Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardens Of Belden Village during CMS and state inspections, most recent first.
Surveyors found that the facility failed to dispose of expired food and thickened beverages in a timely manner, resulting in expired items being stored in the kitchen and previously served to residents. During a kitchen observation, unopened and opened cases of Thick and Easy juices were found past their expiration dates, and the Dietary Manager confirmed that expired peaches from the emergency food supply had been served during a winter storm, with staff only becoming aware after a complaint. This issue potentially affected all residents receiving meals from the kitchen.
Surveyors found that water was leaking from discolored, rust-stained ceiling tiles above the washing machines, with rainwater dripping into a cart used to transport clean clothing and linens and onto the floor where damp towels were observed. The Housekeeper/Laundry Supervisor confirmed that the ceiling leaked when it rained and that water was pooling in the clean laundry cart, and a surveyor was dripped on while walking from the washer area to the dryer area. The Maintenance Director verified the ongoing leak, rusted crossbars, and stained tiles, explained that rainwater traveled along ductwork from the roof over the second floor to the first-floor laundry room, and acknowledged prior attempts to patch the roof and discussions about roof replacement, with the situation having the potential to affect all 80 residents.
Surveyors found multiple systemic failures in care, including a diabetic resident admitted from the hospital with prior hyperglycemia who went more than two months without any blood glucose monitoring or anti-diabetic medications, despite a care plan citing risk for hypo/hyperglycemia and repeated physician notes inaccurately documenting good diabetic control and listing medications that were not actually ordered. Another resident received an antihypertensive medication without required pre-dose BP checks, while a third resident with a hospital history of type II DM underwent frequent finger-stick testing without clear indication or consistent documentation of results, and was coded as non-diabetic on the MDS. Additional residents with diabetic, arterial, and other wounds had no measurements or treatment orders in place until an outside wound nurse evaluated them, a new plantar foot ulcer was first identified by the outside provider rather than facility staff, an ordered bordered foam dressing was not used on a breast wound, and weekly ordered skin checks were not documented on several dates despite the presence of an open wrist area. Ordered diagnostic testing, including urinalysis and other tests, was also not consistently completed as directed.
Two residents with intact cognition and multiple medical conditions, including dysphagia, hemiplegia, dementia, and depression, were observed being fed breakfast in bed by CNAs who stood beside them rather than sitting, despite a facility policy requiring meal assistance to meet individual resident needs. In one case, an LPN confirmed a chair was available but not used; in the other, the CNA reported no chair was present in the room. These observations led surveyors to determine that residents were not provided with dignity during meals.
A resident with multiple chronic conditions had an indwelling urinary catheter care plan that included specific catheter-related interventions, but documentation later showed the catheter was removed and all catheter maintenance orders were discontinued. Despite this change, the catheter care plan remained active and was not revised or discontinued to reflect that the resident no longer had a catheter, a fact confirmed by both the resident and the MDS nurse, resulting in a deficiency for failure to update the care plan.
Two residents who were dependent on staff for ADLs did not consistently receive or have documented basic hygiene care. One resident with multiple chronic conditions had a care plan requiring staff assistance with bathing, showers, and daily hygiene, yet facility records showed bathing was only documented on some scheduled days, with no evidence of bed baths or refusals on numerous missed dates despite leadership stating daily bed baths were provided. Another resident on a secured memory care unit, with orders for eye ointment and baby shampoo eye cleansing, was repeatedly observed in common areas with matted and crusted eyes, while staff acknowledged that CNAs were responsible for cleaning the eyes per orders. These findings showed that ordered and care-planned bathing and eye hygiene were not reliably carried out or documented.
A resident with CHF, COPD, and severely impaired cognition, who was ordered continuous and PRN O2 via nasal cannula with routine O2 saturation monitoring, was found twice in bed with the oxygen tubing left under the blanket at the bottom of the bed instead of in use or properly stored. A CNA confirmed the resident should have been wearing oxygen and was not capable of placing the tubing under the blanket independently. The Regional Director of Operations acknowledged there was no facility policy for oxygen tubing storage and that the nasal cannula should either be in the resident’s nares or stored appropriately when not in use.
A resident admitted with multiple medical conditions and a recent abdominal surgery had a hospital discharge prescription for PRN oxycodone for severe pain, reported ongoing sharp pain affecting sleep, mood, ADLs, and mobility, and was care planned for pain management. However, the resident did not receive any PRN pain medication, pain levels were not documented on the TAR despite required shift assessments, and the MDS reflected no scheduled or PRN pain use. Nursing staff repeatedly attempted to fax the oxycodone prescription to the pharmacy, which reported not receiving it, and the Regional Clinical Director later confirmed that the resident had no PRN pain medication available and did not receive appropriate pain monitoring, despite the ability to obtain authorization from emergency supply with a paper prescription.
A resident with ESRD and multiple comorbidities receiving thrice-weekly hemodialysis at an outside center did not have consistent pre- and post-dialysis monitoring and communication, as required by physician orders. Review of the dialysis communication binder showed multiple treatment days with no forms documenting pre-treatment weights and VS or post-dialysis information. Several LPNs and the ADON acknowledged that forms were not consistently sent and documentation was missing from both the facility and the dialysis center, while the dialysis RN reported not receiving any information from the facility despite faxing post-dialysis reports back. The Regional Director of Operations confirmed the facility lacked a dialysis policy, contributing to the failure to ensure appropriate dialysis care and communication.
A resident with multiple neurological and psychiatric diagnoses received PRN oxycodone that was supplied in 2.5 mg half-tablets, but the MAR was entered only for 5 mg doses and did not match the pharmacy order or the individual controlled substance administration record. Over several days, there were repeated discrepancies between the MAR and the narcotic record in both dose (2.5 mg vs 5 mg) and administration times, including instances where the narcotic record showed doses not reflected on the MAR and a dose documented after the MAR showed the medication as discontinued. The Regional Clinical Director confirmed the MAR was entered incorrectly and that the two records did not match when oxycodone was administered.
A resident with multiple complex conditions, including ESRD, diabetes with neuropathy, post-stroke hemiplegia, vascular dementia, and cognitive communication deficit, had an order for Chlorhexidine 0.12% oral rinse to be given twice daily to swish and spit. Photos taken by the resident’s guardian showed a medicine cup with a capsule and a plastic cup containing yellow oral rinse left on the over-bed tray, indicating medications were left at the bedside. The guardian reported staff were supposed to stay until medications and the rinse were completed, and interviews with LPNs and a regional nurse confirmed that medications were not to be left at the bedside, in contrast to the facility’s medication administration policy.
