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 Diplomat Healthcare during CMS and state inspections, most recent first.
A resident with multiple comorbidities and dependent on staff for care developed a severe wound that was repeatedly documented as moisture-associated skin dermatitis (MASD) rather than a pressure ulcer, despite clear signs of deterioration. Nursing staff were instructed to continue this documentation, and no additional interventions were implemented to address the worsening condition. The resident was eventually hospitalized with an unstageable, necrotic pressure ulcer, dehydration, and malnutrition, leading to palliative care and death.
The facility did not conduct routine care plan conferences for two residents with severe cognitive impairment, resulting in a lack of participation by their representatives in the care planning process. Despite care plan updates, the responsible parties were not included in ongoing conferences, and the Director of Social Services acknowledged delays and missed communications.
The facility did not inform physicians or resident representatives about ongoing medication refusals and new medication orders for three residents with various cognitive and psychiatric conditions. Nursing staff documented medication refusals and new treatments in records, but failed to notify the appropriate parties as required by facility policy, as confirmed by interviews with the DON.
A resident with dysphagia and dementia was given crushed medication mixed with applesauce for pain, but the LPN who administered the medication left the room without confirming it was swallowed. A registered nurse observed the medication had not been swallowed and had to manually stimulate swallowing, highlighting a failure to monitor safe medication consumption.
A resident with multiple medical conditions experienced a fall resulting in injuries and abnormal vital signs, leading to hospital transfer. The facility's fall investigation contained conflicting information about the timing of the incident and when EMS was contacted, and staff could not explain these discrepancies. The investigation did not meet the facility's policy requirements for thorough review and documentation.
A resident dependent on staff for toileting and at risk for skin breakdown was found with dried stool and heavily soiled linens, and did not have the prescribed barrier cream applied after incontinence care. The CNA confirmed not following the care plan and physician orders for cleansing and barrier application, resulting in inadequate incontinence care.
A resident with dementia and other health conditions did not receive adequate fluids, with intake falling below estimated needs and resulting in hospital admission for dehydration and hypernatremia. Observations showed that multiple residents were not consistently provided with drinks during meals, and staff interviews revealed confusion about fluid distribution and documentation. Resident complaints about lack of water were also noted, indicating a systemic failure to follow the facility's hydration policy.
A resident with multiple chronic conditions experienced a delay in UTI treatment due to the facility's failure to promptly obtain and report laboratory results to the provider. The order for a urinalysis and culture was not placed until two days after symptoms were noted, and the final lab results were not reported to the nurse practitioner for an additional three days, resulting in a delay in starting antibiotic therapy.
A resident with cognitive impairment and multiple health issues experienced an acute change in condition when their contracted left arm became flaccid and painful. Despite a hospice-ordered x-ray, the facility delayed the examination for five days, during which the resident continued to experience pain. The x-ray eventually revealed a left humerus fracture, leading to the resident's hospitalization. Interviews indicated a lack of communication and adherence to facility policy regarding the resident's care.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents receiving meals except one. An observation revealed an overflowing trash can, a cart with a thick scummy buildup, and a dirty kitchen floor with sticky areas and a coffee spill. The Dietary Manager confirmed that items on the cart were used for cooking and serving food and drinks to residents. This was found during a complaint investigation.
A resident's representative was not timely notified of a change in condition involving a flaccid left upper arm, which was observed during incontinence care. Despite hospice being informed and an x-ray being ordered, the resident's wife was not notified until several days later, contrary to facility policy requiring prompt notification.
Two residents experienced a failure in maintaining a clean environment, with one resident's room having a strong urine odor due to a saturated brief left by the previous shift, and another resident's room having a foul stool odor with visible stool smears. The facility's policy requires immediate removal of soiled briefs and cleaning of spills, which was not adhered to.
The facility failed to timely report and investigate incidents involving two residents. One resident, with dementia and on hospice, had an unexplained arm injury that was not reported to the State Survey Agency until days later, despite initial signs of injury. Another resident, with Alzheimer's, was involved in a verbal altercation, but the investigation was not completed within the required timeline. The facility's policy mandates immediate reporting and completion of investigations within five days, which was not followed.
