Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 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 Continuing Healthcare Of Cuyahoga Falls during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Resident Discharge: The facility did not notify the State LTC Ombudsman Office of a resident’s discharge. The resident had diagnoses including alcohol abuse, muscle weakness, and difficulty walking, and was discharged to personal residence. Review of the Ombudsman Transfer/Discharge Log showed the discharge was omitted, and the Administrator verified the information was not sent as required.
The facility failed to ensure an MDS 3.0 Discharge Return Not Anticipated assessment for a resident with a fractured back, major depressive disorder, and insomnia was transmitted to CMS within the required timeframe. The assessment was completed but not sent as required, and the MDS nurse verified the late transmission issue during interview.
PASRR recommendations for placement and related services were not implemented for a resident with bipolar disorder, suicidal ideations, and seizures. The Level II PASRR found the resident was not appropriate for continued NF services and could be cared for in a less restrictive setting, but the record showed no discharge planning, referrals, care conferences, or other transition efforts, and the resident remained in the facility without continued stay approval.
Nebulizer equipment was not dated or stored properly for two residents receiving respiratory care. One resident with atrial fibrillation, DM2, depression, and chronic blood clots had an order for ipratropium-albuterol for SOB, and observations showed the nebulizer mask was undated and not stored in a bag when not in use. Another resident with CKD stage 4, CHF, AFib, and SOB had an order to change the nebulizer mask, cup, and tubing weekly and date the mask, but observations showed the mask was not stored in a bag while not in use. An LPN verified the findings, and facility policy required weekly changes, bag storage, and dating of the mask.
A resident with dementia, HTN, and edema had an order for daily amlodipine with hold parameters for low systolic BP or HR. The MAR showed the medication was given regularly without evidence that BP and HR were checked before administration, and vital signs records showed they were not being monitored daily. The DON confirmed the findings.
Respiratory medications were not stored securely when five unopened ipratropium-albuterol unit dose vials were observed on a resident’s kitchenette counter near the nebulizer. An LPN confirmed the vials were facility medication and stated the resident did not appear to be authorized to self-administer. The resident had moderate cognitive impairment, and the record showed the resident was not able to self-administer ipratropium-albuterol.
Surveyors found that secured-unit doors opened immediately without the required delay or code entry and were not continuously monitored by staff, despite alarms sounding and prior staff reports that the doors had been malfunctioning for some time. Maintenance requests for these safety issues were not entered into the facility’s electronic system as required, and a later vendor inspection documented misaligned locks, missing screws, a broken egress wheel, and doors in generally poor condition. In addition, a resident with Alzheimer’s disease, CKD, and hypertension had four documented falls, including with injury, yet an LPN-completed fall risk assessment incorrectly recorded no recent falls, resulting in the resident being classified as not at risk for falls despite a high fall history.
A resident with severe dementia and significant behavioral symptoms, including wandering, aggression, public disrobing, inappropriate urination/defecation, and sexually inappropriate behavior toward female residents, was admitted and later readmitted to a secured unit. Despite known history from a prior facility and ongoing documentation of escalating behaviors, the care plans remained generic and were not revised to address specific risks such as entering female residents’ rooms naked, insisting they were his wife, attempting to get into bed with them, or the need for one-to-one supervision. Staff reported that female residents were afraid and barricading their doors, while leadership minimized or did not recognize the behaviors as sexually inappropriate and did not act on staff concerns. An incident occurred in which the resident, naked from the waist down, refused redirection, physically assaulted an LPN, then entered a female resident’s room and attempted to get into her bed, causing her to fall while trying to escape. Surveyors found that these actions and inactions constituted a failure to provide necessary dementia care and treatment to maintain the safety and well-being of residents on the secured unit.
Surveyors found that doors on a secured unit did not open or alarm as required when pushed, instead requiring a code for exit, affecting all residents on that unit. An ADON confirmed the doors should allow egress after sustained pressure, and an employee reported the doors had been malfunctioning for some time. The Director of Support Services stated he discovered the problem recently and attributed it to a power surge, but no maintenance work orders had been entered into the facility’s electronic system as required by policy. When a vendor later inspected the doors, they found egress wires missing or removed from panels and a loose lock mounting plate, and noted the doors were in poor physical condition and did not always close properly. The Administrator reported being unaware of the malfunctioning doors and the vendor’s recommendation to replace them.
A resident with a history of stroke, diabetes, hypertension, and heart failure was noted by an aide and an LPN to have unexplained swelling and redness on one side of the face, including a swollen eyelid and a scab above the eyebrow. The resident could not explain how the injury occurred and later reported some difficulty with vision in the affected eye. An NP was notified, assessed the resident, and diagnosed facial cellulitis, starting antibiotic treatment. However, facility leadership was not informed of the unexplained injury, no investigation was conducted, staff were not interviewed about how the injury occurred, and the incident was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation policy for injuries of unknown origin.
A resident with a history of stroke, diabetes, hypertension, and heart failure was noted by an aide and an LPN to have a swollen, reddened right eyelid and cheeks, along with a scab above the eyebrow, and the resident could not explain how it occurred. The NP later documented facial cellulitis with associated swelling affecting the resident’s vision and noted no prior history of cellulitis or injuries. Despite the facility’s policy requiring timely investigation of injuries of unknown origin, including evidence gathering and staff interviews, no investigation was conducted, the Administrator was not informed, and the incident was not reported to the State Agency.
A resident with severe dementia and significant behavioral disturbances, including wandering, disrobing, inappropriate urination/defecation, and sexually inappropriate and aggressive behaviors toward others, was involved in a serious incident where he exposed himself, assaulted an LPN, and entered a female resident’s room naked, causing her to fall while trying to escape. Both residents were sent to the ER, and the administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others. However, surveyors found no documentation in the electronic health record of the immediate discharge, no record that the resident’s spouse was informed of the discharge and its reasons, and no scanned discharge notice. A separate paper folder contained a discharge notice inaccurately listing the discharge destination as the family home and notes about notifying the receiving facility and spouse, but the administrator confirmed this information was never entered into the electronic record, contrary to the facility’s discharge/transfer policy.
The facility failed to accurately complete MDS assessments for three residents. One resident with a history of stroke and other comorbidities had a documented fall during a transfer attempt, but the subsequent MDS indicated no falls since the prior assessment. Another resident with Alzheimer’s disease and other conditions had multiple documented falls, including one with a head injury and another with a skin tear, yet the quarterly MDS recorded no falls and omitted the major injury. A third resident with an indwelling Foley catheter and orders for daily catheter care and urine output monitoring was coded on the MDS as always incontinent of urine, even though nursing staff confirmed the resident was always continent due to the catheter.
A dependent resident with a history of stroke, DM, HTN, heart failure, and one-sided impairment was care planned and assessed as needing substantial to maximum staff assistance and total assist of one staff member for bathing, with showers scheduled twice weekly. Review of electronic task records and shower sheets over a three-month period showed multiple missed scheduled showers, and the Administrator confirmed there was no additional shower documentation. The facility’s ADL policy stated residents would be supported to maintain or improve their highest practicable level of function, but the resident did not consistently receive the scheduled showers.
The facility failed to coordinate and implement audiology services and related interventions for two residents. One resident with a mild hearing deficit and bilateral hearing aids had orders for daily insertion and removal of the devices, but the aids were lost, later reported as needing repair and then broken, and the resident stated staff did not place them daily and that she had not seen the audiologist despite his recent visit. Another resident with multiple comorbidities had a physician order for audiology evaluation and treatment after an outside appointment, but was never seen by the facility audiologist, and the resident’s sister reported repeated missed audiology appointments and non-administration of ordered Debrox ear drops, ultimately arranging outside audiology care herself. The Administrator acknowledged that, after the social worker responsible for ancillary services left, no staff were covering audiology coordination, contrary to facility policy requiring assistance with routine audiology services and documentation of coordination efforts.
A resident with arthritis and other chronic conditions had a physician’s order for Tramadol 50 mg TID for pain, but the facility failed to provide the medication as ordered over several days. Narcotic logs and pharmacy records showed the Tramadol supply was exhausted and not replenished for multiple days, while the MAR inconsistently documented some doses as given and others as not administered. Nursing notes indicated the drug was on order or on hold and that an NP was notified of missed doses, but there was no documented order to hold the medication and no documentation on some days about the unavailability. The resident, who was cognitively intact, reported not always receiving medications as ordered, and the DON confirmed that Tramadol was not available during part of the period despite MAR entries indicating administration.
The facility failed to coordinate and provide timely audiology and related social services for two residents with hearing needs. One resident, with multiple complex medical conditions, had a physician order for audiology evaluation and ear flushing, but was never seen by the facility audiologist over several months, and ordered ear drops were reportedly not administered, leading the family to arrange outside audiology care. Another resident with diabetes, hypertension, depression, anxiety, and a documented hearing deficit had bilateral hearing aids that were lost, replaced, then reported as needing repair and later broken, yet was not scheduled with the audiologist during a recent visit and reported that staff did not insert her hearing aids daily as ordered. The Administrator acknowledged that after the social worker left, no one was covering audiology or other ancillary services, despite a policy stating the facility would assist residents in obtaining routine audiology services.
A resident with multiple complex medical conditions and a urostomy had physician orders for urostomy care every three days, including removal, cleansing, assessment, and replacement of the bag and wafer. The resident’s family member reported that staff did not know how to provide proper urostomy care, did not clean the bag, and that she supplied and labeled the ostomy supplies herself, expecting the bag to be checked frequently and replaced every three days. Review of the MAR showed an LPN documented changing the urostomy bag that morning, but an afternoon observation by surveyors and the family member found the bag soiled and stained, indicating the documented care had not been performed. The ADON confirmed nurses should not document tasks as completed when they have not been done.
Surveyors found that the facility did not follow its posted lunch menu for all residents receiving meals in the dining room. Instead of the planned corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake, staff served corn dogs, plain mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and omitted bread entirely. The cook reported there was no specific reason for not preparing cheesy potatoes, acknowledged forgetting to serve bread, and stated that pudding was substituted because cake had not been baked, even though cake mix was in stock. The Corporate Dietary Manager was unaware of some of these deviations, despite facility policy requiring that menus be followed and that any substitutions be nutritionally similar and documented.
Surveyors found that the facility failed to maintain sanitary kitchen conditions and safe food handling practices affecting all 63 residents who received meals. Observations included uncovered trash cans, dirty utensil drawers with scoops and ladles lying in a sticky substance, soiled shelves and food carts, and dry storage floors littered with cardboard and paper. Multiple food items in refrigerators and storage, including cereal tubs, prepared foods, lettuce, bacon bits, and red liquids, were unlabeled or undated. Additionally, two five-pound tubes of hamburger were improperly thawed in standing water and later left on the sink, with temperatures measured at 57.8°F and 49.8°F, which the dietary leadership acknowledged were unsafe. These conditions did not align with the facility’s own policies requiring proper labeling, storage, and sanitation in food service.
An LPN failed to maintain a resident’s privacy by entering the resident’s room during medication administration without knocking or waiting for permission. The resident had multiple behavioral health and medical diagnoses, including schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, substance dependence, major depressive disorder, adult failure to thrive, and PTSD. Observation showed the LPN prepared the medication at the hallway cart and then walked directly into the room, and the LPN acknowledged not knocking, contrary to the facility’s written privacy policy requiring staff to knock before entering resident rooms.
