Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Community Skilled Healthcare during CMS and state inspections, most recent first.
A resident with multiple cardiac and renal conditions and a documented Full Code status was found unresponsive and not breathing by a transportation aide, who immediately sought help from an LPN and the assigned RN. The LPN refused to assist, stating it was not their resident, and the RN twice delayed responding despite being told it was an emergency, leading to a reported five- to ten-minute delay before any nurse entered the room. An LPN from another unit eventually initiated chest compressions, and other nurses joined, but no artificial respirations were provided at any time, even though the resident was apneic and an Ambu bag was available. This response did not follow the facility’s CPR policy or AHA guidelines for trained healthcare providers, which require full BLS with both compressions and rescue breaths for a Full Code resident prior to EMS arrival, and the situation was cited as Immediate Jeopardy with actual serious harm and subsequent death.
Resident council meetings were not consistently held, documented, or communicated in advance. Activity calendars for multiple months showed no council meetings, the AD said she had no evidence of when meetings were held, and the Administrator stated meetings were missed because there was no president. At an observed meeting, a resident said prior meetings had been canceled because no one was available to run them.
Failure to Review Residents' Rights with Resident Council: The facility did not ensure residents were informed of their rights on an ongoing basis. The DON/Administrator reported that resident council meetings were not held for two months because there was no president, and the only available council minutes showed no evidence that Residents' Rights were reviewed. Residents also stated there was no ongoing review of Residents' Rights during council meetings or in any other fashion at the facility.
Failure to Inform Residents of Complaint Rights: The facility did not inform residents of their right to file a complaint with the State survey and certification agency. The ADM stated there were no Resident Council meetings for two months due to lack of a president, and the only available council minutes did not show that residents’ rights were reviewed. During the survey, multiple residents said no information was shared about complaint rights and they did not know where the information was posted.
Residents were not informed on how to file grievances. A posted grievance handbook listed an outdated committee with resident members, while the updated roster showed only facility leadership and staff. During the resident council meeting, residents said they did not know about a grievance committee or how to file a grievance, and council minutes showed the grievance process was not discussed. The facility policy required grievance information to be available and posted in prominent locations.
Activities Program Directed by Unqualified Professional: The facility failed to ensure the activities program was directed by a qualified professional. The AD file showed no proof of the required MEPAP/ADC qualifications or clear documentation of department changes, and the AD stated she was never trained for the role and did not have proof of certification. The Administrator and HRD could not verify her work history or certification status in the file.
The facility failed to manage resident council, resident rights, grievance information, emergency response, activities, transfer planning, facility assessment, and staff training effectively. Residents reported canceled council meetings, no review of rights or grievance procedures, and no clear way to file complaints. A resident was found unresponsive and an LPN and RN delayed response before CPR began, and the resident later died. The memory care unit lacked structured activities, the AD lacked documented qualifications and training, the transfer agreement was not current, the facility assessment did not address the memory care unit or activity services, and several CNAs had no documented memory care training.
Facility assessment was incomplete because it was developed only by the Admin, DON, and Medical Director, without evidence of governing body or direct care staff participation. The assessment did not define or address the locked memory care unit, did not include staffing needs by unit, and did not address the activity dept or specialized activities for residents in that unit. The RVPN and VPN verified the omissions and stated staffing was based on a 24-hour period rather than unit-specific acuity.
Expired Hospital Transfer Agreement: The facility failed to maintain a current transfer agreement with an area hospital. Review of the transfer agreement showed it was signed by the facility and the hospital and was only effective for two years unless terminated earlier. The Administrator confirmed the agreement had not been renewed and stated he did not realize it had a two-year limit.
Care Plans Not Updated for New Conditions and Orders: The facility failed to revise care plans for four residents after new assessments, injuries, infections, wounds, and ordered treatments were documented. One resident’s plan did not reflect a fall with a right femur fracture, another did not include a UTI or antibiotic therapy, a third did not identify pressure injuries and wound care to the upper back, and a fourth did not include PICC line dressing changes. DON and MDS staff confirmed the missing care plan updates.
A resident with severe cognitive impairment and multiple diagnoses was care planned for one-to-one activity visits, but activity logs showed none were provided during the look-back period. The AD confirmed the visits were scheduled after activity staff had already left, and an AA stated she did not complete any one-to-one visits. In addition, residents on the memory care unit were repeatedly observed without structured therapeutic activities, while staff reported that dedicated activities were rare or absent and that the unit lacked a separate activity calendar.
Lack of Specialized Dementia Training for Memory Care Staff: The facility failed to ensure CNAs assigned to the memory care unit had specialized dementia training. Personnel file review and staff interviews showed multiple CNAs had no documented memory care training, and the HRD confirmed the facility did not provide specialized training for the unit. The facility assessment and dementia care policy both required staff training on dementia care practices, care of cognitively impaired residents, and ongoing competency training.
Call lights were not kept within reach for three residents. One resident with dementia and schizophrenia had her call light clipped to the privacy curtain, another resident with Alzheimer's disease had hers lying on the over-bed light, and a third resident with multiple chronic conditions and moderate cognitive impairment had hers hanging from the wall with the cord stuck between the bed and wall. Staff confirmed the call lights were not accessible to the residents.
Failure to Provide Written Notice of Room Changes: A resident with moderate cognitive impairment and diagnoses including intellectual disabilities, seizures, and psychosis was moved to a different room without prior written notice to the resident or the POA. Records showed the resident was told about the move, but interviews confirmed the POA was only notified verbally after the room change and received no written notice. The SSD confirmed written notice was not provided and the facility did not have a Room Change Notice form, despite policy requiring advance written notice with the reason for the move.
A resident with dementia, Alzheimer's disease, and impaired cognition was observed in bed with two pillows tucked under the fitted sheet along her side. A CNA stated the pillows were placed there to keep her in bed because she was a high fall risk and climbed out of bed, and the CNA confirmed she could not remove them. The ADON verified the body pillow was only to be alongside the resident and that placing it under the sheet was a restraint; the facility policy defined this as a physical restraint.
Failure to Provide Bed Hold Notices and Ombudsman Notification: The facility failed to notify two residents of bed hold information before hospital discharge and failed to notify the Ombudsman of hospitalizations. Record review showed no bed hold notices for either resident, and the Administrator confirmed the notices were not completed. The Ombudsman also stated the facility does not notify her when residents go to the hospital.
Failure to include discharge planning in the care plan. A cognitively intact resident with COPD, chronic respiratory failure, type 2 DM, and obesity was admitted temporarily after his AL had water damage and repeatedly stated he wanted to return once repairs were complete. Progress notes referenced a mini care conference, but discharge planning was not documented, and the care plan did not address the resident’s stated discharge preference.
An LPN gave a resident the wrong acetaminophen dose, administering 325 mg tablets instead of the ordered 500 mg tablets. The facility also delayed reviewing x-ray results for another resident after a fall; the results showed a right femur fracture, but the DON said they were not reviewed until the next day and the physician was not promptly notified.
Smoking Materials Not Secured for A Resident: A resident with intact cognition and supervision needs for ADLs, transfers, and mobility kept cigarettes and a lighter in his room despite a smoking assessment stating all smoking items were to be stored in a secure location with staff access only. He signed himself out to smoke several times per day, said he kept the items on his person and had not been told to lock them at the nurses station, and staff observed the cigarettes and lighter stored in a coat pocket in his room closet. The Administrator stated the only policy in place was for a smoke-free facility and no current policy was available for grandfathered smokers.
Unsafe Medication Storage and Undated Tubersol Vial: A resident's fluticasone nasal spray was found in the bedside table drawer even though there was no order to keep meds at bedside or to self-administer. In addition, an opened multi-dose vial of Tubersol in the med storage refrigerator was not dated, and the LPN verified both findings during observation.
The facility failed to obtain dental services for a resident with Alzheimer's disease who had a signed consent for dental care and dentures. Although SS contacted the dental vendor to schedule appointments, the resident was not placed on the dental schedule, and SS stated there was no tracking process to ensure residents with signed consents were actually added to the dental list.
Pureed Diet Food Was Runny and Unappealing: A resident with dx including moderate protein-calorie malnutrition and a pureed diet received lunch items that did not hold form and were runny, thin, and unappealing. The resident said one puree had good flavor but was too thin, while the other had no flavor and was also too thin. An aide confirmed the resident was calling because the pureed food was runny and offered a substitute, but the requested items were not available.
A resident with dementia, mood disorder, osteoporosis, late onset Alzheimer's disease, anxiety, and moderate cognitive impairment did not receive influenza or pneumococcal vaccines even though the responsible party had signed consents for both. The ADON stated the admission nurse is expected to obtain immunization consents during admission and that vaccines are expected within 30 days of consent, but this resident was missed. The facility's vaccine policies required residents to be offered these immunizations unless contraindicated or previously immunized, and the facility could not produce a standing orders policy.
A resident with dementia, malnutrition, osteoporosis, and anxiety had a BIMS score indicating moderate cognitive impairment and required partial to moderate assistance with ADLs. The resident's COVID-19 vaccine was not addressed or administered even after the RP signed consent, and the ADON stated the resident was missed despite the expectation that immunizations be given within 30 days of consent receipt.
A cognitively intact resident with a known history of sexually inappropriate behavior, including entering female residents’ rooms, was observed by a CNA standing in front of a severely cognitively impaired resident in a hallway with his pants halfway down and genitals exposed, telling the other resident to look. The cognitively impaired resident, who required extensive assistance with ADLs and could not reliably report events, affirmed that the exposure occurred and was later overheard saying she was scared. Despite this and a prior note of public indecency involving the same resident, the facility’s internal investigation concluded there was no inappropriate conduct, did not obtain witness statements from all involved staff, and documented findings that were inconsistent with what the Administrator reported, resulting in an unsubstantiated allegation of sexual abuse contrary to the facility’s abuse policy.