A resident with dementia and on hospice care was found with a flaccid left arm, indicating a possible injury. The facility failed to conduct a thorough investigation, omitting hospice records and witness interviews, and delayed obtaining an x-ray that later revealed a fracture. The Director of Nursing confirmed these investigative omissions, which did not comply with the facility's policy.
A resident with a foot wound did not receive proper care as ordered by the physician. The resident's foot was lying directly on a malfunctioning mattress, and the required heel boot was not used. Staff were aware of the mattress issue but did not promptly notify the hospice provider, and the heel boot was unavailable without seeking alternatives. This non-compliance with physician orders and facility policy potentially impacted the wound's healing.
A resident with high fall risk and on hospice care fell during incontinence care due to inadequate assistance. The care plan required two staff members, but only one CNA was present, leading to the resident slipping off the bed and sustaining a head injury. The incident was documented, and medical attention was provided.
A facility failed to provide necessary incontinence care for a cognitively impaired resident with a history of cerebral infarction and dementia. The resident, who was always incontinent, was found with a soiled brief and saturated bedding, indicating a lack of timely care. Interviews revealed the resident was particular about who provided her care, and effective interventions were not in place to manage her preferences. The facility did not provide evidence of care being refused or performed by night shift staff.
A facility failed to assess and provide appropriate wound care for a resident with a groin condyloma, resulting in a deficiency. The resident had a large verrucous mass with drainage, but no comprehensive assessment or wound care orders were documented. Staff interviews revealed that the ADON did not assess the resident due to time constraints, and the LPN who admitted the resident failed to inform the physician about the drainage. The facility's wound care policy was not followed.
The facility failed to report multiple resident-to-resident physical altercations to the State Agency, affecting ten residents in the secured memory care unit. Despite the facility's policy requiring all abuse allegations to be reported, incidents involving residents with cognitive impairments and behavioral disturbances were not documented in the state database. The Director of Nursing confirmed the lack of reporting, possibly due to the absence of major injuries.
The facility failed to provide individualized care-planned interventions for residents, leading to multiple resident-to-resident altercations in the secured memory care unit. The care plans lacked specific interventions tailored to individual stressors and responses, affecting nine residents with behavioral health needs.
The facility failed to secure medications appropriately, affecting all 99 residents. Observations revealed unsecured medications in carts on both the third and first floors, confirmed by LPNs as needing to be discarded. This was contrary to the facility's policy requiring orderly storage of medications.
An LPN failed to sanitize blood sugar glucometers after use, affecting five residents with diabetes. The LPN admitted to not sanitizing the device initially and used an alcohol wipe instead of the required disinfectant wipe. The facility's policy mandates sanitizing glucometers after each use, which was not adhered to.
A resident with severe cognitive impairment and dysphagia was not assisted with eating his breakfast for over two hours due to staffing issues. The delay occurred because one STNA was absent, leaving others to manage additional duties. LPNs were also occupied with medication administration, resulting in the resident's meal being left untouched, contrary to the facility's dining policy.
The facility failed to maintain effective pest control in the kitchen, with gnats observed in the dish room over several days. Despite attempts to address the issue, there was a lack of communication and action among staff, leading to the exterminator being unaware of the problem until informed by a surveyor.
A resident with impaired cognition was found with medications left unattended in their room, despite not being authorized to self-administer. The facility's policy required medications to be locked or supervised, but five pills and an inhaler were found on the bedside table and floor. Staff confirmed the resident should not self-administer, indicating a lapse in policy adherence.
