Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Hills Center during CMS and state inspections, most recent first.
Activities program was not directed by a qualified activities professional. The Activity Director had no documentation showing she met the required qualifications and stated she was not certified or formally trained for the role. The Administrator said CNAs were expected to help with resident engagement, but there was no process to verify evening or weekend activities, 1:1 visits were not being documented, and weekend activities were not being tracked. HR confirmed no formal activity-related training had been provided to aides or CNAs, and the CNA position was vacant.
Food was not served at an appetizing temperature during lunch service. Staff used only one part of the warming shells because there were not enough for all residents, trays ran out and had to be washed and reused, and a test tray that left the kitchen warm arrived on the unit cold by the time it was fully passed out. The kitchen manager confirmed the food should be held at 135 degrees F or higher, and a resident reported the meal was cold and gross.
The facility failed to ensure its activities program was directed by qualified personnel and that residents received consistent activity programming based on assessed interests and preferences. Surveyors observed residents sitting in common areas with little to no staff-facilitated engagement or organized activities despite the activity calendar, and the AD stated one-to-one visits were not consistently documented, weekend activities were not tracked, and resident-specific programs were not completed consistently. The facility also had no Certified Activity Assistant and lacked a process to verify that scheduled activities were occurring.
QAPI failed to identify, monitor, and correct ongoing activity program deficiencies. The Administrator stated activity programming and staffing concerns were being reviewed through QAPI, but survey observations found residents on multiple units with little to no staff-facilitated engagement, individualized programming, one-to-one activities, or organized activities despite the posted calendar. Record review also showed the person functioning as Activities Director lacked documentation of the required qualifications, and the Activities Director reported that one-to-one visits, weekend activities, and resident-specific programming were not being consistently documented or completed.
Dignified dining was not maintained for residents who did not eat in the dining room. Residents were served meals in the sitting nook on bedside tables instead of a stable table, and food was left on serving trays with covers still on. The Kitchen Manager confirmed this was not a dignified, home-like dining environment and stated she was unsure why staff did not remove the lids and trays.
A resident with dementia had a bare room with pictures on the floor, broken dresser drawer fronts, and a radio that the ADM kept in his office for months instead of returning to the family. Another resident with dementia and DM had a bedspread with several holes, which a CNA confirmed was not appropriate; the DORM said linens with holes were used as rags, though invoices did not show blankets had been ordered.
Failure to provide resident-directed activity programming: Surveyors observed residents sitting quietly in common areas or remaining in rooms with no organized or individualized activities taking place, even when the activity calendar showed scheduled programming. Records showed several residents had documented preferences for 1:1 visits, in-unit activities, social events, music, painting, movies, and outdoor walks, but those preferences were not consistently reflected in observed care. The ADON/activities staff acknowledged 1:1 documentation was incomplete, weekend tracking was lacking, and the facility had no method to verify evening or weekend activities were occurring.
Damaged furniture and environmental maintenance issues were identified in the third hall nook, where a chair had exposed rough wood on the arm and a couch had torn, peeling fabric. RN confirmed residents were still using the damaged furniture and could not say how long it had been broken. The report also noted a missing baseboard behind the bed in a resident room; the resident had neurocognitive disorder with Lewy Bodies, aphasia, contracture, adult failure to thrive, muscle wasting, and psychosis, and the BIMS could not be completed.
A resident with dementia, psychosis, MDD, DM, and CKD stage V was admitted to hospice through a specific agency, but the guardian said no choice of hospice provider was offered and no alternatives were presented. The DON verified there was no documentation that provider choice was discussed, and the DSS confirmed hospice was discussed with the family only after the resident had already been admitted to hospice.
Failure to provide timely spend down notices for resident funds. Two residents with dementia and psychotic disturbance, both on Ohio Medicaid, had personal fund balances well above the $2,000 limit, with quarterly statements showing balances over $4,000 and $5,000. Although spend down notices were documented, the BOM confirmed the last notices were provided in April, and the facility did not provide the required notices when the accounts reached the threshold.
Failure to notify the physician and family of a change in condition. A resident with dementia, altered mental status, and dependence for most ADLs vomited in the morning and missed scheduled medications, but the RN did not complete an assessment, document the event, or notify the physician, family, or DON. The record showed no note of the change in condition or missed meds, and the DON stated notification should occur immediately for nausea, vomiting, and missed medications.
Psychotropic Medication Indications and Monitoring Not Properly Documented: Surveyors found that two residents had psychotropic medications ordered without appropriate documented indications, and two residents were not monitored for side effects. One resident with dementia, psychosis, and severe cognitive impairment had Seroquel and Depakote orders, but no adverse-effect monitoring was documented. Another resident with dementia, psychosis, depression, and CKD V had quetiapine orders, but side-effect monitoring was absent and AIMS testing was not completed per policy. A third resident with Alzheimer’s disease and dementia with agitation had olanzapine and risperidone orders with indications the DON confirmed were not appropriate.
Incomplete Investigation of Injuries of Unknown Origin: The facility did not complete thorough investigations for two residents with injuries of unknown origin. One resident with dementia, osteoporosis, and multiple fractures was found in severe pain with a new femur fracture, but the SRI lacked statements from all relevant staff and did not include staff education or like-resident review. Another resident with Alzheimer’s disease and vascular dementia had an unexplained bruise, but the investigation did not identify the reporting staff or hall, included only some staff statements, and lacked evidence of abuse training or a resident assessment.
Failure to Notify Ombudsman and Assist with Discharge Planning: The facility failed to notify the Ombudsman after one resident was hospitalized and transferred for a hip fracture repair, with post-op needs including pain mgmt, wound care, PT/OT, and extensive ADL assistance. The facility also failed to assist another resident with discharge planning when the resident's POA requested a transfer to another facility, and staff had no documentation showing the transfer was completed or followed up.
The facility failed to include care plans for a resident who spoke Somali and did not understand English, a resident with hand and knee contractures, and a resident receiving PT services. Staff were observed communicating with the Somali-speaking resident in English and using gestures or family translation, while the DON confirmed no communication/language care plan was in place. Another resident had an order for rolled washcloths and documented contractures, but no contracture care plan, and a third resident had PT orders and use of PT services, but no PT goals or services were documented in the care plan.
Failure to Complete Required Care Conferences: Two residents did not have care conferences completed as required or as scheduled. One resident with dementia and impaired cognition had no documented care conference since admission, and the resident's representative reported no updates despite a scheduled meeting. Another resident returned after a fall, femur fracture, and hip hemiarthroplasty with new PT, OT, wound care, pain management, and fall precaution needs, but the DON and SSD confirmed no care conferences had been completed or scheduled to review and revise the care plan.
Failure to provide language and communication services for a resident who spoke Somali and did not understand English. The resident had dementia, altered mental status, and was rarely if ever understood, yet the care plan had no language or communication interventions. Staff were observed speaking English to the resident during care and meals, and a CNA used gestures rather than interpreter services. The resident's representative reported staff were using family to translate instead of an actual interpreter, while the RN confirmed staff should use the interpreter phone line.
Delayed X-ray After Fall Led to Missed Fracture Diagnosis: A resident with dementia, COPD, HTN, weakness, and mobility impairment fell while walking to the bathroom and had pain afterward. An x-ray was ordered, but it was not completed as directed. The resident later went to the ED with hip pain, was diagnosed with a femoral neck fracture, and underwent a hemiarthroplasty. The DON confirmed the original x-ray was missed and a STAT x-ray later identified the fracture.
Incomplete assessment of newly identified pressure injuries. A resident with severe cognitive impairment and dependence for mobility and toileting developed new pressure injuries to both inner knees, but the skin grid left the stage and wound description blank. The DON confirmed the documentation was incomplete, and the WNP later assessed the wounds as a stage 3 injury on one knee and an unstageable injury on the other.
The facility failed to ensure residents were assessed by qualified staff after falls and before being moved. A resident with dementia, Parkinson's disease, and a prior femur fracture was found out of bed with a knee on the fall mat, but an SSD moved the resident back to bed without a nurse assessment. Another resident with Alzheimer's disease, dementia, schizophrenia, and muscle weakness had multiple prior falls, but the record showed missing and inaccurate neuro checks and an incorrect injury entry in a fall investigation. The DON confirmed the monitoring errors and that the nurse assessment requirement was not followed.
