Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Daughters Of Miriam Center For Nursing & Rehabilit during CMS and state inspections, most recent first.
A resident experienced a delay in receiving his medical records due to the absence of the newly hired medical records staff, who went on vacation shortly after starting. The request, made on February 4, was not processed until February 24, when the resident paid the fee and received the records. The facility's policy to comply with HIPAA was not followed, resulting in the delay.
A resident with multiple medical conditions, including bladder and bowel incontinence, did not receive proper perineal care as per facility policy. During an observation, a nurse failed to cleanse the resident's front genital area, which was confirmed by the nurse and the DON. The facility's policy requires cleaning the front perineal area first, followed by the buttocks, to ensure cleanliness and comfort.
A facility failed to secure and store medications appropriately, affecting a resident who was left with a medicine cup containing 6 1/2 pills on their overbed tray. The resident confirmed these were their morning medications, which a nurse had left for them to take. A supervisor LPN and the DON verified that medications should not be left unattended in a resident's room, and the responsible LPN admitted to leaving the medications at the bedside.
A facility failed to document the confirmation of a resident's death by an RN, as required by policy. The resident, with a complex medical history, was found deceased by an LPN who informed the Nursing Supervisor. However, the medical record lacked the RN's confirmation of death, which was a requirement according to the facility's documentation policy.
A resident with Alzheimer's and other medical conditions did not receive proper assistance with activities of daily living. Observations showed the resident was improperly dressed, had a full incontinence brief, and received inadequate incontinence care. The CNA used the same washcloth for different areas, and the wheelchair was not disinfected. The resident's hands were not washed until prompted, and their fingernails were excessively long. The DON confirmed the issues, and the care plan was revised to require a stand-up lift for transfers.
A resident with multiple health conditions did not receive necessary interventions for constipation due to staff's failure to follow the facility's bowel protocol. Despite being on the protocol, the resident did not have a bowel movement for five days, and staff were unaware or did not act on the protocol alerts. The facility's policy required specific interventions, which were not administered, leading to a deficiency finding.
A resident with a history of falls and fractures experienced an unwitnessed fall, resulting in a right femur fracture. Despite complaints of pain and visible swelling, the facility delayed obtaining and acting on x-ray results, leading to a lack of timely medical intervention. The resident expired shortly after, unrelated to the fracture, following unsuccessful CPR and EMS intervention.
A resident's pressure ulcer worsened significantly due to the facility's failure to assess and treat the wound promptly upon re-admission from the hospital. Despite being at high risk for pressure ulcer breakdown, wound care orders were delayed, and multiple treatments were missed. Interviews with staff confirmed the lack of timely wound care, and the facility's policy lacked specifics on intervention initiation and tracking.
The facility failed to implement a comprehensive fall prevention program, resulting in harm to a resident who sustained fractures after an unwitnessed fall. Despite a care plan intervention, there was no evidence of monitoring. Additionally, another resident was unsafely transferred using a Hoyer lift by a single CNA, contrary to policy requiring two staff members.
The facility failed to prepare and serve menu items as planned, affecting meal service for residents. During lunch, vegetables and pureed grilled cheese were not served as required, and during breakfast, a resident did not receive the expected eggs, yogurt, and banana. A CNA confirmed discrepancies, and residents reported frequent mismatches between their meals and the menu or meal tickets.
The facility failed to provide palatable and properly temperature-controlled meals, as identified by the Dietary Director and confirmed through resident interviews and observations. Residents reported issues with meal quality, including overcooked and unappetizing food, leading to dissatisfaction and reliance on outside food.
The facility failed to serve meals in a timely manner, affecting all residents. Observations and interviews revealed significant delays, with breakfast and lunch often served later than scheduled. Increased census and changes in serving processes contributed to the issue, and residents expressed a preference for dining room service. Staffing issues also hindered timely meal delivery.
The facility failed to ensure kitchen staff followed proper food safety protocols, affecting meal safety for 159 residents. A Mashgiach refused to wear a hair net, and a staff member improperly handled food and equipment, violating policies on handwashing, glove use, and equipment sanitation. These actions were confirmed by the Dietary Manager.
The facility failed to provide a dignified dining experience for several residents, including one with severe dementia who was left unattended with her meal. Loud music, not preferred by the residents, played during meals, and some residents experienced significant delays in receiving their meals. Staff interviews confirmed these issues, highlighting a lack of coordination and consideration for resident preferences.
The facility failed to follow proper puree preparation techniques for 17 residents requiring a puree diet. A staff member prepared food without consulting recipes, using excessive water and thickener, and added inappropriate chunky seasoning. Interviews confirmed these practices, and recipe reviews showed deviations from the correct preparation methods.
The facility failed to notify physicians in a timely manner about changes in condition for two residents. One resident, with a history of falls, experienced a fall and subsequent fracture, but the physician was not promptly informed due to incorrect contact information and delayed fax checks. Another resident missed a dialysis appointment due to transportation issues, and the medical provider was not notified, preventing necessary medical assessments. These deficiencies highlight lapses in communication protocols.
