Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Dixon Healthcare Center during CMS and state inspections, most recent first.
Failure to Report Declining Condition and Implement Hospice Bowel Protocols: A resident with bilateral nephrostomy tubes, CKD, and recent sepsis had worsening renal labs, decreased nephrostomy output, weight loss, poor intake, weakness, and loose stools without timely provider notification; when labs were finally obtained, the resident had a critical creatinine, hypotension, and tachycardia and was sent to the ER with AKI, dehydration, and sepsis. A second resident on hospice had the bowel protocol omitted from the chart, then went several days without a BM while receiving opioids and later developed abdominal pain, nausea, and vomiting without documented provider notification.
The facility failed to provide complete NOMNC and ABN notices for four residents. Notices for some residents lacked QIO name and contact information, and one resident did not receive a NOMNC when it was due; another resident’s representative was not documented as receiving timely notice or signed copies. The issue involved residents with conditions including fractures, CHF, DM, dementia, COPD, and other chronic illnesses.
The facility failed to maintain a comprehensive infection control log and failed to use EBP during incontinence care. Infection surveillance records for multiple residents were inaccurate or incomplete, including a UTI documented before a urine culture was obtained, an Enterococcus faecalis infection not entered on the log, and a bacteremia entry that did not identify MRSE from blood cultures. During observed incontinence care, two CNAs did not wear required PPE even though EBP signage and supplies were present.
A resident with severe cognitive impairment and multiple complex diagnoses developed a new unstageable pressure injury on the left lateral ankle. Nursing documentation noted the responsible party would be notified the next morning, but there was no record that the resident’s mother/POA was informed, and she later said she learned about the wound only during a visit. The DON acknowledged the representative should have been notified when the wound was discovered.
A resident with anxiety disorder and other psychiatric and pain-related diagnoses received PRN Ativan beyond the 14-day limit for psychotropic meds. The order did not include a stop date, and MAR review showed the medication was given for 23 total days before it was discontinued; the DON confirmed the missing 14-day stop date.
A resident’s PASRR was inaccurate because it indicated no serious mental illness despite diagnoses of anxiety disorder and psychoactive substance-induced psychotic disorder in the record. The resident also had intact cognition on the annual MDS, and both the Corporate RN and SSD confirmed the PASRR did not reflect the resident’s diagnoses.
Failure to provide scheduled showers: A dependent resident with dementia, CKD, DM, chronic pain, and morbid obesity was assessed as needing two staff for bathing. Records showed showers were scheduled twice weekly, but the resident reported missing showers for weeks, and documentation showed refusals without the required reason or nurse notification/follow-up per policy.
Failure to assist a resident with obtaining a state photo ID. A resident with intact cognition and diagnoses including a sacral pressure ulcer, DM, and CKD had requested help getting an ID, but the facility had not obtained the needed provider affidavit stating he was homebound. The DON confirmed the resident still did not have a photo ID.
A resident with anxiety disorder and other diagnoses had a PRN Ativan order without a 14-day stop date. The pharmacist’s MRR recommended a stop date or documented rationale, but the physician did not respond and there was no chart documentation of an address to the recommendation. The resident received the medication repeatedly, and the DON confirmed the MRR was not addressed timely.
A resident with multiple medical diagnoses and a recent urinary catheter had a urine specimen collected for UA/C&S after abdominal pain, nausea, vomiting, and right flank pain were noted. The UA showed abnormal findings, but the C&S was not completed timely and was later reported several days afterward as growing Proteus mirabilis sensitive to ceftriaxone. The DON confirmed the delay and stated the lab was running behind.
A resident with COPD, diabetes, anemia, and cellulitis had abnormal urinalysis findings and flank pain, but no urine culture result was available and charting did not document urinary changes or dysuria. Even so, the IP signed the infection surveillance criteria as met, the infection log recorded a UTI meeting treatment criteria, and the resident was started on ceftriaxone followed by cefpodoxime. The DON and IP later confirmed the resident did not meet criteria for treatment and the criteria documentation was inaccurate.
A cognitively intact hospice resident with multiple chronic conditions reported that two gold rings, one with a purple stone and one with a green stone, went missing after a room change. The concern was not entered into the grievance or missing items logs, and although an Ombudsman and an anonymous complainant raised the issue, the Administrator initially denied awareness of any such grievances. The Administrator later acknowledged knowing of the allegation but did not complete a grievance form or self-report to the state, questioning the resident’s account, while the Social Worker’s search and staff inquiries were not documented and the family was not contacted to verify the jewelry, resulting in a failure to protect the resident from misappropriation.
A resident with multiple chronic conditions and intact cognition reported that two gold rings, including an antique amethyst birthstone ring, went missing after a room change. An anonymous complaint and a volunteer Ombudsman raised the concern to facility staff, but the Administrator initially denied awareness of any grievances and later acknowledged knowing of the allegation without completing a grievance form or self-reporting the incident to the state agency. The Social Worker stated she searched the room and spoke with staff but had no documentation of an investigation, and neither the Administrator nor Social Worker contacted the resident’s family to verify the jewelry. These actions did not follow the facility’s policy requiring immediate reporting, timely investigation, and submission of results to the state agency for alleged misappropriation.
A cognitively intact resident with multiple chronic conditions and on hospice services reported that two gold rings, one with a purple stone and one with a green stone, went missing after a room change. An anonymous complainant and the Ombudsman raised the concern to facility staff, but the Administrator did not complete a grievance form, expressed doubt that the resident had owned the rings, and the Social Worker’s search and staff inquiries were not documented. The facility did not contact the resident’s family to verify the jewelry or complete the investigation steps outlined in its misappropriation policy, including formal documentation and required reporting.
A resident with multiple comorbidities, right-sided hemiplegia, and hospice care had physician orders and ADL documentation for bilateral enabler bars to assist with turning and repositioning, but after a room change and delivery of a new bed, the enabler bars were never installed. Over this period, staff continued to sign MAR/TAR entries indicating the bars were in place, even though the bed had no rails. The resident experienced two falls from bed and reported having repeatedly requested assist bars, while an anonymous complaint and an Ombudsman contact also raised concerns about the missing assist bars. The DON later confirmed that the ordered bilateral enabler bars had not been in place since the room change, despite being part of the resident’s plan of care.
A resident with chronic pain and multiple complex conditions did not receive prescribed opioid pain medication for approximately 30 hours due to delays in pharmacy processing and medication ordering following a pharmacy transition. The resident missed five scheduled doses, expressed concern about withdrawal, and staff were unable to access emergency stock during this period.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient safeguards and oversight by the facility.
The facility did not maintain an effective pest control program, resulting in ongoing issues with cockroaches in the kitchen and a persistent gnat infestation in a resident's room. Structural deficiencies such as cracked tiles, loose wall coverings, and a missing door seal were not repaired, allowing pests to enter and remain. Staff and residents confirmed the continued presence of pests, and pest control measures outlined in facility policy were not adequately followed.
The facility did not ensure residents could access their personal funds after business hours or on weekends. Only one staff member was responsible for distributing funds, and no process was in place for other staff to provide access outside of regular hours. Multiple staff and residents confirmed that this led to frustration and delays in accessing personal money, with some residents waiting days or being unable to obtain funds when needed.
A resident was not adequately protected from the wrongful use of their belongings or money, as required by facility policy. The report identifies a failure to safeguard personal property or funds, resulting in unauthorized use.
A resident with multiple behavioral and neurological diagnoses developed a skin tear and a bruise on the left arm, with no documentation or timely investigation into how these injuries occurred. Facility staff confirmed that an investigation was not initiated as required by policy, resulting in non-compliance.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to the delivery of individualized care.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with complex medical conditions experienced a significant decline, including hypoxemia, tachycardia, and lethargy, which was observed by therapy staff and reported to the ADON and NP. Despite these findings, no comprehensive assessment or timely intervention was performed, and the resident's condition was not escalated to the medical provider. The resident was later found unresponsive and died from acute hypoxic and hypercapnic respiratory failure, with the facility's failure to recognize and respond to the acute change in condition resulting in actual harm.
A resident with multiple chronic conditions and severe cognitive impairment experienced a fall that was observed by her daughter via an electronic monitoring device. The facility failed to notify both the family and the physician of the incident, with inconsistent accounts from nursing staff regarding notification. Documentation of the fall was missing from the medical record on the date of the event, and a late entry was made days later. The DON confirmed there was no evidence of physician notification, in violation of facility policy.
A resident who was fully dependent on staff for care and had a documented preference for daily showers did not receive showers as requested, with records showing a mix of bed baths and showers and no evidence of shower refusals. Staff confirmed the lack of daily showers and absence of refusal documentation, resulting in non-compliance with the resident's care plan and facility policy.
