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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Galion Meadows Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Unsanitary kitchen conditions and improper food handling: The kitchen had dust, debris, and visible contamination in multiple areas, including vents, a fan blowing onto clean dishes, and mold and water dripping behind equipment. Multiple food items in dry storage, refrigerators, and the freezer were open without dates or labels, and during meal service an aide handled ready-to-eat food with contaminated gloves, touched multiple surfaces and the floor, and returned to food prep without handwashing.
Infection surveillance was incomplete because the facility did not track infection bacteria when indicated and had no surveillance documentation for one month, and the ADON/infection control nurse confirmed the gap. The facility also failed to follow EBP PPE requirements for a resident with a gastrostomy tube: an LPN wore gloves but no gown while performing tube flush care, despite the EBP sign and the DON confirming a gown was required.
Lack of Monitoring for Psychotropic Medications: The facility failed to document monitoring for effectiveness and adverse effects for multiple residents receiving psychotropic meds. Residents with diagnoses including dementia, psychotic disturbance, anxiety, depression, COPD, and other conditions received medications such as mirtazapine, olanzapine, buspirone, sertraline, cariprazine, ziprasidone, and lurasidone, but the MAR/TAR and progress notes showed no documented monitoring, despite care plans calling for staff to monitor and report adverse effects.
A facility failed to keep resident records accurate and complete. Documentation was missing for hospice services, skin bruising and an incident-related injury, wound care that was charted as done but was not completed as ordered, a resident behavior involving stool ingestion and a related change in condition, leg treatment when supplies were unavailable, and Foley catheter care that was charted as completed despite staff stating it was not provided. Staff interviews and record review confirmed the documentation gaps and inaccuracies.
Inconsistent advance directive documentation was found for three residents. One resident had a DNRCC-A form and care plan, but the physician order listed DNRCC; another had a care plan and order for DNRCC-Arrest while an uploaded document showed DNRCC; and a third resident’s record initially had no code status, the care plan listed full code, and the physician order listed DNRCC-A. The DON verified the mismatches and noted one resident was changed to full code until paperwork could be completed.
Failure to assess and notify the physician after moving a resident to the secured memory care unit. A resident with depression, anxiety, epilepsy, and cognitive impairment was transferred from the skilled unit after staff reported going to the front doors, but the record had no documentation of a room change, exit-seeking behavior, or completed assessments. The RDON confirmed no assessment was done and the physician was not contacted, while the resident’s sister/POA said she was unaware of the move and of any dementia dx.
Missing Transfer and Bed Hold Notices: A resident with sepsis, cystitis, DM2 with ketoacidosis, malnutrition, and generalized weakness had a significant change in condition, became unresponsive, and was transferred to the hospital after EMS was called and O2 was started. The record had no documentation that a bed hold notice or transfer notice was given to the resident or resident representative, although the facility did document Ombudsman notification.
Failure to complete and update PASRR notifications for two residents with mental health and developmental needs. One resident was readmitted after hospitalization with new acute respiratory failure with hypoxia and sepsis following an incident involving ingestion of feces, but the record lacked historical PASRR documentation and the state mental health authority was not notified. Another resident had a significant change in condition with a newly diagnosed bipolar disorder, yet no updated PASRR was completed until the deficiency was identified.
Failure to assess skin changes and complete ordered wound care: A resident with dementia and behavioral issues developed a skin tear and bruising to both arms, but weekly skin checks, bruising monitoring, and documentation were not completed, and protective sleeves were not in place. A second resident with diabetes, CVA-related weakness, and PVD did not receive ordered bilateral leg wound care when dressing supplies were unavailable, and the resident refused an alternate dressing because it felt tight.
Failure to complete ordered wound treatments was identified for a resident with a stage three pressure ulcer of the right ankle. The resident had diagnoses including brain cancer, cerebrovascular disease, and depression, and was at risk for skin breakdown. The TAR showed missed wound care on several occasions and false documentation that treatments were completed on other days. During observation, the dressing was dated several days earlier and no calcium alginate was in place under the dressing; the ADON and DON verified the wound care had not been completed per MD orders and that the updated wound treatment order had not been implemented.
Failure to Maintain Safe Bed Position for a Dependent Resident: A resident with intact cognition but dependence for bed mobility and transfers, high fall risk, and a history of falls was found on the floor after sliding out of bed. Staff and the fall investigation identified that the bed had been left raised too high after assistance into bed, and the resident was on anticoagulant therapy and sent to the ED for evaluation.
The facility failed to manage nutrition and hydration for three residents. One resident with multiple medical conditions had significant weight loss, but weights were inconsistently documented and the RD and physician were not notified of the loss. Another resident with COPD, schizoaffective disorder, and anorexia nervosa had an order for a magic cup TID, but the supplement was not listed on the meal ticket and was not on the tray. A third resident with ESRD on dialysis had a fluid restriction order, but staff did not document the amount of fluids given, and a water cup remained in the room while the DON verified monitoring was inadequate.
A resident with a G-tube, chronic pancreatitis, DM2, HTN, and impaired cognition received a 90 ml enteral flush from an LPN without first verifying tube placement, despite a physician order to check placement every shift before feeding, flushing, and giving meds. The LPN confirmed the omission, and the DON verified placement should have been checked before the flush.
A resident with COPD and other serious diagnoses had an order for continuous O2 at 2 L via NC, but the resident reported no humidifier bottle, nosebleeds from dryness, and oxygen tubing that had not been changed in over a year. Observation showed undated tubing and a concentrator filter covered in dust, and the roommate confirmed these concerns had been reported to staff. An LPN confirmed the O2 was ordered continuously, and the DON stated all residents on continuous O2 should have humidifier bottles.
Failure to maintain dialysis communication records for a resident receiving dialysis services. The resident had ESRD, CKD, DM2, COPD, vascular dementia, HTN, and AFib, and the care plan called for coordination with the dialysis center. Staff reported that dialysis communication forms were supposed to be sent with the resident and returned after treatment, but no forms were found in the record for several months, and the DON could not locate the binder or the resident’s dialysis communication sheets.
Failure to identify PTSD triggers in care plans. Surveyors found that two residents with PTSD had care plans with general psych and psychosocial interventions, but no documented trauma-informed assessment or specific triggers. Staff, including the DSS, LPN, CNA, and CPA, confirmed they did not know the residents’ triggers or trauma history, and one resident had behaviors such as crying frequently, picking at a colostomy bag, and eating scabs that were not fully documented.
A resident with schizoaffective disorder, PTSD, depression, anxiety, and an intellectual disability repeatedly manipulated his colostomy bag and ate feces, while staff also observed him adding excessive salt to food and becoming tearful or aggressive when redirected. The care plan did not address the feces-eating behavior, trauma history, or triggers, and social services did not follow through on a physician’s guardianship recommendation. The resident later developed nausea, hypoxia, and respiratory distress, and hospital records showed pneumonia likely related to aspiration.
Medication administration errors exceeded the 5 percent threshold, with three errors in 26 observed opportunities. An LPN gave a resident the wrong cough medication and wrong dose, and for another resident failed to administer scheduled doses of sevelamer and divalproex sodium, initially charting them as refused. The DON verified the wrong medication was given and that the omitted doses were not reported until after surveyor intervention.
A resident with COPD, schizoaffective disorder, anorexia nervosa, anxiety, and HTN was ordered a regular diet with mechanical soft texture and thin liquids, but was served a whole cube steak instead of the required ground texture. Staff confirmed the resident was on a mechanical soft diet, and the DM verified the meat should have been ground per the ordered diet and the facility's tray identification process.
A resident with COPD, chronic bronchitis, PVD, and impaired cognition consented to receive the COVID-19 vaccine, but the vaccine was never administered. Records showed the resident was not up to date on COVID-19 immunization, there was no vaccine documented in the immunization record, and no physician order was obtained. The ADON stated the vaccine never arrived from the pharmacy and confirmed follow-up should have occurred.
