Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Divine Rehabilitation And Nursing At Canal Pointe during CMS and state inspections, most recent first.
During meal service, hot foods were not kept at appropriate temperatures due to lack of heat conservation methods, resulting in food being served below the required 135°F. Staff and residents reported ongoing complaints about cold meals, and observations confirmed that food temperatures dropped significantly before reaching residents, contrary to facility policy.
Surveyors identified unsanitary conditions in the kitchen and a second floor kitchenette, including the presence of flying insects, rodent droppings, chipped paint, food debris, standing water, and heavy grime on multiple surfaces. These issues were confirmed by dietary and nursing staff and were not in compliance with facility policy, potentially affecting over 100 residents receiving meals.
Surveyors found that foods in unit refrigerators were not consistently labeled, dated, or discarded when expired, and that refrigerators were not maintained in a clean condition. Multiple expired and undated food items, as well as visible spills and stains, were observed across several floors. Staff interviews confirmed these practices were not in line with facility policy, potentially affecting over 100 residents, including several who were NPO.
The facility did not ensure that employees received and completed required annual training, as staff were provided with in-service packets to sign in advance of the actual due date, and some only briefly reviewed the materials or were unsure of their location. The Human Resource Director lacked a system to track training completion after discontinuing the online program, and the Administrator confirmed that other education provided was insufficient. This affected all employees reviewed and had the potential to impact all residents.
The facility did not ensure that CNAs received the required 12 hours of annual in-service training. Instead of regular training, staff were given a packet of materials to review on their own, with no system to track completion or understanding. This affected all residents in the facility.
A resident was found with unsecured inhalers at the bedside without documentation permitting self-administration, and expired medications were observed in medication storage rooms. Staff confirmed that medications should have been secured and expired items discarded, in accordance with facility policy.
Surveyors found that the facility did not consistently develop or implement comprehensive care plans for several residents, including those using oxygen, receiving high-risk anticoagulant medications, self-managing colostomy and catheter care, requiring enhanced barrier precautions, and experiencing PTSD. Care plans were missing, incomplete, or not individualized to reflect residents' needs and interventions, as confirmed by staff interviews and record reviews.
The facility did not complete timely or accurate smoking safety assessments for several residents, including those with severe cognitive impairment and behavioral issues. Some residents were allowed to smoke without supervision based on outdated or incorrect assessments, and required evaluations were not performed as per facility policy. Staff interviews confirmed lapses in assessment practices and documentation.
Two residents with cognitive impairments were found living in rooms with broken furniture, soiled surfaces, dirty bathrooms, and unclean air conditioning units. Staff confirmed these conditions, and housekeeping practices were found lacking, with no routine cleaning of certain areas and inadequate attention to cleanliness in shared spaces such as the shower room and resident lounge. These deficiencies had the potential to affect many other residents in the facility.
The facility did not thoroughly investigate multiple abuse allegations involving residents with behavioral and cognitive issues. Incidents included a physical altercation between two residents, repeated aggressive behaviors by a resident toward staff and peers, and an unreported allegation of inappropriate touching. Required investigations were not completed, and documentation was lacking or incomplete.
Multiple residents experienced significant medication errors, including late administration of critical medications such as insulin, anticoagulants, and cardiac drugs, as well as improper insulin administration techniques. LPNs failed to check blood sugar before meals and did not prime insulin pens as required. The DON confirmed that medications were often administered outside the facility's policy window, and residents reported receiving medications late or combined with other scheduled doses.
The facility did not serve food portions as specified in the menu, resulting in residents receiving less food than required. Incorrect serving utensils were used, leading to under-serving of items such as onions, peppers, and ground sausage. A resident reported insufficient food, and the Dietary Manager confirmed the portion discrepancies during meal service.
A resident with severe cognitive impairment and multiple vascular diagnoses did not have ordered labs completed due to refusal and lack of available staff. The missed labs were not documented, and neither the physician nor the responsible party was notified, contrary to facility policy.