Two residents experienced lapses in supervision and safety: one with dementia suffered a fall that was not documented or assessed according to policy, and another, cognitively intact, left the facility in a wheelchair and was found in the street without adequate staff monitoring. Both incidents involved failures to follow established protocols for accident prevention and resident supervision.
A resident with multiple chronic conditions did not have any in-person examination notes documented by the attending physician since admission. Instead, the Medical Director only co-signed notes from a Physician Assistant or Nurse Practitioner, contrary to facility policy requiring a physician's own progress note during visits. The DON confirmed the absence of required physician documentation.
The facility did not maintain accurate and timely medical records for two residents, including one with multiple chronic conditions whose fall was not documented until days later, and another who left the facility and was found in the street, with no record of the incident or staff interventions. The DON confirmed that required documentation was missing for both events.
A resident with a history of multiple chronic conditions and a wound infected with carbapenem-resistant Acinetobacter Baumannii was not placed on contact precautions despite uncontained drainage. Staff inconsistently used PPE, and the resident's wound drainage contaminated therapy and common areas. The facility also failed to promptly notify the health department and had confusion among staff regarding the correct isolation protocols.
The facility did not ensure that concerns raised by the Resident Council, such as call light wait times and ice water issues, were addressed or resolved in a timely manner. Meeting minutes lacked documentation of resolutions, required concern forms were not used, and there was no process to communicate outcomes back to the Council. A resident reported ongoing long call light wait times, and staff confirmed that concerns were not formally tracked or resolved.
A resident with intact cognition and requiring hemodialysis was neglected when staff failed to prevent complications from the resident picking at his fistula site, leading to hemorrhage and death. Despite being informed of the behavior, nursing home staff did not implement adequate interventions. Additionally, a staff member was involved in an inappropriate romantic relationship with another resident, raising concerns about professional conduct. These issues highlight deficiencies in monitoring, communication, and staff-resident boundaries.
A facility failed to report an alleged incident of staff-to-resident sexual abuse involving a resident with multiple medical conditions and a CNA. The incident, which was reported by another CNA, involved a kiss in the parking lot. Despite denials from the involved parties, text messages suggested a possible romantic involvement. The facility suspended and later terminated the CNA but did not report the incident to the State agency, believing it was not sexual abuse.
A facility failed to follow physician's orders to monitor a resident's dialysis fistula bruit and thrill every shift. The resident, with end-stage renal disease, had no documentation of this monitoring in the MAR or TAR. The DON confirmed the oversight was due to the order not being transcribed. The resident was later discharged to the hospital, where he expired.
The facility exceeded the acceptable medication error rate with two errors out of 29 opportunities, affecting two residents. Both residents, with chronic respiratory conditions, were administered Fluticasone propionate and salmeterol inhalation powder without being instructed to rinse and spit after use, as required by the manufacturer's guidelines. These oversights were confirmed by the staff involved.
The facility failed to properly handle isolation laundry and implement enhanced barrier precautions (EBP) during tracheostomy care and medication administration. Laundry staff did not use appropriate PPE, and isolation linens were not placed in biohazard bags. A resident with a tracheostomy did not receive proper care, as the RN failed to maintain a sterile environment and did not wear a gown. Another resident with a PEG tube did not receive proper infection control measures during medication administration, as the RN only wore gloves and did not don a gown.
The facility failed to provide adequate hot water for residents' hygiene needs, affecting four residents. Inconsistent hot water availability led staff to obtain hot water from the shower room for bed baths. The Maintenance Director, new to the role, identified a faulty thermostat in one of the hot water tanks and did not document temperature checks. Observations confirmed water temperatures below the required 105-120°F range, with some rooms taking several minutes to reach even the lower end. Despite equipment replacements, the facility lacked an action plan to address the issue.
The facility failed to notify the physician of significant weight loss for two residents. One resident lost 36.4 pounds in 29 days, and another experienced a 10.3% weight loss. Despite these significant changes, there was no documentation of physician notification, contrary to facility policy.
The facility failed to conduct quarterly care conferences for two residents, as required. One resident with multiple health issues had only two documented care conferences, while another had only one documented meeting since admission. The Social Services Designee admitted to not documenting several meetings and not having a formal process for inviting residents. The facility's policy lacked specific time frames for care conferences.
A facility failed to complete a discharge summary for a resident upon discharge or transfer. The resident had multiple diagnoses, including a displaced fracture and diabetes. A review revealed no discharge summary, instructions, or progress note in the medical record. The Administrator confirmed the lack of documentation, stating the family initiated the discharge.
A resident with a lumbar surgical wound did not receive timely and appropriate care due to missing and inconsistent wound care orders. The facility failed to document and follow specific wound care instructions, leading to discrepancies in treatment. The Visiting Wound NP lacked access to the resident's medical records, and the facility's wound nurse did not conduct comprehensive assessments, contributing to the deficiency.
A resident with a sacral pressure ulcer did not receive prescribed treatments, including Triad paste and Santyl, due to documentation and communication failures. The wound worsened, becoming unstageable with slough. The facility's LPN confirmed treatments were not administered as ordered, and the Wound NP's orders were not entered into the electronic medical record due to a system glitch.
A facility failed to monitor and assess a resident's restorative nursing program, leading to a deficiency in care. The resident, with multiple diagnoses, was supposed to receive passive ROM exercises but lacked initial and quarterly assessments, and progress notes. Observations showed incorrect exercises were performed, and the resident reported inadequate assistance. The facility's policy was not adhered to.
The facility failed to maintain hot water temperatures within safe limits, with two residents' rooms having water temperatures of 123.6°F, exceeding Ohio's regulatory requirement. The Maintenance Director confirmed the temperature, and the facility lacked a procedure for addressing such deviations. An interview with the Administrator revealed no action plan for when water temperatures exceed acceptable parameters.
The facility failed to assess and treat urinary incontinence for a resident with multiple health issues, lacking a comprehensive bladder assessment and care plan. Another resident had an indwelling urinary catheter without documented justification, with no known reason for its use confirmed by staff and representatives.
A facility failed to assist a resident in obtaining a state photo ID, necessary for accessing his bank account and maintaining Medicaid eligibility. Despite being notified months earlier, the facility had not provided the required assistance, risking the resident's Medicaid eligibility. The resident had an intact cognition level and was admitted with conditions including a pressure ulcer and diabetes.
A resident with multiple medical conditions, including osteomyelitis, required an eight-week course of IV cefazolin, which was not administered as ordered on several occasions. The facility's DON confirmed the missed doses, and there was no documentation explaining the omissions, despite the facility's policy requiring such documentation.
A facility failed to administer a pneumonia vaccine to a resident who had consented to it. The resident, with multiple health conditions, consented to the vaccine, but the Medication Administration Records for two consecutive months showed it was not given. An interview with the Infection Preventionist confirmed the vaccine was not administered.
A resident with multiple medical conditions experienced significant weight loss due to the facility's failure to provide a comprehensive and individualized plan for monitoring and addressing her nutritional needs. The facility did not consistently weigh the resident or document her intake of nutritional supplements, leading to a deficiency in care.
Failure to Report Declining Condition and Implement Hospice Bowel Protocols
Penalty
Summary
The facility failed to timely identify changes in condition and notify the medical provider for a resident with bilateral nephrostomy tubes and chronic kidney disease, and it also failed to ensure hospice bowel protocols were entered and followed for another resident. For Resident #54, the record showed admission after a recent hospital stay for septic shock, acute on chronic kidney failure, bilateral hydronephrosis, and nephrostomy tube replacement. On admission, the resident was cognitively intact, required substantial assistance with several activities of daily living, and had orders for daily nephrostomy irrigation, weekly weights, and monitoring of nephrostomy output each shift. During the stay, the resident’s creatinine increased from 1.7 to 2.0 to 2.3, but there were no repeat lab orders after that point until a CMP was ordered during a telehealth visit to rule out dehydration and electrolyte imbalance. The CMP was not completed as ordered, was not placed on the TAR, and there was no documentation that the provider was notified that the lab had not been obtained. The resident’s nephrostomy output decreased over time, with several shifts or days showing no recorded output, and there was no evidence the provider was notified of the decreased output or missed documentation. The resident also had a documented 6.4-pound weight loss in one week, worsening weakness, decreased ability to transfer and perform personal care, decreased meal and fluid intake, and recurrent loose stools, but there was no evidence these changes were reported to the medical provider. On the day the resident was finally seen again, the NP documented dark tea-colored urine in the nephrostomy tubes, hypotension, tachycardia, and a creatinine of 4.9. The resident was sent to the emergency room and was admitted to the ICU with acute kidney injury, dehydration, and sepsis related to a UTI. The resident did not return to the facility and later expired at the hospital under hospice services. For Resident #13, who was admitted to hospice with diagnoses including COPD, diabetes, anemia, and cellulitis, the hospice bowel protocol was not entered as an active order in the medical record. The resident had opioid use, discontinuation of prior bowel medications, no documented bowel movement for five days, and later developed abdominal pain, nausea, and vomiting, while the record showed no evidence the provider was notified of the absent bowel movements.
