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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Divine Rehabilitation And Nursing At Sylvania during CMS and state inspections, most recent first.
The facility failed to provide enough CNA coverage to meet resident needs, and call lights and incontinence care were delayed for multiple residents. A cognitively intact resident with multiple chronic conditions reported waiting since the prior night for a brief change, while staff confirmed the resident had not received timely care and that call lights were not being answered promptly because only one CNA was available for too many residents. Other residents reported prolonged waits for assistance, and staffing schedules showed shifts with one CNA for 22 residents and some periods with no CNA assigned.
Menu Not Followed During Meal Service: The facility failed to follow the pre-planned lunch menu, with residents receiving meals that did not match the meal tickets or posted menu. A resident meal included pork loin, mixed vegetables, and corn bread instead of baked beans, and staff confirmed they did not always know what was supposed to be served. On another meal, the vegetable and dessert served did not match the menu, and the Dietary Mgr verified the substitutions had not been approved by the dietitian.
Unsafe and Unclean Resident Areas and Shower Chair: The facility failed to maintain a clean, safe, and homelike environment in a memory care living room and in a resident room. Surveyors observed gouged drywall, a broken outlet cover, torn wall edges, puddles of water, and broken, crumbling floor tile. A shower chair also had a dried brown substance on it, and an RN, CNA, and Maintenance Manager confirmed the conditions.
An LPN failed to perform hand hygiene before and after medication administration for two residents, and another LPN did not clean a BP cuff between residents during vital sign checks. During med prep, an LPN picked up a spilled pill with a bare contaminated hand and returned it to the med cup. In addition, two CNAs provided incontinence care and a gown change for a resident on Enhanced Barrier Precautions without wearing gowns as required by the order and facility policy.
Protected health information was left unsecured when written provider orders for a resident were observed face-up on the nurse station desk and visible to anyone passing by. The DON confirmed the first order should not have been left that way, and an LPN later confirmed a second order was also exposed on the desk. Facility policy stated reasonable measures were required to protect PHI, and the RDCS confirmed the HIPAA policy applied to paper documents.
Failure to Assist Dependent Resident With Feeding: A resident with dementia, Alzheimer's disease, and dysphagia was identified as severely cognitively impaired and totally dependent on staff for feeding. During observation, he was alone in the dining room attempting to eat pureed food and pudding on his own, with spilled thickened liquids and food on his clothing and the floor. Dietary aides later confirmed he needed help eating and had been left trying to feed himself until he was moved away.
Delayed Response to Resident Call Lights: Two residents had call lights sounding for extended periods while staff walked past the nurse station, left the area, or passed meal trays without responding. The DON confirmed call lights should be prioritized and not ignored, and a CNA later stated she heard the alarms but did not answer them. Facility policy stated any staff member who saw or heard an activated call light was responsible for responding.
Delayed Implementation of Ordered Wound Therapy: A resident with a stage 4 pressure ulcer and multiple serious diagnoses had a new order for negative pressure wound therapy, but staff did not implement the ordered treatment for several days. Observation and record review showed no evidence the therapy was in place, and the ADON confirmed it had not been started because she was unsure where to obtain the equipment. Facility policy required wound treatment to be provided in accordance with physician orders.
A resident with MS, chronic pain, depression, anxiety, weakness, tremors, and seizures had a care plan for fall risk that included bed bolsters and keeping the bed low, but staff observed the bed extremely high with no bolsters in place; the CNA and DON confirmed the missing interventions. In addition, three storage closets near the nurse's station were left unlocked or accessible, containing cleaning chemicals, disinfectants, and a biohazard bin with sharps containers, despite the facility's chemical storage policy requiring chemicals to be locked.
Catheter securement devices were not in place for two residents with indwelling catheters, and one resident had no documented catheter care each shift despite orders for routine care and securement. The resident’s care plan and physician orders called for securement and shift catheter care, but observation and staff interviews confirmed the devices were absent and care was not being documented. The facility also failed to provide timely incontinence care to a cognitively intact resident who waited hours for a brief change, with staff confirming the brief was full and that staffing shortages contributed to delayed care.
A resident with significant cognitive and physical impairments, identified as a fall risk, did not have care-planned safety interventions in place, including enabler bars, a body pillow, and an accessible call light. Staff interviews confirmed these items were not provided or available, and the facility's fall prevention policy was not followed.
A resident with dementia, heart failure, and diabetes developed an unstageable pressure ulcer due to the facility's failure to provide timely wound assessment and treatment. The resident's high risk for skin breakdown was not addressed in a care plan, and a low air loss mattress was delayed. Staff interviews revealed inadequate communication and coordination in wound care management.
The facility failed to conduct quarterly care plan conferences for residents, affecting six out of seven reviewed. Despite various medical conditions, residents had fewer than required conferences, with some having none. This deficiency indicates a lack of adherence to the facility's policy of involving residents and their representatives in care planning.
The facility failed to monitor the effectiveness of psychotropic medications for several residents, including those with anxiety, depression, and schizoaffective disorder. Despite care plans requiring monitoring, there was no documentation of behavior tracking or non-pharmacological interventions. Interviews confirmed the lack of monitoring, leading to deficiencies in care.
An LPN failed to sanitize hands between serving meals to residents, affecting four residents. The LPN was observed delivering meal trays and touching surfaces without hand sanitizing between each resident. This was confirmed in an interview with the LPN.
The facility failed to maintain a clean and functional environment, affecting several residents with broken window blinds and other maintenance issues. Residents expressed dissatisfaction, and observations confirmed dirt buildup and loose wiring. Maintenance and housekeeping responsibilities were not fulfilled according to facility standards.
A facility failed to maintain a resident's dignity during meal assistance. The resident, with severe cognitive impairment and requiring meal supervision, was observed being fed by a CNA who stood over them while providing food. This practice was confirmed by the CNA, contradicting the facility's policy on promoting resident dignity.
The facility failed to ensure call lights were accessible to two residents, leading to discomfort and inability to call for assistance. One resident with Parkinson's and dementia was found with the call light and bed remote out of reach, while another resident with brain damage and epilepsy had the call light placed on the wrong side, contrary to the care plan. LPNs were unaware of the care plan requirements, and the facility policy on call light accessibility was not followed.
A resident with anxiety disorder, borderline personality disorder, and insomnia requested access to dental information in his medical record due to dental pain. Despite having intact cognition and making a verbal request to the DON two weeks prior, the resident had not received the requested records. The facility's policy requires records to be accessible within 24 hours of a request.