Multiple incidents showed that residents were not protected from misappropriation of medications. In one case, an LPN took Haldol from one resident’s stock supply and administered it by IM injection to another cognitively impaired resident without a physician’s order, instructing CNAs not to report it. In a second case, narcotic count sheets for a cognitively intact resident on Adderall showed repeated two‑tablet decreases at times when only one tablet was ordered and documented as given, all associated with the same LPN, with the DON later noting the LPN’s inconsistent explanations and refusal or delay in drug testing despite a policy requiring compliance. In a third case, an agency LPN documented removal of two Oxycodone tablets at multiple administration times for a resident ordered only one tablet q4h PRN, while the MAR reflected single‑tablet doses, revealing discrepancies between the narcotic count and the ordered and documented administration. These events demonstrate wrongful use and removal of resident medications contrary to physician orders and facility policies on medication administration, drug‑free safety, and prevention of misappropriation.
A resident with ADHD and other psychiatric and neurologic conditions was ordered Adderall 20 mg twice daily, but narcotic count sheets showed multiple instances where the count decreased by two pills when only one was ordered, all signed out by an LPN. The DON identified inaccurate counts tied to this LPN, who later stated she did not know why the count was wrong and claimed to have wasted a pill without a witness. The LPN refused an in-facility urine drug screen and did not appear for the initially scheduled independent test, yet was allowed to return to work despite a written Drug Free Safety Policy stating that refusal or failure to comply with required testing constitutes a refusal to test and results in termination.
Two residents were involved in an alleged incident of sexual abuse when a cognitively intact male resident with a known history of sexually inappropriate behavior was observed by a CNA standing in front of a severely cognitively impaired female resident in a hallway with his pants halfway down and his genitals exposed, telling her to look. The female resident affirmed that he had shown his genitals and was later overheard saying she was scared. A police report documented that staff reported the male resident exposing himself, although he denied the behavior. Despite this, the facility’s internal SRI concluded the allegation was unsubstantiated, stating there was no behavior suggesting concerning interaction and that the cognitively impaired resident could not provide a statement. The Administrator later acknowledged that his recollection of the event (pants down and genitals exposed) conflicted with the SRI, that not all involved staff provided witness statements, and that sexual abuse could not be ruled inconclusive, indicating the investigation was not complete or thorough as required by facility policy.
A resident with multiple complex medical conditions and cognitive impairment was discharged home with family present, but the LPN responsible did not complete the nursing section of the discharge paperwork. There was no documented review of discharge medications and no indication that prescriptions or a three-day supply of medications were offered, despite facility policy requiring a complete discharge summary and medication reconciliation. The Ombudsman and DON both confirmed the discharge documentation was incomplete and that medications were not reviewed or offered.
The facility did not provide enough nursing staff to meet residents' needs, resulting in missed showers and hygiene care for several residents who required assistance with ADLs. Staff reported inadequate staffing levels, inability to complete showers, and incomplete documentation, while residents dependent on staff did not receive bathing according to their preferences. The DON confirmed the facility failed to meet minimum daily staffing requirements on multiple days, and the facility assessment was outdated.
The facility did not ensure an RN was present for at least eight consecutive hours each day, as required. On two occasions, there was either no RN scheduled or the RN worked less than the required hours, as confirmed by the DON. This affected all residents in the facility.
The facility did not update its facility-wide assessment as required, with documentation showing the last update occurred over two years ago. The Administrator confirmed no evidence of an updated assessment, potentially affecting all residents.
The facility did not notify responsible parties or emergency contacts when two residents were transferred to the hospital—one for a urinary tract infection and another after a fall resulting in a head injury. Despite facility policy requiring prompt notification, documentation and staff interviews confirmed that notifications were not made in these cases.
The facility did not send required health status documentation to the hospital for two residents who were transferred, despite policy and staff statements indicating that transfer forms with key information should accompany residents. Both residents had significant medical needs and required substantial assistance with daily care.
Three residents who were dependent on staff for ADL care did not consistently receive baths or showers according to their documented preferences, with both paper and electronic records showing missed or undocumented bathing events. Interviews with residents and CNAs confirmed that showers were not provided as requested, primarily due to insufficient staffing, and the DON was aware of these ongoing issues. Facility policies required bathing to be consistent with resident choices, but this was not achieved.
A resident with severe cognitive impairment and total dependence on staff was not provided with prescribed interventions to prevent skin breakdown. Despite orders for daily foam dressing application and repositioning every two hours with a wedge pillow, the resident was repeatedly observed without the dressing and not repositioned as ordered, with the wedge pillow left unused on a chair. Nursing staff confirmed these interventions were not followed, contrary to facility policy.
The facility did not thoroughly investigate falls involving two residents, both identified as fall risks with significant medical histories. In both cases, the fall investigations lacked required witness statements, root cause analyses, documentation of toileting or call light use, and evidence of new interventions, despite facility policy mandating these steps. The DON confirmed these omissions during interviews.
Daily nurse staffing information was not updated to reflect the current day and did not include the required census number. A CNA confirmed the posting was outdated and incomplete, noting that the scheduler responsible for updates was on vacation. This issue was identified during a complaint investigation and had the potential to affect all residents.
The facility failed to thoroughly investigate incidents involving narcotic diversion and a resident altercation. In the first case, missing oxycodone tablets were not properly investigated, lacking witness statements, a police report, and resident assessments. In the second case, a resident altercation was inadequately investigated, with insufficient witness statements and no preventative measures. The facility did not adhere to its policy on abuse and misappropriation, resulting in these deficiencies.
The facility did not have an RN on duty for the required eight consecutive hours, affecting all 80 residents. On a specific day, no RN was scheduled for any shift, and only one RN punched in late at night. The DON was not informed of the absence, and the scheduled RN had called off. The facility's policy allowed for shift adjustments and emergency staffing, but these were not utilized.
The facility inaccurately coded MDS assessments for several residents receiving hospice care, failing to indicate their life expectancy of less than six months. Despite being on hospice, the assessments for residents with serious conditions like end-stage Alzheimer's, Parkinson's, and malignant neoplasm were incorrectly marked. An inexperienced LPN, following corporate instructions, contributed to this deficiency.
A resident experienced a persistent strong urine odor in their room, despite frequent incontinence care and being on a diuretic. Interviews with an LPN and an STNA confirmed the odor, and an observation further verified the issue. The facility's policy on resident rights was not upheld, affecting the resident's right to a dignified existence.
A resident with a history of falls and cognitive impairments fell due to inadequate assistance during ambulation. The STNA let go of the resident to move a chair, resulting in a fall. Additionally, the facility failed to conduct quarterly fall risk assessments as required, with the last assessment done over a year prior to the incident.
The facility failed to implement a comprehensive pressure ulcer prevention and care program, resulting in Immediate Jeopardy and actual harm to three residents. A resident developed a Stage III pressure ulcer due to inadequate interventions, leading to hospitalization for sepsis. Two other residents experienced worsening of their pressure ulcers due to insufficient care, including lack of timely repositioning and incontinence care.
The facility failed to provide sufficient nursing staff to meet residents' care needs, affecting six residents and potentially all 78 residents. Staffing levels fell short of the required 3.28 to 4.78 hours of care per resident per day, leading to missed showers, inadequate incontinence care, and insufficient repositioning. Staff interviews confirmed the facility was short-staffed, and the elimination of shower aides added to the burden on STNAs. Specific cases highlighted the impact, with residents not receiving care as per their schedules or preferences.
The facility administration failed to manage resources effectively, impacting the wellbeing of all 78 residents. The interim Administrator and new DON were recently appointed, and the facility was understaffed, leading to inadequate resident care. Persistent bed bug infestations were not properly addressed, and the physical environment was poorly maintained, with unrepaired holes in residents' rooms.
The facility failed to provide showers according to schedules or preferences for six residents, as revealed through observations, record reviews, and interviews. Residents with varying levels of cognitive impairment and assistance needs did not receive adequate bathing, with insufficient documentation of showers. Staff interviews indicated that the removal of shower aides contributed to this deficiency.
Two residents in the facility experienced a deficiency in their living environment due to holes in the walls behind their bed headboards. Despite being aware of the issue, the Environmental and Maintenance Directors had not addressed the problem. Both residents reported the holes, which were not documented in the maintenance log, indicating a lack of action to resolve the issue.
A facility failed to maintain an effective pest control program for bed bugs, affecting a resident and potentially impacting all residents. Despite multiple chemical treatments, bed bugs persisted in several rooms. Interviews confirmed the presence of bed bugs and insufficient pest control measures. The facility opted for chemical treatments instead of recommended heat treatments, contributing to the ongoing infestation.
The facility failed to maintain a sanitary kitchen environment, with observations of built-up dirt, unlabeled food items, expired test strips, and staff not following dress code policies, potentially affecting 80 residents.
Failure to Provide Timely and Complete CPR to a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly and correctly provide basic life support (BLS), including CPR, to a resident with a documented Full Code status who was found unresponsive and without vital signs. The resident had multiple significant diagnoses, including atrial fibrillation, type 2 diabetes, congestive heart failure, end-stage renal disease, anxiety, dementia, kidney cancer, anal fistula, hypertension, and dependence on hemodialysis. The resident’s care plan identified risk for ineffective breathing related to CHF and ESRD, with interventions such as monitoring breath sounds, labored breathing, use of accessory muscles, oxygen therapy as needed, vital signs as needed, cardiac medications, and lab monitoring. On the morning of the event, the resident had last been known responsive when a CNA delivered breakfast and the resident verbally acknowledged the tray. At approximately the time the resident was to be prepared for dialysis, a transportation aide entered the room and found the resident in distress, noting a deep breath followed by absence of respiratory effort and no response to verbal or tactile stimulation. The aide immediately sought help from an LPN, who refused to assist, stating, "that's not my resident," and did not assess or enter the room. The aide then approached the RN assigned to the resident, who twice responded, "I'll get to it when I can," despite the aide stating that the situation could not wait and that the resident was in distress. During this period, the aide reported waiting outside the resident’s room for approximately five to ten minutes before any nurse came to help, and ultimately used the overhead paging system to summon assistance because no nurse initially responded to her direct requests. An LPN from another unit responded to the overhead page, entered the room, and found the resident absent of vital signs, initiating chest compressions and calling for help. Other staff, including the assigned RN and another LPN, then entered and assisted with compressions and obtaining equipment such as the crash cart and AED. However, multiple staff interviews and the assigned RN’s own verification confirmed that no artificial respirations were provided at any time, despite the resident not breathing and an Ambu bag being available on the crash cart. The facility’s CPR policy required adherence to current AHA guidelines, which for trained healthcare providers include cycles of 30 chest compressions to two rescue breaths, and the policy required provision of BLS, including CPR, prior to EMS arrival in accordance with the resident’s advance directives. EMS arrived to find staff performing CPR, determined the resident was pulseless and apneic, and continued advanced resuscitation efforts. The failure to respond promptly to the aide’s report of an emergency, the refusal of one nurse to assist, the delay by the assigned RN in assessing the resident, and the omission of rescue breaths during CPR for a Full Code resident constituted the basis of the cited deficiency and were determined to have resulted in Immediate Jeopardy and actual serious life-threatening harm and subsequent death.