A resident with a feeding tube, dysphagia, and diabetes received tube feeding care that did not follow orders. During a feeding bottle change, the RN left the HOB below 30 degrees, did not wear a gown, did not check residuals or tube placement, did not flush the tube, and did not change the dressing at the insertion site; the pump was also running at 55 mL/hr instead of the ordered 65 mL/hr.
Failure to provide drinks consistently and on request. A resident with dementia, dysphagia, and impaired cognition had no drinks in the room and asked for coffee because he was thirsty. A CNA said drinks were only given with meal trays and coffee came when the coffee cart arrived, while an LPN later provided water after the surveyor intervened. The facility policy stated residents with dementia will forget to drink and should be encouraged and assisted.
Four residents with severe cognitive impairment and dependence on staff for care experienced unwitnessed injuries, including bruises and a fracture, that were not reported or were reported late to the State agency as required by facility policy. Investigations were incomplete, lacking interviews with relevant parties and documentation of conclusions, and the DON confirmed that reporting and documentation procedures were not followed.
Three residents with severe cognitive impairment and high dependency for ADLs experienced injuries of unknown origin, including bruising and a fracture. In each case, the facility did not complete thorough investigations, failed to interview relevant parties, and did not document conclusions in IDT progress notes. Suspected causes were not confirmed, and preventive interventions were not implemented.
A resident with severe cognitive impairment and multiple diagnoses was admitted without a signed consent for treatment by facility providers, as the legal guardian insisted on exclusive care by VA providers. Despite this, staff obtained or attempted to obtain medical orders from facility providers on several occasions, contrary to the guardian's directives and without proper authorization.
Two residents with cognitive impairments were involved in a physical altercation after one entered the other's room, resulting in injury. Despite a physician's order for a stop sign to be placed at the doorway to prevent such incidents, observations confirmed the stop sign was not consistently in place. Staff interviews indicated the sign was frequently removed, and the facility's investigation could not conclusively determine the events due to the residents' cognitive deficits.
The facility did not timely report or investigate multiple injuries of unknown origin and a resident-to-resident altercation, affecting three residents with severe cognitive impairment and histories of behavioral issues or falls. Required documentation, staff interviews, and state agency notifications were not completed, and incidents were only reported after family concerns were raised.
The facility did not conduct or document required investigations into injuries of unknown origin for two residents with severe cognitive impairment, nor into a physical altercation between two residents that resulted in injury. In each case, there was a lack of incident reporting, staff interviews, and formal investigation, despite facility policy requiring these actions.
The facility did not ensure the presence of a registered nurse (RN) for the required hours on multiple days, with several instances of no RN coverage or less than eight hours of RN coverage. This lapse was confirmed by the DON and had the potential to impact all 70 residents.
Staff failed to keep the kitchen clean, with significant buildup of debris and substances under a grate and around equipment, and did not use proper sanitary technique when checking food temperatures, sometimes reusing alcohol swabs between different foods. These actions had the potential to affect all residents who consumed food from the kitchen.
Surveyors found that the laundry room was not kept clean or sanitary, with lint buildup on pipes, wet and discolored puddles on the floor, cracked and peeling flooring, and accumulated dirt and debris. The Maintenance Director confirmed these conditions and acknowledged the need for cleaning, while the facility's policy did not address the issue.
Several residents were prescribed psychotropic medications, including escitalopram and Depakote, for conditions such as agitation, mood, and behaviors without appropriate or documented clinical diagnoses. Care plans did not consistently address the use of these medications, and the DON confirmed that the documented reasons for prescribing were not appropriate indications. This resulted in a deficiency related to the facility's failure to ensure proper medication management and documentation.
A resident with severe cognitive impairment had conflicting code status information in their medical record, with the electronic record indicating Full Code while the care plan and a signed DNRCC-A form indicated DNRCC-A status. Nursing staff and the DON confirmed the inconsistency, which was linked to issues during a recent electronic medical record system change.
A resident with severe cognitive impairment and behavioral disturbances was placed in her room with the door held closed by staff during episodes of aggression, without a documented assessment, physician order, or care plan intervention for physical restraint. Facility policy requiring documentation and evaluation of restraint use was not followed.
The facility failed to properly monitor and document a bruise for a resident with cognitive impairment, as ongoing assessments of the bruise's characteristics were not completed and the care plan was delayed. Additionally, wound care orders for another resident with a burn wound were not implemented in a timely manner due to a system change, and there was no evidence the correct treatment was provided as ordered.
A resident with severe cognitive impairment and a history of falls was left unsupervised in a common area despite care plan interventions requiring supervision. The resident was later found on the floor with a skin tear, and staff confirmed that the supervision intervention was not in place as required by the care plan and facility policy.
A resident with severe cognitive impairment and chronic pain did not receive a prescribed Butrans patch on two occasions due to unavailability, and the physician was not notified of the missed doses. The DON confirmed that neither she nor the physician was informed, and the pharmacy did not receive the prescription until weeks later.
A resident with dementia and behavioral disturbances repeatedly engaged in sexually inappropriate behaviors that were inconsistently documented and inadequately monitored by staff. Despite care plans and staff awareness, detailed reporting and intervention were lacking, resulting in a deficiency in behavioral health care and services.
Required postings with contact information for State agencies and advocacy groups, as well as complaint filing instructions, were placed in an area inaccessible to residents. Two residents confirmed they had never seen this information and would like access to it. The Activities Recreation Director verified that the postings were not in resident living areas and that residents did not have routine access to the posted information.
The facility failed to maintain comfortable temperatures in certain areas, affecting residents' comfort. Observations showed that the Third Street Unit and a room on the First Street Unit were warmer than other areas, with temperatures exceeding the facility's policy range. Malfunctioning PTAC units contributed to the issue, and temporary measures like box fans were not consistently used. Resident interviews confirmed discomfort due to the heat.
The facility failed to follow its abuse policies when two residents with severe cognitive impairments were left alone after a potential observation of abuse. A staff member found a male resident in a female resident's room in a compromising situation but did not immediately call for a nurse, delaying the separation of the residents. The facility's policy required immediate protection of residents, which was not adhered to, leading to a deficiency finding.
The facility failed to implement comprehensive care plans that included activities and preferences for two residents. One resident with severely impaired cognition and multiple diagnoses did not have an activity care plan or preferences documented. Another resident with moderately impaired cognition and various diagnoses also lacked an activity care plan or preferences. The facility's policy required routine assessment of each resident's interests and needs, which was not followed.
A resident with severe cognitive impairment eloped from the facility after a receptionist mistakenly allowed him to exit, thinking he was a visitor. The resident was found by police and returned without injuries. The incident revealed gaps in the facility's supervision and security measures.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified activities professional. Review of the Activity Director job description showed the position was responsible for planning, organizing, developing, directing, and implementing the overall activity department, and required the director to meet specific qualifications such as being a qualified therapeutic recreation specialist, a licensed activities professional, having qualifying experience in a patient activities program, being a qualified OT or OTA, or completing an approved training course. However, review of the personnel file for Activity Director #192 found no documentation showing she met the required qualifications, and the facility roster showed she was the only activity staff member. Interviews confirmed the lack of qualification and oversight. The Administrator stated CNAs were expected to assist residents to and from activities and follow the activity calendar, but acknowledged there was no process to verify activities were occurring during evenings and weekends. Activity Director #192 stated she was not certified for the role and had not received formal training specific to the position, that CNAs/Aids were responsible for resident engagement after 3:00 P.M. and on weekends, and that there was no current process to verify those activities were completed. She also stated one-to-one activity visits were not being documented as required and weekend activities were not being tracked. The HRD confirmed the facility had not provided formal activity-related training for Activity Aides or CNAs responsible for resident engagement, and the CNA position had been vacant since 04/07/26.
