Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franciscan Care Ctr Sylvania during CMS and state inspections, most recent first.
Kitchen sanitation, temperature monitoring, and utensil handling deficiencies: Staff observed grease buildup under a commercial stove and fryer and food splatter on the kitchen ceiling. Refrigerator, freezer, and dish machine temperature logs had multiple missing entries across several days. During breakfast service, a CNA picked up a spoon from the carpeted floor and gave it back to a resident instead of providing a clean utensil.
Infection Prevention and Control Failures: The facility did not follow its Legionella control scheme because it lacked documentation of flushing unused showers and outlets and did not maintain records for hot water tank and circulated water temperature monitoring. An LPN also used the same glucometer for two residents without disinfecting it between uses and administered insulin without disinfecting the insulin pen tip, despite facility policies requiring disinfection after each glucometer use and swabbing the pen top before needle application.
Unsafe and Unclean Resident Environment: Surveyors found multiple environmental issues on the unit, including loose flooring, wall splatter, damaged doors and trim, a dirty CPR board, exposed subflooring, broken wall and outlet components, and a dirty mechanical lift. A resident’s room was freezing with no thermostat and vent air measured 59°F, another resident’s toilet made a loud buzzing/clicking noise audible in the room and hallway, and a third resident’s oxygen concentrator and nearby floor had sticky clear residue. Staff, including an LPN, housekeeper, MT, and the MD, verified the conditions.
Dependent residents did not receive adequate grooming and mobility assistance. One resident had long, curled toenails with no evidence of recent podiatry care, another had long fingernails and toenails with buildup and said staff never offered help, a severely cognitively impaired resident was observed lying in bed throughout multiple days without being offered transfers, and another resident had matted hair and said staff had not brushed it. CNAs and an LPN confirmed the grooming and mobility needs, and the DON/RN were unaware of the matted hair.
Pharmacy recommendations were not reviewed or addressed in a timely manner for multiple residents. One resident with pain meds lacked a current pain scale to guide use of PRN acetaminophen and oxycodone, while other residents had unresolved pharmacy requests for GDRs of psychotropic meds and continued PRN hydroxyzine use without documented rationale in the chart. The DON confirmed several recommendations were not reviewed by the physician.
Medication storage was not kept secure or consistently monitored. Refrigerator temperature logs were incomplete in two medication storage areas, and staff stated the temperatures were supposed to be checked nightly but were not monitored daily. In addition, a resident’s self-administered eyedrops were left unsecured in a basket on the bedside table, and another resident had midodrine tablets found in a dialysis binder kept in an unsecured location.
Failure to offer and document pneumococcal vaccination education and immunization status affected multiple residents. Several residents with intact cognition, and one resident with dementia and chronic respiratory failure, had pneumococcal vaccines that were not up to date; the DON confirmed there was no evidence vaccines were offered to four residents and no evidence education was provided to one resident who refused the Prevnar vaccine. The facility policy required residents or representatives to receive education before the vaccine was offered.
Failure to notify the physician and family after a resident fall. A resident with COPD, adult failure to thrive, repeated falls, and scoliosis had intact cognition but required extensive staff assistance for toileting, transfers, bed mobility, and standing. After the fall, the RN did not notify the provider, the resident's representative, hospice, or the oncoming nurse, and the DON confirmed the required notifications were not completed; the facility policy required physician and family notification after any fall.
Failure to complete fall risk and post-fall assessments: A resident with COPD, adult failure to thrive, repeated falls, and dependence for transfers and toileting was identified as a fall risk, but the facility did not complete required 90-day fall risk evaluations. After an unwitnessed fall, an RN checked VS and orientation but did not perform ROM before moving the resident, and no neuro checks or post-fall assessment were documented. The DON verified the resident was not assessed appropriately after the fall, which was linked to recent narcotic medication changes and acute confusion.
Pain medication orders and administration were not managed accurately for two residents. One resident had duplicate tramadol orders, including a three-day order that continued to be used for months, while another resident missed scheduled Percocet doses when the medication was unavailable and instead received PRN Dilaudid. The DON confirmed the duplicate tramadol orders and that the short-term order was still being used, and staff confirmed the Percocet shortage and use of Dilaudid in its place.
Inaccurate MDS assessments were completed for three residents. One resident with dementia, chronic respiratory failure, and COPD was documented as not using O2, even though she had an O2 order and was observed on a nasal cannula. Another resident with hemiplegia was assessed as having no UE ROM impairment despite being unable to use his left side. A third resident’s MDS incorrectly stated she was not on a scheduled pain regimen, although she received Percocet q4h for pain and the MAR showed it was administered daily.
Care plans were not individualized for three residents with identified needs. One resident with left-sided hemiplegia had no care plan for limited function on the left side, another resident with significant hearing difficulty and impacted ear wax had no hearing-related care area, and a third resident with chronic respiratory failure and oxygen use had no respiratory care focus area. The DON confirmed the omissions.
A resident with AKI, adjustment disorder, anxiety, IBS, CVA, and DM2 was found to have no documented quarterly care conferences and was not included in decisions about her care needs. Although her MDS indicated she participated in care planning, the resident said she was not involved, her daughter reported only one admission care conference was ever scheduled and it was cancelled, and the DON confirmed there was no evidence she had been involved in care planning. The facility policy stated the resident and/or representative would be included in the care planning process.
A resident with CHF, aphasia, AFib, impaired cognition, and significant assistance needs was identified as at risk for skin breakdown, with orders for weekly skin checks and care plan interventions for monitoring skin status. However, the EMR showed the last skin assessment was completed months earlier, and staff observed a bruise with an open area near the resident’s elbow while the DON confirmed no wound assessment had been documented and weekly skin checks had not been performed as ordered.
A resident with intact cognition and moderate hearing difficulty reported that her hearing was terrible and that she had repeatedly asked to see someone about her ears. Record review showed multiple audiology referrals for ear pain, decreased hearing, and decreased responsiveness, with repeated findings of bilateral cerumen needing removal and recommendations for MD consultation and re-evaluation after wax removal. The DON stated she was not aware of the request and the facility had no evidence the resident received assistance with ear wax removal.
Missed Ordered Pressure Ulcer Treatment: A resident with a stage IV pressure ulcer and multiple unstageable heel and ankle wounds had ordered left heel treatments omitted on several occasions. The MAR/TAR showed the wound care was not completed as ordered, and the resident reported treatments were often not done when scheduled; the DON confirmed the missed treatments.
Failure to change oxygen tubing and humidification timely for three residents receiving O2 therapy. One resident’s tubing was not dated, another resident’s tubing was two weeks old, and a third resident’s tubing was not dated and the humidification bottle was empty. An LPN confirmed the tubing should be changed weekly and as needed, and facility policy required weekly changes or changes when empty.
Incorrect Eye Drop Orders in Medical Record: A resident with CHF, respiratory disorders, HTN, and glaucoma had inaccurate eye drop orders in the chart. The eye doctor note and confirmation from Eye Care Physician Staff and the DON showed the current regimen should have been brimonidine, Xalatan, and Cosopt, but the medical record still listed other orders, including dorzolamide and rocklatan.
Failure to post daily nurse staffing data. Observation and DON interview confirmed that the required daily nurse staffing data was not posted in the facility on two consecutive days. The issue affected the facility census of 66 residents.
The facility failed to maintain adequate nursing staff and to respond promptly to resident call lights. Staffing records showed that nurse staffing fell below the facility’s minimum requirement on multiple days, and call light logs documented that dozens of residents had call lights activated for more than 30 minutes before staff responded. Several residents reported routinely waiting over 30 minutes for assistance after activating their call lights. The facility’s own policy requires timely response to call lights by any staff who see or hear them, but this was not consistently followed.
The facility failed to maintain CNA staffing levels in accordance with its own facility assessment and staffing policy, which called for a CNA-to-resident ratio of 1:15–18. On multiple overnight shifts, only two CNAs were assigned despite censuses ranging from the high 60s to low 70s, resulting in each CNA being responsible for approximately 34–36 residents. The Administrator confirmed the census counts, overnight staffing assignments, and resulting CNA-to-resident ratios, and this deficiency affected all residents in the facility.
A resident with multiple chronic conditions and intact cognition, who required maximal assistance for ADLs, developed a new large open area on the coccyx identified by a CNA during incontinence care. An RN assessed the area and applied cream, but there was no documentation that the physician was notified of this new wound, despite facility policy requiring prompt physician consultation for significant changes in condition. The physician later confirmed he had only seen coccyx redness previously and was not informed of the open wound until a later date, contrary to his expectation of same-day notification for new wounds.
Two residents who were dependent on staff for ADLs did not receive required grooming and feeding assistance. One resident with intact cognition but significant physical limitations and dependence for hygiene was observed with long, coarse facial hair and reported that staff did not assist with grooming her facial hair as often as she preferred. Another blind resident with impaired cognition, multiple comorbidities, and a care plan requiring staff assistance with eating and meal setup was observed in bed with her meal tray placed out of her view and reach, and no staff entered to assist her during the meal period. The resident stated she was unaware her lunch was present and had not been assisted, while a CNA confirmed no assistance had been provided, a housekeeper described moving the tray without seeing staff assist, and dietary staff confirmed the resident should receive assisted dining in accordance with facility policies on ADLs and meal supervision.
Surveyors found that the facility failed to implement and document ordered pressure ulcer-related treatments and prevention measures for two residents. For one resident with stage 4 pressure ulcers and lymphedema, physician-ordered Tubigrip compression stockings were not consistently documented as applied or removed as directed, despite policy requiring wound treatments to be recorded. For another resident with multiple comorbidities and high dependence for care, the care plan called for turning and repositioning and a pressure-relieving mattress, but the resident did not have the specialized mattress, staff reported that turning and repositioning were not done routinely, and there were multiple dates with no documentation that repositioning occurred.
Surveyors found that a mechanical lift used to transfer a dependent resident with lumbar spinal stenosis and impaired upper and lower extremities was missing five of six safety latches on its hooks during an observed transfer from bed to a shower bed. Two CNAs performing the transfer confirmed the latches were missing and did not know how long they had been absent. Review of the manufacturer’s manual showed staff were required to check sling attachments and hardware before each use, and facility policy called for use of a maintenance checklist to ensure a safe, functional environment, but the lift was nonetheless in use without the required safety latches.
