Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gillette Nursing Home during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the area.
Surveyors identified that shower rooms used by residents were not maintained at comfortable temperatures, with measured ambient temperatures significantly below the facility's policy range. Multiple residents who required assistance with bathing and had complex medical needs reported the shower rooms as cold or chilly, and prior complaints had been documented in Resident Council meetings.
The facility did not timely report suspected misappropriation of narcotic medications to the state agency as required by policy. Two residents with cognitive impairments and pain management needs had narcotics signed out as administered by an LPN, but there was no documentation in the MAR or progress notes to confirm administration. An internal investigation found the LPN tested positive for multiple narcotics, but the incident was not reported to the state health department despite policy requirements.
Two residents did not receive adequate supervision or assistance during transfers and fall prevention, resulting in one being transferred with a mechanical lift by only one staff member instead of two, and another experiencing multiple falls due to inconsistent use of required interventions and incomplete post-fall investigations. Nursing staff interviews and documentation confirmed that fall prevention protocols and root cause analyses were not consistently followed.
A resident with Parkinson's disease and dementia received nuplazid from a specialty pharmacy, and an LPN combined pills from two bottles into one, rather than keeping each bottle in its original packaging as required. The DON, RN, and the resident's daughter were aware of this practice, which was not in accordance with the facility's medication storage policy.
The facility failed to consistently provide showers for a resident with heart failure, diabetes, and other conditions requiring assistance with personal care. Despite the resident's preference for two to three showers per week, records showed only one shower was provided during certain weeks. The resident confirmed the need for assistance and the preference for more frequent showers, which was not met. The DON could not verify compliance with the resident's shower preferences, and the facility's policy on shower documentation was not followed.
A facility failed to ensure a physician visited a resident as required. The resident, with multiple diagnoses including congestive heart failure and cancer, was last seen by a physician on a specific date, with no further visits documented. The resident confirmed the lack of visits, and the DON acknowledged the absence of documentation. Facility policy required regular physician supervision, which was not followed.
A facility failed to implement proper infection control measures for residents on enhanced barrier precautions (EBP). A resident's room lacked signage indicating EBP, and a staff member did not wash her hands after leaving this room and before entering another resident's room, who was also on EBP. The deficiency was confirmed by the Director of Nursing and affected two residents directly, with the potential to impact others.
The facility failed to maintain a homelike environment for residents on the 600 hall, with numerous instances of wall disrepair such as black scrape marks, gouges, and unpainted patches. Observations and resident interviews revealed dissatisfaction with the state of their rooms, and the Maintenance Supervisor confirmed the ongoing challenge of keeping up with repairs. The facility's policy requires maintaining a comfortable interior, but the current conditions do not meet these expectations.
The facility failed to provide nutritionally equivalent food substitutions for five residents during a lunch meal. When the facility ran out of baked beans, the Dietary Manager instructed staff to substitute cottage cheese, which was not nutritionally equivalent as confirmed by the Dietitian.
A resident with severe cognitive impairment was fed by an STNA who stood while feeding, contrary to facility policy requiring staff to sit. The resident, dependent on staff for eating, was seated in a Geri chair, and the STNA initially claimed she couldn't reach the resident's mouth while sitting. The facility's policy emphasized feeding with attention to safety, comfort, and dignity.
A resident's medical record was left visible on an unattended computer monitor in a hallway, compromising confidentiality. Staff confirmed the screen should have been locked, and a nurse aide admitted to leaving it open. The resident had a complex medical history requiring various assistance levels.
The facility failed to implement care plan interventions for a resident with Alzheimer's and contractures, as staff were unaware of brace orders and the splint was removed from the room. Additionally, two residents lacked comprehensive care plans addressing denture management and sensory needs, leading to inadequate care and staff confusion.
A facility failed to hold a timely care plan meeting for a resident with multiple medical conditions, including intracranial hemorrhage and heart disease. Despite requiring significant assistance, no care conference was held since admission. The oversight was confirmed by the resident's family and a social worker, who cited scheduling issues due to her absence.