A resident with Alzheimer’s disease, severe protein calorie malnutrition, PVD, HTN, depression, CKD, and left eye blindness, who required setup or clean-up assistance for toileting, was found to have a bathroom with two softball-sized holes in the wall under the sink where the baseboard was missing, exposing the interior of the wall. Surveyors observed this damage on multiple occasions, and interviews revealed that the Director of Support Services did not conduct environmental rounds and was unaware of the issue, while the Administrator reported that regular environmental rounds were not performed and that staff relied on informal daily walk-throughs to identify needed repairs.
A resident with intact cognition and multiple comorbidities underwent cataract surgery and was prescribed several ophthalmic drops for post-operative care. The prescriptions were initially sent to the wrong pharmacy, then filled at a hospital pharmacy and personally delivered to the facility. The medications were placed in the wrong med cart, and the nurse on duty was unaware they had arrived. As a result, the ordered eye drops were not started as scheduled, and the resident did not receive any of the prescribed ophthalmic medications until the following day.
Surveyors identified infection control failures when two LPNs handled oral medications with bare hands during medication passes for two residents with multiple chronic conditions, including schizoaffective disorder, CKD, atrial fibrillation, heart failure, and depression, and intended to administer those medications. In a separate incident, a CNA was observed providing care to a resident with COPD, a pulmonary nodule, anxiety, and respiratory failure while a feces-soiled towel and disposable pad lay directly on the floor, contrary to facility policy requiring soiled linens to be bagged or placed in carts at the point of care.
The facility failed to timely notify responsible parties and the county health department of a COVID-19 outbreak and did not implement or document facility-wide outbreak communication and testing. Several cognitively impaired residents on a memory care unit tested positive, but their families were not informed until days later. Staff reported that only two of three nursing units underwent COVID-19 testing, and residents and responsible parties on one unit were not notified of the outbreak. No signage was posted at the main entrance to alert residents or visitors, and interviewed residents were unaware of the outbreak and were not offered masks or other PPE, despite facility policy and CDC guidance requiring prompt outbreak reporting and broad-based testing.
Multiple residents did not receive meals as specified by the dietitian-approved menu, with omissions such as milk and cereal, and some meals not matching the prescribed menu due to staff practices and budget constraints. Staff and dietary management confirmed that unless meal tickets specifically listed certain items, these were not provided, even when required by the menu. Residents affected included those with dementia, malnutrition risk, and other chronic conditions.
Laundry handling and PPE deficiency: The facility failed to properly separate, bag, and transport soiled linen, including linen from isolation rooms and linen contaminated with blood or bodily fluids. Observations showed unbagged soiled linen overflowing from a cart, no clearly marked containers for contaminated laundry, and limited PPE available in the laundry area. Staff reported they had not been trained on a specific protocol for handling contaminated linen, and a laundry aide was observed sorting loose soiled items while wearing only vinyl gloves and no gown or eye protection.
A resident with cognitive impairment eloped from a secured unit by escaping through a window that was not properly secured, despite care plans and monitoring protocols. Another resident with dementia was roughly transferred from a wheelchair to bed by a CNA, as captured on video and reported by family, with the transfer not following safe procedures. Additionally, five residents were observed smoking without proper ashtrays or safety equipment, resulting in cigarette butts scattered in the courtyard and unsafe disposal practices, with staff lacking training on smoking safety protocols.
A facility failed to keep advance directive and code status documentation consistent across paper charts and the EMR for four residents. One resident had full code in the paper chart but DNR-CC in the EMR and hospice paperwork, another had no paper directive but DNR-CCA in the EMR, a third had a signed DNR-CC order but a FULL CODE page in the hard chart, and a fourth had both full code and DNR-CC orders in the EMR, with only the full code order signed. Staff confirmed the mismatches, and the DON acknowledged the conflicting records.
Failure to Record and Monitor Resident Weights: The facility did not ensure monthly weights were obtained and monitored for four residents with nutrition-related diagnoses, including malnutrition, dementia, dysphagia, and CKD. Records showed missing weights, an unfinished admission nutrition assessment, an unexplained weight discrepancy for one resident, and no documented weight refusals for the month in question. The RD stated weights were monitored remotely and that missing weights would not appear on the report, allowing weight trends to be missed.
Inadequate staffing was found on the memory care unit when no staff were present during an early morning observation and residents were left with only limited coverage. An LPN had not yet received report, a CNA had left the unit to assist another resident, and staff confirmed the unit usually had only one CNA at night while the nurse split coverage with another unit. Interviews with the ADON and DON confirmed two staff were supposed to be on memory care at all times, but the facility assessment, BIPPA, and staffing policy did not specify unit-based staffing levels.
Surveyors identified that the facility did not maintain a medication error rate below 5%, with two errors observed among 28 medications administered. One resident received an incorrect dose of an antidepressant, while another did not receive a prescribed supplement, despite documentation stating otherwise. These errors were confirmed through observation, record review, and staff interviews.
Missed Care Conference Meetings: A resident with CHF, anxiety, and pyogenic arthritis was not offered care conference meetings quarterly or as needed. Records showed multiple MDS assessments and care plan meeting forms, but staff verified at least one care conference was missed and the resident's last care conference had occurred earlier than expected. The SSD said she had been covering multiple roles and that resident lists were sent for letters to family and the resident.
A resident with severe dementia, depression, and PTSD received Zyprexa despite no documented schizophrenia, bipolar disorder, mania, or failed antidepressant trials. Psychiatric notes described worry and agitation but no psychosis, and only two AIMS assessments were completed even though the care plan called for ongoing psychotropic monitoring.
A resident admitted with dementia, malnutrition, and psychiatric diagnoses had an MDS showing need for assistance with eating, bathing, toileting, dressing, personal hygiene, and transfers, but the comprehensive care plan lacked both a nutrition care plan and an ADL care plan. Staff interviews showed confusion about who was responsible for completing the care plans, despite facility policy requiring the IDT to develop a comprehensive care plan within seven days of the comprehensive assessment.
Failure to provide and document scheduled bathing for a resident with moderate cognitive impairment and diagnoses including schizophrenia, dementia, and failure to thrive. The resident had a water phobia and requested no showers, but the unit schedule listed only one bathing day per week even though staff stated residents were supposed to receive showers twice weekly. Shower sheets showed multiple refusals and incomplete documentation of bathing opportunities, and an observation found the resident with greasy hair and appearing not recently combed.
Failure to Provide and Document Required Bathing: Two dependent residents with significant cognitive impairment and psychiatric diagnoses did not receive or have documented bathing at the facility’s stated frequency of at least two showers per week. Shower schedules listed only one bathing day for each resident, bathing tasks lacked complete scheduling details, and shower sheets showed missed or undocumented opportunities. Observations found both residents with poor hygiene, including greasy hair and soiled clothing, while the DON and ADON confirmed the facility could not provide evidence of all scheduled bathing opportunities.
Pharmacy recommendations were not addressed in a timely manner for two residents during monthly med regimen review. One resident on hospice and another resident with a pelvic fracture and multiple chronic conditions both had diclofenac gel orders that lacked a dose or ordered amount, and repeated pharmacist requests to provide dosing were not acted on or forwarded to the prescriber. The DON confirmed the recommendations were not timely addressed and no order changes were made.
Failure to provide ordered double portions for a resident. A cognitively intact resident with HF, malnutrition, Wernicke’s encephalopathy, and alcohol abuse had a physician order for a regular, no-lactose diet with double portions, but staff notes and the tray card did not reflect that preference. The resident reported not receiving double portions, and observation of the breakfast tray showed only standard portions; the CNA was unaware of the order and the DON confirmed the tray card did not include it.
The facility failed to follow its abuse prevention policy by not documenting NAR checks for several newly hired employees, including a COTA, dietary manager, DON, and LPN. Personnel file review showed no NAR search results for these staff members, and the DON confirmed the missing documentation during interview. The facility policy required screening potential employees for abuse, neglect, or mistreatment history through required registry and licensure checks.
Employee physical screenings were not completed properly before employment for a DON, an LPN, two CNAs, a COTA, and a Dietary Manager. Personnel file review showed the physicals were not signed or dated by appropriate personnel, and the HRD confirmed the issue during interview. Facility policy required a pre-employment physical exam with the date of examination and the name and credentials of the healthcare professional completing the review.
Facility assessment was not comprehensive or unit-specific. The acuity and services sections listed general care areas without differentiating by unit, and the FTE/contractor section identified RN, LVN, and CNA totals without stating staffing by shift or unit. The DON confirmed the assessment did not specify par staffing levels or distinguish between units and levels of care as required.
Surveyors found that multiple residents' rooms were not maintained in a safe or sanitary condition, with observations including stained carpets and chairs, dirty toilets, sticky floors, moldy food, and significant dust and debris. Staff confirmed these conditions, and one resident reported not having clean clothes for several days due to a blocked closet. The unsanitary environment was observed in both living and kitchen areas, with infrequent cleaning and improper storage of personal and medical items.
The facility did not provide scheduled therapeutic activities for all residents in the secured memory care unit, resulting in residents spending extended periods with minimal engagement, such as watching television or listening to music. Staff interviews confirmed that the activity calendar was often not followed, and some planned activities were either delayed, substituted, or not conducted. The physical setup of the common area limited social interaction, and some previously used engagement items had been removed. Despite having adequate supplies, the activity program did not meet the physical, mental, and psychosocial needs of the residents.
Surveyors found expired medications, opened wound care supplies, and improperly stored medical items in multiple medication storage rooms and carts. These deficiencies were confirmed with the ADON and DON, and were not in compliance with facility policy requiring removal and destruction of expired or unsecured items.
The facility did not ensure that food was served at safe and appetizing temperatures, as confirmed by a test tray and resident interviews. Multiple residents reported receiving meals that were not warm, and staff interviews revealed delays in tray delivery and a lack of urgency in serving food, resulting in food sitting for extended periods before reaching residents.
Surveyors observed that staff did not consistently follow infection control procedures during care for three residents, including not wearing required PPE during high-contact activities, failing to clean or use barriers on bedside tables before placing supplies, and not performing hand hygiene between glove changes. These actions were not in accordance with the facility’s infection control policies.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent assistance with eating and communication, as required by their care plan. Observations showed the resident struggled to use adaptive utensils, ate with her hands, and lacked access to communication tools, with staff only intervening after surveyor involvement. Staff interviews confirmed the absence of communication aids and inconsistent support with meals.
A resident with multiple diagnoses, including type 2 diabetes, did not receive prescribed blood sugar monitoring using a Dexcom G7 Sensor as ordered. The sensor was not administered on several scheduled dates, and documentation was incomplete or missing in the MAR, with no evidence of further attempts to provide the monitoring. The DON confirmed these findings, which were not in accordance with facility policy.
A resident with severe vision impairment and multiple comorbidities was recommended for cataract evaluation by an eye care consultant. Although staff attempted to find an ophthalmologist who accepted the resident's insurance and could accommodate bariatric needs, no appointment was scheduled, leaving the resident without necessary follow-up for vision care.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure the State Long Term Care Ombudsman Office was notified of a resident discharge from the facility. Resident #61 was admitted on 10/07/25 with diagnoses including alcohol abuse, muscle weakness, and difficulty walking, and was discharged on 02/19/26 to her personal residence. Review of the facility’s Ombudsman Transfer/Discharge Log for February 2026 showed that Resident #61’s discharge was not included on the monthly document sent to the State LTC Ombudsman Office. The Administrator verified on 05/20/26 that the resident’s discharge information was not sent to the State LTC Ombudsman Office as required.