The facility failed to complete abuse registry checks upon hire for seven of seven newly hired employees reviewed, including the Administrator, DON, BOM/HR, Activities Director, an LPN, and two Med Techs. Personnel records showed no individual abuse registry checks were maintained, and the BOM/HR and Administrator confirmed the facility was not completing Office of Inspector General abuse registry checks for newly hired staff.
Surveyors identified that the facility did not maintain a pleasant, homelike environment due to persistent strong urine odors in resident areas and unclean wheelchairs for several residents. Multiple staff, residents, and family members confirmed the ongoing odor and lack of wheelchair cleaning, despite facility policy stating wheelchairs should be cleaned regularly. Affected residents had conditions such as cognitive impairment, muscle weakness, hemiplegia, and Parkinson's disease.
Staff failed to follow infection prevention protocols, including not performing hand hygiene before and after resident care, not donning required PPE such as gowns and gloves for residents on Enhanced Barrier Precautions, and not disinfecting a glucometer between use on two residents. These deficiencies were confirmed through staff interviews, observations, and review of facility policies and CDC guidance.
A resident with severe cognitive impairment sustained a skin tear during a mechanical lift transfer, but the responsible party was not notified of the incident or new wound care orders. Staff interviews revealed confusion about notification responsibilities, and the facility's policy requiring timely notification of the resident's representative was not followed.
A resident with severe cognitive impairment and an indwelling catheter did not have urine output documented as ordered by the physician, and new areas of skin breakdown were not timely assessed or treated. Staff failed to record required information in the medical record, and multiple open wounds were observed without corresponding documentation or treatment orders. The Wound Care Nurse was unaware of the new wounds, and CNAs reported the wounds had been present for over a week.
A resident with severe mobility and cognitive impairments sustained a significant skin tear on the right foot during a transfer with a mechanical lift. The injury occurred when the resident's foot became caught under a wheelchair foot pedal while two CNAs were transferring the resident; one CNA was distracted by staff issues, and the other was occupied holding the resident's head due to the lack of a headrest on the manual wheelchair provided by therapy. The incident resulted in a painful wound with active bleeding.
A resident with diabetes received insulin injections from an RN who failed to prime the insulin pens before use, as required by both facility policy and manufacturer instructions. The RN also administered insulin doses later than ordered and delayed subsequent doses. These actions resulted in two medication errors out of 27 opportunities, causing the facility's medication error rate to exceed 5%.
A resident with type II diabetes mellitus received insulin injections from an RN who failed to prime the insulin pens before administration, despite facility policy and manufacturer instructions requiring priming before each use. The RN stated he only primed new pens, and the DON confirmed that priming should occur before every injection. This resulted in a significant medication error for the resident.
A resident with multiple chronic conditions experienced significant and ongoing weight increases over several months. Despite the dietitian's requests for re-weights after each significant gain, these were not completed in a timely manner, and a full nutritional assessment was not performed after the weight changes. Staff interviews and policy review confirmed that required procedures for monitoring and responding to significant weight changes were not followed.
A resident with multiple chronic conditions did not receive prescribed pregabalin for neuropathy due to the facility's failure to ensure a valid prescription was received and processed by the pharmacy. The medication was not administered for several days following the resident's return from the hospital, except for a brief period when an on-call CNP provided a short-term supply. The resident was not informed about the interruption in her pain medication, and facility leadership confirmed the medication was not available or given as ordered.
A resident with significant mobility deficits and a history of falls was injured during van transport when their electric wheelchair was not properly secured using the required four-point securement system and shoulder belt. The driver relied on the wheelchair's positioning belt, which is not intended for vehicle restraint, and there was no formal staff training or documentation on the use of the van's safety systems. The resident sustained injuries requiring hospital admission.
A resident's court-appointed guardian was not notified about the initiation or charges for therapy services, nor was informed consent obtained for dental services after the resident switched to private pay. The resident, who had significant cognitive and medical issues, received multiple therapy and dental services without proper guardian notification or updated consent documentation.
Two residents did not receive care as ordered: one did not have required lab tests completed before a nephrology appointment, resulting in the appointment being rescheduled, and another did not receive all required neurological assessments after a fall with a head injury while on anticoagulant therapy. Staff interviews and record reviews confirmed that care and monitoring were not provided as ordered, and notifications to family and medical staff were delayed.
A resident with severe cognitive impairment and multiple medical conditions received midodrine for hypotension despite physician orders to hold the medication if systolic blood pressure exceeded 120 mmHg. The medication administration record did not reflect the hold parameters, leading to 47 doses being administered when the resident's blood pressure was above the specified limit. The DON confirmed the discrepancy between the physician's order and the MAR.
A resident with multiple chronic conditions and severe cognitive impairment did not have physician-ordered laboratory tests completed prior to a scheduled specialist appointment. The omission was confirmed through medical record review, family interviews indicating missed or rescheduled appointments, and verification by the DON.
A resident with multiple chronic conditions and severe cognitive impairment received a wound dressing change during which the ADON did not change gloves or perform hand hygiene after removing a soiled dressing and before applying ointment to the wound, contrary to facility policy.
The facility's dishwasher failed to reach the required minimum temperature for proper sanitization, potentially affecting all residents receiving food from the kitchen. An observation revealed the dishwasher's wash temperature was 110°F, below the required 120°F. Missing temperature documentation was noted in the facility's Dish Machine log, and the issue was discovered during a complaint investigation.
The facility failed to provide scheduled showers for three residents who required assistance, missing multiple opportunities over nearly two months. One resident, with Parkinson's disease, received only four baths instead of the scheduled twice-weekly showers. Another resident, with schizophrenia and diabetes, also missed 11 scheduled showers. A third resident, with multiple sclerosis and quadriplegia, missed six scheduled showers due to staffing issues. Staff confirmed difficulties in completing ADL care timely due to increased demands.
A facility failed to ensure proper PPE use for a resident on COVID-19 precautions. Staff entered the resident's room without required eye protection and N-95 masks, despite clear signage. The resident, with COVID-19 and other health issues, required isolation. The facility's policies on PPE and transmission-based precautions were not followed, affecting the safety of all residents.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours on two consecutive days, as required. This was confirmed through staff schedules, pay records, and interviews with the Administrator and DON. The absence of an RN had the potential to affect all 50 residents in the facility.
Unsanitary kitchen conditions and improper food handling
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment during the initial kitchen tour. Observations showed a black substance under the sink, loose dust on vents above the stove and food preparation areas, dust collected on the ceiling light fixture, dust hanging around the sprinkler head above the food preparation area, a vent by the refrigerator and freezer heavily coated in dust, and a fan with a large amount of dust on the back blowing directly onto clean dishes. These findings were confirmed by Dietary Aide #232 and Dietary Manager #284 during the observation. The facility also failed to ensure proper food storage, labeling, and equipment cleanliness. In dry storage, open bags of pasta noodles and spaghetti had no open dates. In the refrigerators and freezer, multiple items including lemonade, beef, chicken base, sausage patties, cheese, hash browns, and Eggos were open but had no labels or open dates. A pipe behind the fan in the large refrigerator had visible mold with a wet box underneath from dripping water, the freezer fan had ice buildup with ice chunks on boxes below, and the juice spout had a visible substance present. During lunch meal service, Dietary staff #280 repeatedly handled ready-to-eat food with contaminated gloves, touched clothing, refrigerator handles, a forehead, dishwasher handles, the floor, and equipment, and removed gloves and returned to food service without washing hands before putting on new gloves. The staff member also used gloved hands to write temperatures and then continued handling food, and confirmed these hand hygiene concerns during interview.
