Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Darby Glenn Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Honor Vegetarian Food Preferences: A resident with malnutrition, severe cognitive impairment, and a vegetarian diet order was not consistently served a nutritious vegetarian meal. Meal observations showed trays without an identified vegetarian entree or alternate protein, and the resident stated she did not like what was served. The DM said vegetarian protein substitutes included items such as yogurt or PBJ, but was unaware the resident disliked yogurt and stated dietary would not know unless nursing informed them.
Pain management was not fully documented for three residents. PRN opioid and other analgesic medications were given without documented attempts at non-pharmacological interventions, and for two residents there were no documented pain descriptions before PRN administration. Care plans and orders for the residents included pain-related interventions, but progress notes and MAR entries did not show the required pain details or non-medication measures before PRN use.
PRN pain meds were administered without clear parameters for when to use one analgesic versus another. Three residents with diagnoses including cognitive impairment, dementia, and osteoarthritis had orders for multiple PRN pain medications, but the orders did not specify pain-level guidance. MAR review showed opioids and acetaminophen were given for varying pain scores, including some doses when the recorded pain level was zero. An LPN stated PRN pain meds were given based on resident preference or clinical judgment rather than a defined pain scale.
A resident's money was misappropriated by facility staff, as discovered through an investigation involving security footage from a nearby gas station. The resident, who had intact cognition, reported his wallet missing, leading to the discovery of an unauthorized ATM withdrawal. Three housekeepers were identified at the scene, with one using the ATM. Despite evidence, the staff denied involvement, and the police were notified.
The facility failed to maintain effective pest control in the kitchen, as observed with multiple flying insects around clean dishware, the handsink, and other areas. Despite policies requiring pest control, the kitchen was not serviced in June, and a callback order was made for flying ants, indicating a lapse in pest management.
A resident with multiple health conditions, including hemiplegia and diabetes, experienced discomfort due to her bed being set at an incorrect weight. Despite a physician's order for a low air loss mattress, the bed was set at 300 lbs instead of the appropriate 200 lbs. The resident expressed discomfort, and it was confirmed that the bed setting did not align with her weight, leading to the deficiency.
The facility failed to hold quarterly care conferences for several residents, including one who was cognitively intact and another who was bed-bound. Interviews revealed that the facility did not consistently initiate care conferences, and there was a lack of documentation and communication with residents and their families. Staff turnover contributed to these deficiencies.
A resident with a history of cerebral infarction and major depressive disorder, now in hospice care, was not provided with activities according to her preferences. Despite her enjoyment of activities like bingo and crafts, she was not invited to or did not attend these activities during June and July. The Activity Director acknowledged the oversight, and the resident reported insufficient assistance from staff to participate in activities.
A resident on anticoagulant medication noticed a bruise on his hand and informed an aide, but the nursing staff failed to document or assess it promptly. Despite the resident's concerns and communication with staff, there was no documentation of the bruise in the medical records, which was against the facility's wound assessment policy.
A facility failed to label and date a tube feeding bag for a resident with multiple health conditions, including COPD and diabetes. The resident received significant nutrition and hydration through tube feeding, as per physician orders. During an observation, a clear bag of tube feed was found without any label or date, which was confirmed by a Nurse Manager.
A facility failed to ensure medication error rates were below five percent when an LPN did not prime two insulin pens before administering doses to a resident. This resulted in a medication error rate of 6.25%, affecting a resident with multiple diagnoses, including type II diabetes mellitus.
A resident with type II diabetes and other chronic conditions did not receive properly primed insulin pens, leading to potential medication errors. An LPN administered insulin without following the manufacturer's priming instructions, which could result in incorrect dosing.
Failure to Honor Vegetarian Food Preferences
Penalty
Summary
The facility failed to ensure one resident received a nutritious vegetarian diet. The resident had diagnoses including moderate protein calorie malnutrition, hypertension, anemia, major depressive disorder, osteoarthritis, spinal stenosis, hyperlipidemia, constipation, polyneuropathy, and hypothyroidism. The care plan identified the resident as at moderate risk for malnutrition and noted that the resident followed a vegetarian diet related to cultural patterns, with interventions to honor food preferences as able and monitor the consistency of the diet served. The resident also had a severe cognitive deficit and required set-up assistance with eating. The resident’s physician order specified a vegetarian, mechanical soft diet, and the meal ticket listed vegetarian diet items along with a magic cup, fruit cup, coffee, beverage of choice, and whole milk. The resident disliked cheese, eggs, pasta, grapes, and butter. The weekly menu for the vegetarian diet listed a vegetarian entree, but no entree was identified. During lunch observation, the resident was served cheesy scalloped potatoes, carrots, pears, and a magic cup, with no alternate protein source on the tray. Later, the resident was served carrots, yogurt, a fruit cup, a magic cup, and a roll, and stated she did not like what she was served. The Dietary Manager stated vegetarian residents would receive protein replacements such as grilled cheese, PBJ, yogurt, or cottage cheese, and acknowledged being unaware that the resident did not like yogurt. The manager stated dietary would not know if the resident disliked something unless nursing informed them. The facility policy stated it would identify, honor, and accommodate each resident’s nutritional needs, cultural practices, religious beliefs, and personal food preferences.