Failure to Provide Complete Medicare Non-Coverage and Liability Notices
Penalty
Summary
The facility failed to ensure Medicare non-coverage notices and beneficiary liability notices were completed and provided correctly for four residents reviewed for beneficiary protection notification. The report states that the notices did not include the Quality Improvement Organization (QIO) name and contact information needed to appeal or ask questions, and in some cases the notices were not provided or were not provided timely. The facility census was 51.1, and the deficiency affected Residents #7, #39, #60, and #61. Resident #60 was admitted with diagnoses including left femur fracture, heart failure, diabetes, convulsions, head injury, and hypothyroidism. The facility’s beneficiary protection notification review form showed the resident’s last covered Part A day was 12/09/25 and that the resident was discharged home, but the form indicated a NOMNC was not issued when it should have been. Resident #61 was admitted with left knee effusion, diabetes, anemia, heart failure, and dementia; the resident’s NOMNC and ABN related to discharge from therapy services did not contain QIO contact information, and there was no documented evidence that the resident representative received a two-day notice or signed or received copies of the notices. Resident #39’s NOMNC also lacked QIO name and contact information, and Resident #7’s NOMNC similarly did not contain QIO contact information. The Social Service Director and Administrator confirmed these omissions during interview.
Infection Control Log Incomplete and EBP Not Used During Incontinence Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program because the infection control log was not comprehensive and enhanced barrier precautions were not maintained during incontinence care. Review of the infection control log, medical records, policy, interviews, and observation showed that infection surveillance information was incomplete or inaccurate for multiple residents, and staff did not use required PPE during direct care. For one resident with diagnoses including COPD, diabetes, anemia, and cellulitis, a urinalysis showed abnormal findings and the resident was treated with Rocephin and Vantin for a UTI. The infection surveillance criteria report and infection control log were completed before the urine culture was obtained, yet they documented that the resident met McGeer's criteria and included a urine culture result that was not available at that time. The IP and DON confirmed the log was inaccurate, did not include the organism, and did not include the one-time dose of Rocephin that had been administered. For another resident with dementia, depression, a femur fracture, and hypertension, a urine culture showed greater than 100,000 CFU/ml of Enterococcus faecalis, but the infection control log and trending map did not include this infection. The DON confirmed all infections should be included on the log and map even if no antibiotic was given. For a third resident with a pressure ulcer, diabetes, chronic pain, chronic viral hepatitis C, gout, and a colostomy, the log listed a UTI on one date when the resident was actually being treated with Rocephin for cellulitis, and later listed bacteremia without documenting MRSE from blood culture results. The facility’s trending map only identified infection sites and did not identify the organism, and the IP and DON confirmed there was no way to trend for specific organisms such as MRSA or E. coli. During observation of incontinence care for a resident with chronic respiratory failure with hypoxia, a tracheostomy, quadriplegia, traumatic brain injury, and CHF, two CNAs provided care without donning PPE even though enhanced barrier precautions signage and equipment were present on the door. The ADON observed the care and confirmed the CNAs did not wear PPE as required. The facility policy stated that EBP requires hand hygiene and targeted gown and glove use during high-contact resident care activities, including changing briefs and assisting with toileting.
Failure to Notify Resident Representative of New Pressure Injury
Penalty
Summary
The facility failed to notify the resident representative of a newly identified pressure injury for one resident. Resident #4 had diagnoses including chronic respiratory failure with hypoxia, tracheostomy, gastrostomy, diabetes mellitus, hemiparesis and hemiplegia following cerebrovascular disease, anoxic brain damage, and seizures. The quarterly MDS showed a BIMS score of 03, indicating severely impaired cognition, and the resident required staff assistance with ADLs. The resident’s mother was listed as the emergency contact and medical power of attorney. A nursing progress note documented that a new unstageable pressure injury was found on the resident’s left lateral ankle, with cleansing and dressing care provided and the nurse practitioner notified. The note also stated that the responsible party would be notified when in the facility the next morning, but the record contained no documented evidence that the mother was notified. The mother later stated she was not informed by the facility and learned of the wound only when visiting and asking why her son was not wearing his leg brace. The DON acknowledged the resident representative should have been notified when the new pressure injury was discovered, but said the nurse planned to tell her the next day during her visit.
PRN Ativan Order Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure that an as needed (PRN) psychotropic medication order was limited to 14 days for one resident. Resident #19 was admitted with diagnoses including anxiety disorder, psychoactive substance-induced psychotic disorder, chronic pain, and fibromyalgia, and the annual MDS dated 01/01/26 documented intact cognition and anxiety disorder. The physician order dated 06/17/25 directed Ativan 0.5 mg by mouth every six hours PRN for anxiety, but the order did not specify a 14-day stop date. Review of the June and July 2025 MARs showed the resident received Ativan from 06/17 through 06/24/25, 06/26 through 06/30/25, and 07/01 through 07/10/25, for a total of 23 days. The DON confirmed in interview that the PRN Ativan order did not include a 14-day stop date when the resident received the medication for 23 days before it was discontinued.
Inaccurate PASRR Documentation
Penalty
Summary
The facility failed to ensure a resident’s PASRR document accurately reflected all diagnoses. Resident #19 was admitted with diagnoses including anxiety disorder, psychoactive substance-induced psychotic disorder, chronic pain, and fibromyalgia, and the annual MDS assessment dated 01/01/26 showed intact cognition and a diagnosis of anxiety disorder. Review of the resident’s PASRR document dated 02/01/24 showed that under Section E, “Indications of Serious mental Illness,” “no” was selected, which incorrectly indicated there was not a diagnosis of mental illness. Record review showed the resident had diagnoses of anxiety disorder and psychoactive substance-induced psychotic disorder, and interviews with the Corporate RN and SSD confirmed the PASRR document was not accurate and did not include those diagnoses.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure showers were provided as scheduled for a dependent resident who required physical assistance from two staff members for showers and baths. Resident #2 was admitted with diagnoses including dementia, chronic kidney disease, cervical disk degeneration, diabetes mellitus, chronic pain, and morbid obesity. The 5-Day MDS showed moderately impaired cognition and the care plan identified an ADL self-care performance deficit with the need for two staff members for bathing assistance. Observation and interview found the resident with excess oil in his hair and wearing a hospital gown, and he stated he was scheduled for showers on Fridays but had not received one for the last couple of weeks. The shower binder showed the resident was scheduled for showers twice weekly on Tuesday and Friday, and the shower sheets and body/skin infection forms showed the last shower was received on 04/04/26 with refusals documented on 04/11/26 and 04/17/26. The forms did not document the reason for refusal or a report to the nurse as required by facility policy, and the DON confirmed the nurse did not follow up with the resident and document an intervention per policy.
Failure to Assist Resident With State Photo ID
Penalty
Summary
Provide medically-related social services to help each resident achieve the highest possible quality of life was not met when the facility failed to assist Resident #9 in obtaining a state photo identification. Resident #9 was admitted with diagnoses including a pressure ulcer to the sacrum, diabetes mellitus, and chronic kidney disease, and his MDS quarterly assessment indicated intact and independent cognition. Review of an Ohio BMV document showed that the BMV needed an affidavit from the provider stating the customer was homebound and unable to travel to the Deputy Registrar's Office before a license or identification card could be issued and mailed. The resident stated the facility still had not helped him obtain the state photo ID that had been requested over a year earlier. The DON acknowledged the facility was supposed to help the resident obtain the state-issued photo ID, noted the BMV letter indicated only an affidavit from the provider was needed, and stated that no letter had been obtained and the resident still did not have a photo ID.
Physician Did Not Address Pharmacist MRR Recommendation for PRN Ativan
Penalty
Summary
The facility failed to ensure that a monthly drug regimen review recommendation for a psychotropic medication was addressed by the physician for one resident. Resident #19 was admitted with diagnoses including anxiety disorder, psychoactive substance-induced psychotic disorder, chronic pain, and fibromyalgia. A physician order dated 04/24/25 prescribed Ativan 0.5 mg by mouth every six hours as needed for anxiety, and the order did not include a 14-day stop date. The medication was later discontinued on 06/15/25. The monthly regimen review dated 05/30/25 showed the pharmacist recommended a 14-day stop date for the Ativan order, or a documented rationale if the prescriber believed the PRN order should continue beyond 14 days. The physician did not address the recommendation, as the form was blank, and there was no documentation in the medical record showing a response. The resident received Ativan repeatedly in May and June 2025, and the DON confirmed in interview that the MRR was not addressed timely by the physician.