Resident Council Meetings Not Consistently Held or Documented
Penalty
Summary
The facility failed to take reasonable steps to ensure residents were assisted by a designated staff member for resident council meetings and that residents were informed of meetings in advance. Record review of activity calendars for multiple months in 2025 and 2026 showed no resident council meetings identified, and several months in 2025 had no calendars available for review. The Administrator stated there were no resident council meetings in February and March 2026 because there was no president for the meetings, and only January 2026 meeting minutes were available, which showed five residents attended with the Activity Director and DON present and no future meeting date listed. During interview, the Activity Director stated she was not aware she needed to save activity calendars and had no evidence showing when resident council meetings were held for the months reviewed. She also stated that she and her staff go and get residents for council meetings when they are due to be held, and that resident council meetings are held monthly. At the surveyor-observed resident council meeting, a resident stated there had not been meetings in February and March because there was no president, and that a meeting scheduled for the prior week was canceled and residents were informed it was canceled because no one was available to run it.
Failure to Review Residents' Rights with Resident Council
Penalty
Summary
The facility failed to ensure residents were informed of their rights on an ongoing basis. During an interview, the Administrator stated there were no Resident Council meetings held in February 2026 or March 2026 because there was no president for the meetings, and only one month of council meeting minutes dated 01/28/26 was available for review. The Administrator also stated there was no evidence that Residents' Rights were discussed at the January 2026 Resident Council meeting. During the annual survey resident council portion, Residents #11, #15, and #38 reported there was no ongoing review of Residents' Rights during resident council meetings or in any other fashion at the facility. Review of the available January 2026 Resident Council meeting minutes showed no evidence that Residents' Rights were reviewed, and no additional Resident Council meeting minutes were available.
Failure to Inform Residents of Complaint Rights
Penalty
Summary
The facility failed to inform residents of their right to file a complaint with the State survey and certification agency. During an interview, the Administrator stated there were no Resident Council meetings held in February 2026 and March 2026 because there was no president for the meetings, and only one month of council meeting minutes dated 01/28/26 was available. The Administrator also stated there was no evidence that residents’ rights to file a complaint with the State survey and certification agency were discussed at the January 2026 Resident Council meeting. During the annual survey resident council interview, Residents #11, #15, and #38 stated there was no information shared or discussed regarding their right to file a complaint with the State survey and certification agency, and they said they had no knowledge of where that information was posted in the facility. Review of the available January 2026 Resident Council meeting minutes showed no evidence that residents’ rights were reviewed during the meeting, and no additional Resident Council meeting minutes were available for review.
Residents Not Informed of Grievance Filing Process
Penalty
Summary
The facility failed to ensure all residents were informed on the grievance filing process. Record review showed a Grievance Committee Handbook posted on the bulletin board outside the activity room that listed three residents, a fourth unidentified person, and two staff members as the grievance committee, with a note that an Ombudsman representative would also be invited. The handbook stated that if a grievance was filed, the licensed social worker would contact the committee members for a grievance meeting. However, the facility’s updated Grievance Committee Roster, reviewed in April 2026, listed only the Administrator, DON, Social Service, Infection Preventionist, Food Service Director, and Business Office Manager, with no residents included as committee members. The Administrator verified that the updated roster lacked resident committee members and stated he had no knowledge of the handbook posted outside the activity room and that the information in it was outdated. Resident council minutes from 01/28/26 showed no information was presented to the council on how to file a grievance. During the annual survey resident council meeting, three residents stated they had no knowledge of a grievance committee and were unaware of how to file a grievance. One resident also stated there had been no resident council meetings in February or March 2026 and that the grievance process was not discussed when meetings were held. The facility policy stated residents and family members have the right to voice grievances without discrimination or reprisal, that grievance rights notices will be posted in prominent locations, and that information on how to file a grievance or complaint will be available to residents, including contact information for the grievance official and independent entities.
Activities Program Directed by Unqualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. Review of the job description for the Activity Director position showed the role required completion of MEPAP 1, ADC certification or progress toward it, and at least one year of activity experience in long-term care. Review of the personnel file for Activity Director #876 showed a hire date of 09/09/2020 for housekeeping and a resignation letter dated 08/23/21 from activities, but there were no job descriptions or payroll status changes showing when the employee transferred between housekeeping and activities or what department she moved to after 08/23/21. The personnel file contained no evidence that Activity Director #876 had completed the professional qualifications required for the position. During interviews, she stated she had worked in housekeeping and activities for seven years, started as activity director around 03/19/25, and received her activity certification in March 2026, but she did not have proof of certification. She also stated she was never trained for the activity director position and had no idea what was required. The Administrator stated he was unaware she had worked in housekeeping before becoming activity director and said he promoted her after asking around about her. Human Resources could not verify the dates of her department changes and confirmed there was no evidence in the file that she had successfully completed the required certifications, noting the certification had been requested for over a month.
Administration, resident rights, CPR response, activities, and facility oversight failures
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of job descriptions showed the Administrator was responsible for overall management, the DON for leadership of nursing services, and the Activity Director for planning and implementing a meaningful activity program for all residents. During the annual and complaint survey, concerns were identified involving resident council, resident rights conveyance, grievance processes, activities for residents, qualifications of the Activity Director, quality of care, transfer agreements, facility assessment, and staff training. Resident council meetings were not consistently held or advertised. Activity calendars for 2025 and 2026 did not show resident council meetings, and the Administrator stated there were no resident council meetings in February and March of 2026 because there was no president. The Administrator provided minutes for one meeting only, and there was no future meeting date listed. During a resident council meeting held with surveyors, residents stated there had not been meetings in February and March, one meeting had been canceled, and they were told it was canceled because there was no one to run it. Residents also stated resident rights were not reviewed at council meetings, and they had no knowledge of a grievance committee or how to file a grievance or complaint with the state agency. In addition, the facility did not ensure licensed nursing staff promptly and correctly provided BLS/CPR when a resident was found unresponsive. A transportation aide alerted an LPN that the resident was not responding and needed help, but the LPN refused to assist and told the aide to get an RN. The RN stated she would get to it when she could. CPR did not begin until another LPN responded from a different unit after a five- to 10-minute delay, and artificial respirations were never provided. EMS later found the resident without pulse or respirations, and the resident was pronounced deceased in the hospital emergency room. The facility also did not ensure residents received a program of therapeutic activities and one-to-one activities for their highest practicable well-being, and the Activity Director did not have documented evidence of the qualifications required by the job description. On the memory care unit, residents were observed sitting idle in common areas or lying in bed without structured therapeutic activities, and staff stated dedicated activities rarely occurred, especially after dinner. The Activity Director stated she had not been trained for the position, did not have proof of certification available, did not keep records of memory care activity calendars, and one-to-one activities scheduled for times after activity staff had left were not completed. The facility further lacked a current transfer agreement with a local hospital, and its facility assessment did not include required participants or adequately address the memory care unit, staffing by unit, the locked unit, the activity department, or specialized activities. Personnel files for several CNAs also lacked evidence of specialized memory care training.
Facility Assessment Did Not Address Memory Care Unit Staffing, Environment, or Activities
Penalty
Summary
The facility failed to thoroughly conduct a facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations. A review of the document titled Community Skilled Facility Assessment, completed on 02/15/26 and revised on 04/13/26, showed the assessment was developed by the Administrator, the DON, and the Medical Director. There was no evidence that a member of the governing body or representatives of direct care staff participated in developing the assessment. The document stated the facility provided care and services to individuals with certain medical and cognitive disabilities and used MDS information to determine resident care needs, but it did not define or address the on-site memory care unit. The assessment also failed to address key operational areas related to the memory care unit. The staffing plan was based on resident population and acuity, but it did not contain information by unit and did not address staffing needs for the memory care unit. Under physical environment, the document did not address or define the locked memory care unit. Under services and care offered based on resident needs, the facility did not ensure and define the locked memory care unit. The assessment also did not address the presence of an activity department or the need for specialized activities in the memory care unit. During interviews, the RVPN and VPN verified the assessment participants and acknowledged that staffing per unit was not addressed, that the memory care unit was not defined in the assessment, and that the activity department was not addressed as an additional service provided to residents.
Expired Hospital Transfer Agreement
Penalty
Summary
The facility failed to have a current transfer agreement with an area hospital. Review of the facility document titled Transfer Agreement showed an agreement between Community Skilled Healthcare Center and Mercy Health Youngstown LLC doing business as Saint [NAME] Hospital, stating that it would take effect when signed by both parties and continue for two years unless terminated with 30 days written notice. The document was signed by the facility on 06/01/17 and by the hospital on [DATE], and an interview with the Administrator on 04/13/26 at 4:15 P.M. confirmed the agreement was finalized on 06/13/17. The Administrator stated he did not realize the agreement had a two-year limitation and confirmed it had not been renewed with the hospital.