A resident's family raised concerns about missing dentures and requested medical records, but the facility failed to address these grievances in a timely manner. Despite a meeting with the family and consent for dental care, the facility did not resolve the issues, and the Administrator did not follow up on multiple communications from the family. The facility did not reimburse for the dentures and lost contact with the family after the resident's discharge.
Three residents in an LTC facility did not receive necessary assistance with meals, despite their care plans indicating they required help. A resident with severe dementia and dysphagia was left with minimal feeding assistance, consuming only 10% of her meal. Another resident, needing meal setup and supervision, was left unsupervised. A third resident, with multiple health issues, often did not receive full feeding assistance due to staff being unaware of her needs. Staff interviews confirmed these deficiencies.
A resident with multiple health conditions, including hemiplegia, did not receive prescribed treatments to maintain range of motion, such as a hand splint and PRAFO boot. Observations and interviews revealed the resident was not wearing these appliances, and staff were unaware of the orders. The facility's documentation errors led to the omission of these treatments from care tasks, resulting in a decline in the resident's condition.
A resident with multiple medical conditions, including dysphagia, did not receive appropriate care for their PEG tube. The facility lacked active physician orders for PEG tube site care, leading to inconsistent dressing changes and prolonged beeping of the feeding pump without timely staff intervention. Staff interviews revealed a lack of knowledge and adherence to the facility's PEG tube care policy.
The facility failed to provide adequate dialysis care for residents, with incomplete and inaccurate pre and post-dialysis assessments. A resident's records showed missing assessments and incorrect data, while another resident's documentation lacked vital signs and weights. Staff interviews revealed a lack of understanding of responsibilities, contributing to the deficiencies.
A resident with diabetes did not receive their prescribed insulin due to an LPN's incorrect decision to withhold it based on a blood sugar reading, despite no parameters for withholding being in the physician's order. The facility's policy requires medications to be administered as prescribed, which was not followed in this case.
The facility failed to maintain accurate medical records for three residents, including incorrect timestamps and missing documentation for falls and dialysis assessments. A resident's fall was inaccurately documented, leading to a hospital visit without a physician's order. Another resident's dialysis assessments were incomplete, with missing vital signs and weights. Additionally, discrepancies were found in the documentation of falls for a third resident.
A facility failed to maintain infection control standards during medication administration for a resident, where an LPN did not sanitize hands or use gloves, and her hair contacted the resident. In another case, an LPN did not wear a gown during PEG tube care for a resident, contrary to enhanced barrier precautions policy. These deficiencies were identified during a survey and involved non-compliance with the facility's infection control policies.
A medication cart was left unattended and unlocked in a hallway, with a resident and a family member nearby. An LPN confirmed the cart should have been locked, as per the facility's policy. This oversight had the potential to impact 40 residents on the unit.
The facility failed to adhere to menu production sheets, serving fewer food items and incorrect portion sizes, affecting residents' meals. Observations revealed discrepancies in the lunch tray line, with residents receiving fewer tacos and no cornbread, contrary to the menu. The Registered Dietitian justified the portion size based on protein content, but the menu was not updated to reflect these changes. Residents and their families expressed dissatisfaction with the food quality and service.
A facility failed to follow infection control protocols during medication administration. An LPN was observed placing medications into her bare hand instead of using a medication cup, contrary to the facility's policy. This affected a resident with multiple health conditions, including acute kidney failure and impaired cognition. The LPN admitted that medications should be placed into a medication cup.
The facility failed to provide timely employment verification for STNAs, resulting in their registry status being changed to expired. This was confirmed through a review of staff schedules, the nurse aide registry, and interviews. The Administrator acknowledged the delay in submitting employment verifications, potentially affecting all 150 residents.
The facility did not have daily nurse staffing information posted in a prominent place, affecting all 150 residents. An observation revealed the absence of staffing information, and the Administrator confirmed it should have been available at the front desk but was being printed.
Delay in Providing Medical Records to Resident
Penalty
Summary
The facility failed to ensure timely access to medical records for a resident, which affected one out of three residents reviewed for medical record access. The resident, identified as Resident #75, requested his medical records on February 4, 2025. However, due to a series of delays, he did not receive them until February 24, 2025. The delay was primarily caused by the absence of the newly hired medical records staff member, who went on vacation the day after starting her position and did not return until February 20, 2025. During this period, the request was not processed, and the resident was left waiting for his records. Interviews with the designated social worker and the administrator revealed that the request was not submitted for approval until February 24, 2025, the same day the resident paid the fee and received his records. The facility's policy on medical record requests, which aims to comply with HIPAA requirements, was not followed in this instance, leading to the delay. The administrator confirmed the timeline of events and acknowledged the oversight in processing the request promptly.
