Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grande Oaks during CMS and state inspections, most recent first.
A resident with morbid obesity, chronic respiratory failure, and dependence for ADLs fell out of bed during incontinent care and later returned from the ED with a diagnosed right‑leg contusion. On readmission, nursing staff documented the right lower extremity as red, shiny, and draining, but did not perform a wound assessment, obtain measurements, evaluate the drainage, initiate treatment, or notify the physician, and subsequent notes over several days omitted any reference to the leg despite escalating clinical concerns and eventual sepsis. After a later hospital stay, staff documented discoloration, then a weeping and black wound on the right calf, while the resident frequently refused hygiene and wound care despite education and NP involvement. A necrotic wound was eventually measured and dressed, and a wound care consult later attributed a large posterior right‑leg wound to the earlier fall, with interviews from the resident, the DON, and LPNs confirming that the leg wound evolved from a hematoma and cellulitis and that required assessments, documentation, and provider notifications were not completed in accordance with facility policy.
Two residents experienced deficiencies in hydration and nutritional monitoring when staff failed to ensure accurate tube-feeding flush orders, adequate hydration assessment, and consistent weight monitoring. One resident, fully dependent on enteral feeding, had a tube-feed order written with a free water flush only every 22 hours, received no weekly weights as requested by the RD, and later developed severe hypernatremia and dehydration requiring hospital transfer. Another morbidly obese resident with chronic respiratory failure and heart failure had large, unplanned weight gains over several months without regular weights, physician weight orders, or in-depth nutritional assessments, and the RD reused old weights and completed assessments without in-person evaluation, resulting in documentation that did not reflect the resident’s true nutritional status.
Unsanitary Food Storage and Unit Refrigerator Conditions: The facility failed to maintain kitchen storage areas and a nursing unit refrigerator in a clean, sanitary condition. A DM observed dirty floors and debris in dry storage, dirty food containers, a frozen substance on the freezer floor, and black residue in the ice scoop container, while an RDM later observed sticky shelves, a strand of hair, and a dried splatter inside a unit refrigerator. Nine residents were identified as NPO.
Advance directive documentation was incomplete or conflicting for four residents. One resident with moderate cognitive impairment and another cognitively intact resident had no code status documented, a third resident had DNR-CCA in the hard chart but Full Code in the EMR, and a fourth resident's DNR order lacked a practitioner signature. Staff confirmed the missing and inconsistent records, and the facility policy required advance directives to be communicated and documented in the chart.
A resident with dementia, anxiety disorder, and chronic respiratory failure, but with mild or no cognitive impairment, reported that staff often yelled at her and that some were “very nasty.” Video evidence and staff interviews confirmed that staff, including a CNA and an LPN, addressed the resident by her last name rather than her preferred first name. The resident’s daughter had emailed administrative staff and the state health department alleging that staff called the resident by her last name only, yelled at her, and spoke to her as if she were a child. Leadership denied prior knowledge of these concerns, and there were no related entries in the resident concern log, while the resident stated that being called by her last name was rude and disrespectful.
A resident with a documented care‑planned preference to use an electronic monitoring device in a private room was not accommodated when facility staff repeatedly interfered with and ultimately removed the camera. The care plan directed staff not to obstruct or damage recording devices, yet the resident’s daughter reported two prior cameras had been damaged, and the most recent camera—used for many months—was taken away by the Administrator, despite a door posting indicating electronic recording. The Administrator and nursing leadership cited the camera’s ability to pan and the daughter’s use of two‑way audio as reasons for removal, even though the written monitoring policy only required fixed‑position cameras and did not prohibit audio. The daughter demonstrated that the camera could be locked in a fixed position and provided multiple emails documenting Wi‑Fi failures that caused the camera to reset and rotate, as well as requests for maintenance intervention, but the facility produced no records of addressing these issues, no concern‑log entries supporting claims of ongoing noncompliance, and no explanation for a missing SD card from the camera when it was returned, resulting in failure to support the resident’s right to maintain the monitoring device.
A resident's family member emailed verified facility addresses for the ADON and social worker, and cc'd the LTC Ombudsman, requesting the resident's medical records and any required forms, but the request was not processed according to facility policy. The ADON acknowledged the emails were sent but did not recall seeing the request, while the social worker, who started after the first email, did not review earlier emails and denied knowledge of any request, stating such matters go through the Administrator. The Administrator reported being unaware of the family's request, despite confirming that an email requesting records had been sent to management addresses, and facility policy required all record requests to be referred to the Administrator for review, verification of access rights, and completion.
A resident with dementia, anxiety disorder, and chronic respiratory failure, but with mild or no cognitive impairment per MDS, and the resident’s daughter reported multiple missing or damaged personal items, including cameras, an SD card, a phone, a music device cord, and gifted socks. The daughter emailed the DON, ADON, state health department, and ombudsman about stolen or missing items and broken equipment, while the resident reported missing cameras and a removed cord. The ombudsman confirmed being notified of a missing SD card and that staff denied knowledge of it. The Administrator stated a camera was removed from the room without an SD card present and that staff had not been informed of missing items. The Regional Nurse confirmed there was no inventory list for the resident’s possessions, no recent informal documentation of the family’s concerns, and the concern log for a full year contained no entries for this resident, despite multiple complaints, resulting in a deficiency for failure to protect personal property and uphold resident rights.
The facility failed to follow its abuse and electronic monitoring policies by not properly identifying, documenting, or investigating multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia and chronic respiratory failure. Over several weeks, the resident’s daughter reported that an LPN intimidated the resident, administered Tramadol doses too close together, failed to provide ordered medications, ignored incontinence care requests, and publicly disparaged the resident, while a CNA and another aide allegedly yelled at the resident, disrespected her belongings, and spoke to her in a demeaning manner. The daughter also reported missing personal items, including socks, a camera, and an SD card that she said contained video of staff screaming at the resident. Despite these detailed complaints, facility leadership denied knowledge of the allegations, the concern log contained no entries for the resident, and the only self-reported incident was a vague mistreatment report that lacked specific interviews with the daughter, relied on a generic questionnaire for the resident, and did not include any documented attempt to obtain or review camera footage.
The facility failed to report multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia, anxiety disorder, and chronic respiratory failure. Emails from the resident’s daughter to facility staff and the state agency described an LPN allegedly giving Tramadol doses too close together, intimidating the resident, not administering ordered meds, falsely documenting refusals, and ignoring incontinence care requests, as well as a CNA allegedly disrespecting belongings and speaking to the resident like a small child, another aide allegedly yelling at the resident, and a theft of socks. These concerns were not documented in the resident’s record or concern log, and only one self-reported incident related to the resident appeared on the state website. The Administrator, DON, ADON, and Regional Nurse denied knowledge of the emailed allegations and confirmed they were not investigated or reported, despite facility policy requiring timely reporting of all such allegations to the state agency.
A resident with dementia and chronic respiratory failure, but assessed as having mild or no cognitive impairment, was the subject of multiple detailed email complaints from her daughter alleging that an LPN improperly administered Tramadol, intimidated the resident, failed to provide ordered meds and incontinence care, and used derogatory language, and that a CNA and another aide verbally mistreated the resident and disrespected her belongings, with an item reported stolen and video evidence referenced. Despite these repeated allegations sent to facility staff and the state agency, the only self-reported incident documented vague concerns of mistreatment, lacked specific details, did not include an interview or documented attempt to interview the daughter, relied on a generic questionnaire for the resident, and showed no effort to obtain camera footage. Facility leadership denied knowledge of the reported abuse, neglect, and misappropriation, the concern log contained no entries for this resident, and the call log lacked documentation of call outcomes, all contrary to the facility’s abuse policy requiring immediate, thorough investigation and reporting of all such allegations.
A resident who was totally dependent on staff for ADLs, with significant medical conditions including respiratory failure, paraplegia, and anoxic brain damage, had care plans and orders requiring daily nail checks and twice-daily oral care. Surveyors observed that the resident was non-interviewable, with brown-appearing teeth, a white rough layer on the tongue consistent with thrush, and fingernails extending one to two centimeters beyond the fingertips and curling downward. The ADON confirmed these observations, showing that ordered oral and nail care were not adequately provided.
A resident with paraplegia, anoxic brain damage, and a Stage IV buttock pressure injury was care planned to be turned every two hours due to total dependence on staff for bed mobility and high risk for skin breakdown. On the survey day, the resident was repeatedly observed lying on his back in bed with the head elevated and no positioning devices in use, while a wedge cushion remained on a bedside table. Multiple observations over several hours showed no change in position, and the ADON confirmed the resident had not been repositioned for an extended period, demonstrating failure to follow the care plan and accepted standards of practice for pressure ulcer care.
The facility failed to provide adequate supervision and ensure safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with morbid obesity, chronic respiratory failure, and complete dependence for bed mobility and ADLs was provided incontinent care by a single CNA, despite requiring two-person assistance for transfers; during care, the resident rolled, grabbed the bed rail, and fell from the bed to the floor, later being found to have a painful right-leg contusion. Another resident with post-stroke hemiplegia, multiple comorbidities, and dependence on staff for ADLs and transfers was being moved from wheelchair to bed with a mechanical lift when she slid from the lift pad to the floor because the pad was not fully positioned under her buttocks and could not be adequately adjusted by staff.
The facility did not follow its menu and portion control procedures for residents on mechanically altered diets, as a dietary aide served mechanically altered beef stroganoff using a #12 scoop and provided only one scoop instead of the required portion. The diet extension sheet and scoop size chart showed that a larger #6 scoop, or two #12 scoops, was needed to meet the planned serving size, but three residents on mechanically altered diets received less than the specified amount of meat. The regional dietary manager and the dietary aide confirmed the incorrect scoop size and portion used, contrary to facility policy requiring appropriate portions to ensure nutritional adequacy.
A resident with osteoarthritis, morbid obesity, and type II DM at risk for pressure ulcers reported not having an air mattress, while the medical record showed active orders and TAR documentation for both an air mattress and a pressure-redistribution mattress over the same period. On observation, the resident was found on a regular pressure-redistributing mattress only, and an LPN confirmed that no air mattress was in use, revealing conflicting and inaccurate documentation in the medical record regarding ordered support surfaces.
A resident with dementia, anxiety disorder, chronic respiratory failure, and a documented need for substantial assistance with bed mobility was observed with her call light hanging from the bed rail out of her reach. Three pillows were stacked on the side where the call light cord was located, further preventing her from accessing it. An RN confirmed that the call light was not within the resident’s reach, resulting in a cited deficiency related to the call system.
