Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardens Of North Olmsted during CMS and state inspections, most recent first.
Insufficient nursing staffing led to delayed resident care, including slow call light response and delayed incontinence care. The facility had below-expected CNA, LPN, and RN coverage on multiple shifts, with the DON repeatedly working as a floor nurse to fill gaps. A resident was observed with stool on the skin, a strong odor, and delayed changing, while staff and other residents reported short staffing, unanswered call lights, and delays in trays, showers, and care.
DON Worked as Floor Nurse During High Census The facility failed to ensure the DON worked full-time in the DON role and not as a floor nurse when census was over 60. Staff schedules, time punch detail, and interview confirmed the DON worked multiple floor nurse shifts while the facility census ranged from 78 to 90 residents.
Smoking materials were found in resident rooms and on residents’ persons despite policy prohibiting residents from keeping cigarettes, lighters, vapes, and other smoking articles. Surveyors observed a resident using a vape in her room, and several other residents had cigarettes and lighters stored in pockets or drawers, with staff confirming the materials were kept in rooms and that one resident had been allowed to vape unattended.
A resident with moderate cognitive impairment, hemiplegia, and dependence for toileting hygiene and bed mobility was left waiting for incontinence care while staff failed to honor her request not to receive care from a specific CNA. During the care episode, the resident stated she did not want the CNA in her room, but the CNA remained and assisted with care anyway. The resident reported the CNA had previously cursed at her, and the DON was unaware of the resident’s request.
Failure to Report Alleged Verbal Abuse: A resident with hemiplegia and hemiparesis reported that a CNA cursed at her, made her cry, and left her feeling bad and stressed. The DON was notified and said an investigation was needed, but no SRI was opened or submitted to the State Agency for the abuse allegation.
Failure to initiate an abuse investigation and remove the alleged perpetrator: A resident reported that a CNA cursed at her and made her cry, and she became teary eyed and stressed during interview. The DON was notified, but an SRI was not opened, the CNA was not suspended, and the CNA continued working on the resident’s unit while the resident’s allegation remained uninvestigated.
A resident who was dependent on staff for toileting hygiene and always incontinent of stool was left in a soiled brief with dried stool on the skin and a strong stool odor in the room. Staff reported the resident had last been changed hours earlier, and CNAs stated the unit was short-staffed, residents had to wait during meals or tray pass, and one CNA delayed care until after break. The resident was also observed with redness of the buttocks and food on the chest while lying in bed.
Therapeutic diet not followed for a resident with ESRD on dialysis, vascular dementia, and type II DM. The resident had a physician order for a liberalized renal diet, but the meal tray served contained spinach instead of the buttered cabbage listed on the menu for the renal diet. The RDM confirmed the menu item was incorrect and that the correct item had not been prepared before tray line.
Surveyors found that several nurses lacked proper CPR certification required to support residents with full code status. Some LPNs and an RN had no CPR certification documented in their personnel files, while other LPNs held CPR cards that, although covering adult, child, infant, and AED use, did not specify BLS or healthcare provider-level training. The DON confirmed these gaps, which were inconsistent with facility policies requiring verification of necessary licenses and certifications at hire and ongoing BLS CPR certification for key clinical staff involved in resuscitative efforts.
A resident with a trach, chronic respiratory failure, and laryngeal cancer experienced respiratory distress when the trach inner cannula became dislodged. A CNA promptly reported the issue to an LPN, but the LPN delayed assessment to continue a med pass, while the CNA waited several minutes and then left the room to notify another CNA. When the LPN finally assessed the resident, the resident was in distress and pulled out the entire trach tube; the LPN was unable to reinsert it and left the resident alone to seek help from other nurses on different units. When multiple LPNs returned, the resident was grey and not breathing, CPR was started, and EMS was called, with documentation and staff interviews revealing unclear and delayed timelines in responding to the change in condition.
A resident with rheumatoid arthritis, failure to thrive, depression, and documented pain had scheduled Oxycodone ordered every four hours and PRN Acetaminophen. On multiple occasions, the Oxycodone doses were not administered because the facility was waiting for pharmacy delivery, and several additional scheduled doses were left blank on the MAR without any explanatory documentation. The DON confirmed that the resident did not receive the ordered Oxycodone on several shifts due to pharmacy delivery delays, contrary to facility policy requiring medications to be administered safely, timely, and as prescribed.
The facility failed to maintain accurate and complete medical records for two residents. For one resident with multiple behavioral health diagnoses and functional dependence, nursing documentation described hallucinations and accusations against staff but did not record that the physician initiated a pink slip for psychiatric evaluation, although the hospital record later confirmed the resident arrived with a pink slip citing agitation, threats, refusal of care, hallucinations, and paranoia. For another cognitively impaired resident with Alzheimer’s disease, a self-reported incident documented a resident-to-resident altercation in a secured unit, with staff intervention and assessment, but there was no corresponding progress note entry about the allegation or incident, despite facility policy requiring documentation of such events.
Staff failed to provide consistent food portions and palatable meals, with some residents receiving smaller servings as food ran low and others receiving food at inappropriate temperatures. Food temperature logs were not properly maintained, and staff were unsure of correct serving temperatures, resulting in meals that did not meet facility policy for nutrition and palatability.
Surveyors observed overflowing trash bins, bags of trash on the ground, strong mold odors, flying insects, and water leaks in the basement and laundry areas. Staff confirmed ongoing issues with mold, mildew, and water intrusion due to a leaking sewage pipe and a cracked foundation. Black mold was also found in the first-floor shower room. These conditions were not in accordance with the facility's policy for a clean and safe environment and had the potential to affect all residents.
Multiple residents at high risk for falls did not have their falls properly documented or assessed, and required fall prevention interventions were not consistently implemented. Staff were sometimes unaware of care plan interventions, and post-fall assessments such as vital signs, neurological checks, and pain evaluations were often missing or incomplete. Facility policy for fall management was not consistently followed, as confirmed by staff interviews and record reviews.
Two residents were affected when the facility failed to provide timely access to appropriate stoma supplies for a resident with a urostomy, resulting in leakage and distress, and did not ensure a working television for another resident after a room change due to a water pipe break. Staff and family reported miscommunication, delays, and lack of documentation, impacting the residents' ability to have their needs and preferences met.
A resident with severe cognitive impairment had several personal items, including a phone, abdominal binder, and dentures, go missing. Despite family and staff awareness of the missing items and facility policy requiring immediate reporting, there was no evidence that these incidents were reported to administration or the State agency, nor that an investigation was initiated.
A resident with severe cognitive impairment and multiple health conditions had several personal items, including phones, an abdominal binder, and dentures, go missing. Despite reports from the resident's family and documentation in the missing items log, staff and administration did not initiate or document any investigation into the missing property, as required by facility policy. Interviews with staff revealed uncertainty about the reporting and status of the items, and observations confirmed the items were not found.
A resident with multiple complex medical conditions did not have a care conference scheduled within the required timeframe, as confirmed by record review and facility schedules. The Social Services Designee, who was new to the role and had limited training, was unaware of the quarterly requirement and had not scheduled care conferences for several residents, resulting in noncompliance with facility policy.