Two residents, both with complex medical and behavioral histories, were involved in a physical altercation after one attempted to remove a female resident in a wheelchair from an elevator. Despite a documented pattern of aggression and daily behavioral issues, the facility did not implement additional safety measures such as secured unit placement, citing the resident's refusal. The incident was not substantiated as abuse by the facility, and no witnesses or perpetrator were identified in the records.
A resident with severe cognitive impairment and urinary retention requiring an indwelling catheter did not have daily fluid intake and urine output monitored or documented as required by their care plan. This deficiency was confirmed by the DON, who acknowledged that intake and output should have been tracked both while the catheter was in place and after it was discontinued.
A resident with severe cognitive impairment and multiple diagnoses, including diabetes and dysphagia, experienced significant weight loss after not receiving soup with lunch and dinner as ordered by the RD and physician. Staff failed to provide the prescribed nutritional intervention, did not encourage the resident to eat, and were unaware of the dietary orders, despite clear documentation and care plan instructions.
A resident receiving hospice care and oxygen therapy was found to be using oxygen without a physician's order, and the oxygen tubing in use was not dated as required by facility policy. Staff confirmed the absence of orders and the missing date on the tubing during interviews and observations.
A resident with end stage renal disease requiring dialysis did not have communication from the dialysis provider sent to the facility after each treatment. Staff confirmed that updates were not consistently received, and the resident reported never receiving paperwork to give to the facility. Only monthly summaries were available, and the facility's dialysis policy was not provided during the survey.
A resident with a history of suicidal ideation and multiple mental health diagnoses was not provided with adequate behavioral health care or a safe environment. Staff failed to implement or communicate suicide precautions, allowing the resident access to razors, inhalers, and a full sharps container in her room. Interviews and observations confirmed that staff were unaware of necessary interventions and did not secure potentially dangerous items, contrary to facility policy.
A resident with a history of stroke and on anticoagulant therapy did not receive timely physician-ordered lab tests to assess renal function and medication appropriateness. The lab draw was delayed, and when the resident refused, the lab tech did not inform the floor nurse, resulting in no follow-up, physician notification, or documentation of the missed labs.
Two residents requiring enhanced barrier precautions did not have PPE readily available in their rooms, and staff were observed not using required PPE during high-contact care activities. Soiled dressings were found on the floor, and staff demonstrated confusion about EBP protocols, with no trash cans available for PPE disposal as required by facility policy.
A resident with severe cognitive impairment and behavioral issues reported to a psychiatric NP that she lifted her shirt and a peer touched her breast. The incident was not communicated to the administrator, resulting in a failure to promptly report the abuse allegation to the State agency, initiate an investigation, or notify the resident's guardian as required by facility policy.
Two residents with diabetes had their blood sugar checked and insulin administered after eating breakfast, rather than before the meal as required. In both cases, LPNs did not follow facility policy to prime the insulin pen before each use, with one LPN stating she only primed new pens. The DON confirmed that blood sugar assessments should occur before meals. These failures had the potential to affect additional residents who require pre-meal blood sugar checks and insulin via pen.