A resident with ESRD on dialysis, COPD, and diabetes had conflicting documentation in the medical record regarding a PRN tramadol order initiated with hospice services. A late-entry note stated tramadol was discontinued on the first hospice day, but the actual physician order discontinued it nearly two weeks later, during which time the MAR showed one dose was administered for severe pain. The resident’s guardian later voiced concerns about narcotic use, yet the tramadol order was not promptly discontinued, and documentation remained inconsistent. In addition, ordered total daily fluid restrictions divided between dietary and nursing were not fully documented on two days, with missing intake amounts and staff initials on the MAR/TAR, despite staff reporting that the restriction was carried out.
Incomplete Elopement Care Plan: A resident with psych hx including depression, anxiety, PTSD, and substance abuse was identified as an elopement risk after demanding to leave the facility and going outside. Staff contacted the guardian, returned the resident, and initiated a Wanderguard and 15-minute checks, but the care plan later listed the resident as a wanderer/elopement risk with no interventions documented. The MDS nurse confirmed the care plan lacked interventions.
Improper Storage of Oxygen Tubing: A resident with COPD and severely impaired cognition was ordered O2 at 2 L/min via NC and had oxygen monitoring ordered on day and night shift. Surveyors observed the resident lying in bed with the oxygen tubing under a blanket at the bottom of the bed, and the tubing remained there on a later observation. A CNA verified the resident should be wearing oxygen and could not have placed the tubing there, and the RDO stated the facility had no policy for oxygen tubing storage.
Physician failed to provide comprehensive diabetes care for a resident with DM, CKD, and dementia. The resident was admitted after hospital treatment that included insulin and frequent BG checks, but the physician’s notes repeatedly stated diabetes was well controlled, listed outdated meds and weight, and did not address BG monitoring. No BG checks or anti-diabetic orders were in place until severe hyperglycemia was identified by lab work showing A1C 16.7% to 17% and BG over 400 mg/dL, after which new insulin and oral DM medication orders were written.
Unnecessary Antibiotic Administration: A resident with multiple chronic conditions, including DM2 and hemiplegia, received nitrofurantoin/Macrobid despite not meeting McGeer criteria for UTI treatment. The consultant pharmacist noted the order was written as prophylaxis but dosed like treatment, and the MAR showed the resident received nitrofurantoin/Macrobid twice daily before later being changed to once daily. The ADON verified the resident did not meet criteria and that the infection surveillance checklist had been completed incorrectly.
Failure to use contact isolation PPE for two residents. One resident was admitted with MRSA and was not placed on contact isolation until later, despite positive blood and wound cultures and an order for EBP. Staff were observed entering the room without gowns or gloves and handling items, and another resident on contact precautions for a VRE wound also had staff enter the room without the required gown, despite isolation signage.
A cognitively impaired resident with dementia and severe communication deficits was inappropriately touched on the breast by another ambulatory, cognitively intact resident, as directly witnessed by a CNA at the nurses’ station. The witnessing CNA immediately intervened and reported the incident to an LPN, but the facility’s subsequent investigation concluded that no abuse occurred, relying on an assumption that the cognitively impaired resident had lifted her own shirt and that there were no witnesses. The administrator reported being unaware of the CNA’s written witness statement describing the breast touching, and the resident’s husband stated the incident was downplayed and that he was not informed his wife’s breast had been touched. The facility’s actions did not align with its abuse policy requiring thorough investigation and witness interviews, resulting in a failure to ensure the resident was free from sexual abuse.
A cognitively impaired resident with dementia was allegedly sexually abused when another ambulatory, cognitively intact resident lifted her shirt and touched her breast at the nurses’ station, as witnessed by a CNA who immediately intervened and reported the incident to an LPN and the DON. The facility’s investigation concluded no abuse occurred, but it did not include interviewing all staff who were present and aware of the allegation, including an LPN who heard the CNA’s report and was never asked for a statement. The Administrator was unaware of the CNA’s written statement describing breast touching and told the resident’s husband a different version of events that he felt downplayed what happened, despite facility policy requiring that all witnesses be interviewed in abuse investigations.
Two residents experienced significant weight loss without appropriate individualized nutrition care planning or required weight monitoring. One resident with dementia and other psychiatric diagnoses had documented weight decline and a dietician‑ordered change in Med Pass supplements, but weekly weights were not obtained as required, the new supplement order was not entered for many days, and the care plan was not updated to reflect the weight loss. Another resident with neurologic and psychiatric conditions had multiple documented weight changes, but admission and weekly weights were not consistently taken, and no care plan was developed to address the weight loss, despite a dietician note identifying a significant one‑month weight change and ordering changes to tube feeding and continued monitoring.
A resident with a history of fractures and anxiety disorder experienced symptoms of Norovirus, including nausea and vomiting, which were not documented or addressed by the facility. Despite staff awareness and family concerns, the facility failed to notify the physician or obtain medication orders, violating their policy for change of condition.
Two residents in an LTC facility suffered injuries due to deficiencies in care and equipment maintenance. One resident was not transferred with a gait belt as required, resulting in a hip fracture, while another fell due to a malfunctioning bed side rail, leading to a fibula fracture. The facility lacked proper equipment and maintenance protocols, contributing to these incidents.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 87 residents receiving meals. Observations revealed soiled equipment, undated and unlabeled food items, and non-functional dishwashing facilities. Staff interviews confirmed ongoing issues with the dish machine and sink, which were not promptly addressed. Additionally, unit refrigerators contained spoiled or expired food, and facility policies on sanitization and food labeling were not followed.
The facility failed to ensure proper PPE use for staff interacting with COVID-19 positive residents. A housekeeping staff member did not wear the required N95 mask and eye protection, and a nurse improperly donned and doffed PPE, contrary to facility policy and CDC guidelines.
A resident with end-stage renal disease did not receive proper pre and post-dialysis evaluations as required by physician orders. The facility failed to document vital signs before dialysis and did not assess the dialysis shunt for bruit or thrill. The facility's policy lacked a requirement for pre-dialysis evaluations, contributing to the deficiency.
The facility failed to complete timely repairs for environmental concerns affecting three residents. A resident's room had stained and broken ceiling tiles, and another resident's bathroom sink was plugged with standing dirty water. Despite contractor repairs, the facility did not replace ceiling tiles or address flooring issues. The maintenance policy lacked specifics on repair timeframes, contributing to delays.
A resident with Alzheimer's, depression, and anxiety did not receive proper perineal care after an incontinence episode. Two LPNs failed to follow the facility's policy, which required washing the perineal area from front to back. Instead, they only cleaned from the back to the front, leading to a deficiency.
Expired Food and Thickened Beverages Stored and Served to Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices when expired thickened beverages and previously served expired food items were discovered. During a kitchen observation on 04/01/26 at 11:00 A.M., surveyors found one unopened case of Thick and Easy apple juice expired on 02/17/26, one unopened case of Thick and Easy cranberry juice expired on 02/19/26, and one opened case of Thick and Easy orange juice expired on 03/14/26. In an interview at the time of the observation, the Dietary Manager confirmed these beverages were expired and also acknowledged that expired food had been served to residents in January 2026 during a winter storm, when dietary staff used items from the emergency food supply that included a case of individual cups of peaches that had been expired for several months. The Dietary Manager stated staff were unaware that expired food had been served until a complaint was made. This deficiency had the potential to affect all 80 residents who received food from the kitchen and was investigated under Complaint Numbers 2741464, 2725826, 2593694, 2592864, and 2579173. The facility census at the time was 80 residents, all of whom received food from the kitchen where the expired items were stored and, in at least one prior instance, served. No additional resident-specific medical histories or conditions were documented in the report related to this deficiency.