Three dependent residents did not receive timely incontinence care, skin care, or oral hygiene as required. One resident waited over 20 minutes for incontinence care after activating the call light, while another was left in soiled conditions for hours during a temporary relocation, resulting in a bleeding wound and lack of skin and oral care. A third resident with severe cognitive impairment was found with dry, flaky skin and red buttocks, but was not offered lotion or mouth care. Staff interviews and observations confirmed that facility policies for ADL, skin, and oral care were not consistently followed.
Two residents experienced significant changes in condition that were not properly assessed or communicated by staff. One resident with a history of multiple health issues reported chest pain and later became unresponsive, with staff failing to document follow-up care or timely notify the physician. Another resident on hospice care became unresponsive after staff failed to assess or notify hospice or the physician about his declining status, partly due to confusion about his code status. Facility policy requiring prompt recognition and communication of acute changes was not followed in these cases.
Two residents with significant urinary health risks did not receive timely identification and treatment for UTIs due to missed or delayed urine specimen collection, lack of follow-up on lab results, and poor documentation. One resident's specimen was discarded and not resent, while another's repeat specimen was not collected as recommended, leading to hospitalization for UTI and sepsis.
A resident with end stage renal disease and cognitive impairment missed multiple scheduled dialysis appointments due to failures in transportation arrangements and communication among staff and the transportation provider. The resident was not transported as ordered, resulting in hospitalization for missed dialysis. Facility policy required safe transportation to dialysis, but this was not consistently followed.
A resident with severe cognitive impairment and multiple comorbidities was left without dentures for an extended period after they were reported missing. Staff were unclear about when the dentures were lost, and the resident did not receive a timely dental referral or intervention as required by facility policy. The delay in dental care and lack of documentation regarding interim measures led to a deficiency in providing appropriate dental services.
A resident with dementia and a history of wandering eloped from the facility, prompting an endangered missing adult alert. Despite facility policies requiring investigation and reporting of missing residents, the incident was not reported to the State Agency or entered into the Ohio Department of Health's system. The facility's policies were found to be vague regarding state reporting requirements, and required notifications were not made following the resident's elopement.
A resident with moderate dementia and impaired safety awareness eloped from the facility without staff knowledge, walking several miles and spending the night in a car during cold weather. The resident was not discovered missing until hours later, and there was a lack of timely documentation and reporting in the medical record and incident log. Staff accounts of the resident's whereabouts were inconsistent, and required elopement protocols were not fully followed.
A resident with moderate cognitive impairment and a history of wandering left the facility undetected and was later found after spending the night away. Staff failed to document the resident's absence, notifications to family and authorities, or the resident's return in the medical record, contrary to facility policy requiring such documentation.
The facility failed to keep the courtyard clean and safe, with broken and dirty furniture, overgrown walkways, malfunctioning doors, and structural hazards such as a hole in the roof and fallen gutter. Residents and staff reported limited use of the area due to these issues, and outdoor activities were not conducted because of the unsafe conditions.
Three residents with cognitive and behavioral impairments were not comprehensively assessed for their activity preferences, and their care plans lacked specific interventions to meet their needs. Staff relied mainly on passive activities like television, with inaccurate or missing documentation of participation. The Activities Director reported no comprehensive assessment process and difficulty obtaining supplies, resulting in vague activity calendars and unmet resident needs.
The facility failed to ensure proper hair covering practices in the kitchen, potentially affecting all 75 residents receiving food. The Dietary Manager's dreadlocks were not covered by his hair net, and two dietary staff members had uncovered beards. The facility's policy requires all dietary staff to wear effective hair restraints covering all exposed body hair, including facial and head hair.
The facility failed to maintain a clean and homelike environment, with issues in the outdoor smoking area, dining room, and resident rooms. Overflowing trash, food particles, and inappropriate cleaning equipment were observed in common areas. Resident rooms had dirt, odors, broken furniture, and exposed wires. A room previously occupied by a discharged resident was not cleaned. Housekeeping practices did not align with the facility's policy.
A resident with severe cognitive impairment and multiple diagnoses was improperly placed in a secured unit without documented justification. Despite being assessed as low risk for elopement and having no wandering behaviors, the resident was admitted to the secured unit due to a lack of available rooms and the Admissions Coordinator's decision, who lacked medical training. The facility's policy required evaluations for wandering and elopement risks, which were not followed in this case.
Two residents in the facility did not receive scheduled showers and personal hygiene assistance, missing six out of sixteen opportunities. Both residents, who required substantial assistance due to medical conditions, were observed with poor hygiene and reported inconsistent care. Staff interviews revealed that shower aids were often reassigned, leading to missed showers without proper documentation, contrary to facility policy.
The facility failed to maintain clean and sanitary shower rooms, affecting 53 residents. Observations revealed dirt, debris, cracked tiles, and mold in the shower areas. Staff and residents confirmed the unsanitary conditions, with some staff avoiding the use of the shower rooms. Despite a new cleaning schedule, issues persisted, and residents expressed dissatisfaction with the facilities.
Insufficient Nursing Staffing and Delayed Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. Review of the Facility Assessment showed the facility expected a full-time DON, ADON, Unit Manager, and MDS Coordinator on day shift, along with direct-care staffing ratios for nurses and CNAs across all three shifts. Review of the PBJ report for the third quarter of 2025 showed a one-star staffing rating and low weekend staffing. Review of multiple schedules and time punch records showed staffing levels below the facility’s posted expectations on several dates, including shortages of CNAs, LPNs, and RNs, and instances where the DON worked as a floor nurse to cover staffing gaps. On 01/15/26, there was no shower aide on day shift, only two of seven CNAs worked eight hours, and the total direct care hours per resident day was 2.66. On 04/14/26 and 04/24/26, the DON was the only RN counted for the required RN coverage. On 04/27/26, actual CNA and LPN hours were below the posted staffing hours on both day and night shifts, and the PPD was 2.55. On 04/28/26, there were only two nurses after 11:30 P.M. until the wound nurse/LPN arrived in the early morning, and the posted RN night hours were 16 while actual RN hours were four. On 05/10/26, the posted RN night hours were 12 while actual RN hours were zero. The Administrator acknowledged awareness of staffing issues and verified that some staffing records were completed by person while others were completed by hours. The DON also worked multiple shifts as a staff nurse, including extended hours on several dates in April and May, and she verified she worked those hours as a floor nurse. The DON stated she did not know what the expectation was for the DON covering the floor and said she was not familiar with the Facility Assessment. Former RN #606, LPN #531, LPN #543, WN/LPN #539, and CNA #507 described a staffing breakdown on 04/28/26 when the scheduled nurse left, no replacement was immediately available, calls to on-call staff and administration were unsuccessful or delayed, and the medication cart keys were taken to the police station. Staff also reported that the building was understaffed, call lights were slow to be answered, and there were times when no nurse remained on the secured unit and second floor. Resident #10 was observed with a strong odor of stool, food on his chest, dried stool on the skin, and redness of the buttocks. The resident stated he had last been checked or changed earlier in the day, and CNA #521 confirmed he had not been changed before or after the meal. CNA #521 stated the unit was short-staffed, that staff were not allowed to check and change during meals, and that residents who became incontinent during meals or tray pass had to wait. On another observation, Resident #10 again had a strong foul odor of stool, and staff confirmed stool was present. Other residents also reported slow response to call lights, low staffing at night, and delays in incontinence care, showers, and tray passing.