The facility failed to ensure safe and secure disposal of medications. A sharps disposal container in the third-floor medication room was found without a lid and partially filled with various medications. Staff confirmed this was the method used for destroying medications due to a lack of proper disposal fluid. The DON acknowledged the issue but did not provide the facility's medication destruction policy.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide food at appetizing and safe temperatures, as observed during a lunch meal service. Initial food temperatures at the start of tray line service were within appropriate ranges, but there were no plate warmers or hot pellets used to maintain food temperature after plating. Chicken enchiladas were left uncovered on a cart next to the steam table, rather than being kept on the steam table, resulting in a significant drop in temperature. The last chicken enchilada served from the uncovered baking sheet measured 130°F, below the facility's policy requirement of holding hot foods at 135°F. Additional observations showed that by the time food reached residents, temperatures had dropped further, with one meal measuring 115°F for both the chicken enchilada and mashed potatoes, and 95°F for green beans. Multiple interviews with dietary staff, CNAs, and residents confirmed ongoing complaints about hot foods being served cold. Residents expressed dissatisfaction with the temperature of their meals, specifically noting a preference for warmer food. Review of facility policies indicated that hot foods should be served at appetizing temperatures and held at or above 135°F, but these standards were not met during the observed meal service.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, as evidenced by multiple observations and interviews. Surveyors observed a pervasive problem with small, flying insects throughout the kitchen, including above the handwash sink, around the dishwasher, near a hanging dish cabinet, and near the oven. There were also multiple areas of chipped or bubbled paint and damaged drywall in food preparation areas, a moderate collection of food debris on storage racks and walls, and standing water near the dishwasher. Additionally, several surfaces, such as oven doors, range tops, pipes, kitchen floors, range hood fire suppression nozzles, and sprinkler pipes, were found to have moderate to heavy black grime. These findings were confirmed by the Dietary Supervisor during the inspection. Further inspection of the second floor kitchenette revealed a rodent bait box with multiple rodent droppings on the floor and on the microwave stand behind the microwave. The Assistant Director of Nursing verified these findings. Review of pest control invoices indicated ongoing issues with kitchen insects and rodents, with extra service provided for rodents. Facility policy required all food service areas to be kept clean and protected from pests, with weekly inspections to ensure compliance, but these standards were not met. The deficiency had the potential to affect 108 residents receiving meals from the kitchen, with three residents identified as receiving nothing by mouth (NPO).
Improper Food Labeling, Storage, and Sanitation in Unit Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to ensure that foods stored in unit refrigerators were properly labeled, dated, and discarded when expired, and that the refrigerators were maintained in a clean condition. During an inspection with the Dietary Manager, multiple expired and undated food items were found in nourishment refrigerators on the second, third, and fourth floors, including expired milk, soy sauce, hot sauce, potato salad, apples, yogurt, and a frozen entrée. Additionally, several food items lacked labels or dates, and there were visible spills and stains inside the refrigerators. The base of one refrigerator was stained with an unidentifiable pink substance, and another contained a red sticky substance and crumbs. Interviews with the Dietary Manager confirmed that foods should be labeled, dated, and discarded when expired, in accordance with facility policy. The Administrator and Quality Assurance RN acknowledged that housekeeping staff were responsible for cleaning the unit refrigerators every three days, but were made aware of the unsanitary conditions and expired foods during the survey. Facility policies reviewed indicated that all food items brought in by families or visitors must be labeled and dated, and prepared foods should be consumed within three days or discarded. The deficiency had the potential to affect 108 residents receiving meals from the kitchen, with three residents identified as NPO at the time of the survey.
Failure to Ensure Required Annual Staff Training
Penalty
Summary
The facility failed to ensure that employees received the required annual training as mandated by applicable laws and regulations. Review of personnel files for 13 employees revealed that staff were provided with two types of in-service packets, which they signed to acknowledge receipt and review. However, some employees signed these packets upon hire or in advance of the actual annual due date, indicating that the training may not have been completed at the appropriate time. Additionally, the packets were distributed for the upcoming year, and signatures were obtained before the information was reviewed. Interviews with staff confirmed that some employees only briefly reviewed the materials or were unsure of the location of their packets, suggesting that the training was not effectively delivered or tracked. The Human Resource Director stated that the facility had discontinued its online training program and replaced it with the packet system, but did not have a method to track completion of education otherwise. The Administrator acknowledged that other training provided by the DON throughout the year was insufficient, as it was not conducted monthly. This deficiency affected all 13 employees reviewed and had the potential to impact all 111 residents in the facility.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to provide regular annual training for certified nursing assistants (CNAs), as required for their 12 hours of in-services each year. Review of personnel files for three CNAs showed no evidence of ongoing training throughout the year. Instead, the facility discontinued its online training program over a year ago and began giving staff a packet of in-service materials for the entire year at orientation and annually, with only the first page signed by the employee. There was no system in place to track or verify that staff actually read or completed the training materials, as confirmed by the Human Resource Director. This lack of regular and verifiable training had the potential to affect all 111 residents in the facility.