Water Leak in Laundry Area Contaminating Clean Linens
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, and comfortable environment in the laundry area, where water was actively leaking from the ceiling above the washing machines onto clean laundry. On the survey date at 9:04 A.M., water was observed dripping from discolored ceiling tiles with brownish staining and rusted metal crossbars, and some of the dripping water was pooling directly into a cart used to transport clean clothing and linens from the washers to the dryers. Several damp-looking bath towels were also observed lying on the floor in the same area. The Housekeeper/Laundry Supervisor confirmed that water was dripping from the ceiling into the clean laundry cart and stated that the ceiling leaked when it rained, and as the surveyor walked from the laundry area to the dryer area, water dripped onto the surveyor’s head. Later that morning, the Maintenance Director verified that the ceiling above the washers was leaking and confirmed the presence of rusted crossbars and discolored ceiling tiles. He stated that the leak occurred when it rained, that the laundry room was on the first floor with a second floor above it, and that rainwater could travel along ductwork and emerge from the ceiling in various locations. He also stated he had attempted to patch the roof and that there had been discussions about obtaining a new roof. This situation had the potential to affect all 80 residents residing in the facility and was cited as non-compliance under multiple complaint numbers.
Systemic Failures in Diabetes Management, Medication Monitoring, and Skin/Wound Care
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to orders, resident preferences, and clinical standards, particularly in the areas of diabetes management, medication administration, skin assessment, and diagnostic testing. One resident with a long history of type II diabetes mellitus, acute kidney failure, CKD stage III, and vascular dementia was admitted from the hospital with prior documented hyperglycemia, urine glucose of 3+, and recent use of insulin and oral hypoglycemics that were held in the hospital with instructions to resume at discharge. Despite this history and a facility care plan identifying risk for hypo/hyperglycemia and interventions such as providing diabetes medications as ordered and collecting fasting serum blood sugars, there were no physician orders for blood glucose monitoring or anti-diabetic medications from admission through more than two months of stay. Multiple monthly physician notes during this period repeatedly described the resident as a diabetic with “good control,” listed Glyburide and Metformin as current medications, and used an outdated weight from 2014, yet contained no assessment or plan for diabetes monitoring. No blood glucose readings were obtained until late March, when lab work showed extremely elevated serum glucose and A1C values, and a finger-stick blood glucose of 582 mg/dL was recorded. Interviews confirmed there was no protocol consistently followed for checking blood sugars on admission for diabetics, that the attending physician assumed diabetes was well controlled if no hospital orders for insulin or blood sugar checks were present, and that he did not review the full hospital documentation. The resident’s daughter reported she had informed staff of the resident’s home diabetic medications and had repeatedly requested an A1C test, while being told the facility was managing diabetes through diet. Another resident with encephalopathy, psychoactive substance abuse, and schizoaffective disorder had an order for nifedipine 30 mg upon rising with instructions to hold the dose if systolic blood pressure was less than 90. The medication administration record showed nifedipine was given on two consecutive mornings, but there were no blood pressures documented on the MAR at the time of administration. The blood pressure summary showed readings were taken late at night and late afternoon on those days, not prior to the morning doses. The regional clinical director confirmed that blood pressures were not checked before the antihypertensive medication was administered as ordered. A third resident admitted with diagnoses including acute embolism and thrombosis of the right lower leg, type II diabetes mellitus, and hemiplegia had hospital documentation indicating diabetes and an insulin sliding scale, but the admission MDS coded the resident as not diabetic and without insulin or hypoglycemic medications. Later, an order was written for blood sugar checks three times daily for one week, yet documentation showed some finger-stick tests were performed without recording the results, and the resident, who was cognitively intact, reported finger soreness and questioned why frequent blood glucose checks were being done when he believed he was not diabetic. Facility staff and the physician could not explain why the blood glucose checks were ordered weeks after admission, and the MDS nurse acknowledged the hospital records listed diabetes but there were no anti-glycemic medications ordered. Additional deficiencies involved failures in skin assessment and wound treatment. One resident admitted with cellulitis, type II diabetes, fractures, and MRSA infection had multiple diabetic and arterial ulcers on the feet and hand documented by an outside wound care company several days after admission, with specific measurements and treatment orders initiated at that time. The admission care plan and MDS reflected the presence of venous/arterial and diabetic ulcers and a surgical wound, but an LPN confirmed there were no measurements or treatment orders in place for these ulcers from admission until the outside wound nurse’s first visit, and that nurses could have measured the wounds and contacted the physician for orders. The same outside wound provider later identified a new diabetic ulcer on the plantar surface of the left foot that had not been previously documented by facility staff; the regional clinical director could not explain why nurses had not identified this area. Another resident on a secured memory care unit with moderate cognitive impairment had a physician order to cleanse a right breast wound with normal saline, apply triple antibiotic ointment, and cover with a bordered foam dressing once daily, but observation showed the wound covered with an undated clear Opsite-type dressing instead of the ordered bordered foam, which the RN confirmed was incorrect. A further resident with Alzheimer’s disease, unspecified dementia, and diabetes had an order for weekly skin checks documented in the electronic record and to report new abnormal findings, yet review of the MAR/TAR for an entire month showed no evidence that weekly skin checks were completed on three specified dates. Observation revealed a scabbed, dime-sized open area on the right inner wrist, and nursing staff confirmed that the wound nurse was performing skin checks, indicating a lack of documented compliance with the ordered weekly assessments. The report also describes failures to follow testing instructions and complete ordered diagnostic tests. One resident had testing instructions that were not followed, and another had urinalysis laboratory testing ordered but not completed as directed, though the detailed narrative for these two residents is truncated in the provided text. Across the cited cases, surveyors relied on medical record review, hospital record review, facility policies, national clinical guidance from ADA, CDC, NIDDK, NIH/MedlinePlus, observations, and staff and family interviews to substantiate that the facility did not adequately monitor diabetes, did not ensure medications were available and administered per parameters, did not ensure appropriate indication and documentation for blood glucose testing, did not ensure timely and accurate skin assessments and wound treatments, and did not ensure completion of ordered laboratory testing. These actions and omissions affected eight residents reviewed for quality of care out of a facility census of 80.
