Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Continuing Healthcare At Willow Haven during CMS and state inspections, most recent first.
Staff failed to consistently document required meal intake percentages and bowel/bladder continence status in the EMR for multiple residents with dementia, diabetes, malnutrition risk, incontinence, and skin‑integrity concerns. Despite care plans and facility policy requiring that every meal be recorded and continence status be documented on all three shifts daily in PointClickCare, there were numerous days with no entries and many days with only partial documentation for meals and continence. Leadership confirmed that direct care staff were expected to complete these entries on each shift, but the records reviewed showed that this did not occur.
A resident with multiple chronic conditions and moderate cognitive impairment experienced several changes in condition, including pain and drainage at a nephrostomy tube site, a positive MRSA wound culture with initiation of contact isolation, and a catheter change due to abdominal and back pain, which led to new antibiotic therapy and diagnostic testing. Although the resident was informed of new orders, the facility did not document notification of the resident’s POA, despite the POA being actively involved in decision-making and the resident’s expressed wish that his daughter be notified of changes. This pattern of non-notification occurred despite a facility policy requiring that the resident’s legal representative be informed and that such communication be documented for significant status changes and new treatments.
The facility failed to consistently document meal intake percentages for three residents with care plans identifying risk for malnutrition and requiring that every meal be monitored and recorded. One resident with dementia, depression, dysphagia, and a history of TBI had documented poor appetite and significant weight loss, yet over a 30‑day period many meals were not entered in the EMR, with only some days showing all three meals recorded. A second resident with central cord syndrome, COPD, nutrition deficit, and hemiplegia was dependent on staff for eating and had prior SWL, but review of a 30‑day period showed multiple days with no meal documentation and others with only partial meal recording. A third resident with dementia, prior CVA, DM, protein‑calorie malnutrition, and mobility issues had a care plan requiring intake monitoring and recording of every meal, but review of several weeks of records revealed numerous days with no meals documented and only a few days where all three meals were recorded. The Administrator and regional clinical staff acknowledged that meal intakes were not consistently documented and could not provide missing intake records.
A resident with anxiety, cognitive impairment, and other chronic conditions had a PRN order for lorazepam 0.25 mg (½ of a 0.5 mg tablet) every eight hours for target behaviors such as restlessness and yelling out. Review of the MAR and progress notes showed that an RN documented and later recognized administering 0.5 mg instead of the ordered 0.25 mg. The ADON confirmed the wrong dose was given, and this occurred despite a facility policy requiring adherence to the five rights of medication administration, including verification of the correct dose against the MAR and physician order.
A resident with dementia, CKD, dysphagia, a pressure ulcer, and risk for malnutrition had physician orders and a care plan for large protein portions and bite-sized meats/entrées to support wound healing and nutritional status. Despite these orders and clear instructions on the meal ticket, staff served a breakfast tray with a whole piece of ham, uncut bread, and only a small portion of scrambled eggs, not meeting the ordered large protein portion or bite-sized preparation. The resident reported repeated problems with the kitchen not following his diet preferences and needs, and a CNA confirmed the meal did not match the ticket or facility portion-size policy.
A resident with chronic kidney disease, a nephrostomy tube, MRSA at the nephrostomy insertion site, and multiple comorbidities had physician orders and a care plan requiring enhanced barrier precautions for infection prevention. Surveyors observed the resident’s nephrostomy collection bag lying directly on the floor beside the bed, and a CNA confirmed it should have been supported by a basin that was no longer in place. This failure to maintain the nephrostomy bag off the floor was inconsistent with the facility’s infection control policy and resulted in a cited deficiency.
Multiple shower rooms had malfunctioning equipment and inappropriate water temperatures, with some rooms lacking hot water and others having leaking pipes and missing fixtures. A CNA confirmed that residents requested to use other halls due to these issues, and the Maintenance Director acknowledged that repairs were delayed and water temperatures were not routinely checked. These deficiencies had the potential to affect a significant number of residents.
A resident with intact cognition and multiple chronic conditions reported a missing Apple watch, but the facility did not complete a thorough investigation as required by policy. Key investigative steps were missed, including contacting hospital staff, following up with off-site laundry, using the locator app, and interviewing other residents or documenting police involvement.
Two residents experienced discrepancies in the documentation of controlled substance administration, including missing entries on the MAR and incomplete narcotic count sheets. Staff confirmed that records for opioid medications did not consistently reflect administration times, amounts received, or required signatures, resulting in incomplete and inaccurate medical records.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
The facility did not provide eight consecutive hours of RN coverage per day on multiple occasions, as confirmed by payroll records, staffing schedules, and interviews with the DON and ADON. The shortage of RNs, especially on weekends, limited the facility's ability to accept residents with higher acuity needs such as central lines or frequent IV therapy. Staffing decisions were based on budget rather than a formal policy, and recruitment efforts had not filled the necessary RN positions.
Multiple lapses in kitchen sanitation and food safety were observed, including improper use of hairnets by staff, a malfunctioning and leaking refrigerator contaminating beverages, heavy grease and dust buildup on kitchen equipment, and inadequate sanitizer concentration. Exposed electrical wires were also found under the dishwashing station. These deficiencies had the potential to impact all residents receiving food from the kitchen.
The facility did not maintain a clean and homelike environment, with observations of unclean rooms, sticky floors, overflowing trash, and stained curtains. During a meal, a pest control worker sprayed chemicals and handled traps in the dining area while residents ate, and entered the kitchen without a hairnet. Several rooms had maintenance issues such as leaking, moldy air conditioners and broken furniture. Staff and residents reported frequent shortages of essential supplies and linens, with staff confirming that rooms often lacked gloves, towels, and other necessary items, especially after a laundry fire disrupted operations.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Surveyors found that staff failed to consistently implement enhanced barrier precautions and proper infection control practices, including missing PPE signage, lack of EBP orders, and improper use of PPE during care for residents with indwelling devices and wounds. In addition, perineal care was not performed according to best practices due to insufficient policy detail and staff training, and infection control lapses were observed during wound care and handling of soiled linens.
Expired surety bond left resident funds accounts without documented coverage. Review of the resident funds balance form showed 45 accounts for 42 residents totaling $28,884.44, and the surety bond had expired with no evidence of renewal or replacement at the time of review. The Administrator and corporate staff gave conflicting explanations about whether the facility had changed companies, and corporate later confirmed the bond was being renewed with the prior company.
A facility failed to keep complete and accurate medical records for multiple residents. One resident’s chart lacked documentation of the change in condition and events leading to death, including VS, O2 orders, and signed DNR status, even though the DON later described the decline in a statement. Another resident’s Trilogy ventilator use was charted as applied on nights when the mask seal was broken and the replacement mask had not yet been opened. The facility also documented calcium acetate as administered even though it was never received, and an insulin order listed the wrong route as IM instead of SC.
A resident with multiple medical conditions, including dementia and muscle weakness, did not receive required therapy or restorative services for range of motion and ambulation after being discharged from hospice. Despite care plan interventions and the resident's expressed desire to walk, there was no evidence of therapy screening or maintenance programs, and staff confirmed the absence of regular therapy assessments, leading to a decline in the resident's ability to perform ADLs.
Inaccurate code status documentation affected two residents. One resident had a physician note documenting DNRCC-A, but the chart, care plan, and signed orders remained full code, and no signed Ohio DNR order form was found before the resident expired. Another resident’s EMR listed full code even though the paper chart contained a signed DNRCC advance directive, and an LPN confirmed the mismatch after speaking with the resident’s daughter, who said the resident was supposed to be DNRCC.
Failure to document a rationale for declining a pharmacy recommendation related to a PRN psychotropic medication. A resident with depression, anxiety, and a traumatic subdural hemorrhage had a PRN Lorazepam order, and the pharmacist noted CMS limits PRN psychotropics to 14 days unless the rationale and estimated duration are documented. The NP declined the recommendation to discontinue the PRN or add a stop date, but did not date the response or document a rationale, which RN and DON confirmed was missing.
A resident admitted with fractured vertebrae, ESRD on dialysis, and dysphagia did not have the required admission MDS assessment completed and submitted on time. The EMR showed no completed MDSs available for review, and an RN confirmed the assessments had not been finished or sent to CMS. Later review showed the 5-day MDS was completed but not submitted, the admission MDS was export ready, and the discharge assessment was still in progress.