Failure to Securely Store Medications and Remove Expired Drugs
Penalty
Summary
The facility failed to ensure that medications were securely stored and that expired medications were discarded, as required by policy and professional standards. In one instance, a resident with diagnoses including anxiety disorder, depression, post-traumatic stress disorder, and borderline personality disorder was found to have an albuterol inhaler and a Trelegy inhaler unsecured at the bedside. The resident was cognitively intact and independent with mobility, but there was no physician's order or documentation indicating the resident was permitted to self-administer medications. Nursing staff confirmed that all medications for this resident should have been stored and administered by staff, and that the inhalers should not have been left at the bedside. Additionally, observations of medication storage rooms revealed multiple expired items, including a COVID-19 test, glucose test strips, magnesium, bisacodyl tablets, guaifenesin, and omeprazole. The DON confirmed the presence of these expired house stock items, which should have been discarded according to facility policy. The policy also stated that all drugs and biologicals must be stored in locked compartments and that the pharmacy and medication rooms are routinely inspected for outdated medications.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the full scope of residents' medical, psychosocial, and mental health needs, as identified through record review, observation, and staff interviews. For one resident with diagnoses including malignant neoplasm of the prostate and COPD, who was receiving hospice services and using oxygen, there was no care plan in place for oxygen use, despite observations confirming its use and facility policy requiring such a plan. Another resident receiving high-risk anticoagulant medication did not have a care plan addressing the monitoring and management of side effects, even though physician orders specified monitoring requirements. A resident with a colostomy and suprapubic catheter, who was cognitively intact and self-managed his care, had care plans that did not reflect his self-management, instead listing only standard nursing interventions. For a resident with severe cognitive impairment and chronic wounds requiring enhanced barrier precautions (EBP), there was no care plan addressing EBP, despite physician orders and staff confirmation that such a plan was required. Additionally, a resident with PTSD and other mental health diagnoses had an incomplete care plan that did not identify specific triggers or interventions to alleviate symptoms, with only a single generic intervention documented and no measurable goals. These deficiencies were confirmed through interviews with nursing and social work staff, who acknowledged the absence or incompleteness of required care plans. Facility policies reviewed indicated that comprehensive, person-centered care plans with measurable objectives and time frames were required for all identified needs, but these were not consistently developed or implemented for the affected residents.
Failure to Timely and Accurately Assess Residents for Smoking Safety
Penalty
Summary
The facility failed to timely and accurately assess residents for smoking safety, as evidenced by record reviews, interviews, and policy review. Four residents with varying degrees of cognitive impairment and complex medical histories were affected. For two residents with severe cognitive impairment, the smoking safety screens incorrectly indicated no cognitive loss, despite their low BIMS scores and care plans noting significant cognitive deficits. Orders allowed these residents to smoke without supervision, and the assessments did not reflect their true cognitive status. Another resident, also severely cognitively impaired with behavioral issues, had not received a smoking assessment in the previous 12 months, contrary to facility policy. The resident was listed as a supervised smoker, but documentation and assessment practices were inconsistent. Additionally, a cognitively intact resident had not received a smoking safety screen for nearly two years, despite being an active smoker. Staff interviews revealed a lack of adherence to the facility's policy, which required smoking assessments at admission and with each quarterly or comprehensive MDS assessment. Nursing staff acknowledged that assessments were not being completed as required, and there was confusion regarding the use of cognitive assessments. The facility's failure to conduct timely and accurate smoking assessments resulted in residents being permitted to smoke without appropriate supervision or updated evaluations of their safety needs.