Late Transmission of MDS Assessment
Penalty
Summary
The facility failed to ensure that MDS 3.0 assessments were transmitted to CMS within fourteen days of completion as required. Record review for Resident #18 showed an admission date of 12/24/25 with diagnoses including fractured back, major depressive disorder, and insomnia, and the resident discharged back to the community with his spouse on 02/03/26. Review of the MDS assessment records showed a Discharge Return Not Anticipated assessment that was completed but not transmitted directly to CMS as required. An interview with the MDS Nurse on 05/19/26 at 10:00 A.M. verified that the assessment was not transmitted to CMS within fourteen days of completion.
PASRR Recommendations Not Implemented
Penalty
Summary
The facility failed to ensure PASRR recommendations for placement and related services were implemented and incorporated into the resident's comprehensive care plan for one resident reviewed for PASRR assessments. Resident #42 was admitted with diagnoses including bipolar disorder, suicidal ideations, and seizures. The most recent MDS indicated the resident was moderately cognitively impaired and independent with activities of daily living. A Level II PASRR assessment completed by the Ohio Department of Mental Health and Addiction Services stated the resident was not appropriate for continued nursing facility services and noted the resident required only hands-on assistance with changing incontinence supplies, which could be provided in an assisted living or other residential care setting. The record showed that since the PASRR determination, there was no evidence of discharge planning, referrals, care conferences, or other efforts to transition the resident to a more appropriate setting as recommended by the PASRR authority. The PASRR representative confirmed the resident had a Level II mental illness designation and was denied continued stay approval, and that the denial was upheld on appeal by a third-party hearing officer. The social worker also confirmed the resident remained in the facility without continued stay approval from the State PASRR authority.
Nebulizer equipment not dated or stored properly
Penalty
Summary
The facility failed to ensure nebulizer masks and tubing were dated and stored appropriately for two residents receiving respiratory care. Resident #55 had diagnoses including atrial fibrillation, type 2 diabetes mellitus, depression, and chronic blood clots in the lower extremities, and his physician ordered ipratropium-albuterol inhalation solution every eight hours for shortness of breath. Observation on 05/18/26 and again on 05/19/26 showed Resident #55's nebulizer mask was not stored in a bag when not in use and was undated. During the 05/19/26 observation, an LPN verified the finding and stated nebulizer masks were to be stored in a bag when not in use and dated. Resident #56 had diagnoses including chronic kidney disease stage four, type 2 diabetes mellitus, congestive heart failure, atrial fibrillation, and shortness of breath. The physician order dated 04/24/26 directed that the nebulizer mask, cup, and tubing be changed weekly and that the mask be dated. Observation on 05/18/26 and again on 05/19/26 showed Resident #56's nebulizer mask was not stored in a bag while not in use. The LPN verified the finding during the 05/19/26 observation. Facility policy titled "Nebulizer Aerosol Therapy" stated the nebulizer mask and tubing were to be changed weekly, the storage bag was to be changed weekly, the nebulizer was to be stored in a bag to prevent contamination when not being used, and the mask was to be dated.
Blood Pressure Medication Given Without Required Vital Sign Monitoring
Penalty
Summary
The facility failed to ensure that parameters for Resident #49’s blood pressure medication were monitored before administration. Resident #49 was admitted with diagnoses including dementia, hypertension, and edema, and had an order dated 05/06/25 for amlodipine daily with instructions to hold the medication if systolic blood pressure was under 110 or heart rate was under 60. Review of the medication administration record showed the amlodipine was given regularly without evidence that blood pressure and heart rate were assessed before administration, and review of vital signs assessments showed the heart rate and blood pressure were not being checked daily. The Director of Nursing confirmed these findings during interview on 05/20/26 at 5:05 P.M.
Respiratory Medications Left Unsecured at Resident Bedside
Penalty
Summary
The facility failed to ensure respiratory medications were stored securely. During observation, five unopened ipratropium-albuterol unit dose vials were found on Resident #55’s kitchenette counter near her nebulizer. The LPN present at the time confirmed the vials were from the facility and stated she did not think the resident had an order to self-administer ipratropium-albuterol. Resident #55 was admitted with diagnoses including atrial fibrillation, type 2 diabetes mellitus, depression, and chronic blood clots in the lower extremities. The resident’s MDS showed moderate cognitive impairment, sometimes rejected care, was independent with toileting and personal hygiene, and required supervision with transferring. The medical record included a physician order for ipratropium-albuterol inhalation solution every eight hours for shortness of breath, and a Medication Self-Administration Safety Screen indicated the resident was not able to self-administer ipratropium-albuterol. Facility policy stated medications were to be stored securely and only accessible to authorized personnel, and bedside storage was to be used only if a resident self-administered the medication.
Failure to Maintain Secured-Unit Doors and Accurate Fall Risk Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain properly functioning secured-unit doors and to ensure adequate supervision to prevent accidents for all residents on the secured unit. Surveyor observation showed that one of the three entry/exit doors to the secured unit and dining/kitchen area opened immediately without the required 15‑second delay, did not require a code or button to open, and only triggered an alarm when opened. No staff were stationed at the door to monitor resident movement. The ADON confirmed the door should have been secured, should not open immediately, and that no one was monitoring it. The Director of Support Services (DoSS) reported he first discovered the malfunction on a specific date and attempted to contact a repair company, initially reaching a garage-door company in error, and then a second company days later. An anonymous employee stated the doors had not been working properly “for awhile” and that she had notified the facility, but there were no corresponding work orders in the electronic maintenance system documenting the door problem, despite facility policy requiring urgent safety hazards to be entered and reported. The Administrator was unaware the doors were not working properly and later was also unaware that the vendor had recommended replacement of the doors. The vendor’s subsequent inspection documented that the secured unit had three double-door systems and that one double-door system had only one lock with a push-button reentry, was frequently in alarm, and could not be reset by the facility. The vendor found the lock misaligned, mounted with only three screws, and positioned over 1/4 inch too far from the door, causing poor connection with the armature. The egress wheel was also broken. The vendor realigned the lock, added additional screws, replaced the egress wheel, and adjusted the egress, and noted the doors were in rough shape, rubbing in the center and not always closing properly. These findings showed that the secured-unit doors were not maintained in proper working order for the 17 residents residing on the secured unit, contrary to the facility’s maintenance policy and its dementia care policy that supports a secured/locked environment for residents with dementia or dementia-like symptoms when clinically indicated. A separate deficiency involved the facility’s failure to accurately assess a resident’s fall risk. One resident with diagnoses including Alzheimer’s disease, chronic kidney disease, and hypertension had four documented falls within a span of less than two months, including falls that resulted in a skin tear and a head injury. However, the fall risk assessment completed during this period documented that the resident had no history of falls in the previous three months, which led the assessment tool to indicate the resident was not at risk for falls. An LPN later verified that this assessment was incorrect and that the resident had, in fact, fallen four times during the assessment period and was at high risk for falls. This inaccurate documentation and assessment contributed to the facility’s failure to ensure the resident was properly identified as being at risk for falls.
Failure to Provide Adequate Dementia Care and Behavior Management on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary dementia care and treatment to maintain the safety and well-being of residents on the secured dementia unit, particularly one resident with severe vascular dementia and significant behavioral symptoms. The resident was admitted with diagnoses including severe vascular dementia without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, restlessness, and agitation. Physician orders over time included multiple psychotropic and mood-stabilizing medications (Depakote, Zyprexa, Ativan, Rexulti) and an order for placement on the secured unit. A quarterly MDS assessment documented that the resident was severely cognitively impaired, exhibited hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering, and required maximum assistance for all personal care except eating. From admission through discharge, nursing progress notes documented escalating and persistent behaviors, including wandering into other residents’ rooms, placing clothes and items in toilets, exit-seeking, and increasing agitation and aggression. Early in the stay, staff documented incidents such as the resident exposing himself and urinating on the floor and wall, with staff providing redirection and cleaning. Over time, the resident was repeatedly found in female residents’ rooms, sometimes naked, engaging in inappropriate sexual behavior on their beds, defecating in hallways, and attempting to rub feces on other residents. The resident was transferred for psychiatric evaluation when the psychiatric practitioner indicated the facility was unable to manage his behaviors, and upon readmission he was placed on one-to-one supervision and moved between unsecured and secured units due to a COVID-19 outbreak. Despite these measures, his behaviors of wandering into female residents’ rooms, insisting they were his wife, inappropriate elimination, and physical aggression toward staff and residents continued. Care plan review showed that a behavior care plan and a mood/behavior care plan were initiated early in the stay, with generic interventions such as encouraging social activities, explaining things in a way the resident could understand, administering medications as ordered, monitoring labs, charting behaviors, observing for early warning signs, and consulting psychiatric services. The behavior care plan was last revised on a date that did not reflect the later, more severe behaviors, and the mood/behavior care plan was never revised during the resident’s stay. The care plans did not address specific risks or interventions related to the resident entering female residents’ rooms naked, insisting they were his wife, attempting to get into bed with them, or the use of one-to-one supervision upon readmission. Referral information from the prior facility indicated that the same types of behaviors had been present before admission. Staff and administrator interviews revealed that female residents were afraid of the resident, some were barricading their doors, and that the administrator did not initially consider the resident’s naked entry into female residents’ rooms and attempts to get into bed with them as sexually inappropriate behavior. A documented incident described the resident in the hallway with genitals exposed, refusing redirection, becoming physically aggressive with an LPN, and then entering a female resident’s room naked, claiming she was his wife, and forcefully attempting to get into her bed, leading to the female resident falling out of bed while trying to get away. These events occurred despite the facility’s written dementia care policy, which described person-centered, individualized approaches and staff training for managing dementia-related behaviors, and led surveyors to determine that the facility failed to provide necessary dementia care and treatment for this resident, with the potential to affect all residents on the secured unit. Interviews with staff and leadership further detailed the actions and inactions contributing to the deficiency. An anonymous employee reported that staff concerns about the resident’s behaviors, including entering rooms naked and frightening female residents, were repeatedly brushed off by the administrator until after a female resident fell and subsequently did not walk as before. The administrator acknowledged being aware that the resident had a history of behaviors at the prior facility, including inappropriate urination, wandering, and minimal sleep, and that he believed female residents were his wife. The administrator also stated she did not conduct an on-site review before admission based on advice from the former admissions/marketer director and was initially hesitant to accept the resident. Despite a prior transfer for psychiatric evaluation due to the facility’s inability to manage his behaviors, the administrator decided to readmit him, believing the secured unit could handle his needs. The administrator reported receiving emails from families requesting the resident’s discharge and was unaware that female residents were barricading their doors because staff did not inform her. The combination of inadequate behavior-specific care planning, failure to adjust interventions in response to ongoing and escalating behaviors, and leadership’s handling of staff and resident concerns led to the determination that the facility did not provide appropriate dementia care and services to ensure the safety and well-being of residents on the secured unit.
