Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Foundation Park Care Center during CMS and state inspections, most recent first.
The facility failed to consistently document meal intakes for three cognitively impaired, staff-dependent residents whose care plans and MD orders required monitoring and recording of every meal. Over a review period, multiple meals for two residents with dementia and other comorbidities, including DM and dysphagia, had no recorded intake despite no nursing notes of meal refusals. A third recently admitted and discharged resident had variable documented intakes and several refusals, but nine meals lacked any intake documentation. A CNA reported that staff are expected to record meal percentages at each meal and notify the nurse of refusals, and the DON confirmed that meal intakes were not documented for each meal as required by the residents’ care plans and facility policy.
Food service sanitation failures were observed when a dietary staff member wore the same gloves while touching utensils, plates, drawer handles, and then ready-to-eat buns during meal service. The facility also stored emergency water in a shower stall used by residents, and a resident was served eggs with a foreign substance that the DON removed during breakfast.
The facility failed to fully implement its infection prevention program by not identifying site-specific water flow details in its Legionella risk assessment and by not documenting or carrying out listed Legionella monitoring measures such as flushing, shower head cleaning, and water heater inspections. Staff also did not consistently follow EBP PPE requirements: for one resident with an indwelling urinary catheter, CNAs assisted with catheter-related care and a transfer without gowns, and for another resident with a feeding tube and skin issue, multiple staff provided transfer and care without gowns or gloves, and the EBP sign was not posted. In addition, three CNAs did not complete annual Mantoux TB risk assessments.
Failure to monitor psychotropic medication effectiveness and side effects affected three residents receiving psychotropic meds. One resident with psychosis, mood disorder, anxiety, and dementia had orders for escitalopram, olanzapine, and mirtazapine, but no documented monitoring. Another resident with dementia, hallucinations, anxiety, restlessness, and agitation received PRN clonazepam six times with no evidence of monitoring. A third resident with dementia, Lewy body neurocognitive disorder, PTSD, and depression had orders for mirtazapine and clozapine, but the record showed no monitoring for adverse reactions, EPS, tardive dyskinesia, suicidal ideation, or unusual behavior.
Failure to assist dependent residents with ADLs. Two residents who were dependent for eating had breakfast trays left in their rooms while they remained in bed, and staff reported a CNA call-off left the section unreassigned. One resident was fed only after a delay by an LPN, and another was fed later by a CNA. Other residents were observed with unclean fingernails despite needing help with hygiene and grooming, and one resident was seen wearing the same soiled clothing on consecutive days.
Failure to implement ordered pressure-relief measures affected three residents with significant cognitive and mobility impairments. One resident with dementia, hemiplegia, dysphagia, and epilepsy was observed without ordered repositioning support, without the ordered washcloth in the hand, and later remained in a wheelchair beyond the ordered time limit with poor head support. Two other residents at risk for pressure ulcers were observed without ordered heel protectors in place, and staff confirmed the omissions, including not applying a protector to one heel and not knowing both heels were ordered for protection.
Staff did not follow menus and recipes for residents on a pureed diet. A dietary employee thinned pureed pasta with water instead of the recipe-specified liquid, and the DM directed use of leftover Philly cheesesteak meat rather than the fried fish listed on the menu; the employee also used an incorrect portioning method and added only one hamburger bun for 10 residents. In a separate finding, an LPN fed a resident with dementia, DM, epilepsy, anxiety, and TBI a meal that did not include the ordered double portions, despite the physician order for a regular diet with pureed textures, thin liquids, and double portions.
Dirty Floor Mat and Wheelchairs: The facility failed to keep a resident’s floor mat and two residents’ wheelchairs clean and sanitary. One resident with dementia, hemiplegia, dysphagia, and epilepsy had a stained, discolored bedside mat that was uncovered, and an LPN said it did not provide a homelike environment. Two residents who used wheelchairs had visible debris buildup, including food pieces on one wheelchair, despite a posted cleaning schedule; an AD confirmed the wheelchairs were dirty.
A resident with dementia, diabetes, a prior femur fracture, and warfarin therapy had a weekly skin assessment that documented no chest bruising, but a surveyor later observed a large healing green-and-yellow bruise on the upper chest. The resident denied knowing how it occurred, and the assigned LPN, CNA, and DON were unaware of the bruise at the time it was found.
Failure to maintain ordered fall precautions for a resident with Lewy body dementia, DM, and poor safety awareness. The resident was dependent for transfers and bed mobility, assessed as high fall risk, and had a care plan and MD order for a floor mat at bedside when in bed. During observation, the resident was in bed awake, but the mat was found across the room, and a CNA said staff likely removed it for breakfast and did not replace it.
Failure to secure an IUC: A resident with dementia, severe cognitive deficits, and urinary retention had an IUC in place, but no securement device was observed during catheter care. The care plan did not address catheter securement, a nurse note documented the resident disconnecting the catheter bag and being combative, and the DON and RN supervisor gave conflicting statements about whether securement was needed. CDC guidance reviewed by surveyors stated that IUC maintenance includes proper securement to prevent movement and urethral traction.
A resident with a gastrostomy tube, dementia, hemiplegia, dysphagia, and epilepsy was observed receiving the wrong tube feeding formula. The physician ordered Isosource HN at 80 ml/hr, but the resident was found on Fibersource HN at the same rate, and an LPN confirmed the formula mismatch and said the bag had been hung by the previous shift.
Oxygen Therapy Not Provided Per Physician Order: A resident with emphysema and continuous O2 needs was observed receiving oxygen at settings above the physician-ordered 2 L/min by NC. Staff interviews confirmed the oxygen settings were not at the ordered liters, and the facility policy stated oxygen must be administered by an LPN/RN per physician order.
Missing Dialysis Agreement and Inconsistent Dialysis Communication: A resident with ESRD, dementia, DM2, and hypertensive CKD received hemodialysis, but the facility had no prior agreement with the dialysis provider before the current annual survey. The care plan lacked communication interventions with the dialysis center, and review of dialysis records showed communication forms were present for only a few treatments. Staff described an unclear process, including uncertainty about a dialysis communication book and inconsistent exchange of paperwork between the facility and the dialysis center.
A resident with PTSD, dementia, and other diagnoses did not have specific trauma-informed interventions documented in the care plan. The POA reported the PTSD was related to a military assault and said only female caregivers should provide direct care to avoid triggering behaviors, but the chart had no such instruction. The DON and Social Services Director were unaware of the resident’s PTSD triggers, and a male CNA was observed providing personal care without knowledge of the resident’s request for female staff.
Inaccurate nutrition assessment and failure to update diet order information: A resident with dementia, DM2, epilepsy, anxiety, and TBI had a SLP evaluation for pocketing food and was ordered a regular diet with pureed textures and thin liquids, yet the quarterly nutrition assessment still listed a regular textured diet and a cookie snack. An LPN confirmed the resident continued to receive an oatmeal cookie despite the pureed diet, and the RD stated the assessment was inaccurate because she was unaware of the diet change and did not have access to the SLP notes in the EMR.