The facility failed to ensure staff were aware of trauma-informed care needs for three residents with PTSD. Despite care plans outlining interventions for managing triggers, staff interviews revealed a lack of awareness about these plans. This deficiency affected residents with histories of trauma, including one with Alzheimer's and another with schizophrenia, highlighting a gap in implementing the facility's trauma-informed care policy.
A resident with a history of dysphagia was served intact chicken tenders instead of a mechanical soft diet, as required by their dietary needs. The error was identified during a meal service when a surveyor intervened, and the LPN confirmed the mistake. The SLP and RD later verified that the food served did not meet the mechanical soft diet requirements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Shower Rooms Not Maintained at Comfortable Temperatures
Penalty
Summary
Surveyors found that the facility failed to maintain comfortable temperatures in all resident shower rooms, as required by facility policy, which states that temperatures should be kept between 71 and 81 degrees Fahrenheit. During a facility tour, the Maintenance Director measured the ambient temperature in two shower rooms used by residents and found them to be 64.8°F and 55.9°F, both below the required range. Resident Council meeting minutes from previous months documented complaints about the shower rooms being too cold, and these complaints were confirmed by the Assistant Director of Nursing. Interviews with four cognitively intact residents who required assistance with bathing revealed that they experienced the shower rooms as cold, chilly, or ice cold. These residents had various medical conditions, including COPD, cerebral infarction, metabolic encephalopathy, obesity, muscle wasting, polyneuropathy, and chronic lymphocytic leukemia, and all required substantial to maximal assistance with bathing. The deficiency was identified as affecting these four residents and had the potential to affect all residents who did not have personal showers in their rooms.
Failure to Timely Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of narcotic medications to the appropriate state agency, as required by policy. For one resident with a history of liver disease and moderate cognitive impairment, records showed a narcotic was signed out as administered by an LPN, but there was no corresponding documentation in the Medication Administration Record (MAR) or progress notes to confirm the medication was given. Similarly, for another resident with severe cognitive impairment and chronic pain conditions, a narcotic was signed out as administered, but again, there was no documentation in the MAR or progress notes to support that the medication was actually given. A facility investigation into narcotic diversion revealed that the LPN in question tested positive for multiple narcotics and was subsequently suspended and reported to the Board of Nursing. Despite these findings and the facility's own policy requiring immediate reporting of such allegations to the state health department, no self-reported incident (SRI) was filed with the Ohio Department of Health regarding the suspected misappropriation of narcotics. Interviews with the Administrator and Director of Nursing confirmed that they were aware of the suspicions and investigation but did not report the incident to the state agency, as they believed they could not prove misappropriation since residents did receive pain medications. The facility's policy clearly defined misappropriation and required reporting within 24 hours of an allegation, but this protocol was not followed in these cases.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for two residents, resulting in deficiencies related to accident hazards and fall prevention. One resident, who had multiple diagnoses including a recent hip fracture, required transfers with a mechanical lift and two staff members as per physician orders and care plan. However, during a transfer, only one CNA was present, and the resident's feet were not properly positioned on the sit-to-stand lift, causing the resident to be lowered to the floor. This incident was confirmed through interviews and documentation, which verified that the required two-person assistance was not provided during the transfer. Another resident, with a history of Parkinson's disease, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of several months. The care plan and physician orders included interventions such as nonskid socks, a body pillow, and a floor mat to reduce fall risk. Despite these interventions, documentation revealed that fall interventions were not consistently in place, and several falls occurred when required equipment was either not ordered or not documented as being used. Additionally, post-fall investigations were incomplete, lacking thorough root cause analyses as required by facility policy. Many investigation forms were missing critical information about the circumstances of the falls, interventions in place at the time, and environmental factors. Interviews with nursing staff and review of facility records confirmed that fall investigations for this resident were not fully completed and that interventions were not always implemented or documented as required. The facility's own fall protocol policy mandates timely identification of causes and implementation of interventions, but this was not consistently followed. The lack of adequate supervision, incomplete documentation, and failure to ensure fall prevention measures were in place contributed to repeated falls and the identified deficiencies.