Pain Management Documentation and Non-Pharmacological Interventions Not Provided
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were provided before as-needed pain medications were administered for three residents, and it failed to ensure pain descriptions were documented for two of those residents. The report states that Resident #1, Resident #5, and Resident #30 were reviewed for pain management, and the deficiency involved the lack of documented attempts at non-medication pain relief before PRN analgesics were given. The facility census was 93. Resident #30 was admitted with diagnoses including ataxia, mild neurocognitive disorder, anxiety disorder, and major depressive disorder, and had moderately impaired cognition. The care plan identified risk for altered comfort and included interventions such as administering medications as ordered, offering back rubs or warm blankets, offering nonpharmacological interventions, and providing quiet environment and rest periods. Orders included PRN acetaminophen, Roxicodone, and methocarbamol, each with instructions that nonpharmacological interventions were to be offered or attempted before medication administration. The MAR showed PRN Roxicodone and methocarbamol were administered on multiple dates, but progress notes contained no description of pain or documentation of attempted nonpharmacological interventions for those administrations. Resident #1 had diagnoses including parkinsonism, generalized anxiety disorder, psychotic disorder with delusions, unspecified dementia, gout, dysphagia, rheumatoid arthritis, and alcohol abuse, and the MDS indicated intact cognition. The care plan identified risk for altered comfort related to diagnoses and degenerative changes of the left hip and included interventions such as acknowledging pain, administering medications as ordered, repositioning for comfort, and offering nonpharmacological interventions. Orders included PRN Tylenol and oxycodone with instructions to offer or attempt nonpharmacological interventions before administration. The MAR showed multiple PRN oxycodone administrations and one acetaminophen administration, but progress notes did not document pain descriptions or attempted nonpharmacological interventions before those medications were given. Resident #5 had diagnoses including mild protein malnutrition, bipolar disorder, and restless leg syndrome, and received hospice services for terminal protein-calorie malnutrition. The MDS showed a BIMS of 7 and indicated cognitive impairment, scheduled and PRN medications, and no non-pharmacological interventions for pain. The care plan identified risk for altered comfort and included interventions such as administering medications, repositioning, offering back rubs or warm blankets, and offering non-pharmacological interventions. Orders included scheduled and PRN morphine sulfate concentrate, scheduled acetaminophen, and ropinirole, but there was no evidence in the orders to offer non-pharmacological pain interventions. The MAR and progress notes showed PRN morphine was administered on several dates, yet there was no documented evidence that non-pharmacological interventions were attempted before the PRN doses were given.
PRN Pain Medications Given Without Clear Administration Parameters
Penalty
Summary
The facility failed to ensure pain medication orders included parameters for administration for residents receiving multiple PRN analgesics. Review of the facility policy stated that when more than one pain medication is prescribed as needed, the nurse may consider factors such as the resident’s current pain level, medical condition, and current medication regimen. However, the records for three residents showed PRN pain medications were administered without documented parameters guiding when one medication should be used instead of another. Resident #30 had diagnoses including ataxia, mild neurocognitive disorder, anxiety disorder, and major depressive disorder, and was assessed as having moderately impaired cognition. The care plan identified risk for altered comfort and included pain assessment and nonpharmacological interventions. The resident had orders for acetaminophen for mild pain or discomfort, oxycodone for moderate pain or discomfort, and methocarbamol for pain, discomfort, or muscle spasms. The MAR showed oxycodone and methocarbamol were given on multiple occasions, including times when the recorded pain level was zero, and an LPN stated PRN pain medication was given according to resident preference rather than the pain scale. Resident #1 had diagnoses including parkinsonism, dementia, gout, dysphagia, rheumatoid arthritis, and alcohol abuse, and was documented as cognitively intact. The resident’s care plan addressed pain related to degenerative changes of the left hip, and orders were in place for acetaminophen as needed for pain or discomfort and oxycodone as needed for pain. The MAR showed repeated oxycodone administration for varying pain levels, including pain scores of zero and one, and acetaminophen was also given once for pain of six. Resident #66 had diagnoses including secondary malignant neoplasm of the prostate, benign prostatic hyperplasia, muscle wasting and atrophy, and primary generalized osteoarthritis, with normal cognitive function. The resident had PRN orders for oxycodone and acetaminophen without parameters, and the MAR showed oxycodone was given for pain level five and also once for pain level zero, while acetaminophen was given for pain level five. An LPN confirmed the resident was prescribed both medications PRN without parameters and stated staff used clinical judgment to decide which medication to give.