A resident with CHF, muscle weakness, prior small bowel resection, and impaired cognition required assistance with ADLs and supervision with eating, and was care planned for nutrition/hydration risk and weight monitoring with supplements. The facility failed to obtain the resident’s scheduled monthly weight and did not identify that the resident, who had decreased appetite and moderate reduction in food intake, experienced a significant unplanned weight loss between one month and the next recorded weights. The diet technician later confirmed the weight was missed despite daily IDT meetings and that the resident frequently refused meals without staff notifying nursing or dietary, contrary to the facility’s weight monitoring policy requiring at least monthly weights and weekly weights for residents with weight loss.
A resident with multiple comorbidities, skin integrity issues, and orders for Triamcinolone cream and Nystatin powder had prescription topical medications applied by a CNA instead of a licensed nurse. The CNA, unsure of the correct application sites, relied on the resident’s directions and applied the cream and powder to various areas, including an underarm area the resident identified as psoriasis. An LPN had provided the prescription cream and powder to the CNA without clear instructions and did not assess the questioned skin area when entering the room, focusing instead on a different open area. The DON later confirmed that prescription creams and powders should be applied and assessed by nursing staff, consistent with facility medication administration policy.
A resident with impaired cognition, blindness, and multiple conditions including Type II DM, hypothyroidism, hypokalemia, and adult failure to thrive was care planned to require feeding assistance, meal setup using a clock system, and monitoring of nutritional intake. During an observed lunch meal service, meal trays were delivered on the hall and to rooms, but the resident did not receive a lunch tray over an extended period. A CNA, unfamiliar with the facility and residents, did not verify that all residents had trays, and an RN reported that the resident typically refused meals and preferred Cheerios, confirming that no lunch tray was offered.
An LPN was observed to be intoxicated while on duty, left the facility during their shift, and was reported to police by a resident. The LPN was arrested for public intoxication after exhibiting signs of impairment. Despite facility policy requiring timely reporting of such incidents, the event was not reported to the State Survey Agency. The LPN was responsible for the care of 13 residents during this time.
A nurse was reported by a resident to be intoxicated while on duty, leading to police involvement and the nurse's arrest for disorderly conduct and public intoxication. Although the nurse was responsible for the care of 13 residents during the shift, the facility only interviewed two residents and did not assess or interview all potentially affected individuals, failing to conduct a complete investigation as required by facility policy.
The facility failed to ensure timely wound assessments, prompt physician notification, and completion of ordered treatments for pressure ulcers in two residents. One resident suffered actual harm when a newly discovered wound was not assessed or treated promptly, leading to progression to a stage IV ulcer, while another resident did not receive required wound care or documentation for a stage III ulcer. The DON confirmed missed treatments and lack of documentation for both cases.
Two residents with significant ADL needs did not consistently receive scheduled showers or bed baths as ordered, with documentation and interviews confirming multiple missed bathing opportunities. Both residents required staff assistance for bathing due to medical conditions, and staff interviews verified that if bathing was not documented, it was not completed.
Two residents with complex medical conditions were not properly monitored or assessed for constipation, despite physician orders and facility protocols requiring daily monitoring and intervention after three days without a bowel movement. Documentation showed extended periods without bowel movements and no evidence that as-needed medications or assessments were provided, as confirmed by interviews with the DON and other staff.
A resident with a neurogenic bladder and chronic medical conditions had their indwelling Foley catheter removed by a nurse without a physician's order after reporting severe urinary pain. The nurse had attempted to obtain an order from urology but did not receive a response before proceeding with the removal at the resident's request. Facility protocol requires a physician's order for catheter removal, which was not obtained in this case.
Hazardous chemicals were left unsecured in various areas, allowing a resident with a history of compulsive and self-harming behaviors to access and apply these substances to his body on multiple occasions. This resulted in chemical burns, hospitalization, and serious health complications. Staff and medical records confirmed the resident's need for supervision and the facility's failure to consistently secure hazardous materials.
The facility did not address or follow up on 30 out of 75 resident grievances and multiple concerns raised during Resident Council meetings, including issues with medication administration, food quality, staffing, and care preferences. Documentation and follow-up actions were inconsistent, and interviews with the DON and Administrator confirmed that required grievance procedures were not followed.
The facility did not provide enough nursing staff to meet resident care needs, as shown by the absence of CNAs during a key shift and missing documentation of ADL care for several residents with complex medical conditions. Staff and resident interviews confirmed delays in care, unmet needs, and inadequate staffing, with the facility's own staffing ratios not being met.
Surveyors found persistent foul urine odors throughout multiple halls and the dining area, confirmed by staff and residents as a common issue. The odors were not linked to specific residents or rooms, and facility policies requiring odor control and routine cleaning were not effectively implemented.
The facility did not conduct thorough investigations for five self-reported incidents involving six residents with various medical conditions, including COPD, CHF, diabetes, stroke, and dementia. Required steps such as staff and resident interviews, assessments of similar residents, and staff education were not completed, as confirmed by the Administrator. This was not in accordance with the facility's policy on abuse, neglect, and exploitation.
Multiple residents with complex medical needs did not have proper documentation in their medical records to support that daily living care and treatments were provided as required. In several cases, care tasks and medication administrations were not recorded in the appropriate records, and two nurses were found to have falsely documented wound care as completed when it was not, without noting resident refusals.
A CNA failed to perform hand hygiene before and after delivering and setting up meal trays, handling contaminated items, and assisting multiple residents with their meals. This resulted in unsanitary meal service for eight residents, contrary to facility policy requiring hand hygiene between resident contacts and after handling contaminated objects.
A resident with dementia was the subject of an alleged abuse report made by their family to the DON, but the DON failed to notify the Administrator or initiate the required SRI process until several days later. This delay violated facility policy, which requires immediate reporting of abuse allegations to the Administrator and authorities.
A resident with multiple medical conditions was newly diagnosed with schizophrenia and exhibited increased behaviors, but the facility did not complete an updated PASRR assessment or notify the state mental health agency as required. The DON confirmed the omission, which was not in accordance with facility policy.
A resident with a right above-the-knee amputation did not receive wound care as ordered after a physician updated the treatment to twice daily Betadine application. The facility continued to provide care once daily and did not update the medical record to reflect the new order, with documentation and staff interviews confirming the discrepancy.
A resident was not seen by a provider throughout their entire admission, as confirmed by the absence of physician progress notes in the medical record. The resident was cognitively intact, and facility policy stated that residents should receive care from medical practitioners as needed.
A resident with a history of schizophrenia, paranoia, and hoarding behaviors repeatedly acquired and mixed hazardous chemicals despite requiring 24-hour supervision. Staff were aware of the ongoing behaviors but did not implement timely, individualized psychosocial interventions or update the care plan in response to escalating risks. The situation resulted in the resident sustaining chemical burns to both feet, requiring hospital and burn center treatment.
The facility failed to provide sufficient nursing staff to meet resident needs, resulting in multiple residents missing scheduled showers, baths, and assistance with eating and repositioning. Staff confirmed that care tasks were not completed due to inadequate staffing, and facility records showed consistent understaffing below identified needs and state minimum requirements. Leadership acknowledged ongoing staffing shortages despite efforts to fill shifts.
The facility did not submit required direct care staffing information to CMS for a full quarter, as shown by review of the PBJ Staffing Data Report. The Administrator confirmed the omission and stated that Human Resources was responsible for the submission, but it was not completed. This failure had the potential to affect all 68 residents in the facility.
Several dependent residents with complex medical and cognitive needs did not receive scheduled showers or feeding assistance as required by their care plans. Documentation and staff interviews confirmed that showers and baths were frequently missed, and residents were sometimes left without help during meals, primarily due to insufficient staffing and high care demands.
Surveyors found that multiple dependent residents with significant medical conditions were not repositioned or provided incontinence care as frequently as required by their care plans and physician orders. Observations and staff interviews revealed that residents remained in the same position for extended periods, sometimes exceeding four hours, and staff were often unaware of when repositioning last occurred. Documentation confirmed infrequent repositioning, and residents reported that turning and repositioning did not occur as scheduled.
Kitchen sanitation, temperature monitoring, and utensil handling deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner. During observation of the main kitchen, a thick layer of grease and buildup was seen underneath the commercial gas-range stove and fryer, and a dried brown substance was observed splattered on the kitchen ceiling. Dietary staff confirmed the buildup under the stove and fryer and stated they knew the area needed cleaning but did not know how to clean it because the stove was connected to a gas line. The dietary manager also verified the substance on the ceiling was likely food splatter. The facility also failed to properly monitor food storage and dishwashing temperatures and failed to provide a resident with sanitary eating utensils. Temperature logs for the main kitchen refrigerator, freezer, and the E-Unit refrigerator showed multiple missing entries across several days, despite staff being expected to record temperatures three times daily. Dish machine logs also showed missing temperature recordings for multiple cycles over several days. During breakfast meal service, a CNA picked up a spoon that a resident had dropped on the carpeted floor and handed it back to the resident for use with the meal; the dietary manager later verified that staff should have provided a fresh spoon instead.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to ensure measures to prevent Legionella growth were implemented according to its plan. Review of the facility's Legionella policy showed that hot and cold water services were to be operated and maintained carefully, unused showers and irregularly used outlets were to be flushed if not used within the last week, and hot water tanks and circulated water temperatures were to be monitored monthly. During interview, the Director of Facilities stated the facility did not document flushing of unused showers or outlets and did not maintain documentation of hot water tanks or circulated water flow and return temperatures. The facility also failed to properly implement infection control measures during blood glucose monitoring and insulin administration. An LPN was observed obtaining fingerstick glucose readings for two residents using the same glucometer without disinfecting it between residents, and later administering insulin to one resident without disinfecting the insulin pen tip before applying the needle. The LPN confirmed she did not disinfect the glucometer before, between, or after use and did not disinfect the insulin pen tip prior to needle application, despite facility policies stating glucometers are to be disinfected after each use and insulin pen tops are to be swabbed for 15 seconds before applying the needle.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide residents with a clean, comfortable, and homelike environment on the C-Unit. During observations and interviews, surveyors found multiple flooring planks near the nursing station coming up, dried brown splatter along a wall near the end of the unit, and a soiled utility room door with worn tape, buildup, scrapes, chipped paint, and dried brown splatter. The environmental tour also identified a dirty CPR board with chipped wood and missing paint, missing transition strips in several resident room entrances exposing subflooring, a cracked and crumbling wall area behind one resident’s bed, a cracked and broken wheel used to prevent wall damage, a partially detached outlet box with a broken cover, dried brown substance near the outlet, scrapes inside a shared bathroom, a chipped-paint mechanical lift, and a loose and broken transition strip between a resident room and bathroom. The Maintenance Director verified these concerns. Resident #11’s room was observed to be noticeably cold, and the room had no thermostat. The resident responded negatively when asked about the temperature and was covered with three fleece blankets. An LPN later verified the room was freezing and that the resident was probably cold. The Maintenance Director used an infrared thermometer and found the air coming from the three ceiling vents in the room measured 59 degrees Fahrenheit, and also verified the room was too cold. Resident #12’s bathroom toilet was observed making a loud buzzing noise that could be heard in the resident’s room and in the hallway outside the room. The resident said he was unsure how long the noise had been present. A housekeeper and a maintenance technician both verified the toilet noise, with the technician noting that flushing caused a loud repetitive clicking noise. In Resident #22’s room, the oxygen concentrator had clear sticky drip marks down the front and the floor near the bedside was sticky; an LPN and later a CNA both confirmed the condition. Resident #22’s record showed diagnoses including dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and COPD, and the quarterly MDS indicated she was cognitively impaired, dependent for most ADLs, and required maximal assistance with mobility.