A resident with dementia, incontinence, mobility deficits, and multiple comorbidities developed a coccyx Stage II pressure ulcer that progressively worsened to an unstageable ulcer with necrotic tissue. Although the care plan and facility policy called for monitoring skin changes, notifying clinical staff, weekly skin assessments, barrier cream use, dietitian involvement, and wound specialist management, the record showed no reassessment of the resident’s condition or investigation of the ulcer’s source as it enlarged and deteriorated. Documentation lacked evidence of nutritional assessment or support, mechanical pressure relief devices, or off-loading strategies being implemented, and later wound specialist recommendations for pressure redistribution and nutrition monitoring were not promptly documented as carried out.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall and was found unresponsive on the bathroom floor, diaphoretic and with a head laceration. An LPN initiated neuro checks but notified the physician only by fax rather than by phone, resulting in a delayed physician response, and the resident’s representative was not informed of the fall until several hours after the incident. Facility policy required immediate notification of the physician and resident representative for incidents involving injury and symptoms such as loss of consciousness, but this was not followed, as confirmed by the DON.
A resident with multiple comorbidities and a documented fall-risk care plan was found unresponsive on the bathroom floor with a head laceration after an unwitnessed fall. An LPN and other staff moved the unresponsive resident from the floor to the bed without contacting EMS, despite the observed head injury and lack of consciousness. Although neuro checks were initiated, documentation on the neurological observation form included only vital signs and omitted required assessments of pupillary response and hand grasps, and no additional neurological assessment was recorded. These actions and omissions resulted in a failure to provide appropriate treatment and care according to the resident’s orders and care plan following the fall.
A resident with severe cognitive impairment and multiple health conditions was lowered to the floor during wound care after becoming restless in a stand-up lift. Although the physician was notified, staff did not inform the resident's representative or hospice provider as required by facility policy, and this omission was confirmed through documentation review and staff interviews.
A resident with severe cognitive impairment and multiple comorbidities was not thoroughly assessed for injuries after being lowered to the floor during a mechanical lift transfer. Although staff noted no immediate injury, a comprehensive assessment, including range of motion, was not performed as required by facility policy. The following day, the resident was found to have a fractured and dislocated femur, highlighting the deficiency in post-incident evaluation.
An LPN found a resident unresponsive and without vital signs, and a second LPN confirmed the resident had no pulse or respirations. Although the resident had Full Code status and orders for CPR and 911 to be called if found unresponsive, neither nurse started CPR, called EMS, or contacted a physician, and the resident died in the facility.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Nurses and nurse aides lacked the required competencies to provide care that maximizes each resident's well-being, resulting in residents not receiving individualized care that supports their highest level of well-being.
A resident with Alzheimer's and other conditions was accidentally hit with a dinner plate during an altercation between two other residents, resulting in a laceration and bruise. The facility failed to report the incident to the state agency as required by their policy, as confirmed by the DON and a nurse.
A resident with Alzheimer's disease was accidentally hit in the face with a dinner plate during an altercation between two other residents, resulting in a forehead laceration. The incident was not reported to the state agency as required by the facility's policy, which mandates reporting within 24 hours.
A resident with Alzheimer's and dementia received Nystatin powder without a physician's order, contrary to facility policy. The medication was applied after a STNA reported skin concerns due to the resident's bra. The DON confirmed the lack of a physician order during a complaint investigation.
The facility failed to follow prescribed portion sizes and recipes for diet textures, affecting 83 residents. Observations revealed that incorrect scoop sizes were used for serving baked turkey crunch, and bread and water were improperly added to pureed diets. Interviews with dietary staff confirmed these deviations, impacting the nutritional needs of residents.
The facility failed to maintain clean floors and ensure resident rooms were free from odors. Observations revealed sticky floors in multiple areas and a strong urine odor in a resident's room. Staff interviews confirmed these issues, and it was noted that the problem with the floors occurred yearly when the air conditioning was turned off.
The facility failed to ensure medications were secure and properly labeled, affecting thirteen residents. Medications were found unsecured in residents' rooms and inappropriately stored in a medication cart. Staff confirmed these practices were against facility policy.
The facility failed to include copies of advanced directives in the medical records of two residents, despite having policies requiring such documentation at admission. This was confirmed through staff interviews and medical record reviews.
The facility failed to document a resident's bruising upon admission, despite the hospital referral form indicating a traumatic wound. Subsequent observations and staff interviews confirmed the presence of bruising, which was not recorded during the initial assessment.
The facility failed to maintain appropriate physician orders, accurately assess dialysis access sites, and ensure a dialysis catheter site was covered for a resident requiring dialysis. Observations and interviews confirmed the resident's chest catheter was frequently uncovered, and the fistula did not have a thrill or bruit. The facility's policies on dressing changes and physician orders were not followed, leading to these deficiencies.
The facility failed to implement non-pharmacological interventions for a resident with dementia who frequently refused care, resulting in the resident being heavily soiled with urine and developing blisters. Staff were not provided with specific strategies to manage the resident's behaviors, and the care plan lacked individualized interventions.
A facility failed to ensure an accurate Nutritional Assessment for a resident with dementia and congestive heart failure. The resident's fluid restriction and specific diet orders were not accurately documented, leading to discrepancies in the resident's care plan. Interviews confirmed the oversight, highlighting a deficiency in the facility's food and nutrition services.
Failure to Consistently Document Meal Intakes for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete documentation of meal intakes in the medical records for three residents with severe cognitive impairment who were dependent on staff for eating. One resident with vascular dementia, hemiplegia/hemiparesis after cerebral infarction, dysphagia, and hypertension had a care plan directing staff to monitor intake and record every meal, and a physician’s order for a regular diet with pureed texture and nectar-thick liquids. Review of this resident’s records over a specified period showed multiple missing entries for meal intakes across numerous dates and meals, with no nursing notes indicating that any meals were refused. A second resident with dementia, hypertension, and type 2 diabetes mellitus, also care planned for monitoring and recording every meal and ordered a regular mechanical soft diet with thin liquids, had the same pattern of missing meal intake documentation on the same dates and meals, again without any nursing documentation of meal refusals. A third resident, admitted and later discharged within the review period, had severe cognitive impairment, was dependent on staff for eating, and had a nutrition care plan to provide food, fluids, and supplements as ordered and to monitor and record every meal. This resident had a physician’s order for a regular diet with pureed texture and thin liquids. Review of this resident’s meal intake records showed variable documented intakes from 0 to 75 percent with seven documented meal refusals, but there was no documentation for nine meals. A CNA stated that staff are expected to document the percentage of meal intake for each resident at each meal and to notify the nurse if a resident refuses a meal. The DON confirmed that staff were not documenting meal intakes for each meal for the three residents and acknowledged that staff should have been documenting meal intakes for every meal as ordered. Facility policy on feeding residents required recording meal intakes on the resident meal intake log and reporting concerns to the charge nurse.