DON Worked Floor Nurse Shifts During High Census
Penalty
Summary
The facility failed to ensure the DON worked full-time as the DON and did not work as a staff nurse when the census was over 60. Review of staff schedules and time punch detail showed the DON worked floor nurse shifts on 04/08/26 from 9:11 A.M. to 7:00 P.M., 04/11/26 from 7:08 A.M. to 7:24 P.M., 04/20/26 from 08:41 A.M. to 7:38 P.M., 04/21/26 from 8:48 A.M. to 8:35 P.M., 04/22/26 from 8:00 A.M. to 6:37 P.M., 04/25/26 from 3:44 P.M. to 6:00 P.M., 04/27/26 from 8:36 P.M. to 11:30 P.M., 04/29/26 from 7:44 A.M. to 11:31 P.M., and 05/01/26 from 10:14 A.M. to 11:12 P.M. The DON confirmed in interview that she worked those hours as a floor nurse. The facility daily census was 83 on 04/08/26, 83 on 04/11/26, 80 on 04/20/26, 80 on 04/21/26, 78 on 04/22/26, 78 on 04/25/26, 79 on 04/27/26, 79 on 04/29/26, and 90 on 05/01/26.
Smoking materials kept in resident rooms
Penalty
Summary
The facility failed to maintain a safe environment by allowing smoking materials, including lighters, cigarettes, tobacco paraphernalia, and vapes, to be kept in resident rooms and on residents’ persons, despite facility smoking policy stating that residents were not permitted to keep smoking articles in their possession and that electronic cigarettes were not to be kept in resident rooms. Surveyors found this issue affected five residents who were reviewed for smoking: Residents #6, #31, #60, #73, and #74. Resident #31 had diagnoses including PTSD, schizophrenia, and cannabis use, and was severely cognitively impaired with assistance needs for eating, bed mobility, and toileting hygiene. Her care plan identified her as a current vape user and non-compliant with vape materials. During observation, a vape was found on top of the stand in her room, the room had a strong odor of recently used vape, and the resident stated she used the vape in her room whenever she wanted. A CNA confirmed the resident had several vapes in her room and had used them unattended since admission. An LPN stated the resident’s family mailed vapes to her because she was allowed to vape in her room unattended, while the SWD stated residents who smoked or vaped were supposed to go outside and that the resident did not fully understand the rules. Resident #6 had diagnoses including spinal stenosis, muscle weakness, schizoaffective disorder bipolar type, and nicotine dependence, and was mildly cognitively impaired. He was observed smoking in the courtyard and removed a bag of cigarettes from his shirt pocket and a lighter from his pants pocket. Later, he confirmed he kept cigarettes and a lighter in his room and showed them to surveyors. Resident #60, who had diagnoses including polyosteoarthritis, unspecified dementia, and nicotine dependence, was cognitively intact and used a wheelchair; he was observed in his room with a partially smoked cigarette and lighter in his coat pocket. Resident #73, who had lung cancer, COPD, and nicotine dependence, was cognitively intact and was observed in his room with a lighter in his pants pocket while unattended, and later confirmed to keep cigarettes and a lighter in his room. Resident #74, who had syncope and collapse and nicotine dependence, was cognitively intact and used a wheelchair and/or walker; he was observed with cigarettes in a dresser drawer and a lighter in his pants pocket, and staff confirmed he stored smoking materials in his room.
Resident’s Request to Avoid Specific CNA Not Honored
Penalty
Summary
The facility failed to respect and honor a resident’s choice not to receive care from CNA #588. Resident #39 was admitted on 07/25/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The Annual MDS assessment showed the resident was moderately cognitively impaired, used a wheelchair, was always incontinent of urine, occasionally incontinent of bowel, and was dependent for toileting hygiene and bed mobility. During observation on 05/12/26, the resident was lying in bed, incontinent, and waiting for staff assistance with care. During the care episode, CNA #511 stated she had to add Resident #39 to her assignment when CNA #588 worked because the resident did not want CNA #588 caring for her. While CNA #511 was providing incontinence care, CNA #588 entered the room, and Resident #39 stated loudly, “I don’t want her in here.” CNA #511 responded, “Shhh,” shook her head no, and whispered, “It will be alright,” and CNA #588 remained in the room and assisted with turning and repositioning. Later, Resident #39 stated she had told staff she did not want CNA #588 in her room because CNA #588 had cursed at her before, which made her feel bad and cry. CNA #511 stated she had not told anyone because she thought everyone already knew, and the DON stated she was not aware the resident did not want care provided by CNA #588.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to complete a Self-Reported Incident after an allegation of verbal abuse was made by Resident #39 against CNA #588. Resident #39, who was admitted on 07/25/23 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, reported that CNA #588 cursed at her, told her it made her feel bad, and caused her to cry. During the interview, Resident #39 appeared stressed and became teary eyed while describing the incident and stating she did not want the CNA in her room. The DON was notified of the allegation and repeated that an investigation was needed, but review of the facility’s Self-Reported Incidents submitted to the State Agency from 05/12/26 to 05/14/26 showed that no SRI was initiated for the abuse allegation. The DON and Administrator later confirmed that if a resident alleged that a CNA cursed at her and made her cry, an SRI should have been opened, and the DON confirmed she had been notified of the allegation but no SRI was completed.
Failure to Initiate Abuse Investigation and Remove Alleged Perpetrator
Penalty
Summary
The facility failed to initiate an abuse investigation after an allegation that CNA #588 cursed at Resident #39 and made her cry, and it did not take action to prevent further mistreatment by the alleged perpetrator pending the outcome of the investigation. Resident #39 was admitted on 07/25/23 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. During interview, Resident #39 stated that CNA #588 cursed at her, that she cried, and that she did not want the CNA in her room. The resident appeared stressed and became teary eyed during the interview. The DON was notified of the allegation and repeated that an investigation was needed, but later stated she had spoken to CNA #588 before speaking with the resident. CNA #588 was still working on the unit where Resident #39 resided, and the DON and Administrator confirmed that an SRI was not opened, CNA #588 was not suspended, and an investigation was not initiated per facility abuse policy. The facility policy required abuse investigations to be completed within five working days and stated that if the accused is an employee, the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation.