Failure to Maintain Functional Egress Doors on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all doors on a secured unit remained in proper working order to allow egress. Surveyors observed that one set of double doors leading from the secured unit to another unit and the dining room/kitchen area would not open even after being pushed on for over one minute, and no alarms sounded during this time. A code was required to access or leave the unit, and the ADON confirmed that the doors should open and alarm after being pushed for 15 seconds to allow egress. The secured unit housed 17 residents, all of whom were affected by the malfunctioning doors. An anonymous employee reported that the doors had not been working properly for a while and that the facility had been notified, but there were no corresponding work orders in the electronic maintenance system documenting any issues with the secured unit doors during the review period. The Director of Support Services reported discovering on a specific date that the secured unit doors were not working properly and attributed the malfunction to a recent power surge, stating that he monitors the doors weekly. He initially contacted a company that only serviced garage doors and then contacted another company days later. When the door vendor eventually inspected the three double-door systems on the secured unit, they found that egress wires had been removed or were missing from the panels on two of the door systems, preventing proper egress, and that one lock mounting plate was loose due to insufficient and backing-out screws. The vendor also noted the doors were in rough shape, rubbing in the center and not always closing properly. The Administrator stated she was unaware that the secured unit doors were not working properly and had not received the vendor’s invoice or repair information, including the recommendation to replace the doors, until a later date. Review of the facility’s Maintenance Requests policy showed that urgent safety hazards must be reported both electronically and directly to the Department of Special Services or Administrator, but no electronic work orders had been submitted for the malfunctioning secured unit doors over several months.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency and failed to conduct an investigation for one resident. The resident had been admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure, and a need for personal assistance, and a recent MDS showed intact cognition, no behaviors, and one-sided impairment. On the evening of 01/05/26, an LPN documented that during breakfast an aide noticed swelling on the right side of the resident’s face, including a swollen upper eyelid and reddened, swollen cheeks. When asked, the resident stated he did not know how the swelling and redness occurred and denied pain. The LPN reported the condition to the DON and the practitioner and received new orders, and the NP later documented a scab by the right eyebrow with swelling around the right eye and cheek, diagnosing facial cellulitis and starting an antibiotic. The resident reported some difficulty with vision in the right eye due to eyelid swelling and had no history of cellulitis or injuries. Despite the unexplained nature of the facial injury and the facility’s written policy defining an injury of unknown origin as a physical injury where the cause cannot be readily determined or explained, no investigation was initiated or completed, and the incident was not reported to the State Agency. The LPN who first assessed the resident’s eye stated that she was not interviewed by management about what happened, did not conduct an investigation, and did not ask other staff how the resident obtained the scab or swelling. The Administrator confirmed she was not made aware of the condition to the resident’s right eye, did not report it to the State Agency, and did not investigate the possibility of an injury of unknown origin. The facility’s abuse, neglect, and exploitation policy required timely investigation of any alleged injuries of unknown origin, including evidence gathering, staff interviews, and documentation of findings on appropriate state forms, which did not occur in this case.
Failure to Investigate Injury of Unknown Origin Involving Facial Swelling and Scab
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin for Resident #18, as required by its abuse, neglect, and exploitation policy. Resident #18, admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure, and need for personal assistance, had intact cognition per a recent MDS and an impairment on one side of his body. On 01/05/26, an aide reported to LPN #602 that the resident had swelling on the right side of his face. LPN #602 assessed the resident and noted a swollen right upper eyelid, swollen and reddened cheeks, and documented that the resident did not know how the swelling and redness occurred and denied pain. LPN #602 reported the condition to the DON and the practitioner and documented that new orders were received, but did not specify the orders in the progress note. On 01/06/26, NP #607 documented that the resident had a scab by his right eyebrow with swelling around the right eye and into the cheek, and diagnosed facial cellulitis, noting the resident had no pain or itching but some difficulty with vision in the right eye due to eyelid swelling and no history of cellulitis or injuries. During interviews, LPN #602 stated she did not conduct any investigation into how the resident obtained the scab or swelling, did not ask other staff about the cause, and was not interviewed by management about the incident. The resident later recalled having had a scab and swelling to his right eye but could not remember how it happened and could not recall if he had ever been physically or verbally abused by staff. The Administrator reported she was not made aware of the area to the resident’s right eye, did not report it to the State Agency, and did not investigate it as an injury of unknown origin. The facility’s policy defined an injury of unknown origin as a physical injury where the cause could not be readily determined or explained and required a timely investigation including evidence gathering, interviews, and documentation, which did not occur in this case.
Failure to Accurately Document and Record Immediate Discharge After Behavioral Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an immediate discharge was accurately documented and included in the medical record for a resident with severe cognitive impairment and significant behavioral symptoms. The resident had vascular dementia, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, and generalized anxiety disorder, and required maximum assistance for most personal care. Physician orders included multiple psychotropic and mood-stabilizing medications, and an order for the resident to reside on a secured unit. The quarterly MDS documented severe cognitive impairment, hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering. From admission through discharge, nursing progress notes described escalating agitation and disruptive behaviors, including wandering into other residents’ rooms, placing items in toilets, exit-seeking, refusal of medications, and increasing aggression when redirected. The resident engaged in repeated episodes of public disrobing, inappropriate urination and defecation, and sexually inappropriate behaviors, such as entering female residents’ rooms naked and engaging in inappropriate sexual behavior on their beds, and attempting to rub feces on other residents. The resident was transferred twice for psychiatric evaluation due to behaviors the facility was unable to manage, including anxiety, aggression, exit seeking, sexual aggression toward females, and combative behavior resulting in self-inflicted injury. Despite these events, no interdisciplinary team notes discussing the resident’s behaviors were found in the record during the resident’s stay. On one evening, an LPN documented that the resident was in the hallway with genitals exposed, refused redirection to dress, became physically aggressive, and ripped the LPN’s shirt and pulled out her hair. The resident then entered a female resident’s room naked, claimed she was his wife, and forcefully attempted to get into her bed, causing the female resident to fall out of bed while trying to get away. Emergency services were contacted, and both residents were transferred to the ER for evaluation. After this event, there was no further documentation in the nursing progress notes regarding the resident’s discharge disposition. The Administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others, but review of the electronic health record revealed no documentation of the immediate discharge, no record that the resident’s wife had been informed of the discharge and its reasons, and no scanned copy of the discharge notice. Further review showed that a written discharge notice, dated two days after the incident, inaccurately listed the discharge location as the family home, even though the resident had been transported to the hospital and did not return to the facility. The notice stated that the discharge was immediate due to behaviors endangering the safety of individuals in the home and included information on appeal rights and contact information for the Ombudsman and Administrator. The Administrator produced a separate folder containing a copy of the certified mail to the resident’s wife, an undated and unsigned note about a voicemail to the receiving facility’s social worker stating the resident could not return, and a narrative that the wife was notified of the emergent discharge and believed he would do better on an all-male secured unit. However, the Administrator confirmed that this information and the discharge notice had not been documented or scanned into the resident’s electronic health record, contrary to the facility’s Discharge/Transfer policy, which requires that unplanned discharge information and rationale be documented in the electronic record. The facility’s Discharge/Transfer policy, last revised in June 2025, outlined acceptable rationales for discharge or transfer, including behavioral issues that cannot be safely managed and that endanger others, and required that when unplanned discharges occur, the facility provide specific information in the discharge notice explaining why the resident is being discharged and how the discharge meets criteria, with this information documented in the resident’s electronic health record. In this case, the surveyors found that the facility failed to ensure the immediate discharge was accurately documented in the medical record and that the discharge notice contained accurate information about the discharge location, resulting in a deficiency for failure to ensure the transfer/discharge process met requirements for documentation and accuracy for this resident.
Inaccurate MDS Coding for Falls and Urinary Continence
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments were accurately completed for three residents. For one resident with a history of cerebral infarction, diabetes, hypertension, heart failure, and need for personal assistance, the fall risk assessment documented a fall in the previous three months, and a fall investigation showed he fell while attempting to transfer from his wheelchair to his bed without staff assistance, with no injury noted. However, the subsequent quarterly MDS assessment documented that he had no falls since admission or the prior MDS, despite the documented fall. The Administrator confirmed that the MDS section J was incorrect because the fall without injury should have been recorded. Another resident with Alzheimer’s disease, chronic kidney disease, and hypertension had multiple documented falls over a three‑month period, including falls resulting in a skin tear and a head injury, as well as two falls without injury. Despite these documented events and an admission MDS completed earlier, the quarterly MDS assessment recorded that the resident had no falls since admission or the prior MDS, and an LPN confirmed that this was inaccurate and that one fall with a head injury should have been coded as a major injury. A third resident with multiple diagnoses, including bullous pemphigoid, morbid obesity, asthma, anxiety, depression, heart disease, hypertension, and neuromuscular bladder dysfunction, had a physician’s order for an indwelling urinary catheter with daily catheter care and daily monitoring of urinary output. The annual comprehensive MDS assessment documented that this resident had an indwelling Foley catheter but was always incontinent of urine, whereas an RN confirmed that the resident was always continent of urine due to the Foley catheter, indicating inaccurate coding in the bowel and bladder section.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received scheduled showers as part of activities of daily living (ADLs). The resident was admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure, and a need for personal assistance. The care plan dated 06/07/22 documented a self-care deficit for ADLs and specified that the resident required total assistance of one staff member for bathing. A quarterly MDS 3.0 assessment showed the resident had intact cognition, no behaviors, an impairment on one side of the body, and needed substantial to maximum assistance from staff for showers and bathing. Review of the electronic record task section and shower sheets from 01/01/26 through 03/31/26 showed that the resident, who was scheduled to receive two showers per week on Tuesdays and Fridays, did not receive showers on multiple scheduled days, specifically 01/02/26, 01/06/26, 02/24/26, 03/03/26, and 03/27/26. An interview with the resident indicated he had three strokes and could not remember things. An interview with the Administrator confirmed there were no additional shower sheets or shower documentation available for this resident beyond what was reviewed. The facility’s policy on Activities of Daily Living-Highest Level of Functioning stated that the facility would support each resident in maintaining or improving their highest practicable level of function related to ADLs based on needs, preferences, and goals. This failure to provide and document scheduled showers was identified under Complaint Number 2962348.
Failure to Coordinate and Implement Audiology Services for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure audiology services and related interventions were implemented as ordered and as outlined in facility policy for two residents. One resident with diabetes, hypertension, depression, anxiety, and a documented mild hearing deficit had a care plan indicating bilateral hearing aids, with staff responsible for inserting and removing the devices and consulting audiology as needed. Physician orders directed staff to insert the hearing aids each morning and remove them at night, with storage in the medication cart. Nursing notes documented that this resident’s hearing aids were lost in early December and replaced later that month, then subsequently needed repair in late February and were reported as not working properly and then broken in early March. During a care plan meeting in late January, the resident’s representative asked about the hearing aids, and follow-up with nursing was noted. Despite an audiology visit to the facility in early April, the resident was not seen by the audiologist. On observation and interview in early April, the resident and an LPN noted a wire had come out of the right hearing aid; the LPN pushed the wire back in and placed the hearing aids in the resident’s ears, after which the resident stated she thought they were working. The resident reported she had not seen the audiologist in a long time, had wanted to see him during his most recent visit, and believed she had excessive ear wax requiring audiology evaluation. She also stated that nursing staff did not place her hearing aids in daily as ordered. The resident’s most recent annual MDS assessment documented adequate hearing with hearing aids, intact cognition, and no behaviors. The Administrator confirmed that the former social worker had been responsible for making audiology appointments, that the social worker had left, and that there was no one covering audiology coordination at the time, resulting in the resident not being seen during the audiologist’s last visit. A second resident, admitted with multiple diagnoses including a right ilium fracture, COPD, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, and a history of malignancies with a urostomy, had a physician’s order for audiology to evaluate and treat. The resident’s quarterly MDS showed moderate cognitive impairment, adequate hearing, no need for hearing aids, and independence with personal care. Nursing documentation indicated that after a physician appointment arranged by the resident’s sister, the physician discontinued two medications and ordered audiology assessment. Review of audiology visit records from several months showed the resident was never examined by the facility audiologist, including during the most recent visit. The resident’s sister reported that the resident was supposed to see the facility audiologist on multiple occasions but was not examined, that the facility stated the audiologist went to the resident’s former facility, and that an emergency audiology appointment promised by the facility was not scheduled for several weeks. She also reported being told Debrox ear drops were ordered weekly but never administered, and ultimately arranged an outside audiology appointment herself to have the resident’s ears flushed so the resident could hear again. The ADON confirmed the resident had never seen the facility audiologist since admission, and the Administrator confirmed that no staff were covering audiology or other ancillary services after the former social worker left, despite a facility policy stating the facility would assist residents in obtaining routine audiology services and document coordination efforts in the medical record.