Failure to Maintain Resident Dignity During Assisted Meals
Penalty
Summary
The deficiency involves failure to ensure residents were provided dignity during meals, specifically by not being seated while feeding residents who had intact cognition. One resident with osteomyelitis of the vertebra, dysphagia, generalized anxiety disorder, dementia, heart failure, unspecified psychosis, anemia, and a history of stroke and venous thrombosis/embolism was admitted on a specified date and had physician orders for a regular diet with mechanical soft texture and nectar thickened liquids. The resident’s MDS assessment showed intact cognition. During an observation, a CNA was seen standing beside the resident’s bed while feeding eggs, hashbrowns, and oatmeal. An LPN confirmed there was a chair available in the room that could have been used to sit while assisting the resident with the breakfast meal. Another resident, admitted with hemiplegia, major depressive disorder, and vascular dementia, had physician orders for a regular diet with regular texture and thin liquids, and an MDS assessment indicating intact cognition. During a separate observation, a CNA was seen standing beside this resident’s bed while feeding eggs, hashbrowns, and oatmeal. The CNA confirmed there was no chair in the resident’s room to sit down and assist with the breakfast meal. Review of the facility’s “Assistance with Meals” policy, revised July 2017, stated that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The survey findings were investigated under two complaint numbers and determined that the residents were not provided with dignity during meals.
Failure to Update Care Plan After Catheter Discontinuation
Penalty
Summary
The deficiency involves the facility’s failure to revise a catheter-related care plan to accurately reflect a resident’s current status after the catheter was discontinued. The resident was admitted with multiple diagnoses, including cellulitis of the abdominal wall, COPD, type 2 diabetes mellitus, morbid obesity, depression, heart failure, CKD Stage III, GERD, hypothyroidism, restless legs syndrome, PTSD, generalized anxiety disorder, and bipolar disorder. A catheter care plan dated 01/28/26 documented an indwelling catheter for urinary retention with interventions such as maintaining a 16 French 10 milliliter catheter, positioning the bag and tubing below bladder level, checking tubing for kinks each shift, maintaining a dignity cover over the catheter bag, monitoring and documenting intake and output per facility policy, monitoring for discomfort and pain due to the catheter, and monitoring and recording signs and symptoms of UTI and reporting them to the physician. A progress note dated 02/26/26 documented that the resident’s catheter balloon was out of the urethra and that the resident reported soreness from having catheters placed multiple times and requested a break. Subsequent review of physician orders showed that all urinary catheter maintenance and output monitoring orders were discontinued on 03/01/26, and no new catheter orders were implemented, indicating the resident no longer had a catheter. During interviews conducted in early April, the resident confirmed that she no longer had a catheter, and the MDS nurse verified that the resident still had an active care plan for catheter use, acknowledging that the care plan should have been discontinued because the resident no longer had a catheter. This failure to update the care plan to reflect the resident’s current catheter status constituted the cited deficiency.
Failure to Provide and Document Adequate Bathing and Eye Hygiene for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate bathing and hygiene assistance for a resident who was dependent on staff for activities of daily living. One resident with multiple medical conditions, including COPD, diabetes, morbid obesity, heart failure, CKD, depression, and anxiety disorders, had care plans indicating a self-care deficit and dependence on staff for bathing and showering. The care plan interventions included assistance with grooming and hygiene, setting up bath items and clothing, providing transfer assistance, bathing or showering with attention to dry sensitive skin, providing sponge baths when full baths or showers could not be tolerated, and washing hair weekly per the resident’s preference. Facility shower sheets and EMR documentation showed that bathing was recorded on 16 of 26 scheduled opportunities over a three‑month period, with multiple scheduled bathing days lacking any documentation of showers, tub baths, bed baths, or refusals, and no progress notes indicating that the resident refused bathing. Interviews with the resident revealed concerns about receiving bathing and hygiene assistance. The ADON, DON, and Regional Clinical Director each verified the bathing documentation and acknowledged gaps, stating that the resident was reportedly given daily bed baths as part of routine ADL care but that staff were not consistently documenting these baths, instead only documenting on scheduled shower days. The facility’s “Giving a Bed bath” policy required staff to review the care plan for special needs and to document the date and time of the bed bath, the staff member performing it, assessment data obtained, the resident’s tolerance, any refusals, and the recorder’s signature and title in the ADL record and medical record. Despite this policy, there was no evidence in the record that daily bed baths or refusals were documented for the missed scheduled bathing days. A second deficiency involved the facility’s failure to ensure another resident’s eyes were kept free of debris despite physician orders and the resident’s dependence on staff for personal hygiene. This resident, who lived on a secured memory care unit and had diagnoses including muscle weakness, hypertension, and major depressive disorder, had orders for refresh eye ointment at bedtime for both eyes and for baby shampoo to be applied to both eyes every morning and at bedtime to clean the eyelids and eyes for dry eyes. Multiple observations over consecutive mornings showed the resident seated in common areas with both eyes matted or crusted with debris. Staff, including a CNA, RDO, and RN, confirmed the presence of matted eyes and that CNAs were responsible for cleaning the eyes with baby shampoo per orders. The facility’s bed bath policy also described proper eye washing technique, but the repeated observations of matted and crusted eyes indicated that the ordered eye care and hygiene were not being consistently performed. This deficiency represents non-compliance investigated under Complaint Numbers 2725826, 2721789 and 1282446 (OH00166150).
Improper Storage of Oxygen Tubing for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to properly store a resident’s oxygen tubing when not in use, resulting in the tubing being left under the blanket at the bottom of the bed. The resident had diagnoses including acute kidney failure, CHF, transient cerebral ischemic attack, and COPD, and had a care plan indicating the use of oxygen therapy with interventions to change oxygen tubing and oxygen settings via nasal cannula as ordered. A quarterly MDS assessment documented that the resident had severely impaired cognitive skills and was receiving oxygen therapy. Physician orders directed that the resident’s oxygen saturation be monitored every day and night shift and that oxygen be administered at two liters per minute via nasal cannula every day and night shift and as needed for oxygen saturation below 90%. On the survey date, observations in the morning showed the resident lying in bed with a blanket over her and the oxygen tubing under the blanket at the bottom of the bed, with the same condition noted several hours later. A CNA confirmed that the resident should have been wearing oxygen and that the oxygen tubing should not have been placed on the bed, and also verified that the resident was not able to remove the oxygen tubing and place it under the blanket independently. In an interview, the Regional Director of Operations stated that the facility did not have a policy for the storage of oxygen tubing and acknowledged that the nasal cannula should either be in the resident’s nares or stored appropriately when not in use.