Food Served at Cold Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure food was served at an appetizing temperature. During observation of lunch service, the regular texture chicken, vegetable, and sweet potato were initially measured at 191.7 degrees F, 196 degrees F, and 197 degrees F, respectively. Later, during tray line, staff were observed using only one piece of the warming shells instead of both the top and bottom pieces, and the kitchen manager confirmed the facility did not have enough warming shells for all residents. The kitchen also ran out of trays and had to wait for trays to be collected from the dining room and washed before they could be reused for lunch service. A test tray left the kitchen at 1:08 P.M. and arrived on the unit at 1:13 P.M., but it was not fully passed out until 1:35 P.M. When tested at that time, the chicken was 120 degrees F, the sweet potato was 100 degrees F, and the vegetables were 80 degrees F. The kitchen manager confirmed food should be held at 135 degrees F or higher and acknowledged the test tray was cold and tasted cold. She also stated delays occurred because trays were unavailable, dishes had to be washed for reuse, and staff had to track down bedside tables as residents were moved to an area with tables. A resident interviewed during the meal service reported the food was cold and gross and tasted like jail food.
Activities Program Not Properly Directed or Implemented
Penalty
Summary
The facility failed to administer its activities program effectively by not ensuring the program was directed by qualified personnel and by not ensuring residents received activities that addressed their assessed interests, preferences, and psychosocial well-being. Review of the Activity Director's personnel file did not show documentation that the individual met the qualifications required to direct the activities program, and the facility had been without a Certified Activity Assistant since 04/07/26. Observations throughout the survey found residents on multiple units sitting in common areas with limited to no staff-facilitated engagement, individualized activities, one-to-one programming, or organized activity programming, even though activities were listed on the facility calendar. The Administrator stated CNAs were expected to assist residents to and from activities and follow the calendar, but also acknowledged there was nothing in place to verify that scheduled activities were occurring during evenings and weekends. The Activities Director stated one-to-one visits were not consistently documented, weekend activities were not being tracked, and resident-specific programs were not being completed consistently. The Administrator also stated the facility's QAPI committee routinely reviewed activity programming and staffing concerns and that the facility was aware of concerns involving the activity department.
QAPI Program Failed to Correct Activity Service Deficiencies
Penalty
Summary
The facility failed to implement and maintain an effective QAPI program by not identifying, monitoring, and correcting deficiencies in its activity program. During interview, the Administrator stated the QAPI committee routinely reviewed quality measures, resident concerns, staffing concerns, activity programming, employee retention, and operational issues affecting resident care, and that activity programming and staffing concerns were being monitored through the QAPI process. The Administrator also stated concerns were identified through resident and family complaints, audits, quality measure data, staffing concerns, and trends identified by department managers. Despite those identified concerns, observations throughout the survey showed residents on multiple units were frequently sitting in common areas with limited to no staff-facilitated engagement, individualized programming, one-to-one activities, or organized activity programming occurring even though activities were scheduled on the facility calendar. Review of personnel records showed the individual functioning as Activities Director did not have documentation demonstrating the required qualifications for the position. The Activities Director stated one-to-one activity visits were not consistently documented, weekend activities were not being tracked, and resident-specific activity programming was not being completed consistently.
Dignified Dining Environment Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents who did not eat in the dining room. On 06/01/26 at approximately 9:00 A.M. and again at approximately 12:45 P.M., residents were observed being served meals in the sitting nook on bedside tables that were pulled out from rooms and/or stored in the corner of the sitting nook. Residents were not provided a stable table to sit at, and their food was left on the serving tray with the food covers still in place. During an observation and interview on 06/03/26 at approximately 1:25 P.M., the Kitchen Manager confirmed that residents who did not eat in the dining room were served in the sitting nook on bedside tables and stated this was not a dignified home-like dining environment. She also confirmed that resident food was served and left on trays without removing the trays and food covers. She reported that in the dining room, food is uncovered and plates are placed on the table with drinks and silverware, and stated she was unsure why staff did not remove the lids and trays, noting it was probably faster for staff cleanup. Review of the facility's Customer Service policy stated that every resident deserves to be treated with respect and dignity at all times.
Personal Property Not Maintained and Linen With Holes
Penalty
Summary
The facility failed to maintain a home-like environment for Resident #26 by not ensuring the resident’s personal property and personal items were maintained. The resident had diagnoses including dementia without behaviors, psychotic disturbance, vascular dementia, dysphagia, and pulmonary disease, and the MDS indicated impaired cognition. The care plan noted the resident needed encouragement to participate in activities of interest and preferred self-directed activities such as listening to music in his room, and also documented behaviors of hoarding food in drawers. During observation, the resident’s walls were bare, several pictures were on the floor, and he stated he was not allowed to hang pictures because it would put holes in the walls. The dresser in the room had two drawer face boards broken off and sitting on top of it, and no personal items were observed in the room besides the pictures on the floor. Staff confirmed the resident had pulled pictures down and had broken the dresser drawer face boards, and the resident’s representative stated the room was bare and the resident had a radio that was broken or missing. The facility also failed to ensure linen provided to Resident #50 did not have holes. Resident #50 had diagnoses including unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and Type II Diabetes Mellitus. Observations showed the resident’s bedspread had several holes covering the bed, and a CNA verified the holes and stated it was not appropriate. The Director of Maintenance stated that linens with holes were placed in a pile and used as rags, but the facility had purchased blankets recently; however, purchasing invoices reviewed by surveyors did not show any blankets ordered.
Failure to Provide Resident-Directed Activity Programming
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet residents’ interests, preferences, and psychosocial needs. Surveyors observed multiple residents on the 100 Hall seated in common areas or remaining in their rooms during several observation periods, with residents listening to music or sitting quietly and no organized activities, individualized programming, or staff-facilitated engagement taking place. During an additional observation of the hall, residents were seated with a television on and again no organized activity or individualized activity programming was seen. The facility’s activity calendar showed Oldies Music with Karaoke scheduled during the observation period, but no activity was observed to be occurring. Resident #35 had diagnoses including Alzheimer’s dementia with behavioral disturbance, COPD, hypertension, weakness, difficulty walking, unsteadiness on feet, and a right hip fracture. Records showed the resident enjoyed socializing within the unit, watching television, attending movie and popcorn activities, and preferred one-to-one visits or in-unit activities with occasional group activities due to low energy and a preference for low-stimulation activities. Despite these documented preferences, the record contained extremely limited evidence that one-to-one visits, individualized activities, or in-unit programming were provided consistent with the resident’s assessed preferences. Resident #54 had diagnoses including senile degeneration of the brain, schizoaffective disorder bipolar type, dysphagia, CHF, CKD, type 2 diabetes mellitus with hyperglycemia, and hypertension. The resident’s activity assessment documented enjoyment of socializing, live music, and painting, but survey observations did not show painting, social activities, individualized programming, or staff-facilitated engagement. Resident #28 had diagnoses including dementia, adjustment disorder with mixed disturbance of emotions and conduct, insomnia, and Alzheimer’s disease. Activity assessments documented preferences for in-unit activities, watching TV, classic movies, live music, social events, walking outside when weather permitted, and being around animals. Survey observations on multiple occasions found the resident lying in bed with no independent preferred or group activities provided. Resident #5 had diagnoses including unspecified dementia with behavioral disturbance, major depressive disorder, pre-excitation syndrome, difficulty walking, and muscle weakness. The care plan identified a need for encouragement to participate in activities of interest and listed preferred activities such as bowling, ball toss, basketball, parties, morning coffee socials, walking on the unit, and socializing with peers. Records showed only five documented group activities from March through June 2026 and eight one-to-one sessions per month, but the activity director acknowledged one-to-one activities were not being documented as required and that activities were not being tracked on weekends. Interviews with the activity director and administrator confirmed that resident-specific programs were not consistently occurring and that the facility did not have a method to verify scheduled activities were occurring during evenings and weekends.
Damaged Furniture and Environmental Maintenance Issues
Penalty
Summary
Facility failed to ensure furniture was maintained in a safe manner in the third hall nook. During observation and interview, a chair was found with damage on the arm and exposed rough wood framing, and a couch was observed with torn and peeling fabric. RN #199 confirmed that residents had been picking at the furniture, that residents were still sitting in the damaged chair and couch, and that she could not remember how long the furniture had been damaged. The deficiency affected 25 residents living on the third hall, with a facility census of 74. The report also documented a missing baseboard behind the bed in Resident #55’s room, with the wall behind the bed not intact and hanging off. Resident #55 had diagnoses including neurocognitive disorder with Lewy Bodies, aphasia, contracture of an unspecified joint, adult failure to thrive, muscle wasting and atrophy, and unspecified psychosis not due to a substance or known physiological condition. The most recent MDS showed the BIMS could not be conducted. Facility policy stated the environment must be maintained to provide a safe, functional, sanitary, and comfortable setting, and personnel were responsible for reporting broken equipment.