Failure to Provide Ordered Tramadol for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident with chronic pain needs. The resident, admitted with diagnoses including diabetes mellitus, hypertension, depression, anxiety, and arthritis, had a care plan identifying altered comfort related to arthritis and directing staff to administer medications as ordered. A physician’s order dated 12/27/25 prescribed Tramadol 50 mg three times daily. Review of the narcotic log for February 2026 showed the resident’s last available Tramadol dose was given on 02/13/26 at 6:00 P.M., with no further Tramadol available until 02/17/26 at 2:00 P.M. The MAR documented multiple scheduled Tramadol doses as not administered on 02/14/26 (morning and 3:00 P.M.), 02/15/26 (8:00 P.M.), and 02/16/26 (morning and 3:00 P.M.), despite the standing TID order. Nursing progress notes on 02/14/26 and 02/16/26 indicated the nurse was waiting on Tramadol from the pharmacy and that it was on order or on hold until available, and that the nurse practitioner had been made aware of missed doses, but there was no documentation of any order to hold the medication. Further record review and interviews confirmed that Tramadol was not available in the facility for this resident between 02/14/26 and 02/16/26 until 8:00 P.M. on 02/16/26, even though the MAR reflected administration on 02/14/26 at 8:00 P.M. and on 02/15/26 in the morning and at 3:00 P.M. Pharmacy records showed only two Tramadol deliveries for this resident during the relevant period, on 01/31/26 and 02/16/26, with no additional supply sent between those dates. The resident, who had intact cognition and no behaviors per the most recent MDS, reported that she did not always receive her medications as ordered and that medications were sometimes missed or late. The Interim DON verified that the resident did not receive Tramadol as ordered on the identified dates and that the medication was not available during part of the period in question, despite documentation indicating it had been administered. Facility policies on Medication Administration and Management and Pain Management required nursing staff to administer medications as ordered and to document medication unavailability, but the documentation and medication supply did not align with those requirements.
Failure to Coordinate Audiology and Hearing Aid Services for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medically related social services and coordination of ancillary audiology services for two residents. One resident was admitted with multiple medical conditions, including COPD, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, and a history of malignant tumors with a urostomy. A physician order dated 02/13/26 directed that this resident be evaluated and treated by audiology after returning from an outside physician appointment, where the physician also discontinued two medications. Despite this order and the facility’s policy stating it would assist residents in obtaining routine audiology care, review of audiology visit records from 09/11/24 through the most recent visit on 04/01/26 showed that the resident was never examined by the facility audiologist. The resident’s sister reported that the resident was supposed to see the facility audiologist in January 2026 and again on 02/11/26, but the resident was not examined on either occasion. The facility reportedly told the sister that the audiologist had gone to the resident’s former facility and later stated they would arrange an emergency audiology appointment, which had still not been scheduled three weeks later. The sister stated that on 02/13/26 she brought the resident back from a physician appointment with an order for audiology to see the resident for ear flushing due to hearing difficulty, and that Debrox ear drops were said to have been ordered weekly but were never administered. She further stated she had repeatedly met with the Administrator, ADON, and Ombudsman without changes, and ultimately arranged an outside audiology appointment herself so the resident could have her ears flushed. The second resident had diabetes, hypertension, depression, anxiety, and a documented communication problem related to a mild hearing deficit, with a care plan indicating bilateral hearing aids and staff assistance with insertion, removal, and audiology consultation as indicated. Physician orders directed staff to insert the hearing aids each morning and remove them at night, with storage in the medication cart. Nursing notes documented that the resident’s hearing aids were lost and later replaced, and that by late February and early March 2026 the hearing aids needed repair, were not working properly, and were broken, with the NP and social worker notified. At a care plan meeting, the resident’s representative asked about the hearing aids, and the note indicated follow-up with nursing staff. The resident’s MDS showed adequate hearing with hearing aids, but the audiology visit list for 04/01/26 showed the resident was not seen by the audiologist. During observation and interview, the resident reported not having seen the audiologist in a long time, wanting to see him on his last visit, concern about excessive ear wax, and that nursing staff did not place her hearing aids daily as ordered. The Administrator confirmed that the former social worker, who had made audiology appointments, left on 03/16/26 and that no one was covering audiology or other ancillary services until a new social worker started, despite an undated facility policy stating it would assist residents in obtaining routine audiology services.
Inaccurate Documentation and Soiled Urostomy Bag
Penalty
Summary
The facility failed to ensure a resident’s medical record accurately reflected ostomy care provided, specifically urostomy care ordered by the physician. The resident had multiple medical conditions, including a history of motor vehicle accident with multiple fractures, COPD, major depressive disorder, bipolar disorder with psychotic features, obstructive and reflux uropathy, anxiety disorder, artificial openings of urinary tract status, malignant neoplasm of the bladder, and a history of malignant carcinoid tumor of the bronchus and lung. Physician orders dated 09/12/25 directed that urostomy care be performed on the day shift every three days, including removal of the bag and wafer, cleansing the site with normal saline, observing the skin/ostomy, applying skin prep to the stoma border, allowing it to dry, and then applying a new wafer and bag. The resident’s family member, who is the sister and Power of Attorney, reported that staff did not know how to provide urostomy care, did not clean the bag, and that the bag smelled. She stated the facility was supposed to check and empty the urostomy bag every two hours and replace it every three days, and that she supplied and labeled the ostomy supplies herself. Review of the March 2026 MAR showed that on 03/29/26 an LPN documented changing the urostomy bag in the morning. However, observation later that afternoon revealed the urostomy bag in place appeared soiled and stained a dirty yellowish brown, as seen by two surveyors and the family member, contradicting the MAR entry. The ADON confirmed that nurses should not document a task as completed if it has not been done.
Failure to Follow Posted Lunch Menu and Provide Planned Food Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned lunch menu for all 63 residents receiving meals from the dining room. The written menu for a specific date listed corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake for lunch. During observation of the meal service, staff were instead serving corn dogs, regular mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and no bread was provided. The yellow cake specified on the menu was not served. In an interview, the cook serving the meal acknowledged that the mashed potatoes were not prepared as cheesy potatoes and stated there was no particular reason for this change. The cook also stated that yellow cake was not available because it had not been made, so pudding was served instead, and confirmed that bread had been forgotten entirely. Later, the Corporate Dietary Manager reported she was not aware that cheesy potatoes and bread were not served, but she did know that pudding was substituted for yellow cake because the cake had not been prepared the night before, despite the facility having yellow cake in stock. Facility policy on menus required that menus meet residents’ nutritional needs, that appropriate substitutions be made and recorded when items were not available, and that substitutions be similar in nutritional value to the planned items.
Failure to Maintain Sanitary Kitchen Conditions and Safe Food Handling Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe and sanitary kitchen environment for all 63 residents who received meals from the kitchen. During a kitchen tour with the Corporate Dietary Manager, surveyors observed two large trash cans without lids, a utensil drawer containing scoops and ladles lying in a red, sticky substance, and a stainless-steel shelf under the steam table soiled with food and a yellow liquid. Three three-tiered red food carts were observed soiled with food debris and dried white liquid. In dry storage, several pieces of cardboard and paper littered the floor. In the refrigerator, surveyors found an unlabeled small stainless-steel pan with a white, hard substance, an open bag of lettuce with no date, a bag of bacon bits without an open date, and in a reach-in refrigerator, a large round container and three pitchers of red liquid with no dates or identifying labels. Two large tubs of rice crispy cereal were also not labeled with an open date. The Corporate Dietary Manager confirmed these observations during the tour. Surveyors also observed improper thawing and temperature control of ground beef. Two five-pound semi-frozen tubes of hamburger were initially seen soaking in warm water in a stainless-steel sink and later, at midday, still defrosting in stagnant cool water. Later in the afternoon, the same hamburger tubes were observed out of the water, sitting on the sink and cool to the touch. When a staff member took the temperatures in the presence of the Corporate Dietary Manager and Dietary Manager, one tube measured 57.8°F and the other 49.8°F. The Corporate Dietary Manager verified that these temperatures were not safe. Review of facility policies showed that food was to be received and stored to minimize contamination and bacterial growth, with repackaged food placed in appropriate containers labeled with contents and date, and that the Nutrition/Culinary Service Director was responsible for food safety, sanitation, and implementation and monitoring of a cleaning schedule. These observed conditions and practices were inconsistent with the facility’s written food safety and sanitation policies.
Failure to Knock Before Entering Resident Room During Medication Pass
Penalty
Summary
Facility staff failed to maintain resident privacy when an LPN entered the room of Resident #26 without knocking or waiting for permission during medication administration. Resident #26 had been admitted on an unspecified date with multiple diagnoses, including schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder. On 02/25/26 at 9:00 A.M., observation showed LPN #133 prepared medications for Resident #26 at the medication cart in the hallway and then walked directly into the resident’s room without knocking on the door. In an interview at that time, LPN #133 confirmed she had not knocked or waited for a response before entering, despite the facility’s written privacy policy stating that staff would provide residents with their right to privacy and security and would knock on doors for permission to enter. This deficiency affected one of five residents observed during medication administration and was identified through observation, medical record review, staff interview, and review of the facility’s privacy policy dated 06/19.
Failure to Maintain Safe and Well-Maintained Resident Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable bathroom environment for Resident #10, whose bathroom had two softball-sized holes in the wall where the baseboard was missing under the sink, exposing the interior of the wall. Resident #10 had been admitted with diagnoses including Alzheimer's disease, severe protein calorie malnutrition, peripheral vascular disease, hypertension, depression, chronic kidney disease, and left eye blindness, and the admission MDS documented moderately impaired cognition, no psychosis or behaviors, a need for setup or clean-up assistance with toileting, occasional urinary incontinence, and full bowel continence. On two separate observations, surveyors noted the same unrepaired holes in the bathroom wall. During interviews, the Director of Support Services stated he was unaware of the damage and acknowledged he did not conduct environmental rounds, and the Administrator confirmed the facility did not perform regular environmental rounds, instead relying on informal daily walk-throughs to notice needed repairs. This deficiency was cited under the resident’s right to a safe, clean, comfortable, and homelike environment, specifically related to maintaining the bathroom in a safe and comfortable manner, and was investigated under Complaint Number 2743199.
Failure to Timely Administer Post-Operative Ophthalmic Medications
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administering of prescribed ophthalmic medications for Resident #32 following cataract surgery. Resident #32, who had intact cognition and multiple medical diagnoses including macular degeneration and cataracts, underwent cataract surgery and received post-operative orders for Prednisone 1% ophthalmic drops once daily, Ketorolac Tromethamine 0.5% drops four times daily, and Moxifloxacin 0.5% drops three times daily to the left eye for specified durations. The resident reported he was to start eye drops two hours after surgery and had given the paperwork to staff. Review of the medication administration record showed that none of the ordered eye drops were administered on the afternoon and evening of the surgery date or the following morning. Interviews revealed multiple breakdowns in the medication process. The surgery office initially sent the prescriptions to the resident’s old pharmacy and later had them filled at the hospital pharmacy, with the lead nurse personally delivering the medications to the facility in the late afternoon. The DON stated the facility did not have the eye drops the night before and that the pharmacy was called to drop ship them the next morning. The resident later stated he had been told the drops were delivered around 4:00 p.m. the previous day but were not placed in the medication cart and could not be located. An LPN confirmed she had not administered the drops and was only going to do so once they were found. Another LPN verified the drops had been delivered the previous afternoon by the hospital pharmacy, but the staff member who received them placed them in the wrong medication cart, and the nurse on duty was unaware they had been delivered, resulting in the medications not being started as ordered until the following morning.