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. Two residents were found living in rooms with significant cleanliness and maintenance issues, including broken furniture, soiled and dusty surfaces, stained and dirty curtains, and unclean bathrooms with foul odors and visible stool. One resident, moderately cognitively impaired with Alzheimer's disease, was observed in a room with a broken closet door, food crumbs, dirt, soiled clothing, and a bathroom with dried stool and grime. Another resident, severely cognitively impaired with dementia and ADHD, was found in a room with broken furniture, stained recliner, soiled curtains, and a broken bed footboard. Both residents' rooms had air conditioning units and dressers with dried spills and dust buildup, and staff confirmed these conditions during the survey. Further observations revealed that the facility's cleaning practices were inadequate. Housekeeping staff reported that deep cleaning was only performed for major messes, and that certain areas, such as the edges of floors and privacy curtains, were not routinely cleaned. The second-floor shower room, used by all residents on that floor, had a dirty floor with scum buildup, a rusted bedside commode, and a ceiling with mold and peeling paint. Additionally, the third-floor resident lounge contained worn and ripped chairs. Facility policy required staff to report furniture in disarray and maintain a sanitary environment, but these standards were not met, affecting not only the two residents observed but also potentially impacting 78 additional residents on the second and third floors.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents. In one incident, two cognitively intact residents with significant behavioral histories were involved in a physical altercation in the lobby after a dispute over elevator access. The facility's self-reported incident (SRI) did not identify witnesses or a perpetrator, and the allegation of abuse was unsubstantiated. Documentation showed that one resident had a history of physical aggression and behavioral issues, yet was not placed on a secured unit due to his refusal, despite ongoing threats and aggressive behavior toward others. Another resident with moderate cognitive impairment and behavioral disturbances was involved in several incidents, including making sexually explicit comments to staff, attempting to hit another resident, and becoming physically aggressive during a dispute. On one occasion, after a resident believed another had spit on him, he attempted to punch the other resident. The facility did not file an SRI for this incident, and documentation was limited to separating the residents and providing emotional support, without a thorough investigation as required by policy. A third resident, who was severely cognitively impaired and had a history of delusions and disruptive behaviors, reported to the psychiatric nurse practitioner that a peer had touched her breast after she lifted her shirt. The administrator was unaware of this allegation, and no investigation was initiated because staff did not report the incident. The facility's policy requires all allegations of abuse to be investigated and residents to be protected during investigations, but this was not followed in these cases.
Significant Medication Administration Errors Due to Late and Improper Dosing
Penalty
Summary
Multiple residents experienced significant medication administration errors, including late administration of critical medications and improper insulin administration techniques. For example, one resident with diabetes mellitus and diabetic nephropathy received insulin after consuming breakfast, and the LPN failed to check blood sugar prior to the meal and did not prime the insulin pen before administration. Another resident with type two diabetes mellitus received insulin after breakfast, but the blood sugar was checked only after the meal, contrary to care plan interventions requiring blood sugar monitoring before meals. Several residents with complex medical conditions, such as congestive heart failure, COPD, hypertension, and diabetes, had their scheduled medications administered several hours late on multiple occasions. Medications affected included metoprolol, Entresto, Lasix, Ativan, gabapentin, spironolactone, Macrobid, Colchicine, Eliquis, trazodone, insulin Lispro, insulin Glargine, Depakote, Tamsulosin, and others. These late administrations were confirmed by both medical record review and interviews with the DON, who acknowledged that medications were given outside the facility's policy window of 60 minutes before or after the scheduled time. Residents also reported receiving medications late, sometimes receiving multiple scheduled doses together, such as morning and noon medications at the same time. The facility's own policy required medications to be administered within a specific time frame, but this was not consistently followed. The DON confirmed that these late administrations constituted medication errors, and the deficiency affected multiple residents reviewed for medication administration.
Failure to Serve Menu-Specified Food Portions
Penalty
Summary
The facility failed to provide food items at the designated portions as written on the menu for residents receiving meals from the kitchen. Observations and interviews revealed that the portions served did not match the amounts specified in the menu spreadsheet. Specifically, for a lunch meal, the portions of onions and peppers and ground Polish sausage were under-served by one ounce and one third of a cup, respectively. The dietary staff used incorrect serving utensils, resulting in residents not receiving the full portions as planned. The Dietary Manager confirmed that the portions served were less than required and verified the use of incorrect utensils during the meal service. Additionally, a resident reported that the portions were insufficient and that residents did not always get enough food to eat. The facility census was 111, with three residents identified as NPO and seven residents observed to receive alternate meals. The deficiency was identified through observation, interview, and review of menu documentation, affecting 101 residents who received food from the kitchen.