The facility failed to provide adequate assistance with ADLs for residents dependent on staff for grooming and hygiene. A resident with multiple health issues did not receive scheduled showers, resulting in matted hair and untrimmed facial hair. Another resident with paraplegia reported not receiving showers as scheduled, with no documentation of refusals. A third resident, dependent due to hemiplegia, did not receive showers for over a month due to alleged equipment issues, despite alternative options being available.
The facility failed to follow physician orders for wound care and edema management for two residents. One resident's wound dressing was not changed as scheduled, and another resident did not receive lymphedema pump treatments as ordered, with incorrect settings causing discomfort. These deficiencies were confirmed by staff and medical records.
A facility failed to provide ordered range of motion (ROM) exercises for a resident with bilateral lower extremity contractures. Despite a physician's order for twice-daily ROM exercises, observations and interviews revealed that the exercises were not performed. The resident reported not receiving the exercises, and CNAs confirmed they did not provide them, nor did they observe nurses doing so.
The facility failed to report and monitor falls for two residents at risk. One resident was not documented as having fallen despite expressing pain and later being diagnosed with a fracture. Another resident, who was supposed to be monitored in common areas, was left alone in a dining room, positioned unsafely. These actions were contrary to the facility's fall prevention policy.
A resident with severe cognitive impairment and multiple health conditions was frequently found without access to water, both in his room and in common areas. Despite the facility's policy to offer fluids between meals, staff interviews and observations confirmed inconsistencies in providing water, leading to the resident expressing thirst and being without water on several occasions.
A facility failed to maintain and apply oxygen equipment as ordered for a resident with COPD and chronic respiratory failure. The resident's CPAP machine was not used as prescribed due to a lack of distilled water, and there was no documentation of oxygen saturation levels being monitored every shift. Additionally, the resident's oxygen nasal cannula was heavily soiled, and the Unit Manager LPN confirmed the equipment was not maintained as required.
A resident with end-stage chronic kidney disease did not receive adequate dialysis care at the facility. The facility failed to document monitoring of the dialysis port and fluid intake/output, and communication with the dialysis center was inconsistent. Staff interviews revealed a lack of confirmation on medication administration during dialysis and no documentation of fluid intake during meals. The facility also lacked a dialysis policy.
A resident did not receive prescribed tramadol for pain management on four occasions due to the facility's failure to ensure the medication was available. Despite the resident's awareness and notification to the nurse practitioner, the medication was not administered as a controlled medication form was required. The facility's pain management policy was not followed.
The facility failed to ensure timely physician responses to pharmacy recommendations for three residents, leading to deficiencies in medication management. A resident with chronic conditions did not receive a recommended calcium supplement, another with diabetes had delayed medication adjustments, and a third did not have their medication dosage increased or necessary lab tests conducted. The facility's policy to encourage physician action on pharmacy recommendations was not followed.
The facility experienced a medication error rate of 20%, exceeding the acceptable 5% threshold. Errors included an LPN failing to administer spilled medications to a resident and another LPN not adhering to the required interval between inhaler administrations and lacking a prescribed nasal spray.
The facility failed to ensure proper medication management, as observed during medication administration sessions. An LPN improperly disposed of medications in a trash can attached to the medication cart, and several medications were found opened without being dated. Another LPN left a medication card unattended on a cart. The facility's policy lacked guidelines for dating opened medications, affecting two cognitively impaired residents.
A resident with multiple diagnoses, including anxiety and bipolar disorder, did not receive his requested double portions of meals, despite a physician's order. Observations and interviews confirmed that during dinner and breakfast, the resident received only single portions, leading to reports of hunger.
A facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube. An LPN was observed administering medication without wearing a gown, despite signage indicating the requirement for gloves and a gown during feeding tube care. The LPN acknowledged the oversight, citing nervousness, although PPE was available.
A resident with cognitive impairment and multiple health conditions was found to have a mattress that did not fit the bed, creating a large gap. The facility lacked a program for regular inspections of bed frames, mattresses, and bedrails. The Maintenance Supervisor noted a nine-inch gap, and the DON confirmed the bed was a rental, acknowledging the need for an extender or longer mattress.
The facility failed to provide required transfer/discharge notices to residents and their representatives, affecting four residents who were sent to the hospital without proper notification. The facility's policy requires such notices to be given in an understandable manner, but this was not followed, as confirmed by the administrator.
The facility failed to provide bed hold notices to residents or their representatives at the time of hospital transfer, affecting four residents. The facility's policy requires written notice specifying the bed-hold duration and return information, but this was not documented for residents transferred for medical reasons such as shortness of breath and abnormal lab values. The Administrator confirmed the oversight.
A resident with multiple sclerosis and other conditions was not notified before a new roommate moved in, violating facility policy. The new roommate, who has intellectual disabilities and other mental health conditions, was informed of the change, but the resident was not, leading to a deficiency finding during a complaint investigation.
A facility failed to provide adequate wound care for a resident on hospice, resulting in a significant decline in a wound on the left lower extremity. The wound became infected and necrotic, necessitating emergency services, hospital admission, surgical debridement, and prolonged antibiotic therapy. This situation was classified as Immediate Jeopardy due to the potential for serious life-threatening harm. Additionally, another resident with a surgical incision did not receive proper wound monitoring and documentation, leading to a classification of Severity Level 2 for potential more than minimal harm.
The facility failed to provide appropriate care and ongoing monitoring of a stage IV pressure ulcer for a resident with multiple diagnoses, including paraplegia. The facility did not complete required weekly skin assessments, and there were inconsistencies in the documentation of wound care treatments and assessments. The Director of Nursing confirmed the lack of completed assessments, and an LPN verified that wound appearance was not documented with each dressing change.