Infection Surveillance and EBP PPE Failure
Penalty
Summary
The facility failed to ensure appropriate infection surveillance. Review of the infection surveillance and control sheets for 01/2026 through 03/2026 showed the facility did not track each infection bacteria when indicated, and there was no surveillance documentation for 04/2026. During interview, the ADON, who was also the infection control nurse, confirmed the facility was not tracking the bacteria of infections being treated with antibiotics and confirmed there was no documentation for infection surveillance and control for 04/2026. The facility policy titled Antibiotic Stewardship stated that when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. The facility also failed to ensure PPE was worn during care for a resident on EBP. Resident #9 was admitted with diagnoses including chronic pancreatitis, gastrostomy status, type 2 diabetes mellitus, and hypertension, and had impaired cognition on the quarterly MDS. The resident had a physician order for EBP related to a gastrostomy tube, and the care plan included EBP interventions. Observation showed the EBP sign on the room door directed staff to wear a gown and gloves during high-contact care, including feeding tube care. An LPN administered oral medications and then performed a 90-milliliter enteral flush while wearing gloves but not a gown. The LPN confirmed the resident was on EBP and acknowledged not wearing a gown during the gastrostomy tube flush; the DON also verified staff should wear a gown when flushing the resident's feeding tube.
Lack of Monitoring for Psychotropic Medication Effectiveness and Adverse Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness and adverse effects for five residents reviewed for unnecessary medications. The report identified 43 residents receiving psychotropic medications in a census of 55. Facility records, including care plans, physician orders, MARs, TARs, and progress notes, showed that monitoring for adverse effects and effectiveness was expected in the care plans, but there was no documented monitoring in the clinical record for the residents reviewed. Resident #8 had diagnoses including dementia with behavioral disturbance, psychotic disturbance, atrial fibrillation, altered mental status, and cerebral infarction. The resident had orders for mirtazapine, olanzapine, and later buspirone, and the care plan directed staff to monitor and report adverse effects of antidepressant, antianxiety, and antipsychotic medications. However, review of the progress notes, MAR, and TAR from admission through 05/18/26 showed no documentation of monitoring for adverse effects or efficacy, and the DON verified there was no such documentation. Resident #17 had Alzheimer's disease, nontraumatic subdural hemorrhage, anxiety disorder, and major depressive disorder, with severe cognitive impairment and substantial to maximal assistance needs; the resident received buspirone and mirtazapine, but the MAR and TAR showed no monitoring for side effects of the antidepressant or antianxiety medication. Resident #59 had depression, anxiety, and epilepsy, with cognitive impairment and orders for cariprazine, sertraline, and benztropine; the MAR and TAR showed no monitoring for side effects of antidepressant or antipsychotic medication. Resident #05 had severe vascular dementia with behavioral disturbance, dysphasia, diabetes, major depressive disorder, generalized anxiety disorder, and CKD stage 3B, and received ziprasidone as ordered, but the MAR showed no indication that nurses tracked response, effectiveness, adverse effects, or side effects. Resident #31 had pulmonary embolism, emphysema, COPD, and asthma, was cognitively intact with no behaviors identified, and received lurasidone daily; the MAR showed no documented monitoring for effectiveness, adverse effects, or side effects. Facility policy required documentation of adverse reactions and responses to medications, and the psychotropics policy stated psychotropic medications would be evaluated and monitored, with adverse reactions monitored according to the resident plan of care.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to ensure resident medical records were accurate and complete for six sampled residents. The deficiencies involved missing or incomplete documentation of hospice services, skin findings and incident-related injuries, wound treatment completion, resident behaviors and changes in condition, and catheter care. Facility policy stated the clinical record is a legal document that must be accurate and complete, and that care and treatments are to be recorded only after they are given. For one resident admitted to hospice, the record contained no hospice care documentation since early January, and the ADON stated there was no recent documentation of hospice care provided. The ADON also stated she did not know who was designated as the facility hospice coordinator and that hospice had not been updating the resident’s binder with care documentation. For another resident with dementia and aggressive behaviors, the record did not include documentation of bruising to both forearms, even though CNA task charting showed a new unidentified skin area and an incident report described bruising to both forearms after the resident struck his arms on a bedrail. The incident report was not part of the medical record, and staff interviews confirmed the bruising should have been assessed and documented. For a resident with a stage three pressure ulcer, the TAR showed wound treatment documented as completed on multiple days, but observation revealed the dressing in place was dated several days earlier and had not been changed as ordered. Facility leadership verified the wound treatment had been incorrectly documented by agency staff as completed. For another resident, progress notes did not document an observed episode of eating stool, although a later note described the resident being sent to the ER after a sudden change in condition and reported that he had gotten into his colostomy bag and eaten his stool. Staff interviews confirmed the behavior had been seen but not documented. In addition, one resident’s leg treatment was charted as completed even though the legs were not wrapped and Kerlix supplies were unavailable, and another resident’s Foley catheter care was documented as completed even though staff stated it was not provided because the resident refused during a bed bath.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure advance directives were consistent throughout the medical record for three residents reviewed. For one resident with chronic obstructive pulmonary disease, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension, the record contained a DNRCC-A form and care plan, but a physician order later listed DNRCC instead of DNRCC-A. The DON verified the mismatch between the signed DNR form and the physician order. For another resident with Alzheimer's disease, nontraumatic subdural hemorrhage, anxiety disorder, and major depressive disorder, the care plan and physician order reflected DNRCC-Arrest, while an uploaded document in the electronic record showed a DNRCC order. For a third resident with severe cognitive impairment, fracture of the left humerus, acute respiratory failure, COPD, atherosclerotic heart disease, dementia, depression, and anxiety, the electronic record initially had no code status, the care plan listed full code, and the physician order listed DNRCC-A. The DON confirmed the code status had been entered without a signed paper and that the resident was changed to full code until paperwork could be completed.
Failure to Assess and Notify Physician After Move to Secured Memory Care Unit
Penalty
Summary
The facility failed to ensure proper assessment and physician notification after moving Resident #59 to the secured memory care unit. Resident #59 was admitted with diagnoses including depression, anxiety, and epilepsy, and the admission MDS showed cognitive impairment with assistance needs for several activities of daily living. The care plan later documented that the resident resided on the secured memory care unit for a therapeutic environment related to dementia and had exit-seeking behavior, with interventions to encourage the resident to avoid secured doorways and to periodically reevaluate the need for the secured unit. However, the medical record contained no documentation of a room change or exit-seeking behavior in the progress notes, and the admission evaluation stated the resident had a history of wandering but did not have exit-seeking behavior and had not attempted to elope from the unit or facility. The record showed a census change from the skilled unit to the secured memory care unit, but no further documentation or assessments were noted about the move. An elopement evaluation also stated the resident did not wander within the facility, had no history of wandering, and had no exit-seeking behavior or actual elopement attempts. The resident’s sister and POA stated she was surprised by the move to the secured memory care unit and was unaware of a dementia diagnosis, and the RDON confirmed the resident was moved after staff observed going to the front doors, but no assessments were completed and the physician was not contacted.
Missing Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that a bed hold notice and a notice of transfer were provided to the resident or the resident representative when Resident #56 was discharged to the hospital. Resident #56 was admitted on 04/10/26 and discharged on 04/22/26 with diagnoses including sepsis due to unspecified organism, cystitis without hematuria, morbid obesity due to excess calories, type II diabetes mellitus with ketoacidosis without coma, unspecified protein-calorie malnutrition, and generalized muscle weakness. Nursing documentation on 04/22/26 at 11:30 A.M. showed the resident had a significant change in condition, was found unresponsive with a snoring sound and no verbal response, EMS was called, oxygen therapy was started, and the resident was transferred to the hospital. Electronic medical record entries on 04/23/26 at 12:04 A.M., 9:10 P.M., and 04/24/26 at 8:17 A.M. documented the resident as being at the hospital. Review of the clinical record found no documentation that a bed hold notice or notice of transfer was provided to the resident or resident representative. The Social Worker stated the facility provided Ombudsman notification, but there was no documentation of a transfer notice or bed hold notice. The facility policy required written transfer or discharge notice, including appeal rights, bed hold policy information, Ombudsman contact information, and documentation that the notice was sent to the State Long-Term Care Ombudsman.