Delayed Urine Culture and Sensitivity Testing
Penalty
Summary
The facility failed to ensure ordered urine culture and sensitivity testing was completed timely for Resident #13, who had diagnoses including chronic obstructive pulmonary disease, diabetes, anemia, and cellulitis. The resident had an indwelling urinary catheter that was discontinued on 03/06/26 and later had a urinalysis/culture collected on 04/02/26. The urinalysis showed abnormal findings, including cloudy urine, positive nitrite, blood, protein, elevated red and white blood cells, bacteria, and mucus, but there was no evidence that the culture and sensitivity was performed at that time. On 04/03/26, the resident was seen for abdominal pain, no bowel movement, nausea, vomiting, and right side pain; the note stated there were no concerns of dysuria or hematuria and that urinalysis was pending to rule out UTI as the cause of symptoms. The urine culture and sensitivity was not completed until 04/09/26, when it showed greater than 100,000 CFU/ml of Proteus mirabilis sensitive to ceftriaxone. The DON confirmed in interviews that the culture and sensitivity was not performed timely and stated the laboratory was running behind.
Antibiotics started without confirmed criteria for UTI treatment
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program when it started antibiotic treatment for a resident without evidence that criteria for treatment had been met. The resident had diagnoses including COPD, diabetes, anemia, and cellulitis, and had previously had an indwelling urinary catheter that was discontinued. After a urinalysis showed abnormal findings including cloudy urine, positive nitrite, blood, protein, elevated WBCs, and bacteria, there was no evidence that a urine culture was obtained, and alert charting did not document urinary changes. The resident was seen for abdominal pain, nausea, vomiting, and right flank pain, with no documented dysuria or hematuria, and the encounter note stated urinalysis was pending to rule out UTI as the cause of symptoms. Despite the pending culture and no evidence of greater than 100,000 CFU/ml, the infection surveillance criteria report indicated the resident met criteria for treatment and the Infection Preventionist signed it. Based on that report, the resident was ordered ceftriaxone IM followed by cefpodoxime for UTI, and the MAR showed the antibiotics were administered. The infection control log also documented that the resident had flank pain, had a UTI, met criteria for treatment, and was ordered cefpodoxime. The DON and IP later confirmed the culture had not returned, the resident did not meet criteria for treatment, the criteria form and infection control log were completed inaccurately, and the provider did not give a rationale for treatment without meeting criteria.
Failure to Investigate and Document Resident’s Report of Missing Jewelry
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal belongings when staff did not appropriately respond to the resident’s report of missing jewelry following a room change. The resident, who had multiple medical conditions including COPD, lung cancer, hemiplegia, dementia, and chronic respiratory failure, was under hospice services but had an intact cognitive status with a BIMS score of 14/15. After being moved to a different room, the resident reported that two gold rings, one with a purple stone and one with a green stone, were missing. The resident stated she reported the missing rings to the Administrator on the day of the room change. An anonymous complaint later alleged that several items were missing after the room change, including an antique amethyst birthstone ring that was described in detail and characterized as irreplaceable, and that the Administrator refused to replace it or reach an amicable solution. Despite these reports, there was no documentation of the concern in the grievance/complaint log or the missing items log for the relevant months, and the Administrator initially stated there were no grievances or concerns filed and that he was unaware of missing jewelry. The Ombudsman reported that a volunteer Ombudsman had informed the Unit Manager about the missing rings, and the Unit Manager believed the facility was already aware. The Administrator later confirmed he knew of the allegation a few days after the room change but did not complete a grievance/concern form or self-report the incident to the state agency because he felt the resident could not adequately describe the rings or when she last saw them and questioned whether the rings existed. The Social Worker reported searching the resident’s room and speaking with staff but had no documentation to show an investigation was completed, and neither the Administrator nor the Social Worker contacted the resident’s family to verify the presence of the rings. These actions and omissions occurred despite a facility policy defining misappropriation as wrongful use of a resident’s belongings or money without consent.
Failure to Timely Report and Investigate Alleged Misappropriation of Resident Jewelry
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s property to the state agency, as required by policy and regulation. The affected resident was admitted with multiple significant diagnoses, including COPD, lung cancer, hemiplegia and hemiparesis after stroke, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage 2 chronic kidney disease, and was receiving hospice services. A quarterly MDS showed the resident had a BIMS score of 14/15, indicating intact cognition. The resident was moved from one room to another on Unit 2, and following this room change, the resident reported that several personal items, including two gold rings (one with a purple stone and one with a green stone), were missing. An anonymous complaint later alleged that after the room change, several items were missing, including an antique amethyst birthstone ring described as real gold with a [NAME]-cut stone that was beveled from years of wear, and another gold ring with a green stone. The complaint stated the missing items had been reported to social services but had not been located or replaced, and that the resident reported the Administrator refused to replace the ring or reach an amicable solution. The volunteer Ombudsman visited the facility and spoke with a Unit Manager about the missing rings; the Unit Manager stated she would relay the concern to management. When interviewed, the Administrator initially reported there were no grievances or concerns filed in the last three months and that he was not aware of any concerns regarding missing jewelry. Subsequent interviews and record review showed that the resident had, in fact, reported the missing rings to the Administrator on the day of the room change, and the rings remained missing at the time of survey. The Administrator later confirmed he was aware of the allegation a few days after the room change but did not complete a concern/grievance form and did not submit a self-reported incident to the state agency because he felt the resident could not adequately describe the rings or when she last saw them and was not convinced the resident had the rings. The Social Worker reported searching the resident’s room and speaking with staff but had no documented evidence of an investigation. Neither the Administrator nor the Social Worker contacted the resident’s family to confirm the presence of the rings at the facility. These actions and omissions were inconsistent with the facility’s written policy, which required immediate reporting of misappropriation allegations (no later than two hours after the allegation), timely investigation with documented statements and findings, and submission of investigation results to the state agency within five working days.
Failure to Investigate Allegation of Misappropriated Jewelry
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of misappropriation of a resident’s personal property in accordance with its own abuse, neglect, and misappropriation policy. Resident #3, who had multiple medical conditions including COPD, lung cancer, hemiplegia, dementia, chronic respiratory failure, and was on hospice services, was assessed as cognitively intact with a BIMS score of 14/15. After being moved to a different room on Unit 2, the resident reported that two gold rings, one with a purple stone and one with a green stone, were missing. The resident stated she reported the missing rings to the Administrator on the day of the room change. An anonymous complaint later alleged that several items, including an antique amethyst birthstone ring and another gold ring with a green stone, were missing after the room change, and that the Administrator refused to replace the items or reach an amicable solution. The Ombudsman’s volunteer reported the concern about the missing rings to the Unit Manager, who believed the facility was already aware. The Administrator initially stated he was not aware of concerns regarding missing jewelry, but later confirmed that the resident had reported missing rings a few days after the room change. He acknowledged he did not complete a concern/grievance form and stated he was not convinced the resident had the rings because she could not provide details. The Social Worker reported she searched the resident’s room and spoke to staff but had no documentation to show an investigation was completed, and neither the Administrator nor the Social Worker contacted the resident’s family to confirm the presence of the rings at the facility. Review of the facility’s misappropriation policy showed that each occurrence of misappropriation was to be reported, investigated timely, with statements obtained, documentation in the medical record, and a formal investigation report completed and submitted to the state, none of which were documented for this allegation.
Failure to Provide Ordered Enabler Bars Resulting in Two Bed Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered bilateral enabler bars were in place on a resident’s bed to prevent falls. The resident had multiple significant diagnoses, including COPD, lung cancer, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, depression, urinary incontinence, dysphagia, aphasia, dementia, chronic respiratory failure, and stage two chronic kidney disease, and was receiving hospice services. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 14, used a wheelchair, and required supervision or touching assistance for transfers. The resident’s ADL documentation from late August and late November indicated bilateral enablers to assist with turning and repositioning, and physician orders dated January showed bilateral enabler bars had been ordered since late August for this purpose. Despite these orders, the resident experienced two falls from bed after a room change. Progress notes documented that in December the nurse was called and found the resident on the floor near the bed, with the resident stating she was trying to get up from bed when she fell; neurological status and vital signs were assessed and the resident denied pain. A subsequent clarification indicated this fall was unwitnessed. In mid-January, another progress note recorded the resident lying on her right side on the floor next to the bed, stating she had slid; she denied attempting to get out of bed and denied hitting her head, and a bruise was noted on the left lower extremity. Neuro checks were within normal limits, and the resident was assisted back to a wheelchair while bed linens were changed. Record review showed that staff had been signing the medication and treatment administration records in December and January indicating that bilateral enabler bars were in place, even though no bars were actually on the bed. An anonymous complaint reported that the resident had fallen out of bed because she did not have assist bars, and that she had requested assist bars multiple times since mid-December. The resident confirmed during interview that she had not had enabler bars on her bed since moving to the new room until a half rail was installed the day before the surveyor’s observation, and she stated she preferred an enabler bar. The DON confirmed that when the resident’s room was changed in November, the resident did not take the prior bed, and when hospice delivered a new bed in December, it did not include enabler bars, leaving the resident without the ordered bilateral enabler bars despite ongoing documentation that they were in place and despite two falls from bed during this period.