Insufficient Staffing and Delayed Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident care needs and to have a licensed nurse in charge on each shift. The deficiency involved residents who were incontinent and dependent on staff for activities of daily living, including a cognitively intact resident with Type II diabetes mellitus, hypertension, depression, respiratory failure, chronic kidney disease, difficulty walking, and muscle weakness. That resident was observed with a call light activated, and the resident and spouse reported the brief had not been changed since the prior night and that staff had not responded despite repeated call light use. The call light system showed the call light had been active for an extended period, and a CNA confirmed the resident had not received timely incontinence care. Other residents reported similar delays in assistance. One resident stated aides were not always available and call lights were not answered in a timely manner, and observation showed that resident's call light remained activated for 50 minutes before staff entered the room. A CNA confirmed the delay and stated she was only one person and could not help all residents in a timely manner. Another CNA reported there were supposed to be two CNAs assigned to the unit but she was often the only one working because of staffing shortages, with approximately 11 to 12 residents needing incontinence care. An RN also stated there were not enough CNAs and residents often did not receive assistance in a timely manner. A third resident reported often going 12 to 13 hours without an incontinence brief change, and another resident reported waiting hours for brief changes after activating the call light. Review of the facility assessment showed staffing expectations of one CNA for every nine to 12 residents, but staffing schedules documented multiple shifts with one CNA assigned for 22 residents, one aide assigned for 18 memory care residents, and some shifts with no CNA assigned for certain resident groups. Facility policies stated residents would receive appropriate incontinence care and that sufficient staff with appropriate competencies would be provided.
Menu Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure the pre-planned menu was followed for lunch service, affecting all 67 residents who received food from the kitchen. On 07/13/26, the menu and meal tickets indicated baked beans were to be served with lunch, but observation at 12:10 P.M. showed residents received pork loin, mixed vegetables, and corn bread instead, and baked beans were not served. Resident #31, Resident #34, and Resident #51 each stated during interview and observation that they did not receive the baked beans listed on their meal tickets, and one resident reported never knowing what meals would be served while another said the meal tickets often did not match what was actually served. During interview at 12:30 P.M., Dietary Aide #195 confirmed baked beans should have been served but were not, and stated that a new company had recently taken over and staff did not always know what was supposed to be served, so they just had to make something up. On 07/15/26, the menu and meal tickets listed meatloaf, mashed potatoes, cooked zucchini, a dinner roll, and cherry cheesecake, but observation showed meatloaf, mashed potatoes, cooked squash with minimal zucchini, a dinner roll, and strawberry shortcake were served instead. Dietary Manager #196 verified the vegetable was mostly squash rather than zucchini and that strawberry shortcake was served instead of cherry cheesecake, and reported these substitutions had not been approved by the dietitian.
Unsafe and Unclean Resident Areas and Shower Chair
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in the memory care unit and in Resident #55's room. Observation of the memory care unit living room showed three lightly colored walls and one blue accent wall, with thick gouges past the first layer of drywall, a dark substance smeared across the wall, a broken outlet cover with the top portion missing, and torn drywall edges along the bottom of the wall where it met the baseboard heater. An RN confirmed the concerns and stated she was unsure how long the areas had been in that condition, although it appeared to have been that way for awhile. In Resident #55's room, puddles of water were observed on the floor and some floor tile was broken and crumbling. A CNA reported the floor tiles had been broken for awhile and that the puddles were from a shower chair used earlier in the day. In addition, a shower chair in the shower room on Evergreen Hall had a dried brown substance on the support bar under the open seat. The Maintenance Manager confirmed the substance was present, and it was removed after he obtained cleaning supplies. The facility policy stated residents had the right to a clean and homelike environment and that the facility would provide a safe, clean, comfortable, and homelike environment.
Infection Control Failures During Medication, Vital Signs, and Incontinence Care
Penalty
Summary
The facility failed to ensure infection control measures were followed during medication administration for two residents. Resident #46 had diagnoses including right sided hemiplegia, hypertension, alcohol use, and cognitive communication deficit, and was assessed as cognitively impaired and requiring maximal assistance to dependence with activities of daily living. Resident #48 had diagnoses including congestive heart failure, hypertension, Type Two Diabetes Mellitus, and malignant neoplasm of the prostate, and was also assessed as cognitively impaired and requiring maximal assistance to dependence with activities of daily living. During observation of medication administration, an LPN did not perform hand hygiene before or after preparing and administering medications to both residents, and the LPN confirmed this during interview. The facility also failed to clean a blood pressure cuff between residents during vital sign checks. Resident #32 had diagnoses including chronic obstructive pulmonary disease, schizophrenia, Type Two Diabetes Mellitus, and depression, and was cognitively intact but displayed behaviors toward others and rejected care daily. Resident #46 was observed again during vital sign collection. An LPN obtained blood pressure readings for Resident #46 and then Resident #32 using the same computerized vital sign machine on wheels, placing the cuff on each resident’s bare upper extremity without cleaning the cuff before or after use. The LPNs confirmed the cuff was not cleaned between residents, and the DON later confirmed the cuff should be cleaned between residents. Additional infection control failures were observed during medication preparation and incontinence care. While preparing medications for Resident #46, an LPN spilled a pill onto the medication cart and then used a bare contaminated hand to pick it up and place it back into the medication cup before administering it. The LPN confirmed she touched the pill with her bare hand, and the DON confirmed pills should not be touched by hands during preparation and administration. For Resident #55, who had diagnoses including anoxic brain damage, malnutrition, gastrostomy status, and anemia and was dependent for all activities of daily living, transfers, and mobility, two CNAs provided incontinence care and a gown change without wearing gowns despite an order for Enhanced Barrier Precautions during high-touch care. Both CNAs confirmed they did not wear gowns, and the facility policy required gowns for high-contact resident care including changing briefs and dressing.
Protected Health Information Left Visible on Nurse Station Desk
Penalty
Summary
The facility failed to ensure protected health information was secured when written provider orders for Resident #50 were left face-up on the nurse station desk at [NAME] Hall and visible to anyone passing by. On 07/13/26 at 4:00 P.M., a written podiatry order dated 07/13/26 was observed on the desk in plain view, and the Director of Nursing confirmed it should not have been left face-up. On 07/15/26 at 4:50 P.M., another written provider order dated 07/15/26 for the same resident was again observed face-up on the nurses' desk and visible to passersby, and an LPN confirmed it was exposed on the desk. The facility policy titled HIPAA Security Measures stated the facility would implement reasonable measures to protect residents' electronic identifiable information and protected health information, and the Regional Director of Clinical Services confirmed the HIPAA policy also applied to paper documents.