Misappropriation of Resident's Money by Facility Staff
Penalty
Summary
The facility failed to protect a resident's belongings, resulting in the misappropriation of money by facility staff. A resident with intact cognition and multiple diagnoses, including Parkinson's disease and dementia, reported his wallet missing. Upon investigation, it was discovered that his bank card had been used for an unauthorized ATM withdrawal at a nearby gas station. Security footage from the gas station identified three housekeepers from the facility at the scene during the time of the withdrawal. One housekeeper was observed using the ATM, while the others were present in the vicinity. Despite being confronted with the evidence, the housekeepers denied involvement. The police were notified, and the facility began an internal investigation. The resident's bank confirmed the unauthorized transaction, and the facility's administrator took steps to address the situation by suspending the involved staff. The resident's money was eventually returned, and the police continued their investigation into the theft.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to ensure that pests were not present in the kitchen, which had the potential to affect all 91 residents. During an observation on July 22, 2024, a flying insect was seen around the clean dishware storage, and four flying insects were observed near the windowsill by the handsink. The Dietary Supervisor confirmed the presence of these insects and mentioned that pest control would be contacted. Further observations on July 23 and July 25 revealed additional flying insects around the handsink, stand mixer, and juice machine in the kitchen. The facility's policies, including the 'Infection Control - Dietary/Food Handling' policy and the 'Pest Control Program' policy, require an effective pest control plan to be in place. However, a review of the pest control services over the past 12 months showed that the kitchen was not inspected or serviced in June, and a callback order was made on June 19, 2024, for flying ants. This indicates a lapse in the facility's pest control measures, contributing to the presence of pests in the kitchen.
Improper Bed Setting Causes Discomfort for Resident
Penalty
Summary
The facility failed to ensure that a resident's bed was set to the proper setting to ensure comfort, affecting one resident out of 18 reviewed for specialty mattresses. The resident, who had a history of cerebral infarction, type 2 diabetes mellitus, hemiplegia, and major depressive disorder, required maximal assistance for bed mobility and had a physician's order for a low air loss (LAL) mattress. Despite this, the resident's care plan did not include the special air mattress as an intervention for her risk of discomfort due to pain and hemiplegia. During an interview and observation, it was confirmed that the resident's bed was set at an incorrect weight of 300 lbs, while her actual weight was 132.6 lbs. The resident expressed discomfort, stating that the bed was too hard. The Maintenance Director later confirmed that the mattress should be set to a minimum of 50 pounds higher than the resident's weight, which would be 200 pounds in this case. After the bed weight was adjusted, the resident confirmed that her bed was much more comfortable.
Failure to Hold Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were held quarterly for several residents, as required. Resident #22, who was cognitively intact, had a care conference on 02/28/23, but no further conferences were documented despite being offered one on 10/04/23, which the resident declined. Resident #68's care conference was not held as scheduled on 10/11/23, and no phone conference was documented. The resident's family member reported that the facility did not initiate care conferences, requiring her to contact the facility for updates. Resident #79, who was cognitively intact, was not able to attend care conferences due to being bed-bound, and no conferences were documented despite attempts to contact the resident. Interviews with facility staff, including the Director of Nursing and Social Services, confirmed that care conferences were not held quarterly for the residents in question. The facility had experienced turnover in social workers, which contributed to the lapses in scheduling and documenting care conferences. The facility's policy required informing residents and their representatives of their right to participate in care planning, but this was not consistently implemented. The policy also outlined methods for notifying residents and representatives about care conferences, which were not effectively utilized in these cases.