Failure to Ensure Timely Ordering and Availability of Pain Medication
Penalty
Summary
The facility failed to ensure that medications were ordered in a timely manner and available for administration, resulting in a resident not receiving prescribed pain medication as ordered. The resident, who had a history of traumatic brain injury, quadriplegia, neuropathy, muscle spasms, and chronic pain, was dependent on staff for most activities of daily living and received opioid medication for pain management. The care plan included both pharmacological and non-pharmacological interventions for pain, and the resident was scheduled to receive Percocet multiple times daily. On one occasion, the resident was out of Percocet for approximately 30 hours, missing five scheduled doses. Documentation showed that the facility had recently switched to a new pharmacy, which led to issues with the timely delivery of narcotic medications. Staff were unable to access emergency stock, and there was a delay in the pharmacy receiving and processing the prescription from the pain management clinic. During this period, the resident expressed concern about withdrawal symptoms and was offered transport to the emergency room, which was declined. Interviews with staff and review of records confirmed that the medication was not available due to the pharmacy transition and delays in prescription processing. The resident reported that this was not the first time such an incident had occurred and was told that future orders would be placed earlier to prevent recurrence. The deficiency was confirmed by the DON, who verified the missed doses and the duration the resident went without the ordered pain medication.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented concerns and observations of pest activity affecting both the kitchen and resident areas. Pest control invoices and state survey agency complaints revealed ongoing issues with cockroaches in the kitchen, including German and oriental roaches, as well as structural deficiencies such as loose wall coverings, cracked tiles, gaps between baseboards and walls, and a missing door seal that allowed light and pests to enter. Despite pest control services and repeated identification of these issues, the necessary repairs to prevent pest entry and harboring were not completed. Staff interviews confirmed the persistence of these problems, and the facility was without a Maintenance Director at the time, further delaying resolution. Additionally, a resident with a colostomy bag who was bedbound reported a significant gnat infestation in his room, which was confirmed by both a medical provider and facility staff. Observations documented the presence of multiple gnats on the resident's pillow, bedside table, and wall, with the issue persisting over at least two weeks. Staff and residents reported ongoing problems with both gnats and roaches throughout the building, particularly in the kitchen and the affected resident's room. The facility's pest control policy required regular monthly treatments and prompt response to pest problems, but these measures were not effectively implemented, resulting in continued pest presence.
Failure to Provide Resident Access to Personal Funds After Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds after business hours and on weekends. Four residents with personal funds accounts managed by the facility were affected. Observations and interviews revealed that only one staff member, HR #153, was responsible for dispensing resident funds, and she did not leave the money box accessible to other staff after her shift ended at 5:00 P.M. on weekdays or on weekends. Multiple staff members, including RNs, LPNs, and CNAs, confirmed they did not have access to the funds box outside of business hours, and residents were required to withdraw money before HR #153 left for the day. Residents reported being unable to access their funds after hours and on weekends, with some stating they had to wait days to receive money or that the facility had run out of money in the personal funds box. Staff interviews corroborated that residents voiced frustration and concerns about not having timely access to their funds. Review of the facility's policy indicated a requirement to comply with federal and state regulations regarding resident funds, but the observed practices did not align with this policy.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific details about the actions or omissions that led to this event are not provided in the report excerpt.
Failure to Timely Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely investigate an injury of unknown origin for a resident with multiple complex diagnoses, including Alzheimer's disease, dementia with behavioral disturbances, conversion disorder with seizures, anxiety, depression, paranoid schizophrenia, and a nontraumatic intracerebral hemorrhage. Medical record review showed the resident was admitted with fragile skin and later developed a skin tear on the left elbow, as well as a bruise on the left lower arm. There was no documentation in the resident's record explaining how the skin tear or bruise occurred, nor was there evidence of an investigation into these injuries at the time they were discovered. Observation of the resident revealed a dressing on the left elbow, a dark purple bruise on the left lower arm, scratches on the upper arm, scabs above the dressing, and slight edema to the left arm. Interviews with facility staff confirmed that no investigation had been conducted to determine the cause of the injuries, and the facility's policy required timely identification and investigation of injuries of unknown origin. The lack of timely investigation and documentation regarding the injuries constituted non-compliance with facility policy and regulatory requirements.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Respond to Acute Change in Condition Resulting in Resident Death
Penalty
Summary
The facility failed to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with multiple complex medical diagnoses, including morbid obesity, heart failure, sleep apnea, and respiratory failure. The resident was noted by therapy staff to have a significant decline in health, including hypoxemia, tachycardia, excessive daytime sleepiness, and lethargy while in therapy. Despite these abnormal findings, there was no evidence that a comprehensive nursing assessment was performed, nor were individualized interventions implemented. The therapy staff notified the Assistant Director of Nursing (ADON), who observed the resident and communicated with the on-site nurse practitioner (NP), but the NP did not assess the resident, and no further action was taken to address the acute change in condition. Throughout the day, the resident continued to exhibit increased somnolence, lethargy, and loud snoring, which were not comprehensively addressed by nursing staff. Documentation showed that the resident's oxygen saturation levels were critically low and heart rate was elevated during therapy, and the resident was unable to participate in therapy due to these symptoms. Despite these clear signs of deterioration, there was no evidence of timely communication with the medical provider, no comprehensive assessment, and no escalation of care. Nursing documentation was incomplete, and staff interviews revealed a lack of awareness and follow-through regarding the resident's change in condition. Later that evening, the resident was found unresponsive and without vital signs by an LPN during medication administration. Cardiopulmonary resuscitation was initiated, and emergency services were called, but the resident was pronounced deceased. The cause of death was determined to be acute hypoxic and hypercapnic respiratory failure. The facility's failure to recognize, assess, and respond to the resident's acute change in condition, as well as the lack of communication and documentation, directly contributed to the deficiency and resulted in actual harm and death.
Failure to Notify Family and Physician of Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify both the family and physician of a resident's fall. The resident, who had multiple diagnoses including chronic diastolic congestive heart failure, diabetes, hypertension, and dementia, was admitted with significant cognitive and physical impairments, requiring staff assistance for most activities of daily living. On the date of the incident, the resident's daughter, who monitored her mother via an electronic camera, observed her mother on the floor and reported not receiving any notification from the facility about the fall. The Director of Nursing (DON) confirmed that the daughter presented video evidence of the fall, and the nurse involved gave inconsistent accounts regarding whether the family was notified, including stating that he was told not to call the family and later claiming to have sent a text, which the daughter did not receive. Review of the medical record showed no documentation of the fall on the date it occurred, and a late entry was made several days later, indicating the resident was found slanted in her wheelchair and that the daughter was texted. However, there was no evidence that the physician was notified of the fall, as required by the facility's policy on notification of changes in condition. The DON verified that there was no documentation of physician notification and acknowledged the inconsistencies in the nurse's account of family notification.
Failure to Provide Showers per Resident Preference
Penalty
Summary
A resident with multiple complex medical conditions, including chronic diastolic congestive heart failure, diabetes, hypertension, dementia, and other diagnoses, was admitted to the facility and was totally dependent on staff for activities of daily living, including bathing. The resident's care plan and admission assessment documented that the resident or their representative preferred daily showers. Despite this documented preference, review of bathing records showed that the resident did not receive showers daily; instead, the resident received a combination of bed baths and showers, with at least one day where no bath was documented. There was no documentation of the resident refusing showers, and staff confirmed that no refusal sheets existed for this resident. Facility policy required routine daily care, including bathing, to be provided by certified nursing assistants under the supervision of a licensed nurse. However, the facility failed to ensure that the resident received showers according to their stated preference. This deficiency was identified through record review, hospice communication, and staff interview, and it affected one resident reviewed for showers during the survey.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and adequate supervision was provided to prevent accidents, as evidenced by two separate incidents involving two residents. In the first case, a resident with multiple diagnoses including dementia, congestive heart failure, and impaired decision-making experienced a fall in her room. The fall was discovered by the resident's daughter via electronic monitoring, but there was no documentation of the incident in the medical record, no immediate intervention, and no post-fall assessment or follow-up as required by facility policy. The Director of Nursing confirmed that the nurse on duty did not document the fall, complete an incident report, or implement any new interventions until days later, after being shown the camera footage by the resident's daughter. In the second case, another resident with a history of pulmonary embolism, chronic pain, and no cognitive impairment left the facility in his wheelchair and was found in the middle of a public street. Staff were aware the resident intended to leave to purchase alcohol and attempted to redirect him, but he signed himself out for a leave of absence and remained outside for several hours. Staff did not maintain supervision or check on the resident during this time. The situation escalated to the point where law enforcement and the facility administrator had to intervene to return the resident to the facility. Documentation showed the resident had never previously signed out for a leave of absence, and staff did not contact the physician regarding the resident's request for alcohol. Both incidents demonstrate a lack of adherence to facility policies regarding fall prevention, post-incident assessment, and supervision of residents, particularly those with known risks or behavioral concerns. The facility's failure to document, assess, and intervene appropriately after the fall, as well as the lack of supervision and monitoring of a resident who left the premises, contributed to the deficiencies cited in the report.