A resident with DM2, PVD, HF, urinary retention, and depression was admitted to hospice, but no timely significant change MDS was completed after the decline and hospice order. The MDS nurse confirmed the MDS should have been completed when hospice services were ordered and said she was not aware of the hospice order until the survey start date, when she started a significant change MDS that was still pending.
A resident with DM had an inaccurate quarterly MDS assessment that showed one dose of insulin even though there was no insulin order and the MAR showed no insulin was given during the assessment reference period. An RN verified the resident did not receive insulin and that the MDS was not accurate.
A facility failed to obtain treatment orders and fully assess skin alterations for two residents. One resident developed new draining calf wounds, but no physician orders were written for the dressings despite staff documenting treatment and an RN confirming the lack of orders. Another resident was admitted with an open coccyx area and multiple lower-leg wounds, but the record lacked a comprehensive wound assessment, including wound type and drainage details; the DON and ADON both verified the admission assessment was not completed.
Failure to complete a comprehensive wound assessment, provide pressure prevention interventions, and follow infection control practices occurred for a resident with PAD, DM, bilateral BKA, and multiple wounds. The resident had an open coccyx area that was later identified as a Stage 3 PU, but the initial skin documentation lacked key wound details. The resident was also observed in a wheelchair without a pressure-relieving cushion, with loose BKA dressings, and during incontinence care an LPN and CNA used the same gloved hands and washcloth across the groin, rectum, and pressure ulcer area.
A resident with a gastrostomy tube, multiple GI-related diagnoses, and recent surgery did not have the ordered CT scan or surgical follow-up completed as expected. The tube remained in place and not to be used, but the facility did not have the CT order in the chart, did not arrange the imaging, and the resident reported the missed follow-up delayed discharge home.
Respiratory care was not provided as ordered for multiple residents. One resident with COPD, chronic respiratory failure, OSA, and asthma had a Trilogy mask left out unsanitary, a broken seal on the mask, and a replacement mask that was delivered but not opened for several days while the device was still documented as applied. Two other residents had respiratory equipment left out without sanitary storage, and one resident on O2 was observed without the ordered humidification bottle despite reporting nasal dryness and prior bleeding.
A resident with ESRD and scheduled hemodialysis had delayed transcription of dialysis-center orders, no ongoing facility-to-dialysis communication, and one prescribed phosphate binder was never administered. The resident received Renvela after a delay, but calcium acetate was not delivered or given, and the DON verified the medication was not received as ordered. The facility also did not have the dialysis center named as an additional insured on the GL policy as required by the transfer agreement.
A resident with bipolar disorder, depression, and anxiety was receiving multiple psychotropic meds, but psychiatric services were not provided for months after admission despite care plan interventions for mood monitoring and behavioral health consults. MDS assessments showed ongoing symptoms such as insomnia, depressed mood, loss of interest, and social isolation. The social worker stated the resident had been missed for psych services and had not received counseling, and the psychiatrist later evaluated the resident for med management and reduced Abilify.
Expired insulin remained in the med cart for a resident with DM, heart disease, and CKD. An LPN observed three Humalog pens and a Novolog pen for the resident, including opened Humalog pens that had been left unrefrigerated and were past the 28-day use period, plus a Novolog pen with no active order that had reached its used-by date. The DON and CRN confirmed the insulin should have been discarded.
A resident with osteoarthritis, cervical spinal stenosis, and other chronic conditions received PRN oxycodone for pain, but the order did not define what numerical pain scores counted as moderate or severe. MAR review showed the opioid was given for pain ratings ranging from 0/10 to 8/10, and an LPN and the DON both acknowledged the pain interpretation was subjective and could vary by nurse. The care plan also lacked individualized non-pharmacological pain interventions.
A resident admitted with osteomyelitis, diabetes, MSSA, and absence of the left foot had hospital discharge orders for weekly CBC, BMP, and CK labs, but the medical record showed no evidence the tests were completed. A CRN and an LPN both confirmed the ordered weekly labs were not done.
The facility failed to ensure antibiotic treatment met criteria for two residents reviewed for antibiotic stewardship. One resident received Cefdinir for sepsis/possible respiratory infection despite no documented criteria, with hospital records showing negative infection workup and staff confirming there was no evidence supporting the antibiotic. Another resident received Metronidazole and Vancomycin for osteomyelitis/wound infection, but the facility’s criteria form did not include osteomyelitis, and staff confirmed infections outside the listed categories were marked N/A without verifying CDC criteria.
Two residents reported their mail was opened by facility staff without consent, violating their right to receive unopened mail. Despite having consent agreements on file, both residents denied giving permission. The facility's corporate office instructed staff to open mail from insurance companies or ODJFS, leading to this breach of privacy.
A resident with Alzheimer's and other conditions had their rollator walker, dentures, and glasses go missing after a hospital transfer. The facility's administrator attempted to contact the hospital but received no response, and no further follow-up was conducted. This failure to resolve the concern violated the facility's policy on resident rights, as noted during a complaint investigation.
A facility failed to provide comprehensive transfer information for a resident who had Alzheimer's, diabetes, and other conditions. The Transfer Form omitted the resident's son as the power-of-attorney, which was confirmed by the Administrator.
A facility failed to coordinate care for a resident by not scheduling a gynecology appointment as ordered for post-menopausal bleeding. Despite having intact cognition and multiple health diagnoses, the resident's referral was not made between the order date and a subsequent review. An interview confirmed the oversight, affecting one of three residents reviewed for appointments.
A resident's grievance about missing upper dentures was not addressed promptly by the facility, leading to a deficiency. The resident, admitted with both upper and lower dentures, reported the upper dentures missing, but the facility delayed scheduling a dental appointment and resolving the issue. The corporate office eventually agreed to cover half the replacement cost, but the resident was not informed, leading to frustration. The facility's policy on handling resident concerns was not effectively followed, resulting in a prolonged resolution process.
A resident with a history of abdominal wall infections experienced complications due to inadequate wound vac management and failure to implement a physician's order for a CT scan and surgical referral. The resident's wound vac leaked, leading to increased drainage and infection signs, resulting in hospitalization and surgical intervention. Staff interviews revealed a lack of training in wound vac management, and the facility's policy to notify physicians of wound changes was not followed.
The facility failed to maintain a safe and comfortable environment during a heat advisory, affecting several residents. The main AC units were non-functional, leading to discomfort in common areas despite the use of portable AC units and fans. Additionally, mold was found in shower rooms on two halls, with inadequate signage and cleaning efforts. Maintenance logs lacked documentation of these issues, indicating a failure in reporting and compliance with facility policies.
The facility failed to maintain a safe environment for 14 cognitively impaired residents who were independently mobile. Large portable air conditioning units and various fans were used in hallways due to non-functional main AC units. The fans posed hazards as their blades were accessible, cords were unsecured, and equipment blocked handrails. The facility lacked a policy on accident hazards.
Incomplete EMR Documentation of Meal Intake and Continence Status
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, specifically related to documentation of meal intake percentages and bowel/bladder continence status in the EMR. Surveyors found that for multiple residents, required documentation was missing on numerous days and shifts, despite facility policies and care plans that required this information to be recorded. The facility’s own policies on nutritional documentation and records and documentation required timely, accurate, and complete entries by direct care staff in the PointClickCare system. For one resident at risk for malnutrition with a history of unplanned significant weight loss and refusal of supplements, the care plan required monitoring and evaluating meal intake via meal records and observation, with goals for consuming 50–75% of most meals. Review of 30 days of meal intake records showed that all three daily meals were documented on only 14 days, with entire days where no meals were recorded and multiple days where only one or two meals were documented. Another resident with diagnoses including nutrition deficit and a documented significant weight loss had a care plan requiring that every meal be monitored and recorded. Over a 30‑day period, there were multiple days with no meals documented and several days with only partial meal documentation. A third resident at risk for malnutrition had a care plan requiring that every meal be recorded, yet review of the record over several weeks showed multiple days with no meals documented and many days with only one or two meals recorded. The survey also identified widespread failures to document urinary continence status on each of three shifts daily for several residents with bowel and bladder incontinence or at risk for skin impairment. One resident who was always incontinent of bladder and had a care plan for incontinence had no continence documentation on multiple days and only one or two shifts documented on most other days, with only one day in 30 having all three shifts recorded. Another resident, always incontinent of bowel and bladder and care planned for incontinence, had entire days with no continence documentation and no days in a 30‑day period where all three shifts were documented. Additional residents with incontinence or at risk for skin impairment had similar patterns: days with no continence entries, many days with only one or two shifts documented, and very few or no days with all three shifts completed. A short‑stay resident who was always incontinent of bowel and bladder had no days during a 14‑day review period where continence status was documented on all three shifts. During interviews, facility leadership confirmed that meal intakes and continence status were not consistently documented as required and acknowledged that the EMR system was set up to capture this information by shift, even when staff worked 12‑hour shifts.