Food Service Sanitation and Meal Handling Deficiencies
Penalty
Summary
The facility failed to ensure the dishwashing machine was functional during observation of the high-temperature dishwasher used in dietary services. On 03/10/26, the Dietary Manager observed that no plastic or glass covers were over the washing and rinsing temperature gauges, and during two washing and rinsing cycles the gauge needles did not fluctuate. The Dietary Manager confirmed the gauges did not move while the machine was in use and stated an outside company had serviced the dishwasher. Review of the service report dated 01/27/26 showed appropriate washing and rinsing temperatures. On 03/11/26, new gauges with covers were observed in place, and the company representative stated he replaced both temperature gauges because the probes going into the gauges were rusted and had not been checked previously. The facility also failed to ensure appropriate hand hygiene was practiced during meal service, failed to ensure emergency water was stored in a sanitary environment, and failed to ensure a resident received food without foreign substances. During noon meal service, a staff member wore the same disposable gloves while touching service utensils, plates, drawer handles, and then handling ready-to-eat buns and placing meat into them; the staff member confirmed the gloves had touched multiple surfaces before touching the buns. Emergency water storage was observed in a shower stall in the A-Hall communal bathroom, separated from the rest of the bathroom only by a shower curtain, while residents used that bathroom for toileting and showering and soiled clothing was observed on the floor. During breakfast, a resident had eggs, toast, and sliced banana in front of her, was eating banana with her fingers, and a foreign substance was observed on her eggs. The DON confirmed the substance was on the eggs, removed it with the resident's fork, and the resident stated she did not want any more food.
Infection Control Failures in Legionella Monitoring, EBP PPE Use, and TB Screening
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program related to Legionella prevention. The facility’s Legionella risk assessment did not identify the facility water source or site-specific water flow systems throughout the building, including whether dead-end plumbing was present. Although the assessment listed control and monitoring measures such as weekly temperature checks, weekly flushing of low-use outlets, quarterly shower head cleaning, monthly water heater inspections, and routine cleaning of ice machines and aerators, the facility documentation only showed water temperature monitoring. There was no documentation for flushing or equipment cleaning, and the Maintenance Supervisor stated the facility was flushing unused outlets but was not documenting the monitoring and had no further monitoring in place for the listed control measures. The Administrator and Maintenance Supervisor also verified the control measures in the Legionella risk assessment were not being implemented. The facility also failed to ensure staff used proper PPE for residents on enhanced barrier precautions. Resident #11 had diagnoses including dementia, severe protein calorie malnutrition, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms, and had severe cognitive deficits, dependence for ADLs, and an indwelling urinary catheter. The care plan and physician order required staff to wear a gown and gloves for high-contact care, including dressing, bathing, transfers, hygiene, changing briefs, device care, and wound care. During observation, an LPN wore a gown and gloves while providing catheter care, but a CNA assisting with catheter-related care, brief fastening, and transfer wore only gloves and no gown. The CNA stated a gown was only needed for catheter care, and another CNA who assisted with the transfer also wore no gown. The Infection Preventionist confirmed CNAs should wear PPE when applying a brief and handling a urinary catheter drainage bag. Resident #22 had diagnoses including dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, and was rarely or never understood, had impairment to both sides, and was dependent for transfers and all mobility and ADLs. The resident’s care plan and physician order required gown and gloves for high-contact care, including transfers and feeding tube care. During observation, the DON, RN Supervisor, IPRN, and a CNA were in the room providing care and assisting with a mechanical lift transfer, but no staff wore gowns and the DON was not wearing a gown or gloves. The IPRN confirmed staff should have worn a gown and gloves, disposable gowns were available in the room, and the RN Supervisor confirmed an EBP sign should have been posted outside the room but was not. The facility identified nine residents requiring EBP. The facility also failed to ensure annual Mantoux tuberculosis risk assessments were completed for three CNAs. Review of personnel files showed CNA #433, CNA #472, and CNA #493 did not complete the yearly risk assessment within the previous 12 months. The Human Resource Manager verified the yearly assessments had not been completed, and the facility policy stated the annual TB risk assessment would be completed each January.
Failure to Monitor Psychotropic Medication Effects and Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for three residents reviewed for unnecessary medications. Resident #15, admitted with psychosis, mood disorder, anxiety, frontotemporal neurocognitive disorder, and dementia, had orders for escitalopram, olanzapine, and mirtazapine, and the care plan directed staff to monitor for side effects and effectiveness every shift, but the record contained no orders or documentation showing monitoring for effectiveness, adverse effects, or side effects from 02/01/26 through 03/09/26. The DON verified there was no documentation that Resident #15 was monitored for adverse effects or side effects of the psychotropic medications. Resident #35, admitted with dementia, hallucinations, anxiety, restlessness, and agitation, had a PRN clonazepam order for agitation that was administered six times in February, but the record showed no documentation of monitoring for potential side effects or effectiveness. Resident #10, admitted with dementia, type II diabetes mellitus, lumbar vertebra fracture, neurocognitive disorder with Lewy bodies, hypertension, PTSD, depression, transient ischemic attack, and cerebral infarction, had orders for mirtazapine and clozapine, and the care plan included monitoring for adverse reactions such as tardive dyskinesia, EPS, suicidal ideations, and unusual behavior symptoms; however, the medical record contained no evidence that these psychotropic medications were monitored for side effects or adverse reactions. The DON verified the lack of documentation for monitoring in Resident #10's record, and the facility policy stated that psychotropic medication use would be monitored for efficacy, side effects, and adverse consequences.
Failure to Assist Dependent Residents With ADLs
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living, affecting five of six residents reviewed for ADLs. Resident #65 had diagnoses including dementia, type II diabetes mellitus, epilepsy, anxiety, and traumatic brain injury, and was documented as rarely/never understood and dependent on staff for eating. Resident #82 had diagnoses of dementia and aphasia, was also rarely/never understood, and was dependent on staff for eating. On the morning of observation, breakfast trays for both residents were left in their rooms while they remained in bed with eyes closed, and staff stated a CNA had called off and no one had been reassigned to the residents in those rooms. Resident #65’s breakfast tray remained untouched and out of reach for an extended period before an LPN began feeding him after the section had still not been reassigned. Resident #82’s tray was observed on the nightstand with all items covered, and she was not fed until more than an hour after the tray was first seen in her room. A CNA later fed Resident #82 after the delay. Staff interviews confirmed that residents in the affected section who needed assistance with eating had not been fed when expected. Resident #73 had impaired cognition, was able to eat with setup or clean-up assistance, and was dependent on staff for personal hygiene. During breakfast, she was observed feeding herself while dark debris was visible under each fingernail, and the DON confirmed the condition of her fingernails. Resident #53 was dependent on staff for personal hygiene and grooming, yet was observed with visible dark debris under multiple fingernails, which staff identified as appearing to be feces, and the grooming need was not addressed during the observation period. Resident #11 had severe cognitive deficits and was dependent on staff for toileting hygiene, bathing, and dressing, yet was observed wearing the same clothing on consecutive days, including stained sweatpants, and staff confirmed the clothing appeared unchanged from the prior day.