Failure to Provide Adequate Grooming and Mobility Assistance
Penalty
Summary
The facility failed to ensure dependent residents received adequate grooming and mobility assistance. Review of records, observations, and staff interviews showed that Resident #3, who was cognitively intact and dependent on staff for all ADLs, had no evidence of toenail care since August 2025. On observation, the resident was lying in bed with uncovered feet, and the toenails were long, extending past the tips of the toes and several were curled. The resident stated staff were supposed to trim the toenails but did not, while a CNA confirmed the nails were long and needed trimming. An LPN stated all residents had their toenails trimmed by a podiatrist, but the LSW reported there was no evidence the resident had been seen by podiatry since August 2025. Resident #23, who was cognitively intact but required assistance with personal hygiene and had care plans addressing fragile skin, decreased mobility, hemiplegia, and muscle weakness, also had no evidence of staff assistance with fingernail or toenail trimming. The resident was observed in a wheelchair with long fingernails on the right hand extending past the fingertips and with dark brown buildup underneath them. The resident stated he was unable to trim the nails because he was paralyzed on the left side and wanted help, but staff had never offered. Later observation showed long, sharp toenails extending past the toes, and the resident again stated he wanted them trimmed but could not reach them. A CNA and LPN verified the nails were long and needed trimming, while the LSW stated the resident had never been seen by the podiatrist since admission. Resident #37, who was severely cognitively impaired and dependent on staff for transfers, had a care plan calling for assistance with all transfers and use of a Hoyer lift with two staff. Random intermittent observations over multiple days showed the resident lying in bed throughout the day. A CNA who worked on those days stated staff had not offered to get the resident up and out of bed, although the resident did like to get up sometimes. Resident #20, who had intact cognition and required substantial to maximal assistance with personal hygiene and was dependent on staff for bathing, was observed lying in bed with matted hair and stated she could not remember the last time staff attempted to brush it. The resident’s hair extended below the shoulders and appeared matted in the back. A CNA confirmed the hair was matted and stated it was difficult to brush because the resident stayed in bed, while the resident later stated the staff gave up. The DON and an RN stated they were unaware the resident’s hair was matted.
Pharmacy Recommendations Not Reviewed or Addressed Timely
Penalty
Summary
The facility failed to ensure monthly pharmacist drug regimen reviews were acted on in a timely manner and that pharmacy recommendations were reviewed and addressed by the physician. Medical record review, pharmacy documents, staff interviews, and review of the facility policy showed that non-emergent pharmacy recommendations were not presented to the physician and addressed by the end of the following month as required by the facility policy. For one resident with diagnoses including muscle weakness, heart failure, seizures, dysphagia, and glaucoma, the pharmacist repeatedly noted that the resident was receiving acetaminophen and oxycodone as needed for pain without a current pain scale in the directions to guide selection between the medications. Recommendations were made on multiple monthly reviews to consider adding parameters for consistent pain control, but the recommendations were not reviewed or signed by the physician. The DON confirmed there was no evidence these recommendations were reviewed or signed. For other residents, pharmacy recommendations were also not addressed. One resident with ESRD, hemiplegia, diabetes, PVD, anxiety, and depression had pharmacy requests for the physician to initiate or decline gradual dose reduction of trazodone and paroxetine, but no action was taken to have them reviewed. Another resident with COPD, diabetes, depression, anxiety, heart failure, and chronic ulcer had pharmacy requests for gradual dose reduction of Ambien, Buspar, and sertraline, but these were also not reviewed by the physician. A third resident with depression, insomnia, anxiety, and psychosis received hydroxyzine HCl PRN for anxiety, and pharmacy notes repeatedly asked for evaluation of continued need and documentation of rationale and duration; although handwritten responses later appeared on the forms, the resident’s medical record did not include any rationale for continued use, and the DON confirmed this.
Medication Storage and Security Failures
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secured manner. During observation of the medication refrigerator in the rehabilitation unit storage room, the refrigerator temperature log for May 2026 was incomplete on 05/02/26, 05/03/26, 05/06/26, and 05/08/26. Observation of the medication refrigerator at the A-hall nurse station showed the temperature log for February 2026 was incomplete for all days except 02/05/26, 02/08/26, 02/14/26, 02/22/26, 02/23/26, and 02/24/26. LPNs stated the refrigerator temperatures were supposed to be obtained each night on third shift, and the DON stated none of the medication refrigerator temperatures were monitored daily to ensure consistent and optimal temperatures. The facility also failed to secure medications at the bedside and in a resident binder. One resident had brimonidine, Xalatan, and Cosopt eyedrops in an unsecured basket on the bedside table, and the LPN confirmed the eyedrops were typically kept in the room because they were ordered for self-administration. The DON confirmed the eyedrops should not have been unsecured at the bedside. Another resident had three white round pills identified as midodrine 10 mg tablets in the sleeve protector of a dialysis binder located in the pocket on the back of the wheelchair; the LPN confirmed the finding and stated the binder was typically kept in an unsecured bookshelf at the nurse station and that pills were not uncommon in the binder. Facility policy required medications to be stored in a locked compartment, and bedside storage only when a physician order was present and access by other residents was prevented.
Failure to Offer and Educate Residents on Pneumococcal Vaccination
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received education and were offered pneumococcal vaccines in a timely manner to maintain vaccination status. This affected five of seven residents reviewed for vaccinations in a census of 66. Resident #14, admitted with cardiomyopathy, hypertension, and left ventricular failure, had intact cognition on the annual MDS, but his pneumococcal immunizations were not up to date. Resident #18, admitted with acute kidney injury, adjustment disorder, anxiety, irritable bowel syndrome, cerebral infarction, and type 2 diabetes mellitus, was cognitively intact and did not refuse care, but the record showed she refused the Prevnar pneumococcal vaccine and there was no evidence education had been provided to her. Resident #22, who had dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and COPD, was cognitively impaired, dependent for a majority of ADLs, and had chronic lung disease with respiratory failure, yet her pneumococcal immunizations were not up to date. Resident #27, admitted with COPD, adult failure to thrive, repeated falls, and scoliosis, had intact cognition and required substantial to maximal assistance for personal hygiene and was dependent for toileting, transfers, bed mobility, and moving from sitting to standing, but her pneumococcal immunizations were not up to date. Resident #57, admitted with CHF, chronic lymphocytic leukemia of B-cell type, and malignant neoplasm of the left breast, had intact cognition and her pneumococcal immunizations were not up to date. The DON confirmed the facility could provide no evidence that pneumococcal vaccines were offered to Residents #14, #22, #27, and #57, and confirmed there was no evidence Resident #18 received education regarding the pneumococcal vaccine. The facility policy stated each resident would be offered pneumococcal immunization unless contraindicated or already immunized, and that education on benefits and potential side effects would be provided before offering the immunization.
Failure to Notify Physician and Family After a Resident Fall
Penalty
Summary
The facility failed to make proper notifications after a fall involving Resident #27. Resident #27 was admitted on 10/25/24 with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, and scoliosis. The annual MDS dated 03/24/26 showed intact cognition and dependence on staff for toileting, transfers, bed mobility, and moving from sitting to standing. A nursing progress note dated 04/08/26 documented that the resident's daughter came to the facility asking about the details of a fall that neither she nor hospice had been notified about, and the fall investigation contained no indication that the resident's representative was notified. During interview, RN #167 stated she was the nurse on duty during the resident's fall on 04/07/26 and confirmed she did not notify the provider or the resident's representative of the fall. She also stated she did not tell the oncoming nurse about the fall because there were many things going on that night. The DON confirmed that notifications should have been made regarding the fall and that timely notifications were not completed. The facility policy titled Fall Prevention Program stated that the physician and family will be notified after any resident experiences a fall.
Failure to complete fall risk and post-fall assessments
Penalty
Summary
The facility failed to ensure a resident was assessed for fall risk and properly assessed after an unwitnessed fall. Resident #27 was admitted with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, and scoliosis. The annual MDS showed intact cognition and extensive dependence for toileting, transfers, bed mobility, and moving from sitting to standing. A fall risk evaluation dated 06/02/25 identified the resident as at risk for falls, but the DON later confirmed that fall risk evaluations were not completed every 90 days as required by policy. After an unwitnessed fall on 04/07/26, RN #167 reported checking vital signs and orientation, but did not perform range of motion before moving the resident from the floor to the bed and did not initiate neurological checks because the resident answered orientation questions appropriately. Review of the electronic medical record showed no evidence that neurological checks or a fall assessment were completed after the fall. The DON verified the resident was not assessed appropriately after the fall and confirmed the fall investigation identified recent medication changes, including missed Percocet doses and receipt of Dilaudid, resulting in acute confusion leading to the fall.