Failure to Ensure Availability and Monitoring of Prescribed PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with post-surgical pain had prescribed PRN pain medication available and appropriately monitored. The resident was admitted with multiple diagnoses including cellulitis, type II diabetes, morbid obesity, ventral hernia with obstruction, and venous thrombosis and embolism, and had an abdominal incision following surgery. The hospital discharge paperwork included a paper prescription for oxycodone 5 mg every six hours as needed for up to three days. On admission, the resident reported sharp pain rated 3/10, with a goal of 0, and the pain was documented as affecting sleep, mood, socialization, ADLs, physical activity, and mobility. An interim care plan and pain assessment documented that the resident was not cognitively impaired, had occasional pain that interfered with sleep and daily activities, and required pain medications. Despite this, the MAR showed the resident did not receive any PRN pain medication, and the MDS indicated the resident did not receive scheduled or PRN pain medication. The TAR required pain assessment and monitoring every shift, but while checkmarks were present for two shifts, the actual pain levels were not documented. Progress notes showed that the resident complained of pain and discomfort due to the abdominal incision after arrival and later became agitated, stating that night shift staff were not friendly or helpful. On a subsequent day, nursing staff contacted the pharmacy multiple times regarding the oxycodone prescription; the pharmacy reported not receiving the paper prescription, and the nurse faxed and re-faxed it three times. The Regional Clinical Director confirmed that the resident did not receive any PRN pain medication, did not have appropriate pain monitoring, that the hospital had sent a paper prescription, and that the pharmacy could have authorized oxycodone from the emergency supply with a paper prescription from the facility.
Failure to Maintain Dialysis Communication and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate dialysis care by not consistently monitoring and communicating vital signs and weights before and after hemodialysis treatments for a resident dependent on dialysis. The resident, admitted with diagnoses including end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and cognitive communication deficit, had physician orders for hemodialysis three times weekly at an outside dialysis facility, with instructions to send a communication form. Review of the dialysis communication binder for March 2026 showed missing pre- and post-dialysis communication forms, including pre-treatment weights and vital signs, on multiple treatment dates. Multiple LPNs and the ADON confirmed that dialysis communication forms were not consistently sent and that documentation was missing both from the facility and from the outside dialysis center for the identified dates. The dialysis RN at the outside facility reported they did not receive any documentation from the facility and stated it was important to know the resident’s condition prior to dialysis; the dialysis RN also reported that post-dialysis information was faxed to the facility daily. Additionally, review of physician orders for April 2025 included an order to send a communication form with the resident to dialysis, yet the Regional Director of Operations confirmed that the facility had no dialysis policy in place. These actions and omissions led to the cited deficiency for failure to monitor and maintain adequate communication with the outside dialysis center and to ensure the facility had a dialysis policy.
Inaccurate Documentation of Controlled Substance Dosing on MAR and Narcotic Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and consistent documentation of a controlled substance on both the individual patient-controlled substance administration record and the medication administration record (MAR) for one resident. The resident was admitted with multiple diagnoses including encephalopathy, psychoactive substance abuse, obstructive hydrocephalus, nontraumatic subarachnoid hemorrhage, and schizoaffective disorder, and was cognitively intact at discharge. A physician’s order dated 08/03/25 directed oxycodone 5 mg every eight hours as needed, while the individual controlled substance record for the same date listed an order for 1/2 tablet (2.5 mg) every eight hours as needed or two half tablets (5 mg) every eight hours as needed. The MAR documented administration of oxycodone 5 mg at specific times, whereas the controlled substance record documented differing doses and times, including 2.5 mg and 5 mg doses that did not consistently match the MAR entries. Across multiple days, the MAR and the individual controlled substance record showed repeated discrepancies in both dosage and administration times. On 08/03/25, the MAR showed two 5 mg doses, while the controlled substance record showed 2.5 mg doses at different times. On 08/04/25, the controlled substance record reflected 2.5 mg and 5 mg doses at three times, while the MAR showed only two 5 mg doses. On 08/05/25 and 08/06/25, the controlled substance record documented 5 mg and 2.5 mg doses at various times that were either not reflected or differed on the MAR, including a day where the MAR showed no oxycodone despite doses recorded on the controlled substance record. On 08/07/25 and 08/08/25, the controlled substance record and MAR again differed in dose amounts and in the discontinuation date of oxycodone, with the MAR indicating discontinuation before a dose recorded on the controlled substance record. The Regional Clinical Director confirmed that the MAR order was entered incorrectly for 5 mg only, did not match the pharmacy-supplied half-tablet (2.5 mg) oxycodone, and verified that the two records did not match when oxycodone was administered.
Medications Left Unattended at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were not left at a resident’s bedside, contrary to facility policy and accepted standards for medication security. Resident #7, admitted on 11/28/25, had diagnoses including end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia, and cognitive communication deficit. Physician orders for December 2025 included Chlorhexidine Gluconate 0.12% mouth/throat solution, 15 ml PO every morning and at bedtime, to swish and spit following teeth extractions. Photos provided by the resident’s guardian, dated 12/20/25 at 7:32 A.M., showed a medicine cup on the resident’s over-bed tray with one capsule in it and a plastic drinking cup containing a yellow/pale fluid. In a telephone interview, the guardian identified the yellow/pale fluid in the plastic cup as the resident’s oral rinse and stated that staff were supposed to remain with the resident until medications were taken and the rinse was completed as ordered. Interviews with two LPNs on 03/30/36 and with a Regional Nurse on 04/02/26 confirmed that medications were not to be left at the bedside and that the photo depicted a medicine cup with one capsule and a plastic cup with yellow/pale fluid. Review of the facility’s “Administering Medications” policy, revised December 2012, indicated that medications were to be administered in a safe and timely manner and as prescribed. The surveyors concluded that the facility failed to ensure medications were not left at the bedside for this resident, resulting in noncompliance under Complaint Number 2721789.
Incomplete and Inaccurate Medical Record for Pain Medication and Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with end-stage renal disease on dialysis, COPD, and diabetes, whose daughter was the legal guardian and POA. The resident was admitted to hospice with an order for tramadol 50 mg every six hours as needed for severe pain, along with other medications, and the hospice medication cover sheet was signed by the guardian. A late-entry progress note dated several weeks later documented that tramadol was to be discontinued on the first day of hospice due to non-utilization, but the physician order actually discontinued tramadol nearly two weeks later. During this period, the MAR showed that the resident received a dose of tramadol for severe pain, and the ADON confirmed the discrepancy between the late-entry note and the actual discontinuation order. Further record review showed that the resident’s daughter revoked hospice services the day after hospice admission, and later expressed concerns about tramadol and possible addiction during a care conference. The regional clinical director stated that the guardian believed that revoking hospice would revert the resident’s medications to pre-hospice orders and acknowledged that tramadol should have been discontinued when the family voiced concerns, but it was not discontinued until several days after that conference. The regional clinical director also confirmed uncertainty as to why the former DON entered a late note indicating tramadol was discontinued on the first hospice day when the order was not actually discontinued at that time. These inconsistencies resulted in conflicting documentation regarding tramadol orders and administration in the resident’s medical record. A second component of the deficiency involved incomplete documentation of a prescribed total daily fluid restriction of 2000 ml, divided between dietary and nursing responsibilities. The physician’s order specified 1200 ml for dietary and 800 ml for nursing twice a day, but review of the MAR/TAR for March showed that on two separate days, the morning fluid restriction entries for both dietary and nursing were left blank, with no intake amounts or staff initials. The unit manager LPN confirmed that the MAR/TAR was not completed and should have been, and another LPN later confirmed she had implemented the fluid restriction on those days but acknowledged that the documentation boxes should have contained her initials and the intake amounts. These omissions were contrary to facility policies requiring that all medications, treatments, and services provided be fully documented in the medical record, including date, time, and care-specific details.