Delayed Incontinence Care and Soiled Briefs
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for toileting hygiene and was always incontinent of stool. The resident had diagnoses including gastrostomy malfunction, hemiplegia and hemiparesis, muscle weakness, and need for assistance with personal care. The MDS assessment documented that the resident was cognitively intact, had an indwelling catheter, had one-sided upper and lower extremity impairment, and was dependent on toileting hygiene. The care plan identified risk for skin breakdown related to decreased mobility, desensitized skin, and bowel incontinence, with interventions to keep the skin clean, dry, and odor-free and to check for incontinence with cleansing and drying when wet or soiled. During observation, the resident was found in bed with a strong odor of stool in the room, food on his chest, dried stool on the skin, and redness of the buttocks. The resident stated he had last been checked or changed at 8:00 A.M. A CNA confirmed the resident had finished eating earlier but had not been changed before or after the meal. On another observation, the resident again had a strong foul odor of stool, and the resident stated he had last been changed at 10:30 A.M. A CNA stated the resident had been checked at 11:00 A.M. and said, "He always smells like that. He is tube fed." The CNA also stated she was going on break and would check the resident later. The primary CNA reported the unit was short-staffed, that staff were not allowed to check and change during meals, and that residents who became incontinent during meals or tray pass had to wait. The facility policy stated that when a resident was always incontinent, staff would use a check-and-change strategy at regular intervals to maintain dignity and comfort and protect the skin.
Therapeutic Diet Not Followed for Resident on Renal Diet
Penalty
Summary
A physician-ordered therapeutic diet was not followed for Resident #13. The resident was admitted with diagnoses including end stage renal disease with dependence on dialysis, cognitive social or emotional deficit following stroke, vascular dementia, and type II diabetes mellitus. The 05/13/26 MDS showed moderate memory impairment and that the resident was independent for eating. A 03/06/26 physician order specified a liberalized renal diet with regular texture and thin liquids, and the care plan identified a nutritional problem related to end stage renal disease on hemodialysis, type II diabetes mellitus, and the need for a therapeutic diet, with an intervention to provide and serve the diet as ordered. Review of the facility menu for the Wednesday renal diet showed that the meal should have included buttered cabbage, but observation on 05/13/26 at 11:46 A.M. with the Regional Dietary Manager confirmed the tray prepared for Resident #13 contained spinach instead of buttered cabbage. The Regional Dietary Manager confirmed the menu stated renal diets were to receive buttered cabbage and that it had not been prepared prior to the start of tray line. The facility policy stated therapeutic diets were to be reviewed by the clinical dietitian, nursing staff, and attending physician, and that the food services manager was to use a tray identification system to ensure each resident received the diet ordered.
Failure to Ensure Nursing Staff Held Proper BLS CPR Certification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff held appropriate and current Cardiopulmonary Resuscitation (CPR) certification consistent with facility policy and the needs of residents who had elected full code status. Surveyors reviewed personnel records and found that multiple nurses, including several LPNs and an RN, either had no CPR certification on file or held CPR cards that did not specify Basic Life Support (BLS) or healthcare provider-level training. Specifically, LPNs with certain hire dates had no CPR certification in their files, and an RN also lacked any documented CPR certification. Other LPNs possessed CPR cards that covered adult, child, infant, and AED use, but the cards did not indicate that the training was BLS or designated for healthcare providers. The Director of Nursing confirmed during interview that several identified staff members had no current CPR certification on file and that others had CPR certifications that did not include BLS or healthcare provider designation. Facility policy on Licensure, Certification, and Registration of Personnel required staff who need a license or certification to present verification to Human Resources prior to or upon employment. Another policy on Emergency Procedure Cardiopulmonary Resuscitation required key clinical staff, including non-licensed personnel who would direct resuscitative efforts, to obtain and maintain American Red Cross or American Heart Association certification in BLS CPR. These findings affected residents who had chosen full code status, as the facility did not ensure that staff responsible for providing resuscitation met the specified CPR certification requirements.
Delayed Response to Resident Respiratory Distress After Dislodged Tracheostomy
Penalty
Summary
The deficiency involves the facility’s failure to timely address a resident’s change in respiratory condition after the resident’s tracheostomy inner cannula became dislodged. The resident had a history of tracheostomy, chronic respiratory failure with hypoxia, laryngeal cancer, malnutrition, and received oxygen therapy, trach care, suctioning, and enteral nutrition. The care plan included maintaining oxygen saturation at or above 92% with humidified oxygen via trach mask and providing suctioning and positioning for easier breathing. The resident was cognitively intact, dependent on staff for several ADLs, and had a full code order, later electing hospice with orders to discontinue labs and not hospitalize. On the morning of the incident, the resident’s trach inner cannula became dislodged around 5:50 A.M., and a CNA observed the resident waving and pointing to the disconnected trach equipment, indicating difficulty breathing. The CNA immediately notified an LPN, who was passing morning medications, that the resident was having trouble breathing and that the trach hose was disconnected. The LPN told the CNA to give him a few minutes to finish medication administration instead of immediately assessing the resident. The CNA remained with the resident for about eight minutes, then left to notify another CNA that the LPN had not yet come, and then resumed care of other assigned residents. During this period, the resident remained without timely nursing assessment or intervention for the reported respiratory distress. When the LPN eventually entered the room, he observed the resident in respiratory distress and attempted suctioning, at which point the resident pulled out the entire trach tube. The LPN was unable to reinsert the trach tube and left the resident to go to other units to obtain help from additional nurses, leaving the resident alone. Multiple LPNs then returned to the room together, at which time the resident was described as grey and not breathing, with the trach tube lying on his chest. CPR was initiated and EMS was called, but staff accounts and documentation showed inconsistencies and lacked clear times for the onset of distress, initiation of CPR, and EMS contact. The facility’s own investigation and leadership interviews confirmed there was a delay in addressing the resident’s change in condition, that a staff member did not remain with the resident, and that a code was not called through the overhead paging system as expected by facility policy.
Failure to Ensure Availability and Administration of Ordered Pain Medication
Penalty
Summary
Surveyors identified a failure to ensure ordered pain medications were available and administered as prescribed for Resident #58. The resident was admitted on 09/01/24 with diagnoses including rheumatoid arthritis, failure to thrive, depression, and post cholecystectomy syndrome. A quarterly MDS dated 01/07/26 documented intact cognition, dependence on staff for toileting and transfers, and the presence of pain managed with scheduled and PRN pain medications. Physician orders for January 2026 included Oxycodone 15 mg every four hours and Acetaminophen 500 mg every six hours as needed. Review of the January 2026 MAR showed that on 01/20/26, multiple scheduled Oxycodone doses at 6:00 A.M., 10:00 A.M., 2:00 P.M., and 6:00 P.M. were marked as not administered with directions to see progress notes. Progress notes on 01/20/26 at 10:07 A.M., 1:13 P.M., and 5:42 P.M. documented that Oxycodone doses were not given because the facility was waiting for the pharmacy to deliver the medication. Further review of the MAR revealed additional missed Oxycodone doses on 01/25/26 at 10:00 P.M. and on 01/26/26 at 2:00 A.M., 6:00 A.M., and 2:00 P.M., which were left blank with no explanatory documentation. In an interview on 01/29/26 at 5:00 P.M., the DON confirmed that Oxycodone was not administered on 01/20/26, 01/25/26, and 01/26/26 due to delays in pharmacy delivery and acknowledged there were no notes explaining the missed doses on 01/25/26 and 01/26/26. Facility policy on administering medications, revised December 2012, required medications to be administered safely, timely, and in accordance with prescribed orders, including required time frames. This deficiency was cited under Complaint Number 2711748.