Surveyors found multiple resident rooms with significant environmental issues, including dirty floors with stains, dirt, debris, and food particles, damaged walls with holes, scrapes, missing paint, and crumbling material, and equipment problems such as an AC unit with detached covers, a missing electrical outlet cover powering a television, and loose vent covers. Doors to two rooms were difficult to open or close, with one door dragging and gouging the floor. A RN, the DOM, and the housekeeping supervisor all verified these conditions, which were inconsistent with the facility’s policy requiring housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment.
Inaccurate MDS Weight Coding: A resident with chronic respiratory failure, ventilator dependence, and heart failure had major weight gain documented in the record, but the MDS repeatedly listed the same outdated weight and coded no significant weight gain. The RD said she reused an old weight because no current weight was available, did not assess the resident in person, and relied on risk meetings and the EMR, while acknowledging the MDS did not accurately reflect the resident’s nutritional status.
Failure to honor activity preferences for two residents was identified. One resident with acute respiratory failure, necrotizing fasciitis, and DM2 wanted to use his TV and personal devices, but multiple TV channels were not working and maintenance work orders were closed as completed despite the issue remaining unresolved. Another resident with quadriplegia and a C4 SCI had a stated preference for going outside for fresh air, but staff said he could not go outside without supervision after a prior smoking policy issue; records showed little to no patio or deck participation and the resident reported he was not being taken outside.
Failure to implement ordered contracture care for a resident with severe cognitive and physical impairment. The resident had multiple serious diagnoses, was on hospice, and was dependent for all ADLs and mobility. OT documentation and therapy discharge recommendations called for bilateral palm guards, PROM, hand hygiene, and skin checks, but no treatment order was on the TAR or order listing, the care plan lacked contracture interventions, and surveyors observed contracted hands without palm guards or barriers while the resident’s nails pressed into the palms. The DON and RDC confirmed the missing orders and lack of care plan interventions.
Failure to Obtain Physician Orders for Weight Monitoring: A resident with chronic respiratory failure, ventilator dependence, heart failure, and obesity had a major unplanned weight gain over several months, but the chart showed no physician notification, no orders for daily/weekly/monthly weights, and no documented follow-through on weight monitoring. CNA, LPN, and RD interviews confirmed the resident was not on a weight-monitoring list and no physician orders were present in the record.
A resident with pain, DM2 with neuropathy, anemia, depression, PTSD, and anxiety had multiple pharmacy recommendations during MRR that were not addressed in a timely manner. The recommendations included GDR trials for Diazepam, Duloxetine, Sertraline, and Trazodone, discontinuation of duplicate PRN acetaminophen orders because the resident was already at the max daily dose, and clarification of an incorrect Duloxetine formulation order; an RRN confirmed the delays, and the facility policy did not specify a timeframe for addressing pharmacy irregularities.
A facility failed to honor a resident’s request for palliative/hospice services and failed to keep another resident’s hospice care plan updated. One resident with chronic respiratory failure, ventilator dependence, and heart failure requested palliative care through Echo Hospice, but follow-up was delayed and no physician order was in place until after surveyor intervention. Another resident with severe neurologic and nutritional conditions, total ADL dependence, and severe cognitive impairment had an initial hospice plan of care, but updated hospice documentation was missing from both the chart and the unit binder until after surveyor intervention.
Medical director attendance at required QAA/QAPI meetings was not documented for one quarter. Review of meeting sign-in sheets showed no medical director signature for the quarter, and the Administrator and RRN confirmed the absence of attendance documentation. Facility policy required the interdisciplinary QAA committee to include the medical director or designee and meet at least quarterly.
Multiple rooms lacked functional soap dispensers, and staff did not consistently use hallway alcohol sanitizer before entering or after exiting resident rooms. The DON and Administrator were unaware of the issue due to lack of staff reporting, and it was unclear how hand hygiene was performed in affected rooms, contrary to facility policy requiring accessible alcohol-based hand rub.
Multiple rooms lacked working soap dispensers and several hallway hand sanitizer dispensers were non-functional, with some dispensers missing entirely. Facility leadership confirmed they were unaware of the issues due to lack of staff reporting, and could not verify that hand hygiene protocols were being followed. Additionally, a resident's room had a large hole in the wall with debris left on the floor, which had not been repaired or cleaned up.
A resident with multiple chronic conditions and intact cognition did not receive a requested soft touch pad call light, instead being provided with a push button call light that was difficult to use due to dexterity problems. Additionally, the resident's dietary preferences were not followed, as a meal included bread despite specific instructions to avoid it. Staff and management confirmed these failures to honor the resident's documented preferences.
A resident with severe cognitive impairment and ventilator dependence was placed in mitt restraints due to repeated attempts to remove medical equipment. The facility did not consistently document the ongoing need, usage, or evaluation of the restraints, nor did the care plan include specific interventions or monitoring related to restraint use. Staff interviews confirmed a lack of structured documentation and re-evaluation, despite facility policy requiring these actions.
A resident with significant medical needs did not receive an ordered topical pain-relieving gel to her knees because an LPN assumed she could self-apply it, despite her lack of dexterity. The LPN did not administer or observe the application but documented in the MAR that it was given, contrary to facility policy.
The facility did not consistently obtain and document weights as ordered by physicians for two residents with complex medical conditions, including chronic respiratory failure and obesity. Despite care plans and physician orders requiring monthly and daily weight monitoring, several weights were either not recorded or not obtained, and the DON confirmed these omissions. This failure was not in accordance with facility policy or physician directives.
The facility failed to ensure that ventilator alarms were properly monitored and functioning for two residents requiring ventilator support, resulting in delayed response to a disconnection event and alarms being turned off. Additionally, staff did not consistently follow physician orders for oxygen administration via nasal cannula during meals and medication administration for a resident with diminished lung capacity.
A resident with cognitive impairment and dependency on staff for daily care developed worsening Stage IV pressure ulcers due to the facility's failure to implement an effective pressure ulcer prevention program. Despite being informed by a CNA, an LPN did not change the resident's soiled dressings, leading to infection and hospitalization. The resident's medical history included osteomyelitis, hypertension, and dementia.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week. A review of staffing schedules and staff punch details revealed no RN coverage on a specific day, which was confirmed by the Human Resources Director. This deficiency had the potential to affect all 49 residents in the facility.
The facility failed to serve meals at a palatable temperature, affecting 41 residents. Observations showed inconsistent meal temperature recordings and delays in meal service due to running out of rice. A test tray revealed that food was not served at the appropriate temperature, with some items being too cold and not having the correct consistency. Residents confirmed that meals were sometimes late and not warm enough, contrary to the facility's policy.
The facility failed to provide meals and snacks according to residents' needs and facility policies. Meals were delayed due to food shortages and equipment issues, and snacks were inconsistently available, with staff sometimes bringing snacks from home. These deficiencies affected residents' nutritional needs.
The facility failed to maintain sanitary conditions in food service, affecting 41 residents. The dish machine did not properly sanitize dishes, and logs for temperature and cleaning were incomplete. Additionally, an exhaust fan was heavily soiled, blowing dust towards the serving line. Facility policies required regular maintenance and logging, which were not followed.
The facility failed to ensure safe handling and storage of food brought in from outside, affecting 41 residents. Observations revealed unlabeled and undated food items in resident refrigerators, lack of temperature monitoring logs, and improper storage of employee foods and breast milk. The facility's policy requires labeling and dating of all food items, with immediate disposal of unlabeled items.
The facility inaccurately submitted staffing information to CMS by listing a Nurse Practitioner as an RN in the PBJ. The HR Director was unaware of the Nurse Practitioner's role and mistakenly entered her hours as an RN. The Administrator confirmed the error, noting the Nurse Practitioner was not working as an RN.
The facility failed to maintain cleanliness of wheelchairs and shower rooms, and ensure the functionality of phones. Observations showed soiled wheelchairs and mold-like stains in shower rooms. The phone system was non-functional, affecting communication and access. These issues were confirmed by staff and administration, highlighting a lack of adherence to cleaning schedules and communication protocols.
The facility failed to conduct quarterly smoking safety assessments for two residents, both of whom required supervision while smoking due to their medical conditions. Despite being cognitively intact and independent in daily activities, the residents' care plans required quarterly assessments, which were not completed. The facility's smoking policy lacked specificity on assessment frequency, contributing to this oversight.
A resident with a history of bipolar disorder and opioid dependence was discharged AMA to live with her son, despite a psychological evaluation indicating moderate cognitive impairment and the need for a guardian. The facility failed to address the primary POA's concerns about the discharge's safety and did not notify her until after the resident had left. The facility did not contact adult protective services or the police, leading to a deficiency in ensuring a safe discharge process.
The facility failed to provide scheduled bathing for three residents, with missing documentation and signatures on shower sheets. A resident with intact cognition did not receive a scheduled shower, and two residents dependent on staff for bathing had missing documentation of refusals. The DON confirmed the lack of adherence to bathing schedules and documentation policies.
A facility failed to complete daily weights for a resident with congestive heart failure as per physician orders. Despite the resident's care plan indicating the need for weight monitoring due to obesity, multiple dates in October and November showed missing weight records. Interviews with the resident's daughter, DON, and dietitian confirmed the non-compliance.
The facility failed to ensure required physician visits for three residents, affecting all 49 residents. A resident had no physician or NP visits since early September, while another had a gap in physician visits from mid-June to late September. A third resident had only two physician visits in July and August, with no NP notes found. The DON confirmed the lack of compliance with the facility's policy on alternating visits.
A resident with chronic kidney disease, heart failure, and sepsis did not receive prescribed intravenous antibiotics and Heparin flushes due to the unavailability of an RN. The facility's policy required medications to be administered as ordered, but multiple doses were missed, as confirmed by staff interviews and documentation.
A facility failed to follow a physician-ordered diet with modified texture for a resident with multiple medical conditions, including hemiplegia and diabetes. The resident's care plan required a pureed diet due to dental issues, but a survey revealed that the pureed rice did not meet the required smooth consistency. The Dietary Manager confirmed the deficiency.
The facility failed to provide adequate hydration between meals, affecting several residents. Observations showed hydration cups were not consistently present in rooms, and residents reported water was not offered unless requested. Staff interviews revealed inconsistencies in water delivery, despite facility policy requiring fresh water each shift. This deficiency impacted residents with specific health risks, as their fluid intake was not recorded as required.
A resident, dependent on staff for all activities of daily living, did not receive scheduled showers over a six-week period, receiving only bed baths instead. Despite being stable for showers, as confirmed by a respiratory therapist, the resident's grooming needs were neglected, resulting in a buildup of a black substance under her nails. Staff interviews and family observations confirmed the lack of showers, contrary to the facility's policy of routine bathing per resident preference.
A facility failed to maintain a medication error rate below five percent, resulting in a nine percent error rate. An LPN administered an incorrect dose of Polyethylene Glycol to a resident with multiple diagnoses, and another LPN crushed a morphine extended-release tablet without a physician's order for a resident with complex medical conditions. These actions violated the facility's medication administration policy.