Improper Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide proper incontinence care for Resident #129, who was diagnosed with several conditions including COVID-19, dysphagia, cirrhosis of the liver, nontraumatic intracerebral hemorrhage, hemiplegia affecting the right dominant side, and sickle-cell disease. The resident was admitted with bladder and bowel incontinence, as noted in the care plan dated 12/10/24, which included interventions such as offering to toilet the resident at specific times and providing perineal care after each episode of incontinence. However, during an observation on 03/05/25, Wound Nurse #581 failed to cleanse the resident's front genital area during perineal care, which was confirmed by the nurse during an interview. The Director of Nursing (DON) confirmed that the procedure for perineal care was not followed correctly, as the facility's policy requires cleaning the front perineal area first, followed by the buttocks. The facility's policy, dated August 2009, emphasizes the importance of providing cleanliness and comfort through proper perineal care. This deficiency was identified during a complaint investigation under Complaint Number OH00161455, affecting one resident out of three reviewed for incontinence care, with a facility census of 152.
Failure to Secure and Store Medications Appropriately
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting one resident out of three reviewed for secured medications. On the morning of March 4, 2025, Resident #136 was due to receive several medications, including Amiodarone HCI, Jardiance, Metoprolol Succinate ER, Potassium Chloride ER, sodium chloride, Vitamin C, and Acyclovir. During an observation and interview at 11:52 A.M., it was found that a medicine cup containing 6 1/2 pills was left on Resident #136's overbed tray. The resident confirmed that these were his morning medications, which the nurse had left for him to take. Further interviews and observations confirmed the deficiency. At 12:03 P.M., a supervisor LPN verified that medications should not be left in a resident's room and confirmed the presence of 6 1/2 pills in the medicine cup, which were then removed. The Director of Nursing also verified that medications should not be left unattended in a resident's room. LPN #322 admitted to leaving the medications at the resident's bedside and confirmed that they were the resident's morning medications. The facility's policy on Medication Administration, dated September 14, 2020, states that medications should be administered as ordered and that staff should stay with the resident until the medications are consumed or refused.
Failure to Document Resident's Death Confirmation
Penalty
Summary
The facility failed to ensure that the medical record of a resident accurately reflected the confirmation of the resident's death. The resident, who had a complex medical history including malignant neoplasm of the nasopharynx, respiratory failure, and other serious conditions, was found deceased in the facility. A Licensed Practical Nurse (LPN) checked on the resident and was unable to obtain vital signs, indicating the resident had passed away. The LPN informed the Nursing Supervisor, a Registered Nurse (RN), who verified the absence of vital signs. However, the medical record did not contain documentation from the RN confirming the resident's death. The facility's policy on documenting the death of a resident requires that all pertinent information, such as the date and time of death and the name and title of the individual pronouncing the death, be recorded in the nurse's notes. Despite this policy, the Director of Nursing confirmed that the medical record lacked the necessary documentation from the RN. This oversight in documentation was identified during a review of the resident's medical record, interviews with the involved staff, and a review of the facility's policies.
Inadequate ADL Assistance for Resident
Penalty
Summary
The facility failed to provide adequate and proper assistance for activities of daily living (ADL) to Resident #146, who was dependent on staff assistance. Resident #146 had a medical history that included bradycardia, type two diabetes mellitus, vascular dementia, and Alzheimer's disease. The resident's care plan indicated a need for staff assistance for transfers and incontinence care due to a self-care performance deficit. Observations revealed that Resident #146 was not properly dressed, with one shoe missing, untied shoelaces, and a full incontinence brief. The resident's clothing was also stained, and the incontinence brief was visibly full of urine. During an observation, a Certified Nursing Assistant (CNA) attempted to transfer Resident #146 to the toilet but required additional assistance from a Licensed Practical Nurse (LPN). The transfer was difficult, and the resident's incontinence care was not performed according to the facility's policy. The CNA used the same washcloth for different areas, which was against the proper procedure. Additionally, the wheelchair seat cushion was not disinfected after the incontinence care, and the resident's hands were not washed until prompted. The resident's fingernails were also noted to be excessively long, indicating a lack of proper grooming. The Director of Nursing (DON) confirmed the improper incontinence care and the difficulty in transferring Resident #146. The care plan was subsequently revised to require the use of a stand-up lift with two staff members for transfers. The facility's policies on perineal care and activities of daily living were not followed, leading to the deficiency identified in the report.