Incomplete and Inaccurate Documentation of Behavioral Event and Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with its charting and documentation policy. For one resident with rheumatoid arthritis, failure to thrive, depression, anxiety, and PTSD, the quarterly MDS showed the resident was cognitively intact with moderate depression and dependent on staff for toileting hygiene, showers, and transfers. A progress note documented that the resident was exhibiting hallucinations and making accusations that staff were stealing belongings, drugging her, and transferring her against her will, and that she had called EMS to report people were “messing with” and stealing her furniture. However, this progress note did not document that the resident was pink slipped by the physician for psychiatric evaluation. A hospital summary later showed that the resident arrived via EMS with a pink slip from the facility citing agitation, threats toward staff, refusal of care, hallucinations, and paranoia, indicating a discrepancy and omission in the facility’s medical record. For another resident with type II diabetes, Alzheimer’s disease, cognitive communication deficit, hip pain, and anxiety, the quarterly MDS indicated cognitive impairment and a need for limited assistance with eating, toileting, showering, and transfers. The care plan identified impaired cognitive function and thought processes related to Alzheimer’s disease, with interventions including medication administration as ordered and cueing, reorientation, and supervision as needed. A Self-Reported Incident documented a resident-to-resident altercation in a secured unit, in which this resident reported being pushed by another resident; staff intervened, separated, and redirected both residents, and assessed them with no injuries, and the incident was ultimately unsubstantiated. Despite this, there was no corresponding documentation in the resident’s progress notes regarding the allegation of resident-to-resident abuse or the altercation. The DON confirmed the absence of documentation for both the pink slip for the first resident and the altercation involving the second resident, contrary to the facility’s policy requiring documentation of changes in condition, events, incidents, or accidents involving residents.
Failure to Provide Consistent, Palatable, and Appropriately Portioned Meals
Penalty
Summary
The facility failed to ensure that food portions were appropriate and that meals served were palatable for residents, with the exception of one resident who did not consume meals from the kitchen. Observations during a lunch tray line revealed inconsistencies in portion sizes, with residents on pureed diets receiving different amounts of food compared to those on regular diets, and the last group of residents served receiving smaller portions as food supplies ran low. Additionally, food items such as pureed spaghetti, salad, and garlic bread were not kept within the steam tables, and some food temperatures were not recorded or were recorded incorrectly. The temperature log was not consistently updated, and not all required food temperatures were obtained prior to meal service. Further observations showed that as meal service continued, the quality of the food deteriorated, with spaghetti noodles hardening and becoming crusty. Staff confirmed they were attempting to stretch limited food supplies to serve all residents, resulting in inconsistent portion sizes that did not match the recommended amounts listed on the facility's spreadsheet. A test tray revealed that some food items were served at inappropriate temperatures, and staff were unsure of the correct serving temperatures. Review of facility policy indicated that meals should be nourishing, palatable, well-balanced, and served at safe and appetizing temperatures, but these standards were not met during the observed meal service.
Building Disrepair, Trash Accumulation, and Mold in Resident and Staff Areas
Penalty
Summary
The facility failed to maintain the building in good repair and free of trash buildup, as evidenced by multiple observations in the basement and laundry areas. Surveyors observed two large bins of trash overflowing, several large bags of trash on the ground, and a housekeeping room with a strong odor of mold, flying insects, and approximately ten clear bags of trash piled along the wall. Additionally, two large tubs were collecting water leaking from a sewage pipe, which the Maintenance Director confirmed had not been successfully repaired. The laundry area was found to have water running down a brick wall next to the dryer, with a black mold-like substance present, and staff confirmed persistent mold or mildew odors in the basement. The Maintenance Director also confirmed that the water intrusion in the laundry room was due to a crack in the foundation, allowing melting snow to enter and cause mold buildup. Further observations included a first-floor nursing unit shower room where black mold was visible between the tiles near the floors of both shower areas, as confirmed by a CNA. The facility's policy on providing a safe, clean, and odor-free environment was reviewed, which was not being followed as evidenced by the unsanitary conditions, trash accumulation, and presence of mold and insects. These deficiencies had the potential to affect all 75 residents in the facility and were investigated under multiple complaint numbers.
Failure to Complete Fall Assessments, Documentation, and Interventions
Penalty
Summary
The facility failed to ensure that fall assessments were completed, falls were documented in the medical record, fall prevention interventions were in place, and fall investigations were thorough for multiple residents. For one resident with a history of syncope, falls, and diabetic neuropathy, there were several instances where falls were either not documented in the medical record, follow-up assessments were missing, or interventions such as non-skid strips were not implemented as care planned. Staff interviews confirmed a lack of awareness regarding required interventions, and documentation did not consistently include vital signs, neurological checks, or pain assessments after falls. Another resident with vascular dementia and a high risk for falls experienced a fall that was not documented in the progress notes until the following day, with no evidence of vital signs being recorded or a comprehensive assessment of a resulting skin tear. The care plan interventions, such as therapy for transfers and keeping the room free of clutter, were not consistently documented as being followed or evaluated after incidents. Staff interviews confirmed gaps in documentation and assessment following falls. Additional residents with cognitive impairment and a history of falls also experienced similar deficiencies. Falls were not consistently documented in the medical record, and there was a lack of detail regarding the circumstances of the falls, whether they were witnessed, and the assessments performed afterward. In one case, neurological checks were not continued as required, and there was no documentation of immediate interventions or witness statements. Facility policy required thorough documentation and assessment after falls, but these procedures were not consistently followed, as confirmed by staff interviews and record reviews.
Failure to Accommodate Resident Needs: Stoma Supplies and Television Access
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents, specifically regarding timely access to appropriate stoma supplies and the availability of a working television. For one resident with a urostomy due to a malignant neoplasm of the urinary organs and severe cognitive impairment, there were repeated issues with the availability and appropriateness of urostomy pouches. The resident's care plan required specific stoma care and monitoring, but staff and family reported that the correct supplies were not consistently available. The facility initially provided generic pouches that did not function properly, leading to leakage and distress for the resident. Staff interviews revealed miscommunication and delays in ordering the correct supplies, with insurance approval and administrative turnover contributing to the problem. The resident's family had to supply pouches upon admission and expressed frustration over the lack of communication and continuity of care. Observations confirmed that the resident's urostomy pouch was frequently overfilled, contrary to manufacturer instructions that it should be emptied when one-third to one-half full. Staff acknowledged that when the pouch was not emptied in a timely manner, the resident would manipulate it, causing further leakage. Documentation and interviews indicated that the facility was aware of the issue for several weeks before the correct supplies were consistently ordered and available. The resident's daughter reported that she was not informed when supplies ran out and had to instruct staff on proper pouch application, as improper technique led to excessive use of supplies and further complications. For another resident with severe cognitive impairment and multiple chronic conditions, the facility failed to ensure the availability of a working television after the resident was temporarily relocated due to a water pipe break. The resident, who preferred watching television as a primary activity, was moved to a room without a functioning television, and there was no documentation in the medical record regarding the move or the lack of television. The administrator confirmed the absence of documentation and the non-functioning television during the survey. These failures affected the residents' ability to have their needs and preferences accommodated as required.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property for a resident to the State agency, as required by policy. The resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, had multiple personal items go missing, including a phone, an abdominal binder, and dentures. Documentation showed that the resident's daughter reported the missing phone and abdominal binder to staff, and the missing items were noted in the facility's log. However, there was no evidence that these incidents were reported to administration or the State agency as required. Staff interviews confirmed awareness of the missing items but could not confirm if they had been reported or investigated appropriately. The facility's policy required immediate reporting of alleged misappropriation of resident property to the administrator or designee, and to the State agency within specified timeframes. Despite this, the administrator confirmed that no self-reported incident had been completed for the missing items, and there was no documentation of efforts to remedy the situation or determine whether the items were misappropriated or misplaced. The deficiency was identified during a complaint investigation and was a repeat finding from a previous survey.