Failure to Assess and Treat New Right‑Leg Wound After Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and thorough assessment, monitoring, treatment, and physician notification for a resident’s new right‑leg condition following a fall-related injury. The resident, who was cognitively intact, morbidly obese with a very high BMI, dependent for ADLs and bed mobility, and at risk for falls and skin integrity issues, fell out of bed during incontinent care provided by one CNA. Initial facility documentation on the day of the fall noted no visible injuries, but later that day the resident reported right‑leg pain, portable x‑rays could not be completed due to pain, and she was transferred to the hospital. The hospital identified significant right‑leg pain and diagnosed a contusion of the right lower extremity without fracture before discharging her back to the facility. When the resident returned to the facility in the early morning hours after the hospital visit, nursing documentation described the right lower extremity as red and shiny with moderate drainage. Despite this documented change, there was no wound assessment, no measurements, no description of wound size or characteristics, no evaluation of the drainage, no monitoring parameters, no treatment orders, and no physician notification. From the following day through several subsequent days, progress notes reflected increasing clinical concerns such as pain, confusion, abnormal oxygen saturations, and multiple lab and diagnostic orders, but there was no further mention or documentation of the right‑leg redness or any focused assessment of the leg, even though the earlier finding had been recorded. During this period, the resident ultimately required transfer to the hospital and ICU admission for sepsis, but the facility records did not connect or document the right‑leg condition as part of the ongoing assessment. After the resident later returned from the hospital, staff documented discoloration of the right lower extremity and, the next day, noted a weeping area on the inner right calf and a black weeping wound under the right calf. The resident repeatedly refused measurement and dressing of the wound and refused hygiene and some care despite education on the importance of wound care and hygiene; the NP was notified of her refusals. Later that same day, staff documented a necrotic area on the right lower extremity measuring 5.5 cm by 7.5 cm by 0.1 cm, which was cleansed and dressed, and a care plan was created for an actual skin impairment to the right lower leg. A subsequent wound care consultation identified a posterior right lower extremity wound, attributed to the earlier fall, measuring 9.1 cm by 10.1 cm with undetermined depth. Interviews with the resident and staff confirmed that the leg wound developed after the fall and that there had been no skin assessments, follow‑up documentation, or physician notification regarding the right lower extremity when the red, swollen, draining area was first documented after readmission. The facility’s own pressure injury prevention and management policy required systematic identification, assessment, documentation, treatment, monitoring, and provider notification for all skin integrity concerns, including new wounds and changes in condition, but these steps were not carried out for this resident’s right‑leg condition. The deficiency resulted in the worsening of the untreated right‑leg condition, which progressed to an open necrotic wound requiring hospitalization, surgical debridement, and treatment for sepsis. The resident reported that she had been pushed out of bed during care, injured her leg, and that the wound was not healing, leaving her at risk of losing her leg. Facility nursing leadership and LPNs acknowledged that the leg wound began as a hematoma and cellulitis after the fall, that it became necrotic and required debridement, and that there had been no proper assessment, monitoring, treatment, or documentation of the right lower extremity when the red, swollen, draining area was first observed after the resident’s return from the hospital. They also confirmed that the skin issue was not the focus of care at that time and that the facility did not follow its own policy requiring prompt and systematic management of new skin integrity concerns.
Failure to Ensure Adequate Hydration and Nutritional Monitoring for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient fluid intake and adequate monitoring of nutritional status for two residents who were dependent on staff for nutrition and hydration management. One resident with respiratory failure, hypertension, and dysphagia was totally dependent on enteral tube feeding and had a care plan identifying risk for altered nutrition and hydration, with interventions including monitoring for dehydration and reviewing labs. A progress note documented that this resident was NPO with a feeding tube, had significant weight loss, and was on Isosource 1.5 at 70 mL with a 200 mL free water flush every four hours, but the order was changed to Isosource 1.5 at 70 mL with a 55 mL free water flush. The physician order was written as Isosource 1.5 at 70 mL/hr, off two hours for ADL care, with a free water flush of 55 mL every 22 hours, and this order carried an end date several months later. MAR/TAR review showed the tube feed and flush were administered as ordered, but the flush frequency remained every 22 hours. In the weeks and months that followed, there was no evidence of weekly weights as requested by the RD; only monthly weights were documented. The resident was cognitively intact and required some assistance with ADLs. On the day of the acute event, progress notes described the resident as lethargic, with a moist cough, fever, tachycardia, and dry mucous membranes, and staff documented a change in condition. Orders were obtained for labs, chest x-ray, oxygen as needed, Tylenol, antibiotics, Duoneb, close monitoring of vital signs, extra IV fluids including a bolus of normal saline followed by continuous infusion, and a one-time water bolus via the feeding tube. Critical lab results showed a sodium level of 173 mmol/L, elevated BUN, and reduced GFR, and the resident was transferred to the hospital. Hospital documentation identified hypernatremia from free water deficit and acute kidney injury from dehydration, with toxic metabolic encephalopathy significantly due to dehydration and hypernatremia. Interviews with the ADON, regional nurse, and RD revealed uncertainty about why the flush order was written every 22 hours, acknowledgment that the pump could not run feed and flush simultaneously, lack of documentation that staff were monitoring or inputting formulas correctly, and no clarification of flush orders despite risks of too little flushing and dehydration. The facility’s hydration and feeding tube policies, which required providing sufficient fluids and maintaining acceptable nutritional and hydration status, were not implemented. The second resident had chronic respiratory failure, ventilator dependence, heart failure, and morbid obesity, and required assistance with ADLs. The care plan identified high BMI and obesity with interventions including monitoring and reporting changes, assisting with ADLs, following physician orders, and monitoring weights. Nutrition and hydration assessments documented the resident at 399 pounds on a low concentrated sweets diet with regular texture and interventions of weight monitoring per physician orders, but a later assessment was identical to one completed approximately four months earlier and was not locked until months after its stated date. Weight summaries showed the resident weighed 381 pounds in July, 398.9 pounds in October, and 557.8 pounds in April, indicating a gain of 159 pounds over five months, yet the resident was not being weighed weekly, bi-weekly, or monthly, and there were no physician orders for weight monitoring. A nutrition review note cited significant weight change and new orders for daily weights for a week, but the medical record contained no documentation of physician notification, weight orders, consistent weight monitoring, or in-depth assessments related to the significant weight gain, and only two documented refusals of weights with no further attempts. Staff interviews confirmed that CNAs were responsible for weighing residents according to orders and that most residents were weighed monthly unless otherwise directed, but this resident was not on any list for daily, weekly, or monthly weights, and staff could not recall when she was last weighed. An LPN described the resident as morbidly obese and at nutritional risk due to size, eating habits, diagnoses, and skin issues, and stated the RD followed her to maintain baseline health, yet verified there were no weight orders. The RD reported that the resident had significant weight gain, was on fluid restrictions for presumed water retention, and that she only received updates during Friday risk meetings. The RD acknowledged awareness of over 100 pounds of weight gain, confirmed there were no orders for daily, weekly, or monthly weights and no ongoing documented refusals, and admitted that a January assessment reused a previous weight because no new weight was available. The RD further stated she had not assessed the resident in person and completed documentation using prior assessments and other record information, acknowledging that the medical record did not accurately reflect the resident’s current nutritional health status. The facility’s failure to monitor and document weights, obtain and follow weight orders, and perform accurate, timely nutritional assessments contributed to inadequate monitoring and implementation of interventions to maintain proper nutritional health for this resident.
Unsanitary Food Storage and Unit Refrigerator Conditions
Penalty
Summary
The facility failed to ensure that kitchen storage areas were maintained in a clean and sanitary condition. During a kitchen tour with the Dietary Manager, the dry storage room floor beneath racks on the right side was observed to be dirty with stains and debris, including a large brownish stain beneath the rack holding thickened beverage cartons. Two large storage containers, one holding a box of sugar and the other a bag of flour, were also observed to be dirty inside and outside with various debris present. In the walk-in freezer, a large light pink frozen substance was noted on the floor near the door, and the bottom of the blue ice machine scoop container contained a moderate amount of black residue. The Dietary Manager verified these observations at the time of the tour. The facility also failed to keep a nursing unit refrigerator clean. During an observation with the Regional Dietary Manager, sticky clear shelves were seen on the inside door, a strand of hair was observed beneath the second clear shelf, and a dried orange-reddish splatter was noted running down the inside of the refrigerator door. Review of the diet order list showed nine residents who received nothing by mouth. The facility policy stated that unit refrigerators are to be cleaned weekly by nursing or housekeeping staff, with out-of-compliance food items discarded, and that nursing staff are responsible for cleaning spills as needed or contacting housekeeping.
Advance Directive Documentation Inconsistencies
Penalty
Summary
The facility failed to ensure that residents' advance directives were accurately completed, signed by a practitioner when required, and consistently documented in the medical record. Review of four residents showed missing or conflicting code status information. Resident #4, admitted with vascular dementia, COPD, aphasia following cerebrovascular disease, and CKD stage III, had a BIMS score of 9 indicating moderate cognitive impairment, but no code status was found in either the hard chart or EMR. Resident #17, admitted with bilateral primary osteoarthritis of the hip, morbid obesity, and type II diabetes mellitus with hyperglycemia, was cognitively intact, yet no code status was documented in the medical record or EMR. Resident #18, admitted with chronic respiratory failure, ventilator dependence, and heart failure, had conflicting advance directive documentation: the hard chart physician order and care plan identified DNR-CCA, while the EMR physician orders listed Full Code. Regional Nurse #626 confirmed the mismatch during record review. Resident #28, admitted with respiratory failure, paraplegia, and hypoxic encephalopathy, had a DNR order in the record, but the paper chart was dated and lacked a physician or practitioner signature. Facility staff confirmed the missing signature, and the facility policy stated residents' advance directives were to be communicated with staff and documented in the medical chart.
Failure to Address Resident by Preferred Name and Maintain Dignified Communication
Penalty
Summary
The facility failed to honor a resident’s right to dignity and self-determination by not ensuring staff addressed her using her preferred name. The resident, who had dementia, anxiety disorder, and chronic respiratory failure, was assessed as having mild or no cognitive impairment. A video dated 01/22/26 showed an unseen staff member addressing the resident by her last name during care. Emails from the resident’s daughter to administrative staff and the state health department reported that a CNA called the resident by her last name only, which the daughter considered disrespectful, and that an unidentified aide continued this practice. The emails also alleged that staff yelled at the resident and spoke to her as if she were a child. In interviews, the resident reported that workers yelled at her often and that some were “very nasty.” The Administrator, DON, ADON, and Regional Nurse denied knowledge of concerns about the resident being yelled at or not being called by her preferred name, and the facility’s resident concern log for the past year contained no documented concerns regarding this resident. An LPN and a CNA each acknowledged that they sometimes or routinely addressed the resident by her last name and stated they were unaware this was not her preference, and the CNA denied mistreating or yelling at the resident. The Regional Nurse confirmed that the video showed a staff member addressing the resident by her last name. In a later interview, the resident stated she preferred to be called by her first name and that staff sometimes called her by her last name, which she felt was rude and disrespectful.