Failure to Identify and Document Pressure Ulcer Decline Resulting in Harm
Penalty
Summary
A deficiency occurred when facility staff failed to adequately and accurately identify, document, and respond to a significant decline in a resident's wound condition. The resident, who had diagnoses including Parkinson's disease, dementia, muscle weakness, and was dependent on staff for activities of daily living, was at risk for pressure ulcer development. Despite being identified as at mild risk for pressure ulcers and having a care plan that included interventions such as incontinence care, use of barrier cream, and weekly skin evaluations, the resident developed a wound that was initially documented as moisture-associated skin dermatitis (MASD) rather than a pressure ulcer. Wound assessments and progress notes indicated that the wound was described as MASD and treated accordingly, with no additional interventions implemented to address the resident's large, soft stools or to prevent prolonged moisture exposure. Staff interviews and text messages revealed that nursing staff were instructed to continue documenting the wound as MASD, despite observations that the wound had characteristics of a pressure ulcer, including necrosis, foul odor, and significant decline in condition. The wound nurse lacked official training or certification, and there was a lack of escalation or notification to the physician or responsible party regarding the true nature and severity of the wound. The resident was eventually transferred to the hospital with altered mental status, dehydration, malnutrition, and an unstageable pressure ulcer to the coccyx, which was found to be necrotic and infected. Hospital records and family interviews confirmed that the wound was severe and required surgical intervention, but the family declined surgery and opted for palliative care. The resident was admitted to hospice and subsequently passed away. The facility's failure to accurately assess, document, and communicate the decline in the resident's wound resulted in actual harm, as evidenced by the resident's hospitalization and subsequent death.
Failure to Conduct Routine Care Plan Conferences and Involve Resident Representatives
Penalty
Summary
The facility failed to ensure that routine care plan conferences were conducted for two residents with severely impaired cognition. For one resident with diagnoses including Parkinson's disease, schizophrenia, bipolar disorder, hypothyroidism, dementia, and muscle weakness, the care plan was updated multiple times, but the resident's Power of Attorney (POA) reported that no care conference had been held since March, despite attempts to contact the new Director of Social Services. The resident was unable to participate in care planning due to cognitive impairment, making POA involvement essential. Another resident with dementia, muscle weakness, hypertension, impulse disorder, and insufficient sleep syndrome had an admission care conference with their spouse, but no further care conferences were documented after the initial one, despite care plan updates. The spouse, listed as the responsible party, was not involved in subsequent care conferences. The Director of Social Services confirmed being behind on scheduling and conducting care conferences and was unaware of missed communications from the POA. Facility policy requires resident and representative participation in care planning to the extent practicable, with documentation if not possible, but this was not followed.
Failure to Notify Physician and Resident Representatives of Medication Refusals and New Orders
Penalty
Summary
The facility failed to notify residents' physicians and resident representatives of significant changes in condition and new medication orders for three residents. For one resident with intact cognition and diagnoses including bipolar and schizoaffective disorders, there were multiple refusals of a prescribed antipsychotic injection over several weeks. These refusals were documented in the Medication Administration Record, but there was no documentation in the progress notes regarding the refusals, nor evidence that the physician or family had been notified. Interviews with nursing staff and the Director of Nursing confirmed that the required notifications did not occur and were not documented. For two other residents with cognitive impairments and complex medical histories, new medication and treatment orders were initiated in response to changes in their conditions, such as skin rashes and inflammation. Progress notes documented the new orders but did not indicate that resident representatives had been informed of these changes. The Director of Nursing confirmed that there was no evidence of notification to the resident representatives, despite facility policy requiring such communication when there is a need to alter a resident's medical treatment.
Failure to Monitor Medication Consumption During Administration
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, left-sided weakness, dysphagia, and dementia was not properly monitored during medication administration. The resident had physician orders allowing medications to be crushed unless contraindicated and had an as-needed order for acetaminophen for pain. During an observation of wound care, the resident exhibited non-verbal signs of pain, prompting a nurse to instruct another nurse to administer pain medication as ordered. The nurse returned with crushed medication mixed in applesauce and administered it to the resident, then exited the room without confirming that the medication was swallowed. A registered nurse who remained in the room observed that the resident had not swallowed the medication and proceeded to manually massage the resident's throat to stimulate swallowing. The registered nurse stated that the nurse who administered the medication should have stayed to ensure the medication was swallowed before leaving the room. This failure to monitor medication consumption resulted in non-compliance with ensuring safe medication administration for the resident.