Failure to Investigate Missing Resident Property
Penalty
Summary
The facility failed to thoroughly investigate missing personal items for a resident with severe cognitive impairment, including two phones, an abdominal binder, and dentures. The resident's daughter reported the missing phone and abdominal binder to staff, and the missing items were noted in the facility's log. However, there was no evidence that these incidents were reported to or investigated by administration, nor was there documentation of any formal investigation or self-reported incident (SRI) being completed. Staff interviews revealed uncertainty about the whereabouts of the items and whether they had been reported missing, despite the facility's policy requiring immediate reporting and investigation of such incidents. The resident in question had diagnoses of heart disease, dementia, anxiety, and depression, and required significant assistance with daily activities. The care plan indicated the dentures had been missing for several months, but there was no documentation of an investigation or administrative follow-up. Observations confirmed the missing items were not present in the resident's room or designated storage areas. The administrator acknowledged that no investigation had been initiated for the missing items, contrary to facility policy, which mandates investigation and documentation of alleged misappropriation of resident property.
Failure to Schedule Timely Care Conferences
Penalty
Summary
The facility failed to ensure that a resident's care conference was scheduled within the required timeframe, as mandated by facility policy and federal regulations. Record review showed that the resident, who had diagnoses including type 2 diabetes mellitus, multiple sclerosis, and neuromuscular dysfunction of the bladder, was admitted on 07/09/20 and had significant care needs, including dependence on staff for hygiene and an indwelling catheter. Despite these needs and a care plan revision on 06/26/25, there was no evidence in the medical record or facility care conference schedule that a care conference had been held or scheduled for the resident during the required period. The quarterly MDS assessment confirmed the resident had moderate cognitive impairment and required substantial assistance with daily activities. Interviews with the Social Services Designee (SSD) revealed a lack of understanding regarding the required frequency of care conferences, with the SSD stating she believed they were annual rather than quarterly and had only recently learned of the correct schedule. The SSD also indicated she was new to the role, had minimal training, and was attempting to catch up on overdue care conferences left by the previous SSD. The facility identified additional residents who were also overdue for care conferences. Facility policy requires the care plan to be developed and reviewed by an interdisciplinary team within seven days of the comprehensive assessment, with participation from the resident, family, or legal representative encouraged.
Failure to Provide Timely and Appropriate ADL, Skin, and Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate care and services to three residents who were dependent on staff for activities of daily living (ADL), including incontinence care, skin care, and oral hygiene. One resident with multiple diagnoses, including respiratory failure, stroke, and reduced mobility, was observed to have her call light activated for over 20 minutes before staff responded to provide incontinence care. Staff interviews confirmed that call lights were not always answered within the expected timeframe due to staffing constraints, and the resident herself reported sometimes waiting up to three hours for incontinence care. Another resident, admitted with chronic respiratory failure, diabetes, and morbid obesity, was dependent on staff for all ADLs and had a history of skin issues. During a temporary relocation due to a water leak, this resident and two others were not provided with timely incontinence care, resulting in prolonged exposure to soiled conditions. Observations revealed the resident had very dry, peeling skin on her feet, a bleeding open area on her buttock, and was not offered lotion or oral care during routine care. Staff interviews indicated that aides did not consistently apply prescribed creams or offer mouth care, and there was a lack of documentation regarding the open wound. A third resident with severe cognitive impairment and hemiplegia was also dependent on staff for most ADLs. During care, this resident was found to have very dry, flaky skin on the lower legs and feet, and red buttocks, but no lotion or mouth care was provided or offered. Staff confirmed that lotion was typically only applied on shower days and mouth care was not routinely performed. Facility policies required that lotion or cream be offered during care and that mouth care be provided, but these were not followed. The DON confirmed that staff should have offered these services according to policy.
Failure to Address Changes in Condition and Ensure Timely Intervention
Penalty
Summary
The facility failed to properly address changes in condition for two residents, resulting in deficiencies related to timely assessment, intervention, and communication with medical providers. One resident with a history of bipolar disorder, morbid obesity, stroke, and other conditions reported chest pain and was observed grabbing at her chest. Despite being a full code, she refused hospital transport multiple times, was given an antacid without a physician's order, and the physician was notified only after administration. Later that evening, she was found on the floor, assessed for injury, and again refused hospital evaluation. She was subsequently found unresponsive in her wheelchair and CPR was initiated, but she could not be revived. Documentation revealed that she had refused assessments and vital signs throughout the day, and there was a lack of documented follow-up care or assessment after her initial complaint of chest pain. Another resident, who was moderately cognitively impaired and receiving hospice services, experienced a change in condition characterized by unresponsiveness, altered mental status, and abnormal breathing. Although the nurse practitioner was eventually notified and ordered hospital transfer, prior to this event, staff failed to assess or notify hospice or the physician about the resident's declining condition. Interviews revealed that staff were unaware of the resident's code status and did not know where to locate it, leading to a lack of timely intervention. The resident was ultimately found unresponsive and sent to the hospital, where he was intubated and later passed away. Facility policy required staff to recognize and communicate significant changes in residents' health status, make detailed observations, and report pertinent information to the physician. However, in both cases, staff did not follow these protocols, resulting in missed assessments, delayed notifications, and inadequate documentation of the residents' conditions and care provided during acute changes.
Failure to Timely Identify and Treat Urinary Tract Infections
Penalty
Summary
The facility failed to timely identify and treat urinary tract infections (UTIs) for two residents, resulting in deficiencies related to the management of urinary health. For one resident with vascular dementia and a history of urinary tract infections, a urine specimen was collected as ordered, but the results were not completed or reported to the physician or nurse practitioner. The specimen, collected on a Friday, was likely discarded because the lab did not pick up specimens on weekends, and it was not resent. There was a significant delay before a new specimen was collected and processed, during which time the resident did not receive appropriate follow-up for potential infection. Another resident with multiple sclerosis, diabetes, and a neurogenic bladder had an indwelling catheter and was at risk for catheter-associated complications. This resident exhibited confusion, prompting an order for a urine specimen. The initial specimen was collected and reported as probably contaminated, with a recommendation to repeat the test. However, there was no evidence that a repeat specimen was collected or sent to the lab as ordered. Documentation was lacking regarding the collection and handling of urine specimens, and the resident subsequently experienced discomfort, required catheter replacement, and was hospitalized with a diagnosis of UTI and sepsis. Both cases demonstrated failures in following up on laboratory results, ensuring timely specimen collection, and maintaining adequate documentation. The deficiencies were compounded by changes in medical staff and poor communication, resulting in lapses in care for residents with significant urinary health risks.