Hospice Provider Choice Not Offered
Penalty
Summary
The facility failed to ensure that choice was offered for hospice services provider for one resident. Resident #2 had an admission date of 07/20/18 and diagnoses including dementia with other behavioral disturbance, diabetes mellitus due to underlying condition with diabetic autonomic neuropathy, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder severe with psychotic symptoms, and chronic kidney disease stage V. Physician orders dated 04/02/26 directed admission to Hospice #333 for end stage renal disease, and the care plan documented that the resident/family had elected hospice care and that the resident was admitted to Hospice #333. The Hospice #333 consent form was signed by the resident's guardian on 03/31/26, but the guardian later stated in a telephone interview that they were not offered a choice of hospice providers when hospice services were initiated. The guardian reported they were simply informed that the resident was being placed on hospice through a specific agency and were not given information about alternative providers or the opportunity to select one. The DON verified there was no documentation of hospice provider choice being offered or of conversations about which hospice provider the guardian wanted, and the Director of Social Services stated she discussed hospice services with the family at a care conference after the resident had already been admitted to hospice. The facility policy stated it was the policy to provide and/or arrange hospice services to protect resident self-determination and communication with persons and services inside and outside the facility.
Failure to Provide Timely Spend Down Notices for Resident Funds
Penalty
Summary
The facility failed to provide spend down notices when resident personal funds accounts reached $200 less than the Social Security Insurance resource limit. This deficiency involved two residents, both of whom had diagnoses including dementia and psychotic disturbance, and both were unable to complete an interview to assess mental status on their MDS assessments. Review of the facility records showed that both residents had Ohio Medicaid as their primary payer and had resident fund balances in excess of $4,500, with quarterly statements showing balances of $4,234.16 and $5,162.44 on 03/31/26. Record review showed spend down notices dated 04/23/26 stating that each resident’s fund balance was within $200 of, or exceeding, what is allowable under Medical Assistance. However, interview with the BOM confirmed that the Medicaid spend down limit in Ohio was $2,000, and further interview confirmed that the last documented spend down notice provided to each resident was in April 2026. The report identified this as non-compliance investigated under Complaint 2579178.
Failure to Notify Physician and Family of Change in Condition
Penalty
Summary
The facility failed to ensure the physician and family were notified of a change in condition for Resident #36. The resident was admitted with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive, and edema. The MDS indicated the resident was rarely if ever understood, was dependent with most ADLs, and required moderate to maximum assistance with mobility. The care plan identified impaired cognitive process for daily decision making and a risk for further decline in cognitive status, with interventions to communicate with staff, family, physician, and the resident regarding needs and to obtain input from family and friends. On the morning of the event, the resident did not receive scheduled morning medications. The record contained no documentation of a change in condition, no notification to the family, physician, or DON, and no indication that the resident had nausea or vomiting or that medications were missed. The RN confirmed the resident had been ill earlier in the morning and vomited on the floor, so he did not give the morning medications, but he had not informed the family or physician and had not completed an assessment, including vital signs. The DON stated her expectation was that the physician or NP and family be notified immediately for any change in condition, including nausea and vomiting with missed medications. The facility policy required prompt notification of the physician and resident's family for any change in condition.
Psychotropic Medication Indications and Monitoring Not Properly Documented
Penalty
Summary
The facility failed to ensure appropriate indications for use were documented for psychotropic medications for two residents and failed to ensure two residents were monitored for psychotropic medication side effects. Surveyors reviewed medical records, physician orders, MDS assessments, MARs, and interviewed the DON, and found that the required documentation and monitoring were not present for the residents sampled for unnecessary medications. One resident had diagnoses including dementia, anxiety disorder, mood affect disorder, pseudobulbar affect, psychosis, and frontotemporal neurocognitive disorder, and was assessed as having severe cognitive impairment with total assistance needed for toileting, transfers, and hygiene. The resident had orders for Seroquel for agitation and mood and Depakote for depression with psychotic features, but the MARs for May and June 2026 did not show documentation for monitoring adverse effects of the psychotropic medications. The DON confirmed the indications for use were not appropriate and that there were no orders or documentation for monitoring adverse effects. A second resident had diagnoses including dementia with behavioral disturbance, psychosis, major depressive disorder with psychotic symptoms, and chronic kidney disease stage V, and was assessed as having moderate impaired cognition and receiving routine antipsychotic medication. The resident had orders for quetiapine for agitation and mood disorder, but the record did not include monitoring of side effects related to quetiapine. Although AIMS evaluations were completed on two dates, the DON verified they were not completed per policy and no side effect monitoring was completed. A third resident had diagnoses including Alzheimer’s disease, dementia with agitation, anxiety, and insomnia, and had orders for olanzapine and risperidone; the DON confirmed the indications for use for those psychotropic medications were not appropriate.
Incomplete Investigation of Injuries of Unknown Origin
Penalty
Summary
The facility failed to complete a thorough investigation of injuries of unknown origin for two residents. Resident #20 had diagnoses including displaced fracture of the lateral left fibula, right femur fracture, wedge compression fracture, dementia without behaviors, kidney disease, muscle weakness, and osteoporosis, and had a BIMS score of 6 indicating impaired cognition. On 04/14/26, staff found the resident lying in bed holding her right leg and yelling in pain; she could not state whether she had fallen, a stat X-ray identified a fracture of the neck of the right femur, and she was sent to the hospital. The self-reported incident investigation stated the injury was of unknown origin and that a 72-hour look-back of staff should be completed, but the investigation did not include statements from all staff who worked on the resident’s hall, did not document attempts to interview several staff, and did not include staff education or review/interviews with like residents. Resident #83 had diagnoses including Alzheimer’s disease, vascular dementia, and mood disorder, and had a BIMS score of 99 indicating impaired cognition and required substantial maximum assistance with ADLs. On 03/23/26, staff found discoloration on the right buttocks with yellow outer edges and a purple center, and the resident was guarding his hip; an X-ray showed no fracture or dislocation. The self-reported incident investigation identified the injury as a large bruise of unknown source, but it did not state which staff reported the incident or what hall the resident lived on. The investigation included statements from only some staff working various halls, found no evidence of staff training on abuse, and found no evidence that an assessment was completed for the resident. The Administrator confirmed that several staff were not interviewed and that the file lacked evidence of staff education and like-resident interviews or skin checks. Facility policy required investigation of suspected abuse or neglect, including interviewing all persons involved and completing thorough documentation.
Failure to Notify Ombudsman and Assist with Discharge Planning
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospitalization and transfer of one resident. Resident #35 had diagnoses including Alzheimer's dementia with behavioral disturbance, COPD, essential hypertension, and a right hip fracture. After a fall, the resident was transferred to the hospital, diagnosed with a right femur fracture, and underwent a right hip hemiarthroplasty before returning to the facility with post-operative needs including pain management, wound care, PT, OT services, fall precautions, and substantial to maximal assistance with ADLs. The DON stated requested transfer and care conference documentation was not available, and no documentation was provided showing the Ombudsman had been notified. Social Services Director #181 stated she was unaware that Ombudsman notification was required for the hospitalization and transfer. The facility also failed to assist another resident with discharge planning services. Resident #8 had diagnoses including Alzheimer's disease, dementia, mood affective disorder, and multiple sclerosis, and an MDS showed severe cognitive impairment with total assistance needed for incontinence care, transfers, and mobility. The resident's POA stated she requested a transfer to another facility in November 2025, but the facility did not follow up on needed information or the status of the transfer. Social Services Director #181 stated the facility's process was to send required information, log the transfer, notify the Ombudsman, and follow up as needed, while the Administrator verified there was a transfer request but had no documentation showing the requested documents were sent or that communication with the receiving facility occurred.