Failure to Assist Dependent Resident With Feeding
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for ADLs received assistance with eating. Resident #23 was admitted with diagnoses including Type II Diabetes Mellitus, dementia, hyponatremia, hypertension, Alzheimer's disease, and dysphagia. The admission MDS identified the resident as severely cognitively impaired and dependent on staff for eating. The care plan dated 06/29/26 stated the resident had a nutritional problem or potential nutritional problem and required total assistance with feeding, with interventions to observe for and document signs or symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, several attempts at swallowing, refusing to eat, or appearing concerned during meals. During observation on 07/15/26 at 12:00 P.M., Resident #23 was alone in the dining room seated in a wheelchair with a table in front of him containing a plate of pureed carrots and pureed meatloaf, with a spoon stuck into the food. The resident was holding a cup sideways, had spilled thickened liquid on the floor, and had pureed carrots on his pants and clothing protector. He was also attempting to eat vanilla pudding by picking up the bowl and trying to drink and lick it. Dietary Aide #195 entered at approximately 12:07 P.M. and pushed the resident into a nearby hallway. Dietary Aide #195 and Dietary Aide #197 later confirmed the resident required assistance for eating and had been sitting there attempting to feed himself until he was rolled away. Dietary Aide #197 stated the resident had made a mess and needed help eating. A CNA later verified the resident was totally dependent on staff for feeding assistance.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for two residents. Resident #34 was admitted with diagnoses including COPD, Type 2 DM, left-sided hemiplegia, and atherosclerotic heart disease, and her annual MDS showed she was cognitively impaired, used a wheelchair, and required partial to maximal assistance with ADLs. Resident #38 was admitted with diagnoses including right-sided hemiplegia, COPD, repeated falls, and dementia, and his quarterly MDS showed he was cognitively impaired and dependent for ADLs. During observation at the nurse station, two call lights were actively alarming for Resident #34 and Resident #38. One call light had been on for 27 minutes and the other for 10 minutes, and later both were still alarming with one on for 35 minutes and the other for 18 minutes. CNA #107 was observed leaving the employee restroom and walking off the unit without acknowledging the alarms, and CNA #105 and CNA #148 were observed walking past the nurse station and then passing meal trays while the call lights continued to alarm. The DON confirmed resident call lights should be prioritized and should not be ignored, and later confirmed a written counseling had been completed for CNA #107 after she stated she heard the alarms and did not answer them. Facility policy stated all staff who saw or heard an activated call light were responsible for responding.
Delayed Implementation of Ordered Wound Therapy
Penalty
Summary
The facility failed to timely implement wound care orders for Resident #14, who was re-admitted with diagnoses including osteomyelitis of the lumbar vertebra, acute endocarditis, heart failure, alcoholic cirrhosis of the liver, rheumatic mitral valve disease, and pneumonia. The quarterly MDS assessment indicated the resident was cognitively intact, had no behaviors or refusals of care, used a wheelchair, and required moderate assistance to dependence with activities of daily living. She had one stage four pressure ulcer that was present on admission. Wound care visit notes and orders dated 07/08/26 showed a new order for negative pressure wound therapy. However, observation on 07/15/26 at 11:00 A.M. found no negative pressure wound therapy in place while the resident was resting in bed. Review of orders, treatment administration records, and nursing progress notes from 07/08/26 through 07/15/26 showed no indication that the therapy had been implemented. During interview on 07/15/26 at 2:35 P.M., the Assistant Director of Nursing confirmed the therapy had been ordered but had not yet been started because she was unsure where to obtain the equipment. Facility policy stated wound treatment would be provided in accordance with physician orders, including the type of dressing.
Fall interventions not in place and hazardous storage areas left unsecured
Penalty
Summary
The facility failed to ensure fall interventions were in place for one resident reviewed for falls. The resident was admitted with diagnoses including multiple sclerosis, chronic pain, depression, anxiety, muscle spasm, tremors, weakness, and seizures. The care plan, revised 05/12/26, identified the resident as at risk for falls due to weakness, loss of function, impaired judgment, impulsive behavior, refusal to wait for assistance to transfer, and a history of throwing themselves on the floor when angry. Interventions included a mattress with bolsters attached to the bed and keeping the bed in the lowest position. However, observation on 07/16/26 at 11:55 A.M. showed the resident lying in bed with the bed extremely high in the air, yelling for help and stating they were trying to get out of bed, and no bolsters were observed on the bed. A CNA confirmed the bed was high and not at the lowest level, and the DON also confirmed there were no bolsters on the bed. The facility also failed to ensure hazardous items were secure. Observation of three storage closets adjacent to the nurse's station showed the floor care storage closet was unlocked and accessible, the biohazard storage closet had a key in the door handle and was accessible, and the housekeeping storage closet was unlocked and accessible. These areas contained multiple chemical products labeled as eye irritants, harmful if swallowed, or requiring poison control contact if swallowed or if skin or eye contact occurred, along with a biohazard bin containing five full sharps containers. An LPN confirmed the closets were unlocked and stated the housekeeping closet should be locked, while the Maintenance Manager said he had been instructed to lock all three doors. The Housekeeping Director stated the biohazard and housekeeping closets should be locked, but the floor care closet was typically unlocked. The facility policy titled Chemical Storage stated all chemicals for cleaning would be locked at all times and that staff would correct any unlocked chemical storage area immediately.
Catheter Securement, Catheter Care, and Timely Incontinence Care Not Provided
Penalty
Summary
The facility failed to ensure urinary catheter securement devices were in place for two residents with indwelling urinary catheters. One resident was re-admitted with diagnoses including osteomyelitis of the lumbar vertebra, acute endocarditis, heart failure, alcoholic cirrhosis of the liver, rheumatic mitral valve disease, and neurogenic bladder, and the care plan directed staff to use a catheter securement device. During observation of catheter care, the resident did not have a securement device in place, and the LPN confirmed it should have been there. A second resident was admitted with diagnoses including Type II DM, skin infection, gangrene, anxiety, COPD, and neurogenic bladder, and was on hospice care. Physician orders included securing the catheter tubing with an anchoring device and completing catheter care every shift and as needed. Review of the TAR showed no documented catheter care from March through July 2026, and observation showed the resident did not have a securement device in place. The DON confirmed securement devices should be in place, and the ADON confirmed there was no evidence catheter care was being completed each shift. The facility also failed to ensure timely incontinence care for a resident who was cognitively intact and frequently incontinent of urine. The resident reported waiting since the prior evening for a brief change and said staff had not responded despite repeated call light use. The call light remained activated for 41 minutes during observation, and the CNA confirmed the resident’s brief was full and had not been changed in a timely manner. Additional interviews with other incontinent residents and CNAs described prolonged waits for brief changes and staffing shortages that interfered with timely incontinence care.
Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including multiple sclerosis, chronic pain syndrome, anxiety, muscle spasm, tremor, altered mental status, weakness, seizures, and schizophrenia, was not provided with the safety interventions outlined in their care plan. The resident was assessed as being at risk for falls and was dependent on staff for activities of daily living. The care plan specified the use of enabler bars attached to the bed, a body pillow for positioning, and ensuring the call light was within reach. However, during multiple observations, the resident was found in bed without enabler bars or a body pillow, and the call light was not within reach but instead placed on the resident's wheelchair, which was not accessible to the resident. Interviews with CNAs regularly assigned to the resident confirmed that the required interventions, such as the body pillow and enabler bars, were not in place and that staff were unaware of the need for a body pillow. The facility's fall prevention policy required that interventions be provided as needed, but these were not implemented for this resident. The lack of these safety measures constituted a failure to follow the care plan for a resident identified as being at risk for falls.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident's skin impairment, resulting in the development of an unstageable pressure ulcer. Upon readmission, the resident, who had a history of dementia, heart failure, and type two diabetes mellitus, was noted to have skin impairment to the coccyx and buttocks. However, there was no wound assessment completed, and no physician orders for wound treatment were obtained until two days later. This delay in care led to the resident developing an unstageable pressure ulcer requiring debridement. The facility's documentation and care planning were inadequate. There was no baseline care plan addressing the resident's high risk for skin breakdown, and a care plan was not initiated until five days after the unstageable pressure ulcer was identified. Additionally, the facility failed to implement a low air loss mattress until several days after it was ordered, and there were lapses in completing wound treatments as prescribed. The facility's policies on wound documentation and pressure injury prevention were not followed, contributing to the deficiency. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's wound care needs. The Director of Nursing acknowledged the absence of documentation and timely interventions, while the Registered Nurse and Licensed Practical Nurse involved in the resident's care confirmed the lack of wound assessment and nutritional interventions. The facility's dietitian was no longer employed, and the consultant dietetic technician had not yet assessed the residents, further highlighting the gaps in care coordination and oversight.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for residents and/or their representatives, affecting six out of seven residents reviewed. The facility's policy requires that care plan conferences be held regularly to discuss the plan of care with the resident or their representative. However, the review of medical records and interviews with Social Services revealed that several residents had fewer than the required number of care conferences over the past year. For instance, Resident #14 had only two care conferences, while Resident #49 had none. The residents involved had various medical conditions, including cognitive impairments, dementia, and other chronic illnesses. Despite these conditions, the facility did not adhere to its policy of holding regular care plan conferences. Interviews with Social Services confirmed the lack of compliance, as they verified the insufficient number of care conferences for each resident. This deficiency indicates a failure to ensure that residents and their representatives are adequately informed and involved in their care planning process.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to monitor the effectiveness of psychotropic medications for five residents, leading to deficiencies in care. Resident #26, diagnosed with anxiety disorder, borderline personality disorder, major depression disorder, and insomnia, was on multiple medications including venlafaxine, trazodone, bupropion, sertraline, and buspirone. Despite a care plan addressing behavior problems and the need for monitoring medication side effects and effectiveness, there was no documentation of behavior tracking or non-pharmacological interventions in the medical record. Interviews with staff confirmed the lack of documentation and monitoring. Resident #45, with diagnoses including major depressive disorder, schizoaffective disorder, and insomnia, was also not monitored for medication effectiveness. The resident was on medications such as trazodone, wellbutrin, viibryd, and invega. Despite a care plan that included monitoring for side effects and effectiveness, there was no evidence of such monitoring in the medical record. Interviews revealed that the resident had been experiencing increased depression and insomnia, yet no non-pharmacological interventions were attempted, and the physician was not informed. Similarly, Residents #15, #34, and #10 were not monitored for the effectiveness of their psychotropic medications. Resident #15, with schizophrenia and bipolar disorder, had no documentation of daily monitoring for behaviors and medication effectiveness. Resident #34, with vascular dementia and schizoaffective disorder, also lacked documentation of behavior monitoring. Resident #10, diagnosed with depression and anxiety, had no evidence of behavior monitoring or the use of non-pharmacological interventions. Interviews with the Director of Nursing confirmed the absence of a process for monitoring behaviors related to psychotropic medications.
Failure to Sanitize Hands Between Meal Services
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal service, affecting four residents out of 26 reviewed for dining services. During an observation, an LPN was seen delivering meal trays to residents without sanitizing her hands between serving each resident. Specifically, the LPN was observed passing a meal tray to a resident, touching a bedside table and a used cup, and then continuing to serve other residents without hand sanitizing. This occurred while delivering meal trays to residents in their rooms, and the LPN confirmed in an interview that she did not sanitize her hands between serving the meal trays.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to maintain a clean and functional environment for its residents, as evidenced by multiple observations and interviews. Several residents, specifically seven out of thirteen reviewed, were affected by broken window blinds in their rooms. These residents expressed dissatisfaction with the condition of their blinds, which were confirmed to be broken by the Maintenance Supervisor. Additionally, one resident resorted to placing gloves in the holes of the blinds to block sunlight, indicating a lack of proper maintenance and repair. Further observations revealed additional environmental issues, such as a slightly opened window with dirt buildup on the windowsill in one resident's room and loose wiring above another resident's bed. The Housekeeping Supervisor confirmed the dirt buildup, acknowledging that housekeeping was responsible for daily cleaning, including windowsills. The facility's policies and job descriptions indicated that maintenance and housekeeping were expected to ensure a clean and well-maintained environment, yet these standards were not met, leading to the deficiencies observed.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, specifically affecting one resident. The resident, who was admitted with diagnoses including polyosteoarthritis, dementia, and the presence of a cerebrospinal fluid drainage device, was assessed as severely cognitively impaired and required assistance with activities of daily living, including supervision and set-up assistance with meals. During an observation, a CNA was seen standing over the resident while providing assistance with eating, which involved giving the resident a bite of a banana and two spoonfuls of yogurt. The CNA confirmed this practice during an interview, stating that the resident sometimes needed assistance with eating and that she would offer a few bites at a time. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of respecting resident rights, which was not adhered to in this instance.