Care Plans Not Revised for New Assessments and Ordered Treatments
Penalty
Summary
The facility failed to develop and revise comprehensive care plans in response to resident assessments and physician-ordered interventions for four residents. Facility policy required a person-centered care plan for each resident, prepared by an interdisciplinary team and reviewed and revised after each comprehensive and quarterly assessment. Based on record review and staff interviews, the care plans for Residents #10, #49, #71, and #90 were not updated to reflect new conditions, treatments, or physician orders documented in their records. Resident #10 had an admission date of 09/17/22 and diagnoses including Alzheimer's dementia, hypertension, anxiety, insomnia, and chronic kidney disease. The resident was hospitalized from [DATE] to 01/13/26 after a fall on 01/03/26 that resulted in a right femur fracture. The care plan, last revised 03/31/26, addressed fall risk related to dementia, anxiety, advanced age, and agitation with hands-on care, but did not identify the fall or the right femur fracture and did not include interventions related to the fracture. RN #811 confirmed the care plan was not updated with the most recent fall and injury. Resident #49 had diagnoses including spinal stenosis, type 2 diabetes mellitus, CKD stage three, and alcohol abuse. On 01/14/26, the resident reported burning and itching with urination, contacted hospice, and was started on Macrobid 100 mg BID for 7 days; the medication was administered per orders. The quarterly MDS showed impaired cognition and incontinence of bladder and bowel, but the care plan last revised 04/09/26 did not add the UTI diagnosis or the antibiotic order. Resident #71 had diagnoses including spinal stenosis and mood and behavioral disorders, and physician orders in March 2026 directed wound care to two areas on the right upper back with normal saline, Medi honey, and dry dressings; the MARS/TARS showed these treatments were provided except for refusals. The care plan last revised 04/13/26 did not specify pressure injuries to the right upper lateral back and right upper medial back, although it noted a pressure ulcer as of 03/12/26. Resident #90, admitted 03/26/26 with severe protein-calorie malnutrition and severely impaired cognition, had an April 2026 order for weekly and PRN PICC line dressing changes, which were completed per MARS/TARS, but the care plan last revised 04/07/26 did not identify the PICC line dressing changes.
Failure to Provide Therapeutic Activities and One-to-One Visits
Penalty
Summary
The facility failed to provide one-to-one activities for a resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson’s disease, fibromyalgia, hallucinations, stage four pressure ulcer, protein-calorie malnutrition, chronic viral hepatitis C, generalized anxiety disorder, restlessness, and agitation. The resident’s MDS showed a BIMS score of 03 and indicated dependence on staff for all ADLs, bed mobility, and transfers. The care plan dated 01/13/26 stated the resident had little or no activity involvement due to physical limitations and required one-to-one visits from activity staff, with interventions for one to three one-on-one visits per week. Review of one-to-one activity logs for the last month through 04/13/26 showed the resident did not receive any one-to-one visits during that look-back period. During interview, the AD verified that one-to-one visits were scheduled on the activity calendar for 6:00 P.M., but activity staff were scheduled to leave at 4:00 P.M., and the one-to-one activity did not get done because staff left before the scheduled time. The AA later stated she did not complete any one-to-one visits for the resident and said the employee responsible for completing all one-to-one visits was no longer employed at the facility. The facility also failed to ensure residents on the memory care unit received a program of therapeutic activities for their highest practical well-being. The February and March 2026 dementia unit calendars showed limited daytime activities and no special function or evening activities, and the April 2026 calendar no longer had a separate memory care calendar. Observations and staff interviews showed repeated periods when no structured activities were taking place on the unit, including residents sitting in common areas watching television, dozing, or becoming restless while staff tended to other needs. Multiple staff members stated there were no dedicated activities or that planned activities for the memory care unit were rare, and the AD confirmed she had no records of memory care activity calendars from May 2025 through January 2026.
Lack of Specialized Dementia Training for Memory Care Staff
Penalty
Summary
The facility failed to ensure staff had specialized training for the memory care unit. Review of personnel files showed Certified Nurse Aides #844, #845, #846, and #860 had no documented specialized training for the memory care unit. An interview with the Human Resource Director confirmed there was no documented evidence of memory care unit training for these CNAs and stated the facility did not conduct any specialized training for the memory care unit. The facility assessment, revised 04/13/26, stated the facility routinely serves residents with cognitive impairment, dementia, and behavioral health diagnoses, and that nurse aides will receive core training including dementia management, resident abuse prevention, care of the cognitively impaired, and at least 12 hours of training per year. The facility policy on Dementia Care stated all staff will be trained on dementia and dementia care practices upon hire, annually, and as needed. Interviews with CNAs #841, #855, and #866 also revealed they had no specialized training for the memory care unit.
Call lights not kept within residents' reach
Penalty
Summary
The facility failed to ensure call lights were within reach for Residents #13, #49, and #84. Resident #84 had diagnoses including malignant breast cancer, hypothyroidism, hypertension, adult failure to thrive, unspecified dementia, schizophrenia, and age-related osteoporosis, and her MDS showed impaired cognition and need for assistance with eating, toileting hygiene, oral hygiene, and showering. During observation, her call light was clipped to the privacy curtain and out of her reach, and she stated that if she had her call light she would not have to walk to the nurses' station to tell staff what she needed. RN #861 verified the call light was clipped to the curtain and not where the resident could reach it. Resident #13 had diagnoses including late-onset Alzheimer's disease, generalized anxiety, folate deficiency, cognitive communication deficit, hypokalemia, and dementia insomnia, and her quarterly MDS showed impaired cognition with assistance needed for eating, oral hygiene, toileting, and personal hygiene. Her call light was observed lying on the over-bed light and not within reach, and CNA #839 verified it was not within reach and stated the resident would use it if it were within reach. Resident #49 had diagnoses including spinal stenosis, COPD, type II diabetes mellitus, CHF, obstructive sleep apnea, atrial fibrillation, major depressive disorder, generalized anxiety disorder, and pulmonary hypertension; her MDS showed a BIMS score of 08 indicating moderate cognitive impairment and need for assistance with bathing, dressing, toileting, bed mobility, and transfers. Her call light was hanging from the outlet in the wall with the cord stuck between the bed and the wall, and the resident stated she could not reach it from her bed. Environmental Services Worker #911 and Maintenance Worker #919 confirmed she was unable to reach the call light.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notice of room changes to Resident #79 and the resident's family representative before the changes occurred. Resident #79 was admitted on 07/31/25 with diagnoses including unspecified intellectual disabilities, other seizures, and unspecified psychosis not due to a substance or known physiological condition. The resident's brother was listed as POA effective 03/11/26, and the quarterly MDS assessment showed moderate cognitive impairment, with clear speech, usually self-understood speech, understanding of others, and adequate vision. Record review showed a social services note on 03/11/26 stating the resident was notified of a room change and was okay with it, but there was no documentation that prior written notice was given to the resident or the POA. A nursing note dated 03/17/26 documented that the resident had a room change, personal belongings were moved, and the brother was aware. Interviews confirmed the POA was notified verbally after the room change and received nothing in writing, the resident could not recall receiving written notice or the reason for the room changes, and the Social Service Designee confirmed written notice was not provided prior to the room changes and that the facility did not have a Room Change Notice form available. The facility policy stated that prior to a room change, residents and their representatives would be given advance written notice including the reason for the move.
Physical restraint used with bed pillows
Penalty
Summary
Resident #66 was admitted with diagnoses including moderate protein-calorie malnutrition, dementia, hyperlipidemia, mood disorder, urinary retention, age-related osteoporosis, Alzheimer's disease, and anxiety disorder. Her quarterly MDS showed impaired cognition but that she was able to make needs known, and she required partial to moderate assistance with all ADLs, including eating, showers, personal hygiene, dressing, and bed mobility. Her care plan identified her as at risk for fluctuations and/or decline with ADLs and at risk for falls due to impaired safety awareness, age-related debility, and potential side effects of medications. A physician order directed use of a body pillow to the left side of the bed for body positioning. During observation, Resident #66 was lying in bed with two pillows placed along her left side and tucked under the fitted sheet. She was calm and not trying to get out of bed at the time. A CNA stated the pillows were placed under the fitted sheet to keep the resident in bed because she was a high fall risk and climbed out of bed, and that the resident could not remove the pillows. The CNA also stated there was no fall mat next to the bed. The ADON later verified that the body pillow was only to be alongside the resident and not under the fitted sheet, and stated that placing it under the sheet was a restraint. The facility policy defined a physical restraint as any device or material attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement, including tucking in a sheet tightly so the resident cannot get out of bed.
Failure to Provide Bed Hold Notices and Ombudsman Notification
Penalty
Summary
The facility failed to ensure residents were notified of bed hold information prior to discharge to the hospital and failed to notify the Ombudsman of hospitalizations. This affected two residents out of two reviewed for hospitalizations, with the facility census at 83. Review of Resident #2’s record showed an admission date of 08/24/23 and diagnoses including bipolar disorder, gender identity disorder, and borderline personality disorder. The census data showed Resident #2 was hospitalized and later returned to the facility, but there was no evidence in the record of a bed hold notice. Review of Resident #5’s record showed an admission date of 10/14/25 and a diagnosis of unspecified dementia. The census data showed Resident #5 was hospitalized through 04/10/26, and there was no evidence in the record of a bed hold notice. During interview, the Administrator stated there were no bed hold notices for Residents #2 and #5 and that the Ombudsman had not been notified for Resident #2 and had not yet been notified for Resident #5. The Ombudsman stated she does not receive notification from the facility for residents going to the hospital. The facility’s undated Authorization for Admission document stated Medicaid residents are entitled to 30 bed hold days per year and that the resident and/or responsible party will be notified before any charge takes effect so a decision may be made to hold the bed.
Failure to Include Discharge Planning in Care Plan
Penalty
Summary
The facility failed to ensure a care plan was developed to include discharge planning for Resident #77. The resident was admitted on 01/22/26 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and obesity. The modification of admission MDS assessment showed the resident was cognitively intact, had adequate hearing, could make himself understood, and understood others. Progress notes documented that on 02/06/26 the resident stated he wanted to return to his assisted living and remain at the facility until renovations were completed. An additional progress note dated 02/20/26 documented that a mini care conference took place in the resident’s room, but discharge planning was not documented as discussed. During interview, the resident stated he had moved temporarily to the facility after his assisted living experienced water damage in December 2025 and was waiting for repairs to be finished so he could return. Review of the care plan last revised on 04/05/26 showed no care plan had been developed to address discharge planning. The Social Services Designee confirmed the resident’s discharge plan was to return to his assisted living once the water damage was repaired and confirmed that a discharge plan of care had not been developed.