Improper Medication Storage: Combining Bottles of Nuplazid
Penalty
Summary
Facility staff failed to ensure that medications were kept in their original packaging as required by policy and professional standards. Specifically, a resident with diagnoses including Parkinson's disease, repeated falls, and dementia with mild psychotic disturbance was prescribed nuplazid, which was obtained from a specialty pharmacy by the resident's daughter. The nuplazid was brought into the facility in bottles containing 30 capsules each. Instead of maintaining each bottle separately, an LPN combined pills from an opened bottle into a new bottle, resulting in the medications being stored together in a single bottle rather than in their original packaging. Interviews with the Director of Nursing, the resident's daughter, an RN, and the LPN confirmed that the practice of combining medication bottles occurred and was known to both staff and the resident's family. The facility's medication storage policy, dated October 2013, required that medications be kept in the original packaging dispensed by the pharmacy. This practice was not followed in this instance, leading to non-compliance with medication storage requirements.
Inconsistent Shower Provision for a Resident
Penalty
Summary
The facility failed to consistently provide showers for Resident #51, who was admitted with diagnoses including heart failure, diabetes, kidney disease, unsteadiness on feet, and required assistance with personal care. The comprehensive Minimum Data Set (MDS) 3.0 assessment indicated that Resident #51 was cognitively intact, independent in eating, but required substantial assistance for toileting, partial assistance for showering, and supervision for personal hygiene. The care plan noted a self-care performance deficit due to functional mobility and lower extremity weakness, with a preference for bathing two to three times per week. However, a review of the shower sheets revealed that Resident #51 only received one shower during the weeks of 12/01/24 and 12/21/24. An interview with Resident #51 confirmed the need for assistance with showering and a preference for at least two showers per week, which was not consistently met. The Director of Nursing (DON) could not provide additional information to verify that showers were provided according to the resident's preference. The facility's policy required documentation of the name, date, and time of showers, as well as any refusals, which was not adhered to in this case.
Physician Visit Noncompliance for a Resident
Penalty
Summary
The facility failed to ensure that a physician visited Resident #36 as required. Resident #36, who was admitted with diagnoses including congestive heart failure, diabetes, anxiety, hypertension, and cancer of the head, neck, and face, was cognitively intact and required varying levels of assistance for daily activities. The medical record indicated that the resident was last seen by the physician on 11/06/24, and an interview with the resident confirmed that he had not been seen by the physician since admission, except for the one documented visit. The Director of Nursing confirmed the lack of documented evidence of any additional physician visits. The facility's policy stated that physicians should actively supervise resident care and visit as required, which was not adhered to in this case.
Infection Control Deficiency Due to Lack of Signage and Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control measures for residents on enhanced barrier precautions (EBP). Specifically, there was no signage at the entrance of Resident #45's room to indicate the need for EBP, despite a physician's order for such precautions due to extended-spectrum beta-lactamase (ESBL) in her urine. Additionally, a staff member, identified as [NAME] #204, did not wash her hands after leaving Resident #45's room and before entering Resident #23's room, who was also on EBP for a wound. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the required signage and the failure of staff to adhere to hand hygiene protocols. Resident #45, who was moderately cognitively impaired, had a history of multi-drug resistant organisms and required EBP as per her care plan. Similarly, Resident #23, who was severely cognitively impaired, required EBP due to a wound. The facility's policy on transmission-based precautions mandates that signs be placed at the entrance of rooms to indicate necessary precautions and that staff wash their hands upon entering and exiting rooms of residents on EBP. The deficiency was identified during a complaint investigation and affected two residents directly, with the potential to impact 23 others identified by the facility as being on EBP.