Incomplete Elopement Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan with relevant interventions for Resident #77, who was admitted with diagnoses including psychoactive substance abuse, depression, anxiety, and post-traumatic stress disorder. An elopement risk assessment identified the resident as low risk with a score of 9.0, and no additional elopement risk assessments were available for review. On 03/21/26, the resident demanded to leave the facility and went outside the building; staff called the guardian, who spoke with the resident and informed her she was not allowed to leave per the local probate court. The resident was returned to the facility, and a Wanderguard and 15-minute checks were initiated. The physician ordered a Wanderguard to the left arm with placement checks every day and night shift effective 03/21/26. However, the elopement risk care plan dated 03/23/26 identified the resident as an elopement risk or wanderer related to disorientation to place, history of attempts to leave unattended, and impaired safety, but listed no interventions. On 03/31/26, the MDS Nurse confirmed the care plan did not have any interventions and verified the elopement risk was identified on 03/21/26.
Improper Storage of Oxygen Tubing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when Resident #1's oxygen tubing was found stored under a blanket at the bottom of the bed instead of being in the resident's nares or stored appropriately when not in use. Resident #1 was admitted with diagnoses including acute kidney failure, congestive heart failure, transient cerebral ischemic attack, and chronic obstructive pulmonary disease, and the care plan indicated oxygen therapy with tubing and oxygen settings to be changed as ordered. The quarterly MDS showed severely impaired cognitive skills and that the resident received oxygen therapy. Physician orders required oxygen saturation monitoring every day and night shift and oxygen at 2 liters per minute via nasal cannula every day and night shift and as needed for oxygen saturation below 90%. During observation, Resident #1 was lying in bed with a blanket over her, and the oxygen tubing was observed under the blanket at the bottom of the bed. A later observation showed the tubing was still in the same position. A CNA verified the resident should be wearing oxygen and that the tubing should not be placed on the bed, and also verified the resident was not able to remove the tubing and place it under the blanket at the bottom of the bed. The RDO stated the facility did not have a policy for storage of oxygen tubing and verified the nasal cannula should be in the resident's nares or stored appropriately if not in use.
Physician Failed to Monitor and Document Diabetes Management
Penalty
Summary
The facility failed to ensure the physician provided comprehensive care for a resident with type 2 diabetes mellitus, acute kidney failure, CKD stage III, vascular dementia, and cognitive communication deficit. The resident was admitted after a hospital stay in which blood sugars ranged from 100 to 294 mg/dL, urine glucose was 3+, and treatment included insulin glargine, insulin lispro sliding scale, and Accu-Chek monitoring four times daily. The hospital discharge summary indicated the resident’s home medications were resumed on discharge, but there was no hemoglobin A1C in the hospital records. The resident’s care plan identified risk for hypoglycemia and hyperglycemia and included interventions for diabetes medications, glucose monitoring, education, fasting serum blood sugars, and monitoring for signs of abnormal blood sugar. However, the physician’s notes over the following months repeatedly documented the resident as diabetic with good control, listed Glyburide and Metformin as medications, and used an outdated weight from 2014. Those notes did not include an assessment or plan for diabetes monitoring. The physician’s orders also showed no blood sugar checks or anti-diabetic medications from admission through late March. Laboratory testing later showed severe hyperglycemia, with blood glucose values of 425 mg/dL and 447 mg/dL and hemoglobin A1C values of 16.7% and 17.0%, with mean blood glucose values of 433 mg/dL and 441 mg/dL. After the A1C resulted at 17%, the physician was notified and new orders were written for insulin glargine and Farxiga. During interview, the physician stated blood sugar checks should have been established on admission, then later stated he assumed diabetes was well controlled if the hospital sent no insulin or blood sugar orders and admitted he did not review the hospital documentation on admission beyond the discharge summary and discharge orders. The facility’s diabetes policy stated glucose monitoring frequency should be ordered by the physician and that A1C reflects average blood glucose over two to three months; ADA information also identified A1C of 17% as an estimated average glucose of 441 mg/dL and noted that high A1C indicates frequent high blood glucose.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure Resident #33 did not receive an unnecessary antibiotic. Resident #33 was admitted with diagnoses including acute embolism and thrombosis of the deep vein of the right lower leg, type II diabetes mellitus, and hemiplegia and hemiparesis. A physician order dated 03/03/26 showed nitrofurantoin/Macrobid 100 mg every morning and at bedtime for UTI prophylaxis, and the infection control log listed a UTI onset on 03/03/26 with an unknown pathogen. The revised McGeer Criteria infection surveillance checklist was completed with an infection date of 03/03/36 and review date of 03/17/26, and the criteria were documented as met for skin and soft tissue infections rather than UTI criteria. A consultant pharmacist noted on 03/03/26 that Macrobid 100 mg twice daily was ordered for UTI prophylaxis, but Macrobid is dosed twice daily for UTI treatment and nitrofurantoin is dosed daily for prophylaxis, and asked that the order be clarified and the MAR updated. A progress note by the former DON stated the nitrofurantoin 100 mg was to be discontinued and generic Macrobid 100 mg would be ordered, and the DON updated the order. The MAR showed the resident received nitrofurantoin 100 mg upon rising on 03/03/26, then Macrobid 100 mg at bedtime on 03/03/26 and twice daily through 03/11/26. The resident was cognitively intact and frequently incontinent of bowel and bladder. On 03/12/26 the resident did not receive Macrobid, and on 03/13/26 the resident began receiving Macrobid 100 mg once daily. The ADON verified the resident did not meet McGeer criteria for Macrobid administration and that the revised McGeer Criteria checklist had been completed incorrectly.