Pain Medication Orders and Administration Errors
Penalty
Summary
The facility failed to ensure accurate orders for and administration of pain medications for two residents reviewed for pain management. For one resident, the medical record showed diagnoses including acute kidney injury, adjustment disorder, anxiety, irritable bowel syndrome, cerebral infarction, and type 2 diabetes mellitus. Her MDS indicated she was cognitively intact and reported her worst pain as 8 out of 10, with pain occasionally interfering with daily activities and sleep. The record showed duplicate active tramadol orders at the same time, including one order written for only three days that continued to be used for medication administration over multiple months. Medication administration records showed tramadol was given on multiple dates from December 2025 through May 2026 under the three-day order, as well as under the other active tramadol order. The DON confirmed there were two active tramadol orders from 10/22/25 through 02/25/26 and confirmed the three-day order was still being used to administer tramadol. The facility policy stated medications would be administered as ordered by the physician. For the second resident, the record showed diagnoses including COPD, adult failure to thrive, repeated falls, and scoliosis. The annual MDS showed intact cognition and dependence for multiple ADLs. The physician orders included Percocet 10-325 mg every four hours for pain and Dilaudid oral liquid 1 mg/ml, 3 ml every two hours as needed for pain. On one day in April 2026, five scheduled Percocet doses were not given because the medication was not available, and the resident instead received four doses of Dilaudid. Staff interviews confirmed Percocet was not ordered by facility staff and was not available, and hospice staff had told nursing staff to use Dilaudid until Percocet was delivered. The DON stated the Dilaudid was not given every four hours because the order did not specifically say to give it that way, and it was intended to be used as needed until Percocet was replaced.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for three residents. For one resident with dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and COPD, the quarterly MDS stated she was cognitively impaired, had no behaviors or refusals of care, and did not use oxygen, even though a physician order dated 05/29/20 directed oxygen at 2 liters per minute and survey observation found her in bed wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at 3 liters per minute. The DON confirmed the resident used oxygen and that the MDS was incorrect. For another resident with hemiplegia affecting the left nondominant side, muscle weakness, anxiety disorder, and need for assistance with personal care, the admission, Medicare five-day, and quarterly MDS assessments all indicated no impairment causing functional limitation in range of motion of the upper extremities. However, interview and observation showed the resident was unable to move or use his left upper and lower extremities, and the DON verified the assessments incorrectly stated there was no upper extremity impairment. For a third resident with COPD, adult failure to thrive, repeated falls, and scoliosis, the annual MDS stated she was not on a scheduled pain regimen and that no pain assessment was completed, despite current physician orders for Percocet 10-325 mg every four hours for pain and MAR documentation showing the medication was given every four hours daily; the DON confirmed the MDS was completed incorrectly regarding the scheduled pain regimen.
Care plans did not address residents’ identified needs
Penalty
Summary
The facility failed to ensure care plans were implemented to include person-centered needs and interventions for three residents. Resident #23 was admitted with diagnoses including hemiplegia affecting the left nondominant side, muscle weakness, anxiety disorder, and need for assistance with personal care. The quarterly MDS showed the resident was cognitively intact and needed setup or cleanup assistance with personal hygiene, and during interview and observation the resident was unable to move or use the left upper and lower extremities. Review of the current plan of care showed no care plan or interventions addressing the resident’s limitations on the left side, and the DON verified this omission. Resident #30 was admitted with diagnoses including atrial fibrillation, COPD, morbid obesity, depression, and muscle weakness. The quarterly MDS showed intact cognition and moderate hearing difficulty without use of a hearing aid, while observation and interview showed the resident lying in bed and stating her hearing was terrible and that she had repeatedly asked to see someone about her ears. Audiology assessments noted hearing could not be assessed because of wax in both ears, and the DON stated the audiologist had seen another resident, not Resident #30, and the facility could provide no evidence of ear wax removal since the earlier assessment. Resident #33 was admitted with diagnoses including atherosclerotic heart disease, atrial fibrillation, chronic respiratory failure with hypoxia and hypercapnia, and emphysema. The admission MDS showed she was cognitively intact, used a wheelchair, required maximal assistance with ADLs, and needed oxygen therapy, but her current care plan had no respiratory care focus area. Observation showed her in bed wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at seven liters per minute, and the DON confirmed there was no respiratory care plan.
Missed Care Conferences and Resident Exclusion From Care Planning
Penalty
Summary
The facility failed to ensure quarterly care conferences were completed and that the resident was included in her care planning process. Resident #18 was admitted with diagnoses including acute kidney injury, adjustment disorder, need for assistance with personal care, anxiety, irritable bowel syndrome, cerebral infarction, and type 2 diabetes mellitus. Her quarterly MDS assessment indicated she was cognitively intact, did not display behaviors, did not refuse care, and participated in her care planning, but the resident later stated in interview that she was not included in decisions made regarding her care needs. Review of the record showed no progress note documentation indicating care conferences had been conducted from 12/13/24 through 05/20/26. A social services note documented that the resident’s daughter was contacted to schedule a care conference, and the daughter reported that only one care conference had been scheduled when the resident was admitted, but it was cancelled because several team members were unable to attend. She further stated no other care conferences were scheduled until she was contacted by the facility social worker. The DON confirmed there was no evidence that the resident had been involved with planning for her care needs. The facility policy stated the resident and/or resident representative would be included in the care planning process.
Failure to Complete Ordered Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed as ordered for Resident #53 to assess for new wounds. Resident #53 was admitted on 06/11/25 and readmitted on 10/31/25, with diagnoses including congestive heart failure, aphasia, need for assistance with personal care, and atrial fibrillation. The quarterly MDS dated 04/30/26 showed impaired cognition and significant assistance needs for bed mobility, transfers, and toileting, and also indicated no skin breakdown. The care plan identified the resident as at risk for skin breakdown due to immobility, incontinence, and fragile skin, and included weekly skin checks as an intervention. A physician order dated 04/08/26 directed weekly skin assessments every Wednesday on first shift. Review of the electronic medical record on 05/18/26 showed the most recent weekly skin assessment had been completed on 03/19/26. During observation on 05/17/26, the resident was seen sitting up in bed with a circular bruise near the left elbow measuring about three to four inches in diameter, with an open area of skin near the center that appeared about one-fourth inch long. The DON stated she believed she had been told the resident bumped her arm, but could not recall when or by whom, and confirmed no assessment of the wound had been documented at the time of interview and that weekly skin checks had not been performed since 03/19/26. The facility policy stated that a full body skin assessment would be conducted upon admission/re-admission and weekly thereafter.
Failure to Provide Ear Wax Removal and Hearing Services
Penalty
Summary
The facility failed to ensure Resident #30 received adequate ear care to facilitate hearing. Resident #30 was admitted with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, morbid obesity, depression, and muscle weakness. The quarterly MDS dated 02/12/26 indicated the resident had intact cognition, moderate difficulty hearing, and did not use a hearing aid. During observation and interview on 05/17/26, the resident was lying in bed and stated her hearing was terrible and that she had asked many times to see someone about her ears. Medical record review showed audiology assessments on 07/06/22, 09/26/23, and 09/23/24 related to hearing concerns, ear pain, and decreased responsiveness/decreased hearing. Each review identified bilateral ear wax needing removal, and recommendations included medical doctor consultation for wax removal with re-evaluation after removal. One assessment noted no assessment was completed. The DON stated on 05/19/26 that she was not aware of a request by Resident #30 to see the audiologist, and on 05/20/26 stated the facility could provide no evidence that Resident #30 received assistance with ear wax removal since 07/06/22. The facility policy stated it was to ensure all residents had access to hearing and vision services.
Missed Ordered Treatment for Pressure Ulcer
Penalty
Summary
Failure to provide pressure ulcer care occurred for Resident #31, who was admitted with diagnoses including a stage four pressure ulcer, need for assistance with personal care, muscle weakness, hypertension, and osteomyelitis of the left ankle and foot. The quarterly MDS showed the resident was cognitively intact and dependent on staff for activities of daily living. The care plan, last revised 10/29/25, identified four unstageable pressure ulcers on the bilateral heels and ankles and directed staff to provide treatments as ordered. Physician orders for the left heel included wound cleansing and dressing treatments, first with moistened gauze, medical honey, iodoform packing, abdominal pad, Kerlix, double-layer tubi-grip, and all cotton elastic wrap, and later with moistened gauze, alginate, abdominal pad, Kerlix, double-layer tubi-grip, and all cotton elastic wrap. Review of the treatment administration record for 05/01/26 through 05/21/26 showed the left heel treatment was not completed on 05/01/26, 05/06/26, and 05/20/26. The resident stated his wound treatments were often not completed when they were supposed to be, and the DON verified that the treatments were not completed in accordance with physician orders on those dates.
Failure to Change Oxygen Tubing and Humidification Timely
Penalty
Summary
The facility failed to ensure oxygen tubing and humidification were changed timely for three residents receiving respiratory care. Resident #22 had diagnoses including dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and COPD, and was observed resting in bed on oxygen at 3 L/min by nasal cannula. Her oxygen tubing was not labeled with the date it had been initiated, and an LPN confirmed it was not labeled and should be changed weekly and as needed. Resident #33 had diagnoses including atherosclerotic heart disease, atrial fibrillation, chronic respiratory failure with hypoxia and hypercapnia, and emphysema, and was observed resting in bed on oxygen at 7 L/min by nasal cannula. Her oxygen tubing was dated two weeks earlier, and an LPN confirmed it was two weeks old and should be changed weekly and as needed. Resident #51 had diagnoses including neurogenic bladder, a stage four pressure ulcer, pulmonary hypertension, chronic respiratory failure, and malignant neoplasm of the lung, and was observed resting in bed on oxygen at 5 L/min by nasal cannula. Her oxygen tubing was not labeled with the initiation date, and the humidification bottle on the concentrator was empty; an LPN confirmed the bottle was empty and the tubing was not labeled. The facility policy stated oxygen tubing and humidification bottles were to be changed weekly or as needed when empty.