Failure to Notify Resident Representative of Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal representative of multiple changes in condition and new medical orders, as required by facility policy. The resident, who had diagnoses including epilepsy, dementia, chronic kidney disease, a pressure ulcer, TIA, anxiety, major depressive disorder, hypertension, and dysphagia, was readmitted to the facility and later complained of pain at the right nephrostomy tube insertion site. On one occasion, documentation showed the area was warm, red, and draining, with preliminary lab results leading to new orders for doxycycline 100 mg BID for seven days. The record indicated the resident was informed and agreed to the new orders, but there was no documentation that the resident’s POA was notified of this change in condition or the new medication. Further record review showed that a wound culture from the nephrostomy tube site was positive for MRSA, and the resident was placed on contact isolation precautions for seven days, again with no documentation that the POA was notified of this change in condition. The resident’s MDS showed a BIMS score of 08, indicating moderate cognitive impairment, and dependence for toileting, showering, transfers, and mobility. Later, the resident’s indwelling urinary catheter was changed due to complaints of lower abdominal and back pain, with 550 ml of urine retrieved and a urinalysis sent, but there was still no documentation that the POA was informed of this status change. In interviews, the resident stated he wanted his daughter (POA) notified of changes and believed this was in the record, and a nurse confirmed that the POA was very involved in decision-making and should have been notified of the new medication orders and changes in condition, but was not. Facility policy required notification of the resident, physician, and legal representative or resident representative for significant changes in status and new treatments, with documentation of the exchange of information in the record, which did not occur in this case.
Failure to Consistently Document Meal Intakes for Residents at Risk of Malnutrition
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to monitor and record meal intakes for every meal as required by residents’ care plans and facility policy. The facility’s Nutritional Documentation Guidance policy required daily meal documentation by direct care staff, with CNAs or licensed nurses observing and documenting meal intakes in the EMR (PointClickCare) under point of care. Despite this, record review and staff interviews confirmed that meal intake percentages were not consistently documented for three residents who had active care plans addressing risk for malnutrition and required monitoring and recording of every meal. For one resident with diagnoses including unspecified dementia, epilepsy, hallucinations, delusional disorder, anxiety, major depressive disorder, muscle wasting, dysphagia, and a history of traumatic brain injury, the quarterly MDS showed moderately impaired cognition and poor appetite. The resident had an active care plan for risk of malnutrition, with goals for adequate energy intake and maintaining 50–75% intake of most meals, and interventions requiring monitoring and evaluation of meal percentage intake via meal records and observation. Review of 30 days of meal intake documentation showed multiple days with no meals recorded and several days with only one or two of three meals documented, with only 14 of 30 days having all three meals recorded, despite the resident having experienced significant weight loss over time. Another resident, with central cord syndrome, cervical disc disorder with myelopathy, COPD, anxiety, nutrition deficit, muscle weakness, depression, anemia, and hemiplegia following CVA, had a significant change MDS indicating moderate cognitive impairment, dependence on staff for eating, and a therapeutic diet. This resident’s care plan for risk of malnutrition noted prior significant weight loss and required that intake be monitored and every meal recorded. Review of 30 days of meal intake records showed multiple days with no meals documented and several days with only two of three meals recorded. A third resident, with dementia, history of stroke, diabetes, depression, protein-calorie malnutrition, muscle weakness, and difficulty walking, had an admission MDS showing moderate cognitive impairment and a care plan for risk of malnutrition requiring monitoring and recording of every meal. Review of this resident’s meal intake records over several weeks showed multiple days with no meals recorded, days with only one or two meals documented, and only seven days where all three meals were recorded. The Administrator and Regional Clinical Support confirmed that meal intakes were not consistently recorded for all three residents and could not provide additional documentation to show that care plans were followed.
Significant Medication Error in Lorazepam Dosing
Penalty
Summary
A resident with multiple diagnoses including type 2 diabetes, major depressive disorder, anxiety, blindness of one eye, cognitive impairment, and COPD was admitted on 02/26/18 and discharged on 12/24/25. The resident had a care plan, dated 09/20/23 and revised 04/10/25, identifying a behavior problem and use of anti-anxiety medications, with interventions that included administering medications as ordered. A physician’s order dated 12/16/25 directed lorazepam 0.5 mg tablets to be given as 0.25 mg (½ of a 0.5 mg tablet) by mouth every eight hours as needed for anxiety, with target behaviors of restlessness, yelling out, and combativeness. Review of the December 2025 MAR showed that on 12/16/25 at 9:18 p.m., RN #401 documented administration of lorazepam 0.5 mg, rather than the ordered 0.25 mg dose. A progress note entered by nurse #401 on 12/17/25 at 5:26 a.m. documented that the nurse recognized a medication error had occurred with lorazepam. A subsequent progress note at 5:27 a.m. by the ADON recorded that RN #401 notified the ADON that the resident had received 0.5 mg instead of 0.25 mg. During interview, the ADON confirmed that RN #401 administered the wrong dose. Facility policy on medication administration required nurses to observe the five rights of medication administration, including verifying the right dose against the MAR and checking the physician’s original order if there was a concern or question.
Failure to Provide Ordered Bite-Sized, High-Protein Diet
Penalty
Summary
The facility failed to ensure a resident received food prepared and portioned according to physician diet orders and the resident’s identified needs. The resident had diagnoses including epilepsy, dementia, chronic kidney disease, a pressure ulcer, anxiety, major depressive disorder, and dysphagia, and was care planned as at risk for malnutrition and dehydration with a history of unplanned significant weight loss, fluctuating intakes, poor appetite, and multiple episodes of skin breakdown. A physician order dated 02/03/26 required large protein portions at meals and that meats/entrées be cut into bite-sized pieces for wound healing. The care plan interventions included providing meals per physician diet orders, monitoring and evaluating meal intake, and providing feeding and dining assistance as needed. The resident’s MDS showed moderate cognitive impairment and a need for setup/cleanup assistance with eating. During an interview, the resident reported ongoing concerns with the dietary department, stating the kitchen repeatedly “messed up” his food, that it was hard to eat some foods because he did not have teeth, and that despite his stated food preferences being on his meal ticket, he still received the wrong items. Observation of a breakfast meal showed the resident was served a tray with one whole piece of ham, one piece of bread, and a small portion of scrambled eggs. The meal ticket on the tray, highlighted in pink, instructed staff to cut food into bite-sized pieces and provide large protein portions. A CNA confirmed that the ticket specified bite-sized food and large protein portions, but the ham and bread were not cut and the protein portions of ham and eggs were not large. Facility policy defined large portions as one and a half times the standard portion unless otherwise indicated on the meal ticket. This failure to follow the diet order and meal ticket instructions led to the cited deficiency.