Failure to Complete Accurate and Thorough Fall Investigation
Penalty
Summary
The facility failed to ensure an accurate and thorough fall investigation was completed for a resident with significant medical needs, including Parkinson's disease, dementia, muscle weakness, and dependence on staff for activities of daily living. The resident was found on the floor with lacerations and abnormal vital signs, including tachycardia and hypoxia, and was subsequently transferred to a hospital. Documentation and interviews revealed discrepancies in the reported time of the fall and when emergency medical services (EMS) were contacted. The facility's records indicated the fall occurred at approximately 3:00 A.M., while the EMS report showed a call was placed before midnight, and staff reported the resident had been assisted back to bed prior to EMS arrival. The facility's fall investigation did not reconcile these conflicting time frames, and staff were unable to provide an explanation for the discrepancies. The facility's policy required a thorough interdisciplinary review of falls, including assessment of causal factors and environmental review, but the investigation lacked clarity and completeness regarding the circumstances and timing of the incident. This deficiency affected the resident's care and did not meet the facility's own standards for fall prevention and management.
Failure to Provide Adequate Incontinence and Skin Care
Penalty
Summary
A resident with a history of stroke, muscle weakness, and dementia was found to be incontinent of bowel and bladder and fully dependent on staff for toileting. The resident's care plan included interventions for incontinence care and the application of a skin barrier ointment after incontinence episodes to prevent skin breakdown. Physician orders specified cleansing the buttocks with soap and water and applying a thick zinc barrier every shift and as needed. During an observation of incontinence care, a large amount of dried stool was found in the crease of the resident's buttocks, and the bed linens were heavily soiled with dried urine and other debris, accompanied by a strong odor of urine. The certified nursing assistant (CNA) responsible for the resident reported having provided incontinence care approximately one hour prior to the observation. However, the CNA confirmed that she had not applied the required barrier cream after the last care episode and had not noticed the soiled linens at that time. There was no evidence of barrier cream residue on the resident during the observation, despite the resident being at risk for skin breakdown and having a care plan and physician order for its use. Facility policy required thorough cleansing of the rectal area and application of a moisture barrier if care planned, but these steps were not followed, resulting in inadequate incontinence care for the resident.
Failure to Provide Sufficient Fluids to Maintain Resident Hydration
Penalty
Summary
The facility failed to ensure that residents were consistently offered sufficient fluids to maintain proper hydration and health. One resident with diagnoses including Parkinson's, dementia, and muscle weakness was identified as having a high risk for dehydration, with a registered dietitian estimating daily fluid needs between 2040-2380 ml. However, the resident's diet orders only provided 1440 ml, and actual intake was significantly lower on several days prior to hospital transfer. The resident was admitted to the hospital with acute hypernatremia and dehydration, as confirmed by laboratory results and interviews with facility nursing leadership, who acknowledged the decreased fluid intake. Observations in multiple dining areas revealed that several residents did not have drinks provided during meals, and some reported being thirsty with empty cups. Staff interviews confirmed that water was not consistently passed out during meal times, and there was confusion about documentation of fluid intake. Resident Council meeting records also documented complaints about water not being provided. Despite staff re-education, observations continued to show that water was not reliably offered, and the facility's hydration policy requiring sufficient fluid intake was not followed.
Delay in Reporting Lab Results Led to Delayed UTI Treatment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that laboratory results were obtained and reported to the provider in a timely manner, which delayed treatment for a urinary tract infection (UTI). A resident with multiple diagnoses, including chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder, hyperlipidemia, anxiety, hypertension, and malignant neoplasm of the large intestine, exhibited symptoms of a UTI and was seen by a nurse practitioner, who ordered a urinalysis with culture and sensitivity (UA C&S). However, the order for the UA C&S was not placed until two days after the initial assessment, and the urine sample was collected and sent to the lab on the same day the order was placed. The urinalysis indicated infection, and the urine culture, received by the facility three days later, confirmed the presence of Escherichia coli ESBL. Despite receiving the final urine culture results, the facility did not report these results to the nurse practitioner until three days after they were available. Only then was an antibiotic ordered and started for the resident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the delay in reporting the abnormal laboratory results to the provider, and the ADON was unable to provide a reason for the delay. Facility policy required prompt notification of the provider when there was a need to alter medical treatment, including changes in provider orders.