Incorrect Eye Drop Orders in Medical Record
Penalty
Summary
The facility failed to ensure accurate medication orders were maintained in the medical record for one resident. Resident #57 was admitted with diagnoses including congestive heart failure, respiratory disorders, hypertension, and glaucoma, and her quarterly MDS showed she was cognitively intact, had no behaviors or refusals of care, used a wheelchair, and required partial to maximal assistance with ADLs, with dependence for transfers and mobility. Review of active physician orders showed brimonidine tartrate ophthalmic solution 0.2%, dorzolamide hydrochloride ophthalmic solution, rocklatan ophthalmic solution 0.02-0.005%, and Xalatan ophthalmic solution 0.002%. However, the resident’s eye doctor note from the most recent appointment documented orders to continue brimonidine and Xalatan, discontinue dorzolamide hydrochloride, and start Cosopt ophthalmic solution. Eye Care Physician Staff #231 confirmed the current eye drop regimen should be brimonidine, Xalatan, and Cosopt, and the DON also confirmed the medical record orders were incorrect.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post the daily nurse staffing data as required. Observation on 05/17/26 and 05/18/26 at random times showed that the daily nurse staffing data was not posted in the facility. During an interview on 05/18/26 at 4:45 P.M., the DON confirmed that the daily nurse staffing data had not been posted on either day. The facility census was 66 residents.
Insufficient Staffing and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs and to ensure timely response to call lights. Review of the facility’s staffing tool showed that staffing levels fell below the Minimum Staffing Requirement on three identified dates. Review of call light system logs for a four-day period showed that 42 residents had call lights that remained activated and unanswered for 30 minutes or longer before staff responded. The facility’s own policy, dated 12/01/25, states that call lights will relay to staff or a centralized location to ensure appropriate response and that all staff who see or hear an activated call light are responsible for responding or notifying appropriate personnel. Multiple resident interviews corroborated the call light data, with several residents reporting that call lights were not responded to in a timely manner and that they often waited more than 30 minutes for a response. These interviews occurred over two days and consistently described prolonged wait times for assistance. The Administrator confirmed that staffing fell below the Minimum Staffing Requirement on the identified dates, and an RN confirmed that 42 residents had call lights unanswered for 30 minutes or longer during the reviewed period. This deficiency was investigated under Complaint Number 2743940.
Failure to Maintain CNA Staffing Levels per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a manner that ensured adequate staffing in accordance with its own facility assessment and staffing policy. The facility assessment dated 11/15/25 specified that CNAs would be staffed at a ratio of one CNA to every 15 to 18 residents. The facility’s written staffing policy dated 11/05/25 stated that there shall be a sufficient number of trained staff members on duty to ensure each resident’s physical, social, and emotional health, care, and safety needs are met in accordance with their individualized care plans, and that staffing levels would be based on day-to-day resident needs, activity, and intensity of staff assistance. Surveyor review of census and overnight staffing records showed that on three consecutive nights the facility did not meet its stated CNA staffing ratios. With a census of 69 residents, only two CNAs were on duty, resulting in each CNA being responsible for 34.5 residents. On the following night, with a census of 70 residents, two CNAs were again assigned, resulting in each CNA being responsible for 35 residents. On the third night, with a census of 71 residents, two CNAs were assigned, resulting in each CNA being responsible for 35.5 residents. The Administrator confirmed the overnight census numbers, the number of CNAs assigned on those nights, and the calculated CNA-to-resident ratios. This failure affected all residents in the facility, with a reported census of 71 residents at the time of the survey.
Failure to Promptly Notify Physician of New Coccyx Wound
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a resident’s change in condition, specifically the development of a new open skin area on the coccyx. The resident was admitted with multiple diagnoses including COPD, cardiac arrhythmia, OSA, CHF, lymphedema, RA, atherosclerotic heart disease, HTN, morbid obesity, major depressive disorder, and anxiety. A recent quarterly MDS showed a BIMS score of 13, indicating relatively intact cognition, and documented that the resident had unilateral upper extremity impairment and required maximal assistance for hygiene, toileting, rolling, and transferring. The most recent skin assessment dated 02/11/26 documented no skin impairments. On 02/18/26, during incontinence care, a CNA observed a large open area on the resident’s coccyx and notified an RN, who assessed the area and applied a cream. The CNA confirmed this was a new skin impairment. Review of the medical record the following day showed no documentation that the physician had been notified of this new wound. The RN who completed the 02/11/26 skin assessment confirmed there were no skin impairments at that time. The physician reported that when he last saw the resident on 02/11/26, the coccyx was reddened but not open, and he confirmed he was not notified of the new wound until 02/19/26, stating his expectation that new wounds be reported the same day they are discovered. Facility policy titled “Notification of Change” required prompt consultation with the resident’s physician when there was a significant change in condition, including deterioration in health, which was not followed in this instance.
Failure to Provide Required Grooming and Feeding Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance with grooming and feeding to residents who were dependent on staff. One resident with multiple diagnoses including COPD, cardiac arrhythmia, generalized muscle weakness, osteoarthritis, OSA, CHF, lymphedema, RA, atherosclerotic heart disease, HTN, morbid obesity, major depressive disorder, and anxiety had a quarterly MDS showing relatively intact cognition (BIMS 13) but unilateral upper extremity impairment and dependence or need for maximal assistance with all functional abilities, including hygiene. During observation, this resident was noted to have multiple long, coarse hairs on her chin and upper lip. In a concurrent interview, she stated the facility did not assist her with grooming her facial hair as much as she liked and that it bothered her when the hair was long enough to be visible. A CNA later verified the presence of the long, coarse facial hair. Another resident, admitted with diagnoses including Type II diabetes mellitus, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder, had a quarterly MDS indicating impaired cognition (BIMS 8) and a need for assistance with meals and dependence on staff for ADL care. The care plan documented an ADL self-care performance deficit related to impaired vision and arthritis, with interventions for staff to assist with eating, encourage self-feeding if possible, and use a clock system to describe plate setup because the resident was blind. The care plan also identified risk for nutrition and hydration deficits related to multiple conditions and diuretic use, with interventions including providing ordered supplements and monitoring intake and weight. The facility’s assisted dining list also identified this resident as requiring assistance with eating. During a lunch observation period, this blind resident was in bed on her right side with the head of the bed elevated, while her meal tray was placed on the left side of the bed, out of her line of sight, and an additional tray with milk, a nutritional supplement, and a fruit cup was left on a chair near the door. No staff entered the room to assist her with eating during the observation. The resident reported she was not aware her lunch was on the bedside table and that no staff had been in to assist her. A CNA confirmed the resident had not been assisted to eat and acknowledged she had not been in the room and did not know who had set up the tray. A housekeeper reported moving the tray from the chair to the bedside table after noticing it, and stated she did not see staff assisting the resident and tried to help when she could. A dietary technician confirmed the resident should be assisted at meals and offered the facility meal, with an alternative if refused. These events occurred despite facility policies stating that residents unable to carry out ADLs would receive necessary services for grooming and that staff would supervise and assist with meals, including arranging trays so residents could reach items and opening containers.
Failure to Implement and Document Pressure Ulcer Treatments and Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer-related treatments and to implement documented pressure ulcer prevention interventions. For one resident with multiple serious conditions including osteomyelitis, stage 4 pressure ulcers, cellulitis, lymphedema, neuropathy, and a non-pressure chronic ulcer, the physician ordered Tubigrip compression stockings with specific instructions for application and removal. Review of the Treatment Administration Record over several months showed multiple dates on which there was no documentation that the Tubigrips were applied as ordered, and additional dates with no documentation that they were removed at bedtime as ordered. An RN confirmed the lack of documentation for both the application and removal of the Tubigrips on the identified dates, despite facility policy requiring that wound treatments be documented on the TAR or in the electronic health record. The deficiency also includes failure to implement and document pressure ulcer prevention measures for another resident with multiple comorbidities such as COPD, cardiac arrhythmia, CHF, lymphedema, RA, morbid obesity, and mental health diagnoses, who required maximal assistance for mobility and self-care. The resident’s care plan called for assistance with turning and repositioning and the use of a pressure-relieving mattress. Observation showed the resident did not have a pressure-relieving mattress on the bed, and nursing staff confirmed its absence. Staff also reported that the resident was not turned and repositioned every two hours or routinely, and record review revealed multiple dates with no documentation that turning and repositioning occurred. Facility policy stated that turning and repositioning would be implemented as part of a systemic approach to pressure injury prevention and that the frequency would be documented in the plan of care.
Mechanical Lift Used for Dependent Resident with Missing Safety Latches
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a mechanical lift in safe working condition and to ensure the environment was free from accident hazards. One resident, admitted with lumbar spinal stenosis and documented as cognitively intact with a BIMS score of 15, was assessed as having impaired upper and lower extremities bilaterally and being dependent for all functional abilities, including toileting, bathing, dressing, hygiene, turning/repositioning, and transferring. During an observation of incontinence care and a transfer from bed to a shower bed using a mechanical lift, surveyors noted that five of the six safety latches on the lift hooks were missing. During the same observation, the two CNAs performing the transfer confirmed that five of the six safety latches were missing and were unable to state how long the latches had been absent. Review of the mechanical lift manufacturer’s user manual showed that staff were required to check all sling attachments and hardware each time the lift was used to ensure proper connection and patient safety. Additionally, review of the facility’s Maintenance Inspection policy indicated the facility would use a maintenance checklist to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Despite these requirements, the lift was in use with missing safety latches at the time of the observed transfer.