Failure to Honor Resident’s Care‑Planned Preference for Electronic Monitoring Device
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s longstanding, care‑planned preference to use an electronic monitoring device in her private room. The resident’s care plan, initiated in June 2024, documented her preference for electronic monitoring and directed staff not to obstruct, tamper with, or destroy recording devices. Despite this, the resident’s daughter reported that two prior cameras had been damaged by staff, and the most recent camera, in place since June 2025, was removed by the Administrator in March 2026 against the resident’s wishes. At the time of survey, the resident’s room displayed a notice of electronic recording, but no camera was present. Care conference documentation from December 2025 showed that the Administrator discussed alternate placement with the resident and POA, stating the facility could not meet the resident’s needs and that the POA was non‑compliant with the camera policy, but the notes did not specify how the policy was violated or what steps were taken to honor the resident’s right to use the device. The Administrator later informed the daughter that the camera had been removed for noncompliance with policy. During interviews, the Administrator and nursing leadership stated the camera was removed because it could pan the room and be remotely controlled, and because the daughter had spoken or yelled at staff through the camera, even though the written electronic monitoring policy only required fixed‑position cameras and did not prohibit two‑way audio. The resident’s daughter demonstrated that the camera could be set to a fixed position via an app and explained that frequent Wi‑Fi outages in the resident’s room caused the camera to reset and rotate automatically, prompting her repeated, documented email requests for maintenance to address Wi‑Fi failures. Emails over many months indicated the camera was always set to a fixed position and not on motion tracking, and raised concerns about Wi‑Fi disruptions, but the facility did not provide documentation of responses or corrective measures. The facility also provided no documentation of any new or immediate safety risk justifying abrupt removal of the camera, no concern‑log entries reflecting the Administrator’s claim of ongoing camera‑related issues, and no explanation or investigation regarding the missing SD memory card from the camera when it was returned to the daughter. These actions and omissions resulted in the facility not supporting continuation of the resident’s electronic monitoring device in accordance with her rights, preferences, and care plan.
Failure to Process Family Request for Resident Medical Records
Penalty
Summary
The facility failed to honor a resident medical records request in accordance with its own policy, affecting Resident #41. Record review showed that the resident's daughter sent emails on 03/15/26 and 04/25/26 to verified facility email addresses for the Assistant Director of Nursing (ADON) #563 and Social Worker #574, and carbon copied the Long-Term Care Ombudsman, requesting the resident's medical records and asking to be sent any required forms needed to complete the request. During an interview on 04/27/26 at 1:47 P.M., ADON #563 confirmed that these emails were sent but stated she did not recall seeing the records request. In a separate interview at the same time, Social Worker #574 reported she began employment on 03/16/26, one day after the first email was sent, and although she used the same social worker email address to which the request was sent, she did not review emails that predated her start date and denied knowledge of any records request, stating such requests would go through the Administrator. In an interview on 04/27/26 at 4:35 P.M., the Administrator stated he was not aware that Resident #41's family had made a records request, but confirmed that an email dated 03/15/26 requesting records had been sent to facility management addresses. Review of the facility's medical records release policy dated 06/01/24 showed that all resident record requests must be referred to the Administrator, who is responsible for ensuring each request is reviewed, the requesting party's access rights are verified, further information is requested if needed, and the relevant office is notified to complete the request. This process was not followed for Resident #41's records request.
Failure to Protect Resident Personal Property and Document Reported Losses
Penalty
Summary
The facility failed to protect a resident’s right to maintain personal property and to receive care in a manner that upholds dignity and autonomy. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and mild or no cognitive impairment per a recent MDS, had no documentation in her medical record of missing items or damaged property, including an SD card, socks, cord, phone, or cameras. Emails from the resident’s daughter to the DON, ADON, and the state health department reported that a set of cabin socks given as a Christmas present was stolen, and that two cameras and a phone had been broken by staff without reimbursement. Another email from the daughter to the ombudsman reported a missing camera and SD card. The facility’s Regional Nurse confirmed there was no inventory list for the resident’s possessions, and state records showed no alleged misappropriation events reported by the facility in the prior six months. During interviews, the resident reported that cameras were missing and that staff had taken the cord from her music device, rendering it unusable, though she was unsure if she had notified staff and believed her daughter likely had. The ombudsman confirmed being notified of a missing SD card and stated that when they followed up, facility staff denied knowledge of the missing item. The Administrator reported removing a camera from the resident’s room and stated there was no SD card present at that time, and that staff had not been informed of missing items such as the cord, socks, or SD card. The resident’s daughter stated that staff removed a camera from the bedside and returned it without the SD card she had purchased, and that staff had broken two cameras and the resident’s phone by dropping it. The Regional Nurse later confirmed there was no recent “soft file” documenting the facility’s response to the family’s concerns, and review of the resident concern log over a one-year period showed no entries related to this resident, despite multiple complaints, resulting in a deficiency related to resident rights and personal property.
Failure to Investigate and Respond to Repeated Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for promptly identifying, reporting, and investigating allegations of abuse, neglect, and misappropriation involving a resident. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and was assessed as having mild or no cognitive impairment, had no documented abuse or misappropriation allegations in her progress notes for 2026 despite multiple concerns raised externally. The Ohio Department of Health (ODH) website showed only one self-reported incident (SRI) related to this resident within the prior six months, dated 03/09/26, for alleged neglect and mistreatment by an LPN and a CNA, even though numerous additional allegations had been communicated by the resident’s daughter. Record review of emails from the resident’s daughter to facility staff and ODH showed repeated allegations over several weeks, including that an LPN administered Tramadol doses too close together, displayed animosity, intimidated the resident, failed to provide ordered medications, falsely documented refusals, and ignored calls for incontinence care after turning off the call light. Additional emails alleged that a CNA disrespected the resident’s belongings and spoke to her in a demeaning manner, that an unidentified aide yelled at the resident, and that personal items such as cabin socks were stolen. The daughter also reported a missing camera and SD card to the ombudsman, and later alleged that the SD card containing footage of staff screaming at the resident had been stolen. Despite these detailed complaints, the Administrator, DON, ADON, and Regional Nurse all denied knowledge of the abuse, neglect, and misappropriation allegations contained in the emails. The facility’s handling of the one documented SRI did not follow its abuse policy requirements for a focused investigation. The SRI described staff speaking to the resident in a loud, abrasive manner and referenced mistreatment concerns but lacked specifics, did not include an interview or attempted interview with the daughter, and documented only a generic questionnaire-style interview with the resident in which pre-written answers were circled indicating she felt safe and had no concerns. There was no documented attempt to obtain footage from the monitoring camera that had been in the resident’s room until it was removed by the facility. A call log later produced by the facility showed several calls to and from the daughter but contained no record of the content or results of those calls. The resident concern log for the past year contained no entries regarding this resident, and the Administrator stated that the resident did not know what he was talking about during the SRI interview and that the daughter did not respond to his attempts to reach her, further underscoring the lack of documented, policy-compliant investigation and response to the reported allegations.
Failure to Report Multiple Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and misappropriation involving one resident to the State Agency as required by its abuse policy and state regulations. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and was assessed as having mild or no cognitive impairment, had no documented abuse or misappropriation allegations in her progress notes for 2026, and the resident concern log for the past year contained no concerns related to her. Review of the Ohio Department of Health (ODH) Certification and Licensure website showed only one self-reported incident (SRI) involving this resident within the last six months, dated 03/09/26, related to alleged neglect and mistreatment by an LPN and a CNA. However, record review of emails sent by the resident’s daughter to verified facility staff email addresses and ODH showed multiple unreported allegations. These included claims that an LPN administered Tramadol doses too close together, displayed animosity and hatred, intimidated the resident, failed to give medications as ordered, falsely documented refusals of care, and ignored calls for incontinence care after turning off the call light for several hours. Additional emails alleged that a CNA disrespected the resident’s personal belongings and spoke to her like a three-year-old, that an unidentified aide verbally abused the resident by continually yelling at her, and that a pair of cabin socks was stolen. In interviews, the Administrator, DON, ADON, and Regional Nurse denied knowledge of these allegations and confirmed that no SRI investigations or reports to ODH had been completed for them, despite facility policy requiring all allegations of abuse, neglect, and exploitation to be reported to the state agency within specified time frames.
Failure to Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, neglect, and misappropriation involving one resident. The resident was admitted with dementia, anxiety disorder, and chronic respiratory failure, but her MDS assessment indicated mild or no cognitive impairment. Progress notes for the year contained no documentation of abuse or misappropriation allegations, and the resident concern log for the past year showed no concerns regarding this resident, despite numerous detailed complaints made by her daughter via email to facility staff and the state agency. Emails from the resident’s daughter alleged that an LPN administered Tramadol doses too close together, spoke with animosity and hatred, and made disparaging remarks about the resident and her daughter; that the LPN intimidated the resident, who was afraid to be alone with her; that the LPN failed to administer medications as ordered, falsely documented refusals, and failed to respond to calls for incontinence care for several hours after turning off the call light. Additional emails alleged that a CNA disrespected the resident’s personal belongings and spoke to her like a three-year-old, that an unidentified aide verbally abused the resident by continually yelling at her, and that a set of cabin socks was stolen. The daughter also reported that the LPN publicly called the resident a derogatory name, that the resident was terrified of the alleged perpetrators, and that her repeated reports were being ignored. The only self-reported incident involving this resident in the prior six months was one SRI alleging staff spoke to her in a loud, abrasive manner, which documented only general concerns of mistreatment without specifics. The SRI contained no interview or attempted interview with the daughter, and the only interview with the resident was a generic questionnaire with pre-circled answers indicating she felt safe and had no concerns. There was no documented attempt to obtain video footage from a monitoring camera that had been in the resident’s room until it was removed, despite progress notes and the daughter’s email referencing video evidence. Facility leadership, including the Administrator, DON, ADON, and Regional Nurse, denied knowledge of the various allegations described in the emails and interview, and a call log produced by the facility showed calls to the daughter without any documentation of the content or results of those calls. These actions and omissions were inconsistent with the facility’s abuse policy, which required immediate, focused investigations of all reports of abuse, neglect, or exploitation, including interviews of all involved persons and timely reporting to the state agency.