Failure to Ensure Timely Transportation for Dialysis Appointments
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident requiring dialysis was transported to scheduled dialysis appointments as ordered by the physician. The resident, who had end stage renal disease, type 2 diabetes, and vascular dementia, was dependent on staff for mobility and personal care, and required dialysis three times per week. Documentation revealed that the resident missed multiple dialysis appointments due to failures in transportation arrangements and communication among facility staff and the transportation provider. On at least two occasions, the resident missed dialysis appointments. On one occasion, the transportation company did not arrive, and on another, the transportation provider reported that the driver arrived on time but could not locate staff to bring the resident to the lobby, resulting in the resident not being transported. There was conflicting information from staff regarding whether the resident was waiting in the lobby, but no documentation supported that the resident was present and ready for pick-up. The facility's process for notifying and preparing residents for transportation was inconsistent, with some staff unaware of scheduled appointments and others not following established procedures for confirming transportation. As a result of missed dialysis, the resident experienced a decline in condition and required hospitalization for missed dialysis, where she received two sessions of dialysis. Interviews with staff and the resident's family member confirmed that the resident had missed dialysis appointments while at the facility. The facility's policy required arrangements for safe transportation to and from dialysis, but this was not consistently implemented, leading to the deficiency.
Failure to Provide Timely Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to provide appropriate dental services to a resident who was severely cognitively impaired and dependent on staff for personal care, including oral hygiene. The resident was admitted with multiple diagnoses, including heart disease, dementia, anxiety, and depression, and had upper and lower dentures identified as missing. Despite facility policy requiring referral for dental services within three days of lost dentures, the resident's dentures were not promptly replaced, and there was no evidence of timely dental intervention or documentation regarding measures taken to ensure adequate nutrition and hydration while awaiting dental services. Staff interviews revealed uncertainty about when the dentures were lost and a lack of awareness regarding the resident's current dental status. The Social Service Designee confirmed that the resident should have been seen by a dentist as soon as the dentures were found missing, but the first dental appointment occurred months after the loss. The facility's failure to follow its own policy and ensure timely dental care resulted in the resident being without dentures for an extended period.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report a resident elopement to the State Agency as required. A resident with diagnoses including chronic obstructive pulmonary disease, alcohol dependence with alcohol-induced dementia and psychotic disorder, and moderate dementia with psychotic disturbance was identified as being at risk for elopement due to disorientation, impaired safety awareness, and wandering behaviors. The resident's care plan included interventions such as distraction and structured activities, but no alarms or wander guards were in place. The resident was assessed as low risk for elopement, but an endangered missing adult alert was issued when the resident went missing. There were no nursing progress notes documenting the resident being missing or returning to the facility. During an interview, the Administrator confirmed that the facility did not notify the State Agency or open a self-reported incident through the Ohio Department of Health's Certification and Licensure System after being notified of the resident's absence. Facility policy required staff to investigate and report missing residents, but the policy was vague and did not specifically mention reporting elopements to the state agency. Another policy required notification of the Ohio Department of Health for all alleged violations involving abuse, neglect, or exploitation within 24 hours, but this was not followed in this case.
Failure to Prevent Resident Elopement and Ensure Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, psychotic disturbance, and impaired safety awareness eloped from the facility without staff knowledge. The resident was assessed as having moderate cognitive impairment and required supervision for activities of daily living, but was considered low risk for elopement according to the facility's assessment. The care plan included interventions such as distraction from wandering and offering structured activities, but there were no alarms or wander guards in place, and no physician orders for safety monitoring devices or a secured unit. On the day of the incident, the resident was last seen by staff and other residents at various times in the afternoon, with the last confirmed sighting being when the resident was observed leaving the building through the front exit doors. Staff did not notice the resident was missing until several hours later when medication administration was attempted. A search was initiated inside and outside the facility, and the police and family were notified. The resident was eventually found the next morning by a staff member searching the surrounding area, having walked several miles to a previous address and spending the night in a car in cold weather. Documentation in the resident's medical record was lacking, with no evidence of the resident being observed missing, notifications, or details of the resident's return. The incident was also not recorded in the facility's incident/accident log. Staff interviews revealed inconsistent accounts of the resident's whereabouts and the timing of events, and the facility's policy on elopement required investigation and reporting of missing residents, which was not fully followed in this case.
Failure to Document Elopement and Related Events in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, alcohol-induced dementia, and moderate cognitive impairment. The resident was identified as being at risk for elopement due to disorientation, impaired safety awareness, and wandering behaviors, as documented in the care plan. Despite these risks, the resident was able to leave the facility undetected and was later found by a staff member after having spent the night away from the facility. A review of the resident's medical record revealed significant gaps in documentation. There were no nursing progress notes related to the resident being observed missing, notifications to family, physician, or police, the resident being found, being taken to the hospital, or returning to the facility. The last progress note prior to the incident was dated several weeks before, and the next note was entered days after the resident's return, with no mention of the elopement event or related actions. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that documentation of the incident and subsequent notifications was not completed as required by facility policy. The policy specified that events, incidents, or accidents involving the resident, as well as changes in condition and notifications, should be documented in the medical record. The lack of documentation represented a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Courtyard Not Maintained in Clean and Safe Condition
Penalty
Summary
The facility failed to maintain the courtyard in a clean and safe condition, as evidenced by multiple interviews, observations, and record reviews. Residents and staff reported limited use of the courtyard due to broken and dirty furniture, uneven ground, and malfunctioning doors. The Activities Director stated that outdoor activities had not been conducted this year because of these issues, and a grievance regarding the patio chairs had been submitted. Resident Council records also indicated requests for improved access and furniture in the outdoor area. Observations confirmed the presence of broken dining room chairs, dirty tables, trash, garden supplies covered in dust and cobwebs, and overgrown garden boxes and walkways. Additionally, there were structural issues such as a hole in the roof, missing shingles, a fallen gutter, and wood debris on the ground. Staff interviews revealed a lack of awareness regarding some of the hazards, such as the hole in the roof, and confirmed that residents only accessed the courtyard under supervision. The outside door's keypad was broken, requiring staff assistance for re-entry. The courtyard's condition, including blocked walkways, empty bird feeders, and unsafe furniture, had the potential to affect all 72 residents in the facility by limiting their access to a safe and clean outdoor environment.