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents, affecting two residents. Resident #49, who was admitted with diagnoses including Parkinson's disease and dementia, was observed in an uncomfortable position in bed with the bed remote and call light out of reach. The resident expressed discomfort and inability to adjust the bed due to the inaccessibility of the remote and call light. The Unit Manager LPN confirmed the inaccessibility of these items. Resident #70, with diagnoses including anoxic brain damage and epilepsy, was dependent on staff for all activities of daily living. The care plan specified that the call light should be placed in the resident's right hand, but observations revealed it was consistently placed on the left side, out of reach. LPNs were unaware of the care plan requirements, and the Director of Nursing confirmed the call light should be on the right side. The facility's policy required staff to ensure call lights were within reach, which was not adhered to in these cases.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records as requested by a resident. Resident #26, who was admitted with diagnoses including anxiety disorder, borderline personality disorder, and insomnia, requested access to dental information in his medical record due to experiencing dental pain and concerns. The resident, who had intact cognition and no recorded behaviors, made a verbal request to the Director of Nursing (DON) approximately two weeks prior to the interview conducted on 03/03/25. Despite the request, the DON confirmed that the copies of the dental records had not yet been provided. The facility's policy on the release of medical records states that records should be accessible within 24 hours (excluding weekends and holidays) following an oral or written request.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for residents who were dependent on staff for grooming and hygiene. Resident #42, who had multiple diagnoses including chronic obstructive pulmonary disease and morbid obesity, required substantial assistance with bathing and personal hygiene. Despite being scheduled for showers twice a week, documentation revealed that Resident #42 received only bed baths and there was no record of hair washing or facial hair grooming. Observations confirmed the resident's hair was matted and greasy, and facial hair was long, which the resident preferred to have removed. Resident #14, with a history of paraplegia and traumatic brain injury, was also dependent on staff for showers. The care plan indicated a need for total assistance with bathing, yet the resident reported not receiving showers as scheduled. Documentation showed inconsistencies in the provision of showers and bed baths, and there was no record of refusals, despite the Director of Nursing acknowledging the resident's occasional refusals. Resident #60, who was cognitively intact but dependent on staff due to conditions like hemiplegia and congestive heart failure, was scheduled for showers twice a week. However, the resident reported not receiving a shower for over a month, citing a broken shower cot as the reason. Interviews with staff revealed conflicting information about the condition of the shower cot, with some staff unaware of any issues and others suggesting alternative equipment was available. The facility's policy required necessary services for ADLs, but the lack of showers for Resident #60 was confirmed by the Administrator and DON.
Non-Compliance with Physician Orders for Wound and Edema Management
Penalty
Summary
The facility failed to adhere to physician orders for wound care and edema management for two residents. Resident #44, who has a history of encephalopathy, diabetes, congestive heart failure, and leg contractures, was observed with a wound dressing on the left knee that had not been changed as per the physician's order. The dressing, dated 02/26/25, was supposed to be changed every Monday, Wednesday, and Friday, but was found unchanged on 03/03/25. This oversight was confirmed by both a Licensed Practical Nurse and a Wound Specialist Physician, who verified the dressing change schedule. Resident #42, diagnosed with chronic obstructive pulmonary disease, diabetes, morbid obesity, and lymphedema, did not receive lymphedema pump treatments as ordered. The medical record lacked specific pump settings and times for application, and the resident reported that the pumps were not applied daily and caused pain when used. An LPN documented the application of the pumps despite the resident's refusal, and the Director of Nursing confirmed the absence of a setting order. Subsequent observations revealed the pump settings were incorrect, further indicating non-compliance with physician orders.
Failure to Provide Ordered Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that range of motion (ROM) exercises were provided as ordered by the physician for a resident with bilateral lower extremity contractures. Resident #44, who was admitted with diagnoses including encephalopathy, type II diabetes mellitus, congestive heart failure, and contractures, had a physician order dated 04/22/24 for gentle ROM exercises to be performed twice daily. Despite this order, observations over several days revealed that the resident was consistently found lying in bed with legs in a flexed position, indicating a lack of ROM exercises. Interviews with the resident and staff confirmed the deficiency. Resident #44 reported not receiving the prescribed ROM exercises daily. Certified Nurse Aides (CNAs) frequently assigned to the resident admitted they did not perform the exercises and had not observed nurses doing so either. The Unit Manager LPN verified the CNAs' lack of knowledge regarding the provision of ROM exercises, highlighting a breakdown in communication and adherence to the care plan for the resident's contracture management.
Failure to Report and Monitor Falls in Residents
Penalty
Summary
The facility failed to timely report and monitor a fall incident involving Resident #18, who was at risk for falls due to conditions such as dementia and gait problems. On the evening of 01/21/25, Resident #18 was lowered to the floor by a CNA after becoming unsteady while standing. Despite the resident expressing hand pain, the RN on duty did not document the incident as a fall or report it, believing it was not a fall since the resident was lowered to the ground. The following day, the resident was found to have a fracture in the right distal radius, requiring emergency room evaluation. In another incident, Resident #68, who had impaired cognition and was dependent on staff for mobility, was found face down on the floor next to her bed. Although interventions were developed to place her in common areas during periods of restlessness, observations revealed that she was left alone in a dining room, positioned unsafely in a Broda chair. Staff interviews confirmed that Resident #68 was not consistently placed in common areas due to her disruptive behavior, contrary to her care plan. The facility's policy on fall prevention was not followed, as evidenced by the lack of documentation and reporting of Resident #18's fall and the failure to implement and monitor interventions for Resident #68. These deficiencies were identified during a complaint investigation, highlighting lapses in the facility's adherence to its fall prevention program.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to ensure that water was readily available for proper hydration for a resident with severe cognitive impairment and multiple health conditions, including aphasia, chronic obstructive pulmonary disease, chronic kidney disease, and dementia. Observations over several days revealed that the resident often did not have access to water, both in his room and while in common areas such as the dining room. On multiple occasions, the resident was observed without water, and staff interviews confirmed that water had not been consistently provided. Despite the facility's policy requiring staff to offer a variety of fluids between meals and ensure beverages are within reach, the resident was frequently found without water. Staff interviews revealed inconsistencies in the provision of water, with some staff unsure if water had been passed or if the resident had taken water to meals. The resident expressed thirst, and staff confirmed the absence of water in his room. The deficiency was identified under Complaint Number OH000162077.