Failure to Provide Adequate Oral and Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide appropriate oral and nail care for a totally dependent resident. The resident was admitted with respiratory failure, paraplegia, and anoxic brain damage, and his care plan documented that he was totally dependent on staff for ADLs and that his nails should be checked daily for length and cleanliness. His MDS assessment indicated he was never or rarely understood, dependent on staff for ADL care, and that his mouth could not be assessed for dental problems, and physician orders required oral care twice daily with no orders for thrush treatment. During observation, the resident was non-interviewable with his mouth hanging open, his teeth appearing brown, and a white rough layer visible on his tongue consistent with thrush, and his fingernails extended approximately one to two centimeters beyond the fingertips and curled downward. The ADON confirmed these findings, demonstrating that ordered and care-planned oral and nail care were not being adequately provided to this dependent resident.
Failure to Reposition Dependent Resident With Stage IV Pressure Injury
Penalty
Summary
A resident with respiratory failure, paraplegia, anoxic brain damage, and a documented Stage IV pressure injury on the buttocks was care planned to be turned every two hours due to total dependence on staff for ADLs and high risk for skin breakdown. The MDS indicated the resident was never or rarely understood and was dependent on staff for bed mobility, with pressure sores present on admission. The care plan dated 07/21/25 specified the need for repositioning every two hours as part of pressure ulcer prevention and care. On the survey date, multiple observations showed the resident lying on his back in bed with the head of the bed elevated about 30 degrees and no pillows or devices in place to offload pressure or turn him off his back. A wedge cushion was noted on a bedside table at the foot of the bed rather than in use for positioning. Observations at 10:18 A.M., 12:54 P.M., 3:09 P.M., and 5:05 P.M. consistently found the resident in the same supine position. The ADON later confirmed that the resident had not been repositioned for several hours that day, indicating the facility failed to follow the resident’s care plan and accepted standards of practice for pressure ulcer care and prevention.
Inadequate Supervision and Improper Use of Assistive Devices During Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and ensure the safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with chronic respiratory failure, ventilator dependence, heart failure, morbid obesity (weight 557.8 pounds), bilateral lower-extremity range-of-motion limitations, and complete dependence for bed mobility and ADLs was identified as at risk for falls and skin integrity issues. Her care plan included protective and preventative skin care and monitoring during daily care, and the MDS documented she was dependent on staff for bed mobility and always incontinent of bowel and bladder. Despite this, the facility’s staff and regional nurse continued to assert that only one staff member was required for ADL care, even though the resident required a two-person assist with a mechanical lift for transfers and was completely dependent for bed mobility. On the date of the incident, a single CNA provided incontinent care to this resident in bed. During care, the resident rolled onto her side toward the door, grabbed the bed rail, attempted to reposition her legs, and continued rolling until she fell from the bed to the floor. The CNA’s witness statement indicated she was on one side of the bed, saw the resident roll and fall, then moved to the other side to check on her before leaving the room to get assistance. The resident was later documented as having severe pain in the right leg, with hospital evaluation revealing tenderness and a contusion of the right lower extremity, though no fracture was found. The investigation and interviews confirmed that the resident’s size, dependence for bed mobility, and need for two-person assistance for transfers were not translated into a requirement for two-person assistance during bed mobility and incontinent care. The second resident involved had a history of hemiplegia and hemiparesis following a stroke, hypertension, dysphagia, dysarthria, acute and chronic respiratory failure, heart failure, and type II diabetes mellitus. Her care plans identified her as a fall risk and documented dependence on staff for ADLs and transfers, with interventions including use of a mechanical lift for chair-to-bed and bed-to-chair transfers. During a two-staff transfer from wheelchair to bed using a mechanical lift, the resident slid from the lift pad to the floor. Staff statements and the facility’s fall/skin incident report documented that the mechanical lift pad was not positioned fully under the resident’s buttocks, and staff attempted to adjust it but were unsuccessful, resulting in the resident slipping out of the pad. This event demonstrated improper pad placement and unsafe use of the mechanical lift during the transfer.
Incorrect Portion Sizes for Mechanically Altered Meat
Penalty
Summary
The facility failed to ensure that menus were followed and that residents on mechanically altered diets received the correct portion size of meat as planned on the menu. During observation of the lunch tray line, a dietary aide was seen serving mechanically altered beef stroganoff using a green-handled #12 scoop and providing only one scoop per meal to residents on mechanically altered diets. The diet extension sheet specified that mechanically altered meat was to be served with a #6 scoop, and the facility’s scoop size chart showed that a #12 scoop provides 2.78 ounces while a #6 scoop provides 4.66 ounces. The regional dietary manager confirmed that when using a #12 scoop, two scoops should have been given to meet the required portion size, and the dietary aide acknowledged that only one scoop had been provided to each resident receiving mechanically altered beef. Record review confirmed that three residents were on mechanically altered diets at the time, and facility policy on portion control required that residents receive appropriate food portions to ensure nutritional adequacy. This deficiency represents non-compliance investigated under the cited complaint numbers related to failure to provide correct serving sizes for mechanically altered meat for three residents receiving mechanically altered diets.
Inaccurate Medical Record Due to Conflicting Mattress Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and consistent medical record for a resident when documentation contained conflicting information about ordered support surfaces. The resident, admitted with bilateral primary osteoarthritis of the hip, morbid obesity, and type II diabetes mellitus with hyperglycemia, was cognitively intact and identified as at risk for developing pressure ulcers per a recent MDS 3.0 assessment. During an interview, the resident reported not having an air mattress since the end of March 2026, yet physician orders dated 04/16/26 and the April 2026 Treatment Administration Record showed active orders for both an air mattress and a pressure-redistribution mattress from 04/16/26 through 04/19/26, with documentation indicating that both surfaces were in place from 04/16/26 through 04/18/26. An observation on 04/19/26 revealed the resident was on a regular pressure-redistributing mattress and not an air mattress. At the time of this observation, an LPN confirmed that only a pressure-redistributing mattress was in use, despite the presence of two conflicting mattress orders in the medical record. This inconsistency between the resident’s report, the actual mattress in use, and the documented orders and TAR entries demonstrated that the facility did not ensure the accuracy and consistency of the resident’s medical record.
Call Light Not Left Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a working call system was left within reach for a resident in her room, as required for resident bathrooms and bathing areas and evaluated under environmental concerns. The resident had been admitted with dementia, anxiety disorder, and chronic respiratory failure, and her MDS 3.0 assessment documented that she required substantial assistance from staff for bed mobility. During observation, the resident’s call light was found hanging from the bed rail on the right side of the bed, outside of her reach, with three pillows stacked on that side further preventing her from accessing the call cord. A registered nurse confirmed this observation during interview. This deficiency was cited as non-compliance under Complaint Number 2726820.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in multiple resident rooms, as observed during surveyor rounds and confirmed by staff interviews and policy review. In one room, there was a large hole in the wall behind the head of the bed, with multiple scrapes, scratches, and areas of missing paint. The walls, floors, and nightstand in that room had large brown- and yellow-colored dried splatter stains of unknown origin, and the floor was visibly dirty and covered with food particles and debris. A RN verified these environmental conditions at the time of observation. Additional observations in two other resident rooms showed further environmental deficiencies. One room had an air conditioner unit with the front cover hanging off and the vent cover detached and lying on the floor, a floor with dirt marks and debris, and a long curved gouge in the floor by the entrance door caused by the door dragging, making the door very difficult to close. Another room had a door that was difficult to open, a dirty floor with stains, dirt, and debris, a missing outlet cover supplying power to the television, a partially detached vent cover, and a small dent with crumbling wall material above the baseboard near the entrance. The Director of Maintenance verified the damaged doors, missing outlet cover, dented wall, and loose vent covers, and the Housekeeping Supervisor verified the dirty floor conditions, noting prior staffing issues. These conditions occurred despite a facility policy stating that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Inaccurate MDS Weight Coding
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected Resident #18’s clinical status. Resident #18 was admitted with diagnoses including chronic respiratory failure, dependence on respirator (ventilator status), and heart failure. The medical record showed substantial weight changes between October 2025 and April 2026, with the resident’s weight increasing from 398.9 lbs to 557.8 lbs, yet the MDS assessments dated 10/26/25, 01/21/26, and 04/08/26 all coded that the resident had no 5% weight gain in one month and no 10% gain in six months, and repeatedly entered the same weight of 399 lbs for multiple assessments. During interview, the Registered Dietitian confirmed awareness that the resident had gained over 100 lbs but stated she had no current weight available at the time of the January 2026 assessment and reused a previous weight despite the documented weight increase. She also stated she had not assessed the resident in person and relied on risk meetings and the EMR to complete nutritional documentation. She acknowledged that the medical record did not accurately reflect the resident’s current nutritional status and confirmed the MDS coding was not accurate based on available clinical information. The facility’s MDS 3.0 Completion policy required staff to attest to the accuracy of the sections they complete, but the facility did not follow that policy as shown by the repeated use of outdated weight data and inaccurate MDS coding.
Failure to Honor Resident Activity Preferences
Penalty
Summary
The facility failed to ensure resident activity preferences were honored for two residents reviewed for activities. One resident, admitted with acute respiratory failure with hypoxia, necrotizing fasciitis, and type II diabetes mellitus, had a care plan and activity assessment indicating a preference for independent leisure activities such as using a tablet or phone and staying in bed to watch television. He was alert and oriented with a BIMS score of 15 and was dependent on staff for ADLs. During interview and observation, he reported being upset because he could not watch the NBA playoffs due to television channels not working, and he stated he had reported the issue to staff and maintenance. Review of maintenance work orders showed the resident’s television channels were documented as not working over multiple dates, but the work orders were closed as completed. During interview, the Maintenance Director stated the channels were fixed and there were no issues, but the resident demonstrated that channels 14, 15, 18, and 21 were still inoperable. The Maintenance Director then acknowledged the work order had been submitted but not completed, and that it had been closed out as rectified. The resident’s preference for in-room leisure activity was not being met while the television remained unusable. The second resident, admitted with quadriplegia, osteomyelitis, and a C4 spinal cord injury, had a recreation assessment stating that going outside for fresh air was very important to him. He was alert and oriented with a BIMS score of 15 and dependent on staff for ADLs. His care plan included encouragement to participate in activities, in-room activities if unable to attend out-of-room activities, and escort to activities of choice. Staff stated he was not allowed outside without supervision after a prior smoking policy violation, and the resident said staff told him he could not go outside and that he just wanted to go outside sometimes. The guardian stated he loved going outside, had not been taken outside, and had been told by the facility that it was a law that he could not go outside. Activity records showed no patio or deck socialization participation in the last 30 days, and the activity director confirmed he was only taken outside once during the prior week and could not recall other times.