Failure to Provide Timely Treatment for Resident's Acute Condition
Penalty
Summary
The facility failed to provide adequate, necessary, and timely treatment for a resident with cognitive impairment following an acute change in condition. The resident, who was dependent on staff for activities of daily living and had a history of senile degeneration of the brain, dementia with agitation, reduced mobility, age-related osteoporosis, and muscle wasting, experienced a significant change when their normally contracted left arm became flaccid and painful. Despite a hospice-ordered x-ray examination on the day of the change, the facility did not complete the x-ray until five days later, after a visiting hospice nurse identified continued pain and bruising. The resident's medical records indicated multiple physician orders for pain management, including Oxycodone, Acetaminophen, and Morphine. However, there was no evidence of follow-up monitoring, assessment, or treatment by facility staff for the resident's flaccid arm from the time of the initial observation until the x-ray was finally conducted. The x-ray revealed a left humerus fracture, and the resident was subsequently transported to the hospital for further evaluation and treatment. Interviews with facility staff and hospice personnel revealed a lack of communication and follow-through regarding the resident's condition and the x-ray order. The facility's Director of Nursing was unaware of the x-ray order, and there was confusion among staff about the resident's care needs and the hospice's instructions. The facility's policy on resident change in condition was not followed, contributing to the delay in addressing the resident's acute change in condition.
Unsanitary Kitchen Conditions Found During Investigation
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all residents receiving meals, except for one resident who was not receiving anything by mouth. During an observation on December 10, 2024, at 11:33 A.M., the kitchen was found to have an overflowing trash can with a swivel lid, confirmed by Food and Nutrition Aide #229. Further observation and interview with Dietary Manager #221 revealed a tall cart across from the tray line with pudding, silverware, cups, and cereal stored on its shelves. Each shelf and the four legs of the cart had a thick scummy buildup covered in thick dust particles. The kitchen floor was dirty with multiple sticky areas, and there was a large coffee spill under the coffee pot. DM #221 confirmed that the items stored on the shelves were used for cooking and serving food and drinks to the residents. This deficiency was discovered incidentally during a complaint investigation.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to timely notify the representative of Resident #67 of a change in condition, which was a deficiency identified during a survey. Resident #67, who was on hospice services for senile degeneration of the brain and dementia with agitation, was observed by a caregiver to have a flaccid left upper arm during incontinence care. The resident vocalized pain and showed a grimace, prompting LPN #279 to notify the nighttime supervisor and hospice. However, there was no evidence that Resident #67's representative was informed of this change in condition on the same day. The hospice coordination notes indicated that LPN #279 believed the resident's left arm/shoulder was dislocated, and an x-ray was ordered. Despite this, the resident's wife was not notified until several days later, when the x-ray was ordered, and she was unaware of the situation until contacted by Hospice LPN #402. The facility's policy required family notification as soon as the resident was stable, but this did not occur in a timely manner, leading to the deficiency noted in the report.
Failure to Maintain Clean Environment and Proper Incontinence Care
Penalty
Summary
The facility failed to maintain a clean environment free of foul odors, affecting two residents. Resident #5, who has bipolar type schizoaffective disorder and dementia, was found in a room with a strong urine odor. A saturated brief was discovered behind the entrance door, which had been left there since the previous shift. The CNA confirmed the presence of the odor and the brief's condition, indicating a lapse in proper disposal and room cleanliness. Resident #39, who is cognitively intact and requires assistance due to an amputation and muscle weakness, experienced a similar issue. A foul stool odor was detected emanating from the resident's room into the hallway. Inside, a soiled brief with stool was found in the trash can, and stool smears were visible on the floor. The CNA confirmed that the room was often in this condition at the start of her shift, and the resident expressed discomfort due to the odor. The DON stated that soiled briefs should be removed immediately, and spills should be cleaned promptly, as per the facility's policy.