Missing Care Plans for Communication, Contractures, and PT Services
Penalty
Summary
The facility failed to ensure a care plan was created for communication and language services for Resident #36. The resident was admitted with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive, and edema. The care plan addressed impaired cognitive process and the need to communicate with staff, family, physician, and the resident, but it did not include a communication or language care plan even though the record documented that the resident spoke Somali and did not speak or understand English. A special instruction note stated to call the interpreter and provided the phone number. Record review and interviews showed staff were communicating with the resident in English and using family to translate. The resident's representative stated the resident did not speak or understand English and expressed concern that medical needs were being communicated without an actual interpreter. Observations showed staff speaking English to the resident during meals and redirection, and a CNA confirmed she communicated by gestures and was unaware of translation services or communication devices. The DON confirmed therapy had provided a communication board and that translator services were available, but the resident did not have a communication/language care plan. The facility also failed to develop care plans for Resident #55's contractures and Resident #84's physical therapy services. Resident #55 had diagnoses including neurocognitive disorder with Lewy Bodies, aphasia, contracture, muscle wasting and atrophy, and psychosis, and had an order to place rolled washcloths in both hands at all times while at rest. The ADL care plan included rolled washcloths but did not address contractures, and a podiatry note documented mild bilateral knee contractures. Resident #84 had diagnoses including Type 2 diabetes mellitus and amputations of the right foot and left toes, had severe cognitive impairment, and had an order for PT five times a week for 30 days for gait training, neuromuscular reeducation, therapeutic exercise, therapeutic activity, and group activity, but the care plan contained no information about PT services or objectives.
Failure to Complete Required Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were completed as required and completed as scheduled for two residents reviewed. Resident #36 was admitted with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive, and edema. The care plan identified impaired cognitive process for daily decision making and risk for further decline in cognitive status, and the MDS showed a BIMS of 99, indicating the resident was rarely if ever understood. However, the medical record contained no evidence that care conferences were completed or even scheduled. The resident's representative reported that a care conference had been scheduled but no one contacted him, and he stated he had not received any care conferences since admission. The SSD and DON confirmed the resident had not had a care conference since admission and that the scheduled conference had to be rescheduled because of the annual survey. Resident #35 had been admitted with diagnoses including Alzheimer's dementia with behavioral disturbance, COPD, essential hypertension, and a right hip fracture. After a fall and hospitalization for a right femur fracture, the resident underwent a right hip hemiarthroplasty and returned to the facility with orders for pain management, wound care, PT, OT, and fall precautions. Documentation showed substantial to maximal assistance was needed for dressing, toileting, personal hygiene, transfers, and bed mobility after the hospitalization, reflecting significant changes in mobility and functional status. The DON confirmed no care conferences had been completed for the resident since January 2026, including none after the hospitalization and return with new care needs. SSD #181 also confirmed no care conferences had been scheduled or completed and could not provide documentation that the interdisciplinary team met to review and revise the care plan after the resident's surgery and return to the facility.
Failure to Provide Language and Communication Services
Penalty
Summary
The facility failed to ensure communication and language services were provided to a resident who did not understand or speak English. Resident #36 was admitted with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, Alzheimer's disease, altered mental status, failure to thrive, and edema. The care plan identified impaired cognitive process for daily decision making and risk for further decline in cognitive status, but the 05/01/26 care plan contained no communication or language interventions for a resident who spoke Somali and did not speak or understand English. A special instruction note in the medical record stated the resident spoke Somali and included a phone number to call the interpreter. The resident's representative reported that the resident speaks Somali, understands Somali, and does not speak or understand English, and expressed concern that staff were using family to translate rather than an actual interpreter. During observations, the DON was speaking to the resident in English while assisting with a meal, and later an RN redirected the resident and handed him off to a CNA, who gave instructions in English without any staff attempting to use translator services. The RN confirmed the resident did not speak English and stated staff should contact family or use the interpreter phone line. The CNA stated she believed the resident understood English and said she used gestures to communicate, while the DON confirmed therapy had provided a communication board and that translator services were available for staff use.
Delayed X-ray After Fall Led to Missed Fracture Diagnosis
Penalty
Summary
The facility failed to ensure timely completion of an ordered diagnostic test after a fall for one resident with a history of Alzheimer's dementia with behavioral disturbance, COPD, hypertension, weakness, difficulty walking, unsteadiness on feet, and a right hip fracture. The resident had been admitted with mobility limitations but was still able to transfer with staff assistance and ambulate 10 feet. After the resident fell while walking to the bathroom and complained of pain, the CNP was notified and an x-ray was ordered, but the ordered test was not completed as directed. The resident later presented to the emergency department with right hip pain following the fall and was diagnosed with a right femoral neck fracture, then underwent a right hip hemiarthroplasty. The DON stated that when she arrived the next day, she found the x-ray had not been completed and contacted the CNP, who then ordered a STAT x-ray. The STAT x-ray identified the femoral neck fracture, and the resident was transferred to the hospital for further evaluation and treatment. The facility confirmed the originally ordered x-ray was not completed following the fall.
Incomplete Assessment of Newly Identified Pressure Injuries
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to accurately assess newly identified pressure ulcers for one resident with severe cognitive impairment and dependence on staff for bed mobility, transfers, and toileting. The resident had diagnoses including Alzheimer's disease, encephalopathy, anxiety, dementia, mood disorder, and intellectual disabilities, and the care plan included pressure-reduction interventions such as a pillow between the legs in bed, heel floating, a pressure-reducing chair cushion, and a pressure-reducing mattress. Physician orders were in place for wound care to the coccyx and to both inner knees, including cleansing and dressings. The resident's skin grid documented new pressure injuries to the left inner knee and right inner knee, each measured about 3.0 cm by 2.0 cm with light drainage, but the stage and wound description were left blank. The DON confirmed the skin grids were incomplete and that there was no other wound description in the medical record. The wound nurse practitioner later assessed the bilateral knee wounds and identified the left inner knee as a stage 3 wound measuring 2.0 x 2.0 x 0.2 and the right inner knee as an unstageable wound due to slough measuring 3.0 x 2.0 x visible depth of 0.2. The wound nurse practitioner stated the wounds were likely unavoidable due to the resident's comorbidities, cognition, and frailty.
Failure to Assess Falls and Complete Required Monitoring
Penalty
Summary
The facility failed to ensure a resident was assessed by qualified staff after a fall and before being moved by staff. Resident #4 had diagnoses including left femur fracture, Parkinson's disease, dementia, muscle weakness, psychosis with hallucinations, heart disease, and arthritis, and was documented as cognitively impaired and dependent for activities of daily living. During observation, the resident was found out of bed with one knee on the fall mat bearing weight. A social services designee entered the room, closed the door, and then assisted the resident back to bed without obtaining a nurse assessment for possible injury. The designee stated she did not consider it a fall because the resident was not lying fully on the floor, and the ADON initially was unaware of the event before later confirming it was a fall and that a nurse should have assessed the resident. Resident #47 also had a history of impaired cognition and dependence for activities of daily living, with diagnoses including Alzheimer's disease, dementia, mood affective disorder, heart disease, kidney disease, schizophrenia, and muscle weakness. The resident had multiple prior falls documented in the record, including an unwitnessed fall in another resident's room, an unwitnessed fall in the hallway with a skin tear to the forehead and a bruise to the left knee, and a fall from a chair with a bump to the eyebrow. The record showed incomplete and inaccurate neuro checks after prior falls, including missed entries, incorrect dates, and failure to follow the ordered monitoring schedule. The DON confirmed the neuro checks from the prior falls were missing entries and inaccurately dated, and that the schedule in the instructions was not followed. The DON also confirmed the fall investigation for the chair slide incorrectly documented the injury type as a burn, even though the medical record showed no burn injury. Facility policy required that each resident be assessed for fall risk, all falls be reviewed and investigated, and that in the event of a fall the resident be assessed by a nurse; the head injury policy required reporting head injuries to the physician and completing neuro checks as indicated for 72 hours.