Failure to Maintain Nephrostomy Collection Bag per Infection Control Standards
Penalty
Summary
The deficiency involves the facility’s failure to implement infection control interventions for the maintenance of a nephrostomy collection bag under its infection prevention and control program. A resident was re-admitted with multiple diagnoses including epilepsy, dementia, chronic kidney disease, a left buttock pressure ulcer, transient ischemic attack, anxiety, major depressive disorder, hypertension, and dysphagia. Physician orders included enhanced barrier precautions every shift due to an indwelling urinary catheter, nephrostomy tube, and a wound at the right nephrostomy insertion site with MRSA, as well as a recent course of IM ceftriaxone for a UTI. The resident’s quarterly MDS showed moderate cognitive impairment and dependence for toileting, showering, transfers, and mobility, with an indwelling nephrostomy tube and frequent bowel incontinence. The care plan documented a need for enhanced barrier precautions related to the nephrostomy site to reduce the potential spread of multi-drug resistant organisms. During observation, the resident’s nephrostomy collection bag was seen lying directly on the floor beside the bed. A CNA confirmed that the nephrostomy bag was on the floor and reported that there had previously been a basin under the bag to prevent it from touching the floor, but she did not know what had happened to it after being off work for a few days. This situation occurred despite the facility’s written infection control prevention program policy, dated December 2019, which states that residents have the right to reside in a safe environment that promotes health and reduces the risk of acquiring infections. The failure to maintain the nephrostomy bag off the floor constituted a lapse in following the facility’s infection control interventions and policies, leading to the cited deficiency during the complaint investigation.
Deficient Shower Room Maintenance and Inadequate Water Temperatures
Penalty
Summary
The facility failed to maintain safe and functional shower room environments, resulting in inappropriate water temperatures and malfunctioning equipment across multiple units. Observations and interviews revealed that the 200-hall shower room had a faulty valve and leaking pipes, with water dripping into a glove placed over the pipes. The shower room was not operational, leading residents to request showers in other halls. The 400-hall shower room had no hot water at the sink, and the water temperature in both the 400 and 500-hall shower rooms was consistently cold, measured at 101°F and 102°F, which was verified as not appropriate for resident bathing. Additionally, the 200-hall shower room had a missing exhaust fan cover and water-stained ceiling light cover. Maintenance records showed that parts had been ordered to address the issues, but repairs had not been completed due to competing maintenance demands. The Maintenance Director confirmed that water temperatures were not being routinely checked in the shower rooms. These deficiencies had the potential to affect 56 residents residing on Units 200, 300, 400, and 500, out of a total facility census of 76.
Failure to Thoroughly Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation involving a resident who reported a missing Apple watch. The resident, who had intact cognition and multiple medical diagnoses including COPD, anxiety disorder, and chronic respiratory failure, reported the watch missing after returning from a hospital stay. The resident's personal inventory at admission did not list the Apple watch, and staff acknowledged that inventories were not always updated when residents received new items. Multiple employees confirmed seeing the watch in the resident's room prior to the report, and the resident had a locator app on her phone to track the device. However, there was no documentation that the locator app was effectively used, and the missing item was not recorded in the facility's missing items log. The facility's investigation lacked several critical steps as outlined in their abuse policy. There was no evidence of communication with hospital staff to determine if the watch was left there, nor was there documentation of contact with the off-site laundry service beyond an initial message, with no follow-up recorded. Additionally, there was no documentation of interviews with other residents on the same unit to determine if they had knowledge of the missing watch or had experienced similar issues. The facility also did not document any police involvement or statements from other potentially affected residents, as required by their own investigative protocols.
Incomplete and Inaccurate Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete regarding the administration of controlled substances for two residents. For one resident with multiple diagnoses including diabetes, COPD, and chronic kidney disease, there was a discrepancy between the Individual Patient Controlled Substance Administration Record and the Medication Administration Record (MAR) for Hydrocodone-Acetaminophen. The controlled drug record indicated the medication was administered at a specific time, but the MAR did not reflect this administration. This discrepancy was confirmed during an observation of the medication cart and through interviews with facility staff. For another resident with a history of hemiplegia, diabetes, and chronic pain, the MAR showed that Oxycodone was administered at bedtime, but the narcotic count sheet marked this dose as an error, suggesting it was not given. Additionally, two narcotic sheets for this resident lacked critical information such as the date and amount of narcotic received, amount sent, and the signature of the person receiving the medication. These omissions were verified by staff interviews and were not in accordance with the facility's policy for controlled medication storage and accountability.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of registered nurse (RN) coverage per day, as required, which had the potential to affect all 68 residents. Payroll-Based Journal records for the second quarter of 2025, along with staffing schedules from January through July 2025, showed multiple dates where there was no RN coverage for the required consecutive hours. The facility assessment tool indicated an average daily census of 69 to 78 residents, and the staffing plan was based on resident needs, but the facility did not meet the RN coverage requirement on numerous specific dates. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the lack of RN coverage on these dates and verified ongoing shortages, particularly on weekends. The DON stated that the facility had only one RN on nights, two PRN RNs, and a wound nurse who was on medical leave. The facility was unable to accept residents with central lines, TPN, or orders for IV therapy more than twice a day due to the lack of available RNs or IV-trained LPNs. The DON and Administrator confirmed that there was no staffing policy in place and that staffing decisions were based on the facility's budget. Efforts to recruit RNs included job postings and participation in job fairs, but these had not resulted in sufficient hires to meet the required RN coverage.
Failure to Maintain Safe and Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, as evidenced by multiple observations during meal preparation and service. Staff were observed not following proper food safety and hygiene protocols, including a dietary staff member whose hairnet did not fully cover her hair while serving food, and a pest control employee entering the kitchen without a hat or hairnet. The reach-in refrigerator was found to be malfunctioning, with water leaking onto beverages prepared for meal service, and the thermometer inside was not working. Staff confirmed that the refrigerator had been leaking for several weeks and that the thermometer was not functional. Additionally, the stove and kitchen hood had heavy grease and dust buildup, with food debris present along gas pipes, outlets, and serving carts, all of which were verified by staff at the time of observation. Further deficiencies included improper sanitizer concentration in a red bucket used for cleaning, which tested below the required level according to posted guidelines. Exposed electrical wires with only wire nuts for protection were found under the dishwashing station, though staff stated these wires were not in use. Facility policies required food contact and non-food contact surfaces, equipment, and utensils to be kept clean and sanitized, and for thermometers to be maintained in working order, but these standards were not met. These failures had the potential to affect all 68 residents who received food from the kitchen.
Failure to Maintain Clean, Homelike Environment and Adequate Supplies
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several resident rooms were found to be unclean, with sticky floors, overflowing trash, stained privacy curtains, and bathrooms with stained caulking. Housekeeping logs indicated that some rooms had not been cleaned or had their floors mopped or trash emptied for several days, particularly over weekends when only one housekeeper was on duty. The Housekeeping Manager confirmed that staffing shortages on weekends prevented all rooms from being cleaned as required. During a lunch meal in the main dining room, a pest control employee was observed spraying chemicals and handling glue traps in the presence of residents eating their meals. The pest control employee also entered the kitchen without a hairnet during meal service. The chemical used, PT Fendona Pressurized Insecticide, has aspiration hazards and should be kept away from food and drink, according to its safety data sheet. The Regional Culinary Manager verified that it was inappropriate to spray pest chemicals during meal service and that the pest control employee was not following proper hygiene protocols. Multiple resident rooms had maintenance issues, such as leaking and moldy air conditioning units, broken headboards, scraped and dirty walls, and floors that were dull, dirty, or covered in debris. Residents and family members reported that maintenance requests, such as mounting a television or fixing air conditioning units, were not addressed in a timely manner. Additionally, the facility consistently lacked adequate supplies and linens, including gloves in appropriate sizes, wet wipes, tissues, towels, and washcloths. Staff interviews confirmed that they frequently ran out of these essential items, impacting their ability to provide proper care. The facility's laundry operations were disrupted due to a fire, resulting in further shortages of clean linens, and the par level for washcloths was insufficient to meet the needs of incontinent residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) and proper infection control practices during resident care, as evidenced by multiple observations and interviews. For several residents with indwelling medical devices such as gastrostomy tubes and urinary catheters, there was a lack of EBP signage, absence of personal protective equipment (PPE) outside rooms, and missing physician orders for EBP. Staff were observed providing care without appropriate PPE, and some were unaware of the requirements for EBP during high-contact activities, such as dressing changes and hygiene care. In one instance, a sign was incorrectly placed above the wrong bed, and a PPE basket was missing due to being broken and not replaced. During incontinence care, staff did not follow proper perineal cleansing techniques. One CNA was observed not cleansing the inner labia as required, and both the skills checklist and facility policy lacked specific instructions on how to perform perineal care. The Director of Nursing confirmed that the policy and competency documents did not provide detailed guidance, and staff training was insufficient in this area. This resulted in incomplete hygiene practices for residents requiring incontinence care. Additionally, improper infection control practices were observed during wound care for a resident with multiple wounds, including a Stage III pressure ulcer. Staff used the same gloves for different tasks, such as cleansing the perineal area and then handling the wound and clean supplies, which could lead to cross-contamination. Dirty linens were also left on the floor instead of being properly bagged. These lapses in infection prevention and control affected multiple residents and were confirmed through interviews, observations, and policy reviews.