Facility Fails to Maintain Homelike Environment Due to Wall Disrepair
Penalty
Summary
The facility failed to maintain a homelike environment for residents on the 600 hall, as evidenced by numerous instances of wall disrepair in residents' rooms. Observations revealed various issues such as black scrape marks, gouges, punctures, and unpainted patches on the walls behind recliners and other furniture. These conditions were noted in the rooms of 20 residents, affecting nearly half of the residents on the 600 hall. Interviews with residents indicated dissatisfaction with the state of their rooms, with some expressing that the damage was present upon their admission and that it would have been repaired if they were at home. The maintenance issues were confirmed during an environmental tour with the Maintenance Supervisor, who acknowledged the ongoing challenge of keeping up with painting and patching tasks. The supervisor mentioned that while efforts to repair the walls were initiated, they were often interrupted by other duties. This lack of timely maintenance was also reflected in the Resident Council Meeting minutes, where residents had previously voiced concerns about the delay in addressing repairs. The facility's policy on Housekeeping & Maintenance, dated 09/30/12, outlines the responsibility to provide necessary maintenance services to ensure a sanitary, orderly, and comfortable interior. However, the observations and resident feedback indicate a failure to adhere to this policy, resulting in an environment that does not meet the residents' expectations for a homelike setting.
Inadequate Food Substitution for Residents
Penalty
Summary
The facility failed to provide nutritionally equivalent food substitutions for five residents during a lunch meal. On the specified day, the menu included a chili dog, baked beans, country potatoes, and watermelon. However, during the meal service, the facility ran out of baked beans. The Dietary Manager instructed the staff to substitute cottage cheese for the baked beans for five residents. This substitution was not nutritionally equivalent, as confirmed by the Dietitian, who stated that baked beans were intended to be the starchy vegetable for the meal and should have been replaced with another vegetable instead of cottage cheese.
Failure to Feed Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident was fed in a dignified manner, as observed during a survey. The resident, who was severely cognitively impaired and dependent on staff for eating, was fed by a State tested Nursing Assistant (STNA) who was standing while feeding the resident. This was observed in the main dining room where the resident was seated in a Geri chair. Despite a chair being available behind the STNA, she initially chose to stand, stating she couldn't reach the resident's mouth while sitting. The resident's medical record indicated a history of Alzheimer's disease, Bell's Palsy, unspecified dementia, and other conditions requiring assistance with personal care. The care plan noted the resident's dependency on staff for eating due to severe cognitive and communication deficits. The facility's policy on the serving of food emphasized feeding residents with attention to safety, comfort, and dignity. An interview with the Speech Language Pathologist confirmed that staff should be sitting while feeding residents, highlighting the deviation from the facility's policy in this instance.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident records, specifically affecting one resident. During an observation, a computer monitor in the 500 hall was found displaying the medical record of a resident, including their name, medical record, and plan of care tasks, while unattended. This occurred in a public area where another resident was present, and staff members were observed passing by without securing the information. The resident in question had a complex medical history, including type two diabetes mellitus, schizophrenia, and recurrent depressive disorder, and required various levels of assistance for daily activities. Interviews with staff confirmed that the screen should have been locked to protect the resident's information. A Licensed Practical Nurse acknowledged the issue and mentioned that she had encountered similar situations before, where she would lock the screen and re-educate staff on HIPAA regulations. A State Tested Nurse Aide admitted to leaving the computer open when responding to a call-light, acknowledging the mistake. The facility's policy on confidentiality, dated 2013, mandates that all resident information be treated confidentially and safeguarded to protect privacy.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement care plan interventions as directed for Resident #5, who was admitted with Alzheimer's Disease, systolic congestive heart failure, and required assistance with personal care. The care plan required the resident to wear a left arm and wrist splint and a left ankle-foot orthotic (AFO) when out of bed to prevent worsening contractures. However, observations revealed that the resident was not wearing the hand/wrist splint as required, and staff were unaware of the brace orders. Interviews with staff confirmed a lack of knowledge and documentation regarding the splint, and the splint was improperly removed from the resident's room. For Resident #51, the facility failed to develop a comprehensive care plan addressing her denture management needs. Despite having upper dentures and being on a minced moist diet due to chewing difficulties, the care plan did not include specific interventions for denture care. Observations showed the resident's dentures frequently fell out, causing embarrassment and discomfort. Interviews with staff revealed a lack of awareness and documentation regarding the resident's denture care needs, and the facility's interdisciplinary team did not consistently include denture care in care plans. Resident #67's care plan lacked interventions related to her impaired hearing and vision, despite her need for corrective lenses and hearing aids. Observations indicated the resident was not consistently wearing her hearing aids, and staff were unsure of the care plan details regarding hearing aid use. Interviews with staff confirmed the absence of documented care plan tasks for hearing aid assistance, and the interdisciplinary team did not adequately address the resident's sensory needs in the care plan.