Feeding Tube Care Not Performed per Orders
Penalty
Summary
Resident #9, who was admitted with diagnoses including duodenal ulcer, dysphagia following cerebral infarction, and type 2 diabetes mellitus, was assessed as rarely or never understood and was using a feeding tube. The resident had orders for enteral nutrition by pump with Glucerna 1.2 at 65 mL/hr for 22 hours, with tube placement to be checked every shift before formula, medication administration, and flushing, gloves and gown to be worn during feeding tube care, residual checks to be done every shift with specific instructions if residual exceeded 100 mL, and tube flushing every 4 hours for hydration and patency. The care plan also directed staff to keep the head of the bed elevated at all times when tube feed was infusing. During observation of a feeding tube change, the resident was lying in bed with the head of the bed not elevated above 30 degrees. The RN performing the care washed hands and donned gloves but did not wear a gown. The RN changed the feeding bottle and reused an infusion setting of 55 mL/hr, which was later acknowledged to be incorrect because the ordered rate was 65 mL/hr. During the procedure, there was no residual check, no flush of the feeding tube, no check of tube placement, and no dressing change at the insertion site. The RN stated that tube placement checks were usually done with a stethoscope during bolus feeds, that the pump provided automatic flushes, and that dressing changes were done later in the day for residents on the hall.
Failure to Provide Drinks Consistently and on Request
Penalty
Summary
The facility failed to ensure drinks were provided regularly and upon resident request for one resident reviewed for hydration. The resident had diagnoses including dementia without behaviors, psychotic disturbance, vascular dementia, dysphagia, and pulmonary disease. The MDS showed a BIMS of 99 indicating impaired cognition, and the care plan included interventions to provide favorite foods and fluids for altered nutrition. There was no order for fluid restrictions in the medical record. During observation and interview, the resident had no drinks or hydration in the room and requested coffee, stating he was thirsty. A CNA stated the resident would get coffee when the coffee cart came, but could not say when that would occur and said staff did not pass out drinks or water, with residents getting drinks only on meal trays. The CNA confirmed a second time that residents only got drinks with meal trays. An LPN later confirmed that after the surveyor asked about the resident's hydration and drinks, the resident was given water until the coffee cart arrived. Observation showed meals arrived on the unit around 12:30 P.M. The facility policy stated residents with dementia will forget to drink and should be provided encouragement and assistance.
Failure to Timely Report Injuries of Unknown Source to State Agency
Penalty
Summary
The facility failed to timely report injuries of unknown source to the State agency for four residents with severe cognitive impairment. Each of these residents was dependent on staff for activities of daily living and had significant communication deficits, making them unable to explain the cause of their injuries. The injuries included significant bruising and, in one case, a fracture, all of which were unwitnessed and lacked a clear explanation. Despite facility policy requiring immediate or timely reporting of such incidents, these injuries were either not reported or reported late to the State agency. For one resident, a large bruise was discovered on the left lower arm, but the internal investigation did not include interviews with outpatient therapy staff or the resident's daughter, both of whom were present during therapy sessions. The Director of Nursing (DON) confirmed that the injury was not reported to the State agency and that the investigation's conclusion was not documented. Another resident was found with a bruise on the forehead, and although it was suspected to be caused by a broda chair, no interventions were implemented to prevent recurrence, and the injury was not reported to the State agency. The DON again confirmed the lack of reporting and documentation of the investigation's conclusion. A third resident was observed with a forehead bruise and was sent to the hospital for evaluation. The self-reported incident was not submitted to the State agency until two days after the injury was discovered. The fourth resident had swelling and discoloration of the left hand and wrist, later diagnosed as a fracture, with no known cause. The DON suspected the injury might have occurred due to the resident's hand getting caught in a wheelchair wheel, but this was not documented, and the injury was not reported to the State agency. In all cases, the facility's own policy defined injuries of unknown source as possible indicators of abuse and required timely reporting, which was not followed.
Failure to Thoroughly Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown sources for three residents with severe cognitive impairment and high dependency for activities of daily living. In one case, a resident was found with significant bruising on her left lower arm, but the internal investigation did not include interviews with outpatient therapy staff or the resident's daughter, both of whom were present during therapy sessions. The Director of Nursing (DON) suspected the injury occurred during therapy but did not document a conclusion in the interdisciplinary team (IDT) progress notes. Another resident was discovered with a bruise on her forehead, and although the physician and family were notified and a new treatment was initiated to monitor the bruise, the investigation did not determine the cause of the injury. The resident was unable to describe the incident due to cognitive impairment, and the IDT note lacked documentation of the cause. The Administrator suspected the injury was related to the resident's broda chair, but no interventions were implemented to prevent recurrence, and the investigation's conclusion was not documented. A third resident was noted with swelling and discoloration of the left hand and wrist, later diagnosed as a fracture. The cause of the injury was unknown, and no staff or witnesses could provide an explanation. The DON suspected the injury might have occurred when the resident's hand became caught in a wheelchair wheel, but again, no conclusion was documented in the IDT progress notes. The Administrator acknowledged that investigations had not been fully completed in the past and indicated that this issue would be addressed in future quality assurance meetings.
Failure to Ensure Resident Received Care Only from Approved Physicians
Penalty
Summary
This facility failed to ensure that a resident received care and services only from approved physicians, as required. The resident in question was admitted with diagnoses including Alzheimer's disease, heart disease, and obstructive sleep apnea, and had a severely impaired cognitive status as indicated by a BIMS score of 3 out of 15. The resident's legal guardian, who was also the daughter, refused to sign the facility's consent for treatment and insisted that all medical care be provided exclusively by VA providers. The guardian also took responsibility for scheduling and notifying the VA for all appointments, declining involvement from the facility's medical director or related providers. Despite the lack of consent for treatment by facility providers, there were multiple instances where facility staff either attempted to obtain or did obtain medical orders for the resident. These included a new order for Depakote from a CNP for increased agitation, notification of a provider regarding leg swelling, and a treatment order for a skin injury after the medical director's group was contacted. Interviews with the Administrator and DON confirmed that the facility did not have a signed consent on file and that staff actions were taken without the required authorization from the resident's legal guardian.
Failure to Prevent Resident-to-Resident Altercation and Maintain Ordered Safety Interventions
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically by not preventing a resident-to-resident altercation that resulted in injury, and by not ensuring that a physician-ordered stop sign was in place at a resident's doorway. Two residents with cognitive impairments were involved in an incident where one resident entered another's room, leading to a physical altercation. The resident who entered the room sustained injuries including a cut to the nose and upper lip, and the loss of a tooth. Both residents were unable to provide reliable accounts of the incident due to their cognitive status. Medical record reviews showed that one resident had diagnoses of Alzheimer's disease, psychosis, and mood disorder, with a moderately impaired cognition, and was receiving daily antidepressants and opioid medication. The other resident had Alzheimer's disease, dementia, and heart failure, with severely impaired cognition and a history of wandering and entering other residents' rooms. The care plan for the first resident included a stop sign at the doorway to provide privacy and prevent such incidents, and staff were ordered to ensure the stop sign was in place. However, observations on multiple dates confirmed that the stop sign was not present as ordered, and staff interviews revealed it was often removed by the resident and their roommate. The facility's self-reported incident investigation was inconclusive due to lack of witnesses and the cognitive deficits of both residents, making it impossible to verify the exact sequence of events. Documentation confirmed that the required stop sign was not in place at the time of the incident, and the facility's policy defined abuse as the willful infliction of injury or unreasonable confinement. The failure to maintain the ordered intervention and prevent the altercation constituted non-compliance with regulations protecting residents from abuse and neglect.
Failure to Timely Report and Investigate Injuries and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to timely report injuries of unknown origin and a resident-to-resident altercation to the state agency, as required by regulation and facility policy. In the case of one resident with severe cognitive impairment and a history of aggressive behaviors, two separate injuries of unknown origin were identified: a hand injury with a possible fracture and a significant hematoma to the forehead. In both instances, there was no documentation of a formal investigation, no staff interviews were conducted, and the incidents were not reported to the state agency within the required timeframe. The facility only filed a self-reported incident after the family raised concerns, and there was no evidence of staff education or training on abuse or injuries of unknown origin. Another resident, also with severe cognitive impairment and a history of falls, was found to have extensive bruising on the right shoulder, chest, and arm, as well as acute rib fractures and a clavicle fracture. Despite the presence of multiple injuries and the resident's inability to explain their origin, there was no documented investigation or timely reporting to the state agency. The facility's leadership was unaware of the incidents, and no self-reported incidents were filed for these events. Staff interviews and documentation required by facility policy were not completed. Additionally, a physical altercation occurred between two residents, resulting in a skin tear injury. The incident was documented in the medical record, but no self-reported incident was filed, and no investigation was conducted as required. Facility policy mandates that all alleged violations, including injuries of unknown origin and resident-to-resident altercations, be reported to the administrator and state agency within 24 hours and that thorough investigations with staff interviews and documentation be completed. These requirements were not met in the cases reviewed.