Expired Surety Bond for Resident Funds
Penalty
Summary
The facility failed to assure the security of residents’ personal funds deposited with the facility because the surety bond had expired and there was no documented evidence that it had been renewed or replaced. Review of the resident funds balance form showed 45 accounts for 42 residents, totaling $28,884.44. Review of the surety bond showed it was effective for a limited period and had expired, and interviews confirmed the bond had lapsed. The Administrator stated corporate had reported the facility was changing companies, but there was no evidence of a current surety bond. Corporate staff later confirmed the facility did not change companies and had decided to renew the bond with the previous company, with the bill paid later that day.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for four residents. For one resident who later expired in the facility, the record did not contain documentation of the change in condition or events leading up to death, including vital signs, oxygen orders, or a signed DNR code status. Although a typed statement from the DON described the resident becoming hypoxic, receiving oxygen, having family confirm DNR status, and later receiving comfort-focused medications, the medical record itself did not contain evidence of those events. The DON and Corporate Regional Nurse both confirmed there was no documented evidence in the chart of the resident’s decline before death. For another resident with COPD, chronic respiratory failure, OSA, diabetes, asthma, hemiplegia, and anxiety disorder, the record showed orders for a Trilogy ventilator and related cleaning and mask care. The resident stated the machine was not being used because it was broken, and staff observed the mask was not contained in a bag for sanitation. An LPN reported the mask seal was damaged and another mask had been ordered, but the treatment record still showed the device as applied on multiple nights when the old mask seal was broken and before the replacement mask was opened for use. Staff confirmed the documentation was inaccurate and that the machine was not actually applied as recorded. For a resident with ESRD and dialysis dependence, a dialysis progress note ordered calcium acetate 667 mg with meals, but the physician order was not transcribed until later. The eMAR showed doses documented as given even though the medication was unavailable and the facility had not received it from the pharmacy or dialysis center. The DON confirmed the resident did not receive the medication during the period in question and that the eMAR entries showing administration were not accurate. For another resident with diabetes, the electronic physician order directed lispro insulin to be given intramuscularly before meals, and the eMAR documented five IM doses. RN #193 verified the order was inaccurate because lispro insulin is administered subcutaneously.
Failure to Maintain Resident's ADL Abilities Due to Lack of Therapy and Restorative Services
Penalty
Summary
The facility failed to ensure that a resident maintained the ability to perform activities of daily living (ADLs), including range of motion (ROM) and ambulation, without a documented medical reason for decline. The resident, who had diagnoses including heart failure, unspecified dementia, muscle weakness, and cognitive communication deficit, was discharged from hospice but did not receive therapy or restorative services for ROM or ambulation in the months following discharge. Medical record review showed no evidence of therapy screens or restorative programs in 2024 or 2025, except for a single therapy screen after the resident slid out of her wheelchair. The resident's care plan noted impaired mobility and encouraged participation in ADLs, but there was no documentation of ongoing therapy or maintenance programs to support ambulation or ROM. Observations and interviews revealed that the resident expressed a desire to walk again and reported not receiving recent therapy or ROM services. Staff interviews confirmed that the resident had not been screened by therapy since hospice discharge, and that quarterly therapy screens, which were standard practice, had not been completed. The Rehab Manager acknowledged the lack of recent ROM assessment and services, and certified nurse aides reported only seeing the resident self-transfer or take steps during toileting, with no independent ambulation observed in the room or hallway. The lack of regular therapy screening and absence of restorative or maintenance programs contributed to the resident's decline in ADL performance.
Inaccurate resident code status documentation
Penalty
Summary
The facility failed to ensure residents’ code statuses were accurate for two residents reviewed. For one resident, the record showed admission from another LTC facility with multiple diagnoses including malignant neoplasm of both breasts, atrial fibrillation, anemia, chronic kidney disease, osteoporosis, pain, and difficulty walking, and the resident later expired in the facility. The face sheet showed no advance directives selected, the admission assessment did not document code status, and the care plan and signed orders identified the resident as full code. However, the physician’s history and physical note documented the resident’s code status as DNR Comfort Care Arrest (DNRCC-A), and there was no documented evidence that a State of Ohio DNR order form or new DNRCC-A order had been completed. For the same resident, the late entry care conference note created after death also identified the resident as DNRCC-A. During interviews, the DON confirmed the provider had signed a full code order, the physician had documented DNRCC-A in the history and physical without writing a new order or completing the state DNR form, and the resident declined with the family reporting they did not want the resident sent out and that the resident had a DNRCC-A on file at the hospital. Corporate nursing also confirmed the signed orders and care plan remained full code despite the physician documentation, and the facility received a verbal DNRCC-A order only a few hours before the resident expired, but it was never signed by a provider. For the second resident, the record showed admission with diagnoses including fracture of the left femur, vascular dementia, congestive heart failure, chronic kidney disease stage III, weakness, disorientation, and history of falling. The quarterly MDS showed severe impairment in daily decision making. The electronic record listed the resident as full code, while the paper chart contained a signed advance directive for DNRCC. LPNs verified the mismatch, and one LPN contacted the resident’s daughter, who stated the resident was to be DNRCC. The daughter also reported the hospital did not have the advance directive, so it was not sent with discharge, and the facility made the resident full code because it did not have the paperwork.
Failure to Document Rationale for Declining Pharmacy Recommendation on PRN Lorazepam
Penalty
Summary
The facility failed to ensure pharmacy recommendations were addressed, including documenting a rationale for declining gradual dose reductions or other pharmacist recommendations related to a psychotropic medication. Resident #67 was admitted and readmitted with diagnoses including depression, anxiety disorder, and traumatic subdural hemorrhage. The quarterly MDS 3.0 assessment showed the resident was cognitively intact for daily decision-making and had an anxiety disorder. A pharmacist review dated 12/09/24 identified that Resident #67 had a PRN order for Lorazepam 0.5 mg, a psychotropic anxiolytic, and stated that PRN psychotropic medications are limited to 14 days under CMS requirements unless the rationale and estimated duration of use are documented. The pharmacist offered options to comply, including discontinuing the PRN order or adding a stop date. The nurse practitioner declined the recommendation, but did not date the response and did not document a rationale. RN #193 and the DON both verified that no prescriber rationale was provided, and the facility policy stated that clinical contraindications will be documented by the physician in the medical record.
Delayed Completion and Submission of Admission MDS Assessments
Penalty
Summary
The facility failed to complete Resident #80’s admission comprehensive assessment in a timely manner. Resident #80 was admitted with diagnoses including fractured vertebrae, end stage renal disease, dependence on renal dialysis, and dysphagia, and was later discharged from the facility on 08/18/25. Review of the electronic medical record showed no completed MDS assessments available for review, and both the admission MDS assessment and the 5-day MDS assessment were not completed or submitted within 14 days of admission as required. During interview on 08/19/25, RN #123 verified that Resident #80 did not have an MDS assessment available because the assessments had not been finished or submitted to CMS. Later review on 08/21/25 showed the 5-day MDS assessment was marked completed but not submitted to CMS, the admission assessment was marked export ready, and the Discharge Return Not Anticipated assessment remained in progress.
Delayed Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to ensure a significant change of condition MDS was completed timely for Resident #3, who was admitted with diagnoses including type 2 diabetes mellitus, peripheral vascular disease, heart failure, urinary retention, and depression, and was admitted to hospice. Medical record review showed orders dated 07/07/25 indicating the resident was admitted to hospice, and the hospice plan of care dated 07/10/25 stated the resident and responsible party had elected hospice/end-of-life care services. Review of the MDS showed no evidence that a significant change of condition MDS was completed. During interview, the RN/MDS Nurse confirmed the resident should have had a significant change MDS completed when the resident declined and was ordered hospice services, and stated she was not aware until the survey start date that the resident had been ordered hospice; she had started a significant change MDS that was still pending.