Failure to Implement Bowel Protocol for Resident
Penalty
Summary
The facility failed to implement adequate interventions for a resident's constipation as per the facility's bowel protocol. The resident, who had multiple diagnoses including bradycardia, type two diabetes mellitus, vascular dementia, and Alzheimer's disease, was admitted and reentered the facility on specified dates. The resident's care plan indicated a need for assistance with activities of daily living due to various health conditions, and the resident was noted to be always incontinent of urine and bowel. Despite this, the resident did not have a bowel movement for five days, and there was no evidence of assessment for bowel sounds, pain, tenderness, or firmness of the abdomen during this period. The facility's electronic medical record showed that the resident was on a bowel protocol, which was not effectively communicated or acted upon by the staff. Certified Nursing Assistant (CNA) #402 and Licensed Practical Nurse (LPN) #403 were unaware of the resident's status on the bowel protocol, despite it being displayed on their computer screens. The Unit Manager (UM) #404 also failed to check the bowel protocol list due to being busy, and did not ensure that the nurses were aware of the residents on the protocol. This lack of communication and follow-through resulted in the resident not receiving the necessary interventions for constipation. The facility's bowel protocol policy required nursing staff to maintain a record of bowel movements and initiate a bowel protocol if there was no bowel movement for three days or six shifts. The protocol included administering Milk of Magnesia, Dulcolax suppository, and potentially a Fleets enema if necessary. However, these steps were not followed for the resident, and there was no documentation of bowel movements or related assessments in the medical record. This deficiency was part of a complaint investigation and represented continued non-compliance from a previous survey.
Delayed Response to Fall and Fracture
Penalty
Summary
The facility failed to ensure timely injury identification and physician notification and treatment following a fall with fracture for Resident #162. After an unwitnessed fall, the resident complained of pain, had swelling, and an abrasion to the knee, and was unable to stand. An x-ray was ordered, but the results indicating a right femur fracture were not located by the facility staff until several hours later, delaying medical intervention. The resident expired shortly after, unrelated to the fracture, following unsuccessful CPR and EMS intervention. Resident #162 had a history of chronic respiratory failure, COPD, malignant neoplasm of the bronchus or lung, atherosclerotic heart disease, essential hypertension, and a history of fractures. The care plan indicated the resident was at risk for falls and required staff to follow the facility fall protocol. Despite these precautions, the resident experienced a fall, and the facility's response was inadequate, as evidenced by the delay in obtaining and acting upon the x-ray results. Interviews with facility staff revealed communication breakdowns and procedural lapses. The x-ray results were received but not identified until hours later, and the physician was not contacted promptly. The facility's investigation confirmed these failures, and the Director of Nursing acknowledged the delay in identifying the x-ray results and the incorrect contact information for the physician, which contributed to the lack of timely care for the resident's fracture.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to properly assess and treat a pressure ulcer for a resident upon re-admission from the hospital, leading to a significant decline in the resident's condition. The resident, who had diagnoses including end-stage renal disease, diabetes, and moderate malnutrition, was readmitted to the facility with a new wound on the buttocks. Despite being identified as having a very high risk for pressure ulcer breakdown, the facility did not initiate wound care orders until four days after re-admission. The resident's pressure ulcer progressed from a Stage III to an unstageable ulcer with suspected osteomyelitis due to the lack of timely assessment and implementation of wound care orders. The facility's records revealed multiple instances where wound care was not completed as ordered, with no documented evidence of care on specific dates. The resident's treatment administration record showed missed wound care on several occasions, and there was no documentation of wound care on the afternoon of certain days. Additionally, the facility's pressure ulcer prevention policy lacked specifics on how interventions should be initiated or tracked, contributing to the deficiency. Interviews with facility staff, including the Unit Manager, Wound Nurse Practitioner, and Director of Nursing, confirmed the resident's wound care was not completed as ordered, and there were multiple missed treatments. The Wound Nurse Practitioner expressed concerns about the resident's wound care not being completed and noted that orders sometimes had to be made twice daily to ensure care was provided. The Director of Nursing verified the decline in the resident's wound and acknowledged the lack of documentation indicating the decline was unavoidable.
Deficiencies in Fall Prevention and Transfer Safety
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized fall prevention program, resulting in actual harm to a resident. Resident #19, who was cognitively impaired and at high risk for falls, sustained an unwitnessed fall that resulted in displaced fractures of the right seventh through 12th ribs and a non-displaced sternal fracture. Despite having a care plan intervention to check on the resident between 10:00 P.M. and 12:00 A.M., there was no evidence that this intervention was monitored or completed. The resident was transferred to the hospital due to pain and admitted to the ICU. The facility's investigation into the fall revealed several deficiencies. There was no documentation indicating when Resident #19 was last checked by staff before the fall. The fall investigation and witness statements were incomplete, and there was a discrepancy in the medication administration records. Interviews with staff revealed confusion about the documentation process and the timing of interventions. The Director of Nursing confirmed that the intervention to check on the resident was not documented, as it was considered a routine check. Additionally, the facility failed to ensure safe transfer practices for another resident, Resident #68. The resident required assistance from two staff members for transfers, but a CNA completed a transfer using a Hoyer lift without a second staff member present. This was confirmed by both the CNA and the resident, and it was not the first time such an incident occurred. The facility's policy required two staff members for mechanical lift transfers, highlighting a failure to adhere to established safety protocols.