Failure to Implement Ordered Pressure-Relief Measures
Penalty
Summary
The facility failed to ensure pressure-reducing measures were implemented as ordered for three residents reviewed for pressure ulcer prevention. Resident #22 had diagnoses including unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, and was documented as rarely/never understood, at risk for skin breakdown, and dependent on staff for all ADLs and mobility. Physician orders required turning or repositioning every couple of hours around the clock, a washcloth in the left hand as tolerated, and no more than two hours in a chair at a time to relieve pressure from a buttock wound. Observations showed Resident #22 lying on his back without pillows or other offloading devices, and no washcloth in the left hand. A CNA and LPN stated a CNA had called off and the section had not been reassigned, and the LPN confirmed care had not been provided since the start of the shift. Later, Resident #22 was observed in a wheelchair with his head not supported by the headrest, and the LPN confirmed he had remained in the chair beyond the ordered two-hour limit. On another observation, the resident’s left palm was intact but no washcloth was in place, and the LPN confirmed the washcloth was not present. Resident #2 had severe cognitive impairment, was dependent for ADLs, incontinent of bowel and bladder, and assessed at moderate risk for pressure ulcers. The care plan directed staff to turn or reposition every couple of hours around the clock, and a physician order required heel protectors to both heels at all times while in bed. Multiple observations showed only the right heel protector in place, with no protector on the left heel, and a CNA confirmed the left heel protector had not been applied and stated she was unaware both heels were to be protected. Resident #5 had Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and lymphedema, was dependent for transfers and bed mobility, and had a history of bilateral heel skin alteration. Her orders required bilateral heel protectors while in bed, but she was observed in bed without them; a CNA verified the omission and found only one protector, with the second unable to be located. The facility policy stated heels require particular attention to reducing pressure because of their limited surface area.
Pureed Diet Menus and Ordered Portions Not Followed
Penalty
Summary
The facility failed to ensure staff followed menus and recipes for residents on a pureed diet. During observation of the midday meal, a dietary employee was seen pureeing parmesan pasta for 10 residents and added unmeasured hot water to thin it, even though the recipe directed that chicken broth be used and specifically stated that if thinning was needed, liquid other than water should be added to achieve the proper consistency. The Dietary Manager also directed the employee to puree leftover Philly cheesesteak meat from the prior evening instead of serving fried fish as listed on the menu, and no pureed fish was prepared. The employee used a 4-ounce scoop for the pureed Philly cheesesteak and later added one hamburger bun to the meat prepared for the 10 residents, while the recipe indicated the whole sandwich should be prepared and then pureed for each resident. Ten residents were identified as receiving the pureed diet. The facility also failed to ensure a resident received double portions as ordered by the physician. The resident had diagnoses including dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury, and was dependent on staff for eating. The current physician order specified a regular diet with pureed textures, thin liquids, and double portions. During breakfast observation, an LPN fed the resident and stated the meal ticket showed a pureed diet with double portions, but the resident was served one bowl of eggs, one bowl of an unidentified substance possibly bread, a bowl of oatmeal, and a bowl of pureed fruit. The LPN stated the resident did not receive double portions, and the resident consumed the meal without refusing it.
Dirty Floor Mat and Wheelchairs
Penalty
Summary
The facility failed to ensure floor mats and wheelchairs were maintained in a clean sanitary condition for three residents reviewed for environment. Resident #22, who had diagnoses including unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, was observed lying in bed with a bedside floor mat next to the bed that was discolored and stained over approximately three-fourths of the mat. The resident’s physician order required a bedside floor mattress when in bed, and the LPN confirmed the mat was stained and discolored and did not provide a homelike environment; the LPN also stated the mat was usually covered with a fitted sheet, but this resident’s mat was uncovered. Resident #65, who had dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury, used a wheelchair for mobility and was dependent on staff for mobility. Although the posted wheelchair cleaning schedule indicated the wheelchair should have been cleaned during third shift, the wheelchair frame on both sides was observed dirty and covered in debris, and the AD confirmed the wheelchair was dirty with buildup of debris. Resident #82, who had dementia and aphasia and was dependent on staff for wheelchair mobility, also had a wheelchair that was observed with a buildup of debris and food on both sides of the rails, including pieces of food in the space between the seat and the frame. The AD confirmed the wheelchair was dirty with debris buildup and food pieces and stated it should have been cleaned on the previous night shift.
Inaccurate Skin Assessment and Unrecognized Chest Bruising
Penalty
Summary
The facility failed to ensure an accurate resident assessment was completed for a resident with Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and a left femur fracture who was dependent on staff for all ADLs and used a wheelchair. Her care plan identified her as being at risk for falls due to cognitive impairment, communication deficit, poor safety awareness, decreased judgment, impulsivity, history of falling, mobility and balance deficits, incontinence, and prescribed medications. She also had a fall risk evaluation indicating she was at risk for falls and had a physician order for warfarin sodium for atrial fibrillation. During a weekly skin assessment, the LPN documented that the resident was free of chest bruising. However, when the resident was observed shortly afterward, she had a large healing bruise below the mid clavicular area that was green and yellow in color and measured approximately four by four inches. The resident stated she was unaware of the bruise and did not know how she received it, denying any injury. The nurse assigned that morning and the CNA were unaware of the bruising, and the DON also confirmed the bruise during observation but was unaware of it. The LPN who completed the skin assessment verified that no bruising had been noted to the upper chest. The DON's nursing note documented that the discoloration was brought to nursing attention by the state surveyor, and the facility policy required weekly skin assessments and nurse visualization of each shower with documentation of a skin assessment in the medical record.
Failure to Maintain Ordered Fall Precautions
Penalty
Summary
The facility failed to implement fall safety precautions for a resident with Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and lymphedema. The resident’s change in condition MDS assessment showed moderate cognition, and she was dependent on staff for transfers and bed mobility. Her care plan identified her as at risk for falls due to cognitive impairment, communication deficits, decreased safety awareness, decreased judgment, impulsivity, history of falling, mobility and balance deficits, weakness, incontinence, prescribed medications that could affect balance, need for an assistive device, easy fatigue, and being wheelchair bound/non-ambulatory. Interventions included a bedside mattress to the floor when in bed. The resident’s fall risk assessment identified her as high risk for falls, and a physician order directed staff to place a floor mat next to the bed every shift when she was in bed because of poor safety awareness. During observation, the resident was lying in bed awake, but the bedside mat was found leaning against a chair on the opposite side of the room rather than in place at the bedside. A CNA confirmed the resident was in bed and the fall prevention floor mat was not in place, stating staff likely removed it when breakfast was served and did not replace it.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide an indwelling urinary catheter securement device for a resident with an IUC. Resident #11 was admitted with diagnoses including unspecified dementia, severe protein calorie malnutrition, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. The admission MDS showed a BIMS score of four, indicating severe cognitive deficits, and the resident was dependent on others for toileting hygiene, bathing, and dressing. The initial care plan identified the resident as having an IUC due to urinary retention and obstructive uropathy, but it did not include any interventions for securing the catheter tubing. The physician order specified an 18 French IUC for obstructive and reflex uropathy. A nurses note documented that the resident continued to disconnect the catheter bag and was physically combative with staff during care. During observation, an LPN performed IUC care and a CNA dressed the resident, and no IUC securement device was in place. The LPN confirmed the absence of a securement device and then obtained and applied one. The DON stated that a securement device was not necessarily needed and that if a resident arrived with one, the facility would continue its use, but also confirmed that if the resident was pulling at the IUC, a securement device should have been in place. An RN supervisor stated he was unsure of the standards of care for IUC securement devices and believed they could cause discomfort for residents with cognitive deficits. Review of CDC guidance showed that IUC maintenance includes proper securement to prevent movement and urethral traction, while the facility policy on catheter care provided no direction on securement devices.