Failure to Complete and Update PASRR Notifications for Residents With Mental Health and Developmental Needs
Penalty
Summary
The facility failed to notify the state mental health authority when Resident #03 was readmitted after a hospitalization with new diagnoses of acute respiratory failure with hypoxia and sepsis following an incident in which he ingested his own feces. Resident #03 had a history that included paraplegia, type II diabetes mellitus, schizoaffective disorder, bipolar type, cognitive communication deficit, major depressive disorder, PTSD, generalized anxiety disorder, unspecified intellectual disabilities, chronic kidney disease, and dysphagia. The record showed a hospital exemption document but no PASRR documentation, and Social Services Director #269 stated she could not find a historical PASRR. A PASRR was later completed and submitted, and the result notice indicated the resident required a level II evaluation due to indications of serious mental illness and developmental disability. The facility also failed to complete an updated PASRR for Resident #16 after a significant change in condition that resulted in a newly diagnosed mental health condition. Resident #16 had diagnoses including bipolar disorder, severe vascular dementia with behavioral disturbance, and epilepsy. The record showed a newly identified diagnosis of bipolar disorder with an onset date and no PASRR reflecting the updated mental health diagnosis. Social Worker #269 stated the facility previously did not have access to PASRR documentation following corporate acquisition, and the newly diagnosed bipolar disorder was not captured on an updated PASRR. A PASRR was completed after the deficiency was identified, and the Administrator stated the facility had no policy on PASRR processes.
Failure to assess skin changes and complete ordered wound care
Penalty
Summary
The facility failed to timely assess, monitor, and treat a change in skin condition for a resident with dementia, Alzheimer’s disease, anxiety, peripheral vascular disease, atrial fibrillation, hypertension, and depressive disorder who was dependent on staff for activities of daily living. The resident had a skin tear to the left hand after being combative and agitated during care, and the incident report noted bruising to both forearms. Although the care plan included skin inspections every seven to ten days and protective sleeves to both arms, there were no physician orders to monitor bruising, no weekly skin assessment completed after the prior assessment, and no documentation in the nurse’s notes or TAR for bruising monitoring. The resident was observed with multiple bruised areas on both lower arms and without protective sleeves in place on more than one occasion. The record also showed that a new unidentified skin area was observed by CNA task charting, but there was no corresponding nurse’s note documenting assessment of that area. A nurse’s note later documented the skin tear on the back of the left hand, but there was still no documentation regarding bruising to the bilateral lower arms. During interviews, facility leadership acknowledged that the resident should have had something in place for monitoring bruising, that nursing assistants should have reported the areas to the nurse, and that the nurse should have assessed and documented the bruising and skin assessment. The DON and RDON verified that weekly skin assessments had not been completed since the earlier assessment date. For the second resident, who had diabetes, TIA, hemiplegia and hemiparesis following cerebral infarction, difficulty walking, muscle weakness, peripheral vascular disease, hyperlipidemia, cellulitis, and acute kidney failure, the facility failed to ensure ordered bilateral lower extremity wound care was completed. The active physician order required cleansing both legs, applying Xeroform to open areas, covering with Kerlix, and wrapping with ACE bandages from toes to knee, with circulation and skin integrity monitoring every shift. The MAR and treatment documentation showed the wound care was documented through one day, but there was no completed documentation the next day, and nursing documentation stated Kerlix was not available in the facility and the resident’s legs were not wrapped. Staff and leadership confirmed the Kerlix supply had been out of stock for several days, the resident reported supplies had not been available since the prior week, and the resident refused an alternative ABD pad dressing because it felt tight.
Failure to Complete Ordered Wound Treatments
Penalty
Summary
Failure to provide pressure ulcer care and prevent new ulcers from developing was identified for one resident with a stage three pressure ulcer of the right ankle. The resident had diagnoses including malignant neoplasm of the brain, cerebrovascular disease, depression, and a stage three pressure ulcer of the right ankle, and the quarterly MDS indicated intact cognition and risk for skin breakdown. The care plan included pressure reducing boots, heel elevation, a low air loss mattress, turning and repositioning as needed, and wound treatments per physician orders. A physician order required cleansing the right lateral ankle wound, applying collagen particles and calcium alginate, and covering it with a bordered dressing daily and as needed. A wound NP later documented the ulcer as chronic stage three and ordered a revised treatment using collagen with silver, normal saline moistened to the wound base, and a bordered dressing daily and as needed. Review of the TAR showed no documentation that the ordered wound treatment was completed on several dates, and staff falsely documented the treatment as completed on other dates. During observation, the resident’s dressing was dated several days earlier, there was no calcium alginate under the dressing, and the wound care was then completed by the ADON. The ADON and DON/RDON verified the treatment had not been completed per orders and that the new wound care order had not been implemented.
Failure to Maintain Safe Bed Position for a Dependent Resident
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards when a dependent resident was left in bed with the bed raised too high after staff assisted the resident into bed. The resident had diagnoses including pulmonary embolism, emphysema, COPD, and asthma, had a BIMS score of 15 indicating intact cognition, and was dependent for bed mobility, transfers, and activities of daily living. The resident was also identified as high risk for falls on the fall risk assessment and had a care plan addressing generalized weakness, history of falls, decreased strength and endurance, and need for assistance with activities of daily living. The resident was found on the floor on the left side with a knot to the left side of the head after sliding out of bed, and the resident stated the legs slid out of bed first and pulled the body out. The fall investigation identified the contributing factor as the bed being left up too high by staff after a transfer, and the resident was on anticoagulant medication and was sent to the emergency department for evaluation. A prior positioning fall had also occurred from the recliner, and staff interviews confirmed the resident could not move the feet without assistance, was yelling for help before the fall, and that protocol for dependent residents is to lower the bed when placing them in bed.
Failure to Monitor Weight Loss, Provide Ordered Supplements, and Track Fluid Restrictions
Penalty
Summary
The facility failed to ensure interventions were implemented for significant weight loss for a resident admitted with trigeminal neuralgia, atrial fibrillation, heart failure, pneumonitis, and pleural effusion. The resident’s hospital weight was documented as 130 pounds on discharge to the facility, and the admission orders included weekly weights for three weeks. The record showed no orders or interventions for significant weight loss through the review period, and the nurse’s notes did not document that the physician or RD had been notified of the resident’s weight loss. The care plan and RD note identified the resident as at risk for altered nutritional status and called for weekly weights, but the resident’s weight was not consistently monitored in the record. The resident’s weight documentation was inconsistent and incomplete. The record showed a weight of 130 pounds on admission, then later a weight of 180 pounds that was struck out as incorrect documentation. During a care conference, family reported the resident had lost over 20 pounds since hospitalization and felt weak, and the resident stated she had difficulty eating because of surgery for trigeminal neuralgia and had not wanted the pureed diet. When the resident was weighed during survey observation, she weighed 109 pounds, reflecting a 16 percent weight loss since admission. The DON stated there was no documentation of the resident’s weight since the initial admission weight in the electronic record, and the RD stated he had not been notified of the weight loss until the survey date. The facility also failed to provide a prescribed nutritional supplement to another resident and failed to monitor fluid restrictions for a third resident. One resident with COPD, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension had an order for a magic cup three times daily, but the meal ticket did not list the supplement and observation of the lunch tray showed no supplement present. The dietary manager verified that if the supplement was not listed on the meal ticket, the resident would not receive it, and later stated an email about the supplement had been missed. For the resident with diabetes, COPD, end stage renal failure, CKD, vascular dementia, hypertension, atrial fibrillation, and dialysis dependence, the record showed a physician order for a 1500 ml fluid restriction, while the care plan referenced an 1800 ml restriction. The TAR contained shift check marks for the restriction, but there was no documentation of the amount of fluid actually received. Survey observations found a large water cup in the room, half full of water, and staff stated the resident was given water with medications and that CNAs also filled the cup. The DON verified the monitoring of the fluid restriction was not adequate and stated nursing staff should have documented the amount of fluids the resident received.