Failure to Timely Report and Investigate Incidents
Penalty
Summary
The facility failed to timely report an injury of unknown origin for Resident #67 to the State Survey Agency and did not complete the self-report incident investigation within the required five-day timeline. Resident #67, who had diagnoses including senile degeneration of the brain and dementia with agitation, was on hospice services. On 11/21/24, during incontinence care, a caregiver observed Resident #67's left upper arm to be flaccid, and the resident vocalized pain. Despite notifying hospice and receiving orders to treat for pain, there was no follow-up on the condition until 11/26/24, when an x-ray revealed a humeral fracture. The facility reported the injury to the State Survey Agency on 11/26/24, but the initial signs of the injury were not addressed as an injury of unknown origin in the investigation. Resident #78, who had Alzheimer's disease and severe cognitive impairment, was involved in a verbal altercation with a visitor on 10/14/24. The facility's self-reported incident investigation for this event was not completed within the required five-day period, as it was initiated on 10/14/24 and completed on 10/22/24. The Assistant Administrator acknowledged the delay was due to an oversight caused by a busy schedule. The facility's policy requires that all allegations of abuse or injuries of unknown origin be reported immediately to the Administrator, Director of Nursing, and applicable State Agency, with investigations completed within five working days. The failure to adhere to these timelines represents non-compliance, as investigated under Complaint Number OH00160241.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, which was identified during a review of a self-reported incident. The resident, who was on hospice care for senile degeneration of the brain and dementia with agitation, was found with a flaccid left upper arm during incontinence care. Despite the observation of pain and grimacing, the initial report by the LPN to hospice did not result in immediate action, and the x-ray revealing a fracture was not conducted until several days later. The facility's investigation into the incident was incomplete, as it lacked hospice records, did not address the initial findings by the LPN, and failed to include witness interviews. The Director of Nursing confirmed these omissions, acknowledging that the investigation did not comply with the facility's policy, which requires a comprehensive investigation including witness interviews and documentation of all medical reports. This deficiency was identified under Complaint Number OH00160241.
Failure to Implement Physician Orders for Wound Care
Penalty
Summary
The facility failed to implement physician orders to promote the healing of a wound on a resident's foot. The resident, who was admitted with diagnoses including senile degeneration of the brain and dementia, was dependent on staff for various activities, including personal hygiene and bed mobility. The resident had a skin tear on the left medial bunion, which was being treated with specific wound care orders, including the use of heel lift boots to offload pressure and promote healing. During observations, it was noted that the resident's left foot was lying directly on a malfunctioning low air loss mattress, which was partially deflated and beeping due to low pressure. The resident did not have the ordered heel boot on the left foot, and the wound was in direct contact with the mattress. Staff interviews revealed that the mattress had been malfunctioning for several days, and the hospice provider had not been notified promptly. Additionally, the heel boot was not available, and staff did not seek an alternative from the therapy department. The facility's policy on skin and wound care best practices required that pressure injuries and wounds be treated with evidence-based interventions as ordered by the provider. However, the failure to ensure the resident had the necessary pressure-relieving equipment and the delay in addressing the malfunctioning mattress contributed to non-compliance with the physician's orders and the facility's policy, potentially impacting the healing of the resident's wound.
Inadequate Assistance During Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received appropriate assistance during incontinence care, leading to an accident. Resident #67, who was on hospice services for senile degeneration of the brain and had a high risk for falls, was dependent on staff for toileting hygiene and bed mobility. The care plan for Resident #67 included the need for two staff members during incontinence care and repositioning. However, on the day of the incident, only one Certified Nursing Assistant (CNA) was present during incontinence care. As the CNA attempted to turn Resident #67 in bed, the resident's feet began to slip off the bed, resulting in a fall. The incident resulted in Resident #67 hitting their head and sustaining a skin tear with bruising and a bump. The CNA was unable to prevent the fall despite trying to use her body to stop it. The resident experienced generalized pain and required medical attention, including the application of steri strips to the skin tear. The incident was documented, and the physician and resident representative were notified. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with ensuring adequate supervision and assistance to prevent accidents.
Inadequate Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary incontinence care for Resident #11, who was cognitively impaired and dependent on staff for incontinence management. Resident #11 had a history of cerebral infarction, hemiplegia, aphasia, dementia, and muscle weakness, and was always incontinent of bowel and bladder. The care plan for Resident #11 required incontinence care after each episode, but observations revealed that the resident was found with a soiled brief and saturated bedding, indicating a lack of timely care. The resident's room had a strong foul urine odor, and the resident had moisture-associated skin damage (MASD) to the gluteal fold and bilateral buttocks, which was stable but not improving. Interviews with staff revealed that Resident #11 was particular about who provided her care, allowing only certain CNAs to assist her. CNA #290, who was assigned to Resident #11, had not provided incontinence care since the start of her shift, and there was no evidence that the resident had refused care during that time. The Director of Nursing stated that residents should be checked and changed every two hours, but the Assistant Director of Nursing confirmed that effective interventions were not in place to manage the resident's care preferences. The facility did not provide evidence of incontinence care being refused or performed by night shift staff prior to the morning shift.