Failure to Implement Ordered Contracture Care
Penalty
Summary
The facility failed to implement therapy-ordered contracture care for a resident with severe cognitive and physical impairment. The resident was admitted with diagnoses including Moyamoya Disease, severe protein calorie malnutrition, anemia, acute kidney failure, metabolic encephalopathy, dysphagia, cerebral infarct, and hypertension, and was admitted under hospice services. Assessments showed a BIMS score of 0 and that the resident was dependent on staff for all ADLs and mobility. The record showed therapy communication and OT documentation directing staff to provide hand hygiene, gentle PROM, apply bilateral palm guards, remove them for hygiene, monitor skin, and provide nail care as needed. A telephone order dated 04/14/25 documented that the resident was to be encouraged to wear bilateral palm guards for up to 8 hours daily with appropriate skin checks, and therapy discharge recommendations in July 2025 repeated the need for bilateral palm guards, PROM to both upper extremities, and daily hand hygiene. However, the TAR and facility order listing showed no treatment order for palm guards, and the care plan did not include interventions for hand/wrist contractures or the therapy recommendations. Survey observations on multiple dates showed the resident’s contracted hands and wrists without palm guards or any barrier between the palms and fingers, and the resident’s long nails were pressing against the palms. CNA and leadership interviews confirmed the resident had no palm guards or palm barriers in place, and the DON and RDC verified there was no care plan, intervention, or treatment order in place for the therapy recommendations. The DON also stated the facility did not have a formal restorative nursing program.
Failure to Obtain Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to ensure Resident #18’s care was adequately supervised by a physician by not obtaining, initiating, or implementing physician orders for weight monitoring despite significant documented changes in nutritional status and body weight. Resident #18 was admitted with chronic respiratory failure, ventilator dependence, and heart failure, and her care plan identified her as having a high BMI related to obesity with interventions to observe, monitor, and report changes, follow physician orders, and monitor weights. Her weight increased from 398.9 lbs to 557.8 lbs over about five months, but there was no documentation of physician notification or orders for daily, weekly, or monthly weights, and no comprehensive assessment or monitoring was documented in response to the change. The record also showed that nutrition assessments dated 10/31/25 and 01/23/26 were identical and did not reflect updated recommendations despite the resident’s ongoing nutritional risks and marked weight gain. A progress note documented a weight of 573 lbs after hospitalization, yet no physician notification or follow-up orders were documented. A later nutrition review noted a BMI of 90 and stated the weight gain required confirmation with daily weights, but there were still no corresponding physician orders, attempts to obtain orders, or weight-monitoring follow-through. CNA #570, LPN #513, and RD #630 confirmed the resident was not on a weight-monitoring list, had no orders for daily, weekly, or monthly weights, and the RD verified no physician orders were present in the medical record.
Pharmacy Recommendations Not Addressed Timely
Penalty
Summary
The facility failed to ensure pharmacy recommendations from the monthly drug regimen review were addressed in a timely manner for one resident. The resident had diagnoses including pain, type II diabetes mellitus with diabetic neuropathy, anemia, depression, PTSD, and anxiety disorder, and the quarterly MDS indicated intact cognition with no behaviors and use of antianxiety, antidepressant, antibiotic, diuretic, opioid, antiplatelet, hypoglycemic, and anticonvulsant medications. Pharmacy recommendations identified the need for a GDR trial for Diazepam 2.5 mg BID, Duloxetine 30 mg daily, Sertraline 100 mg daily, and Trazodone 100 mg QHS, but the recommendation was not addressed at the time it was reviewed. Additional pharmacy recommendations noted the resident was receiving Acetaminophen 1,000 mg TID along with two PRN acetaminophen orders, and that the PRN orders should be discontinued because the resident was already at the maximum recommended daily dosage of 3 grams. Another recommendation stated the resident had been entered for Duloxetine sprinkle capsules, which were described as a reserved dosage form for tube use and not the intended formulation, and asked for clarification of the order. Interviews with the RRN confirmed the pharmacy recommendations were not addressed timely, and the facility policy stated staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities, but it did not specify a timeframe for addressing them.
Hospice Services Not Honored and Hospice Care Plan Not Updated
Penalty
Summary
The facility failed to ensure hospice services were honored for Resident #18. Resident #18 was admitted with chronic respiratory failure, ventilator dependence, and heart failure, and her care plan reflected that she required assistance with ADLs, was at risk for falls, had a high BMI related to obesity, and had a DNR-CCA advance directive. Her MDS showed a BIMS score of 15 out of 15, indicating she was alert and oriented. The interdisciplinary care plan conference summary documented that she requested a palliative consultation through Echo Hospice, and she told the surveyor she had requested palliative care through Echo Hospice but had not received follow-up information after more than a week. Interviews showed the request was not fully acted on. The Administrator stated the facility honored hospice and palliative care requests and that the process was started immediately, but SSD #574 said Echo Hospice was called on the 13th or 14th of April and no other follow-up was initiated. The Administrator and Regional Nurse #626 stated palliative care consultations required physician orders, and Resident #18 did not have an order in place until after surveyor intervention. No further follow-up was documented in the medical record before the order was obtained. The facility also failed to ensure hospice care plans were updated for Resident #7. Resident #7 had diagnoses including Moyamoya Disease, severe protein calorie malnutrition, anemia, acute kidney failure, metabolic encephalopathy, dysphagia, cerebral infarct, and hypertension, and was dependent for all ADLs and mobility with severe cognitive impairment and moderate fall risk. The facility care plan included hospice care election and coordination with hospice, and the initial hospice care plan in the physical chart showed an active plan of care, but there were no updated hospice plans of care in the electronic record or physical chart until after surveyor intervention. The hospice RN stated updated plans are delivered every 60 days during recertification, and the DON and Regional Director of Clinical confirmed the current hospice plan of care was not on the nursing unit or in the medical record for Resident #7.
Medical Director Did Not Attend Required QAA/QAPI Meetings
Penalty
Summary
The facility failed to ensure the medical director attended the Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly. Review of monthly meeting sign-in sheets from April 2025 through March 2026 showed no signature for the medical director for the April 2025 through June 2025 meetings, which represented the second quarter. During interview on 04/29/26 at 2:03 P.M., the Administrator and Regional Registered Nurse #626 confirmed there were no medical director signatures for that quarter to show attendance. The facility policy titled Quality Assurance and Performance Improvement, revised 01/04/23, stated the QAA committee must be interdisciplinary and include, at a minimum, the DON, the medical director or designee, at least three other staff members, at least one leadership role member, and the infection preventionist, and must meet at least quarterly.
Failure to Maintain Functional Soap Dispensers and Ensure Hand Hygiene Compliance
Penalty
Summary
The facility failed to ensure consistent hand hygiene practices in accordance with accepted standards, specifically by not maintaining functional soap dispensers in multiple resident rooms. During a facility tour, it was observed that several rooms lacked working soap dispensers, and in one case, the dispenser was missing entirely. This issue affected residents in the south hallway, as their bathrooms did not have the necessary supplies for proper hand hygiene. The Director of Nursing (DON) and Administrator confirmed that they were unaware of the non-functional dispensers, as staff had not reported the issue. Further observations revealed that staff did not use the hallway alcohol sanitizer before entering or after exiting resident rooms, and it was unclear how hand hygiene was being performed in rooms without functional soap dispensers. The DON was unable to verify staff compliance with hand hygiene protocols in the affected area and stated that audits and education had not previously identified any issues. Review of the facility's policy indicated that alcohol-based hand rub should be accessible in every resident room, but this standard was not met in the identified cases.
Non-Functioning Hand Hygiene Dispensers and Damaged Resident Room Wall
Penalty
Summary
Surveyors observed that multiple resident rooms lacked functioning soap dispensers necessary for hand hygiene, with some dispensers missing entirely from the walls. Additionally, several alcohol-based hand sanitizer dispensers in the north hallway and outside certain rooms were found to be non-functional. These deficiencies were confirmed during a facility tour with the Administrator and DON, who acknowledged that staff had not reported the issues and could not confirm that proper hand hygiene was being maintained. One resident confirmed that her soap dispenser had not worked for several days, leading her to use her own sanitizer. Further inspection revealed that a resident's room had a significant hole in the wall behind the head of the bed, with plaster and drywall debris present on the floor next to a fall mat. The DON and Administrator confirmed that the wall damage should have been addressed and cleaned up. Review of the facility's Enhanced Barrier Precautions policy indicated a requirement for access to alcohol-based hand rub in every resident room, but did not address soap dispensers. These findings affected 14 out of 48 residents reviewed for a safe and sanitary environment.
Failure to Honor Resident Preferences for Call Light and Diet
Penalty
Summary
The facility failed to honor a resident's preferences as requested, specifically regarding the use of a call light system and dietary accommodations. The resident, who had multiple diagnoses including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, required assistance with activities of daily living and had intact cognition. The care plan indicated that a soft touch pad call light should be clipped to the resident's gown at all times due to dexterity issues. However, observations and interviews revealed that the resident only had access to a push button call light, which was difficult for her to use, and the requested call pad was not provided. Staff interviews confirmed awareness of the resident's preference and the facility's agreement to provide the call pad, but it was not implemented. Additionally, the resident's dietary preferences were not honored. The resident was on a minced and moist diet with specific instructions to avoid bread and to have biscuits mashed with gravy. A photo submitted by the resident's daughter showed a roll on the resident's plate, contrary to the dietary order. The Food Service Director confirmed that the meal did not comply with the resident's preferences as documented. Facility policies required evaluation of unique resident needs and prompt reporting and resolution of issues with accommodations, but these were not followed in this case.
Failure to Document and Re-Evaluate Ongoing Use of Physical Restraints
Penalty
Summary
The facility failed to ensure proper documentation and ongoing evaluation for the use of physical restraints on a resident with multiple complex medical conditions, including acute respiratory failure, COPD, encephalopathy, ventilator dependence, and significant cognitive impairment. The resident was admitted with a history of attempting to remove life-sustaining medical equipment, leading to the use of mitt restraints as ordered by the provider. However, the provider order lacked essential details such as the specific diagnosis justifying the restraint, instructions for breaks in restraint usage, and requirements for monitoring the effectiveness of less restrictive interventions. Nursing progress notes indicated that mitt restraints were applied and skin assessments were performed on select dates, but there was no consistent documentation of the ongoing need, usage, or evaluation of the continued use of restraints as required by facility policy. The care plan did not include specific goals or interventions related to the mitt restraints, nor did it address ongoing monitoring or plans for removal. The Medication Administration Record showed that mitt restraints were signed off for each shift, but this did not substitute for the required comprehensive documentation and evaluation. Interviews with facility staff, including the DON, respiratory therapist, nurse practitioner, and LPN, revealed a lack of clarity and consistency in the documentation and management of restraints. Staff acknowledged the need for restraints due to the resident's behaviors but confirmed that there was no daily checklist or structured process for documenting alternatives attempted, ongoing re-evaluation, or effectiveness of the restraint. The facility's own policy required documentation of medical symptoms warranting restraint use, less restrictive alternatives, and ongoing re-evaluation, none of which were adequately present in the resident's record.