Failure to Conduct Timely Care Plan Meeting
Penalty
Summary
The facility failed to hold an initial care plan meeting in a timely manner for a resident, affecting one out of 22 residents reviewed for care plans. The resident was admitted to the facility and later discharged to the hospital, returning a few days later. The resident's medical conditions included sequelae of nontraumatic intracranial hemorrhage, essential hypertension, atherosclerotic heart disease, obstructive sleep apnea, chronic heart failure, dysphagia, hemiplegia, and hemiparesis. The resident required various levels of assistance for daily activities and was dependent on staff for certain tasks. Despite these needs, there was no indication that a care conference had been held since the resident's admission. Interviews with the resident's family and the facility's social worker confirmed that a care conference had not been conducted. The social worker acknowledged the oversight, attributing it to her absence from work and being the sole person responsible for scheduling care conferences. The facility's policy stated that residents and their families should be encouraged to participate in care plan development and revisions, but this was not adhered to in this case.
Failure to Implement Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that direct care staff were knowledgeable about and understood the trauma-informed care needs of three residents identified with PTSD. Resident #83, who was admitted with diagnoses including depression and a history of trauma, had a care plan that required staff to identify and manage triggering situations. However, interviews revealed that both an STNA and an LPN were unaware of Resident #83's PTSD triggers and the care plan interventions designed to prevent re-traumatization. Resident #81, with a history of trauma related to abuse and diagnoses including schizophrenia and schizoaffective disorder, had a care plan that included identifying triggers and managing them. Despite this, an RN and a CNA were unaware of any PTSD triggers or care plan interventions for Resident #81. The resident's pre-admission review and trauma checklist indicated discomfort with bathing due to past trauma, yet this information was not communicated to the care staff. Resident #62, diagnosed with Alzheimer's and anxiety, had a care plan addressing trauma from past assaults. The plan included providing a calm environment and encouraging the resident to express feelings. However, interviews with the social worker and LPN revealed a lack of awareness of the resident's PTSD triggers and care plan interventions. The Director of Nursing also admitted to not being aware of the PTSD triggers and interventions for these residents, despite reviewing care plans. The facility's policy on trauma-informed care was not effectively implemented, as evidenced by the staff's lack of knowledge and understanding of the residents' trauma-related needs.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food at the appropriate consistency for a mechanical soft diet to Resident #39, who was one of four residents reviewed for food and nutrition. Resident #39 had a medical history that included Alzheimer's disease, unspecified dementia, chronic diastolic heart failure, type two diabetes, and oropharyngeal phase dysphagia, which required a mechanical soft diet with thin liquids. Despite these dietary requirements, during a lunch meal service, Resident #39 was served intact, breaded chicken tenders, which did not meet the mechanical soft diet specifications. The incident occurred when the Dietary Manager served the resident the incorrect meal, and the error was observed by a surveyor. The Licensed Practical Nurse present confirmed the dietary mistake and removed the inappropriate food from the resident. The Speech Language Pathologist and Registered Dietitian later confirmed that the intact chicken tenders were not suitable for a mechanical soft diet and should have been cut up before serving. The facility's document on Mechanical Soft Diet Allowances also indicated that soft tenders were allowed only if cut up.
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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.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Nursing & Rehab | 0.4 mi | ★★★★★ | 51 | 1 |
| Shepherd Of The Valley Howland | 1.6 mi | ★★★★★ | 0 | 0 |
| Washington Square Healthcare Center | 2.5 mi | ★★★★★ | 26 | 0 |
| Community Skilled Healthcare | 2.6 mi | ★★★★★ | 36 | 1 |
| White Oak Manor | 3.3 mi | ★★★★★ | 3 | 1 |
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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.