Failure to Obtain Monthly Weight Resulting in Unrecognized Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to obtain a required monthly weight for a cognitively impaired resident with multiple medical conditions, resulting in an unrecognized, significant unplanned weight loss. The resident had diagnoses including unspecified systolic congestive heart failure, muscle weakness, and unspecified intestinal obstruction, and required a wheelchair for mobility, supervision or touching assistance with eating, and substantial assistance with ADLs. The care plan identified self-care performance deficits related to limited mobility, anemia, cognitive communication impairment, polyneuropathy, hypotension, and congestive heart failure, and included interventions such as setting up meal trays, encouraging self-feeding, offering assistance or finger foods, opening and cutting food, and notifying the nurse if the resident was not eating. The care plan also identified risk for nutrition and hydration deficits related to a recent small bowel resection and planned significant weight gain, with interventions including weighing as ordered, providing supplements as ordered, and monitoring for signs and symptoms of malnutrition and significant weight loss. Despite these identified risks and interventions, the medical record showed that the resident’s weight was recorded as 142 lbs in early December, but no weight was obtained in January, contrary to the facility’s weight monitoring policy that required monthly weights for all residents and weekly weights for residents with weight loss. Subsequent weights in early February showed a drop to 123.6 lbs and then 121.4 lbs. A dietician progress note documented that the resident reported decreased appetite, had a moderate decrease in food intake over the prior three months, was receiving Ensure daily and was receptive to increasing it to twice a day, and had a mini nutrition score indicating malnutrition, with a notation that no January weight was recorded. In an interview, the diet technician confirmed the resident had a significant weight loss, should have been weighed weekly, and was not weighed in January, stating the missed weight must have been overlooked during daily interdisciplinary team meetings and acknowledging that the resident frequently refused to eat and that staff should have notified nursing or the diet technician if the resident was refusing meals.
Unlicensed Staff Applied Prescription Topical Medications Without Nurse Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that prescription topical treatments were administered by a licensed nurse, as required by facility policy and professional standards. A cognitively intact resident with cerebral palsy, osteoarthritis, morbid obesity, a break in skin integrity, and risk for skin breakdown had physician orders for Triamcinolone Acetonide 0.1% cream to the shoulders and thighs twice daily for psoriasis, and Nystatin powder to the thighs and under the breasts twice daily for fungus. The resident’s care plan included treatments as ordered and weekly skin checks, as well as interventions for ADL self-care deficits and transfers with a mechanical lift and two-person assist. On observation, a CNA was seen performing ADL care and applying a cream from a four-ounce cup and powder to the resident’s under-breast area and bilateral thighs. The CNA was unsure where the prescription cream should be applied and relied on the resident’s directions, including application to the left armpit, which the resident identified as an area of psoriasis. The CNA questioned whether the area was psoriasis, stating it looked like a pimple. Shortly afterward, an LPN entered the room; the CNA asked if the left armpit area was psoriasis, and the LPN did not respond. The LPN measured and treated a new open area on the resident’s abdominal fold but did not assess the left armpit area. Interviews confirmed that the nurse had given the prescription Triamcinolone cream and Nystatin powder to the CNA to apply, that the CNA was unsure of the correct application sites, and that the LPN was uncertain whether CNAs should be applying prescription creams and powders and had not instructed the CNA on where to apply them. The DON confirmed that nurses should be applying prescription creams and powders and observing and charting on areas of concern, and that the LPN should have assessed the left armpit area. Facility policy stated that medications are to be administered by licensed nurses or other staff legally authorized to do so.
Failure to Provide Ordered Lunch Meal to Dependent, Visually Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a nourishing, palatable, well‑balanced diet that met the resident’s nutritional needs. The resident had multiple diagnoses including Type II DM, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder, and was blind with impaired cognition (BIMS score of eight). The care plan documented ADL self‑care performance deficits related to impaired vision and arthritis, required staff assistance with meals, and specified that staff should help the resident eat, encourage self‑feeding when possible, and use the clock system to describe plate setup. The resident was also care planned as being at risk for nutrition and hydration deficits due to multiple medical conditions and diuretic use, with interventions including providing ordered supplements and monitoring intake and weight. Facility documentation identified the resident as requiring feeding assistance. On the observed lunch meal service date, surveyors noted that the resident was in her room at 11:39 A.M. with no meal tray present. Hall trays were delivered to the hallway at 11:52 A.M., and to resident rooms by 11:58 A.M., yet from 12:02 P.M. through 12:40 P.M. the resident still did not have a lunch tray. A CNA interviewed at 12:45 P.M. stated she was unaware the resident had not received a lunch tray, explained she was unfamiliar with the residents and the facility’s lunch tray process because it was her first time in the facility, and confirmed she did not check to ensure all residents had their lunch trays. An RN interviewed at 12:49 P.M. stated the resident always refuses meals and was not offered a tray because the resident likes Cheerios, further stating the resident would not allow a plate to sit on the tray table and again confirming that lunch was not offered to the resident.
Failure to Report Alleged Neglect by Impaired Nurse
Penalty
Summary
The facility failed to report an allegation of neglect involving a nurse to the State Survey Agency, Ohio Department of Health, as required by policy. On the night in question, an LPN arrived for work, received report, and then left the facility with another LPN and a CNA to go to a gas station, returning after approximately 15 minutes. During this shift, a resident called 9-1-1 to report that the nurse was intoxicated and smelled of alcohol. Upon police arrival, the LPN exhibited signs of impairment, including glossy eyes and slurred speech, and was subsequently arrested for disorderly conduct due to public intoxication. The police requested that the RN on duty contact a supervisor, and administrative staff were notified. Despite the incident and the facility's policy requiring all alleged violations to be reported to the Administrator, state agency, and other required agencies within specified timeframes, the facility did not file a Self-Reported Incident (SRI) for this event. Staff interviews confirmed that the CNA observed the LPN's intoxication and attempted to notify the Administrator and RN on duty. The LPN was responsible for 13 residents during the shift in question. The failure to report the allegation of neglect as required constitutes the identified deficiency.
Failure to Thoroughly Investigate Alleged Resident Neglect by Impaired Nurse
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into possible resident neglect by a nurse who was reported to be intoxicated while on duty. On the night in question, a resident called 9-1-1 to report that her nurse was intoxicated and smelled of alcohol. Police arrived and observed the LPN with glossy eyes, slurred and abnormal speech, and behaving in a disorderly manner, including speaking loudly and using vulgar language in front of residents. The LPN was subsequently arrested for disorderly conduct and public intoxication. Facility records showed that the LPN was responsible for the care of 13 residents during this shift. Despite the seriousness of the allegations and the facility's policy requiring immediate and thorough investigation of suspected neglect, the facility only interviewed two residents and did not assess or interview all 13 residents assigned to the LPN. The Director of Nursing reviewed medical records and medication administration records for these residents and determined that no medication or care had been provided by the LPN during the shift. However, the lack of direct assessment or interviews with all potentially affected residents constituted a failure to follow the facility's own investigative procedures.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide adequate and timely pressure ulcer care for two residents, resulting in actual harm to one. For a resident with multiple comorbidities including diabetes and peripheral vascular disease, staff did not promptly assess a newly discovered open wound, nor did they notify the physician or obtain treatment orders in a timely manner. The wound was left unaddressed for several days, during which time it increased in size and severity, eventually being classified as a stage IV pressure ulcer. Even after wound care orders were obtained, staff did not consistently perform the ordered treatments, as evidenced by multiple missed dressing changes documented in the treatment administration records. Another resident, who was at high risk for skin breakdown and required total care, also did not receive timely wound assessments or treatments as ordered for a stage III pressure ulcer. There was a lack of documentation regarding wound assessments, measurements, and descriptions, and several ordered dressing changes were not completed. The facility's own policy required prompt physician notification and adherence to treatment orders, but these procedures were not followed for either resident. Interviews with the Director of Nursing confirmed the absence of required documentation and the failure to complete wound care treatments as ordered. The deficiencies affected two of three residents reviewed for pressure ulcers, with one resident experiencing actual harm due to the lack of timely intervention and ongoing missed treatments.
Failure to Provide Timely Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents received timely bathing as required by their care plans and physician orders. Medical record reviews for two residents revealed that scheduled showers or bed baths were not consistently offered or completed on the designated days. One resident, with diagnoses including dementia, peripheral vascular disease, COPD, and chronic pain syndrome, required substantial assistance with ADLs and had physician orders for showers or bed baths twice weekly. Documentation showed missed bathing opportunities on several scheduled days, and the resident reported that showers were not provided because staff were too busy. Another resident, with hemiplegia, cerebral vascular accident, sickle-cell disease, and seizures, also required staff assistance for bathing and had similar orders for regular showers. Records indicated multiple missed or undocumented showers on scheduled days, and the resident confirmed that showers were not completed as expected. Interviews with the DON and CNAs confirmed the absence of documentation for bathing on the missed dates and verified that if the electronic medical record was blank, the shower task was not completed. The facility's policy required that care and services for ADLs, including bathing, be provided based on the resident's assessment and needs. The deficiency was identified through medical record review, resident and staff interviews, and facility policy review, and was investigated under multiple complaint numbers.
Failure to Monitor and Intervene for Constipation in Two Residents
Penalty
Summary
The facility failed to monitor and intervene appropriately for constipation in two residents with significant medical histories, including chronic obstructive pulmonary disease, diabetes, heart disease, and other chronic conditions. For one resident, records showed a six-day period without a bowel movement, despite physician orders for both scheduled and as-needed medications for constipation and an order to monitor for medication side effects, including constipation. There was no documentation that the resident was assessed for constipation or offered the as-needed medication during this period. For the second resident, a five-day period without a bowel movement was documented, despite orders for daily and twice-daily medications for constipation and instructions to monitor for constipation every shift. Again, there was no documentation of assessment for constipation during this time. Interviews with the DON, Administrator, and an RN confirmed that the facility's standard of practice is to monitor daily bowel movements, assess for constipation, and initiate interventions after three days without a bowel movement. The absence of documentation and lack of intervention for both residents was confirmed by the DON. The findings were based on medical record review, staff interviews, and reference to national clinical guidelines, and represent continued non-compliance from a previous survey.