Medication Dose Error and Delayed Review of X-ray Results
Penalty
Summary
The facility failed to administer the ordered dose of acetaminophen to Resident #60. The resident was admitted on 01/22/26 with diagnoses including osteoarthritis of the knee and pain in an unspecified knee. The medical record showed an order for acetaminophen 500 mg, two tablets by mouth two times a day for pain, and the resident was cognitively intact with scheduled pain medication noted on the MDS. During medication administration observation on 04/08/26, an LPN removed acetaminophen from the cart and dispensed two tablets from a bottle labeled 325 mg. When questioned, the LPN verified that the resident received 325 mg tablets, two tablets, instead of the ordered 500 mg tablets, two times daily. The facility also failed to address x-ray results in a timely manner for Resident #10 after a fall. The resident had diagnoses including Alzheimer’s dementia, hypertension, anxiety, insomnia, and chronic kidney disease, and was severely cognitively impaired and dependent for several activities of daily living. After an unwitnessed fall in the resident’s room, the record documented skin tears, monitoring, and Tylenol for discomfort. An x-ray was later ordered for complaints of hip pain, and the results showed a right femur fracture. The x-ray results were electronically available to the facility on 01/08/26, but the DON stated they were not reviewed until the morning of 01/09/26 when they were noticed on the electronic dashboard. The DON stated the results should have been reviewed on 01/08/26 and the physician promptly notified. The facility policy required prompt notification of results outside the clinical reference range, but the report showed the fracture result was not reviewed and acted on until the next day.
Smoking Materials Not Secured for Resident
Penalty
Summary
The facility failed to secure smoking materials for a resident who was the facility’s only smoker. Resident #52 was admitted with diagnoses including COPD, type II diabetes mellitus with hyperglycemia, atherosclerotic heart disease, depression, HTN, MI, and a lesion of the ulnar nerve of the left upper limb. The resident’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition, and he required set-up/supervision with all ADLs as well as supervision with shower transfers and mobility. The resident’s smoking assessment documented education on smoking safety, including use of designated smoking areas and times, and stated that cigarettes, e-cigarettes, and lighters would not be kept in the resident’s room and that all smoking items were to be kept in a secure location with staff access only. However, the resident signed himself out to smoke several times per day over approximately the last nine months, stated that he kept his cigarettes and lighter on his person in his room and had not been instructed to store them locked up at the nurses station, and an observation confirmed cigarettes and a lighter stored in a coat pocket in his room closet. The Administrator stated the facility’s only smoking policy was for a smoke-free facility and that no current policy was available for smoking residents grandfathered in before the building became smoke-free.
Unsafe Medication Storage and Undated Tubersol Vial
Penalty
Summary
The facility failed to ensure Resident #9's fluticasone nasal spray was stored in a safe manner. Resident #9 was admitted on 02/25/26 and had diagnoses including chronic diastolic congestive heart failure. Her medication orders included fluticasone 50 micrograms suspension, one spray in each nostril daily for allergies, and there were no orders allowing medications to be kept at the bedside. The resident's MDS assessment showed a BIMS score of 15 out of 15, indicating she was cognitively intact. During medication administration observation on 04/07/26 at 9:22 A.M., the fluticasone nasal spray was found in the top drawer of her bedside table, and the LPN verified it was there. The LPN stated the resident did not have an order to keep medication at the bedside and did not have an order for self-administration of the nasal spray. The facility also failed to date an opened multi-dose vial of Tubersol in the low three medication storage refrigerator. During observation on 04/07/26 at 9:25 A.M., a one milliliter multi-use vial of Tubersol, labeled as 10 doses, was found opened but not dated. The LPN verified the opened, undated vial at the time of the observation. The manufacturer's package insert stated that vials in use for more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The facility policy titled Medication Storage, dated 03/31/25, stated that medications are to be stored according to manufacturer recommendations and that all drugs and biologicals are to be stored in locked compartments.
Failure to Obtain Dental Services for a Resident
Penalty
Summary
The facility failed to ensure dental services were obtained for one resident who was reviewed for dental services. The resident was admitted with Alzheimer's disease with late onset, severe, with agitation, and had a signed consent to treat for dental services completed by the POA because the POA wanted the resident fitted for dentures. The care plan identified the resident as edentulous and noted a preference not to wear dentures, with dental checkups listed as ordered. Facility records showed Social Services contacted 360 Dental Services by email to schedule dental appointments for the facility, but the vendor did not respond with a scheduled appointment. An additional email was sent later, and the vendor again stated it would get back to the facility about scheduling. The resident was not listed on the 360 Dental appointment schedule despite the signed consent, and Social Services verified there was no tracking process in place to ensure residents with signed dental consents were actually placed on the dental list to be seen.
Pureed Diet Food Was Runny and Unappealing
Penalty
Summary
The facility failed to ensure attractive and palatable pureed food was served to Resident #39. The resident was admitted on 04/26/25 with diagnoses including diaphragmatic hernia without obstruction or gangrene, other idiopathic peripheral autonomic neuropathy, and moderate protein-calorie malnutrition. His ordered diet was pureed texture with regular consistency and no added salt. During interview, Resident #39 stated that most days his pureed food was runny and not appealing. During lunch observation on 04/08/26, the resident’s tray contained two pureed food items that did not hold form. One item, identified as Philadelphia cheesesteak, was a brown circle of runny, thin consistency food that was running into and touching a second white food item, identified as onion rings, which was also runny and thin. The resident tasted both items and said the brown puree had good flavor but was too thin, while the white puree had no flavor and was also too thin. He then called the kitchen to discuss the tray, and Dietary Aide #111 confirmed he was calling because the pureed food was runny and the white food had no flavor, offering a substitute for the pureed onion rings. The resident requested French fries or mashed potatoes, but was told those items were not available and was suggested ketchup on the pureed onion rings, after which he appeared unhappy.
Missed Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure influenza and pneumococcal vaccines were addressed and administered timely for Resident #66. The resident was admitted with diagnoses including moderate protein-calorie malnutrition, unspecified dementia, unspecified mood disorder, osteoporosis, late onset Alzheimer's disease, and anxiety. The MDS assessment showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment, and the resident required partial to moderate assistance with ADLs including bed mobility and transfers. The immunization record showed that neither the influenza nor pneumococcal vaccine had been addressed or administered even though the resident's responsible party signed consents for both vaccines on 03/06/26. During interview, the ADON stated the admission nurse is expected to obtain immunization consents as part of the clinical admission process and that the expectation was for immunizations to be given within 30 days of receiving consent, but this resident was missed. The facility's influenza and pneumococcal vaccine policies required residents to be offered these immunizations unless medically contraindicated or previously immunized, and the facility was unable to produce a policy related to standing orders.
Missed COVID-19 Vaccination for a Resident
Penalty
Summary
The facility failed to ensure a COVID-19 vaccine was addressed and administered timely for Resident #66. The resident was admitted with diagnoses including moderate protein-calorie malnutrition, unspecified dementia, unspecified mood disorder, osteoporosis, late onset Alzheimer's disease, and anxiety. The MDS 3.0 assessment showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment, and the resident required partial to moderate assistance with ADLs, bed mobility, and transfers. Review of the immunization record showed the COVID-19 vaccine had not been addressed or administered even though the resident's responsible party had signed consent for the vaccine to be given. During interview, the ADON stated the admission nurse was expected to obtain immunization consents as part of the clinical admission process and that immunizations were expected to be given within 30 days of consent receipt, but this resident was missed. The facility policy stated COVID-19 vaccinations would be offered to residents when supplies were available and administered according to physician-approved standing orders, but the facility was unable to produce a policy related to standing orders.
Failure to Prevent and Properly Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident sexual abuse between two residents, one of whom had known sexually inappropriate behaviors and one who was severely cognitively impaired. One resident had diagnoses including autistic disorder, developmental disorder, anxiety, hypertension, and scoliosis, and was assessed as severely cognitively impaired, requiring extensive assistance or total dependence for most ADLs and unable to provide a reliable statement. The other resident had diagnoses including diabetes, depression, high cholesterol, and respiratory disorders, was cognitively intact, and was independent in ADLs. This cognitively intact resident had a care plan documenting sexually inappropriate behaviors, including entering female residents’ rooms, with interventions such as anticipating needs and discussing inappropriate behavior. On the date of the incident, a CNA reported witnessing the cognitively intact resident standing in front of the cognitively impaired resident in the hallway with his pants halfway down and his genitals exposed, telling the cognitively impaired resident to look. When the exposing resident saw the CNA, he returned to his bedroom. The CNA stated she asked the cognitively impaired resident if the other resident had shown his genitals, and the resident responded yes. The CNA also reported overhearing the cognitively impaired resident later tell another CNA that she was scared. A prior nursing note documented that the same resident had indecently exposed himself to another resident in the hallway on a different date. The facility’s self-reported incident and internal investigation documented that the exposing resident’s pants appeared to be positioned below his waist but concluded there was no evidence of inappropriate conduct, unintentional harm, or adverse outcome, and the allegation of sexual abuse was unsubstantiated. The investigation did not include a witness statement from a nurse, and witness statements were not obtained from all staff involved. The Administrator later confirmed that he had reported that the resident’s pants were down and his genitals were exposed to the cognitively impaired resident, which was inconsistent with the conclusion in the submitted self-report, and acknowledged that sexual abuse could not be ruled inconclusive based on the investigation results. Facility policy defined abuse to include resident-to-resident altercations and identified sexual abuse as non-consensual sexual contact, with an expectation that residents’ capacity to consent would be determined and recorded.