Failure to Verify G-Tube Placement Before Flush
Penalty
Summary
The facility failed to ensure placement of a gastrostomy tube prior to administering a gastrostomy tube flush for Resident #9, the only resident reviewed for tube feeding. Resident #9 was admitted on 05/27/25 and had diagnoses including chronic pancreatitis, gastrostomy status, type 2 diabetes mellitus, and hypertension. The quarterly MDS assessment dated [DATE] indicated the resident had impaired cognition. The care plan, initiated on 08/18/25 and revised on 05/01/26, identified the resident as having a gastrostomy feeding tube with interventions to provide enteral nutrition per physician orders, flush the feeding tube per physician orders, and check for tube placement and residual as indicated. A physician order dated 05/28/25 directed staff to check tube placement every shift prior to feeding, flushing, and administering medication. Another order dated 08/05/25 directed a 90 ml fluid flush every four hours. During observation on 05/19/26 at 4:05 P.M., LPN #272 administered a 90 ml enteral flush to Resident #9 without checking tube placement first. The LPN confirmed she had not checked placement prior to flushing, and the DON verified the nurse should have checked for placement before flushing the feeding tube. The facility policy on Gastrostomy Tube/Jejunostomy Tube Care, dated 09/2021, stated to follow physician-ordered treatments and described methods to confirm tube placement in the stomach.
Failure to Provide Ordered Oxygen Equipment and Maintenance
Penalty
Summary
The facility failed to ensure necessary respiratory care and services were provided to a resident with COPD, severe protein-calorie malnutrition, chronic atrial fibrillation, and chronic combined systolic and diastolic heart failure. The resident had impaired respiratory status with shortness of breath with exertion, at rest, and while lying flat, and the care plan included oxygen as ordered, changing oxygen tubing per policy, and elevating the head of bed as needed for comfort and breathing. The physician order required oxygen at 2 liters per nasal cannula continuously every shift and for oxygen tubing and setup to be changed weekly at bedtime every Sunday. During interview, the resident stated he was getting nosebleeds from dryness because there was no humidifier bottle connected to his oxygen and said the oxygen tubing had not been changed in over a year. Observation at that time showed no date on the oxygen tubing, and the resident said the concentrator filter was fuzzy and smelled like something was growing on it; the filter was observed to be covered in dust. The roommate confirmed these concerns had been shared with facility staff, including the dusty filter and lack of a humidifier bottle. An LPN stated humidifier bottles are only used when oxygen is continuous and confirmed the resident’s oxygen was ordered continuously, and the DON stated all residents on continuous oxygen should have humidifier bottles. The facility policy on oxygen administration stated oxygen therapy should be administered safely and noted bacterial contamination associated with certain nebulizers and humidifiers may occur.
Failure to Maintain Dialysis Communication Records
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis services provider for one resident who required dialysis services. The resident was admitted on 01/10/25 and had diagnoses including type 2 diabetes mellitus, COPD, end stage renal failure, CKD, vascular dementia, hypertension, atrial fibrillation, and dependence on renal dialysis. The quarterly MDS assessment documented intact cognition, and the care plan identified end stage renal disease with dialysis services, including an intervention for staff to coordinate the resident’s care in collaboration with the dialysis center. A physician order dated 02/26/26 indicated dialysis three times per week. Review of the medical record found no dialysis communication forms from 01/01/26 through 05/26/26. The facility’s blank dialysis communication form showed that staff were to document pre-dialysis vital signs, weight, glucose level, cognition status, COVID-19 status, pain medications, and any changes in condition, and the dialysis center was to return the form with post-dialysis information such as weight, vital signs, treatment duration, fluid removed, medications administered, condition or events during or after dialysis, and special instructions. Staff interviews revealed the forms were supposed to be prepared, sent with the resident, returned after dialysis, and filed or scanned, but the DON and LPN could not locate the resident’s dialysis communication forms or the binder where they were kept. The DON reported receiving only two dialysis reports from the dialysis center and was unable to find the resident’s dialysis binder for surveyor review.
Failure to Identify PTSD Triggers in Care Plans
Penalty
Summary
The facility failed to ensure that residents with PTSD received care and services that addressed their psychosocial needs. Surveyors found this affected two residents reviewed for trauma-informed care, both of whom had diagnoses that included PTSD along with multiple other medical and psychiatric conditions. The facility record review and staff interviews showed that the residents’ care plans included general behavioral health and psychosocial interventions, but did not identify specific PTSD triggers or document a trauma-informed assessment related to their histories. For one resident, the record showed an admission with diagnoses including COPD, asthma, pulmonary embolism without acute cor pulmonale, and PTSD. The quarterly MDS indicated intact cognition and PTSD, and the care plan included interventions such as behavioral health consults, monitoring for mood changes or distress, providing a calm safe environment, and encouraging expression of feelings. However, there was no documentation of identified PTSD triggers in the care plan, and the PTSD assessment was not completed until later, still without written triggers. The Director of Social Services confirmed that no trauma-informed care assessment related to PTSD triggers had been completed. For the other resident, the record showed a long-term admission history with diagnoses including paraplegia, diabetes, schizoaffective disorder, bipolar disorder, major depressive disorder, generalized anxiety disorder, intellectual disabilities, dysphagia, and PTSD. The care plan addressed impaired psychiatric and mood status and psychosocial wellbeing, but it did not mention specific trauma triggers or trauma history. Staff interviews showed they did not know the resident’s triggers, and one LPN reported behaviors such as picking at the colostomy bag and eating scabs, while a CNA said the resident cried frequently and cried when told what to do. The CPA confirmed she was unaware of the ongoing behaviors, did not know the resident’s triggers or trauma history, and stated that if she had known the behaviors were chronic she would have considered additional psychiatric diagnoses and talk therapy.
Failure to Address Recurrent Coprophagia and Behavioral Health Needs
Penalty
Summary
The facility failed to facilitate guardianship and appropriate behavioral health services for a resident with schizoaffective disorder, PTSD, depression, anxiety, and an intellectual disability, while the resident continued to display behaviors that were detrimental to his psychosocial and physical well-being. The resident also had paraplegia, diabetes, chronic kidney disease, dysphagia, and a colostomy. Care plans addressed elimination needs and psychosocial/mood concerns, but the record did not include interventions for the resident opening his colostomy bag, eating feces, or what staff should do when that behavior was observed or suspected. The social services director confirmed there was no care plan mention of the resident’s trauma history or triggers and no evidence that a PASRR had been filed regarding his intellectual disability, psychiatric diagnoses, and acute respiratory illness with hypoxia. The record showed repeated episodes of the resident manipulating his colostomy bag and ingesting stool. A nurse documented witnessing the resident eating bowel movements from a leaking colostomy bag, and the resident became yelling and hit the nurse when educated. A provider note later described the behavior as consistent with pica and documented that staff had seen the behavior multiple times. Additional notes and staff interviews described the resident putting multiple salt packets into food, crying when redirected, picking at his colostomy bag, and eating his own scabs. Several staff members stated they had seen the resident eat feces or touch and lick stool from the colostomy bag, but some said they did not document the behavior or did not think it was a big deal. The resident’s behavior escalated to a hospital transfer after he was found to have gotten into his colostomy bag and eaten stool, followed by nausea, dry heaves, minimal intake, sudden hypoxia, tachycardia, sweating, and low-grade fever. Hospital records documented pneumonia, likely aspiration, and acute respiratory failure with hypoxia. The physician later noted the resident lacked decision-making capacity for surgery and recommended expediting guardianship, but the medical record contained no follow-up documentation related to that recommendation. Interviews also confirmed the social services director had not followed up on the guardianship request and did not know the resident’s triggers, while staff and providers described the resident as childlike, tearful, and unable to understand the impact of his behaviors.