Failure to Follow Menu and Substitution Protocols
Penalty
Summary
The facility failed to ensure that all menu items were prepared in advance and that menus and substitutions were followed during resident meal service. On 10/30/24, during lunch, the facility did not serve oven-roasted vegetables to residents on regular and mechanical soft textured diets, nor did they serve pureed grilled cheese to residents on puree textured diets. It was only halfway through the tray line that vegetables were brought out, and pureed grilled cheese was not available until later. This oversight was confirmed by the Dietary Director and Dietary Manager, and there was no evidence that the missing items were provided to residents who had already been served. Additionally, during breakfast on the same day, the facility did not follow the menu or substitution log. A resident expected eggs as per the menu but received a Danish, applesauce, and farina instead, without the yogurt and banana listed on her meal ticket. A CNA confirmed the discrepancy and noted that several residents received applesauce instead of yogurt and banana. A group interview with several residents revealed that food often did not match the menu or meal tickets, and they were not informed of substitutions. The facility's policy on menu substitutions requires recording changes and notifying residents, which was not adhered to.
Deficiency in Meal Quality and Temperature Control
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. The Dietary Director identified issues with meal timeliness and temperature control, noting that the new facility ownership had changed the process from serving meals from the pantry on each unit to serving from the main kitchen. During an observation, a test tray revealed that the grilled cheese sandwich was soggy and lacked sufficient cheese, and the tomato soup was lukewarm and not palatable. These findings were confirmed by the Dietary Director and Dietary Manager. The Food Committee Meeting Minutes from August indicated that proper food temperatures and meal delivery were already a focus of concern. Multiple residents expressed dissatisfaction with the quality of food served. One resident described the food as horrible, citing examples of burnt cabbage rolls, undercooked baked potatoes, and dry, hard chicken breasts. This resident relied on food brought in by her son to have enough to eat. Another observation revealed a meal tray with hard, dry toast and no condiments, which the resident refused to eat. A group interview with several residents highlighted concerns about overcooked breaded items, unappealing breakfast options, and food presentation that made meals look unappetizing. These issues were investigated under a specific complaint number, indicating non-compliance with dietary service standards.
Delayed Meal Service in LTC Facility
Penalty
Summary
The facility failed to ensure meals were served in a timely manner, affecting all residents receiving meals from the kitchen. The facility's meal times were scheduled with a 15-minute deviation allowance, but observations and interviews revealed significant delays. Residents reported receiving meals late, with breakfast trays being delivered well past the scheduled time. Staff interviews confirmed that meal trays were routinely delivered late, particularly on the secured dementia unit, and lunch was often served later than scheduled. The facility's increased census contributed to the delays, as noted in interviews with dietary staff. The Dietary Director acknowledged issues with meal timeliness and temperature, attributing some delays to a change in the serving process initiated by new facility ownership. The Registered Dietitian reported that concerns about meal times had been raised multiple times, and residents expressed a preference for returning to dining room service, which had previously resulted in higher customer satisfaction. Observations further highlighted the inconsistency in meal delivery, with some residents waiting extended periods for their meals. On one occasion, two residents did not receive their lunch trays until 30 minutes after others had been served. Staff interviews indicated that the process of passing trays was hindered by staffing issues, including the use of agency aides who interrupted tray pass to provide morning care. The facility had experienced turnover in dietary management, which may have contributed to the ongoing issues with meal service.
Non-compliance with Food Safety Protocols in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to proper food safety and handling protocols, which could potentially affect all 159 residents receiving meals from the kitchen. Observations revealed that a Mashgiach in the kitchen area was not wearing a hair net, despite being asked to do so by the Dietary Director. The Mashgiach refused, citing that wearing a wig negated the need for a hair net. Additionally, a staff member preparing pureed foods was observed adjusting his beard net with gloved hands without changing gloves or washing hands, improperly cleaning and sanitizing equipment, and not allowing equipment to dry before reuse. This staff member also failed to wash hands after handling soiled gloves and continued to use wet gloves during food preparation. The facility's policies on hair restraints, hand washing, general safe food handling, and disposable gloves were not followed. The staff member was seen rinsing food processor parts and utensils in a preparation sink, allowing water to splash into food, and using utensils without proper drying. The Dietary Manager confirmed these observations and acknowledged the failure to adhere to the facility's policies. The report highlights the lack of compliance with established food safety protocols, which are critical to maintaining a safe and sanitary environment for food preparation and service.
Deficiency in Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, including Resident #62, Resident #13, Resident #52, and Resident #24. Observations revealed that Resident #62, who has severe dementia and requires assistance with feeding, was left unattended with her meal tray, resulting in her consuming only 10% of her meal. The dining environment was further compromised by loud rock-n-roll music, which was not to the residents' liking, and they were not given a choice in the music selection. This lack of consideration for resident preferences contributed to an undignified dining experience. Additionally, Resident #13 and Resident #24 experienced delays in receiving their meals, which were not served simultaneously with other residents seated at the same table. Both residents expressed concerns about the extended wait times and lack of communication regarding the delay. The meal cart arrived late, and these residents did not receive their meals until much later than others, causing them distress and uncertainty about whether they would be served. Interviews with staff, including CNA #900 and LPN #763, confirmed the issues observed. CNA #900, who was from a contracted staffing agency, was unaware of Resident #62's need for feeding assistance and acknowledged the staggered meal service. LPN #763 confirmed that Resident #62 required feeding assistance and that the responsibility lay with the CNA supervising the dining room. The facility's failure to coordinate meal service and respect resident preferences for dining conditions led to a deficiency in providing a dignified dining experience.