Infection Control Failures During Medication Administration and Handling of Soiled Linens
Penalty
Summary
The deficiency involves failures in infection prevention and control during medication administration and handling of feces-soiled linens. For one resident with schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder, an agency LPN was observed during a morning medication pass popping an Amlodipine 5 mg tablet directly from the medication card into her bare hand before placing it into a medication cup. When stopped and interviewed by the surveyor, the LPN confirmed she had touched the tablet with her bare hands and intended to administer it to the resident. In a separate observation, another resident with chronic kidney disease, atrial fibrillation, heart failure, depression, and cerebral infarction was receiving medications when an LPN poured an Aspirin 81 mg tablet from a bottle into her bare hand and then popped Carvedilol 25 mg and Eliquis 5 mg tablets from medication cards into her bare hand before placing all tablets into a medication cup. This LPN also verified during interview that she had handled the tablets with bare hands and planned to administer them. The deficiency also includes improper handling of feces-soiled linens for a resident admitted with chronic obstructive pulmonary disease, a solitary pulmonary nodule, anxiety disease, and respiratory failure. During the initial tour, the resident’s room door was open and a CNA was brushing the resident’s hair while a hand towel and a blue disposable pad, both heavily soiled with feces, were lying directly on the floor. During interview at that time, the CNA acknowledged that feces-soiled items should not have been placed directly on the floor without a barrier or in a plastic bag. Review of the facility’s Laundry Services policy dated 02/2022 stated that soiled linens should be handled as little as possible, with minimal agitation, and that all soiled linen would be bagged or placed in carts at the location where the resident was cared for, with linens saturated in blood or body fluids placed in a biohazard bag.
Failure to Timely Report and Communicate COVID-19 Outbreak and Implement Facility-Wide Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and accurate documentation and reporting of a COVID-19 outbreak, including delayed notification to residents’ responsible parties and the county health department, and incomplete facility-wide outbreak communication and testing. Three residents residing on the memory care unit, all with dementia or significant cognitive impairment and poor memory, tested positive for COVID-19. One resident tested positive on 01/02/26, and two additional residents tested positive on 01/03/26. Documentation showed that their responsible parties or families were not notified of the COVID-19 outbreak until 01/06/26 by the Social Service Designee, despite the earlier positive test results. Record review for 24 residents on the Buckeye Trail unit showed no documented evidence that facility-wide COVID-19 testing was implemented following identification of the outbreak, and no documentation that these residents or their responsible parties were notified of the outbreak. The Social Service Designee reported she was informed on 01/06/26 that the facility had determined there was a COVID-19 outbreak and that she notified residents and responsible parties on the Cascade and memory care units, but did not notify residents, responsible parties, or visitors for those on the Buckeye Trail unit. The Infection Control Preventionist stated that after learning of the first positive case, the facility tested residents on the memory care unit and identified two additional positive residents and one LPN, and that testing was conducted on two of the three nursing units, but not on the Buckeye Trail unit. The Infection Control Preventionist also stated she called the county health department to report the outbreak, while the county health department RN reported that the facility notified her of the outbreak on 01/07/26. The receptionist stated she had not placed any signage at the main entrance and had not been instructed by administrative or supervisory staff to do so, confirming there was no sign on the main entrance door during the outbreak. Two residents interviewed reported they were unaware of a COVID-19 outbreak in the facility and were not offered masks or other PPE, and one resident who frequently used the main entrance stated there were no signs posted to alert visitors or residents of the outbreak. Facility policy required outbreaks of COVID-19 to be reported to the county health department and state LTC bureau by the end of the next business day, and CDC guidance cited in the report called for broad-based testing in nursing homes during outbreaks, rather than limiting testing to close contacts.
Failure to Serve Dietitian-Approved Menus to Residents
Penalty
Summary
The facility failed to ensure that meals were served according to the dietitian-approved menu, affecting multiple residents and potentially all residents who consumed meals at the facility. Observations and interviews revealed that several residents did not receive all components of the prescribed meals, such as milk and cereal, despite these items being listed on the approved menus and required by the meal tickets. Staff confirmed that unless the meal tickets specifically indicated certain items, such as milk or cereal, these were not provided, even though the menu required them. This practice was confirmed by both the Dietary Manager and the Administrator. Several residents with significant medical histories, including dementia, malnutrition risk, and other chronic conditions, were directly impacted. For example, one resident at risk for malnutrition and with recent weight loss did not receive milk or cereal as required by the menu. Another resident, who was malnourished and required finger foods and health shakes, did not receive all menu items, including cereal and milk, during observed meals. Similar deficiencies were observed for other residents, including those with Alzheimer's disease, multiple sclerosis, and other serious diagnoses, who did not receive the full menu as approved by the dietitian. Additionally, there were instances where the meals served did not match the menu due to substitutions or omissions, such as serving a taco instead of a cheeseburger or omitting buttered carrots from a lunch meal. Staff interviews indicated that some menu items were not provided due to budget constraints or lack of clarity on meal tickets. The dietitian and dietary staff confirmed that the approved menus were not consistently followed, and some residents did not have completed nutritional assessments or care plans at the time of the survey.
Laundry Handling and PPE Deficiency
Penalty
Summary
The facility failed to ensure the safe handling, transport, and separation of laundry to minimize exposure to contaminated items. During observation of the laundry area, an open laundry cart contained bags of soiled linen and a trash can was labeled for resident personal laundry, but there were no bins or carts marked for laundry from isolation rooms or for linen heavily soiled with blood or bodily fluids. A box of vinyl exam gloves was observed between two washing machines, and no other PPE was readily available for rinsing or sorting laundry. The laundry aide stated she did not know whether gowns, masks, goggles/face shields, or rubber gloves were available for handling contaminated laundry and said she had never worn a gown or eye protection to sort or rinse contaminated linen. Interviews with CNA staff and the Director of Support Services indicated the facility had previously used red biohazard bags for contaminated linen from isolation rooms, but those bags had not been seen on the unit for a while. Staff reported no education on handling soiled linen differently when it came from an isolation room or was contaminated with blood or bodily fluids, and the Director of Support Services stated laundry staff would not be able to recognize heavily contaminated laundry and were not trained on a specific protocol for gown, mask, or eye protection use. Observation of the soiled laundry room later showed the laundry cart overflowing with unbagged soiled linen, including items with brownish stains and linen hanging over the side of the cart. The laundry aide was observed sorting loose soiled items while wearing only vinyl gloves and a long sleeve shirt/jacket, with soiled linen touching her arms and front of her body, and she confirmed she had no gown and no knowledge of rubber or non-porous gloves for heavily soiled laundry. The ADON confirmed soiled linen should be bagged before leaving resident rooms and that linen soaked with blood or bodily fluids should be placed in a red bag for transport to the laundry room. The facility policy also stated soiled laundry was to be bagged at the point of care and that protective barriers such as fluid resistant gowns or aprons, gloves, masks, and face protection should be readily available and used by laundry personnel. This deficiency was identified as continued non-compliance from the prior survey.
Failure to Prevent Accidents, Unsafe Transfers, and Inadequate Smoking Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with a history of alcohol abuse, depression, anxiety, and moderate cognitive impairment, residing on a secured memory care unit, was assessed as a moderate elopement risk and had care plans and physician orders in place for frequent monitoring and a wander guard. Despite these interventions, the resident was able to elope by dislodging screws from a window, climbing out, and leaving the premises undetected. The resident was missing for several hours before being located at a family property four miles away. Observations after the incident revealed that the window in the resident's room could still be fully opened, and screws intended to prevent this were not in place. Another deficiency involved the unsafe and undignified transfer of a resident with Alzheimer's disease and severe cognitive impairment. A CNA was observed on video roughly transferring the resident from a wheelchair to a bed, lifting the resident under the arms and throwing the resident's legs onto the bed, resulting in an audible thump and a verbal expression of discomfort from the resident. The incident was reported by the resident's family, who had video evidence from a camera in the room. Although no injuries were found on assessment, the transfer was confirmed by the DON to be inappropriate and not in accordance with facility policy, which requires cooperative and safe transfer techniques. Additionally, the facility failed to implement proper smoking procedures for five residents. During a supervised smoking break, residents were observed without access to appropriate ashtrays, flicking ashes onto the ground, and handing lit cigarettes to staff for disposal. Cigarette butts were found scattered throughout the courtyard, including in non-combustible trash cans and among dried leaves. One resident with severe visual impairment and motor/dexterity concerns was not provided with a clothing protector during smoking, and the smoking safety assessment did not accurately reflect the resident's needs. Staff supervising the smoking break reported a lack of formal training on safe smoking protocols, and the facility's policy requiring fire blankets and approved ashtrays was not followed.
Conflicting Advance Directive Documentation
Penalty
Summary
The facility failed to ensure resident advance directives matched across paper charts and the electronic medical record (EMR) for four residents reviewed. The report identified conflicting or missing code status documentation for Residents #8, #12, #32, and #42, and the facility policy required advance directives to be completed on admission and verified during reassessments and quarterly care planning, with code status recorded in physician orders and DNR orders signed by a physician before being considered valid. Resident #12 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, bilateral cataracts, seizures, and protein-calorie malnutrition. The paper chart contained a bright yellow sheet showing full code, while the EMR showed DNR-CC with a signed date and the same status appeared in the EMR status bar and care plan. A hospice facsimile also showed DNR-CC, but the hospice binder did not contain an advance directive. An LPN reviewed both records and confirmed the paper chart and EMR did not match, and the DON was informed of the discrepancy. Resident #42 had diagnoses including heart failure, protein-calorie malnutrition, Wernicke's encephalopathy, and alcohol abuse. The paper chart showed no advance directive, while the EMR showed DNR-CCA and the care plan also listed DNR-CCA. Resident #32 had a signed DNR-CC form and DNR-CC orders, but the hard chart still contained a FULL CODE page under advance directives. Resident #8 had a DNR-CC order in the hard chart and EMR, but the EMR also contained two active, conflicting code status orders: one for full code that was signed by a provider and one for DNR-CC that had not yet been signed. Staff confirmed the conflicting documentation, and the DON stated that because the last signed order was full code, CPR would have to be initiated until a signed order stating otherwise was obtained.
Failure to Record and Monitor Resident Weights
Penalty
Summary
The facility failed to ensure resident weights were recorded and monitored to meet nutritional needs for four residents reviewed for nutrition. The deficiency involved Residents #5, #38, #59, and #63, all of whom had diagnoses or care plan concerns related to malnutrition, dementia, diabetes, dysphagia, kidney disease, or other conditions affecting nutritional status. The facility policy stated residents were to be weighed and monitored at least monthly, with new admissions weighed within 24 hours, then weekly for four weeks, and monthly thereafter. For Resident #5, the record showed an admission diagnosis of severe protein-calorie malnutrition and a physician-prescribed weight gain program with a mechanically altered diet. The physician orders did not include a weight order, and the monthly weight record showed no weight for October 2025. Nursing progress notes did not show any documented weight refusal for that month. The RD stated she monitored weights remotely and confirmed Resident #5 did not have a weight obtained in October 2025. For Resident #38, the record showed severe cognitive impairment, a recorded weight of 108 pounds on one date and 170.2 pounds on another date, with no admission weight listed. The admission nutrition assessment was started but not finished, and the summary section listed the last known weight as 170 pounds from the hospital. Nursing progress notes did not show evidence of an admission weight, a reweight request, or documentation addressing the discrepancy between the two recorded weights. For Resident #59, the record showed severe cognitive impairment, malnutrition, dysphagia, and a mini nutrition assessment indicating decreased food intake and weight loss, yet no weight was recorded for October 2025 and no refusal was documented. For Resident #63, the record showed diagnoses including unspecified protein-calorie malnutrition, no nutrition care plan, no order for weights, an admission weight of 154 pounds, no October 2025 weight, and a later weight of 150.6 pounds. The RD confirmed that if a weight was not obtained, it would not appear on the weight report and weight trends could be missed.