Failure to Use Contact Isolation PPE
Penalty
Summary
The facility failed to implement infection prevention and control precautions for two residents who were on contact isolation precautions. Resident #62 was admitted with diagnoses including cellulitis of the right leg, type II diabetes, a nondisplaced fracture of the head of the radius, and MRSA infection. Hospital discharge records showed several blood cultures and wound cultures positive for MRSA. Although a physician order on 03/17/26 placed the resident on enhanced barrier precautions, the record showed contact isolation precautions were not ordered until 03/26/26, and the Assistant Director of Nursing verified that the resident was admitted with MRSA but was not placed in contact isolation until that date. During observation of Resident #62's room, a contact isolation sign was posted outside the room, but CNA #832 entered the room twice without donning gloves or a gown. The CNA turned off the resident's call light, spoke with the resident, and later returned to the room again without PPE. The CNA verified that the resident was in contact isolation and that gowns and gloves were to be worn, and also picked up the resident's lunch tray and carried it out of the room without having worn PPE. Resident #45 also had contact isolation precautions ordered for a VRE left breast wound and had a history that included MRSA infection and pseudomonas aeruginosa infection. During observation, COTA #868 was in the resident's room moving the resident's right leg while wearing gloves but no isolation gown. Later, HR #802 was observed moving items around in the resident's room without gloves or an isolation gown, despite signage on the door indicating contact precautions. Both staff members confirmed the resident was in isolation precautions and that gowns should have been worn.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident. One resident was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and was care planned for impaired cognitive function requiring supervision, reorientation, and monitoring. A 5-Day MDS documented severe cognitive impairment, and the resident’s husband reported she was confused and unable to make her needs known. There were no progress notes documenting physical or sexual abuse involving this resident on the date of the incident. Another resident, admitted with cerebral infarction, schizophrenia, and psychoactive substance abuse, had intact cognition and was ambulatory per the admission MDS. This resident’s care plan did not include any information related to sexual history or sexual behaviors. On the evening in question, a CNA witnessed this cognitively intact resident lift the cognitively impaired resident’s shirt and rub her left breast at the nurses’ station. The CNA immediately intervened, separated the residents, questioned the resident who did the touching, and reported the incident to an LPN. The resident who committed the touching denied the behavior and made a comment that the other resident should wear a bra. The facility’s self-reported incident described the CNA’s account, but the facility’s investigation ultimately concluded that no abuse had occurred, based on a belief that the cognitively impaired resident had lifted her own shirt and that there were no witnesses. The administrator later stated he was unaware of the CNA’s written witness statement describing the breast touching. The resident’s husband reported that the administrator downplayed what had happened and that he was not informed that his wife’s breast had been touched inappropriately. Review of facility policy on abuse, neglect, exploitation, and misappropriation of resident property showed that all alleged violations of abuse were to be investigated and all witnesses interviewed, but the investigation did not fully incorporate the CNA’s eyewitness account, leading to a failure to ensure the resident was free from sexual abuse.
Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of sexual abuse involving Resident #77. Resident #77 was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and had a care plan identifying impaired cognitive function and the need for supervision, reorientation, and monitoring for changes. A 5-Day MDS assessment documented severe cognitive impairment, and an attempted interview during the survey showed the resident could only state her name and was unable to answer questions. Despite these documented cognitive limitations, there were no progress notes in the medical record addressing the alleged physical or sexual abuse on the date of the incident. The alleged perpetrator, Resident #43, had diagnoses including cerebral infarction, schizophrenia, and psychoactive substance abuse, and was documented as cognitively intact and ambulatory on the admission MDS. The care plan for Resident #43 did not include any information related to sexual history or sexual behaviors. According to the facility’s self-reported incident (SRI), a CNA witnessed Resident #43 lift Resident #77’s shirt and touch her left breast at approximately 10:30 P.M., then immediately separated the residents and reported the incident to an LPN, who notified the DON. The SRI indicated an investigation was started, including monitoring both residents, and the facility ultimately concluded that no abuse had occurred. However, the investigation did not include interviewing all relevant witnesses as required by the facility’s abuse policy. LPN #267, who was working and orienting with the reporting LPN at the time of the incident and who heard the CNA’s report that Resident #43 went into Resident #77’s shirt and rubbed her breast, was never interviewed or asked to provide a statement. The Administrator acknowledged he did not interview LPN #267 and was unaware of the CNA’s written witness statement describing breast touching, and he stated the allegation was found unsubstantiated because it was reported that the resident lifted her own shirt and there were no witnesses. Additionally, Resident #77’s husband reported that the incident was downplayed to him by the Administrator and that he was not informed that his wife’s breast had been touched inappropriately. The facility’s policy required interviewing all witnesses, but this was not done, resulting in an incomplete investigation of the sexual abuse allegation.
Failure to Implement Individualized Nutrition Care Plans and Required Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain individualized, comprehensive nutrition plans and appropriate weight monitoring for two residents, in accordance with its own weight assessment policy. For one resident with Alzheimer’s disease, dementia, and intermittent explosive disorder, the admission orders included a regular diet with Med Pass supplement and the care plan identified risk for malnutrition due to diagnoses, depression, and supplement use. However, the care plan was not revised or individualized to address subsequent weight loss. Weight records showed a decline from 121.2 lbs on admission to 110 lbs over several weeks, and weekly weights were not obtained as required during the first four weeks after admission. The registered dietician documented a significant 8% one‑month weight loss and ordered a change in the Med Pass supplement regimen and continued weight monitoring per physician order. Despite this, the original Med Pass order was not discontinued until 11 days later, and the new Med Pass order was not entered into the system or reflected on the MAR until that same later date. Interviews with the RD, the regional director of operations, and the DON confirmed that weights were not taken on admission and weekly for four weeks as required, that weights were not monitored weekly after the significant weight change, that the supplement order change from 01/19/26 was not entered until 01/30/26, and that the nutrition care plan was not updated to reflect the resident’s weight loss. For another resident with cerebral infarction, schizophrenia, and psychoactive substance abuse, the care plan did not include any plan for weight loss. Weight records showed an admission weight of 164 lbs, followed by weights of 166 lbs, 156 lbs, and 154 lbs, and the resident’s weight was not taken at admission or weekly for four weeks as required by policy. The RD later documented a significant 7% one‑month weight change and ordered changes to tube feeding (Jevity 1.5) and continued nutrition monitoring with weights per physician order. However, interviews confirmed that required admission and weekly weights were not obtained, that weekly weights were not taken after the significant weight loss, and that there was no care plan addressing the resident’s weight loss, contrary to the facility’s policy requiring multidisciplinary, individualized care plans for weight loss or impaired nutrition.
Failure to Address Resident's Change of Condition
Penalty
Summary
The facility failed to provide timely care and services to a resident who experienced a change of condition. The resident, who had a history of multiple fractures and anxiety disorder, was admitted following a motor vehicle accident. During her stay, she experienced symptoms consistent with Norovirus, including nausea, vomiting, and diarrhea, which were not documented in her nursing progress notes. Despite her complaints and visible symptoms, there was no evidence of physician notification or medication orders to address her condition. Interviews with staff and family members revealed that the resident was visibly ill around Christmas, with severe symptoms that limited her participation in therapy sessions. The therapy director and certified nursing assistants recalled the resident's condition and confirmed that the nursing staff was aware of her symptoms. However, the registered nurse on duty could not recall if the resident had requested medication for nausea, and the facility's policy for change of condition was not followed. The facility's policy required prompt notification of the physician and obtaining medication orders when a resident experienced a significant change in condition. The regional director of nursing confirmed that the facility did not adhere to this procedure for the resident, resulting in a deficiency. The family member also reported concerns to the facility administrator, who acknowledged receiving the complaint and passing it on to nurse managers, but no action was taken to alleviate the resident's symptoms.