Catheter Removed Without Physician Order
Penalty
Summary
Staff failed to obtain a physician's order prior to removing an indwelling urinary catheter from a resident with a history of bacteremia, chronic kidney disease, and neuromuscular dysfunction of the bladder. The resident, who was always incontinent of bowel and bladder and dependent on staff for all activities of daily living, had an intact cognitive function and was under hospice care. The care plan indicated the presence of an indwelling Foley catheter due to neurogenic bladder, with interventions to monitor for pain or discomfort related to the catheter. On the day of the incident, a nurse contacted urology to request an order for catheter removal but did not receive a return call or order. Later, the resident reported severe urinary pain, and after administering pain medication, the nurse removed the Foley catheter at the resident's request without a physician's order. The resident was subsequently transferred to the hospital to rule out a urinary tract infection. Review of facility protocol confirmed that a physician's order is required for catheter removal, and the Director of Nursing verified that no such order was present in the medical record.
Failure to Secure Hazardous Chemicals Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that hazardous chemicals were properly stored in secured areas and kept out of the reach of residents. Multiple observations and staff interviews revealed that cleaning chemicals, germicidal wipes, mouthwash, and other potentially harmful substances were found unsecured in resident rooms, common areas, and unlocked storage rooms. These chemicals were accessible to residents, despite facility policies requiring that such items be locked away when not in use. Several doors to storage rooms containing hazardous materials were found unlocked or with malfunctioning locks, and chemicals were left unattended on housekeeping carts and countertops. A resident with a history of compulsive behaviors, poor decision-making, and mental health issues, including schizophrenia with disorganized thoughts and paranoia, was able to access and apply hazardous chemicals to his body on multiple occasions. The resident had previously been found with wound cleanser, scissors, and various cleaning chemicals in his room, and had a documented pattern of taking unsafe items from around the facility. On two separate incidents, the resident applied cleaning chemicals to his feet and peri-area, resulting in second-degree chemical burns and subsequent hospitalization, including admission to a burn unit and later to the ICU for sepsis evaluation. Staff discovered the incidents after responding to the resident's complaints of pain and upon finding chemical containers in the resident's room. Medical records and staff interviews confirmed that the resident required 24-hour supervision, had a care plan noting self-harm behaviors, and had previously been redirected for taking unsafe items. Despite these known risks, hazardous chemicals remained accessible in the environment, and staff were not consistently ensuring that chemicals were secured. The facility's failure to secure hazardous chemicals directly resulted in serious physical harm to the resident, including chemical burns and hospitalization.
Removal Plan
- Hold a Quality Assurance and Performance Improvement (QAPI) meeting.
- Search the facility for unsecured hazardous chemicals and secure any found.
- Remove spray bottles of bleach solution and odor control from public bathrooms.
- Remove odor control and multi surface peroxide from nurses' stations, resident rooms, activity room, and common sitting areas.
- Relocate spray bottles of odor control, multi surface peroxide, floor cleaner, and bleach solution from the top of housekeeping carts into a locking compartment on each cart.
- Conduct a facility wide audit to ensure all hazardous chemicals are properly stored, supply room doors and cabinets are locked, housekeeping carts are locked, and all hazardous chemicals are secured within the housekeeping cart if not in use.
- Complete skin assessments on all residents.
- Complete door audits to ensure all hazardous material storage rooms have properly functioning doors and that the doors lock securely.
- Educate all staff on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured.
- Educate any staff not yet educated at the start of their first scheduled shift.
- Educate new hires during new hire orientation on chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured.
- Conduct random audits with staff to ensure understanding of where to find pertinent policies to ensure the safe storage of harmful chemicals. Reeducate employees unable to speak to the policies and the safe storage of hazardous chemicals.
- Continue audits until specific interventions identified, and policies and procedures are operationalized to prevent the same actions or practices from occurring in the future.
- Address any concerns or questions regarding hazardous chemicals immediately.
- Verify completion of education on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured by all staff.
- Conduct audits of the facility to ensure all hazardous chemicals are properly stored, supply room doors and cabinets are locked, housekeeping carts are locked when not in use.
- Conduct audits on doors where hazardous materials are kept.
- Secure or repair any door found to be unsecured or in need of repair. Enter work orders for any door found unsecured and in need of repair in the electronic work order system for tracking and reporting.
- Provide audit results to the Administrator.
- Review audits in Quality Assurance (QA) and monitor in the QAPI meeting until deemed compliant.
Failure to Address and Follow Up on Resident Grievances and Council Concerns
Penalty
Summary
The facility failed to address and follow up on resident grievances and concerns in a timely manner, as evidenced by a review of facility documents, staff interviews, and policy review. Out of 75 grievances filed between April 2025 and September 2025, 30 had not been followed up on. Additionally, multiple concerns raised during Resident Council meetings from June through October 2025—including issues with untimely medication administration, undercooked food, staffing, staff approach, and showers—were not addressed or followed up on. The facility census at the time was 70 residents, indicating that the failure had the potential to affect all residents. Further review revealed inconsistencies in documentation and follow-up actions. For example, meeting minutes from August 2025 indicated that an LPN had been counseled for untimely medication administration, but the personnel file contained no documentation to support this. Interviews with the DON and Administrator confirmed that the grievances and concerns had not been addressed as required by facility policy, which designates the Administrator as the Grievance Official responsible for oversight and written decisions. The facility's policy also requires action and communication regarding Resident Council concerns, which was not followed.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of all residents, as evidenced by the absence of Certified Nursing Assistants (CNAs) on duty during a specific shift and lack of documentation for care provided. Medical record reviews for three residents with significant care needs, including diagnoses such as obstructive hypertrophic cardiomyopathy, myasthenia gravis, schizophrenia, Parkinson's disease, and adult failure to thrive, revealed gaps in documentation of activities of daily living (ADL) care, particularly between 3:00 P.M. and 7:00 P.M. on a specified date. For these residents, task sheets showed either no documentation or infrequent documentation of personal hygiene and toileting assistance, despite their dependence on staff for these tasks. Interviews with residents, their representatives, and staff confirmed ongoing staffing shortages, especially the absence of CNAs during the identified shift. Residents and their representatives reported delays in call light responses, unmet care needs, and instances where residents remained in soiled briefs or received late medications. Staff interviews corroborated these accounts, with LPNs and CNAs stating that they sometimes worked without adequate support, leading to prioritization of care and difficulty fulfilling all resident needs. The facility's own assessment tool outlined required CNA-to-resident ratios for each shift, which were not met during the period in question. Timecard reviews confirmed no CNAs were present during the critical hours, and the administrator was unable to verify that required care was provided outside of what was documented. Multiple complaints and interviews further substantiated the deficiency in staffing and the resulting lack of timely and adequate care for residents.
Failure to Control Foul Odors in Resident Halls and Dining Area
Penalty
Summary
Surveyors observed intermittent foul urine odors throughout A, B, and C halls, as well as in the adjacent dining room, during multiple visits. These odors were not associated with any specific resident, resident rooms, or soiled utility rooms. Staff interviews, including with an LPN and an activities assistant, confirmed that the urine odor was common on most days. Resident interviews and a representative also confirmed that the foul odor was bothersome and present throughout the hallways. Review of facility policies revealed that the facility was required to provide a clean and homelike environment, with specific instructions to minimize odors by reporting lingering odors and cleaning needs to the housekeeping department. The facility also had a policy for routine cleaning and disinfection to ensure a sanitary environment. Despite these policies, the persistent foul urine odor indicated a failure to maintain a safe, clean, and comfortable environment for residents on the affected halls.
Failure to Complete Thorough Investigations for Self-Reported Incidents
Penalty
Summary
The facility failed to conduct thorough investigations for five self-reported incidents (SRIs) involving six residents. The review found that for each of these incidents, the facility did not obtain staff interviews or statements, did not conduct resident interviews, did not assess other residents with similar conditions, and did not provide staff education related to the incidents. These failures were confirmed by the Administrator, who acknowledged that these investigative steps were not completed as required by facility policy. The residents involved had a range of medical conditions, including chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), cerebral vascular accident (CVA), systemic lupus, dementia, and vascular dementia. Some residents were cognitively intact, while others had cognitive impairment. The facility's policy on abuse, neglect, and exploitation requires immediate and thorough investigations, including interviews with all involved parties and complete documentation, but these procedures were not followed for the incidents reviewed.
Failure to Accurately Document Care and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation in resident medical records, affecting multiple residents. For several residents, including those with complex medical histories such as obstructive hypertrophic cardiomyopathy, myasthenia gravis, and pressure ulcers, there was a consistent absence of documentation to support that daily living cares were provided on multiple days and shifts. Task sheets for these residents often lacked entries for personal hygiene and other activities of daily living, despite their dependence on staff for these tasks. Interviews with the administrator confirmed these documentation gaps for the reviewed periods. In one case, a resident's narcotic count sheets indicated that tramadol was removed and presumably administered on specific days, but there was no corresponding documentation in the medication administration record (MAR) as required by facility policy. The LPN responsible admitted to only documenting administration on the narcotic count sheet and not in the MAR, even though the resident confirmed receiving the medication. Facility policy clearly stated that all administered medications must be documented in the MAR, which was not followed in this instance. Additionally, for a former resident with multiple wounds and a history of sepsis and kidney disease, the treatment administration record (TAR) indicated that wound care was completed on certain days. However, an internal investigation revealed that two nurses had signed off on wound care that was not actually performed, and failed to document the resident's refusal of treatment. Both nurses were disciplined for falsifying electronic medical record documentation, which led to misleading records indicating that care was provided when it was not. Facility policy required that wound treatments be documented in accordance with physician orders, including the effectiveness of the treatment, which was not done in these cases.
Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
The facility failed to ensure that meal trays were served in a clean and sanitary manner, as observed during meal tray service to eight residents. Certified Nurse Assistant (CNA) #525 repeatedly did not perform hand hygiene before or after retrieving meal trays from the cart, delivering trays to residents' bedside tables, setting up meal trays, or after handling potentially contaminated items such as bedside tables, dirty water cups, trash bags, and cleaning up spills. The CNA also failed to perform hand hygiene after touching her face, picking up items from the floor, and after assisting residents with their meals, including cutting up food with silverware from the meal tray. These actions were directly observed during a meal service period, and the CNA confirmed during interview that she did not perform hand hygiene as required between resident contacts, after cleaning, or after handling trash. Review of the facility's hand hygiene policy indicated that all staff are required to perform proper hand hygiene to prevent the spread of infection, specifically between resident contacts and after handling contaminated objects. The failure to follow these procedures was observed to affect all eight residents who received meal trays during the observation period.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident with dementia who was cognitively impaired at the time of the incident. The resident's family reported the alleged abuse to the former Director of Nursing (DON), but the DON did not notify the Administrator or initiate the required Self-Reported Incident (SRI) process until three days later. According to facility policy, allegations of abuse must be reported to the Administrator and appropriate authorities immediately, but not later than two hours after the allegation is made if abuse or serious bodily injury is involved, or within 24 hours if not. The delay in reporting was confirmed through record review, staff interviews, and examination of the facility's SRI and policy documents. The Administrator only became aware of the incident after being informed by the former DON several days after the initial report from the resident's family. This resulted in a delay in both the suspension of the alleged perpetrator and the initiation of the investigation, constituting non-compliance with the facility's abuse reporting policy.
Failure to Notify State Agency of Significant Change in Mental Health Condition
Penalty
Summary
The facility failed to notify the appropriate state agency, the Ohio Department of Mental Health, of a significant change in a resident's mental health condition as required by regulation. Record review showed that a resident was admitted with multiple diagnoses, including anxiety and epilepsy, and later received new diagnoses of disorganized schizophrenia and schizophrenia. Despite these new mental health diagnoses and an increase in behaviors, there was no evidence in the medical record that an updated PASRR assessment was completed or that the state agency was notified. Staff interviews confirmed that no updated PASRR was completed at the time of the new diagnoses, and the Director of Nursing acknowledged that a PASRR should have been conducted. Facility policy requires prompt referral to the state mental health authority for a level II resident review when a resident exhibits a newly evident or possible serious mental disorder. The failure to follow this policy and regulatory requirement resulted in the deficiency.
Failure to Update and Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders for a resident with a right above-the-knee amputation (RAKA) were accurate and completed as ordered. The resident, who was cognitively intact and required assistance with activities of daily living, had a history of disruption of wound healing, infection following procedure, dehiscence of amputated stump, gangrene, acidosis, and peripheral vascular disease. Physician orders initially directed that Betadine be applied to the surgical incision and wrapped with fluff gauze once daily. However, after a follow-up with a vascular surgeon, the wound care order was changed to Betadine application twice daily. This updated order was communicated to the facility but was not reflected in the resident's medical record or implemented in practice. Documentation and observation revealed that wound care was only being performed once daily, and on at least one occasion, the dressing was not changed as documented. Staff interviews confirmed that the wound care orders had not been updated in the system to reflect the new instructions from the vascular surgeon, and the facility's policy required treatments to be provided in accordance with physician orders. The inaccuracy in the medical record and failure to follow the most current wound care orders resulted in the deficiency.
Failure to Ensure Required Physician Visits During Admission
Penalty
Summary
A review of the medical record, staff interviews, and facility policy revealed that a resident was not seen by a provider during the entire admission period from 05/07/25 through discharge on 08/21/25. The medical record for this resident, who was cognitively intact according to the five-day Minimum Data Set (MDS) assessment, showed no physician progress notes for the duration of the stay. Facility assessment documentation indicated that residents should expect a standard of care from medical practitioners and other healthcare professionals necessary to provide the required support and care. This deficiency was identified during an investigation under Complaint Number 2572811.
Failure to Address Psychosocial Needs and Prevent Harm from Hazardous Behaviors
Penalty
Summary
The facility failed to timely address the psychosocial needs and implement individualized interventions for a resident with a history of mental disorder, paranoia, hoarding behaviors, and a pattern of acquiring hazardous chemicals. The resident, who had diagnoses including schizophrenia with disorganized thoughts, anxiety, and paranoia, was noted to have intact cognition but poor decision-making skills. Despite being identified as requiring 24-hour supervision and having a care plan that included interventions for behaviors potentially causing harm to self or others, the resident continued to obtain and hoard facility chemicals over several months. Staff interviews and record reviews revealed that the resident's behaviors, including acquiring and mixing cleaning chemicals, were known to the staff and had been ongoing. On one occasion, staff found a spray bottle in the resident's room containing mixed chemicals, and on a prior day, other cleaning chemicals were also found and removed. The psychiatric nurse practitioner was unaware of the recent escalation in behaviors and hospitalizations, despite noting an increase in behaviors earlier in the year. The administrator confirmed that while the resident was educated about not having chemicals, there was no evidence that the interdisciplinary team addressed the increase in behaviors or implemented a psychosocial plan of care. The deficiency culminated when the resident was found with wet, blistered, and inflamed feet, which upon assessment were determined to be partial thickness burns. The resident was sent to the hospital and subsequently transferred to a burn center for treatment. The facility's policy required person-centered behavioral health care and regular review of care plans, especially when interventions were not effective or when there was a change in condition, but there was no documentation that these requirements were met in this case.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the needs of all residents, as evidenced by multiple documented instances of missed care and insufficient staff coverage. Several residents with significant care needs, including those with cognitive impairment, mobility limitations, and dependence on staff for activities of daily living (ADLs), did not receive scheduled showers, baths, or assistance with eating. For example, one resident who was dependent on staff for bathing and feeding missed 16 scheduled baths over three months and was observed not receiving assistance with meals, resulting in uneaten food. Staff interviews confirmed that showers and other care tasks were often not completed due to inadequate staffing levels. Another resident, who was dependent on staff for all ADLs and at risk for pressure ulcers, received only one documented bath or shower in a month and was not repositioned as required, with documentation showing only seven repositioning entries over a month. Staff reported that they were unable to provide timely incontinence care and repositioning due to the high workload and lack of sufficient staff. Additional residents also missed scheduled showers or received only bed baths, with staff confirming that the extensive care needs and lack of available staff prevented them from completing required care tasks. Review of staffing schedules and Payroll Based Journal (PBJ) reports revealed that the facility consistently scheduled fewer licensed nurses and CNAs than identified as necessary to meet resident needs. On multiple days, the facility did not meet the state minimum staffing requirement of 2.5 hours of direct resident care per resident per day. The facility also triggered for excessively low weekend staffing and had a one-star staffing rating, indicating ongoing issues with staffing sufficiency. Facility leadership acknowledged the staffing shortages and confirmed that even with management staff assisting, there were not enough staff to meet resident care needs.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit required direct care staffing information to CMS for Quarter Four of 2024, as mandated by federal regulations. Review of the Payroll-Based Journal (PBJ) Staffing Data Report showed that the facility did not submit staffing data for the period of July 1 to September 30, 2024. During an interview, the Administrator confirmed that the data was not submitted and stated that Human Resources was responsible for the submission, but it was not completed. The Administrator was unable to provide a reason for the failure to submit the required data. The facility's policy indicated that staffing data should be collected and submitted monthly before the 15th of each month. This deficiency had the potential to affect all 68 residents in the facility, as reflected by the facility census.
Failure to Provide Scheduled Showers and Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), specifically feeding assistance and scheduled showers, to dependent residents. Multiple residents with significant medical conditions and cognitive or physical impairments were affected. For example, one resident with congestive heart failure, chronic kidney disease, and other comorbidities was documented as dependent on staff for ADLs and at risk for pressure ulcers, yet received only one shower or bath over a month-long period, despite care plans indicating the need for more frequent hygiene support. Staff interviews confirmed that scheduled showers were often missed due to insufficient staffing and the extensive care needs of residents. Another resident with severe cognitive impairment, morbid obesity, and chronic respiratory failure was dependent on staff for bathing and had physician orders for regular showers or bed baths. Documentation revealed missed scheduled baths, and the facility administrator verified the lack of evidence that these were provided as ordered. Similarly, a resident with metabolic encephalopathy, hemiparesis, and diabetes, who was dependent on staff for ADLs, missed at least one scheduled shower or bed bath, with both the resident and assigned CNA confirming that showers were frequently not provided due to staff shortages and high workload. A further case involved a resident with a history of stroke, dysphagia, and moderate cognitive impairment, who required staff assistance for bathing and feeding. Documentation showed that this resident missed 16 scheduled baths over three months. Observations and interviews with the resident, her POA, and staff revealed that she was not consistently assisted with eating or bathing, often due to inadequate staffing. On multiple occasions, the resident was left without assistance during meals, resulting in uneaten food, and her hygiene needs were unmet. Staff interviews consistently cited lack of sufficient staff as the reason for these deficiencies.
Failure to Provide Timely Repositioning and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide timely repositioning and offloading for dependent residents at risk for pressure ulcers, as evidenced by observations, medical record reviews, and staff interviews. Three residents with significant mobility limitations and multiple comorbidities, including congestive heart failure, chronic kidney disease, fractures, diabetes, and malnutrition, were identified as not receiving repositioning at the frequency required by their care plans and physician orders. Documentation showed that one resident was only repositioned five times over a month, and another only seven times, despite orders for repositioning at least every two hours. Direct observations revealed that residents remained in the same position in bed for extended periods, sometimes exceeding four hours without repositioning or incontinence care. Staff interviews confirmed a lack of awareness regarding when residents were last repositioned, and there was no consistent communication between shifts about residents' care needs. In several instances, residents were found soiled and had not received care since the previous shift, further indicating lapses in routine care and monitoring. Residents themselves reported infrequent repositioning, with one stating that repositioning occurred only once during an eight-hour shift. Staff confirmed these accounts, acknowledging that they had not provided care or repositioned residents for several hours after assuming responsibility. These findings demonstrate a pattern of non-compliance with established care protocols for pressure ulcer prevention among dependent residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 570 citations issued within 25 miles in the last 12 months — including the 3 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
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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) |
|---|---|---|---|---|
| Rosary Care Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Kingston Health Center Of Sylvania | 1.9 mi | ★★★★★ | 35 | 0 |
| Arbors At Sylvania | 1.9 mi | ★★★★★ | 3 | 0 |
| Divine Rehabilitation And Nursing At Sylvania | 2 mi | ★★★★★ | 10 | 0 |
| Otterbein Sunset House | 3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.