Improper Puree Preparation Techniques
Penalty
Summary
The facility failed to ensure proper puree preparation techniques were followed, affecting 17 residents who required a puree textured diet. During an observation, a staff member was seen preparing puree cake, Brussels sprouts, sweet potatoes, and tomato soup without referring to any recipes or diet manual. The staff member added large amounts of water and thickener to the food items and used a chunky seasoning that contained large pieces of dried garlic, onion, and other spices. There was no additional check to ensure the appropriate consistency of the pureed food. Interviews with the staff member, the Dietary Director, and the Dietary Manager confirmed the excessive use of water and thickener, as well as the use of inappropriate seasoning. The staff member admitted to not consulting the puree recipes or diet manual, relying instead on his own judgment of the desired texture. A review of the recipes revealed that the sweet potatoes should have been prepared with milk, margarine, ground cinnamon, and ground nutmeg, while the Brussels sprouts should have been prepared with broth or gravy, and the tomato soup did not require any thickening or seasoning.
Failure to Notify Physician of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding a change in condition for two residents, leading to significant deficiencies. Resident #162, who had a history of falls and fractures, experienced an unwitnessed fall and was found on the floor complaining of pain. Despite the X-ray results indicating a fracture, there was a delay in notifying the physician due to incorrect contact information and failure to check the fax machine promptly. This delay in communication contributed to the resident being found unresponsive and subsequently pronounced deceased without timely medical intervention. Resident #126, who required regular dialysis due to end-stage renal disease, missed a scheduled dialysis appointment because the transportation company failed to show up. The facility did not notify the medical provider of the missed appointment, which was against the protocol. The resident confirmed missing the dialysis session, and the unit secretary and RN acknowledged the lapse in communication. The failure to inform the medical provider prevented necessary medical assessments and interventions from being conducted. The facility's policies on notifying medical providers of significant changes in residents' conditions were not adhered to in both cases. The lack of timely communication and incorrect contact information for the physician were critical factors in the deficiencies observed. These lapses in protocol highlight the need for accurate and prompt communication channels to ensure residents receive appropriate and timely medical care.
Failure to Address Grievances Timely for a Resident
Penalty
Summary
The facility failed to follow up on grievances involving a resident in a timely manner, affecting one of the three residents reviewed for grievances. The resident, who had diagnoses including heart failure, dysphagia, and dementia without behavioral disturbance, was admitted and later discharged from the facility. The family of the resident raised concerns about missing dentures and requested medical records. Despite a meeting with the family and a consent given for the resident to be seen by a dentist, the facility did not resolve the issues promptly. The resident's son sent multiple voicemails and an email to the Administrator regarding the medical records, but the Administrator only forwarded the request and did not follow up further. Additionally, the resident's daughter sent an email marked as important regarding reimbursement for dentures, which the Administrator claimed not to have received, despite it being sent to the correct email address. The facility did not pay for the dentures and lost contact with the family after the resident was discharged. This deficiency was investigated under several complaint numbers.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to ensure that three residents, identified as Resident #62, Resident #108, and Resident #79, received the necessary assistance with eating their meals, which is a critical activity of daily living (ADL). Resident #62, who had severe dementia, hemiplegia, and dysphagia, was observed during a meal service where she was not adequately assisted with her meal. Despite her care plan indicating she required one-person assistance for feeding, she was left with her meal tray and only received minimal assistance, resulting in her consuming only 10% of her meal. The staff involved, including a CNA and an LPN, confirmed the lack of proper feeding assistance. Resident #108, diagnosed with osteoporosis and vitamin D deficiency, required assistance with meal setup and supervision during meals. However, observations revealed that she was not encouraged to get out of bed for meals and was left unsupervised while eating. Interviews with the CNA responsible for her care confirmed that Resident #108 was not consistently assisted out of bed and was not supervised during meals, contrary to her care plan requirements. Resident #79, who had multiple diagnoses including epilepsy, diabetes, and dysphagia, required full feeding assistance as per her care plan. However, documentation and observations indicated that she frequently did not receive the necessary assistance, with staff often unaware of her feeding needs. Interviews with various staff members, including CNAs and a dietitian, confirmed inconsistencies in providing feeding assistance, with some staff unaware of her need for assistance due to inadequate communication and documentation on assignment sheets.