Inadequate Night Staffing on Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate staffing was provided for the memory care unit, affecting 20 residents on that unit. On observation at 6:56 A.M., no staff were present on the memory care unit after a tour was completed. Two residents were sleeping in chairs in the common area, and another resident was sleeping in a chair in the kitchen area, while the remaining residents were observed in their rooms in bed. At 7:02 A.M., an LPN coming on shift stated she had not seen any night staff walking onto the unit and had not yet received report, and confirmed staff should have been on the unit. Review of time punches showed a CNA worked from 6:44 P.M. until 7:03 A.M. The CNA stated she left the memory care unit at 6:50 A.M. to assist another resident outside the unit because the resident requested no male aide care, and she was off the unit for about 10 minutes before returning to get her coat and leaving shortly after 7:00 A.M. She also stated there is usually just one aide on the memory care unit during the night shift and the nurse splits time with another unit and checks the unit periodically. An LPN who covered both the Buckeye Unit and the memory care unit stated she had last been on the memory care unit around 6:45 A.M. before leaving to assist someone else and was not aware the CNA had left the unit. Interviews with staff on 12/03/25 and 12/04/25 consistently confirmed that the memory care unit usually had only one CNA on night shift, that staff did not have walkie talkies, and that they relied on the unit phone or personal phones to request help when no one was at the desk. The ADON confirmed there were supposed to be two people back on memory care at all times and that staff should not have left the unit unattended. The DON stated the facility used PPD and census for staffing, usually had one CNA on memory care at night, and confirmed the facility assessment did not specify staffing levels for the different units or levels of care. Review of the BIPPA and the facility policy on contingency staffing did not identify specific staffing levels for memory care.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.14% during the survey period. Specifically, two medication errors were observed among 28 medications administered to residents. In one instance, a resident with a history of alcohol abuse, depression, and anxiety, and exhibiting moderate cognitive impairment, was prescribed 75 mg of Sertraline (Zoloft) to be administered in the morning. However, the LPN administered only 25 mg, which was confirmed by both observation and subsequent interview with the nurse involved. In another case, a resident with diagnoses including alcohol abuse, muscle weakness, and difficulty walking, and also exhibiting moderate cognitive impairment, was prescribed Thiamine 100 mg daily. During medication administration, the LPN failed to administer the ordered Thiamine, despite documentation indicating it had been given. The DON later confirmed that the Thiamine was not administered as ordered and was located on another medication cart. These events were verified through record review, direct observation, and staff interviews, demonstrating non-compliance with the facility's medication management policy.
Missed Care Conference Meetings
Penalty
Summary
The facility failed to ensure Resident #15 was offered a care conference meeting quarterly or as needed. Resident #15 was admitted on 02/12/25 with diagnoses including acute congestive heart failure, anxiety disorder, and pyogenic arthritis. The record showed MDS assessments completed on 02/12/25, 02/18/25, 05/21/25, 08/21/25, and 11/20/25, and the quarterly MDS dated 11/20/25 indicated the resident was cognitively intact. Care plan meeting assessments were documented on 2/25/25, 3/25/25, 5/27/25, and 7/23/25, and the 07/23/25 form showed the resident attended. During interview on 12/03/25, the Social Service Designee verified the facility missed at least one care conference meeting with Resident #15 and stated the resident's last care conference was 07/21/25. The SSD also stated she had been covering Activity Director duties since February 2025 along with her SSD/Marketing responsibilities, and that resident lists due for MDSs were given to the receptionist to send letters to family and resident. The facility policy stated every effort would be made to schedule care plan meetings to accommodate the availability of the resident and family or responsible party.
Unnecessary antipsychotic use and incomplete monitoring
Penalty
Summary
The facility failed to ensure an antipsychotic medication was prescribed only for an approved indication and that the resident was monitored appropriately for side effects. Resident #9 was admitted with diagnoses including Alzheimer's disease, severe unspecified dementia with agitation, mild depressive disorder, PTSD, altered mental status, and other language and cognitive impairments. The annual MDS showed severely impaired cognition and mild depression with no behaviors, wandering, or rejection of care, yet the resident received high-risk medications including an antipsychotic, antidepressants, a diuretic, an opioid, and an anticonvulsant. Resident #9 had olanzapine (Zyprexa) ordered at 2.5 mg at bedtime, then increased to 5 mg at bedtime, despite psychiatric review notes showing no indication of schizophrenia, bipolar disorder, or acute mania and no documented failed antidepressant trials. Psychiatric assessment visits documented excessive worry and agitation, but no psychosis-related symptoms. The care plan identified psychotropic use for major depressive disorder and included monitoring and AIMS assessments, but only two AIMS assessments were completed, and the DON confirmed quarterly AIMS assessments had not been done between those dates. The psychiatric NP stated there were no supporting diagnoses for the antipsychotic and acknowledged it appeared to have been used for agitation in dementia.
Incomplete Comprehensive Care Plan for a Resident with Nutrition and ADL Needs
Penalty
Summary
The facility failed to ensure comprehensive care plans were completed for Resident #63, who was admitted on 09/12/25 with diagnoses including dementia with psychotic disturbance, unspecified protein-calorie malnutrition, paranoid schizophrenic, anxiety disorder, delusional disorders, and paranoid personality disorder. The 09/25/25 admission MDS 3.0 showed a BIMs score of 13 and indicated the resident required set up for eating and bathing, supervision for toileting, dressing, personal hygiene, and transfers. Review of the comprehensive care plan dated 10/15/25 showed no evidence of a nutrition care plan or an ADL care plan. During interview, the RD stated she does not complete resident care plans and said facility staff complete them, while the MDS RN stated she thought the RD completed nutrition care plans and was unaware the nutrition and ADL care plans were not completed. The facility policy stated the interdisciplinary team shall develop a comprehensive care plan for each resident within seven days of completion of the comprehensive assessment.
Failure to Provide and Document Scheduled Bathing
Penalty
Summary
The facility failed to ensure bathing was provided and documented for one resident who was reviewed for bathing. The resident was admitted on 06/13/24 and had diagnoses including paranoid schizophrenia, vascular dementia, schizoaffective bipolar type disorder, adult failure to thrive, unspecified protein-calorie malnutrition, and Alzheimer's dementia. The quarterly MDS dated 10/30/25 showed a BIMs score of 9, indicating moderate cognitive impairment, and the ADL section indicated the resident was independent for bathing. The care plan, last reviewed on 10/31/25, noted a phobia of water and a request for no showers, with interventions to offer non-water hygiene products and provide a sponge bath when a full bath or shower could not be tolerated. The resident's shower task scheduled bathing for Tuesday and Saturday nights, but the facility shower schedule listed only one bathing day per week and did not specify day or night shift. Review of shower sheets from September through November 2025 showed multiple documented refusals and only 21 bathing opportunities documented out of 26 opportunities, with bathing completed on some dates and refusals on others. During observation on 12/01/25, the resident was sitting in the common area and appeared to have greasy hair that did not appear to have been recently combed. Interviews with an LPN and the ADON confirmed residents were supposed to receive showers twice weekly and that staff were to complete shower sheets and document refusals in the medical record. The ADON also confirmed the memory care shower schedule listed only one day a week and the facility could not provide evidence of all scheduled bathing opportunities for the resident over the prior three months. The DON confirmed the facility did not have a specific bathing policy and stated it was the facility's policy to provide at least two showers per week.
Failure to Provide and Document Required Bathing
Penalty
Summary
The facility failed to ensure bathing was provided and documented for two dependent residents, both of whom required staff assistance with activities of daily living. Resident #14 was admitted with diagnoses including vascular dementia, altered mental status, transient cerebral ischemic attack, anxiety disorder, and unspecified protein-calorie malnutrition. Her quarterly MDS showed severe cognitive impairment with a BIMS score of 3, and her care plan indicated she needed staff assistance with bathing. During observation, she was sitting in the common area with stains on her clothes and greasy hair. The facility’s memory care shower schedule listed only one bathing day for her and did not identify a second day or shift, despite staff stating residents were to receive at least two showers weekly. Review of shower sheets for Resident #14 from September through November 2025 showed 16 completed bathing entries out of 26 bathing opportunities, and the facility could not provide evidence of all scheduled bathing opportunities. CNA staff stated she usually did not refuse showers and that she received showers on day shift, while another CNA confirmed the schedule did not list a second shower day. The ADON confirmed staff were to provide at least two showers weekly, complete the shower sheet each time, and document refusals in the medical record, but also confirmed the memory care shower schedule listed only one day per week for each resident and that the facility could not provide evidence of all bathing opportunities for the past three months. Resident #63 was admitted with diagnoses including dementia with psychotic disturbance, paranoid schizophrenia, and delusional disorders. Her bathing task did not specify a date or shift, and her care plan contained no ADL care plan. The memory care shower schedule listed Monday as a shower day but did not identify a second day or shift. Shower sheets showed 12 bathing opportunities offered out of 22 since admission, including one refusal, and an observation found her walking on the unit with visibly dirty clothes and greasy, uncombed hair. Staff stated residents were supposed to receive showers twice weekly and that refusals should be documented on the shower sheet and in the medical record, while the ADON and DON confirmed the facility’s practice was to provide at least two showers per week and that the facility lacked evidence of all scheduled bathing opportunities for the resident.
Pharmacy Recommendations for Diclofenac Gel Not Addressed
Penalty
Summary
The facility failed to ensure pharmacy recommendations were addressed in a timely manner during monthly drug regimen review, including review of the medical chart and irregularity reporting per facility policy. This affected two residents reviewed for unnecessary medications. Resident #6 had diagnoses including COPD, chronic kidney disease, depression, anemia, anxiety, heart failure, and hypertension, and was on hospice services. Her order for diclofenac sodium external gel 1% to the knees every six hours as needed for pain did not include a dose, and a pharmacy recommendation dated 08/18/25 requested that a dose be provided. The DON verified that the diclofenac gel order did not list a dose and that the recommendation was not addressed timely. Resident #10 was admitted with diagnoses including a right ileum fracture, muscle weakness, gait and mobility abnormalities, severe protein-calorie malnutrition, COPD, venous insufficiency, major depressive disorder, anemia, neuropathy, and acute pain related to trauma. Her order for diclofenac sodium external gel 1% to the lower back twice daily for pain also did not include an ordered amount to apply. Pharmacy recommendations dated 09/22/25, 10/16/25, and 11/20/25 each requested that a dose be provided, but the facility did not respond on the first recommendation and later added handwritten notes without date or signature on the subsequent recommendations. The DON confirmed no medication order changes were made and that the recommendations were not forwarded to the physician or NP for review or action because they were labeled to nursing staff.