Failure to Maintain and Apply Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment was maintained and applied as ordered by the physician for Resident #42, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), morbid obesity, acute and chronic respiratory failure, shortness of breath, and congestive heart failure. The resident required substantial to maximal assistance with activities of daily living and received oxygen therapy. Physician orders specified the use of an Auto C-Pap with specific settings and oxygen therapy to be applied at bedtime and during naps. Additionally, the orders required the change of C-pap/Bi-Pap tubing and oxygen tubing weekly and as needed for infection control, and to monitor oxygen saturation levels every shift. Observations on March 3, 2025, revealed that Resident #42's CPAP machine was not being used as ordered due to the absence of distilled water for humidification, which staff were unaware of. The resident reported that this resulted in the CPAP machine not being applied each night. Furthermore, there was no documentation of oxygen saturation levels being obtained every shift, and the resident was found with a heavily soiled oxygen nasal cannula. The Unit Manager LPN confirmed that the oxygen equipment and monitoring were not maintained as required. The facility's policies on Noninvasive Ventilation and Oxygen Administration, which included infection control measures and equipment maintenance, were not adhered to, leading to this deficiency.
Inadequate Dialysis Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide adequate dialysis care and services for Resident #75, who was diagnosed with bilateral pleural effusion and end-stage chronic kidney disease. The resident required dialysis three times a week, and the care plan included monitoring fluid intake and output, as well as the dialysis access port for signs of infection, swelling, or bleeding. However, the facility did not document the monitoring of the dialysis port every shift, nor did they track the resident's fluid intake and output daily. Additionally, communication with the dialysis center was only documented twice over a period of several weeks, indicating a lack of consistent communication regarding the resident's care. Interviews with facility staff revealed further deficiencies in the care provided to Resident #75. An LPN stated that the facility sent the resident to dialysis with necessary documentation and medication, but there was no confirmation of whether the medication was administered at the dialysis center. The Director of Nursing confirmed that there was no documentation of the resident's fluid intake during meals and that communication with the dialysis center was insufficient. Furthermore, the facility lacked a dialysis policy, which contributed to the inadequate monitoring and documentation of the resident's dialysis care.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's prescribed pain medication, tramadol, was available and administered as ordered by the physician. Resident #60, who was admitted with diagnoses including hemiplegia, acute cholecystitis, and chronic systolic congestive heart failure, was cognitively intact and required scheduled and as-needed pain medication. However, the Medication Administration Record for March 2025 showed that the resident did not receive the prescribed tramadol on four occasions over two days. Interviews revealed that the resident was aware of the lack of medication, stating that the facility had been out of tramadol for two days. The Unit Manager RN was unaware of the issue, while the Unit Manager LPN confirmed that the nurse practitioner was notified about the need to order the medication. Despite the controlled medication being accessible in the facility, a physician's completion of a controlled medication form was necessary. The facility's policy on pain management emphasized the need to provide pain management services consistent with professional standards and the resident's care plan, which was not adhered to in this case.
Failure to Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacy recommendations for three residents, leading to deficiencies in medication management. Resident #15, diagnosed with conditions including chronic obstructive pulmonary disease and schizophrenia, was recommended by the pharmacist to receive a calcium supplement alongside Alendronate for bone health. Despite repeated recommendations on four separate occasions, there was no documentation of the physician's response or any orders for the supplement. Similarly, Resident #34, with diabetes mellitus and related complications, was advised to adjust their diabetic medication regimen to reduce the risk of hypoglycemia. Although there were notations of some medication adjustments, the facility did not respond promptly to the pharmacist's recommendations. Resident #10, diagnosed with depression, anxiety, and vascular dementia, was recommended to have their Donepezil dosage increased and to undergo laboratory assessments for Depakote levels. The facility did not act on these recommendations, and there was no physician response documented. The Director of Nursing confirmed the lack of action on these recommendations, which were only addressed during the annual survey. The facility's policy stated that physicians should act on pharmacy recommendations, but this was not adhered to, resulting in the identified deficiencies.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered per physician's orders, resulting in a medication error rate of 20 percent, which is significantly above the acceptable threshold of 5 percent. This deficiency was observed during medication administration for two residents. For Resident #37, an LPN spilled three pills on the medication cart, discarded one, and failed to notice the other two, which were later identified as vitamin B1 and magnesium oxide. These medications were not administered to the resident as the LPN was unaware of the spill until surveyor intervention. For Resident #64, the LPN did not have the prescribed Flonase nasal spray available and failed to administer it. Additionally, the LPN did not adhere to the required five-minute interval between administering the Incruse inhaler and the Breo inhaler, as per the manufacturer's guidelines and facility policy. The Director of Nursing confirmed that the nurses should follow these guidelines, which were not adhered to in this instance.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management, as observed during a medication administration session. An LPN was seen disposing of medications improperly by throwing them into a trash can attached to the medication cart. This included a Lasix tablet and other medications that were spilled on the cart. The LPN acknowledged that the medications should not have been disposed of in this manner. Additionally, several medications on the medication cart and in the storage room were found to be opened without being dated, which is against the facility's policy. Another LPN was observed leaving a medication card unattended on top of a medication cart while administering medications in a resident's room. Further inspection revealed that several bottles of medications on the medication cart were opened and not dated. The facility's policy on medication storage requires that all drugs be stored in locked compartments and under direct observation during medication passes, but it lacked guidelines for dating medications when opened. This oversight affected two residents identified as cognitively impaired and independently mobile, posing a potential risk to their safety.
Failure to Provide Double Portions as Ordered
Penalty
Summary
The facility failed to provide a resident with his food preference of double portions, as per his physician's order and personal request. The resident, who was cognitively intact and required assistance with eating, was admitted with diagnoses including hyperlipidemia, anxiety disorder, hypoglycemia, bipolar disorder, hypotension, and paranoid schizophrenia. Despite the physician's order for a regular diet with double portions, the resident reported feeling hungry and not receiving enough food. Observations confirmed that during a dinner meal, the resident received only a single portion of a chicken quesadilla, rice, and peaches, and during a breakfast meal, he did not receive double portions of French toast and sausage links. Interviews with CNAs verified that the resident did not receive the double portions as ordered.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to Enhanced Barrier Precautions (EBP) when providing care to residents, specifically affecting one resident. This resident, who was admitted with diagnoses of cerebral palsy and a gastrostomy status, required EBP due to the presence of a feeding tube. The care plan for this resident included the implementation of EBP during personal care, which necessitated the use of gloves and gowns by staff during high-contact activities such as feeding tube care. An observation revealed that an LPN provided medications to the resident without wearing the required gown, despite a sign outside the resident's room indicating the need for gloves and a gown during feeding tube care. The LPN confirmed the omission, attributing it to nervousness, although PPE was available. This failure to follow EBP was noted in the context of CDC guidance, which emphasizes the importance of targeted gown and glove use to prevent the transmission of multidrug-resistant organisms in skilled nursing facilities.