Lack of Physician In-Person Examination Documentation
Penalty
Summary
The facility failed to provide evidence that the attending physician conducted in-person examinations for all residents as required. Specifically, for one resident with multiple complex diagnoses including Type 2 Diabetes Mellitus with neuropathy, asthma, morbid obesity, bipolar disorder, atrial fibrillation, acute respiratory failure, hypertension, and hyperlipidemia, there were no physician progress notes documented in the medical record since admission. The medical record review showed that the Medical Director, who was the attending physician, only co-signed notes written by a Physician Assistant or Nurse Practitioner and did not write any direct physician notes for the resident. The facility's policy requires the physician to review the resident's plan of care during visits and to write and sign a progress note, but this was not followed in this case. The Director of Nursing confirmed the absence of physician notes for the resident.
Failure to Maintain Accurate and Timely Medical Records for Significant Resident Events
Penalty
Summary
The facility failed to maintain accurate and timely medical records for two residents, resulting in incomplete documentation of significant events. For one resident with multiple chronic conditions, including congestive heart failure, diabetes, and dementia, there was no documentation of a fall that occurred in her room until three days after the incident, when her daughter presented video evidence to the DON. The nurse did not document the fall, complete an incident report, or implement immediate interventions, leaving the resident's medical record incomplete and inaccurate. In another case, a resident with a history of pulmonary embolism, pleural effusion, and chronic pain left the facility in a wheelchair and was found in the middle of a street. Police and facility administration were involved in returning the resident to the facility. Despite the seriousness of the event, the medical record did not include any documentation of the resident being in the street, the involvement of law enforcement, or the efforts made by staff and administration to return the resident to the facility. Interviews with the DON confirmed that in both cases, the medical records did not accurately reflect the events that occurred, nor did they include timely or complete documentation as required by facility policy. The lack of documentation failed to provide a truthful and current account of the residents' status and the care provided during these incidents.
Failure to Implement Contact Precautions for Resident with Uncontained MDRO Drainage
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate contact isolation precautions for a resident with a multi-drug resistant organism (MDRO) infection, specifically Acinetobacter Baumannii Carbapenem Resistant, whose wound drainage was not contained. The resident had a complex medical history including cellulitis, morbid obesity, congestive heart failure, chronic kidney disease, and lymphedema, and was admitted for skilled care with ongoing wound management. Despite orders for enhanced barrier precautions, the resident was not placed on contact precautions even after the wound culture confirmed the presence of a highly resistant organism with uncontained drainage. Staff interviews and record reviews revealed that the resident's wound was actively draining, resulting in wet footprints and contaminated surfaces in therapy and common areas. Staff used gloves and sometimes gowns during therapy, but there was no consistent use of contact precautions, no dedicated equipment, and no requirement for staff to gown and glove upon entering the resident's room. The resident was observed to move independently through the facility, leaving wet areas from the wound drainage, indicating a failure to contain infectious material and prevent potential transmission. Additionally, the facility did not promptly notify the local health department as required after the identification of the MDRO, and there was confusion among staff regarding the implementation and discontinuation of enhanced barrier versus contact precautions. Documentation inconsistencies were noted, with forms indicating contact precautions were in place when only enhanced barrier precautions had been implemented. The infection control oversight was in transition, with responsibilities shifting between staff, contributing to the lack of appropriate infection prevention measures for the resident.
Failure to Address Resident Council Concerns in a Timely Manner
Penalty
Summary
The facility failed to address concerns raised by the Resident Council in a timely manner, as evidenced by a review of Resident Council meeting minutes, policy documents, and staff and resident interviews. Concerns about call light wait times were repeatedly mentioned in several meetings, and issues with ice water were also raised. However, the minutes did not document any resolutions to these concerns, and the facility's policy requiring concerns to be documented, distributed to department heads, and followed up through the Resident Grievance Procedure was not followed. Staff interviews confirmed that concern forms were not used, concerns were not formally presented to department heads, and there was no process to communicate resolutions back to the Resident Council. A resident reported ongoing issues with excessive call light wait times, including a specific instance of a two-hour wait. The Director of Activities, who presides over Resident Council meetings, acknowledged that resolutions to concerns were not brought back to the Council. The Social Service Designee maintained a separate concern log for other issues but did not handle Resident Council concerns. The Administrator confirmed there was no documentation of complaint resolution for Resident Council issues, and the last call light audit was conducted prior to the most recent meeting where call light concerns were still being reported. This deficiency was identified during an investigation under a specific complaint number and had the potential to affect all residents in the facility.
Neglect and Inappropriate Staff-Resident Relationship
Penalty
Summary
The facility failed to prevent an incident of neglect involving a resident who required hemodialysis. The resident, who had intact cognition, was observed by dialysis staff picking at his fistula site. Despite being educated not to pick at it, the resident continued to do so. The dialysis staff communicated this incident to the nursing home staff, but no adequate measures were taken to prevent complications. The night shift nurse only applied a dressing without further assessment or intervention. Subsequently, the resident was found unresponsive, hemorrhaging from the fistula site, and later passed away. The facility's failure to implement effective interventions after identifying the resident's behavior of picking at his fistula site led to the resident's death. The resident's call light was activated, but it is unclear for how long before he was found unresponsive. The facility's documentation revealed no evidence of staff checking the dialysis graft site for bruit and thrill every shift as ordered. Additionally, the facility investigation showed that the last staff to see the resident alive did not observe any picking at the fistula site, indicating a lack of proper monitoring and communication among staff. Another concern identified was the facility's failure to prevent potential staff-to-resident abuse when a staff member was involved in an inappropriate romantic relationship with another resident. This issue, although not rising to the level of Immediate Jeopardy, affected two residents. The facility's investigation into this matter revealed conflicting statements and text message exchanges between staff members, indicating a lack of clear boundaries and professional conduct within the facility.
Removal Plan
- The DON began collecting statements from all staff who worked on Resident #72's unit in last 24 hours. All statements were collected.
- The Director of Human Resources #260 gave the DON all cardiopulmonary resuscitation (CPR) cards of the nurses completing CPR.
- Licensed Practical Nurse (LPN) Unit Manager (UM) #208 completed assessments on residents who had dialysis ports or fistulas. The assessments included checking for any signs of infection, any bleeding, dry and intact dressings, and bruit and thrill for Resident #71's arteriovenous (AV) fistula and Resident #64's right upper cervical (RUC) hemodialysis (HD) port.
- The DON initiated education to all 24 licensed nurses. The education pertained to the policy titled Hemodialysis Care and Monitoring with emphasis on the assessment of ports and shunts, pre and post assessments on dialysis residents, all dialysis orders, and on dialysis monitoring orders. The education also included communication between the facility and dialysis center every dialysis day and to initiate immediate dialysis interventions. New licensed nurses would be educated by the DON or designee during new hire orientation.
- The DON initiated education of the facility's Abuse, Neglect, and Misappropriation Policy. The education was completed for all 24 licensed nurses and all 29 CNA's. New nurses and CNAs would be educated during new hire orientation.
- The DON initiated an audit on all dialysis residents to validate dialysis orders to monitor residents' dialysis sites. Orders were corrected for Resident #71's left upper arm fistula and added to the treatment record. A physician order to check Resident #71's dialysis graft site for bruit and thrill every shift was initiated.
- The DON reviewed and revised care plans for dialysis residents to ensure accuracy and Resident #71's was updated to ensure accuracy related to the type of fistula he had.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Regional Director of Operations (RDO) #217, Regional Director of Clinical Operations (RDCO) #218, Diversional Director of Clinical Operations (DDCO) #219, President (VP) of Risk #220, VP of Operations #221, and VP of Clinical Operations #222.
- A Root Cause Analysis was completed by the DON, Administrator, Assistant Director of Nursing (ADON) #213, Divisional Director of Risk #223, and LPN UM #208. Licensed nurses CPR licenses were verified. The analysis determined the problem to be cardiac arrest secondary to hypovolemic shock due to hemorrhage from AV fistula per hospital documentation. Care plans, orders, and code statuses were reviewed for accuracy, dialysis patients were assessed, and nurses received education on Hemodialysis Care and Monitoring and medication administration.
- The facility initiated audits for neglect through Angel Rounds (monitoring completed by department heads Monday through Friday on the residents) through observation and interviews of three staff and three residents, five days a week for four weeks.