Failure to Provide Activities per Resident Preferences
Penalty
Summary
The facility failed to provide and offer activities according to the preferences of a resident, identified as Resident #65, who was affected by this deficiency. Resident #65, who has a medical history including cerebral infarction, type 2 diabetes, anxiety, insomnia, and major depressive disorder, was admitted to hospice services and is moderately cognitively impaired. Her activity assessment indicated a preference for one-on-one and small group activities such as bingo, crafts, and social events. Despite these preferences, the resident was not invited to or did not attend any of her preferred activities, such as arts and crafts, bingo, or party/social hour, during June and July. Interviews and observations revealed that Resident #65 expressed a desire to participate in activities like bingo and coloring but was not scheduled for any activities. The Activity Director acknowledged that the resident's preferred activities were not offered, and she did not attend them. Additionally, the resident reported that direct care staff rarely assisted her in getting out of bed or taking her outside, which she enjoys. The facility's Program Planning/Scheduling policy requires the activity department to plan and schedule activities that are consistent with residents' wishes and needs, which was not adhered to in this case.
Failure to Document and Assess Resident's Bruise
Penalty
Summary
The facility failed to timely identify and assess a new skin impairment for a resident, which was a deficiency observed during the survey. Resident #62, who was cognitively intact and on anticoagulant medication, noticed a bruise on his hand the evening before it was reported. Despite the resident informing an aide about the bruise and expressing concern due to his anticoagulant therapy, the nursing staff did not document the bruise or assess it promptly. The resident was anxious about the bruise, fearing hospitalization due to his recent medical history, including complications from eye surgery. Interviews with the LPN and NP revealed that the bruise was not communicated effectively among the staff, and there was no documentation of the bruise in the resident's medical records. The Director of Nursing confirmed the lack of documentation and stated that the facility's policy required staff to document any skin impairments, including bruises, with detailed descriptions. The failure to document and assess the bruise was a clear deviation from the facility's wound assessment policy.
Failure to Label and Date Tube Feeding Bag
Penalty
Summary
The facility failed to ensure that a tube feeding bag was properly labeled and dated, affecting one resident. The resident, who was cognitively intact, had multiple diagnoses including chronic obstructive pulmonary disease, type two diabetes, and dysphagia, and was receiving more than 51% of their calories and over 501 milliliters of fluid intake per day through tube feeding. The physician's orders specified a tube feed of Diabetisource AC to be administered at 75 milliliters per hour for 22 hours daily. During an observation, a clear bag of tube feed was found hanging on a pole without any label or date indicating the type of solution or when it was hung. This was confirmed by a Nurse Manager, who acknowledged the oversight and stated she would discard the unlabeled tube feed.
Failure to Prime Insulin Pens Resulting in Medication Errors
Penalty
Summary
The facility failed to ensure medication error rates were not five percent or greater when staff did not prime two insulin pens for a resident. There were 32 medication administration opportunities with two errors, resulting in a medication error rate of 6.25%. This affected one resident who had multiple diagnoses, including type II diabetes mellitus, chronic congestive heart failure, and other conditions. The resident had physician orders for humalog kwikpen and lantus solostar insulin pens, which were not primed before administration by an LPN. Observations revealed that the LPN did not prime the insulin pens before administering the doses, and the LPN confirmed in an interview that she was unaware of how to prime the pens. Manufacturer instructions for both insulin pens indicate that priming is necessary to ensure accurate dosing and to remove air bubbles. Failure to prime the pens could result in the resident receiving too much or too little insulin. This deficiency was investigated under Complaint Number OH00153387.
Failure to Prime Insulin Pens Leads to Medication Error
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when staff did not prime two insulin pens for a resident. This incident involved a resident with multiple diagnoses, including type II diabetes mellitus, chronic congestive heart failure, and other chronic conditions. The resident had physician orders for humalog kwikpen and lantus solostar insulin pens, which required priming before each use to ensure accurate dosing. However, during an observation, an LPN administered insulin without priming the pens, leading to potential underdosing or overdosing of insulin. The LPN confirmed in an interview that she did not prime the insulin pens and was unaware of the priming procedure. The manufacturer's instructions for both insulin pens clearly state the importance of priming to remove air bubbles and ensure the pen is working correctly. Failure to prime the pens could result in the resident receiving too much or too little insulin, which could adversely affect their blood sugar levels. This deficiency was identified during a complaint investigation and affected one of the three residents reviewed for medication administration.
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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 Hilliard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norwich Springs Health Campus | 1.1 mi | ★★★★★ | 3 | 0 |
| Trueman Pointe Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Mill Run Care Center | 2.3 mi | ★★★★★ | 24 | 0 |
| The Sanctuary At Tuttle Crossing | 2.5 mi | ★★★★★ | 4 | 0 |
| Mayfair Village Nursing Care Center | 2.8 mi | ★★★★★ | 13 | 0 |
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