Incompatible Mattress and Bed Frame
Penalty
Summary
The facility failed to ensure that a mattress was compatible with a bed, affecting a resident with anoxic brain damage, tracheostomy status, and generalized idiopathic epilepsy. The resident, who had moderate cognitive impairment and was dependent on staff for all activities of daily living, was observed to have a mattress that did not fit the bed, leaving a large gap between the end of the bed footboard and the mattress. The Maintenance Supervisor was unsure if the bed was a rental or a bariatric bed from the facility and noted a nine-inch gap between the mattress and the end of the bed. The facility lacked a program for regular inspections of bed frames, mattresses, and bedrails. The Director of Nursing confirmed the bed was a rental and acknowledged the need for an extender or longer mattress, verifying that there should not be a space between the mattress and the bed. The manufacturer's guidelines indicated that the mattress should be sufficiently wide and long enough to prevent any part of the patient's body from falling between the bed and mattress.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents and their representatives, as required by policy. This deficiency was identified during a review of medical records, staff interviews, and policy review. Four residents were affected by this oversight, as they were transferred to the hospital without receiving the necessary notice of transfer or discharge. The facility's policy mandates that such notices be provided in a language and manner understandable to the resident and their representative, but this was not adhered to in these cases. Resident #78 was sent to the hospital for shortness of breath, Resident #180 for abnormal laboratory values, Resident #181 for an unspecified reason, and Resident #79 for a change in condition requiring evaluation. In each instance, there was no documentation indicating that the residents or their representatives were informed of the transfer or discharge. The facility administrator confirmed the lack of notification for these residents during an interview, highlighting a systemic issue in the facility's adherence to its transfer and discharge policy.
Failure to Provide Bed Hold Notices at Time of Transfer
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives at the time of transfer to a hospital, as required by their policy. This deficiency was identified during a review of medical records, staff interviews, and policy review. Four residents were affected by this oversight, as there was no documentation of bed hold notices being provided at the time of their transfer to the hospital. The facility's policy, revised in September 2024, mandates that a written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed should be given at the time of transfer. The specific cases involved residents who were transferred to the hospital for various medical reasons, including shortness of breath, abnormal laboratory values, and changes in condition. Interviews with the facility's Administrator confirmed that the bed hold notices were not provided to the residents or their representatives at the time of transfer. This issue affected all four residents reviewed for transfer/discharge, and the facility had identified a total of 12 residents sent to the hospital in the past 90 days, with a census of 75.
Failure to Notify Resident of Roommate Change
Penalty
Summary
The facility failed to notify a resident, identified as Resident #85, before a change in roommate occurred, which is a violation of the resident's rights. Resident #85, who has multiple sclerosis, kidney cancer, and chronic kidney disease, was not informed prior to Resident #22 moving into her room. The facility's policy requires that all residents involved in a room change be notified verbally or in writing, in a manner they understand, but this was not adhered to in this instance. Resident #22, who has intellectual disabilities, schizophrenia, dementia, and bipolar disease, was informed of the room change, but Resident #85 was not. The Business Office Manager confirmed that Resident #22 received a written notice, but Resident #85 did not receive any notification until the new roommate arrived. This oversight was identified during a complaint investigation, highlighting a lapse in the facility's adherence to its own policy regarding room changes.
Neglect in Wound Care Leads to Immediate Jeopardy and Potential Harm
Penalty
Summary
The facility failed to ensure Resident #59, admitted on hospice care, was free from neglect as staff did not provide ongoing wound assessments, care, and services to prevent a significant decline in a wound on the left lower extremity. This led to a situation where emergency services were called due to a deteriorating mental status, and it was found that the wound was infected and necrotic. Resident #59 required inpatient hospital admission, surgical debridement, and prolonged antibiotic therapy due to the severity of the wound. The deficiency was classified as Immediate Jeopardy due to the potential for serious life-threatening harm. Additionally, the facility also failed to provide ongoing wound assessments for Resident #42, placing the resident at potential risk for more than minimal harm. Despite having a surgical incision, Resident #42 did not receive proper monitoring and documentation of wound measurements and descriptions as required by policy. The deficiency was noted in the lack of weekly skin assessments and wound monitoring for Resident #42, with the last assessment documented on 02/29/24. The deficiency was classified as Severity Level 2, indicating potential for more than minimal harm that is not Immediate Jeopardy.
Failure to Provide Appropriate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care, assessments, and ongoing monitoring of a pressure ulcer for Resident #9, who had multiple diagnoses including paraplegia and a stage IV pressure ulcer to the left ischium. The resident's care plan included interventions such as a low air loss mattress, pressure-relieving cushion, and assistance with transfers and repositioning. However, the facility did not complete weekly skin assessments as required, and there were inconsistencies in the documentation of wound care treatments and assessments. The medical record lacked weekly nursing skin assessments, and the Director of Nursing confirmed that these assessments had not been completed as they should have been. The review of the medical record and physician orders revealed that the treatment for the pressure ulcer changed multiple times between December 2023 and March 2024. Despite these changes, the wound care notes and weekly wound evaluations showed varying measurements and descriptions of the wound, indicating a lack of consistent monitoring and documentation. For instance, the wound was noted to have 100% necrosis with no drainage on one occasion and later described with 50% necrosis and a small amount of serosanguineous drainage. Additionally, the wound care notes indicated that the pressure ulcer was healed at one point, only to be described as a stage IV pressure ulcer again in subsequent notes. During an observation of a dressing change, the LPN followed proper procedures, but it was verified that the LPN had not documented the wound appearance with each dressing change. The facility's policies on wound treatment management and skin assessment required documentation of wound treatments and full body assessments, including measurements and descriptions of wounds. The failure to adhere to these policies and the lack of consistent documentation and monitoring led to the deficiency identified in the report.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 606 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sylvania
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franciscan Care Ctr Sylvania | 2 mi | ★★★★★ | 51 | 1 |
| Rosary Care Center | 2.2 mi | ★★★★★ | 1 | 0 |
| Kingston Health Center Of Sylvania | 3.6 mi | ★★★★★ | 35 | 0 |
| Otterbein Sunset House | 3.7 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Toledo | 3.8 mi | ★★★★★ | 18 | 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 October 2026) and official state health department websites.