Misappropriation of Resident Medications and Failure to Safeguard Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of medications and to ensure medications were administered only as ordered. For one resident with Alzheimer’s disease, malnutrition, anxiety, and other conditions, the quarterly MDS showed cognitive impairment and a need for supervision with eating and staff assistance for all ADLs, including medication administration. On an evening in August, an LPN obtained a vial of Haldol 5 mg IM from another resident’s stock supply without a physician’s order for this resident and administered an injection in the resident’s room. Multiple CNAs reported being asked to assist the resident to the room, witnessed the LPN pull down the resident’s pants and give the injection, and stated the LPN told them not to say anything because the medication was not prescribed for the resident and had been taken from another resident’s supply. The DON confirmed there was no Haldol order for this resident on that date, that a vial was missing from the other resident’s Haldol supply, and that the LPN denied giving the dose. A second deficiency involved misappropriation and inaccurate handling of a controlled substance prescribed for another resident with ADHD, bipolar disorder, seizures, Tourette’s disorder, and other diagnoses. This resident was cognitively intact and independent with ADLs, and had an order for Adderall 20 mg twice daily at specific times. Review of the narcotic count sheets showed that on multiple occasions over two days, the Adderall pill count decreased by two tablets at times when only one tablet was ordered to be administered, all associated with the same LPN’s signatures. These discrepancies indicated that two pills were removed from the count when only one was ordered for the resident at each administration time. The DON later described that the LPN could not explain the discrepancies, claimed to have wasted a capsule without a witness, initially refused an in‑facility urine drug screen, delayed completion of an independent drug test, and that the facility’s policy stated refusal or failure to comply with drug testing requirements would be considered a refusal to test and subject to immediate termination. A third deficiency involved another resident with intact cognition and independence in ADLs who had multiple medical diagnoses and an order for Oxycodone 5 mg, one tablet by mouth every four hours as needed for pain. The MAR documented that this resident received single 5 mg doses at several times over two days, all administered by an agency LPN. However, the narcotic count sheet for the same period showed that the agency LPN repeatedly signed out two tablets at each administration time, including multiple entries for the same early‑morning time, despite the order being for only one tablet as needed. A subsequent review of the narcotic count by another LPN revealed discrepancies between the MAR and the narcotic sheet, with repeated documentation of two tablets being removed when only one tablet was ordered and documented as given. The DON stated that misappropriation occurred in all three incidents and that the facility’s abuse, neglect, and exploitation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and that the facility had unsubstantiated these incidents despite the misappropriation having occurred. The facility’s own policies and job descriptions further framed the deficiencies. The LPN job description required accurate preparation and administration of medications according to physician orders and accurate recording of medications administered. The Drug Free Safety Policy specified that refusal to comply with testing requirements, failure to provide valid specimens, or refusal to submit to reasonable suspicion or follow‑up tests would be considered a refusal to test and subject to immediate termination. The Abuse, Neglect, and Exploitation policy stated that the facility would implement policies and procedures to prevent and prohibit misappropriation of resident property. Despite these written expectations, the events described show that medications belonging to or prescribed for specific residents were wrongfully used or removed, and that in one case an LPN’s conduct around drug testing did not align with the facility’s stated policy, contributing to the overall deficiency in protecting residents from misappropriation.
Failure to Enforce Misappropriation and Drug-Free Workplace Policies for Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies related to misappropriation and drug-free workplace requirements in connection with a resident’s controlled medication. One resident, admitted with multiple diagnoses including ADHD, bipolar disorder, seizure disorder, and Tourette’s Disorder, had an order for Adderall 20 mg twice daily at 8:00 A.M. and 3:00 P.M. The resident’s MDS showed the resident was cognitively intact and independent with ADLs. Review of the resident’s Adderall narcotic count sheets showed that on specific dates, the pill count decreased by two tablets at times when only one tablet was ordered to be administered, indicating that two pills were signed out instead of one on multiple occasions. The facility’s SRI documented that the DON became aware that the Adderall count for this resident was inaccurate and identified that an LPN had signed out the medication at the times when the count decreased by two instead of one. During an interview, the LPN stated she did not know why the count was incorrect and claimed there was a day she punched out two capsules and wasted one but could not find another nurse to witness the waste. The DON reported that the LPN refused to complete an in-facility urine drug screen and did not appear for the initially scheduled independent drug test, despite facility policy stating that refusal or failure to comply with testing requirements constitutes a refusal to test and is subject to immediate termination. The DON acknowledged that, contrary to the written Drug Free Safety Policy, the LPN was allowed to return to work after refusing and missing the drug test, even though the policy specified that refusal to submit to required testing would result in termination.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident sexual abuse involving two residents. Resident #40, admitted on 04/07/16, had diagnoses including autistic disorder, developmental disorder, anxiety, hypertension, and scoliosis, and was documented as severely cognitively impaired, requiring extensive assistance with activities of daily living. Resident #52, admitted on 03/20/25, had diagnoses including diabetes, depression, high cholesterol, and respiratory disorders, was cognitively intact, and was independent in all ADLs. His care plan, initiated on 03/24/25, identified sexually inappropriate behaviors, including entering female residents’ rooms, with interventions focused on anticipating needs and addressing inappropriate behavior. On 01/11/26 at 9:32 P.M., a nursing note documented that Resident #52 indecently exposed himself to another resident in the hallway. The facility’s self-reported incident (SRI) and investigation dated 01/12/26 stated that Resident #52 was observed standing to the left of Resident #40 in the hallway with his pants appearing to be positioned below his waist, but asserted there were no movements, physical contact, or behaviors suggesting concerning interactions, and concluded the allegation of sexual abuse was unsubstantiated. The SRI noted that Resident #40 lacked the cognitive ability to provide a statement and that other resident interviews revealed no findings of abuse. However, a witness statement from CNA #213 documented that she saw Resident #52 standing in front of Resident #40, exposing his genital area and saying, "There you go, look at it," after which he rushed back to his bedroom when he saw her. CNA #213 reported that Resident #40 answered "yes" when asked if Resident #52 had shown his genitals and that Resident #40 was overheard telling another CNA she was scared. A police report recorded that staff reported Resident #52 exposing his genitals to Resident #40, though Resident #52 denied it. LPN #214 confirmed being told that Resident #52 exposed himself and acknowledged knowledge of his history of inappropriate sexual behaviors. The Administrator later confirmed he recalled reporting that Resident #52’s pants were down and his genitals were exposed to Resident #40, which was inconsistent with the SRI’s conclusion, and acknowledged that witness statements were not obtained from all involved staff and that sexual abuse could not be ruled inconclusive, contrary to the facility’s abuse policy requiring immediate, complete, and thorough investigation and documentation.
Incomplete Discharge Documentation and Medication Review for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and complete discharge process for one resident. The resident had multiple complex diagnoses, including rhabdomyolysis, moderate protein-calorie malnutrition, hypertensive chronic kidney disease stage V, seizures, hypothyroidism, anemia, hyperfunction of the pituitary gland, urinary retention, hyperlipidemia, diabetes insipidus, and hypopituitarism. A discharge MDS assessment showed the resident had cognitive impairment and required setup or cleanup assistance for ADLs. On the day of discharge to home via private car, progress notes documented that family was present, gathered belongings, and discharge paperwork was given. However, the nursing section of the discharge documents completed by the LPN responsible for the discharge was not filled out. Review of the medical record and interviews revealed there was no evidence that discharge medications were reviewed or offered to the resident or family, and the discharge paperwork was incomplete. The Ombudsman reported that the resident was discharged without medication prescriptions and that the discharge paperwork was not filled out completely. The DON confirmed that the discharge documentation was incomplete and that there was no evidence discharge medications were reviewed or offered. The LPN who discharged the resident acknowledged she did not complete the discharge paperwork and did not document reviewing discharge medications or offering a three-day supply, despite this being required by facility policy. The facility’s Transfer and Discharge policy specified that the nurse caring for the resident at the time of discharge must ensure the Discharge Summary is complete, including a recap of the stay, final status, and reconciliation of pre- and post-discharge medications, which was not done in this case.
Insufficient Staffing Leads to Missed Resident Showers and Hygiene Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple interviews, record reviews, and policy review. Certified nurse aides reported that there were not enough staff to complete essential activities of daily living (ADL) care, including showers and hygiene tasks. Staff described working without breaks, working overtime to complete charting, and being unable to provide showers or baths according to residents' preferences due to inadequate staffing levels. The Director of Nursing confirmed that the facility did not meet the minimum direct care daily average of 2.5 hours per resident per day on several dates, and the facility assessment had not been updated since April 2022. Three residents were specifically affected by the staffing deficiency. One resident, with severe cognitive impairment and total dependence on staff, preferred tub baths three times a week but often received bed baths instead, and there was no documented evidence of regular bathing or showers in the electronic medical record. Another resident, fully dependent for transfers and requiring a mechanical lift, preferred a weekly bath but had incomplete or missing documentation for showers and baths, with only two days marked as completed in the electronic record. A third resident, also fully dependent on staff for bathing and with a history of depression, had inconsistent documentation of showers and bed baths, and some shower sheets were not filled out. The facility's policy required assisting residents with bathing and maintaining proper hygiene according to their preferences, but this was not consistently followed. The lack of sufficient staffing directly impacted the ability to provide care as planned and documented, affecting residents' ability to receive showers or baths as preferred and required. The deficiency was identified through interviews with staff and residents, review of staffing schedules, and examination of care documentation.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present in the facility for at least eight consecutive hours each day, seven days a week, as required. Review of staffing schedules and tools for specific weeks in May 2025 showed that no RN was scheduled to work on one day, and on another day, an RN worked only 7.25 hours. During an interview, the Director of Nursing (DON) confirmed there was no additional evidence to show that an RN had worked the required hours on those days. This deficiency was identified incidentally during a complaint investigation and had the potential to affect all 75 residents in the facility.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to update its facility-wide assessment annually as required. Review of the assessment showed it was last dated over two years prior to the survey, and the Administrator confirmed during interview that the date had not been changed and could not provide evidence of any updates since that time. This lapse had the potential to affect all 75 residents in the facility. The deficiency was identified during a complaint investigation and was based on both document review and staff interview.
Failure to Notify Responsible Parties of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the responsible party, Power of Attorney (POA), or emergency contact when residents were transferred to the hospital. In the case of one resident with quadriplegia, kidney disease, and anemia, there was no documented evidence that his emergency contact, who is his sister, was informed of his hospital admission for a urinary tract infection. The resident was cognitively intact and required significant assistance with daily activities. The Director of Nursing confirmed that there was no evidence of notification to the responsible party regarding this transfer. Another resident, who had Alzheimer's disease, kidney disease, anemia, depression, and high cholesterol, was found to be severely cognitively impaired and dependent on staff for most activities. After sustaining a laceration on her forehead from a fall, she was transferred to the emergency department and treated for a closed head injury. Although the DON and physician were notified, there was no documentation that her responsible party, POA, or emergency contact was informed of the transfer. Staff interviews confirmed the lack of evidence for notification in both cases. Facility policy requires prompt notification of the resident's representative in such events, regardless of the resident's cognitive status.