Medication Administration Errors Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure medications were administered per physician orders, resulting in a medication error rate of 11 percent based on 26 observed medication administration opportunities with three errors. This affected two residents, including one resident with diagnoses of paranoid schizophrenia, vascular dementia with behavioral disturbance, bipolar disorder, dysphagia, anxiety, and hypertension, and another resident with type 2 diabetes mellitus, COPD, end stage renal failure, chronic kidney disease, vascular dementia, hypertension, atrial fibrillation, and dependence on renal dialysis. For one resident, the ordered Robitussin Cough plus Chest Congestion DM was not available in the medication cart, medication room, or other carts, and an LPN administered a different cough medication containing dextromethorphan polistirex without guaifenesin instead of the ordered product. For the other resident, the LPN did not administer scheduled doses of sevelamer and divalproex sodium and initially documented the doses as refused, although she later stated she had not meant to document refusal and that the medications had not been given. The DON verified the incorrect medication was administered to one resident and that the omitted medications for the other resident had not been reported until after surveyor intervention.
Mechanical Soft Diet Not Provided as Ordered
Penalty
Summary
The facility failed to ensure a resident ordered a regular diet with mechanical soft texture and thin liquids received food prepared in the correct form. Resident #38 was admitted with diagnoses including COPD, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension, and the admission MDS indicated intact cognition. The care plan identified the resident as at risk for altered nutritional status due to significant weight loss and included an intervention to provide meals, snacks, and fluids based on food preferences and physician orders. A physician order specified a regular diet with mechanical soft texture and thin liquid consistency. The facility menu for the day indicated cube steak for a mechanical soft diet should be ground and served with gravy, and the resident's meal ticket reflected a mechanical soft diet with an added grilled cheese at each meal. During lunch observation, the resident received a tray that included a whole cube steak rather than a ground texture. A CNA verified the resident was on a mechanical soft diet and confirmed the cube steak was not appropriate, and the Dietary Manager verified the cube steak should have been ground and not served whole. The facility policy stated mechanically altered diets are therapeutic diets and that the food service manager would use a tray identification system to ensure each resident received the ordered diet.
Failure to Administer COVID-19 Vaccine After Resident Consent
Penalty
Summary
The facility failed to ensure Resident #22 received the coronavirus (COVID-19) vaccination after the resident consented to receive it. Resident #22 was admitted with diagnoses including COPD, chronic bronchitis, and PVD, and the quarterly MDS indicated impaired cognition and that the resident was not up to date on the COVID-19 vaccination. The care plan addressed impaired respiratory status related to COPD and pulmonary disease. Review of the Vaccine Informed Consent Form showed the facility offered the COVID-19 vaccination and Resident #22 accepted it, but review of immunizations showed no COVID-19 vaccine was administered. There were also no physician orders for the vaccine. During interview, the ADON stated the resident signed to receive the vaccine, but it never arrived from the pharmacy, and confirmed it should have been followed up. The facility policy stated the COVID vaccine shall be offered to residents in accordance with current CDC recommendations unless medically contraindicated.
Failure to Complete Abuse Registry Checks for Newly Hired Staff
Penalty
Summary
The facility failed to ensure newly hired employees were screened through the abuse registry upon hire to identify potential findings related to abuse, neglect, exploitation, or misappropriation of property for seven of seven newly hired employees reviewed. Personnel file review showed no abuse registry check completed upon hire for the Administrator, DON, Business Office Manager/Human Resources #500, Activities Director #248, LPN #258, Med Tech #238, and Med Tech #266. The facility census was 55, and the deficiency was identified based on personnel file review, staff interview, and facility policy. During interview, the Business Office Manager/Human Resources #500 stated the facility was not completing abuse registry checks for employees hired at the facility. The Administrator stated corporate staff provided monthly Microsoft Excel reports indicating no Office of Inspector General matches were identified, but the facility did not maintain individual abuse registry checks for newly hired employees and only kept a filled-out Excel sheet. The Administrator later confirmed the facility had not been completing Office of Inspector General abuse registry checks for newly hired staff to ensure there were no previous abuse concerns prior to employment.
Failure to Maintain Clean Environment and Wheelchairs
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by persistent strong foul odors of urine throughout the North and South units and unclean wheelchairs for multiple residents. Observations and interviews with residents, family members, and staff confirmed that the odor was present in resident living areas over multiple days, and both nursing and housekeeping staff acknowledged the ongoing issue. The Director of Nursing also confirmed the presence of the odor during the survey. Additionally, the facility failed to ensure that residents' wheelchairs were clean. Three residents who used wheelchairs were observed to have wheelchairs with thick coatings of grime, dust, dirt, dried spills, food particles, and unidentified stains. Residents and family members reported that staff did not clean the wheelchairs, and staff interviews confirmed that cleaning was supposed to occur on shower days and as needed, but this was not being done. The affected residents had various diagnoses, including cognitive impairment, muscle weakness, hemiplegia, and Parkinson's disease.
Infection Control Failures in Hand Hygiene, PPE Use, and Equipment Disinfection
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed among staff during medication administration, resident care, and use of medical equipment. A registered nurse failed to perform hand hygiene after exiting a resident's room and before preparing and administering insulin injections to another resident. The nurse also did not wash hands before donning gloves, exited the room with the same gloves, and handled medication equipment without performing hand hygiene. These actions were confirmed by the nurse during the interview. Certified nursing assistants did not follow Enhanced Barrier Precautions (EBP) when providing care to residents with indwelling catheters. Specifically, staff did not don isolation gowns or perform hand hygiene before or after providing catheter care, despite signage indicating EBP requirements. One CNA provided catheter care to a resident with an indwelling catheter and then entered another resident's room without washing or sanitizing hands. Another CNA and an LPN also failed to don gowns or perform hand hygiene as required during high-contact care activities for residents on EBP. A medication technician used a single glucometer for blood sugar assessments on two residents without cleaning or disinfecting the device between uses, contrary to CDC guidance and manufacturer instructions. The technician also failed to remove gloves or perform hand hygiene between residents. The Director of Nursing confirmed that staff were expected to clean glucometers between each use and to perform hand hygiene before and after resident care. Facility policies and CDC guidance reviewed during the investigation supported these requirements, but staff interviews and observations revealed consistent non-compliance.
Failure to Notify Resident Representative of Incident and Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of an incident involving the resident, specifically a skin tear sustained during a mechanical lift transfer. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and cognitive communication deficit, was assessed as severely cognitively impaired. Documentation showed that the resident's son was listed as the responsible party and emergency contact. Despite this, there was no record that the son was informed of the skin tear or the subsequent new wound care orders. The son only learned of the injury days later during a visit, after inquiring about his father's comments regarding his foot. Staff interviews revealed confusion and inconsistency regarding notification responsibilities. The ADON stated she did not notify the family because she believed the resident was sometimes alert and oriented, and typically notified the resident directly. The DON admitted to not checking the responsible party information and assumed the resident was his own responsible party. Other staff confirmed the resident's cognitive status fluctuated, with orientation primarily to self and inconsistent recognition of others. Facility policy required notification of the resident's representative within 24 hours of any incident or change in condition, unless otherwise instructed by the resident, but this was not followed in this case.