Wrong Tube Feeding Formula Administered
Penalty
Summary
The facility failed to ensure that a resident received enteral nutrition as ordered by the physician. Resident #22 had diagnoses including unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, and the MDS indicated the resident was rarely or never understood, had a gastrostomy tube, and relied on enteral nutrition for 51% or more of fluid and nutrition needs. The current physician order directed Isosource HN at 80 ml per hour, but during observation the resident was receiving Fibersource HN at 80 ml per hour instead. The tube feeding bag was dated 03/10/26 at 4:00 A.M., and an LPN confirmed the resident was receiving the wrong formula and stated the bag had been hung by the previous shift.
Oxygen Therapy Not Provided Per Physician Order
Penalty
Summary
The facility failed to ensure a resident was receiving oxygen therapy per physician orders. Resident #56 was admitted with diagnoses including vascular dementia, emphysema, Raynaud's syndrome, and peripheral vascular disease. Her quarterly MDS indicated she required continuous oxygen therapy, and her care plan directed oxygen by nasal cannula per physician orders for emphysema and a history of shortness of breath on exertion, when sitting, and when lying flat. A physician order dated 04/25/25 directed oxygen at 2 liters per minute by nasal cannula every shift for chronic respiratory deficit/shortness of breath/oxygen saturations less than 90% related to emphysema. During observation, Resident #56 was found in bed with her nasal cannula attached to a concentrator running at 5 liters per minute instead of the ordered 2 liters per minute. A CNA stated she had just been assigned to the hall and was unaware of the resident's ordered oxygen setting, and an LPN verified that the oxygen was not at the liters ordered by the physician. On a later observation, the resident was seen walking in the hall with a portable oxygen concentrator on her rollator walker, and the concentrator was set at 4 liters per minute. Another LPN verified that the portable oxygen setting was not at the ordered liters. The facility policy stated oxygen is administered by a licensed nurse and requires a physician order.
Missing Dialysis Agreement and Inconsistent Communication With Dialysis Center
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident who required hemodialysis. Resident #12 was admitted with unspecified dementia with other behavioral disturbances, end stage renal disease, type 2 diabetes, and hypertensive chronic kidney disease. The care plan for end stage renal disease, revised 11/13/25, included assessment of the central line site every shift and dialysis on Tuesdays, Thursdays, and Saturdays, with the resident leaving the facility around 10:00 A.M. for an 11:00 A.M. chair time. However, there were no care plan interventions for communication with the dialysis center. Review of dialysis communication notes from 01/01/26 to 03/12/26 showed forms only for five dialysis treatments, with no communication forms for the remaining listed treatments during that period. Staff interviews showed confusion about the communication process and the absence of a consistent dialysis communication book. The DON stated the facility had a dialysis communication book but needed to locate it, and later verified that copies of past communication forms were not kept and that she had not called the dialysis center requesting daily communication forms. The RN supervisor stated the current process was to send a face sheet, blank progress note, medication list, and blank order form with the caregiver on dialysis days, and the Administrator stated that prior to the effective date of 03/12/26 on the dialysis agreement, there was no previous agreement between the facility and the dialysis provider used by the resident.
Failure to Document and Provide PTSD Trigger-Based Care
Penalty
Summary
The facility failed to ensure trauma-informed and culturally competent care for a resident with PTSD. Resident #10 was admitted with diagnoses including dementia, neurocognitive disorder with Lewy bodies, depression, and PTSD. The medical record showed a social history and assessment completed by Social Services that listed PTSD, but there was no additional documentation describing the cause or treatment of the PTSD. The social services plan of care addressed mood problems related to cognitive impairment, hallucinations, unspecified PTSD, major depressive disorder, and anxiety disorder, but it did not document specific PTSD triggers, causes, behaviors, or interventions. The resident’s POA stated that the resident’s PTSD was related to an assault while serving in the military and that staff had previously been informed that only female caregivers should provide direct care because male caregivers could trigger behaviors. The medical record contained no documentation directing caregivers to be female. The DON verified there was no knowledge of the resident’s PTSD trigger related to male assault in the military and confirmed the resident had previously received care from male caregivers. Social Services also stated they were unaware of the cause of the PTSD or any potential triggers and verified that no specific PTSD assessment or plan of care had been completed. During observation, a male CNA was providing morning personal care to the resident and stated he was unaware of any request for female direct care staff or PTSD-related care.
Inaccurate nutrition assessment and failure to update diet order information
Penalty
Summary
The facility failed to ensure nutrition assessments were completed accurately and updated with new diet orders for one resident reviewed for food and nutrition. Resident #65 was admitted with diagnoses including dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury. The quarterly MDS dated 02/11/26 showed the resident was rarely or never understood and was dependent on staff for eating. The resident had a physician order from 12/14/23 for a cream cookie twice daily for nutritional adequacy, and progress notes from 01/01/26 through 03/12/26 did not document incidents or concerns with eating, swallowing, or choking. A Speech Language Pathology evaluation and plan of treatment dated 01/07/26 documented that the resident was referred for therapy due to pocketing food, and a physician order initiated the same day showed a regular type diet with pureed textures and thin liquids with double portions. However, the quarterly nutritional assessment dated 02/06/26 stated the resident was on a regular textured diet and received a cookie for a snack. An LPN confirmed the resident would still receive an oatmeal cookie for snacks even though he was on a pureed diet. The RD later confirmed the assessment was completed inaccurately, stated she was unaware the resident was on a pureed diet at the time, and said the facility did not notify her of the diet change or provide access to the speech therapy notes through the EMR.