Failure to Assess and Provide Wound Care for Resident with Groin Condyloma
Penalty
Summary
The facility failed to ensure appropriate assessments and care for a resident with a groin condyloma, which is a type of genital wart. The resident had a history of a large verrucous mass surrounding the penis, which was noted to have oozing and bloody drainage. Despite the presence of this condition, there was no comprehensive assessment or wound care orders documented in the resident's medical record during their stay at the facility. The resident had been admitted with multiple diagnoses, including condyloma latum, muscle weakness, and malignant neoplasm of the esophagus. Interviews with facility staff revealed that the Assistant Director of Nursing did not assess the resident for wounds due to time constraints and was unaware of any existing wounds. The LPN who admitted the resident noticed the dressing on the groin area and the clear fluid drainage but failed to inform the physician to obtain appropriate dressing orders. The facility's Skin and Wound Care Best Practices policy, which aims to provide evidence-based preventative skin care and wound treatment, was not adhered to in this case, leading to the deficiency.
Failure to Report Resident Altercations
Penalty
Summary
The facility failed to report resident-to-resident physical altercations to the State Agency as required, affecting ten residents in the secured memory care unit. The incidents involved residents with various cognitive impairments and behavioral disturbances, leading to physical altercations that were not reported to the Ohio Department of Health's Enhanced Information Dissemination Collection System (EIDC). Despite the facility's policy requiring all allegations of abuse to be reported, these incidents were not documented in the EIDC database. One incident involved a resident with Alzheimer's disease and dementia who was physically assaulted by another resident, resulting in a bruise and droopy eye. Although the local police and responsible party were notified, the incident was not reported to the state. Another case involved a resident with paranoid schizophrenia who was attacked by a resident with severe cognitive impairment, leading to a nosebleed and the need for staff intervention. This altercation was also not reported to the state. Additional incidents included a resident being struck in the mouth, another being hit in the face, and a resident being thrown to the floor. In each case, the facility's staff separated the residents and notified responsible parties, but failed to report the incidents to the state agency. The Director of Nursing, who had recently been promoted, confirmed that these incidents were not reported, possibly due to the absence of major injuries, despite the facility's policy requiring such reports.
Lack of Individualized Care Plans Leads to Resident Altercations
Penalty
Summary
The facility failed to ensure individualized care-planned interventions were in place to prevent resident behaviors resulting in resident-to-resident altercations on the secured memory care unit. This deficiency affected nine residents who were reviewed for behavioral health services. The care plans for these residents lacked specific interventions tailored to their individual stressors and responses, which contributed to multiple incidents of physical altercations between residents. For instance, Resident #28, diagnosed with Alzheimer's disease and other mental health disorders, was involved in a physical altercation with Resident #69 due to noise on the unit. The care plan for Resident #28 included general interventions but did not specify individualized stressors or responses. Similarly, Resident #30, with a history of dementia and behavioral disturbances, was involved in an altercation with another resident, yet their care plan also lacked specific triggers and responses. Other residents, such as Resident #39, #48, #57, #58, #69, #77, and #85, also experienced similar issues where their care plans did not include individualized interventions to manage and modify behaviors. These deficiencies were confirmed through interviews with MDS coordinators and nursing staff, who acknowledged the lack of individualization in the care plans and the ongoing efforts to improve them.
Failure to Secure Medications in Facility
Penalty
Summary
The facility failed to secure medications appropriately, which had the potential to affect all 99 residents residing in the facility. During an observation on the third floor, a medication cart was found with 14 unsecured unidentified medications. An LPN verified that these loose medications should be discarded. A subsequent observation on the same floor revealed another medication cart with 19 unsecured unidentified medications, which was again confirmed by an LPN as needing to be discarded. Additionally, on the first floor, a medication cart was observed with 9 unsecured unidentified medications, with an LPN verifying the need for these medications to be discarded. The facility's policy titled 'Storage and Expiration Dating of Medications and Biologicals,' dated 2024, requires staff to ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, and refrigerators. The observations indicate a failure to adhere to this policy, as medications were not stored securely in the medication carts.