Failure to Investigate Injuries of Unknown Origin and Resident Altercations
Penalty
Summary
The facility failed to conduct thorough investigations into injuries of unknown origin and a resident-to-resident altercation, affecting three residents. For one resident with severe cognitive impairment and a history of aggressive behaviors, there were two separate incidents involving significant injuries—a hand injury with a possible fracture and a head injury with hematomas and bruising. In both cases, there was no documented evidence of a formal investigation, no staff interviews, and no incident reports were submitted at the time of the injuries. The Director of Nursing and Administrator confirmed that they did not complete or document investigations, often assuming the injuries were self-inflicted due to the resident's behaviors. Another resident, also with severe cognitive impairment and a history of falls, was found with extensive bruising on the shoulder, chest, and arm, and later diagnosed with acute rib and clavicle fractures. Despite the severity and unexplained nature of these injuries, there was no documented investigation or self-reported incident filed. Staff interviews revealed that no one witnessed the events leading to the injuries, and the Director of Nursing attributed the bruising to a fall without supporting evidence or documentation of staff interviews. A third resident was involved in a physical altercation with another resident, resulting in a skin tear. The incident was documented in the medical record, but no self-reported incident was filed and no investigation was conducted. Facility policy required that all injuries of unknown origin and resident-to-resident altercations be investigated, including staff interviews and thorough documentation, but these procedures were not followed in any of the cases reviewed.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required registered nurse (RN) coverage, as evidenced by a review of staff schedules from 07/14/24 to 08/31/24, which showed multiple days with either no RN coverage or less than the mandated eight hours of RN coverage. Specific dates were identified where no RN was present, and on some days, RN coverage was less than the required duration. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged the lack of proper RN coverage on the listed dates. The absence of adequate RN staffing had the potential to affect all 70 residents residing in the facility.
Unsanitary Kitchen Conditions and Improper Food Temperature Practices
Penalty
Summary
Facility staff failed to maintain the kitchen in a clean and sanitary condition and did not follow proper procedures for obtaining food temperatures. Observations on two separate occasions revealed a large grate in front of the oven with a thick layer of black and brown substances, appearing moist, covering the area underneath. The floor under kitchen equipment and around the edges was found to have a buildup of dirt, food debris, and miscellaneous items, including a plastic cup under the reach-in refrigerator. Staff interviews confirmed that the area under the grate sometimes emitted a smell and that both the floor and the area under the grate required cleaning. The grate area was identified as a drain for the dishwasher and was subject to both backflow and cleaning activities by kitchen and maintenance staff. Additionally, a staff member was observed taking food temperatures in a manner that did not meet sanitary standards. The staff member used the same alcohol swab to clean the thermometer between different food items on multiple occasions, rather than using a new swab for each item. This practice was confirmed by the staff member during an interview at the end of the observation.
Laundry Room Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain the laundry room in a clean and sanitary condition, as observed during a walkthrough with the Maintenance Director. The washers were positioned approximately one and a half to two feet from the back wall, where PVC pipes and water lines were present, and the area between the wall and pipes was covered in lint. The floor had multiple wet spots, including two green puddles, and was blackened in appearance. On the dirty side of the laundry room, a sink was found with a buildup of dust, lint, and debris, and the floor had several cracked and peeling areas with accumulated dirt and leaves along the wall. The Maintenance Director confirmed these observations and acknowledged the need for cleaning. The facility's provided policy did not address these concerns.
Inappropriate Use of Psychotropic Medications Without Proper Diagnoses
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had appropriate diagnoses to justify their use. Medical record reviews revealed that several residents were prescribed medications such as escitalopram and Depakote for conditions like depression, agitation, mood, and behaviors, without corresponding or appropriate clinical diagnoses documented in their records. For example, one resident was prescribed escitalopram for depression despite not having a diagnosis of depression, and Depakote was ordered for several residents with indications such as agitation, mood, and behaviors, which are not approved indications for the medication. Care plans for these residents did not consistently address the use of these psychotropic medications or specify the behaviors or symptoms being treated. In some cases, the care plans mentioned potential side effects and monitoring interventions but failed to link these to specific, clinically justified diagnoses. Interviews with the DON confirmed that terms like "behaviors," "agitation," and "mood" were not appropriate diagnoses for the use of Depakote, and that some residents were receiving medications without a proper diagnosis to support their use. Review of prescribing information for Depakote indicated that its approved uses are for the treatment of seizures, prophylaxis of migraine headaches, and treatment of manic episodes associated with bipolar disorder. The facility's own policy on psychotropic medication use requires that such medications be prescribed with a documented clinical indication consistent with accepted clinical standards of practice. The lack of appropriate diagnoses and documentation for the use of these medications constituted a deficiency in the facility's medication management practices.
Inconsistent Advanced Directive Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that accurate advanced directive information was consistently present throughout the medical record for one resident. The resident in question had multiple complex diagnoses, including severe cognitive impairment, and was unable to make decisions independently. A review of the resident's records revealed discrepancies: the electronic medical record and its banner indicated the resident was a Full Code, while the care plan and a signed physician DNRCC-A (Do Not Resuscitate Comfort Care Arrest) form indicated a DNRCC-A status. The care plan detailed specific interventions consistent with DNRCC-A, and the DNR form was filed in the electronic medical record. Interviews with nursing staff and the DON confirmed the inconsistency between the electronic medical record's code status and the care plan documentation. Staff reported that the electronic medical record banner is the primary source for verifying code status, which could lead to confusion in an emergency. The DON and Senior Administrator acknowledged the discrepancy and attributed it to issues with data transfer during a recent change in the electronic medical record platform.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to assess a resident prior to the use of a physical restraint. The resident, who had diagnoses including dementia, pseudobulbar affect, anxiety, frontotemporal cognitive disorder, psychosis, major depressive disorder, and mood disorder, exhibited behaviors such as running and screaming in the hallway, physical and verbal aggression, wandering, and rejection of care. According to the physician's consult, staff would place the resident in her room and hold the door closed for approximately 30 minutes during episodes of violent behavior to prevent her from harming herself or others. A review of the resident's medical record, facility assessments, and care plan revealed no documentation of a physical restraint assessment, no physician orders for restraint use, and no care plan interventions related to restraints. The facility's policy required documentation of medical symptoms warranting restraint use, attempts at less restrictive alternatives, ongoing re-evaluation, and care plan updates, none of which were present in this case. Interviews with the Medical Director and DON confirmed the absence of incident reports, documentation, or restraint assessments for the resident.
Failure to Monitor Bruises and Timely Implement Wound Orders
Penalty
Summary
The facility failed to properly monitor and document the progression of a bruise for a resident with significant cognitive impairment and multiple complex diagnoses, including dementia, hemiplegia, and malignant neoplasm. After a bruise was noted on the resident's right eye, an order was given to monitor the area every shift until resolved. However, from the time the bruise was first documented until it was considered healed, there was no ongoing documentation describing the size, condition, color, or other relevant characteristics of the bruise, aside from the initial assessment. The care plan addressing the bruise was not implemented until several weeks after the injury had resolved, and the facility was unable to provide requested documentation supporting that the bruise was properly monitored during the specified period. Additionally, the facility did not implement wound care orders in a timely manner for another resident with severe cognitive impairment and multiple medical conditions, including hemiplegia, diabetes, and a burn wound. Although a physician's order was in place to provide specific wound care, there was a delay in updating and carrying out the correct treatment due to a system changeover. The unit manager confirmed that the correct order was not timely implemented and was unable to provide evidence that the prescribed wound care was administered as ordered. These deficiencies demonstrate lapses in both the monitoring and documentation of skin conditions and the timely implementation of physician-ordered treatments for residents with complex medical needs. The lack of proper documentation and timely care interventions directly affected the residents reviewed for skin conditions during the survey.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall prevention interventions were in place for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, peripheral vascular disease, and psychosis. The resident had a documented history of falls and was assessed as being at risk for further falls due to cognitive and physical limitations. The care plan included specific interventions such as keeping the resident in supervised areas, particularly by the nurse's station or in activities when in a wheelchair, and staff education to maintain supervision. Despite these interventions being documented in the care plan and progress notes, the resident was observed in the dining area without supervision on multiple occasions. On one occasion, the resident was found on the floor in the lounge area with a skin tear on his right elbow, and staff confirmed that the required supervision intervention was not in place at the time of the fall. Interviews with facility staff, including a CNA and the DON, verified that the resident had been left unsupervised in the dining area, contrary to the care plan and facility policy. The facility's fall prevention policy required individualized interventions based on assessment and risk factors, which were not consistently implemented for this resident.