Failure to Reassess and Intervene as Pressure Ulcer Progressed to Unstageable
Penalty
Summary
The deficiency involves the facility’s failure to implement and adjust interventions to prevent a pressure ulcer from worsening in a resident who was initially assessed as low risk for pressure ulcer development. The resident had multiple diagnoses including dementia, Alzheimer’s disease, autonomic neuropathy, edema, and incontinence, and was dependent on staff for most activities of daily living. The care plan in place identified the resident as at risk for pressure ulcer development due to cognitive impairment, incontinence, mobility and balance deficits, weak gait, decreased activity, and medications affecting sensory perception. Planned interventions included monitoring and documenting skin changes, notifying appropriate clinical staff of new breakdown, weekly skin assessments, use of barrier cream, dietitian assessment for nutritional needs, and management by a wound specialist center. On a documented date, a CNA notified an RN that the resident had an open area on the coccyx, which the RN assessed as a Stage II pressure ulcer. Barrier cream was applied, and the wound care nurse was to assess the resident. The initial wound documentation described a small Stage II ulcer with scant serosanguinous drainage and epithelial tissue. A nursing plan of care was then developed to address the coccyx skin alteration, including topical treatments such as triad paste and chamosyn with honey. However, there was no evidence in the medical record of any reassessment of the resident’s overall condition or investigation into the source of the pressure ulcer at that time, and no nutritional interventions or evaluations were documented despite the resident’s identified risk for malnutrition. Subsequent weekly wound documentation showed that the coccyx pressure ulcer progressively increased in size and changed in tissue characteristics over several weeks. The ulcer measurements increased from 1 cm by 1.5 cm by 0.1 cm to 2.0 cm by 1.5 cm by 0.1 cm, with the development of slough tissue, and eventually to 3.0 cm by 4.0 cm by 2.0 cm with foul odor and moderate necrotic tissue, at which point it was assessed as an unstageable pressure ulcer. Throughout this period of worsening, the record lacked evidence of reassessment of the resident’s condition in response to the ulcer’s progression, lacked documentation of efforts to identify the possible source of pressure, and did not show implementation of mechanical pressure relief devices, off-loading strategies, or nutritional support and evaluation. Although a wound specialist later evaluated the ulcer and made recommendations including an air pressure mattress, repositioning, frequent incontinence checks, and nutritional monitoring, the medical record did not show that these recommendations were promptly implemented, and there continued to be no documented additional interventions for mechanical off-loading or nutritional evaluation. The facility’s own skin care and pressure management policy stated that any new pressure ulcer should trigger reevaluation of the prevention plan and interventions, but the infection preventionist/wound care nurse confirmed there was no documentation that the facility attempted to determine the origin of the ulcer or implement nutritional interventions as required by the care plan and policy. The deficiency affected one resident out of three reviewed for pressure ulcer prevention and wound healing, in a facility with a census of 89 residents. The resident’s Minimum Data Set assessment had identified severely impaired cognition, rejection of care on some days, dependence on staff for ADLs, always incontinent of bowel and bladder, and an in-house acquired unstageable pressure ulcer. Despite these identified risks and the facility’s policy requirements, the medical record showed that the facility did not reassess the resident’s condition or modify interventions in response to the development and worsening of the pressure ulcer, and did not complete nutritional assessments or implement nutritional support after the ulcer was first identified.
Failure to Timely Notify Physician and Representative After Unresponsive Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and resident representative when a resident was found unresponsive on the floor with a head laceration. The resident had multiple diagnoses, including dementia, COPD, type 2 diabetes with neuropathy, bladder cancer, coronary artery disease, major depression with psychotic symptoms, anxiety disorder, osteoarthritis, history of TIA, and hypertension, and had been assessed with severe cognitive impairment but independent ambulation and transfer. The care plan for fall risk required that if the resident fell or was found on the floor, staff were to assess for injury and notify the MD and responsible party. On the morning of the incident, a CNA informed an LPN that the resident had an unwitnessed fall and was lying on the bathroom floor. The LPN found the resident on the bathroom floor with his head under the sink, diaphoretic, sweaty, clammy, with a laceration to the top of the head, and unable to perform ROM due to lack of consciousness. Neuro checks were initiated. Despite the resident’s loss of consciousness and head injury, the physician was notified only by fax at 9:00 a.m., and there was no immediate telephone contact. The physician’s faxed response to send the resident to the emergency room was not received until 12:45 p.m., approximately four hours and 45 minutes after the fall, by which time the resident had already been transported to the hospital. The resident’s representative (POA) was not notified of the fall until 10:45 a.m., about two hours and 45 minutes after the incident, and was later notified again regarding the transfer to the emergency room. The facility’s policy required immediate notification of the resident, physician, and resident representative when there is an accident, significant change in status, or symptoms such as loss of consciousness. In an interview, the DON confirmed that the physician was not contacted immediately and that a telephone call should have been made instead of relying on a fax, and also confirmed the delay in notifying the resident representative.
Failure to Provide Appropriate Post-Fall Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to provide appropriate treatment and neurological assessments after a resident was found on the bathroom floor unresponsive with a head laceration following an unwitnessed fall. The resident had multiple diagnoses including dementia, COPD, type 2 diabetes with neuropathy, coronary artery disease, major depression with psychotic symptoms, anxiety, osteoarthritis, history of TIA, and hypertension, and had a care plan identifying fall risk with interventions requiring assessment for injury and completion of neuro checks after a fall with possible head injury or unwitnessed fall. On the morning in question, a CNA found the resident unresponsive on the bathroom floor; an LPN observed the resident diaphoretic, sweaty, clammy, with a head laceration and unable to perform range of motion due to lack of consciousness. Staff, including the unit manager, LPNs, and CNAs, lifted the unresponsive resident from the floor and placed him in bed, and EMS was not contacted at the time of discovery. The neurological observation form initiated at 8:00 A.M. documented only vital signs at multiple time points and did not include any documentation of pupillary responses or hand grasps, despite these being required elements on the form and part of a post-fall neurological assessment. The medical record contained no additional neurological assessment or further documentation beyond these vital signs. The LPN faxed the physician about the fall and awaited a response, notified the POA later that morning, and the DON was notified of the fall and change in condition; however, the resident remained unresponsive and never regained consciousness. The DON confirmed that the post-fall neurological assessment only contained vital signs and that staff did not contact EMS when the resident was first found unresponsive with an observed head injury, instead moving him back to bed. This sequence of actions and omissions formed the basis of the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Notify Resident Representative and Hospice Provider After Incident
Penalty
Summary
The facility failed to ensure that required notifications were made to a resident's representative and hospice provider following an incident in which the resident was lowered to the ground during care. The resident involved had a history of dementia, type II diabetes, a recent right femur fracture, generalized anxiety disorder, major depressive disorder, anemia, and a terminal diagnosis of rectal cancer. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and was receiving hospice care at the time of the incident. On the day of the incident, staff were providing wound care to the resident using a stand-up lift. During the process, the resident became restless and managed to remove his arm from the sling, resulting in staff lowering him to the floor for safety. The resident then flung his body to the side before staff could unstrap his legs from the lift. He was subsequently assisted back into his wheelchair, and no injuries or pain were noted at the time. Documentation confirmed that the resident's physician was notified of the incident, but there was no evidence that the resident's spouse or hospice provider were informed. Interviews with staff involved in the incident, including a registered nurse and a licensed practical nurse, confirmed that neither the resident's family nor hospice provider were notified about the event. Review of facility policies indicated that it was required to notify the resident, physician, and resident representative in the event of an accident or significant change in status. The lack of documentation and staff confirmation established that the required notifications were not made following the incident.