Failure to Provide Prescribed ROM Treatments
Penalty
Summary
The facility failed to ensure that a resident received prescribed treatments to maintain or prevent a decline in range of motion (ROM). Resident #27, who had diagnoses including chronic obstructive pulmonary disease, depression, primary hypertension, osteoarthritis, muscle weakness, pain in the left shoulder, and hemiplegia following a cerebral infarction, was affected by this deficiency. The resident was supposed to wear a left hand splint throughout the day and a PRAFO boot on the left foot when in bed, as per physician orders. However, there was no documentation in the medical record indicating that these appliances were applied, and the resident reported not having worn the hand splint for several months. Observations and interviews revealed that the resident was not wearing the prescribed hand splint or PRAFO boot during multiple checks. The resident expressed concerns about her hand becoming tighter and more closed, indicating a decline in her condition. Staff interviews confirmed a lack of awareness and documentation regarding the application of the splint and boot. The resident's care plan included these interventions, but they were not reflected in the point-of-care task documentation or the medication and treatment administration records. Further investigation revealed that the facility did not provide restorative nursing services, and the orders for the splint and boot were incorrectly entered on the care plan, leading to their omission from the Kardex for nursing staff. This oversight resulted in the resident not receiving the necessary support to maintain her ROM, as recommended by occupational therapy. The deficiency was identified during a complaint investigation, highlighting a significant lapse in the facility's care processes.
Deficiency in PEG Tube Care for a Resident
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with an enteral feeding tube, specifically a PEG tube. The resident, who had multiple medical conditions including dysphagia, relied on the PEG tube for primary nutrition and hydration. Despite the care plan indicating the need for PEG tube site care, there were no active physician orders for such care. Observations revealed that the resident's feeding pump was beeping for an extended period without staff intervention, and the PEG tube dressing was stained and dated several days prior. Interviews with staff confirmed a lack of consistent care and knowledge regarding the PEG tube site care, with one LPN unable to specify the strength of the antiseptic solution used or the orders for the care performed. Further interviews revealed that the resident experienced discomfort around the PEG tube site, and there was inconsistency in the dressing changes. The facility's policy on PEG tube care and maintenance was not followed, as no orders were in place for the application of dressings or cleaning solutions. The LPN Unit Manager confirmed that PEG tube site care should be done daily, yet there were no orders for such care, only for checking placement and residuals. This lack of adherence to policy and absence of specific care orders contributed to the deficiency in the resident's care.
Inadequate Dialysis Monitoring and Documentation
Penalty
Summary
The facility failed to provide appropriate assessments and monitoring for residents requiring dialysis, affecting three residents. For Resident #126, the facility did not complete pre-dialysis or post-dialysis assessments on multiple occasions, and the assessments that were completed often contained inaccurate or duplicated data. The facility's electronic medical record system showed assessments with statuses of 'Errors' or 'In Progress,' indicating incomplete documentation. Interviews with staff confirmed that the pre-dialysis and post-dialysis assessments did not reflect actual times and were not completed as required. Resident #50 also experienced deficiencies in dialysis care. The facility's records showed missing pre-dialysis and post-dialysis vital signs on several dates. Additionally, the assessments often used outdated or incorrect vital signs and weights, failing to provide accurate monitoring of the resident's condition before and after dialysis sessions. The facility's documentation practices were inconsistent, with vital signs and weights not being recorded accurately or timely. The facility's policy required pre and post-dialysis assessments, but these were not consistently performed or documented. Interviews with staff revealed a lack of understanding of the facility's responsibilities regarding dialysis care, particularly concerning the recording of weights and vital signs. The facility's failure to adhere to its policy and ensure accurate and timely assessments contributed to the deficiencies identified in the care of residents receiving dialysis.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that Resident #107 received their prescribed insulin medication as ordered by the physician. Resident #107, who was readmitted with a diagnosis of diabetes mellitus and required long-term use of insulin, had a physician's order to receive 21 units of Insulin Glargine Solution subcutaneously once a day. However, during an observation of medication administration, the insulin was not given as scheduled. The Medication Administration Record (MAR) indicated that the insulin was not administered because it was either unavailable or deemed outside the parameters for pulse, blood pressure, or blood sugar, despite no such parameters being specified in the physician's order. An interview with the LPN responsible for administering the medication confirmed that the insulin was withheld due to a blood sugar reading of 98 mg/dL. The LPN acknowledged that there were no parameters in the physician's order to hold the insulin and that it was a long-acting insulin scheduled for daily administration. The facility's policy on administering medications, which was revised in December 2012, mandates that medications be administered safely, timely, and as prescribed. This incident was investigated under Complaint Number OH00159071, highlighting a significant medication error affecting Resident #107.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation for three residents, leading to deficiencies in maintaining medical records. For Resident #19, the documentation of a fall incident was inaccurately recorded with incorrect timestamps, and there was no witness statement from the LPN who documented the progress note. The resident experienced an unwitnessed fall, was in significant pain, and was sent to the hospital without a physician's order. Interviews with staff confirmed the inaccuracies in the documentation and the lack of a witness statement. Resident #50's medical records revealed inconsistencies in documenting pre- and post-dialysis assessments. The MARs for several dates lacked vital signs, and some assessments were time-stamped while the resident was out of the facility. The DON confirmed that dialysis assessments were not completed every dialysis day, and the RN Supervisor verified missing weights and assessments. The Unit Manager acknowledged that the time stamps did not necessarily reflect when the assessments were completed. For Resident #15, the facility's fall investigations showed discrepancies between the documented times of falls and the nursing progress notes. Several falls were recorded without timely progress notes, and there was no indication of late entries to correct the timing. An LPN verified these findings, highlighting the facility's failure to maintain accurate and timely documentation of fall incidents.