Failure to Provide Ordered Pain Medication and Notify Physician
Penalty
Summary
The facility failed to provide pain medication as ordered for a resident with multiple complex medical conditions, including hemiplegia, aphasia, diabetes, COPD, vascular dementia, and chronic pain syndrome. The resident had a physician's order for a Butrans transdermal patch to be applied weekly for pain management. Review of the Medication Administration Record showed that the patch was not applied on two scheduled dates, and progress notes indicated the medication was unavailable at those times. Despite the unavailability of the ordered pain medication, there was no documentation that the physician was notified of this issue. The Director of Nursing confirmed that neither she nor the physician had been informed that the Butrans patch was not available. The pharmacy did not receive the prescription until several weeks after the initial order, as the physician was unaware of the situation. The resident's pain was managed by switching as-needed medication to a scheduled regimen during this period.
Failure to Monitor and Document Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to adequately monitor, document, and prevent a resident's inappropriate sexual behaviors, despite clear evidence of ongoing incidents. The resident, who had a history of dementia with behavioral disturbances, agitation, and other psychiatric diagnoses, exhibited sexually inappropriate behaviors on multiple occasions as documented by CNAs. However, these behaviors were not thoroughly documented in the resident's progress notes, and there was a lack of detailed reporting regarding the nature of the incidents. The care plan included interventions for these behaviors, but physician orders did not specifically address monitoring for sexual behaviors, and staff documentation was inconsistent and incomplete. Observations revealed the resident engaging in inappropriate physical contact with another resident in a common area, with staff present but not intervening until prompted. Interviews with staff confirmed awareness of the resident's behaviors and the expectation for detailed documentation and reporting, which was not consistently followed. The DON acknowledged that aides' documentation of sexual behaviors was vague and that more detailed notes and reporting to responsible parties were necessary. The failure to monitor, document, and prevent these behaviors constituted a deficiency in providing necessary behavioral health care and services.
Required Resident Rights Postings Not Accessible
Penalty
Summary
The facility failed to ensure that required postings, including the list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups, as well as the statement that residents may file a complaint with the State Survey Agency, were readily accessible to all residents. Observations during the annual survey revealed that these postings were located in a hallway outside of the building's interior locked doors, an area inaccessible to residents. Further observations confirmed that the postings were not present within the three locked hallways where residents were confined. Interviews with two residents during a resident council meeting confirmed they had never seen the postings or documents with information on how to contact the ombudsman or state department of health and expressed a desire to have this information. The Activities Recreation Director also confirmed that the postings were not in resident living areas and that residents did not have routine access to the area where the postings were located.
Failure to Maintain Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain a comfortable temperature in specific areas, affecting residents' comfort and potentially their health. Observations and interviews revealed that the Third Street Unit and a room on the First Street Unit were significantly warmer than other areas of the facility. The temperature in these areas exceeded the facility's policy range of 71 to 81 degrees Fahrenheit, with readings as high as 83 degrees Fahrenheit in some locations. The deficiency was identified during a survey following a complaint investigation. The issue was exacerbated by malfunctioning Packaged Terminal Air Conditioner (PTAC) units in several rooms, including one that was not working at all and another that was only blowing faint air. Despite a facility audit identifying the need for replacement units, the new PTAC units had not yet been received, and temporary measures such as box fans were not consistently implemented. Resident interviews confirmed discomfort due to the heat, with one resident using her t-shirt to fan herself. The facility's failure to monitor and maintain appropriate room temperatures contributed to the deficiency.
Failure to Follow Abuse Policies in Resident Interaction
Penalty
Summary
The facility failed to adhere to its abuse policies and procedures when two residents were left alone after a potential observation of abuse. Resident #10, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was found in a compromising situation with Resident #15. Resident #15, also with severe cognitive impairment and dependent on staff, was observed by a staff member in Resident #10's room with his pants down, engaging in inappropriate behavior. The incident was reported by a State Tested Nurse Assistant (STNA) who found Resident #15 in Resident #10's room, with Resident #10's shirt lifted and Resident #15 kissing her chest while touching himself. The STNA did not immediately call for a nurse but instead went to get the Licensed Practical Nurse (LPN) to separate the residents. The facility's policy required immediate protection of residents from further abuse, which was not followed as the residents were left alone initially. The facility's policy on abuse, neglect, and exploitation mandates immediate response to protect alleged victims and increase supervision during and after an investigation. However, the actions taken by the staff did not align with these procedures, as the residents were not immediately protected from further interaction after the incident was observed. This deficiency was identified during the investigation of a complaint, highlighting non-compliance with the facility's abuse prevention policies.
Failure to Implement Comprehensive Care Plans for Activities and Preferences
Penalty
Summary
The facility failed to implement comprehensive care plans that included activities and preferences for two residents. Resident #17, who was admitted with diagnoses such as diabetes mellitus type two, dementia, chronic kidney failure, and paranoid personality disorder, had severely impaired cognition with a BIMS score of zero out of 15. The resident required assistance for activities of daily living, including transfers and mobility. However, the comprehensive care plan dated 05/17/24 did not include an activity care plan or activity preferences for this resident, as confirmed by the Administrator during an interview. Similarly, Resident #66, admitted with diagnoses including diabetes mellitus type two, senile degeneration of the brain, alcohol dependence, dementia, and delusional disorders, had moderately impaired cognition with a BIMS score of 11 out of 15. This resident required limited assistance for activities of daily living but was independent with ambulation and mobility. The comprehensive care plan initiated on 06/03/24 also lacked an activity care plan or activity preferences, as confirmed by the Administrator. The facility's policy on activities, dated 06/01/24, required that each resident's interests and needs be assessed routinely, including an activity assessment. This deficiency was investigated under Complaint Number OH00154476.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment from eloping. The resident, who had diagnoses including encephalopathy, Alzheimer's disease, type II diabetes mellitus, and anxiety disorder, was admitted to the facility and assessed as being at high risk for elopement. Despite this, the resident was able to leave the facility unsupervised. On the day of the incident, the resident was noted to be agitated and expressed a desire to leave. The resident was last seen by staff with a personal belonging bag and was later found missing from the unit. The receptionist mistakenly allowed the resident to exit the facility, thinking he was a visitor. The resident was eventually found by police and returned to the facility without any injuries. The incident occurred when the receptionist let the resident out, mistaking him for a visitor. The resident was able to leave the facility through a door that had been propped open by a family member. Staff quickly realized the resident was missing and initiated a search, involving both facility staff and the police. The resident was found at a nearby restaurant and returned to the facility. Interviews with staff and the receptionist revealed that the receptionist was not aware of the new resident's identity and did not have a picture of him in the elopement binder. The facility's policies on elopement and wandering residents were not adequately followed, leading to the resident's unsupervised departure. The receptionist's lack of awareness about the new resident and the failure to verify the identity of individuals leaving the facility contributed to the incident. The facility's response included immediate actions to locate the resident and assess him for injuries, but the initial failure to prevent the elopement highlighted gaps in the facility's supervision and security measures.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westerwood Rehabilitation | 0.5 mi | ★★★★★ | 10 | 0 |
| The Laurels Of Walden Park | 1.8 mi | ★★★★★ | 2 | 0 |
| Westerville Post Acute | 1.8 mi | ★★★★★ | 7 | 0 |
| Inniswood Health And Rehabilitation | 2.8 mi | ★★★★★ | 2 | 0 |
| Buckeye Terrace Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 7 | 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 August 2026) and official state health department websites.