Failure to Notify Physician and Responsible Party of Missed Lab Orders
Penalty
Summary
The facility failed to notify the physician and the resident's responsible party when laboratory tests ordered for a resident were not completed as directed. The resident, who had diagnoses including vascular dementia, cerebral infarction, and a history of TIA, was severely cognitively impaired and receiving Eliquis, a blood thinner. A pharmacy review noted that the resident's renal function might require a dosage adjustment, prompting the physician to order a complete metabolic panel, complete blood count, and renal function panel. However, these labs were not completed, and there was no documentation in the medical record explaining the missed tests or indicating that the physician or responsible party had been informed. Further investigation revealed that the lab technician attempted to collect the blood sample, but the resident was combative and refused, and no qualified personnel were available to assist. The lab requisition was left incomplete, and the floor nurse was not made aware that the labs were not obtained, resulting in a lack of follow-up or documentation. The facility's policy required notification of the physician and responsible party in such circumstances, but this was not done, constituting a failure to follow established procedures for notification of changes affecting the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents. One resident, with a history of chronic medical and psychiatric conditions including PTSD and major depressive disorder, was involved in an altercation with another resident who had paraplegia and a documented pattern of physical and verbal aggression. The incident occurred when several residents attempted to use the elevator at the same time, leading to one resident attempting to forcibly remove a female resident in a wheelchair to gain access. The other resident intervened, resulting in both residents physically striking each other and falling to the floor before being separated by staff. Documentation and interviews revealed that the aggressive resident had a history of daily physical and verbal aggression, including attacking staff, using foul language, and rejecting care. Despite these ongoing behaviors, the facility did not implement additional safety measures such as placement in a secured unit, citing the resident's refusal and status as his own responsible party. The facility had planned to present a behavior contract at a care plan conference, but the resident was discharged to a psychiatric unit before this could occur. The facility's abuse policy required protection of residents and review of risk factors, but the incident was not substantiated as abuse by the facility due to uncertainty about who initiated the altercation. The facility's records did not list witnesses or identify a perpetrator for the incident, and the administrator confirmed that the allegation of abuse was unsubstantiated. The aggressive resident was eventually given an immediate discharge notice and escorted from the property by police after returning from the hospital against medical advice. The facility's failure to implement effective interventions to address the known aggressive behaviors contributed to the occurrence of resident-to-resident physical abuse.
Failure to Monitor Intake and Output for Resident with Urinary Retention
Penalty
Summary
A deficiency was identified regarding the facility's failure to monitor and document daily fluid intake and urine output for a resident diagnosed with urinary retention and requiring an indwelling urinary catheter. The resident, who was severely cognitively impaired and had diagnoses including vascular dementia, cerebral infarction, neuromuscular dysfunction of the bladder, and retention of urine, was admitted with an indwelling urinary catheter. The care plan specified that intake and output should be monitored and documented per facility policy. Despite these requirements, review of the medical record revealed that from the time the resident had the indwelling catheter and after its discontinuation, there was no documentation of daily fluid intake or urine output. This lack of monitoring occurred even after the resident experienced a change in condition, was sent to the emergency room, and returned with a Foley catheter in place. The deficiency was confirmed by the Director of Nursing, who acknowledged that intake and output should have been documented and monitored for this resident due to the diagnosis of urinary retention.
Failure to Provide Ordered Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, type one diabetes mellitus, and dysphagia experienced a significant weight loss of 6.72% over a three-month period. The resident was assessed as severely cognitively impaired and required set up or clean up assistance with meals. The care plan and physician orders specified that the resident should receive a regular diet with thin liquids and soup provided with lunch and dinner as a nutritional intervention to address weight loss. Despite these orders, observations revealed that the resident was not served soup with either lunch or dinner, and staff confirmed that soup was not routinely provided. Additionally, staff did not encourage the resident to eat or offer alternatives when the resident did not consume the meal provided. Interviews with staff indicated a lack of awareness regarding the resident's dietary orders, with one CNA stating she did not read the meal tickets and an LPN expressing uncertainty about the resident's dietary requirements. The registered dietitian confirmed that soup was added to the resident's meals as an intervention for weight loss and expected staff to encourage meal consumption and offer alternatives as needed. The facility's policy required individualized nutritional interventions and monitoring, but these were not consistently implemented for this resident.