Inaccurate MDS Assessment for Insulin Use
Penalty
Summary
The facility failed to ensure a comprehensive assessment was accurate for Resident #54, who was admitted with diagnoses including diabetes mellitus. Review of the quarterly MDS 3.0 assessment showed that the resident received one dose of insulin, but review of the electronic physician orders for May 2025 showed there was no insulin order for the resident. Review of the electronic MAR for May 2025 also showed the resident did not receive insulin during the quarterly MDS assessment reference dates. During an interview on 08/18/25 at 12:28 P.M., RN #123 verified that Resident #54 did not receive insulin and that the MDS assessment was not accurate.
Missing wound orders and incomplete admission skin assessments
Penalty
Summary
The facility failed to obtain treatment orders and comprehensively assess skin alterations for two residents. One resident had a complex medical history including lymphedema, venous insufficiency, diabetes, chronic kidney disease, chronic respiratory failure, Parkinson’s disease, severe protein calorie malnutrition, and pyoderma gangrenosum. During a dressing change, staff identified new skin impairment to both calves, with the left calf showing yellow/green drainage and the right calf showing serosanguinous drainage. The areas were cleansed, dressed, and offloaded, and new lab and wound culture orders were obtained, but the physician orders and treatment sheet contained no orders for dressings to either calf. An RN verified that no orders had been written for the newly identified calf wounds. A second resident was admitted with diagnoses including peripheral vascular disease, diabetes mellitus, and lower extremity amputations, and was readmitted from the hospital with altered mental status. The admission packet documented an open red area to the coccyx and open areas on both lower legs, including the right lower leg and two areas on the left lower leg. The skin documentation included measurements, but there was no evidence of a comprehensive assessment of the wounds, including wound type, odor, drainage, or other required characteristics. A weekly skin check also noted erythema/redness, and the record showed orders for cleansing the coccyx and applying triad, as well as applying ointment to the right below-knee amputation site. The facility’s wound management policy required wounds to be assessed at admission or within 24 hours and to include a comprehensive evaluation of wound characteristics and differentiation of wound type. The DON verified that no comprehensive skin assessment had been completed on admission for the second resident’s wounds and stated that weekend admissions were not completed until the wound nurse or designee returned the following week. The ADON also verified that there was no comprehensive assessment of the wounds upon admission.
Failure to Assess and Protect a Resident With a Coccyx Pressure Ulcer
Penalty
Summary
Failure to complete a comprehensive assessment of a pressure ulcer skin impairment occurred for Resident #77, who had multiple admissions to the facility and diagnoses including peripheral arterial disease, diabetes mellitus, bilateral below-the-knee amputations, and multiple wounds. The resident was most recently admitted with an open area to the coccyx documented on the Illustration of Documentation and Measurements of Skin Areas dated 08/08/25, but there was no evidence of a comprehensive assessment of the skin area, including the type of wound, description, odor, or drainage. RN #193 verified on 08/12/25 that no comprehensive assessment had been completed on 08/08/25 before the resident was discharged to the hospital and later returned to the facility. The resident’s skin condition was later documented as an open area to the coccyx classified as moisture associated skin damage measuring 4.5 cm by 3.0 cm with no depth, and a wound care re-consultation on 08/14/25 identified a Stage 3 pressure ulcer to the coccyx present on admission measuring 3.5 cm by 4.9 cm by 0.2 cm with 100% granulation tissue and scant serous drainage. The care plan for impaired skin integrity/pressure ulcers included interventions such as no briefs in bed, peri-care after each incontinence episode, pressure reduction devices if ordered, and treatments as ordered. The wound management program also stated that wounds are to be assessed at the time of admission, or within 24 hours if not possible. The facility also failed to provide pressure prevention interventions and failed to follow infection control practices during wound care. On 08/18/25, the resident was observed sitting in a wheelchair without a pressure relieving cushion, with loose and falling-off dressings to bilateral BKA wounds, and he stated his butt was sore and he had to keep shifting his weight. During observation of coccyx wound care and incontinence care on 08/19/25, CNA #107 and LPN #131 were observed cleansing the resident’s groin, scrotum, rectum, and then over the Stage 3 pressure ulcer using the same gloved hands and washcloth, and LPN #131 used the same gloved hands to press on the peri-wound and wound bed before applying triad cream around the wound perimeter. LPN #131 later stated she had messaged the physician due to a change in the wound’s appearance, and the general note documented the coccyx as moist with clear drainage and slough in the wound bed.
Failure to Manage Gastrostomy Tube Follow-Up and CT Scheduling
Penalty
Summary
The facility failed to ensure a resident's gastrostomy tube was properly managed. Resident #32 was admitted with multiple diagnoses including unspecified protein-calorie deficit, gastrostomy, GERD, bariatric surgery status, peritoneal abscess, nausea with vomiting, hypokalemia, COPD, diabetes, muscle wasting, muscle weakness, depression, and atherosclerotic heart disease. Hospital discharge orders indicated the resident was to have a CT scan the following week and follow up with a surgical specialist, and the resident's record showed orders to flush the enteral tube daily to maintain patency. The resident's record showed no evidence that the CT scan was completed or that the surgical follow-up occurred as ordered. A dietary note indicated the resident was on a full liquid diet until follow-up with the surgeon, and later progress notes documented that the gastrostomy tube remained in place and was not to be used, with a soft diet ordered until another follow-up appointment. The surgical specialist note stated the resident had undergone laparoscopic drainage of intraperitoneal abscesses and gastrostomy tube placement, was tolerating blended and full liquids, and that a CT scan of the abdomen and pelvis would be obtained to assess for remaining fluid collection before the tube could be removed. Interview findings showed the resident expected the CT scan to be arranged before the specialist appointment, but the facility had not scheduled it. The driver/scheduler stated the specialist had said the CT was needed before the next appointment, but she did not help the resident schedule it and confirmed there was no CT order in the medical record. The resident and her family stated they believed the facility was responsible for arranging the appointment and authorization, and the resident reported her discharge home was delayed because the CT scan and follow-up were not completed.
Respiratory equipment not maintained sanitarily and device application not provided
Penalty
Summary
The facility failed to ensure respiratory equipment was maintained in a sanitary manner and failed to assist with the application of a respiratory device for three residents receiving respiratory care. Resident #48 had diagnoses including COPD, chronic respiratory failure, OSA, asthma, hemiplegia, diabetes, and anxiety disorder, and was ordered to use a non-invasive home ventilator (Trilogy) with a heated humidifier and mask. During observation, the resident stated the bipap was not being put on because it was broken, while the Trilogy machine and mask were seen on the bedside table, with the mask not contained in a bag for sanitation. The resident was also observed on oxygen by nasal cannula at 4.5 LPM with a humidification bottle dated 06/15/25 unopened and not attached to the oxygen condenser. For Resident #48, staff identified that part of the gel came off the Trilogy mask and a new mask was ordered, but the replacement mask was not opened until several days after it had been delivered. The treatment administration record showed the device was documented as applied on multiple nights when the seal on the old mask was broken. The resident later stated she had worn the Trilogy only two nights earlier, that it beeped the prior night, and that she had not worn it for about a month because the mask did not fit. LPN interviews confirmed the mask was in the unopened box on the cabinet and that the device had been signed off as applied even though the broken seal would have caused it to beep. Resident #5 had diagnoses including chronic respiratory failure with hypoxia and COPD and received continuous oxygen therapy. Observation showed the resident's nebulizer machine and mask on the recliner, with the mask face down on the arm of the recliner and not contained in a bag for sanitation. Resident #45 had diagnoses including CHF, atrial fibrillation, angina, diabetes, obesity, and dependence on supplemental oxygen. The resident was observed in bed on oxygen at 4.5 LPM without a humidification bottle, and stated her nose became dry and had bled before. LPN verification confirmed the oxygen was in place without the humidification bottle attached.