Failure to Thoroughly Assess Resident After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident for injuries after an incident involving a mechanical lift transfer. The resident, who had severe cognitive impairment, was dependent on staff for all activities of daily living and had a significant medical history including dementia, diabetes, a recent right femur fracture, and a terminal diagnosis of rectal cancer. During a wound care procedure, the resident became restless and managed to remove his arm from the lift sling, resulting in staff lowering him to the floor while his legs remained strapped in the lift. The resident then threw himself to the side before being fully released from the lift. Following the incident, staff assisted the resident back into his wheelchair and noted no immediate signs of pain or injury. However, there was no documentation of a comprehensive injury assessment, such as a range of motion evaluation, being performed at that time. Staff interviews confirmed that only a basic physical check was conducted, and no range of motion assessment was completed. The facility's policy required a thorough assessment for injuries after such incidents, but this was not followed. The following day, a hospice aide reported concerns about the resident's leg, which was then found to be rotated inward. An x-ray revealed a right femur fracture with severe dislocation, and the resident was sent to the hospital for further treatment. The deficiency was identified due to the lack of a thorough post-incident assessment as required by facility policy, despite the presence of multiple staff members during and after the event.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, and failed to call 911 for a resident who was found unresponsive, absent of breaths, and without a pulse/heartbeat. The resident had advance directives and a physician order for Full Code status, meaning full life-saving measures were to be taken in the event of cardiac or respiratory arrest. The event occurred when an LPN entered the resident’s room to check blood sugar and found the resident without vital signs, then called the shift supervisor to confirm the condition. The resident had multiple diagnoses, including dementia with behaviors, diabetes mellitus, peripheral vascular disease, chronic heart failure, chronic kidney disease stage four, atrial fibrillation, and atherosclerotic heart disease. The resident’s quarterly MDS showed cognitive impairment. The care plan and physician orders documented Full Code status, and the plan of care directed staff to call for immediate assistance, initiate CPR, call 911, and notify the family if the resident was found unresponsive. According to the record and staff interviews, the two nurses confirmed the resident had no vital signs but did not start CPR, did not call 911, and did not contact a physician for direction. One nurse stated she believed the resident had passed away in his sleep and was unsure what to do, while the other confirmed that CPR was not performed and EMS was not called. The resident subsequently died in the facility without life-saving measures being initiated.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Inadequate Nursing Staff Competency
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of appropriate skills and knowledge among the nursing staff, which impacted their ability to meet the individualized needs of residents. This failure resulted in residents not receiving care in a manner that supports their highest level of well-being.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its policy regarding the requirement to report a resident-to-resident altercation to the state agency. This incident involved a resident with Alzheimer's disease, chronic obstructive pulmonary disease, and atrial fibrillation, who was inadvertently hit in the face with a dinner plate during an altercation between two other residents. The incident resulted in a laceration and a large bruise on the resident's forehead. Despite the injury, the facility did not report the incident to the Ohio Department of Health as required by their policy. The Director of Nursing and a Registered Nurse confirmed that the resident was accidentally hit during the altercation, which was not directly involving her. The facility's policy mandates that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property, and injuries of unknown source must be reported to the state agency within 24 hours. However, this policy was not followed, as verified by the facility's Administrator.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving Resident #15, who was affected by the incident. Resident #15, diagnosed with Alzheimer's disease, chronic obstructive pulmonary disease, and atrial fibrillation, was in the dining room when an altercation between two other residents occurred. During the altercation, Resident #15 was accidentally hit in the face with a dinner plate, resulting in a cut to her forehead. The nursing staff assessed Resident #15, provided wound care, and initiated neurological checks. However, the incident was not reported to the state agency as required by the facility's policy. Interviews with the Director of Nursing and a Registered Nurse confirmed that Resident #15 was unintentionally struck by a plate during the altercation between two other residents. The Director of Nursing and the Administrator acknowledged that the incident was not reported to the Ohio Department of Health within the required timeframe. The facility's policy mandates that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property, and injuries of unknown source be reported to the state agency within 24 hours of the incident being known to staff.
Failure to Obtain Physician Order for Medication
Penalty
Summary
The facility failed to ensure that treatments were provided with a physician's order, affecting one resident who was reviewed for physician orders. The resident, diagnosed with Alzheimer's disease and dementia, had impaired cognition. A review of the medical records revealed that there were no physician orders for Nystatin powder, a medication used to treat fungal or yeast infections on the skin, from July 1, 2024, through the current date. Despite this, a progress note dated August 1, 2024, indicated that Nystatin powder was applied to the resident's skin without a documented physician order. The incident was discovered during a complaint investigation, where a State tested Nursing Assistant (STNA) reported finding marks on the resident's shoulders and under her breasts, which she attributed to the resident's bra being too tight or worn for too long. The STNA reported the skin concerns to a nurse, who then applied the Nystatin powder. The Director of Nursing confirmed that the nurse documented the application of the powder without a physician's order, which was against the facility's policy that requires medications to be administered only upon a written order from a licensed prescriber.
Failure to Follow Prescribed Portion Sizes and Recipes for Diet Textures
Penalty
Summary
The facility failed to ensure portion sizes were followed when serving all diet textures, affecting 83 residents who received food from the kitchen. Specifically, the facility did not adhere to the prescribed portion sizes for baked turkey crunch for residents on regular, mechanical soft, and pureed diets. Observations revealed that a size 16 scoop, which is two ounces, was used instead of the required 5 1/3 ounces for regular diets and four ounces for mechanical soft and pureed diets. Additionally, the preparation of pureed baked turkey crunch included the addition of five slices of bread and an unmeasured amount of water, contrary to the recipe instructions that specified using chicken broth and not water for thinning the mixture. Interviews with the dietary staff, including Cook #506 and Dietary Manager (DM) #501, confirmed these deviations from the prescribed recipes and portion sizes. Cook #506 admitted to adding extra scoops of food and using bread and water to achieve the desired texture for pureed diets. DM #501 verified that the incorrect scoop sizes were used during meal service and acknowledged that bread and water should not have been used in the preparation of pureed baked turkey crunch. This deficiency affected five residents with physician-ordered pureed diets and potentially compromised the nutritional needs of all residents receiving food from the kitchen.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure that floors were adequately maintained, which had the potential to affect all 83 residents. Observations on multiple dates revealed sticky substances on the floors of the Bayview Dining Room, B Hall, and C Hall, causing shoes to stick and become tacky. Staff interviews confirmed the presence of sticky floors, and it was noted that this issue occurred yearly when the air conditioning was turned off. Additionally, it was revealed that housekeeping staff had been re-educated on the correct dilution for cleaning chemicals, but the floors remained sticky due to a staff member calling off on the day the floors were supposed to be cleaned with an auto floor scrubber. The facility also failed to ensure that resident rooms were free from odors, specifically affecting one resident with a diagnosis of dementia and incontinence issues. Observations of the resident's room on multiple occasions revealed a strong urine odor. Staff interviews confirmed the presence of the odor and indicated that the resident sometimes urinated in bed. The facility's policy for daily cleaning of care areas was reviewed, which stated that housekeeping, laundry, and maintenance staff were responsible for maintaining a sanitary and comfortable environment.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were secure and properly labeled, affecting thirteen residents. For Resident #69, a red pill identified as amitriptyline hydrochloride 100 mg was found on a plastic cup lid on the nightstand, indicating the medication was not taken as prescribed. The resident, who has neurocognitive disorder with Lewy bodies and other conditions, confirmed the pill was from the previous night. An LPN verified the medication and acknowledged that residents should be observed taking their medications. Additionally, a pink pill identified as Levothyroxine was found on the floor of Resident #36's room, who has severe cognitive impairment and multiple health conditions. An LPN confirmed the pill's identity and its inappropriate storage on the floor. Further observations revealed that an RN was administering medications from a cart containing a clear plastic cup with several unlabeled white tablets. The RN admitted the cup was present before her shift and attempted to return the tablets to a house stock bottle of acetaminophen, which was against facility policy. The DON confirmed that medications should not be removed from their original containers until administered. The facility's policy mandates that unused medications should be disposed of properly, and any medication refusals should be documented on the medication administration record.