Deficiencies in Resident Transfer and Equipment Maintenance Lead to Injuries
Penalty
Summary
The facility failed to ensure effective measures were in place to prevent resident falls with injury, affecting two residents. Resident #38 was not transferred appropriately using a gait belt, as care planned, resulting in a fall and a fractured hip. The incident occurred when a CNA attempted to transfer the resident from a bedside commode to a wheelchair without the use of a gait belt, which was a required intervention in the resident's care plan. The CNA admitted to not using a gait belt, citing the facility's lack of availability of such equipment. The resident, who had intact cognition, sustained a closed intertrochanteric fracture of the left hip, requiring surgical repair and resulting in chronic pain. Resident #48 experienced a fall due to a malfunctioning bed U-bar side rail, which was not maintained in good repair. During incontinence care, the resident used the side rail to assist in rolling over, but the rail detached, causing the resident to fall out of bed and sustain a fracture to the left fibula. The facility's policy lacked specific information on the frequency of maintenance checks for bed rails, contributing to the incident. The resident, who was cognitively intact and required assistance for bed mobility, was admitted to the hospital following the fall. Both incidents highlight deficiencies in the facility's adherence to care plans and equipment maintenance protocols. The lack of proper equipment and maintenance checks directly contributed to the harm experienced by the residents. Interviews with staff and review of facility policies confirmed these lapses, indicating a need for improved safety measures and adherence to care protocols to prevent future occurrences.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, affecting all 87 residents receiving meals. During an inspection, it was observed that the reach-in refrigerator had visible caked-on soiling, undated and unlabeled food items, and multiple spills with food particles. The steam table was also visibly soiled, and the three-compartment sink was non-functional due to a plugged drain. The high-temperature dish machine did not reach the required temperature for proper sanitation. Interviews with staff revealed that the issues with the dish machine and sink had been ongoing, with the maintenance director aware of the problems but unable to resolve them promptly. Additionally, the facility's unit refrigerators for resident use contained undated and unlabeled food items, some of which were spoiled or expired. The facility's policy on sanitization was not followed, as manual washing and sanitizing were not conducted according to the three-step process outlined. The facility's policy on food brought in by visitors also lacked specific dating timeframes, contributing to the improper labeling and storage of perishable food items. These deficiencies indicate a failure to adhere to professional standards for food storage, preparation, and sanitation, impacting the quality of care provided to the residents.
Improper Use of PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) for staff interacting with COVID-19 positive residents, affecting multiple residents on the second floor. In one instance, a housekeeping staff member was observed exiting a COVID-19 positive resident's room wearing a blue surgical gown, gloves, and a blue surgical mask, but not the required N95 mask and eye protection, despite signage indicating the need for such precautions. This staff member confirmed the oversight and acknowledged cleaning both resident rooms and common areas on the second floor. In another instance, a registered nurse was observed improperly donning PPE before entering a COVID-19 positive resident's room. The nurse initially entered the room without eye protection, believing her glasses sufficed, and only applied goggles after being prompted. After completing her tasks, the nurse failed to doff her N95 mask and eye protection before interacting with other residents and staff, contrary to the facility's COVID-19 policy and CDC guidelines. These actions were inconsistent with the facility's established procedures for PPE use during droplet precautions.
Failure to Monitor Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper monitoring of a resident requiring dialysis care, specifically Resident #13, who was affected by this deficiency. Resident #13 had multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, and was scheduled for dialysis treatments at an off-site center three times a week. Despite having physician orders to check the dialysis site for signs of infection every shift, the facility did not complete pre-dialysis evaluations from January 2024 through October 2024 and post-dialysis evaluations from December 2023 through October 2024. Additionally, there was no documentation of vital signs being monitored before dialysis, and only post-dialysis vitals were recorded from June to October 2024. The facility's nursing progress notes and the Medication and Treatment Administration Records did not show any documentation of the assessment of the bruit or thrill of the resident's dialysis shunt. The care plan for Resident #13 included interventions such as checking the arteriovenous fistula every shift and coordinating care with dialysis, but these were not followed. An interview with RN #885 revealed that pre and post-dialysis vitals were checked at the dialysis center, and the paper documenting these vitals was discarded after being reviewed and entered into the electronic medical record. The facility's policy on Hemodialysis Access Care, revised in September 2010, did not include a requirement for pre-dialysis evaluations, contributing to the deficiency.
Delayed Repairs and Environmental Concerns in Resident Rooms
Penalty
Summary
The facility failed to ensure timely repairs following identified environmental concerns, affecting three residents. Observations revealed that Resident #59's room had multiple ceiling tiles with dried water stains, a hole in the bathroom drywall exposing a pipe, rust stains on the floor, and broken ceiling tiles. Resident #48's room had missing and stained ceiling tiles. Interviews confirmed these findings, and it was noted that the original water leak stemmed from issues with the toilet flange, causing damage to multiple rooms. Although repairs were completed by a contractor, the facility had not replaced the ceiling tiles or addressed the flooring issues in Resident #59's room. Additionally, Resident #69 and her daughters reported a plugged bathroom sink that was often full of dirty water, which had not been addressed by maintenance. An observation confirmed the sink was half full of standing dirty water. The facility's maintenance policy lacked specifics on the timeframe for completing repairs, contributing to the delay in addressing these issues. The deficiency was investigated under Complaint Number OH00158304.
Inadequate Perineal Care for Incontinent Resident
Penalty
Summary
The facility failed to ensure proper perineal care for a resident with incontinence of bowel and bladder, leading to a deficiency. The resident, who had been diagnosed with Alzheimer's disease, depression, and anxiety, was observed during incontinence care by two LPNs. The care plan for the resident included checking for incontinence and ensuring the skin was clean and dry if wet or soiled. However, during the observation, the LPNs did not perform perineal care appropriately after an episode of urinary and bowel incontinence. During the care, the LPNs unfastened the resident's brief, cleaned the rectal area and buttocks, and then attempted to refasten the brief without adequately cleaning the perineal area. When questioned, one of the LPNs admitted to not cleaning the resident appropriately, as she had only reached from the back to the front without following the facility's policy for perineal care. The facility's policy required washing the perineal area from front to back, separating the labia, and cleaning with downward strokes, which was not followed in this instance.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines Healthcare Center | 2.7 mi | ★★★★★ | 4 | 0 |
| Altercare Of Nobles Pond, Inc | 2.8 mi | ★★★★★ | 7 | 0 |
| The Pavilion At Edgefield For Nursing And Rehabili | 2.8 mi | ★★★★★ | 38 | 0 |
| Saint Luke Lutheran Home | 2.9 mi | ★★★★★ | 31 | 0 |
| Windsor Medical Center Inc | 3 mi | ★★★★★ | 1 | 0 |
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