Dialysis orders were delayed and a prescribed phosphate binder was not administered
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident with end stage renal disease who required hemodialysis. Resident #80 was admitted with diagnoses including vertebrae fractures, ESRD, dependence on renal dialysis, diabetes mellitus, hypocalcemia, and depression, and was scheduled for dialysis every Monday, Wednesday, and Friday from 6:00 A.M. to 10:00 A.M. The resident was discharged back to the community on 08/18/25. Review of the record showed no ongoing communication between the facility and the dialysis center from 08/09/25 through 08/18/25 while the resident was receiving hemodialysis. On 08/08/25, the dialysis center called the facility and gave new orders because the resident was congested while at dialysis. Those orders included calcium acetate 667 mg, two tablets with the first bite of each meal, and Renvela 800 mg, two tablets with the first bite of each meal. The orders were not transcribed until 08/12/25. Renvela was ordered and delivered to the facility, and the resident received the first dose at lunch on 08/13/25. The record showed no evidence that calcium acetate was delivered by the pharmacy on 08/12/25, 08/13/25, 08/14/25, or 08/15/25, and the medication was not administered at any time from the original order through discharge. On 08/15/25, the ADON spoke with the pharmacy and was told it did not provide the medication; the dialysis center was notified and stated it would send the medication to the facility, but there was no evidence it was received. The DON verified the facility did not receive the calcium acetate as ordered, and also verified the order was not transcribed when first received and that follow-up with the pharmacy did not occur until three days later. Review of the dialysis transfer agreement also showed the facility did not have the dialysis center named as an additional insured on the general liability policy as required by the contract.
Delayed Psychiatric Evaluation and Behavioral Health Services
Penalty
Summary
The facility failed to timely provide psychiatric services for a resident with diagnoses including cerebral infarction, intracerebral hemorrhage, bipolar disorder, depressed mild or moderate severity, and anxiety disorder. The resident was receiving multiple psychotropic medications, including Abilify, Prozac, trazodone, Lamictal, and buspirone. The care plan identified a potential mood problem and included interventions for medication administration, behavioral health consults as needed, and monitoring mood, but the medical record showed no evidence that the resident was seen or evaluated by the facility psychiatrist/behavioral health physician for several months after admission. MDS assessments documented ongoing mood symptoms during that period, including trouble falling or staying asleep, depressed or hopeless feelings, little interest or pleasure in doing things, and social isolation. The psychiatrist’s initial visit note later documented the visit was for medication management and psychiatric evaluation, with the resident described as pleasant, cooperative, euthymic, and denying suicidal, homicidal, or psychotic symptoms; the psychiatrist decreased Abilify and continued the other medications. The social worker stated the resident had been missed and had not seen the psychiatrist since admission until that evaluation, that the resident had not received counseling sessions, and that mood indicators had fluctuated since admission.
Expired insulin remained in medication storage
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure expired insulin was discarded. This affected Resident #77, who was admitted with diagnoses including diabetes, heart disease, and chronic kidney disease and had an order for Humalog Kwikpen subcutaneous pen injector to be given per sliding scale before meals. Review of the MAR showed the resident received Humalog per sliding scale 11 times during the reviewed period, and there was no evidence of an order for Novolog. During observation of the 200-medication cart with an LPN, Resident #77 had three Humalog pens, including two opened pens dated when they were opened and one unopened pen. The LPN confirmed the opened Humalog pens had not been refrigerated after opening and would have expired 28 to 30 days after opening, but they remained in the cart. A Novolog pen was also present for the resident even though there was no order for Novolog, and staff confirmed it had expired and should have been discarded. The DON and CRN stated the Humalog should have been discarded 28 days after opening and the Novolog should have been discarded on its used-by date.
Opioid PRN Order Lacked Clear Pain Parameters
Penalty
Summary
The facility failed to adequately monitor the appropriate use of opioids for Resident #67, who was admitted with diagnoses including osteoarthritis, cervical spinal stenosis, arthrodesis status, traumatic subdural hemorrhage without loss of consciousness, and muscle wasting. The resident’s care plan identified risk for pain related to multiple chronic conditions and directed staff to administer analgesia per orders and respond immediately to pain complaints, but it did not include individualized non-pharmacological pain interventions. The quarterly MDS showed the resident was cognitively intact, received PRN pain medication and opioids, and reported occasional pain with moderate pain as the worst pain in the prior five days. The physician order for oxycodone HCL 5 mg PRN for moderate to severe pain did not include numerical parameters defining moderate or severe pain. MAR review showed oxycodone was administered on multiple occasions when the resident’s documented pain ratings ranged from 0/10 to 8/10 across March, April, June, and August 2025. An LPN stated pain scores could mean different things to different nurses and that her interpretation of moderate and severe pain could differ from the resident’s interpretation. The DON verified the order lacked a numerical scale and stated the current orders were subjective and could be interpreted differently, and the facility pain policy stated pain should be assessed regularly and that non-pharmacological interventions may be used alone or with medications.
Failure to Complete Ordered Weekly Laboratory Testing
Penalty
Summary
Laboratory testing was not performed per discharge orders for Resident #82, who was admitted with diagnoses including osteomyelitis, diabetes, methicillin susceptible staphylococcus aureus, and absence of the left foot. Review of the hospital discharge notes dated 06/16/25 showed orders for weekly CBC, BMP, and CK testing until 07/16/25, but the resident's medical record contained no evidence that any of these labs were completed. Corporate Regional Nurse #193 confirmed by email that the resident did not have the ordered weekly labs, and LPN #179 also confirmed that the ordered weekly labs were not completed after admission.
Antibiotics Given Without Documented Criteria
Penalty
Summary
The facility failed to ensure residents met criteria for antibiotic treatment for two residents reviewed for antibiotic stewardship. One resident was admitted with diagnoses including sepsis of an unspecified organism, metabolic encephalopathy, diabetes, respiratory failure, heart disease, and a pressure ulcer. The resident was ordered Cefdinir for wound infection, then the order was changed to Cefdinir for sepsis, likely respiratory, and the MAR showed the antibiotic was administered for those indications. The infection control log listed the resident under other for infection with sepsis as the organism, marked not applicable for antibiotic stewardship, and the McGeer criteria form had a handwritten note stating there was no criteria for sepsis. Hospital records for that resident showed sepsis was unclear, with chest x-ray and urine negative for infection, COVID, influenza, RSV, and RPP negative, blood cultures possibly contaminated, and MRI/CT spine showing no infection. During interview, the LPN/IP and RCN confirmed the resident did not meet criteria for antibiotic treatment and that there was no documented evidence explaining why the antibiotic was needed. The facility’s McGeer criteria form only addressed UTI, respiratory, skin and soft tissue, and gastroenteritis, and the infection control log showed multiple residents in June and July marked N/A, blank, or no for McGeer criteria while receiving antibiotics. A second resident was admitted with diagnoses including osteomyelitis, diabetes, UTI, heart failure, bacteremia, and hemiplegia. The resident received Metronidazole for osteomyelitis and Vancomycin for wound infection, and the infection control log recorded the antibiotics as being for a joint infection with N/A marked for McGeer criteria. The IP stated osteomyelitis was not one of the criteria she checked because it was not on the form being used, and the RCN confirmed that if an infection did not fall under the listed categories, it was documented as N/A and the IP did not ensure the resident met CDC criteria for treatment. The report also noted the CDC criteria for osteomyelitis and the facility policy stating the infection prevention program would use current CDC guidance.
Violation of Residents' Mail Privacy
Penalty
Summary
The facility failed to ensure residents had their mail delivered unopened, affecting two residents. Resident #19, who was cognitively intact and had no communication issues, reported that his mail from the Ohio Department of Jobs and Family Service (ODJFS) was opened by facility staff without his consent. Although the facility claimed he had signed a Mail and Package Consent Agreement, Resident #19 denied ever giving such consent and revoked any perceived consent after the incident. The facility's process for obtaining consent was unclear, and the resident was not aware of signing any electronic form. Resident #69, who was also cognitively intact, experienced similar issues with her mail being opened. She reported that her insurance card and another letter, mistaken for junk mail, were opened by the facility. Despite having a Mail and Package Consent Agreement on file, she denied giving consent for her mail to be opened and expressed dissatisfaction with the situation. The receptionist acknowledged the mistake and apologized, indicating the mail was opened accidentally. Interviews with facility staff revealed that the corporate office instructed them to open mail from insurance companies or ODJFS for Medicaid recipients. The facility's Administrator confirmed this practice and acknowledged the violation of residents' rights to receive unopened mail. The facility's Welcome Packet included a copy of the Resident's Rights, which stated that residents have the right to receive unopened mail, yet the facility's actions contradicted this policy.