Failure to Ensure Physician Orders and Proper Dating of Oxygen Tubing
Penalty
Summary
A deficiency was identified when a resident with diagnoses including malignant neoplasm of the prostate, chronic obstructive pulmonary disease, anxiety, and hypertension was observed receiving oxygen therapy without a corresponding physician's order in place. The resident was cognitively intact, receiving hospice services, and was noted to be using oxygen during multiple observations. Review of the medical record and interviews with staff confirmed that there were no orders for oxygen administration documented in either the paper or electronic records, despite facility policy requiring physician orders for oxygen except in emergencies. Additionally, the oxygen tubing in use for the resident was not dated as required by facility policy, which mandates that oxygen tubing and cannulas be dated and changed weekly or as needed. Staff interviews verified that the tubing should have been dated and that this requirement was not met. The lack of proper orders and failure to date the oxygen tubing were observed and confirmed by both direct observation and staff interviews.
Failure to Obtain Post-Dialysis Communication from Provider
Penalty
Summary
The facility failed to obtain communication from the dialysis provider after each dialysis treatment for a resident who required such services. The resident was admitted with multiple diagnoses, including end stage renal disease dependent on dialysis, and had physician's orders to attend dialysis three times a week with a fluid restriction. While the facility completed pre and post dialysis assessments on the days the resident attended dialysis, there was no evidence that the facility received or documented communication from the dialysis center after each treatment. Interviews with facility staff confirmed that communication from the dialysis center was not consistently received after each visit, and the resident reported never being given paperwork to provide to the facility following dialysis sessions. When requested, the facility was only able to provide a monthly summary of lab work and weights, with no documentation of updates from the dialysis center after each treatment. Additionally, the facility's dialysis policy was requested but not provided during the survey.
Failure to Ensure Safe Environment and Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure a safe environment and provide necessary behavioral health care and services for a resident with a history of suicidal ideation and multiple mental health diagnoses, including anxiety disorder, depression, PTSD, gender identity disorder, and borderline personality disorder. The resident had previously expressed suicidal thoughts, including specific plans and intent, which led to a hospital transfer. Upon return, the resident continued to express thoughts of self-harm and disclosed access to a razor in her room. Staff interviews revealed a lack of awareness and implementation of suicide precautions for the resident. Several CNAs and an LPN who worked with the resident were either unaware of any interventions in place or did not know of any specific precautions being used. The resident was able to access potentially dangerous items, such as disposable razors, inhalers, and a full sharps container in her room. The DON and other staff confirmed that these items should not have been unsecured and accessible to a resident with suicidal tendencies. Observations confirmed the presence of unsecured inhalers and a full sharps container in the resident's room, and staff acknowledged these were not appropriate. The facility's behavioral health policy emphasized person-centered care and safety, but staff actions and interviews demonstrated a failure to follow through with necessary interventions and environmental safety measures for a resident at risk for self-harm.
Failure to Complete and Communicate Physician-Ordered Labs
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed in a timely manner for a resident with multiple diagnoses, including vascular dementia, cerebral infarction, and a history of transient ischemic attack. The resident was prescribed Eliquis, an anticoagulant, and a pharmacy review raised concerns about the appropriateness of the dosage based on the resident's renal function. As a result, a physician ordered a complete metabolic panel, complete blood count, and renal function panel to assess the resident's suitability for the prescribed medication. Despite the order, the laboratory tests were not completed as required. The blood draw was scheduled several days after the order and was not performed because the resident was combative and refused, and no qualified personnel were available to assist. The lab technician did not notify the floor nurse of the unsuccessful attempt, and the nurse did not follow up, notify the physician, or document the missed lab or any reattempts. This sequence of inactions resulted in the ordered labs not being completed or communicated appropriately.