- The DON/designee would audit three dialysis residents, three times a week for four weeks then randomly thereafter to ensure dialysis orders were in place to monitor the shunt site with the schedule, pre/post dialysis forms were completed, and care plans and orders reflected dialysis recommendations, and any monitoring needed. The DON/designee will validate that the facility received communication forms from the dialysis center three days a week for four weeks then randomly thereafter.
- Education to all staff on answering call lights in a timely fashion was completed by the DON/designee. New staff would be educated during new hire orientation.
- The ED/designee would initiate call light audits on three call lights, three days a week and interview five residents a week on call light response times for four weeks then randomly thereafter.
- The results of audits will be forwarded to the facility QAPI committee for further review and recommendations until substantial compliance is maintained. The Medical Director will give input into any data presented and plans proposed by the Committee.
Failure to Report Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident sexual abuse to the State agency, affecting one resident. The incident involved a resident with multiple medical conditions, including end-stage renal disease and major depressive disorder, who was reported to have kissed a Certified Nursing Assistant (CNA) in the parking lot after her shift. The facility's investigation revealed conflicting accounts from the involved parties, with the resident and the CNA denying any inappropriate behavior, while another CNA reported witnessing the incident. The facility's investigation included reviewing text messages between the CNAs, which suggested a possible romantic involvement between the resident and the CNA. Despite the denial from both the resident and the CNA, the facility suspended the CNA pending investigation and later terminated her employment for violating company policy. The facility updated the resident's psychosocial care plan to address potential psychosocial issues. Interviews with staff and residents revealed that there were rumors and observations of inappropriate behavior between the CNA and the resident. The facility's Administrator was aware of these rumors but did not report the incident to the State agency, believing it was not sexual abuse due to the denials from the involved parties. The facility's policy required reporting of non-consensual sexual contact, but the Administrator did not consider the incident to meet this criterion.
Failure to Monitor Dialysis Fistula as Ordered
Penalty
Summary
The facility failed to follow physician's orders to monitor the dialysis fistula bruit and thrill for a resident who required such services. The resident, who had multiple diagnoses including end-stage renal disease with dialysis, was admitted to the facility and had an order to check his dialysis graft site for bruit and thrill every shift. However, the review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) revealed no documentation of staff checking the dialysis graft site for bruit and thrill every shift for the resident. An interview with the Director of Nursing confirmed that the resident had an order to check his dialysis bruit and thrill every shift, but the nurse had not been performing this task because it was never transcribed onto the MAR or TAR. The facility's policy on Hemodialysis Care and Monitoring emphasized the importance of monitoring the vascular access device for signs such as thrill and bruit, but this was not adhered to in the case of the resident. The resident was later discharged to the hospital, where he expired.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.9% due to two medication errors out of 29 opportunities. This affected two residents who were observed for medication administration. Resident #66, diagnosed with chronic respiratory failure, COPD, dyspnea, and schizophrenia, was administered Fluticasone propionate and salmeterol inhalation powder without being instructed to rinse and spit after use, as per the manufacturer's guidelines. This oversight was confirmed by Medication Technician #200 during an interview. Similarly, Resident #59, with diagnoses including COPD, acute respiratory failure, asthma, cerebral ischemia, dependence on supplemental oxygen, and emphysema, was also administered the same medication without being instructed to rinse and spit. This was confirmed by Intern Registered Nurse #201. Both instances of non-compliance with the manufacturer's instructions contributed to the facility's medication error rate exceeding the acceptable threshold, as investigated under Complaint Number OH00163468.
Infection Control Deficiencies in Laundry and Resident Care
Penalty
Summary
The facility failed to properly handle and sanitize isolation laundry, as well as implement enhanced barrier precautions (EBP) during tracheostomy care and medication administration. Laundry staff did not use appropriate personal protective equipment (PPE) such as gowns or face protection while sorting linens, and they were unaware of the procedures for handling isolation laundry. The facility's policy required all soiled linen to be treated as contaminated, but staff interviews revealed that isolation linens were not being placed in biohazard bags, leading to improper washing procedures. Resident #53, who had multiple medical conditions including a tracheostomy, was not provided with proper tracheostomy care. The registered nurse (RN) did not use a complete tracheostomy cleaning kit, failed to maintain a sterile environment, and did not wear a gown as required by the resident's physician's orders. The RN set up a sterile field directly on the resident's bed and used non-sterile gloves and containers during the procedure, which was against the facility's policy for maintaining aseptic technique. Resident #37, who had a PEG tube and required EBP, did not receive proper infection control measures during medication administration. The RN only wore gloves and did not don a gown as required by the EBP policy. The facility's policy for medication administration by enteral tube required the use of gloves and any other necessary PPE, but this was not followed, leading to a breach in infection control protocols.
Inadequate Hot Water Temperatures for Resident Hygiene
Penalty
Summary
The facility failed to maintain adequate hot water temperatures for residents' personal hygiene needs, affecting four out of fifteen residents interviewed. Residents reported inconsistent hot water availability, with some having to rely on staff to obtain hot water from the shower room for bed baths. The Maintenance Director, who had been in the position for two weeks, acknowledged the issue and noted that one of the three hot water tanks was not functioning due to a faulty thermostat control unit. The Maintenance Director was unsure which tank serviced specific parts of the building and did not document water temperature checks, which ranged from 98 to 117 degrees Fahrenheit. Observations confirmed that water temperatures in various rooms were below the regulatory requirement of 105-120 degrees Fahrenheit, with some rooms taking several minutes to reach even the lower end of this range. The Maintenance Director used a digital thermometer to verify these temperatures in the presence of a surveyor. Despite replacing one hot water tank and a mixing valve, the facility lacked an action plan to address the low water temperatures. The facility's policy did not include procedures for addressing non-compliance with regulatory water temperature requirements.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for two residents, which was a deficiency in their care. Resident #73 experienced a weight loss of 36.4 pounds over 29 days, with no evidence of being weighed during two weeks in October. Despite this significant weight loss, there was no documentation that the resident's physician was notified. The resident's family member reported taking her sister to the emergency room immediately after discharge, where she weighed only 96 pounds. Interviews with the Director of Nursing and the Nurse Practitioner confirmed the lack of notification to the physician about the resident's weight loss. Similarly, Resident #45 experienced a 10.3% weight loss, dropping from 172.4 pounds to 154.6 pounds. The nutritional assessment noted a significant weight loss of 15.4 pounds over three months, which was discussed with the Interdisciplinary Team. However, there was no evidence in the medical record that the physician or nurse practitioner was informed of this significant weight loss. The facility's policy required that any weight loss concerns be reported to the practitioner and discussed at the weekly clinical meeting, which was not adhered to in these cases.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly for two residents, as required. Resident #56, who has diagnoses including a pressure ulcer, diabetes mellitus, and chronic kidney disease, was admitted on an unspecified date. The resident's medical record showed care conferences documented only twice within the year, and the resident confirmed not attending any care conferences. The Social Services Designee (SSD) verified that the required quarterly care conferences were not completed for this resident. Additionally, the facility's policy lacked specific time frames for when care conferences should be conducted. Resident #34, with multiple diagnoses including chronic kidney disease, anxiety, and depression, had only one documented care conference since admission, which the resident did not attend. The SSD confirmed that the resident was supposed to have quarterly care conferences but failed to document several of them. The SSD also admitted to not having a formal process for inviting residents or documenting their attendance. The facility's policy required that care plan meetings be scheduled with the resident and responsible party, and a care plan note should be created, but these procedures were not consistently followed.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident upon discharge or transfer. This deficiency was identified during a closed record review and interview, affecting one of two residents reviewed for discharge. The resident in question was admitted with multiple diagnoses, including a displaced fracture, hypertension, atrial fibrillation, and diabetes, among others. Upon discharge, there was no evidence in the medical record of a discharge summary, discharge instructions, or a progress note indicating the resident's discharge or transfer. An interview with the Administrator confirmed the absence of necessary documentation, noting that the family had initiated the discharge or transfer process.
Inadequate Surgical Wound Care for Resident
Penalty
Summary
The facility failed to provide timely and appropriate surgical wound care for a resident with a lumbar surgical wound. Upon admission, there were no wound care orders for the surgical incision on the spine, except for a wound vac application. The initial order lacked details on the type of foam to be used and the suction settings. On 09/22/24, a specific order was given for wound care, but it was discontinued the same day, leaving a gap in treatment orders from 09/22/24 to 09/26/24. During this period, the Visiting Wound Nurse Practitioner (NP) changed the wound vac dressing, but there were no documented orders in the resident's medical record. The resident's wound care was inconsistent, with discrepancies in the type of foam used and the frequency of dressing changes. The Treatment Administration Record (TAR) indicated a missed treatment on 09/29/24, with no evidence of completion on 09/28/24. Subsequent wound assessments by the Visiting Wound NP showed that the white foam was not applied as per the orders, and the wound vac pump settings were adjusted without proper documentation. The facility's wound nurse confirmed that there were issues with entering orders into the electronic medical record, leading to further inconsistencies in wound care. Interviews with facility staff revealed that the Visiting Wound NP did not have full access to the resident's medical records and could not enter her own orders. The facility's wound nurse admitted to entering the NP's orders but was unaware of discrepancies until questioned by surveyors. The facility's policy on skin care and wound management was not followed, as daily rounds to verify wound treatments were not conducted. The lack of comprehensive assessments and documentation contributed to the deficiency in providing appropriate wound care for the resident.