Infection Control Deficiencies in Medication Administration and PEG Tube Care
Penalty
Summary
The facility failed to maintain infection control standards during medication administration for Resident #107. The LPN involved did not sanitize or wash her hands before handling medications and touched the medications with her bare hands. Additionally, her long hair came into contact with the resident during the process, and she placed her finger inside the cup of water given to the resident. These actions were in violation of the facility's hand hygiene policy, which requires handwashing or the use of an alcohol-based hand rub before handling medications and after direct contact with residents. In another incident, the facility did not adhere to enhanced barrier precautions during PEG tube site care for Resident #111. The LPN performing the procedure wore gloves but failed to don a gown, which was required by the facility's policy for high-contact resident care activities. The absence of gowns in or near the resident's room contributed to this oversight. The LPN and the unit manager confirmed that a gown should have been worn during the procedure, as per the facility's policy. These deficiencies were identified during a survey and were part of a complaint investigation. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, leading to potential cross-contamination risks during care for the residents involved. The report highlights specific instances where infection control standards were not maintained, affecting the quality of care provided to the residents.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure medications were stored securely at all times, as observed on the [NAME] three unit. A medication cart was found unattended and unlocked in the hallway between two residents' rooms, with one resident and a family member present in the vicinity. This incident was confirmed by an LPN, who acknowledged that the cart should have been locked. The facility's policy on Medication Administration/Treatment, dated 10/18, requires that medication carts be locked when unattended. This deficiency had the potential to affect 40 residents residing on the unit.
Deficiency in Meal Portion Sizes and Menu Adherence
Penalty
Summary
The facility failed to provide all food items and portion sizes as indicated on the menu production sheets, potentially affecting all residents except those with orders for nothing by mouth. During an observation of the lunch tray line, it was noted that residents received one soft beef taco, half a cup of rice, half a cup of corn, and half a cup of fruit, whereas the tray tickets indicated that two tacos and a piece of cornbread should have been served. The absence of cornbread was attributed to a vendor issue, and fruit was substituted without updating the menu production sheet or tray tickets. The Registered Dietitian confirmed that only one taco was served because it contained four ounces of meat, which was deemed sufficient to meet protein requirements, despite the menu indicating two tacos per serving. Interviews with residents and their families revealed dissatisfaction with the food quality and discrepancies between what was served and what was supposed to be served. A resident's family member described the food as awful, and a resident confirmed not receiving the planned lunch meal. The facility's Administrator and Registered Dietitian insisted that the protein portion was adequate, despite the menu production sheet not specifying the size or protein content of the tacos. This deficiency was investigated under Complaint Number OH00157273.
Infection Control Breach in Medication Administration
Penalty
Summary
The facility failed to maintain standard infection control protocols during medication administration, affecting one resident. During a random observation, an LPN was seen administering medications to a resident with acute kidney failure, spastic quadriplegic cerebral palsy, and neuromuscular dysfunction of the bladder. The resident also had impaired cognition. The LPN placed three out of thirteen medications from medication cards into her bare hand, which is against the facility's policy. The facility's policy, dated 2010, clearly directs staff not to touch medications with their hands and to use a medication cup instead. During an interview, the LPN acknowledged that medications should be placed into a medication cup, not a bare hand.
Failure to Provide Timely Employment Verification for STNAs
Penalty
Summary
The facility failed to provide timely employment verification for State tested Nurse Aides (STNAs) #400 and #403, which resulted in their status on the nurse aide registry being changed to expired. This deficiency was identified through a review of staff schedules, the nurse aide registry, employment verification letters, and staff interviews. The review revealed that no evidence of employment had been provided for these STNAs within a 24-month period. An interview with the Administrator confirmed that the facility had not submitted the necessary employment verifications until after the expiration of their registry status. This deficiency had the potential to affect all 150 residents in the facility and was investigated under Complaint Number OH00156057.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place on 09/05/24, which had the potential to affect all 150 residents. During an observation at 10:45 A.M., it was noted that the staffing information for that day was not available. An interview with the Administrator at 10:53 A.M. confirmed that the staffing information should have been in a binder at the front desk, but it was not present and was in the process of being printed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,181 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beachwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beachwood Pointe Care Center | 0.3 mi | ★★★★★ | 11 | 0 |
| Shaker Gardens Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Harvard Gardens Rehabilitation & Care Center | 2.1 mi | ★★★★★ | 35 | 0 |
| Avenue Care And Rehabilitation Center, The | 2.5 mi | ★★★★★ | 42 | 0 |
| Suburban Healthcare And Rehabilitation | 2.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.