Failure to Administer Ordered Topical Medication and Inaccurate MAR Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, did not receive an ordered topical pain-relieving medication (Biofreeze gel) to both knees as prescribed. The resident required assistance with activities of daily living and did not have the dexterity to self-apply the medication. Despite this, the LPN responsible for the resident did not apply the Biofreeze gel as ordered, instead leaving it on the resident's bedside table and assuming the resident could self-administer it. The LPN subsequently documented in the medication administration record (MAR) that the medication had been given, even though she neither applied it herself nor observed the resident applying it. The issue was identified when the resident and her daughter reported that the medication was not being applied as ordered. Upon interview, the LPN confirmed she had not administered the medication but had signed it off in the MAR. The facility's policy required staff to only sign the MAR after actually administering the medication. The DON confirmed that the resident was not capable of self-application and that the LPN's actions were not in accordance with facility policy.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders and its own policy regarding weight monitoring for two residents. For one resident with chronic respiratory failure, tracheostomy, type II diabetes, and morbid obesity, the care plan required monthly weight monitoring due to increased risk for malnutrition. However, there was no recorded weight or documented refusal for one month, and the DON confirmed the absence of required documentation for that period. The resident was dependent on staff for activities of daily living and had intact cognition. For another resident with multiple respiratory and cardiac diagnoses, including obesity and chronic respiratory failure, the care plan also required monthly weight monitoring, and a physician order specified daily weights. A review of records showed that daily weights were missing on several specified dates, and the DON confirmed these weights were not obtained as ordered. The facility's policy required weights to be recorded at the time obtained and to follow physician orders for frequency, but this was not consistently done for these residents.
Failure to Ensure Proper Ventilator Alarm Monitoring and Oxygen Administration
Penalty
Summary
The facility failed to ensure that external ventilator alarms were properly monitored and functioning for two residents who required ventilator support. In one instance, a resident using an AVAPS ventilator experienced a disconnection of her oxygen hose, which triggered the internal alarm in her room. The call light was tied to the side of the bed and not within the resident's reach, delaying her ability to summon help. A CNA eventually responded, reattached the oxygen hose, and the alarm ceased. However, the external alarm outside the room was found to be turned off, and it was not reactivated until a respiratory therapist entered the room later. The resident and staff confirmed that the external alarm was not sounding during the incident, and the alarm log verified a patient circuit disconnect alarm lasting approximately 11 minutes. Another resident, dependent on an ACVC ventilator, was observed with the external ventilator alarm turned off during a routine walk-through. The respiratory therapist confirmed that the alarm should not have been off. Facility policy required that staff be trained and competent in the use of mechanical ventilation, including responding to alarms, but the policy for noninvasive ventilation did not specify alarm monitoring procedures. The failure to ensure alarms were active and monitored had the potential to affect additional residents using ventilators in the facility. Additionally, the facility failed to follow physician orders regarding oxygen administration for a resident who required oxygen via nasal cannula at three liters per minute during all medication administrations and meals due to diminished lung capacity and aspiration risk. Video evidence showed the resident eating lunch without her nasal cannula on, and the respiratory therapist had not transitioned her to the nasal cannula after removing the AVAPS mask. Interviews with staff confirmed that the resident was supposed to be on nasal cannula during meals and medication administration, but this was not consistently implemented.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to implement an adequate and effective pressure ulcer prevention program for a resident who was cognitively impaired, dependent on staff for activities of daily living, and incontinent of bowel. The resident had Stage IV pressure ulcers on the left lateral ankle and foot, which required timely dressing changes. On a specific date, a CNA informed an LPN that the resident's dressings were saturated with fecal material, but the LPN failed to change the dressings promptly. This inaction led to the deterioration of the ulcers, contributing to the development of sepsis and osteomyelitis, and necessitated hospitalization in the intensive care unit. The resident's medical record indicated a history of osteomyelitis, hypertension, contracture of the right knee, and dementia. The care plan required staff to continue treatments as ordered by the physician and to observe for signs of infection or worsening of the wound. Despite daily dressing orders being documented as completed, the as-needed orders were not utilized on the dates in question. The wound evaluation and management summary revealed that the pressure ulcers had worsened, with increased size and signs of infection, leading to the suspicion of osteomyelitis. Interviews with staff and review of witness statements confirmed that the dressings were not changed when they became soiled, despite the facility's policy allowing for such changes. The LPN admitted to forgetting to change the dressing after being informed by the CNA. The wound physician noted the deterioration of the wounds and ordered further medical interventions, including antibiotics and diagnostic tests. The facility's investigation and disciplinary actions highlighted the failure to provide necessary care to prevent further breakdown in the resident's wounds.
Removal Plan
- DON and LPN #206 provided nursing staff education on the facility policy titled, Wound Treatment Management, including changing the dressing if feces had seeped underneath the dressing or the dressing was soiled as well as adding an order for all residents with wounds to check the integrity of the dressing each shift and replace if needed.
- LPN #206 completed wound and dressing audits for all residents to ensure dressings were intact and the orders were correct without negative findings.
- The Administrator provided LPN #291 education and disciplinary action.
- Audits were initiated of wound dressing observations including if the dressing was clean, dry and intact as well as if the order was in place to check the integrity of the dressing each shift. These audits were to be completed by the DON or her designee three times a week for one week and then weekly thereafter for three weeks. The results would be taken to the quality assurance meetings.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of staffing schedules and staff punch details for the period from October 1, 2024, to October 31, 2024, which revealed a lack of RN coverage on October 27, 2024. An interview with the Human Resources Director confirmed the absence of RN coverage on that date. This issue had the potential to affect all 49 residents residing in the facility and was investigated under Complaint Number OH00159004.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to serve meals at a palatable temperature, affecting 41 residents who received food from the kitchen. Observations revealed that meal temperatures were not consistently recorded on multiple dates, including no lunch temperatures for certain days and no dinner temperatures for several others. During an observation of the lunch tray line, it was noted that the tray line was delayed due to running out of rice, causing a delay in meal service. A test tray conducted later showed that the food was not served at the appropriate temperature, with carrots being too cold and pureed rice not having the correct consistency. Interviews with residents confirmed that meals were sometimes late and not warm enough. The facility's policy stated that meals should be served within 45 minutes of the scheduled mealtime and at an appetizing temperature. However, the test tray conducted with the Dietary Manager confirmed that the meal was served later than 45 minutes past the posted delivery time, and the food was not at the appropriate temperature, leading to the deficiency noted in the report.
Deficiency in Meal and Snack Service
Penalty
Summary
The facility failed to ensure that meals and snacks were provided in accordance with residents' needs, preferences, and requests, as well as the facility's own policies. Observations and interviews revealed that meals were not served at the posted times, and there were instances where residents were not offered snacks when there was more than a 14-hour gap between dinner and breakfast. This deficiency had the potential to affect all 41 residents receiving meals from the kitchen, with specific issues noted for several residents who did not receive meals or snacks as required. One significant issue was the delay in meal service due to running out of food items, such as rice, which caused a delay in the tray line and resulted in residents receiving their meals later than scheduled. Additionally, there were reports of dinner trays being delivered late, sometimes more than 45 minutes past the posted time, due to issues such as equipment malfunction and lack of disposable supplies. These delays were confirmed by staff interviews and observations, indicating a systemic issue in meal service delivery. Furthermore, the facility failed to consistently provide snacks to residents, as required by their policies. Interviews with staff and residents revealed that snacks were not always available, and staff sometimes had to bring snacks from home to meet residents' needs. The facility's policies stated that snacks should be available 24 hours a day, yet there were multiple reports of snacks not being delivered or available, particularly at night. This inconsistency in snack availability further contributed to the deficiency in meeting residents' nutritional needs.
Sanitation Deficiency in Food Service
Penalty
Summary
The facility failed to ensure that food was stored and served under sanitary conditions, potentially affecting 41 residents who received food from the kitchen. During an initial kitchen tour, it was observed that the low temperature dish machine reached the appropriate temperature of 125.6°F, but the chlorine chemical test strip did not change color, indicating a failure in the sanitization process. The staff member confirmed that disposable dishes would be used until the dish machine was fixed. Additionally, it was noted that temperature logs for the dish machine had not been completed since November 6, and there were no cleaning logs for September, October, or November to date. The sanitizer bucket test log and the three-compartment sink log were also incomplete past November 6. Further observations revealed that the exhaust fan near the ceiling on the back wall across from the serving line was heavily soiled with dark brown dust on the grates, which blew out towards the serving line. The facility's undated policy on sanitary conditions stated that all equipment would be maintained in a clean and sanitary fashion, with a schedule for cleaning and sanitizing established by the Food Service Director. The policy also required that dish machine temperatures be maintained at 120°F for wash with 50 parts per million Hypochlorite, and a temperature log be maintained for every meal. This deficiency was investigated under Complaint Number OH00159004.
Deficiency in Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure the safe handling and storage of food brought in from outside for residents, which could potentially affect 41 residents who received food from the kitchen. During an observation, the Dietary Manager (DM) noted several issues with the resident refrigerator on the south resident hall, including three unlabeled and undated meat sandwiches, and a lack of temperature monitoring logs for the refrigerator. Additionally, the unit microwave was found to have dried food particles stuck to its ceiling and sides. These findings were confirmed by the DM at the time of observation. Further inspection of the resident refrigerator on the skilled hallway revealed multiple concerns, such as an unlabeled and undated plastic container of ice cream, an open and undated bottle of ketchup, and several other food items that were either expired or not labeled with a resident's name. An undated and unlabeled bag of employee-pumped breast milk was also found, which was against facility policy. The Assistant Director of Nursing (ADON) confirmed that employee foods and breast milk should not be stored in the resident refrigerator. The facility's policy mandates that all food brought in for residents must be labeled with the resident's name and date, and any unlabeled items should be discarded immediately. This deficiency was investigated under Complaint Number OH00159004.
Inaccurate Staffing Information Submitted to CMS
Penalty
Summary
The facility failed to ensure accurate direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified through a review of punch details and interviews, revealing that a Nurse Practitioner was incorrectly listed as a Registered Nurse (RN) in the payroll-based journal (PBJ) for several days. The Human Resources Director was unaware of the Nurse Practitioner's actual role and mistakenly entered her hours as an RN, believing her hours could still be utilized in that capacity. The Administrator confirmed that the hours should not have been entered as RN hours since the individual was working as a Nurse Practitioner during the specified time frames.