Failure to Administer Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed according to orders for a resident with multiple medical conditions, including a pressure ulcer to the sacral region. Upon admission, the resident had a suspected deep tissue injury on the sacrum, but there was no evidence that the hospital's order to apply Triad hydrophilic paste was administered. Subsequent orders to cleanse the sacrum with normal saline and cover with a foam dressing were not consistently followed, as treatments were missed on specific days. The resident's wound condition worsened, with the wound becoming unstageable and covered with slough. Despite new orders from the Wound Nurse Practitioner (NP) to apply Santyl and antifungal cream, these treatments were not documented as completed in the Treatment Administration Record (TAR). The LPN responsible for wound care confirmed that the treatments were not administered as ordered and that the facility did not conduct its own weekly wound assessments, relying instead on the Wound NP's entries. Interviews with facility staff revealed communication and documentation issues, including the Wound NP's inability to enter orders directly into the electronic medical record due to a system glitch. The facility's policy on skin care and wound management was not adhered to, as evidenced by the lack of documentation and communication of treatment interventions. The deficiency was confirmed by the facility's administrator and corporate RN, who acknowledged the failure to implement the Wound NP's orders.
Failure to Monitor and Assess Restorative Nursing Programs
Penalty
Summary
The facility failed to ensure that restorative nursing programs were properly monitored and assessed quarterly for a resident, leading to a deficiency in care. The resident, who had diagnoses including cellulitis, legal blindness, arthritis, hypertension, and depression, was supposed to receive a passive range of motion (PROM) exercise program for his lower extremities five to seven days per week. However, there was no initial assessment or quarterly monitoring assessments documented since the initiation of the program. Additionally, there were no progress notes available to track the resident's progress or decline in mobility. Observations revealed that a Certified Nursing Assistant (CNA) performed an active range of motion (ROM) exercise instead of the prescribed passive ROM exercise. Interviews with the resident and the Director of Nursing (DON) confirmed the lack of assessments and progress notes. The resident reported that facility staff did not assist with the daily exercise program as required. The facility's policy on restorative programs was reviewed, which outlined the definitions and purposes of active and passive ROM exercises, but the policy was not followed in practice for this resident.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures within safe limits, resulting in a potential hazard for residents. During an observation, the water temperature in the rooms of two residents was found to be 123.6 degrees Fahrenheit, exceeding the regulatory requirement of 105-120 degrees Fahrenheit in Ohio. The Maintenance Director confirmed the elevated temperature using the facility's digital thermometer in the presence of the surveyor. The facility's policy on water temperatures did not include procedures for addressing temperatures that fall outside of acceptable parameters. An interview with the Administrator revealed that the facility lacked an action plan for when water temperatures exceed the acceptable range. The Centers for Medicare and Medicaid Services (CMS) guidance highlights that hot water can pose a significant risk of burns, especially for residents with conditions such as decreased skin thickness, sensitivity, or mobility. The report notes that at 120 degrees Fahrenheit, a third-degree burn can occur within five minutes, and at 124 degrees Fahrenheit, within three minutes, underscoring the potential danger posed by the facility's failure to control water temperatures.
Inadequate Assessment and Care for Urinary Incontinence and Catheter Use
Penalty
Summary
The facility failed to adequately assess and treat urinary incontinence for Resident #73, who was admitted with multiple diagnoses including osteomyelitis, endocarditis, diabetes, and pressure ulcers. Upon admission, the resident was noted to be incontinent of bladder and bowel, yet there was no comprehensive bladder assessment conducted to identify the type of incontinence. Additionally, there was no plan of care developed to address the resident's incontinence. The resident's records showed a significant number of incontinence episodes, and interviews with the Director of Nursing and Corporate RN confirmed the lack of assessment and care planning. For Resident #57, the facility failed to provide an adequate indication for the use of an indwelling urinary catheter. The resident, who had diagnoses including end-stage renal disease and diabetes, was readmitted with orders for a urinary catheter without documented justification. Medical records, including physician and nurse practitioner assessments, lacked evidence of a valid indication for the catheter's use. Observations during the survey confirmed the presence of the catheter, and interviews with the Director of Nursing and the resident's representative revealed no known reason for its use.
Failure to Assist Resident in Obtaining State ID
Penalty
Summary
The facility failed to provide timely assistance to a resident in obtaining a state photo identification, which was necessary for the resident to access his personal bank account. This deficiency was identified through interviews with the facility Ombudsman, the resident, and staff members, as well as a review of the resident's medical record. The resident, who was admitted with diagnoses including a pressure ulcer, diabetes mellitus, and chronic kidney disease, had an intact and independent cognition level according to his Minimum Data Set (MDS) 3.0 quarterly assessment. The Business Office Manager (BOM) was informed by a case worker from the local Job and Family Services (JFS) office that the resident needed to reapply for Medicaid and spend down his bank account balance to maintain eligibility. Despite being notified in July, the facility had not yet assisted the resident in obtaining the necessary identification by December, putting the resident at risk of losing Medicaid eligibility by the end of the month. The Social Services Designee confirmed the delay in providing the required assistance.
Failure to Administer IV Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of intravenous (IV) cefazolin. The resident, who had multiple medical diagnoses including osteomyelitis, opioid use, and type two diabetes mellitus, was admitted with a surgical dehiscence wound and required an eight-week course of IV cefazolin. Despite the clear orders for administration every eight hours, the medication was not administered on several occasions, including multiple missed doses in September, October, and November. There were no documented reasons for these missed doses, and the facility's Director of Nursing (DON) confirmed the lapses in administration. The resident's Medication Administration Records (MAR) showed numerous instances where the cefazolin was not signed off as administered, and there were no corresponding notes to explain the omissions. The facility's policy on medication administration requires that medications be administered as prescribed and documented accordingly, including any refusals or withheld doses. However, the facility's use of medication techs who were unable to administer IV medications contributed to the failure, as the DON had to arrange for staff to administer the medication, which was not consistently documented or executed.
Failure to Administer Pneumonia Vaccine After Consent
Penalty
Summary
The facility failed to administer a pneumonia vaccine to Resident #45 despite having obtained consent for the vaccination. Resident #45 was admitted to the facility with multiple diagnoses, including hypokalemia, bulbous ureteral stricture hematuria, benign prostatic hyperplasia, retention of urine, diabetes, hyperlipidemia, respiratory failure, atrial fibrillation, osteoarthritis, major depressive disorder, and dementia. The medical record showed that the resident consented to the pneumonia vaccine on June 28, 2024, but the Medication Administration Records for June and July 2024 indicated that the vaccine was not administered. An interview with the Infection Preventionist confirmed the oversight in administering the vaccine after consent was given.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #73, was provided with a comprehensive and individualized plan to monitor and address significant weight loss. The resident, who had multiple medical conditions including osteomyelitis, endocarditis, diabetes, and heart failure, experienced a weight loss of 36.4 pounds over 29 days. The resident was on a regular diet with specific calorie and protein needs, but there was no evidence that the facility consistently monitored the resident's weight or dietary intake as ordered. The resident's dietary assessments indicated that she was consuming between 50-100% of most meals, and her estimated nutritional needs were being met. However, there were discrepancies in the resident's height measurements, which affected the accuracy of her nutritional assessments. The facility failed to weigh the resident during two critical weeks, and there was no documentation of the intake percentages for nutritional supplements like Juven and Med Pass, which were part of her dietary plan. Interviews with the Director of Nursing and the Registered Dietician revealed that the facility staff did not accurately document the resident's height and failed to monitor her weight and supplement intake as required. The Registered Dietician confirmed the unexplained weight loss and noted that the resident's pain and infection could have increased her calorie needs. Despite these factors, the facility did not adjust the resident's care plan to address her significant weight loss, leading to the deficiency cited in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 226 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wintersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sienna Skilled Nursing & Rehabilitation | 0.9 mi | ★★★★★ | 24 | 0 |
| Steubenville Country Club Manor | 2.7 mi | ★★★★★ | 0 | 0 |
| Villa Vista Royale Llc | 2.9 mi | ★★★★★ | 3 | 0 |
| Carriage Inn Of Steubenville | 3.4 mi | ★★★★★ | 18 | 0 |
| Laurels Of Steubenville The | 4.5 mi | ★★★★★ | 2 | 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.