Failure to Document Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that a copy of the advanced directives was included in the medical records of two residents. Resident #59, who was admitted with multiple diagnoses including type II diabetes mellitus, dementia, and chronic kidney disease, had a physician order and care plan indicating a Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest) directive. However, the medical record did not contain a signed copy of the advanced directive, a fact confirmed by a Registered Nurse during an interview. Similarly, Resident #236, admitted with a diagnosis of dementia, did not have any advance directive order or code status documented in the electronic medical record. This was confirmed by a Licensed Practical Nurse, who also noted the absence of a paper copy of the advance directive. The facility's policy mandates that each resident should have an advance directive in place at admission, and these directives should be documented in the medical record, which was not adhered to in these cases.
Failure to Document Skin Condition Upon Admission
Penalty
Summary
The facility failed to ensure accurate skin assessments were completed upon admission for Resident #236, who was admitted with a diagnosis of dementia. Despite the hospital referral form indicating a traumatic face superior wound with edema and bruising, the Nursing Admission Screening completed on the admission date did not document any skin concerns. Subsequent observations and interviews revealed that Resident #236 had noticeable bruising on her face, which was not recorded during the initial assessment. This discrepancy was confirmed by multiple staff members, including LPNs and an RN, who noted the bruising in later assessments and interviews with the resident. The failure to document the bruising upon admission was highlighted during an interview with RN #514, who admitted to not observing or documenting the discoloration on Resident #236's face during the initial head-to-toe assessment. Further interviews with other staff members corroborated that the bruising was present shortly after admission, indicating that the initial assessment was incomplete. The facility's policy on assessments requires that any abnormalities be documented in the medical record, which was not adhered to in this case.
Failure to Maintain Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to maintain appropriate physician orders, accurately assess dialysis access sites, and ensure a dialysis catheter site was covered for a resident requiring dialysis. The medical record review revealed that the resident had orders to check thrill and bruit every shift and to assess and document the condition of the central line catheter site. However, there was no documentation of a sterile dressing change for the dialysis catheter site from 03/10/24 to 05/15/24. Observations confirmed that the resident's chest catheter was frequently uncovered, and the fistula did not have a thrill or bruit, which was also confirmed by the Director of Nursing (DON). Additionally, the medication administration record (MAR) and treatment administration record (TAR) did not reflect the correct catheter site, and the order to use a sterile dressing kit did not populate on the MAR/TAR as it should have. The facility's policies on dressing changes and physician orders were not followed, leading to these deficiencies. The resident involved had diagnoses including dementia, end-stage renal disease, and dependence on renal dialysis. The care plan indicated the need for dialysis three times a week and required monitoring for signs of acute failure, edema, and weight gain. Despite these requirements, the facility failed to ensure proper documentation and assessment of the dialysis access sites. Interviews with staff, including the DON and a registered nurse, confirmed the lack of proper documentation and adherence to physician orders. The facility's failure to follow its policies and procedures for dressing changes and physician orders contributed to the deficiencies observed during the survey.
Failure to Implement Non-Pharmacological Interventions for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure non-pharmacological behavioral interventions were assessed or implemented to address a resident's resistance to care, resulting in a lack of timely care and treatment. Resident #46, who was moderately cognitively impaired and had multiple diagnoses including dementia, frequently refused care and medications. Despite the resident's care plan outlining various interventions for managing behavioral symptoms, there was no evidence that these non-pharmacological strategies were attempted or documented by the staff. The resident's medical record lacked specific interventions and assessments to determine the underlying cause of resistance to care. Observations and staff interviews revealed that Resident #46 frequently refused care, resulting in the resident being heavily soiled with urine and developing blisters on the left posterior thigh. Staff members confirmed that they were not provided with specific interventions to manage the resident's behaviors effectively. Despite some staff being able to provide care without resistance, these successful strategies were not communicated to other caregivers. The resident's room consistently had a strong urine odor, indicating a lack of timely and appropriate care. Further interviews with staff, including STNAs and the LPN, confirmed that there were no individualized interventions established to promote the resident's acceptance of care. The Director of Nursing and Licensed Social Worker also verified that the resident's plan of care lacked specific non-pharmacological interventions, and the medical record did not contain strategies for de-escalating behaviors. This deficiency in care led to the resident being frequently soiled, developing blisters, and experiencing a strong urine odor in the room, indicating a significant lapse in the quality of care provided.
Inaccurate Nutritional Assessment for Resident with Fluid Restriction
Penalty
Summary
The facility failed to ensure an accurate Nutritional Assessment for a resident diagnosed with dementia and congestive heart failure. The resident was admitted with specific diet orders, including a no added salt diet, low fat, 2000 mg sodium, low cholesterol, and a fluid restriction of 1500 ml per day. However, the Nutritional Assessment completed on 04/12/24 did not reflect the resident's fluid restriction and inaccurately stated that fluid was encouraged. This discrepancy was confirmed by interviews with the RN and the Director of Nursing, who acknowledged the resident's fluid restriction due to congestive heart failure and risk for weight gain from fluid intake. The Registered Dietitian admitted to being unaware of the fluid restriction and the two diet orders in place for the resident, leading to an inaccurate assessment of the resident's nutritional needs. Further review of the resident's medical records revealed conflicting diet orders and fluid restrictions, which were not accurately documented in the Nutritional Assessment. The resident's fluid restriction was updated to 1800 ml per day on 05/01/24, but the initial assessment failed to capture this critical information. The failure to accurately document and assess the resident's nutritional needs and fluid restrictions highlights a significant deficiency in the facility's food and nutrition services, impacting the resident's care and well-being.
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 572 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 Toledo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concord Care Center Of Toledo | 0.7 mi | ★★★★★ | 6 | 0 |
| Advanced Healthcare Center | 1.8 mi | ★★★★★ | 9 | 0 |
| Continuing Healthcare Of Toledo | 1.8 mi | ★★★★★ | 6 | 0 |
| Heatherdowns Rehab & Residential Care Center | 1.8 mi | ★★★★★ | 7 | 0 |
| Ohio Living Swan Creek | 2.2 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.