Failure to Provide Ordered Double Portions
Penalty
Summary
The facility failed to ensure food was provided according to a resident’s preference for double portions. Resident #42 was admitted with diagnoses including heart failure, unspecified protein-calorie malnutrition, Wernicke’s encephalopathy, and alcohol abuse. His physician ordered a regular diet with no lactose and double portions, and the resident was cognitively intact and independent with eating. However, nurses’ notes from admission through 12/02/25 did not mention the double-portion preference at meals. The resident stated he was not receiving double portions at meals and said this began three days after admission. During observation, his breakfast tray contained coffee, grape juice, oatmeal, one hard-boiled egg, and one piece of toast, while the tray card listed only a regular, lactose-free diet with coffee and orange juice and did not note double portions. The CNA confirmed the breakfast items did not constitute double portions and was unaware of the double-portion order, and the DON confirmed the tray card did not reflect the resident’s preference for double portions and that the breakfast tray did not provide them.
Failure to Verify New Staff on the Nurse Aide Registry
Penalty
Summary
The facility failed to implement its abuse prevention policy and procedure by not ensuring new staff were checked on the Nurse Aide Registry (NAR) as required. Review of personnel files showed no evidence of NAR search results for Certified Occupational Therapy Assistant #836, Dietary Manager #820, Director of Nursing, and Licensed Practical Nurse #803, despite each having a documented start date in the facility. During interview on 12/02/25 at 2:12 P.M., the DON verified that the personnel records did not contain evidence of NARs for these staff members. Review of the facility’s policy titled Abuse, Neglect, and Exploitation (ANE) Prohibition, revised 10/2024, showed that the facility screened potential employees for a history of abuse, neglect, or mistreatment of residents through licensure verifications and misconduct registry as required by applicable state or federal regulation.
Employee Physical Screenings Not Completed Properly Before Hire
Penalty
Summary
The facility failed to complete employee physical screenings prior to employment. Review of personnel files showed that the DON, an LPN, two CNAs, a Certified Occupational Therapy Assistant, and the Dietary Manager all had hire dates documented, but their physicals were not signed or dated by appropriate personnel. The report states that the physicals were not signed or dated by appropriate personnel for each of these six employees. During interview, the HRD stated she had been on medical leave from 09/12/25 through 11/19/25 and was only in the facility on Mondays, Wednesdays, and Fridays. She explained that physicals were completed at orientation, with a facility nurse obtaining height and weight, the employee completing the form, and the form then reviewed and signed by the CNP during weekly visits. The HRD verified that the six physicals were not signed or dated by appropriate personnel. Facility policy titled Employee Health Screening, revised June 2025, required all employees to complete a pre-employment physical examination and specified that the exam must include the date of examination and the name and credentials of the healthcare professional completing the review.
Facility Assessment Not Unit-Specific
Penalty
Summary
The facility failed to ensure its facility assessment was comprehensive as required. Review of the assessment dated [DATE] showed that the acuity section listed different examples of care areas but did not differentiate them by unit, and the services provided section listed various general care areas without unit-specific differentiation. The Full Time Employees (FTEs)/Contractors required section identified seven FTEs for RNs, 16 FTEs for LVNs, and 33 FTEs for CNAs, but did not specify how many FTEs were needed per shift or how many of each staff type were needed per unit. The staff considerations by unit section stated that day shift is typically staffed with a charge nurse and CNA coverage and that night shift is typically staffed with a charge nurse and CNA coverage, with staffing levels varying based on patient acuity, census, and staffing variables. During interview, the DON confirmed the facility assessment was not specific to par staffing levels and did not differentiate between the different units and levels of care as required.
Failure to Maintain Safe and Sanitary Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain resident rooms in a safe and sanitary condition, affecting six residents. Specific findings included numerous stains on carpets and chairs, strong odors, dirty toilets, and the presence of brown stains and debris in multiple rooms. In some cases, bedpans with brown stains were found on the floor, and residents' personal items, such as wheelchairs and medical equipment, were improperly stored. Sticky floors, dirty and dusty floorboards and walls, holes and dents in walls, and missing drawers and cabinet handles were also noted. Moldy food, dirty dishes, and evidence of flies were present in some rooms, and in one instance, a resident reported not having clean clothes for several days, with their closet blocked and containing dirty clothing. These observations were confirmed through interviews with facility staff, including the Administrator, CNAs, and the DON. The unsanitary conditions extended to kitchen areas, where dried liquid stains, food debris, and black dirt were found around sinks and refrigerators. In several cases, moldy food was discovered and removed only after being pointed out by surveyors. Residents reported infrequent cleaning, and staff confirmed the presence of dirt, dust, and debris. The findings were substantiated under a specific complaint investigation, indicating a pattern of inadequate environmental maintenance and failure to provide a clean, safe, and homelike environment for residents.
Failure to Provide Therapeutic Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide therapeutic activities in the secured memory care unit to meet the physical, mental, and psychosocial well-being of all 18 residents in that unit. Observations over several weeks revealed that scheduled activities were not consistently implemented, with residents often sitting in common areas with minimal engagement, such as a single television being on or music playing. The activity calendar was frequently not followed, and some planned activities, such as crafts, manicures, and basketball trivia, were either delayed, substituted, or not conducted at all. Staff interviews confirmed uncertainty about why activities were not occurring as scheduled and acknowledged that there were not enough activities, especially for residents unable to leave the secured unit. The physical environment in the common area was not conducive to social interaction, with chairs arranged in a way that limited conversation among residents. Some residents were taken off the unit for activities like bingo, but those who could not leave had no alternative activities provided. Staff also reported that items previously used for engagement, such as sofas, baby dolls, and cribs, had been removed. Despite having adequate supplies, the activity program did not meet the needs of the residents, and hydration or bathroom assistance was sometimes listed as an activity. The facility's own policy required meaningful, person-centered activities, but this was not being met according to observations and staff interviews.
Expired and Improperly Stored Medications and Supplies Found in Facility
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were properly labeled, unexpired, and stored according to policy and professional standards. During inspection of two medication storage rooms, two treatment carts, and two medication carts, multiple expired medications and medical supplies were found, including a bottle of Children's Flonase, Zyno Medical administration sets, Monject filter needles, ICU Medical sterile caps, and Assure blood glucose control solutions. Additionally, opened and unsecured wound care supplies such as DermaRite xeroform gauze, hydrogel gauze, and DermaGinate/AG dressings were present in the treatment carts. These findings were verified with the Assistant Director of Nursing and the Director of Nursing at the time of observation. Review of the facility's policy confirmed that expired or unsecured medications and supplies are to be removed and destroyed according to procedure. However, the presence of expired and opened items in medication storage areas and carts indicated non-compliance with these policies. The deficiency had the potential to affect all residents served from the affected storage rooms and carts, as these areas are used for medication and treatment supply storage throughout the facility.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at appetizing and safe temperatures, as required by their Nutrition Services Policy. Observations and interviews revealed that residents who typically eat meals in their rooms often received food that was not warm. A test tray plated and delivered to a hall was found to have food items below appropriate temperatures, with pasta measured at 122.4°F and raspberry applesauce at 61°F. The pasta was described as lukewarm, though both items tasted appetizing. These findings were confirmed by the Dietary Manager, who acknowledged awareness of issues with cold food. Resident Council minutes documented complaints that CNAs only passed trays to their assigned residents, resulting in food sitting for extended periods before being served. There was no evidence of resolution to these complaints in subsequent council minutes. The Dietary Manager and Administrator confirmed that it took over 20 minutes to pass out 13 trays, and despite efforts to expedite the process, there was a lack of urgency among staff. The facility's policy required food temperatures to be maintained at acceptable levels during all stages of food handling, but this was not achieved, affecting nearly all residents except one who was not receiving food by mouth.
Failure to Follow Infection Control Procedures During Resident Care
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices affecting three residents. For one resident with dementia, dysphagia, and an ostomy, Enhanced Barrier Precautions (EBP) were ordered, requiring the use of gloves and gowns during high-contact care. Despite an EBP sign on the door, staff were observed changing the resident’s leaking ostomy bag while only wearing gloves, not gowns as required. The resident’s hospital gown was stained and wet from the leak, and the call light was out of reach, with the resident reporting not being changed in two days. The unit manager acknowledged not wearing a gown during the procedure, contrary to facility policy. In another instance, two CNAs provided incontinence care to a resident with diabetes and myelitis without cleaning the bedside table or placing a barrier before setting down supplies. During care, a pack of wipes was placed directly on the resident’s bed, and one CNA changed gloves without performing hand hygiene. For a third resident with a history of sepsis and multiple comorbidities, an LPN performed wound care without cleaning the bedside table or using a barrier before placing supplies, which was confirmed in interview. These actions were inconsistent with the facility’s infection control policies, which require hand hygiene, proper glove use, and clean surfaces or barriers for supplies during resident care.
Failure to Provide Adequate Nutritional and Communication Assistance
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, dysphagia, and severe cognitive impairment, did not receive adequate assistance with activities of daily living (ADLs), specifically related to nutrition and communication. The resident's care plan indicated a risk for malnutrition and required staff to provide assistance with all meals, snacks, and supplements, as well as to use communication tools and gestures the resident could understand. However, observations revealed the resident struggled to open a milk carton, was unable to use adaptive utensils, and resorted to eating with her hands. Staff only became aware of the need for assistance after surveyor intervention, and no communication tools were present in the resident's room or at bedside during multiple observations. Interviews with staff confirmed that the resident was sometimes unable to feed herself and was difficult to understand, yet no communication aids were available to facilitate interaction. The facility's policy required necessary care to be provided to residents unable to perform ADLs independently to ensure proper nutrition, but this was not consistently implemented for the resident in question. The deficiency was substantiated through record review, direct observation, and staff interviews, demonstrating a failure to provide the required nutritional and communication assistance.
Failure to Administer and Document Blood Sugar Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that blood sugar monitoring was performed as ordered for Resident #55, who had diagnoses including heart failure, type 2 diabetes, atrial fibrillation, and low back pain. The resident had a physician's order for a Dexcom G7 Sensor to monitor blood sugars every ten days. Review of the Medication Administration Record (MAR) showed that the sensor was not administered on several occasions, including a period from 08/20/25 to 09/18/25, and there were blank entries and missed documentation regarding administration. Additionally, there was no documentation in the progress notes indicating any further attempts to administer the sensor during this time. The Director of Nursing confirmed these findings. Facility policy required medications to be administered as ordered, recorded on the MAR, and for explanatory notes to be entered if a medication was not given, which was not followed in this case.
Failure to Ensure Timely Ophthalmology Follow-Up for Severely Impaired Vision
Penalty
Summary
A resident with multiple diagnoses, including chronic diastolic heart failure, type 2 diabetes mellitus, morbid obesity, asthma, insomnia, major depressive disorder, dry eyes syndrome, and bilateral age-related cataracts, was admitted to the facility and assessed as having severely impaired vision. The resident was alert, oriented, and cognitively intact. Medical records showed that the resident was seen by an eye care consultant, who recommended a follow-up with an ophthalmologist for cataract evaluation. Despite this recommendation, the resident reported being unable to see due to cataracts and stated that cataract surgery had been recommended but no appointment had been scheduled. Facility staff documented attempts to contact eight ophthalmologist offices, noting difficulties in finding a provider who accepted the resident's insurance and could accommodate bariatric patients, but there was no evidence that an appointment was ultimately scheduled.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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 Cuyahoga Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bath Creek Estates | 0.8 mi | ★★★★★ | 2 | 0 |
| Altercare Of Cuyahoga Falls Ctr For Rehab & Nursin | 1.4 mi | ★★★★★ | 0 | 0 |
| Falls Village Skilled Nursing & Rehabilitation | 2.1 mi | ★★★★★ | 0 | 0 |
| Wayside Farm Inc | 2.6 mi | ★★★★★ | 1 | 0 |
| The Pavilion At Stow For Nursing And Rehabilitatio | 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.