Failure to Document Urine Output and Timely Assess Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and the resident's needs for one resident. Specifically, staff did not document or record urine output as ordered by the physician for a resident with an indwelling catheter. Review of the medical record, Medication Administration Record (MAR), and Treatment Administration Record (TAR) showed no documentation of urinary output, and this was confirmed by the Regional Director of Clinical Services. The physician order required urine output to be recorded every shift, but this was not done. Additionally, the facility failed to timely assess and treat new areas of skin breakdown for the same resident. Observations revealed multiple open wounds and areas of redness and scabbing in the peri area, buttocks, thigh, and coccyx, which had been present for over a week. Certified Nursing Assistants (CNAs) reported the wounds but there was no documentation or treatment orders for these wounds in the medical record. The Wound Care Nurse was unaware of the new wounds and confirmed there were no treatment orders or documentation for them. The resident was severely cognitively impaired, dependent on staff for care, and had a history of resolved wounds, but the new wounds were not assessed or treated in a timely manner.
Resident Injury During Mechanical Lift Transfer Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, morbid obesity, and significant mobility deficits was injured during a transfer using a mechanical lift. The resident, who was dependent on staff for bed mobility and required two-person assistance for transfers, sustained a skin tear on the right foot after it was caught under the foot pedal of a manual wheelchair during the transfer. The incident happened while two CNAs were transferring the resident from a chair to bed using a Hoyer lift. One CNA was distracted due to interpersonal issues with another staff member and did not notice the resident's foot was caught, resulting in a skin tear with moderate bleeding. The resident's care plan specified the need for two-person assistance, and the transfer was being performed with two staff present, but one was preoccupied and failed to ensure the resident's safety. Further contributing factors included the use of a manual wheelchair without a headrest, which was provided by therapy after the resident experienced a decline and could no longer use his personal electric wheelchair with a headrest. During the transfer, one CNA had to hold the resident's head due to the lack of a headrest, limiting her ability to ensure the resident's extremities were clear of hazards. The wound was later assessed as a large skin tear with bruising and active bleeding, causing pain to the resident. Staff interviews confirmed that the distraction and the need to support the resident's head during the transfer contributed to the incident.
Medication Error Rate Exceeds 5% Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two errors were identified out of 27 observed opportunities, resulting in a 7.4% error rate. The errors involved a resident with type II diabetes mellitus who was severely cognitively impaired and required daily insulin injections. During medication administration, a registered nurse did not prime either of the two insulin pens before administering them to the resident, contrary to manufacturer instructions and facility policy. The nurse stated that he only primed insulin pens if they were brand new, and did not perform the priming step for pens that had been previously used. Additionally, the nurse administered the resident's morning insulin doses significantly later than the prescribed times and delayed the next scheduled dose due to the late administration. The DON confirmed that insulin pens should be primed before each use and that medications should be administered according to physician orders. Facility policy and insulin pen manufacturer instructions both require priming before each injection to ensure proper dosing and function.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A deficiency was identified when nursing staff failed to prime insulin pens prior to administering insulin to a resident with type II diabetes mellitus. The resident, who was severely cognitively impaired and required daily insulin injections, had physician orders for Basaglar and Admelog insulin pens to be administered at specific times. During an observed medication administration, a registered nurse attached new needles to both insulin pens, dialed in the prescribed doses, but did not perform the required priming procedure before injecting the insulin subcutaneously. The nurse later confirmed that he only primed insulin pens if they were brand new, contrary to manufacturer instructions and facility policy, which require priming before each use to ensure proper dosing. Further review of the resident's care plan and physician orders confirmed the necessity of administering medications as prescribed and in a timely manner. The Director of Nursing verified that insulin pens should be primed before every use and that medications must be given according to physician orders. The facility's policy and the insulin pen instruction manuals both specify the need for priming before each injection to ensure the pen and needle are functioning correctly and to deliver the correct dose. The failure to prime the insulin pens constituted a significant medication error affecting the resident.
Failure to Timely Complete Nutritional Assessments and Re-Weights for Significant Weight Gain
Penalty
Summary
The facility failed to timely complete nutritional assessments and obtain re-weights for a resident who experienced significant and continued weight increases. The resident, who had multiple diagnoses including chronic kidney disease, morbid obesity, type II diabetes, and other chronic conditions, showed a pattern of substantial weight gain over several months. Despite documented requests from the dietitian for re-weights following significant weight increases, these re-weights were not performed in a timely manner. For example, after a 5.6% weight increase in one month, a re-weight was requested but not completed until nearly a month later. Similarly, after another significant weight gain, a re-weight was again delayed by several weeks. Additionally, a full nutritional assessment was not completed after any of the significant weight increases, with the last assessment having been done months prior to the continued weight gains. Staff interviews confirmed that nurse aides obtain weights as directed by nursing staff, and that the dietitian relies on timely notification and completion of re-weights to perform further assessments. The facility's policy requires monthly weights and timely evaluation of significant weight changes by the multidisciplinary team, but these procedures were not followed. The dietitian confirmed that her requests for re-weights were not completed within her preferred timeframe, and that she was not notified promptly of significant weight changes. This resulted in a lack of timely intervention and assessment for the resident experiencing ongoing weight increases.
Failure to Obtain and Administer Ordered Medication
Penalty
Summary
The facility failed to obtain and administer a prescribed medication, pregabalin, to a resident following their return from a hospital admission. The resident, who had diagnoses including chronic kidney disease, convulsions, morbid obesity, type II diabetes mellitus, anxiety disorder, major depressive disorder, and lymphedema, had a care plan that included pain management with medications as ordered by a physician. Upon readmission, a physician ordered pregabalin 75 mg twice daily for neuropathy, but the medication was not administered from the evening of admission through several days, as documented in the medication administration record and progress notes. The lack of administration was due to the facility's failure to ensure a valid prescription was received and processed by the pharmacy. The pharmacy required a new prescription for the changed dosage, but did not receive it despite notifications to the facility's nurse practitioner and follow-up attempts. The resident did not receive pregabalin for multiple days, except for a brief period when an on-call nurse practitioner provided a three-day supply. The resident was unaware of the reason for the interruption in her pain medication, and facility leadership confirmed the medication was not available or administered as ordered during the specified periods.
Failure to Properly Secure Resident During Transport Results in Injury
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including congestive heart failure, diabetes, and a history of falls, was not properly secured during transport in the facility's van. The resident, who was cognitively intact but required extensive assistance for mobility and used an electric wheelchair, was being transported to an outside appointment. During the trip, the van driver had to make a sudden stop, causing the resident's wheelchair to tip forward and the resident to fall, resulting in injury. The incident led to the resident being admitted to the hospital for pain control and monitoring after sustaining a head injury and significant back pain. The investigation revealed that the resident's wheelchair was equipped with a positioning belt, which is not designed for use as a seatbelt in a motor vehicle. The facility's transport van was equipped with a four-point wheelchair securement system (Q'Straint) and a shoulder and pelvic belt restraint, which are required to be used together for safe transport. However, the driver only used the wheelchair's positioning belt and did not secure the resident with the van's shoulder belt. There was also uncertainty about whether the wheelchair was properly attached to the van floor at the time of the incident, as conflicting accounts were given by staff and the resident. Further review found that the facility did not have a formal training policy or documentation for staff responsible for operating the van and its securement systems. Training was informal and undocumented, with no checklists or records of topics covered. The lack of proper use of the securement system and inadequate staff training directly contributed to the resident's injury during transport.