Failure to Assess and Provide Activities to Meet Resident Needs
Penalty
Summary
The facility failed to comprehensively assess and provide for the activity preferences and needs of three residents with significant cognitive and behavioral impairments. For two residents, the Minimum Data Set (MDS) Section F, which addresses preferences for routine and activities, was not completed, and there was no evidence of further assessment or attempts to gather information from family members or significant others as required. For the third resident, while some activity preferences were documented on admission, there was no ongoing assessment or care plan in place to address these preferences. The care plans for the affected residents lacked specific details about the types of activities the residents were interested in, how these activities would be offered, or when they would occur. Observations and interviews revealed that residents on the secured unit, particularly those with severe cognitive impairment or behavioral issues, were not provided with a formal activity program tailored to their needs. Instead, staff primarily relied on passive activities such as watching television in common areas, and some residents were not engaged in any meaningful activities throughout the day. Activity logs were found to be inaccurate, with participation marked for days that had not yet occurred and for activities in which residents did not actually participate. Additionally, some residents had no documentation of activity participation at all. Staff interviews indicated a lack of knowledge about where to find information on residents' interests, and the Activities Director confirmed that no comprehensive assessment process was in place to identify or address activity preferences. The Activities Director also reported challenges in obtaining supplies for activities due to budget constraints and inconsistent approval of requested items. As a result, the activities calendar was kept vague, and planned activities were sometimes not carried out. The facility's policy required the interdisciplinary care team to evaluate residents' personal history and preferences, but this was not consistently implemented for the residents reviewed.
Improper Hair Covering Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper hair covering practices in the kitchen area, which could potentially affect all 75 residents receiving food from the kitchen. During an observation, the Dietary Manager was seen wearing a hair net that did not cover his long dreadlocks, leaving them exposed. Additionally, both the Dietary Manager and two other dietary staff members had uncovered beards while working in the kitchen. One of the dietary staff members mentioned that they did not have beard covers available. The facility's policy requires all dietary staff to wear effective hair restraints that cover all exposed body hair, including facial and head hair, before entering the kitchen. This deficiency was identified during a complaint investigation under Complaint Number OH00161306.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by several observations and interviews. In the outdoor smoking area, trash cans were overflowing with various debris, including styrofoam cups, cigarette packs, and used disposable gloves. Food particles and cigarette butts were scattered on the ground, and bottles of salad dressing and cheese sauce were left on a window ledge. Maintenance staff acknowledged the condition of the area, and the administrator mentioned that a plan was being developed to assign responsibility for cleaning the smoking area. In the dining room, a trash can was observed overflowing with meal tray waste, and the floor was covered with food crumbs and particles. A soiled plunger and dustpan were left in the corner, which residents found unappealing while eating their meals. The administrator and DON confirmed that the dining room should be cleaned after every meal, and the presence of cleaning equipment in the dining area was inappropriate. Resident rooms were also found in unsatisfactory conditions. One resident's room had scattered dirt, food, and trash, with a strong odor of body odor and urine. Another room had broken furniture and exposed wires due to a missing outlet cover. A third room contained dirty silverware, food particles, and a malfunctioning refrigerator with ice buildup. Additionally, a room previously occupied by a discharged resident had not been cleaned, with soiled sheets, trash, and sticky floors. Housekeeping staff indicated that resident rooms were cleaned twice a week, contrary to the facility's policy of cleaning surfaces regularly and when visibly soiled.
Improper Admission to Secured Unit
Penalty
Summary
The facility failed to ensure that a resident met the criteria to be admitted to and reside on the secured unit. This deficiency involved a resident who was admitted with multiple diagnoses, including anoxic brain damage, traumatic brain injury, and bipolar disorder, among others. The resident was severely cognitively impaired and required substantial assistance for daily activities. Despite being assessed as low risk for elopement and having no documented behaviors of wandering or exit-seeking, the resident was placed in the secured unit without documented justification. The decision to place the resident in the secured unit was made by the Admissions Coordinator, who lacked medical training and was unaware of specific guidelines for admission to the secured unit. The resident's parent was initially assured that the facility could address the resident's needs and provide therapy and socialization with peers of similar age. However, upon admission, the resident was placed in the secured unit due to a lack of available rooms and the Admissions Coordinator's belief that the resident would receive more attention there due to a seizure disorder. The Medical Director stated that the secured unit was intended for residents who were a threat to leave the facility or had dementia, and that placement should be determined on a case-by-case basis. The facility's policy for the secured unit emphasized providing a safe environment and preventing accidents related to wandering and elopement, with evaluations conducted as part of the preadmission process and upon changes in residents' conditions or functionality.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents dependent on staff for activities of daily living received adequate assistance with showers and personal hygiene. Resident #24, who was admitted with diagnoses including fibromyalgia, hemiplegia, and muscle weakness, was found to have missed six out of sixteen scheduled showers/baths over a review period. Despite being cognitively intact and dependent on staff for personal hygiene, there was no documentation of make-up days for missed showers, and the resident reported not receiving baths consistently. Observations revealed a foul body odor and unkempt fingernails, indicating a lack of personal hygiene care. Similarly, Resident #70, with diagnoses including asthma, lymphedema, and type two diabetes mellitus, also missed six out of sixteen scheduled showers/baths. This resident required substantial assistance with personal hygiene and reported that staff were sometimes too busy to provide showers. Observations confirmed a strong body odor and dirty fingernails. Interviews with staff, including the DON and a CNA, revealed that shower aids were often reassigned to other duties, leading to missed showers without proper documentation of refusals or attempts to provide care. The facility's policy required documentation of care provided or refused, which was not adhered to in these cases.
Facility Fails to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-repaired environment for its residents, affecting 53 out of 65 residents. Observations revealed that the main shower room on the first floor and the shower room in the secured unit were in poor condition. The floors were covered with dirt and debris, and there were cracked tiles with sharp edges. The shower stalls had black debris between the tiles, and the privacy curtains were stained. Additionally, there were safety strips that had rubbed off, and the presence of a brown substance that appeared to be stool was noted. The spa tub was cluttered with personal items and debris, and the drainpipe was surrounded by sharp wire netting. Interviews with staff and residents confirmed the unsanitary conditions, with some staff expressing reluctance to use the shower rooms due to their state. The Resident Council Meeting notes indicated ongoing complaints about the cleanliness of the shower rooms over several months. Despite the implementation of a new cleaning schedule by the new maintenance director, the issues persisted. Housekeeping staff acknowledged the challenges in maintaining cleanliness, particularly in removing mold from the grout. The lack of scheduled assignments for housekeeping staff prior to the new maintenance director's tenure contributed to the inconsistency in cleaning. Residents expressed dissatisfaction with the shower facilities, with some preferring bed baths due to the unsanitary conditions. The deficiency was investigated under specific complaint numbers, highlighting the facility's non-compliance with maintaining a homelike environment.
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 982 citations issued within 25 miles in the last 12 months — including the 9 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 North Olmsted
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| O'neill Healthcare North Olmsted | 1.1 mi | ★★★★★ | 0 | 0 |
| O'neill Healthcare Fairview Park | 1.6 mi | ★★★★★ | 0 | 0 |
| Welsh Home The | 1.7 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Westlake | 2.2 mi | ★★★★★ | 8 | 0 |
| Aristos Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 33 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.