Failure to Maintain Enhanced Barrier Precautions and PPE Availability
Penalty
Summary
The facility failed to maintain proper infection control practices and ensure that personal protective equipment (PPE) was readily available for two residents who required enhanced barrier precautions (EBP). For one resident with a history of attention deficit hyperactivity disorder, dementia, and a chronic wound, observations revealed a soiled dressing on the floor next to the bed and no PPE available inside or outside the room. Staff interviews confirmed that the resident frequently removed dressings and that there was confusion among staff regarding the purpose of the EBP signage. Additionally, there was no trash can near the exit for disposing of used PPE, and staff confirmed that PPE was not readily accessible for use. For another resident with severe protein calorie malnutrition, an indwelling catheter, and a feeding tube, staff were observed administering medications and handling the feeding tube without donning an isolation gown, as required under EBP. The LPN involved stated that she did not believe a gown was necessary for medication administration via tube feeding and confirmed that she worked across multiple floors. Facility policy required gowns and gloves to be available near or outside the resident's room and a trash can positioned for discarding PPE, but these measures were not observed to be in place.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse to the State agency as required by policy. A resident with severe cognitive impairment, delusions, and disruptive behaviors reported to the psychiatric nurse practitioner that she lifted her shirt and a peer touched her breast. The resident denied being assaulted, but the incident was not communicated to the facility administrator by either the nurse or the nurse practitioner. As a result, the allegation was not reported to the State agency, was not investigated, and the resident's guardian was not notified in a timely manner. The facility's policy requires all allegations of abuse to be reported and investigated, but this process was not followed until several days later when a self-reported incident was filed.
Failure to Perform Pre-Meal Blood Sugar Checks and Proper Insulin Pen Priming
Penalty
Summary
The facility failed to ensure that blood sugar assessments were performed prior to breakfast and that insulin pens were properly primed before administration for two residents with diabetes. In both observed cases, residents had already consumed their entire breakfast before LPNs assessed their blood sugar levels and administered insulin. For one resident, the LPN administered a total of nine units of Humalog insulin (six units routine and three units per sliding scale) after breakfast, without priming the insulin pen. The LPN stated she only primed new pens and had not been priming the pen for ongoing use, despite working with all residents on all floors. The resident's care plan and physician orders required blood sugar checks and insulin administration in relation to meals, and the facility policy specified that insulin pens should be primed prior to each use. A second resident, also with diabetes, had their blood sugar checked and received both Humalog and glargine insulin after finishing breakfast. The LPN confirmed the timing of the blood sugar assessment and insulin administration occurred post-meal. The Director of Nursing confirmed that blood sugar assessments were to be completed prior to meals. Facility policy required insulin pens to be primed before each use, but this was not followed. These failures affected two observed residents and had the potential to impact an additional 24 residents identified as requiring pre-meal blood sugar assessments and/or insulin via pen.
Improper Medication Disposal
Penalty
Summary
The facility failed to ensure all medications were disposed of in a safe and secure manner. During an observation of the third-floor medication room, a large sharps disposal container was found on the counter, approximately one quarter full of various medications, without a lid. Interviews with a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) confirmed that the container was not secure and that this was the method used to destroy medications for discharged residents or discontinued medications. Both nurses stated that there was no fluid available for the destruction of the medications, so they continued to place them in the sharps container. The Director of Nursing (DON) acknowledged that the facility was out of the liquid used for medication destruction and mentioned that more would be ordered from the pharmacy. However, the facility's policy for the destruction of medications was not provided when requested. A review of the Medication Administration policy revealed no information regarding the destruction of expired or discontinued medications. This deficiency was investigated under Complaint Number OH00153460.
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.
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What surveyors actually found near you
We read the 1,082 citations issued within 25 miles in the last 12 months — including the 6 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Ridge Nursing & Rehabilitation Center | 1.1 mi | ★★★★★ | 19 | 0 |
| The Merriman | 1.5 mi | ★★★★★ | 19 | 1 |
| Ohio Living Rockynol | 2.2 mi | ★★★★★ | 0 | 0 |
| Highland Square Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 5 | 1 |
| Tallmadge Health & Rehab Center | 3.1 mi | ★★★★★ | 6 | 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.