Failure to Sanitize Glucometers
Penalty
Summary
The facility failed to appropriately sanitize blood sugar glucometers, which had the potential to affect five residents who required blood sugar testing and monitoring. During an observation, an LPN was seen checking a blood glucose level for a resident and then placing the glucometer back in the medication cart without sanitizing it. Upon interview, the LPN confirmed that she did not sanitize the glucometer initially and then proceeded to clean it with an alcohol wipe, stating that bleach wipes were too strong for cleaning. This LPN was responsible for conducting blood sugar checks for five residents. The medical records of the affected residents revealed that they all had diagnoses of type two diabetes mellitus, with varying cognitive statuses. Each resident had specific orders for blood sugar testing, ranging from daily to three times a day. The facility's policy, dated 2020, required staff to sanitize the glucometer with a disinfectant wipe after each use, which was not followed in this instance.
Resident Meal Assistance Delay
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple medical conditions, including dysphagia, was assisted with eating his meal in a timely manner. The resident required substantial assistance with meals due to his condition, as indicated in his Minimum Data Set (MDS) assessment and care plan. On the day of the observation, the resident's breakfast tray was left untouched for approximately two hours and fifteen minutes before he was assisted with eating. This delay occurred because one of the State Tested Nursing Assistants (STNAs) assigned to the third floor did not arrive on time, leaving the remaining staff to manage additional responsibilities. The STNA who was present prioritized her assigned residents and then began assisting those assigned to the absent STNA. Licensed Practical Nurses (LPNs) on the floor were also occupied with their duties, including medication administration, and did not assist the resident with his meal. The facility's policy on dining experience at mealtimes requires staff to assist residents with their meals promptly, which was not adhered to in this instance. The deficiency was identified during a complaint investigation, highlighting a lapse in the facility's adherence to its dining policy.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control management system, specifically related to the presence of gnats in the kitchen, which has the potential to affect all 99 residents who receive meals from the kitchen. During an initial tour of the kitchen, approximately 10 gnats were observed flying around near the exit door in the dish room. This observation was confirmed by the Food Service Director (FSD). Subsequent observations on the following days revealed that gnats were still present in the dish room area, and these observations were confirmed by the Regional Dietitian and another staff member. Interviews with facility staff revealed a lack of communication and action regarding the ongoing gnat issue. The FSD had attempted to address the problem by power washing the dish room but did not notify the maintenance director or administrator about the continued presence of gnats. The Maintenance Director was unaware of the issue until informed by the surveyor, and the Assistant Administrator was also not aware of the problem. The exterminator, who visits the facility monthly, confirmed that the facility had been experiencing an ongoing issue with fruit flies, which had worsened in the past month. However, the exterminator had not been notified of the current concerns until after the surveyor's observation.
Medication Storage Deficiency in Resident Room
Penalty
Summary
The facility failed to ensure medications were not left unattended in resident rooms, specifically affecting one resident with impaired cognition. The resident, who had diagnoses including congestive heart failure, hypertension, chronic obstructive pulmonary disease, and acute kidney disease, was not supposed to self-administer medications. Despite this, an observation revealed five pills and an inhaler left unattended in the resident's room. The medications identified were Farxiga, aspirin, isosorbide mononitrate, Lisinopril-Hydrochlorothiazide, and a Symbicort inhaler. The facility's policy required all drugs to be maintained under locked security unless under direct supervision of a nurse. However, the medications were found on the bedside table and floor, indicating a lapse in adherence to this policy. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the resident was not to self-administer medications and that nurses were responsible for ensuring medications were taken under supervision. This incident highlights a failure in following the facility's drug storage regulations.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Royalton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Royalton Post Acute | 1.9 mi | ★★★★★ | 11 | 0 |
| Royal Oak Nursing & Rehab Ctr | 2.3 mi | ★★★★★ | 0 | 0 |
| Falling Water Healthcare Center | 3 mi | ★★★★★ | 0 | 0 |
| Greenbrier Health Center | 3 mi | ★★★★★ | 25 | 1 |
| Pleasantview Care Center | 3 mi | ★★★★★ | 1 | 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.