Deficiencies in Cleanliness, Phone System, and Shower Room Sanitation
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards for wheelchairs and shower rooms, as well as ensure the functionality of facility phones. Observations revealed that the power wheelchairs for three residents were heavily soiled with dried spills, food crumbs, and even a used disposable glove. The facility's schedule indicated that wheelchairs should be cleaned on resident shower days, but this was not adhered to, as confirmed by the Administrator. Additionally, the facility's phone system was not functioning properly, which hindered communication and access to the facility. The surveyor experienced difficulty entering the facility due to non-functional doorbells and phones that did not audibly ring. Interviews with staff and administration revealed that the phone system had been problematic since June 2024, with issues persisting despite attempts to address them. The facility had not communicated these issues to residents' families or provided alternative contact methods. The shower rooms were also found to be in unsanitary conditions, with black mold-like stains on the tiles and dried feces on the shower bed and floor. These findings were confirmed by the DON, who acknowledged that aides were responsible for cleaning the showers and equipment after each use. The presence of mold and feces indicates a failure to maintain a sanitary environment, which could potentially affect the health and safety of the residents.
Failure to Conduct Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to implement care-planned interventions by not completing quarterly smoking safety assessments for residents who smoke, as required by their policy. This deficiency affected two residents, one of whom was Resident #150, who was admitted with diagnoses including spastic hemiplegia, epilepsy, and schizoaffective disorder. Despite being cognitively intact and independent in activities of daily living, Resident #150 required supervision while smoking due to a loss of upper limbs. The last smoking assessment for this resident was completed several months prior to the survey, indicating a lapse in the quarterly assessment schedule. Similarly, Resident #153, who had diagnoses including type II diabetes mellitus, opioid dependence, and bipolar disorder, was also affected by this deficiency. This resident was cognitively intact and independent in daily activities but required supervision while smoking. The care plan for Resident #153 also stipulated quarterly smoking assessments, which were not completed as required. The facility's policy on resident smoking, revised in 2021, did not specify the frequency of smoking assessments, contributing to the oversight. This deficiency was investigated under a specific complaint number.
Failure to Ensure Safe Discharge for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure a safe discharge for Resident #153, who had a history of type II diabetes mellitus, opioid dependence, and bipolar disorder. Despite being cognitively intact according to a BIMS score of 15, a subsequent evaluation using the Montreal Cognitive Assessment (MoCA) indicated moderate cognitive impairment, suggesting the need for a guardian. The resident expressed a desire to live with her son in New York, contrary to her daughter's wishes, who was the primary power of attorney (POA) and expressed concerns about the safety of this discharge. The facility's social worker had been in contact with the resident's son, who was listed as the third POA, and began discharge planning without adequately addressing the daughter's concerns or the psychological evaluation recommending a guardian. The resident's daughter was not informed of the discharge until after it occurred, and the facility did not contact adult protective services or the police, despite the daughter's concerns about potential harm. The Director of Nursing (DON) and other staff members were aware of the resident's desire to leave with her son and allowed the discharge against medical advice (AMA) to proceed, citing the resident's BIMS score. However, the facility did not fully consider the MoCA results or the daughter's request for a guardian, leading to a deficiency in ensuring a safe discharge process for the resident.
Failure to Provide Scheduled Bathing and Document Care
Penalty
Summary
The facility failed to ensure that scheduled bathing was provided for three residents, leading to a deficiency in care. Resident #121, who had intact cognition and was dependent on staff for bathing, did not receive a scheduled shower on one occasion, and there was no documentation of a refusal. Additionally, the shower sheets were often missing required signatures from the nurse and aide, indicating a lack of proper documentation and review. Resident #122, who also had intact cognition and was dependent on staff for bathing, preferred bed baths but did not receive scheduled bathing on two occasions. Similar to Resident #121, the shower sheets for Resident #122 were missing nurse signatures, and there was no documentation of refusals in the nursing progress notes. This indicates a failure to adhere to the facility's policy of documenting and reviewing bathing activities. Resident #155, who had moderate cognitive impairment and was dependent on staff for bathing, did not have a shower sheet provided for one scheduled day, and most of the provided shower sheets were missing nurse signatures. The Director of Nursing confirmed the missing documentation for all three residents, highlighting a systemic issue with the facility's adherence to its bathing schedule and documentation policies.
Failure to Complete Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure that daily weights were completed as per physician orders for a resident with congestive heart failure. The resident, who had intact cognition and was dependent on transfers, had a physician order dated 07/03/24 for daily morning weights due to their condition. However, a review of the resident's daily weight records revealed multiple dates in October and November 2024 where weights were not recorded, indicating non-compliance with the physician's order. Interviews conducted with the resident's daughter, the Director of Nursing, and the dietitian confirmed the failure to complete daily weights as ordered. The resident's care plan highlighted the risk for alteration in nutrition and/or hydration related to obesity, with an intervention to monitor weight as per physician orders. This deficiency was investigated under Complaint Number OH00159004, affecting one resident out of three reviewed for weight monitoring in a facility with a census of 49.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed as required for three residents, which had the potential to affect all 49 residents residing at the facility. For Resident #122, the medical record review revealed that there were no physician or nurse practitioner visits since early September 2024, with only a few visits documented in the past year. The Director of Nursing (DON) confirmed the lack of monthly alternating physician and nurse practitioner visits for this resident. Similarly, Resident #153's medical record showed a gap in physician visits between mid-June 2024 and the resident's discharge in late September 2024, despite frequent nurse practitioner visits. The DON confirmed the absence of the required alternating visits. For Resident #154, the medical record indicated only two physician visits in July and August 2024, with no nurse practitioner visit notes found. The DON again confirmed the lack of compliance with the facility's policy on alternating visits. The facility's policy allows for alternating visits between physicians and nurse practitioners, but this was not adhered to, leading to the deficiency.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #155 was free from significant medication errors, as evidenced by the failure to administer prescribed intravenous antibiotics and Heparin flushes according to physician orders. Resident #155, who had diagnoses including chronic kidney disease, heart failure, and sepsis, was admitted to the facility and later discharged to the hospital for gastrointestinal bleeding. During the resident's stay, there were multiple instances where Ceftriaxone and Ampicillin were not administered as ordered, and Heparin flushes were missed on several occasions. These omissions were documented in the Medication Administration Record (MAR) and nursing progress notes. Interviews with facility staff, including a Regional RN and an LPN, confirmed that the medications were not administered due to the unavailability of an RN, as LPNs were not permitted to administer intravenous medications to residents with central lines. The facility's policy on medication administration required medications to be administered as ordered by the physician, which was not adhered to in this case. The deficiency was investigated under Complaint Numbers OH00159247 and OH00159004.
Non-Compliance with Physician-Ordered Diet Texture
Penalty
Summary
The facility failed to ensure that a physician-ordered diet with modified texture was followed for a resident. This deficiency was identified during a survey where the facility's compliance with dietary requirements was assessed. The resident involved had a medical history that included acute postprocedural respiratory failure, hemiplegia, dependence on a respirator, type II diabetes mellitus, and moderate protein-calorie malnutrition. The resident's care plan indicated a risk for dental or chewing problems due to missing or broken teeth, and the physician had ordered a diet of regular no added salt double portions with pureed texture and thin liquids. During the survey, an observation of a test tray revealed that the pureed rice did not have a smooth consistency as required by the facility's policy for a Dysphagia Puree (Level 1) Diet. The rice appeared to have visible particles and was not the consistency of moist mashed potatoes or pudding, as stipulated by the policy. The Dietary Manager confirmed that the pureed rice did not meet the required smooth pureed texture. This non-compliance was investigated under a specific complaint number.
Inadequate Hydration Practices in Facility
Penalty
Summary
The facility failed to ensure adequate hydration was provided between meals, affecting four residents and potentially impacting 41 others who received food from the kitchen. Residents #121 and #122, both cognitively intact, reported that water was not consistently provided between meals unless requested. Observations confirmed that hydration cups were not consistently present in resident rooms, and the facility's policy required State Tested Nurse Aides (STNAs) to provide fresh ice water to residents each shift, which was not adhered to. Resident #121, who has chronic respiratory failure and other health issues, was at risk for dehydration due to obesity and diuretic use. Her care plan included monitoring for dehydration signs, but there was no evidence of fluid intake being recorded in her medical records for the past 30 days. Similarly, Resident #122, with conditions like congestive heart failure and moderate protein-calorie malnutrition, had no recorded fluid intake in her medical records, despite her care plan requiring meal intake, including fluids, to be recorded. Interviews with staff, including CNAs and LPNs, revealed inconsistencies in water delivery practices. Some staff were unsure of the frequency of water passing, while others confirmed that water was supposed to be provided each shift but was not consistently done. The facility's policy, revised in 2018, mandated that fresh water be delivered each shift and upon request, but this was not consistently implemented, leading to the deficiency noted in the report.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide showers for a resident who was dependent on staff for all activities of daily living, including grooming and bathing. The resident, who was severely cognitively impaired and dependent on a respirator, was scheduled to receive showers twice a week according to the facility's shower schedule. However, a review of shower sheets revealed that the resident only received bed baths or partial bed baths over a period of approximately six weeks. Interviews with staff confirmed that the resident had been receiving showers in the past, but they had stopped for reasons unknown to the staff. Observations and interviews further highlighted the deficiency, as the resident was found to have a buildup of a black substance under her nails, which was confirmed by a Licensed Practical Nurse. A State tested Nursing Assistant and the resident's family member both noted the resident's habit of digging in her stool, which contributed to the buildup under her nails. The family member also confirmed through a camera in the resident's room that showers were not being provided, despite the facility's policy stating that residents should be bathed or assisted to shower routinely and as needed per their preference.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a nine percent error rate during a medication administration observation. This deficiency affected two residents out of three observed. Resident #32, who has multiple diagnoses including chronic respiratory, kidney, and heart failure, was administered an incorrect dose of Polyethylene Glycol by LPN #355. The nurse did not fill the cap to the top as required for the correct 17-gram dose, leading to a medication error. Additionally, Resident #40, with a complex medical history including sepsis, asthma, and quadriplegia, was administered morphine inappropriately. LPN #361 crushed a morphine extended-release tablet and mixed it with applesauce without a physician's order, contrary to the facility's medication administration policy. The policy specifies that medications requiring crushing must have a prescriber's order, and certain medications, like extended-release tablets, should not be crushed unless specifically authorized by a physician.
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 1,266 citations issued within 25 miles in the last 12 months — including the 12 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 Oakwood Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Health Care Center | 0 mi | ★★★★★ | 1 | 0 |
| Aventura At Walton Hills | 1.3 mi | ★★★★★ | 21 | 0 |
| Northfield Village Retirement Community | 2.2 mi | ★★★★★ | 0 | 0 |
| Solon Pointe At Emerald Ridge | 3.1 mi | ★★★★★ | 21 | 0 |
| Avenue At Macedonia | 3.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Grande Oaks.
100% money-back within 48 hours.
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.