Failure to Send Required Resident Information During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation regarding resident health status to the hospital upon transfer for two of three residents reviewed for hospitalizations. For one resident with quadriplegia, kidney disease, and anemia, who was cognitively intact and dependent on staff for most activities of daily living, there was no evidence that any information was sent to the hospital when he was admitted due to a urinary tract infection. For another resident with Alzheimer's disease, kidney disease, anemia, depression, and high cholesterol, who was severely cognitively impaired and dependent on staff for care, there was also no documentation that information was sent to the hospital following a transfer after a fall resulting in a laceration. Interviews with facility staff, including an RN and the DON, confirmed that the process for hospital transfers should include sending a transfer form with resident demographics, physician's orders, and a list of medications. However, review of the records and facility policy revealed that this information was not sent for the two residents in question, despite the policy stating that such documentation should accompany residents for continuity of care during hospital transfers.
Failure to Provide Bathing Services per Resident Preference Due to Staffing Issues
Penalty
Summary
The facility failed to provide bathing and showering services according to resident preferences for three residents who were dependent on staff for activities of daily living (ADL) care. Documentation and interviews revealed that residents did not consistently receive their preferred method or frequency of bathing, despite their preferences being documented in care plans and assessments. For example, one resident with severe cognitive impairment and total dependence on staff preferred a tub bath three times a week, but records showed they often received bed baths or showers instead, and there was no consistent documentation of bathing in the electronic medical record. Another resident, who was cognitively intact but fully dependent for transfers and required a mechanical lift, reported not receiving baths according to their preference of once a week. Paper shower sheets were frequently left unfilled, and electronic records only sporadically documented completed bathing tasks. A third resident, also fully dependent on staff for bathing and with a history of depression, reported not being bathed as frequently as preferred, with gaps in both paper and electronic documentation. This resident had also voiced concerns to staff about the issue. Interviews with multiple CNAs confirmed that resident showers were not regularly provided according to resident preferences, citing insufficient staffing as a primary reason. The Director of Nursing acknowledged awareness of staffing issues affecting the provision of care. Facility policies reviewed indicated that bathing should be consistent with resident choices and requests, but these were not followed in practice, resulting in the deficiency.
Failure to Follow Physician Orders for Pressure Injury Prevention
Penalty
Summary
The facility failed to follow physician orders for the prevention of skin breakdown for one resident who was at risk for pressure ulcers. The resident, who was severely cognitively impaired, totally dependent on staff for care, and always incontinent of urine and bowel, had a care plan and physician orders in place to address their risk for pressure injuries. These included daily application of a foam dressing with protective cream to the coccyx area and repositioning every two hours using a wedge pillow. However, during observations, the resident was repeatedly found lying on their back without the prescribed foam dressing in place, and the wedge pillow intended for repositioning was consistently found on a bedside chair rather than being used for the resident. Interviews with nursing staff confirmed that the foam dressing was not applied as ordered and that the wedge pillow was not being used for repositioning, despite the presence of a physician's order and facility policy requiring evidence-based interventions for pressure injury prevention. The resident was observed to have a significant reddened area on the coccyx, and staff acknowledged the lack of adherence to the prescribed interventions. Facility policy review further supported that such interventions should have been implemented for residents at risk for pressure injuries.
Failure to Thoroughly Investigate Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate falls for two residents, resulting in incomplete fall investigations. For one resident with diabetes, heart disease, and other chronic conditions, a fall occurred when her incontinence brief slid down during a transfer, causing her to trip. Although she was assessed and found to have no injuries, the facility's fall investigation lacked witness statements, a root cause analysis, documentation of when she was last toileted, evidence of call light use, and implementation of new interventions. The care plan had identified her as a fall risk, but the investigation did not meet the facility's policy requirements. Another resident with Alzheimer's disease and multiple comorbidities experienced a fall resulting in a head laceration and required emergency treatment. The investigation for this incident also lacked staff witness statements, a root cause analysis, documentation of toileting or call light use, and evidence of new interventions. The DON confirmed that these elements were missing from both investigations, and the facility's policy required such steps to be completed for all falls, especially unwitnessed ones. These deficiencies were confirmed through record review, interviews, and policy review.
Failure to Timely and Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted both timely and accurately. On the morning of 06/10/25, the posted staffing information was observed to be for the previous day, 06/09/25, and did not include the facility census as required. During an interview at the time of observation, a CNA confirmed that the information had not been updated for the current day and that the scheduler, who was responsible for updating the posting, was on vacation. The CNA also verified that the census number was missing from the displayed information. This deficiency was identified incidentally during a complaint investigation and had the potential to affect all 75 residents in the facility.
Inadequate Investigation of Narcotic Diversion and Resident Altercation
Penalty
Summary
The facility failed to conduct thorough investigations regarding the diversion of narcotics and a resident-to-resident altercation, affecting three residents. In the first incident, two oxycodone tablets were missing from a resident's narcotic count. The investigation lacked essential components such as witness statements, a police report, and assessments of the resident involved or other residents on narcotic pain medication. Additionally, there was no evidence of staff education on narcotic counts or misappropriation, and no preventative measures were implemented. In the second incident, a resident-to-resident altercation occurred, where one resident pulled a chair from under another, causing the latter to fall. The investigation into this incident was incomplete, with only one resident witness statement and no assessment of the resident who caused the altercation. There were no interviews or assessments of other residents regarding potential abuse, and no staff education or preventative interventions were documented. The facility's policy on abuse, mistreatment, neglect, and misappropriation of resident property was not followed. The policy requires interviews with all involved parties, obtaining written statements, and documenting evidence of the investigation. It also mandates that the facility's interdisciplinary team determine appropriate interventions and that the quality assurance committee reviews the investigative materials to prevent future incidents. These steps were not adequately executed, leading to the identified deficiencies.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours, seven days a week, as required by regulations. This deficiency had the potential to affect all 80 residents of the facility. On 08/04/24, the staff schedule and the facility's Daily Staffing Sheet revealed that no RN was scheduled for any shift, and only one RN punched in late at night, well after the required hours. Interviews with the Staffing Coordinator and the Director of Nursing (DON) confirmed that no RN was scheduled for the required hours on that day. The DON was not notified of the absence of an RN, and the scheduled RN had called off, resulting in the lack of RN coverage. The facility's policy indicated that staff might be required to work different shifts to maximize staffing, and administrative or third-party agency staff would be used in emergencies, but these measures were not implemented on the day in question.
Inaccurate MDS Coding for Hospice Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for five residents, leading to deficiencies in the documentation of their health conditions. These residents were admitted with various serious diagnoses, including end-stage diseases, and were receiving hospice services. However, their MDS assessments incorrectly indicated that they did not have a life expectancy of less than six months, despite being on hospice care. Resident #5 was admitted with cerebral atherosclerosis and other conditions and was on hospice care from admission. Similarly, Resident #11, with chronic kidney disease and congestive heart failure, was also on hospice care. Both residents' MDS assessments failed to reflect their life expectancy accurately. Resident #51, with Alzheimer's disease, and Resident #71, with Parkinson's disease, were also on hospice care, yet their assessments were incorrectly coded. Resident #73, with a malignant neoplasm, was similarly affected. The MDS Licensed Practical Nurse (LPN) responsible for these assessments was inexperienced and had been instructed by corporate not to code residents as having a life expectancy of less than six months. This instruction led to the incorrect coding of the MDS assessments, as confirmed by the review of the MDS 3.0 Resident Assessment Instrument (RAI) manual, which states that residents receiving hospice services should be coded as having a life expectancy of less than six months.
Failure to Maintain Resident Dignity Due to Persistent Urine Odor
Penalty
Summary
The facility failed to maintain a dignified existence for Resident #36, as evidenced by the persistent strong odor of urine in the resident's room. Resident #36, who was admitted with diagnoses including memory deficit, morbid obesity, hypertensive congestive heart failure, and major depression, was frequently incontinent of urine and bowel. Despite being on a diuretic, Lasix, and receiving incontinence care every two hours, the resident's room continued to have a strong urine odor. This was confirmed through interviews with a Licensed Practical Nurse and a State Tested Nurse Aid, both of whom acknowledged the persistent odor. An observation conducted in Resident #36's room further confirmed the strong urine odor, which was also acknowledged by the resident during an interview. The facility's policy on Resident Rights, revised in June 2015, states that residents have a right to a dignified existence, which was not upheld in this case. This deficiency was investigated under Complaint Number OH00156094, affecting one of the three residents reviewed for dignity in a facility with a census of 80.
Inadequate Assistance and Lapse in Fall Risk Assessment
Penalty
Summary
The facility failed to provide adequate assistance to Resident #37 during ambulation, resulting in a fall. Resident #37, who had a history of falls and was diagnosed with dementia, major depression, and anxiety, required maximum assistance for walking and transfers. Despite this, on the day of the incident, a State Tested Nursing Assistant (STNA) let go of the resident to move a chair obstructing the path to the bathroom, leading to the resident losing balance and falling. The resident was subsequently sent to the emergency room for evaluation, although no fractures were found. Additionally, the facility did not complete fall risk evaluations and assessments quarterly as required. The last fall risk assessment for Resident #37 was conducted over a year before the fall incident, despite the facility's policy mandating such assessments quarterly and after any fall. The Director of Nursing confirmed the lapse in conducting timely fall risk assessments, which contributed to the deficiency in ensuring the resident's safety.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer program, resulting in Immediate Jeopardy and actual harm to Resident #44. This resident, who was at risk for pressure ulcer development and dependent on staff for all activities of daily living, developed a Stage III pressure ulcer on the sacrum. The ulcer progressed from moisture-associated dermatitis to a Stage III pressure ulcer due to inadequate interventions, including poor incontinence care, lack of timely turning and repositioning, and insufficient offloading of pressure. The resident's condition deteriorated, leading to hospitalization for sepsis secondary to the pressure ulcer. Resident #10, who was also at risk for pressure ulcer development, experienced actual harm when the facility failed to provide necessary care and services, resulting in the development and worsening of a Stage III pressure ulcer. The ulcer increased in size and drainage due to the resident not being repositioned timely and per facility policy. There was no documentation of timely incontinence care, turning, repositioning, or showers being completed as per the resident's care plan and preference. Similarly, Resident #72 developed an in-house acquired Stage III pressure ulcer to the sacrum, which worsened due to new damaged skin around the wound. The facility failed to provide timely incontinence care, turning, repositioning, and showers as per the resident's care plan. The lack of proper care and interventions led to the deterioration of the pressure ulcer, affecting the resident's overall condition.