Failure to Resolve Missing Resident Property
Penalty
Summary
The facility failed to ensure the timely resolution of a concern regarding missing resident property, specifically affecting a resident with moderately impaired cognition due to Alzheimer's disease and other medical conditions. The resident, who had been admitted with a rollator walker, dentures, and glasses, was transferred to a hospital and upon return, these items were missing. The resident's power-of-attorney filed a concern about the missing items, but the facility's efforts to resolve the issue were inadequate. The facility's administrator made an attempt to contact the inpatient psychiatric hospital where the resident had been transferred, but no response was received. Interviews with the Social Services Designee and the Administrator confirmed that the last attempt to resolve the concern was made shortly after the resident's return, with no further follow-up. The facility's policy on resident rights emphasizes the right to retain personal possessions, but this was not upheld in this instance, leading to the deficiency being noted during a complaint investigation.
Failure to Provide Accurate Transfer Information
Penalty
Summary
The facility failed to ensure comprehensive resident information was provided to the receiving facility during a transfer, affecting one resident reviewed for death. The resident, who had diagnoses including Alzheimer's disease, diabetes mellitus, anxiety disorder, depression, and a personal history of malignant neoplasm, was admitted to the facility and later expired there. A review of the resident's Transfer Form revealed that the facility did not include accurate information regarding the resident's representative, specifically omitting the resident's son, who was the power-of-attorney (POA)/resident representative. This omission was confirmed during an interview with the Administrator.
Failure to Schedule Gynecology Appointment for Resident
Penalty
Summary
The facility failed to ensure coordination of care for a resident related to a gynecology appointment to address medical symptoms in a timely manner. The resident, who had diagnoses including multiple sclerosis, anxiety disorder, chronic kidney disease stage four, and chronic diastolic heart failure, was noted to have intact cognition. A progress note dated 10/23/24 indicated a new order for a referral to gynecology for post-menopausal bleeding, and a physician order dated 10/24/24 confirmed the referral. However, a review of the resident's medical record from 10/23/24 to 11/11/24 revealed no evidence that the referral had been made. An interview with the Administrator on 12/17/24 confirmed that an appointment with gynecology had not been scheduled as ordered by the physician. This deficiency affected one resident out of three reviewed for appointments, with the facility census being 76 at the time. The incident was identified during a closed record review, facility investigation, and staff interview, highlighting a lapse in the coordination of care for the resident.
Delayed Resolution of Missing Dentures Grievance
Penalty
Summary
The facility failed to address a resident's grievance regarding missing upper dentures in a timely manner, leading to a deficiency. The resident, who was admitted with both upper and lower dentures, reported the upper dentures missing on October 1, 2024. Despite the resident being cognitively intact and able to communicate effectively, the facility did not resolve the issue promptly. The dentures were reportedly missing since the resident's move from the 400 hall to the 100 hall in August 2024, and the resident had repeatedly informed staff about the missing dentures. The facility's investigation into the missing dentures was delayed, with a dental appointment scheduled over a month after the initial report. The cost of replacement dentures was not covered by the resident's insurance, and the facility's corporate office was involved in discussions about covering the cost. The corporate office eventually agreed to pay half the cost, but this decision was not communicated to the resident, who was frustrated with the delay and lack of resolution. The resident's son, who was not initially aware of the missing dentures, believed the facility should cover the full cost of replacement since the dentures were lost while under the facility's care. Interviews with staff revealed that the resident's dentures were initially stored in an emesis basin rather than a denture cup, which may have contributed to their loss. The facility's policy on handling resident concerns was not followed effectively, as the investigation and resolution process took several months without a satisfactory outcome for the resident. The deficiency was identified during a complaint investigation, highlighting the facility's failure to ensure the resident's grievance was addressed promptly and appropriately.
Failure in Wound Vac Management and Physician Order Implementation
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and knowledgeable in the use of Negative-Pressure Wound Therapy (NPWT) and did not implement a physician's order for a CT scan and surgical referral for a resident showing signs of an infected abdominal wound. This deficiency affected a resident with a history of abdominal wall infections, who displayed possible signs of infection in an abdominal wound. The wound physician ordered a CT scan and a referral to a surgeon, but the facility did not make these referrals as ordered. The resident experienced complications related to the use of a wound vac, and a nurse failed to adequately intervene or notify the wound physician of these complications. The resident's wound vac began to leak, and the drainage increased throughout the night, saturating the area around the abdominal wound. By morning, the wound area became red, hard, and warm to the touch, with the resident experiencing mild to severe abdominal pain. The resident was transferred to the hospital, where he was hospitalized and required two separate incisions and drainage procedures to debride the abdominal abscess and remove a foreign body. The hospital's CT scan revealed a retained foreign body, identified as a large white vac sponge, which was likely left from a previous wound vac dressing. Interviews with staff revealed that the facility's nurses were not adequately trained in wound vac management prior to the incident. The facility's policy required notifying the physician when a change in wound condition was noted, but this was not done. The resident's medical record lacked evidence of the CT scan being ordered or the surgeon being contacted for a re-consult. The facility's failure to act on the physician's orders and the lack of proper wound vac management led to the resident's hospitalization and the need for surgical intervention.
Facility Fails to Maintain Safe Environment During Heat Advisory and Mold Issues
Penalty
Summary
The facility failed to maintain a comfortable and safe living environment during an excessive heat advisory, affecting five residents. The main air conditioning units were not functioning properly, leading to the use of portable AC units and fans to cool the common areas. Despite these measures, residents reported discomfort due to high temperatures in the hallways and common areas. Maintenance staff confirmed that the AC units on certain halls had been non-functional for an extended period, and there was a lack of documented temperature monitoring during the heat advisory. Additionally, the facility had issues with mold in the shower rooms on the 100 and 200 halls. The 100 hall shower room had exposed water pipes and mold on broken drywall and tiles, which had not been addressed or tested for black mold. The shower room was supposed to be out of use, but there was no signage indicating this. The 200 hall shower room also had mold, and staff were instructed to clean it with bleach, but the mold persisted. The presence of mold was verified by multiple staff members, and it was noted that residents used the 200 hall shower room. The facility's maintenance logs did not document the AC unit failures or the mold issues in the shower rooms, indicating a lack of proper reporting and documentation. The facility's policy on temperature extremes required specific monitoring and safety measures in case of AC system failure, which were not adequately implemented. This deficiency was investigated under specific complaint numbers, highlighting the facility's non-compliance with maintaining a safe and comfortable environment for residents.
Facility Fails to Maintain Safe Environment Due to Improper Use of Fans
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment, affecting 14 residents identified as cognitively impaired and independent with mobility. During an observation, large portable air conditioning units with dual vent coils were noted in each hallway, along with various types of fans placed on the floor. These fans included three freestanding metal fans, a high-velocity fan, a box fan, and two stand-up cylinder fans. The Environmental Services Director confirmed that the main air conditioning units were not operational, and the fans were used to circulate air. However, the fan blades were accessible through the slats, posing a risk to residents. Further observations revealed that the fans' cords were unsecured, and the placement of air conditioning units and fans, along with other equipment, obstructed access to handrails. Additionally, some fan plugs were not securely inserted into outlets. The Administrator acknowledged these hazards, particularly for cognitively impaired residents who were independently mobile. The facility did not have a policy regarding accident hazards, contributing to the deficiency identified under Complaint Number OH00155031.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Zanesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adams Lane Healthcare And Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Oaks At Bethesda The | 0.7 mi | ★★★★★ | 4 | 0 |
| Continuing Healthcare At Cedar Hill | 0.9 mi | ★★★★★ | 4 | 0 |
| The Oaks Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Altercare Zanesville Inc. | 2.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.