Failure to Notify Guardian and Obtain Informed Consent for Therapy and Dental Services
Penalty
Summary
The facility failed to notify a resident's court-appointed guardian about the initiation and potential charges for therapy services, as well as failed to obtain informed consent prior to starting dental services. Record review showed that the resident, who had multiple diagnoses including Parkinson's disease, dementia, and malnutrition, was rarely or never understood and had a guardian appointed. Despite multiple therapy orders and treatments, there was no documentation that the guardian was informed of the therapy evaluations, treatments, or the associated charges. Billing statements confirmed that charges were incurred for occupational, speech, and physical therapy, but the guardian was not notified. Additionally, after the resident switched from Medicaid to private pay, there was no evidence that updated consent was obtained for dental services or that the guardian was notified of a dental visit. The previous ancillary consent form had been signed by the resident's wife for other services while the resident was on Medicaid, but no updated consent was documented after the change in payor status. The administrator confirmed that no updated informed consent was obtained and that billing for ancillary services was handled by the service providers, not the facility.
Failure to Complete Physician-Ordered Labs and Neurological Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate cases. For one resident with severe cognitive impairment and multiple chronic conditions, the facility did not complete physician-ordered laboratory tests, including a urinalysis and several blood draws, prior to a scheduled nephrology appointment. As a result, the laboratory work was not available for the appointment, leading to the appointment being rescheduled. Family interviews confirmed that missed or delayed laboratory tests had resulted in rescheduled or missed appointments for this resident. The Director of Nursing verified that the laboratory tests were not completed as ordered. In another case, a resident with severe cognitive impairment, multiple diagnoses, and on anticoagulant therapy experienced a fall resulting in a head injury. The care plan required neurological assessments at specific intervals following the fall. While initial 15-minute checks were completed, subsequent 30-minute and hourly checks were missed or incomplete. Documentation showed that the nurse responsible was passing medications on another hall during the missed assessments. Additionally, at one assessment time, only vital signs were taken, and the resident could not be fully assessed as she was sleeping. The Director of Nursing confirmed that the neurological checks were not completed as required and that family and medical staff notifications about the fall and injury were delayed. Interviews with staff and review of records confirmed that the required care and monitoring were not provided according to physician orders and facility protocols. The deficiencies affected two of three residents reviewed for quality of care and treatment, as verified by the Director of Nursing and staff interviews.
Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that the parameters for administering midodrine, a medication used to treat low blood pressure, were correctly entered into the medical record and followed during administration for a resident with multiple diagnoses including Alzheimer's disease, neuromuscular dysfunction, dysphagia, type 2 diabetes, schizoaffective disorder/bipolar type, and depressive disorder. The physician's order specified that midodrine should be held if the resident's systolic blood pressure (SBP) was greater than 120 mmHg. However, review of the medication administration records showed that the resident received 47 doses of midodrine when their SBP was above this threshold, with the highest recorded blood pressure at the time of administration being 169/103 mmHg. The Director of Nursing confirmed that the hold parameters were present in the physician's order but were not reflected on the medication administration record, resulting in the medication being given contrary to the specified parameters.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for one resident with multiple chronic conditions, including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure. The resident, who had severely impaired cognition, was admitted on 01/15/25 and had a follow-up nephrology appointment scheduled for 07/20/25, with laboratory tests ordered to be completed on 07/14/25. These tests included a complete blood count, hepatic function panel, magnesium, microalbumin/creatinine ratio, renal function panel, sodium, protein/creatinine ratio, and urinalysis. Review of the medical record showed no evidence that the laboratory tests were completed as ordered. Family interviews confirmed that the facility had not completed the ordered tests prior to appointments, resulting in rescheduled or missed appointments. The Director of Nursing verified that the laboratory tests were not completed as ordered.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
During a wound dressing change for Resident #28, who had diagnoses including Alzheimer's disease, type 2 diabetes, major depressive disorder, and chronic kidney disease, the Assistant Director of Nursing (ADON) failed to follow established infection control procedures. The resident, who had severe cognitive impairment, was being treated for a skin tear on the right lower leg. The ADON removed the soiled dressing while wearing gloves, placed the soiled dressing on a paper towel on an over-bed table, and did not remove her gloves or perform hand hygiene before proceeding to the next steps of the wound care process. The ADON then used her gloved finger, which may have been contaminated from removing the soiled dressing, to apply ointment directly to the wound before covering it with a new dressing. At the time of observation, the ADON confirmed that she did not change gloves or perform hand hygiene between removing the old dressing and applying the new treatment. Review of the facility's wound care policy indicated that gloves should be changed and hand hygiene performed between these steps, but these procedures were not followed during the observed dressing change.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher reached the minimum temperature required to properly sanitize dishware, which had the potential to affect all residents receiving food from the kitchen. During an observation, the dishwasher, model ES 2400, was noted to have a wash temperature of 110 degrees Fahrenheit and a rinse cycle of 130 degrees Fahrenheit. Dietary Aide #200 confirmed that the wash cycle was only 110 degrees Fahrenheit and believed it should be at 120 degrees Fahrenheit. A review of the facility's Dish Machine log for November 2024 showed missing temperature documentation for several days and meals, while other entries recorded temperatures of 120 degrees Fahrenheit. The dishwasher guidelines specified a minimum wash temperature of 120 degrees Fahrenheit. This issue was discovered incidentally during a complaint investigation.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for residents who required help with bathing and showers. This deficiency affected three residents who were dependent on staff for these services. Resident #38, diagnosed with Parkinson's disease and other conditions, was scheduled for showers twice a week but only received four baths over nearly two months, missing 11 scheduled opportunities. The resident expressed a preference for bed baths due to her inability to get out of bed, but the facility did not document reasons for missed baths. Resident #52, with diagnoses including schizophrenia and diabetes, also required substantial assistance for showers. Despite being scheduled for showers twice weekly, he only received four showers over the same period, missing 11 opportunities. The resident expressed a desire for timely showers, but again, there was no documentation explaining the missed care. Resident #41, who has multiple sclerosis and quadriplegia, was similarly affected. Scheduled for showers twice a week, he only received two showers in a month, missing six opportunities. The resident reported being told that showers were missed due to staffing issues, despite a recent schedule change intended to accommodate him. Interviews with staff confirmed that they were unable to complete ADL care timely due to increased demands following the closure of a dementia unit.
Inadequate PPE Use for Resident on COVID-19 Precautions
Penalty
Summary
The facility failed to implement its infection control policies, specifically regarding the use of personal protective equipment (PPE) for staff entering the room of a resident on droplet/contact precautions due to a positive COVID-19 test. Observations revealed that staff, including a physical therapist, a rehab services manager, and a state-tested nurse assistant, entered the resident's room without the required eye protection and N-95 masks, despite a sign on the door indicating the need for such precautions. Interviews with the staff confirmed the lack of appropriate PPE, and the Director of Nursing acknowledged that eye protection was not available for the resident in question or another resident in contact isolation. The resident involved had been admitted with diagnoses including hypoxic ischemic encephalopathy, hemiplegia, and COVID-19 acute respiratory disease. The resident was cognitively intact and required varying levels of assistance for daily activities. The facility's policy on PPE and transmission-based precautions was not followed, as PPE was not maintained outside the resident's room for easy access. This deficiency was identified during a complaint investigation and had the potential to affect all 52 residents in the facility.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to comply with the requirement of having a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This deficiency was identified during a review of the nursing staff schedule and pay records, which revealed that no RN was present or working in the facility on 06/15/24 and 06/16/24. Interviews with the Administrator and the Director of Nursing (DON) confirmed the absence of an RN on these dates. This non-compliance had the potential to affect all 50 residents residing in the facility, as the facility census was 50.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 157 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Galion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Galion Pointe, Llc | 0.6 mi | — | 0 | 0 |
| Mill Creek Nursing & Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Crestline Rehabilitation And Nursing Center | 5.5 mi | ★★★★★ | 2 | 0 |
| Altercare Of Bucyrus Center Fo | 8.9 mi | ★★★★★ | 3 | 0 |
| Unger Park Post Acute | 11.2 mi | ★★★★★ | 19 | 0 |
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