nursing and the Administrator confirmed the lack of documentation and communication from external medical providers, as well as the absence of consent to obtain necessary after-visit notes for Resident #35.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer a medication as ordered, affecting one of three residents reviewed for medication administration. The resident, who was cognitively intact, had a medical history that included psychoactive substance abuse, obesity, osteomyelitis, pulmonary embolism, and attention-deficit hyperactivity disorder. A physician's order dated 09/12/24 prescribed Ertapenem Sodium Reconstituted, an antibiotic, to be administered intravenously at one gram every 24 hours for an infection until 10/29/24. However, the medication administration records revealed that the antibiotic was not documented as administered on multiple dates: 09/18/24, 09/27/24, 10/02/24, 10/04/24, 10/08/24, 10/10/24, 10/16/24, and 10/17/24. This was confirmed by the Director of Nursing during an interview on 10/29/24.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grafton Oaks Nursing Center | 1.7 mi | ★★★★★ | 16 | 0 |
| Gem City Healthcare And Rehabilitation Center | 2 mi | ★★★★★ | 9 | 0 |
| Riverside Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 21 | 1 |
| Aventura At Carriage Inn | 2.6 mi | ★★★★★ | 13 | 0 |
| Dunbar Health & Rehab Center | 2.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.