Removal Plan
- Director of Nursing (DON) #804 began staff education for licensed nurses and State tested Nursing Assistants (STNAs) on the need to ensure that all pressure relieving interventions were in place in accordance with the plans of care and that incontinence care, turning and repositioning, and showers/bed baths were implemented timely and in accordance with the plan of care for all residents, including those with wounds.
- All nursing staff were also in-serviced on the need to inform the nurse if wound dressings become soiled with urine or stool so they can be changed.
- Any staff not In-serviced would be in-serviced prior to their next working shift.
- Licensed Practical Nurse/Wound Nurse (LPN/WN) #800 re-assessed the resident's sacral wound and a new order to cleanse with normal saline, apply Santyl nickel thick and cover with bordered gauze was obtained.
- The resident's care plan was reviewed and included interventions of turn and reposition side to side, lay down after meals, and Chamosyn to buttocks after incontinence episodes was initiated.
- All necessary physician orders including medication orders and wound care orders were reviewed to ensure accurately reflected in the care plan.
- LPN/WN #800 initiated review of care plans for all residents who had existing wound, Resident #7, #10, #44, #45, #46, #49, #58, #61, #65 and #72.
- LPN/WN #800 again reviewed all necessary physician orders for Resident #44 and the facility implemented a plan to review these orders daily to ensure they were accurately reflected in the resident's care plan.
- The resident was also scheduled to see the wound care physician.
- Director of Nursing (DON) #804 began in-service with all licensed nurses on the need to ensure the physician was timely notified of all wound changes, treatments were implemented in accordance with orders, and all orders for cultures and labs were obtained timely and orders for antibiotics were implemented timely.
- Any staff not educated would be educated prior to their next working shift.
- Licensed Practical Nurse/Wound Nurse (LPN/WN) #800, LPN #801, LPN #802, and LPN #803 completed skin sweeps and new Braden Scales on all facility residents. No new pressure ulcers or infections were identified.
- All resident care plans would be reviewed to ensure appropriate preventative interventions were in place and appropriate treatments were in place if appropriate.
- DON #804 posted the STAT phone number for the lab at all nurse's stations to ensure staff had access and were calling the correct number when STAT labs need to be drawn, and in-serviced all nurses on the number as well as the need to contact the DON or Administrator if the lab cannot be reached.
- LPN/WN #800 checked all culture containers (urine and swabs) and discarded all expired items and contacted the lab to request non-expired culture containers be provided.
- LPN/WN #800 would then check culture containers monthly and discard expired containers.
- DON #804 in-serviced all licensed nurses on the process for monthly checking of culture containers for expired containers and on the need to check all containers, including swabs for expiration prior to use.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON #804, LPN/WN #800, and Medical Director (MD) #900 to review the plan.
- The meeting included a discussion of skin issues identified with the skin/wound CQI report.
- The facility implemented a plan for LPN/WN or designee to complete observations of at least five random residents per day for four weeks to ensure pressure relieving interventions were being implemented in accordance with the plan of care, including offloading, incontinence care provided timely, and showers completed in accordance with the plan of care and shower schedule.
- The observation/audits would include residents with and without wounds. All audits would be reviewed by the QAPI committee.
- The facility implemented a plan for LPN/WN or designee to complete observations/audits of at least three residents with wounds per day to ensure wound treatments were being implemented as ordered, dressings were changed if soiled, and new orders for labs or cultures are implemented timely.
- The audits/observations would be completed for four weeks, and all audits would be reviewed by the QAPI committee.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to maintain sufficient nursing services staff to meet the total care needs of residents according to their plan of care. This deficiency affected six residents and had the potential to affect all 78 residents residing in the facility. The facility's staffing plan indicated that licensed nurses and State tested Nursing Assistants (STNA) should provide a range of 3.28 to 4.78 hours of direct resident care per resident per day. However, during the periods reviewed, the facility did not meet these minimum staffing requirements, providing only 2.95 to 3.65 hours of care per resident per day. Interviews with staff revealed that the facility was short-staffed, leading to inadequate care for residents. STNAs reported being unable to complete showers, provide timely incontinence care, or reposition residents as needed. The facility had eliminated the shower aide position, further burdening the STNAs with additional responsibilities. The Director of Nursing (DON) acknowledged the staffing concerns and had begun some staff education, but more training was needed. Specific resident cases highlighted the impact of insufficient staffing. For example, a resident with cerebral palsy and a pressure ulcer did not receive timely incontinence care or showers, contributing to the development of a pressure ulcer. Another resident, who preferred bed baths, reported that staff did not assist him unless he attempted to wash himself. Several residents confirmed they did not receive showers according to their schedules or preferences, and documentation of care was lacking, with missing shower sheets for multiple residents.
Resource Mismanagement and Environmental Deficiencies in LTC Facility
Penalty
Summary
The facility administration failed to manage resources effectively, impacting the wellbeing of all 78 residents. The interim Administrator and the new Director of Nursing (DON) were both recently appointed, with the Administrator starting on 06/28/24 and the DON on 06/21/24. The facility was found to be understaffed, with State Tested Nursing Assistants (STNAs) and licensed nurses providing fewer hours of direct care per resident per day than outlined in the Facility Assessment. Interviews with staff revealed that the lack of staffing led to residents not receiving showers, timely incontinence care, or being turned and repositioned as needed. The facility also struggled with a persistent bed bug infestation. Despite multiple chemical treatments, bed bugs were still present in several rooms, and residents reported being bitten. The exterminator confirmed that the facility had not followed recommended procedures, such as heat treatment and treating adjacent rooms, which are necessary to eradicate bed bugs effectively. The facility's approach was limited to chemical treatments, which were insufficient to address the infestation. Additionally, the physical environment of the facility was not maintained adequately. Observations revealed holes in the walls of residents' rooms, which had not been repaired despite being known to the Environmental Director and Maintenance Director. Residents reported these issues, but they were not documented in the maintenance log, indicating a lack of attention to maintaining a safe and comfortable environment for residents.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents received showers according to their schedules or preferences, affecting six residents out of the six reviewed. The facility's census was 78. The deficiency was identified through observations, medical record reviews, shower schedule reviews, facility policy reviews, and interviews with staff and residents. The facility's policy, last revised in December 2013, stated that residents should receive baths or showers according to their preferences, which was not adhered to. Resident #4, who had intact cognition and required partial assistance for personal hygiene and showers, preferred bed baths over showers. However, the facility could only provide evidence of one bed bath over a two-month period. Resident #10, with impaired cognition and requiring substantial assistance for showers, reported not having had a shower in a long time, and no shower sheets were available for the requested period. Resident #32, who was severely cognitively impaired and dependent on staff for all ADLs, had only one shower sheet available for the two-month period. Resident #44, who was severely cognitively impaired and dependent on staff for all ADLs, had only four shower sheets available for the requested period. An observation revealed a strong odor of urine, indicating inadequate bathing. Resident #72, with severely impaired cognition and dependent on staff for all ADLs, had no shower sheets available for the requested period. Resident #79, with intact cognition and requiring partial assistance for showers, confirmed not receiving showers per schedule or preference, with only four shower sheets available. Interviews with staff revealed that the facility had eliminated shower aides, leading to inadequate showering for residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain the physical environment in a safe and homelike condition for two residents, as evidenced by the presence of holes in the walls of their rooms. Resident #1, who has a history of hypertensive urgency, chronic kidney disease, and other health issues, was admitted to the facility with slight cognitive impairment and required varying levels of assistance with daily activities. Resident #79, diagnosed with multiple sclerosis and other conditions, had intact cognition but required significant assistance with personal care. Observations revealed holes in the walls behind the headboards in both residents' rooms, which were confirmed by the Environmental Director and Maintenance Director, who acknowledged the issue but had not yet addressed it. Interviews with both residents confirmed their awareness and concern about the holes, with Resident #1 expressing that the holes were bothersome and had been reported to staff without resolution. Resident #79 also reported the issue to the administration team, but no action had been taken. A review of the maintenance log from May to July did not document any mention of the holes, indicating a lack of formal acknowledgment or action to repair the damage. This deficiency was investigated under Complaint Number OH00154346.
Ineffective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program for bed bugs, affecting one resident directly and potentially impacting the entire resident population. Resident #4, who had intact cognition and required partial assistance for some activities, was prescribed hydrocortisone cream for itching caused by bed bug bites. Despite multiple chemical treatments by an exterminator, bed bugs were observed in several rooms, including those previously occupied by Resident #4. Interviews with residents and staff confirmed the presence of bed bugs and indicated that the facility's pest control measures were insufficient. The exterminator noted that the facility opted for chemical treatments rather than the recommended heat treatments, which are necessary to eradicate bed bugs effectively. The facility's approach was limited to treating only the infested rooms, rather than adjacent areas, which contributed to the persistence of the infestation. The deficiency was investigated under multiple complaint numbers, highlighting the ongoing nature of the issue.
Sanitary Deficiencies in Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect 80 residents who receive food from the kitchen. During a tour of the kitchen, it was observed that the floor in the dry storage area had built-up dirt and debris underneath the shelves. Additionally, there were opened and unlabeled bags of macaroni and a container of cornstarch with a pan stored inside it for scooping. The three-sink sanitation station contained expired Hydrion test strips, and the standup refrigerator had opened and unlabeled food items, including a half brick of queso cheese and beverages belonging to staff. The Dietary Manager verified these findings during the tour. Further observations revealed that a dietary aide with a full beard was preparing coffee without a beard cover, which could lead to contamination. The facility's policies on food storage and uniform dress code were reviewed, indicating that scoops should not be stored in food containers and leftover food should be labeled and dated. The dress code policy also required staff to wear hair nets and beard covers. These deficiencies indicate a failure to adhere to professional standards for food storage, preparation, and sanitation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 434 citations issued within 25 miles in the last 12 months — including the 6 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 Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Washington Square Healthcare Center | 0.6 mi | ★★★★★ | 26 | 0 |
| Gillette Nursing Home | 2.6 mi | ★★★★★ | 6 | 0 |
| Warren Nursing & Rehab | 3 mi | ★★★★★ | 51 | 1 |
| White Oak Manor | 3.2 mi | ★★★★★ | 3 | 1 |
| Windsor House At Champion | 3.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Community Skilled Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.