Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Village Skilled Nursing & Rehabilitation Ltd during CMS and state inspections, most recent first.
Surveyors found that expired Hydrion test strips were being used to check sanitizer levels at the manual dishwashing station. The Dietary Manager was unaware of the expiration date requirement for test strips, despite facility policy mandating regular checks with test strips to ensure proper sanitation. Previous audits showed test kits were available and used, but only expired strips were present during the inspection.
Staff failed to follow infection control protocols, including using an insulin pen labeled for one resident to prepare a dose for another, and not adhering to required PPE use for residents on contact and enhanced barrier precautions. These lapses included not donning gowns or gloves as required and improper disposal of PPE after providing care.
Two residents with complex medical needs did not have comprehensive care plans that included all required goals and interventions. One resident's care plan lacked interventions for refusal of care behaviors, while another resident's care plan did not address opioid use or monitoring for side effects, despite being on a scheduled pain regimen. These omissions were confirmed by facility staff and were not in accordance with facility policy.
A resident with multiple diagnoses, including mobility and balance issues, experienced a fall with injury. Although new interventions such as signage to remind the resident to use the call light were documented and ordered, the care plan was not updated to reflect these changes. The DON confirmed the omission, and facility policy requiring timely care plan updates was not followed.
A resident with a history of spinal stenosis, depression, and anxiety did not receive a prescribed daily nicotine patch on three occasions because the medication was unavailable. Documentation indicated the patch was not given, but there was no evidence that the physician was notified. The DON was also not informed, and the same nurse was responsible for the missed doses.
A resident with a history of urge incontinence had a urine culture ordered, which later returned positive for E. coli and other abnormal findings. There was no documentation of the reason for the test, no follow-up assessments, and no evidence that the results were communicated to the resident, her provider, or PCP, despite facility policy requiring such notifications.
A resident with multiple health conditions, including severe malnutrition and diabetes, experienced significant unplanned weight loss that was not timely addressed or communicated to the physician as required by facility policy. The Registered Dietitian was not made aware of the weight loss prior to the resident's hospitalization, and there was no documentation of physician notification or intervention for the weight change.
A resident with multiple chronic conditions received scheduled and as-needed pain medications, including opioids, without clear indications for use or proper documentation of pain reassessment and monitoring for adverse effects. Nursing staff frequently recorded the effectiveness of pain medications as "unknown" and did not consistently follow up with pain assessments or monitor for opioid side effects, contrary to facility policy.
Two residents experienced medication errors when a nurse prepared to administer insulin from another resident's device without proper priming, and an LPN gave only half the prescribed dose of vitamin D3. These incidents resulted in a medication error rate of 6.9%, exceeding the 5% standard.
A resident with multiple chronic conditions and moderate cognitive impairment did not receive showers as specified in her care plan and preferences, instead receiving mostly bed baths. Documentation of bathing and refusals was inconsistent or missing, and staff interviews confirmed the resident's shower schedule was not followed, partly due to the shower being blocked by equipment.
A facility failed to ensure proper PPE use for Enhanced Barrier Precautions during high-contact care for a resident with a chronic Foley catheter. An STNA did not wear a gown as required by facility policy, despite being aware of the need for gown and gloves during such activities.
Expired Test Strips Used for Dish Sanitization
Penalty
Summary
During an inspection of the facility's kitchen, it was observed that the Hydrion test strips used to check sanitation levels at the three-sink manual dishwashing station were expired. The Dietary Manager confirmed the test strips were expired and was unaware that test strips had expiration dates. Facility policy required staff to maintain kitchen sanitation and to regularly check the sanitation sink using test strips to ensure appropriate sanitizer levels. Documentation from previous kitchen sanitation audits indicated that test kits were available and being used appropriately, but at the time of the survey, only expired test strips were present.
Failure to Follow Infection Control Protocols and Proper Use of Insulin Pens
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols in multiple instances. During an insulin administration, a registered nurse prepared to administer insulin to a resident using a Humalog Kwikpen labeled for a different resident. The nurse confirmed the error when questioned and subsequently obtained a new insulin vial for the correct resident. Manufacturer instructions and facility policy both specify that insulin pens are not to be used for multiple residents due to infection risk. Additionally, staff did not follow required contact and enhanced barrier precautions for residents with specific infection control needs. One resident with active C. difficile infection had physician orders and a care plan requiring contact precautions, including the use of gowns and gloves when entering the room. However, a certified nursing assistant entered the resident's room and provided care without donning a gown, and only put on gloves after entering. The same staff member then entered another resident's room without changing PPE. In another case, a resident requiring enhanced barrier precautions for wound care was assisted by a CNA who wore gloves and a mask but failed to wear a gown as required, and disposed of gloves outside the resident's room. Facility policies specify that appropriate PPE must be donned prior to entering rooms and removed before exiting.
Failure to Develop and Implement Complete Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans for two residents included all necessary goals and interventions to address their total care needs. For one resident with multiple diagnoses including COPD, diabetes with neuropathy, chronic pain, atrial fibrillation, gout, depression, psychosis, and mild cognitive impairment, the care plan documented a history of refusal of care, such as refusing showers, getting out of bed, ancillary services, and removing a Dexcom sensor. However, the care plan did not include any goals or interventions to address these refusal behaviors, and there were no updates or edits related to interventions or desired outcomes for this problem, despite multiple revisions to the care plan over time. This omission was confirmed by the MDS Coordinator during an interview and was not in accordance with the facility's care planning policy, which requires care plans to be specific to each resident's needs and to include measurable goals and interventions. For another resident with diagnoses including acute on chronic diastolic CHF, respiratory failure, depression, COPD, osteoarthritis, kidney neoplasm, SIRS, muscle spasms, contractures, and constipation, the care plan did not address opioid use, despite the resident being on a scheduled pain regimen and receiving opioids. The care plan noted altered comfort related to various conditions but did not include goals or interventions for monitoring or reporting adverse effects of opioid use. The DON confirmed that such interventions should have been included. The facility's policy requires care plans to be based on comprehensive assessment data and to be reviewed and updated regularly, but these requirements were not met for these two residents.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following a fall with injury, despite documentation and orders indicating that a new intervention—signage reminding the resident to use the call light for assistance—was to be implemented. The resident, who had diagnoses including syncope, lower back pain, head injury, dizziness, muscle weakness, and difficulty walking, experienced a fall resulting in fractures. The medical record showed that after the fall, both a fall assessment and progress notes specified the need for signage as a new intervention, and a physician's order was written to this effect. However, review of the resident's care plan revealed that it had not been updated with the new intervention since before the fall, and no additional interventions regarding signage were added. The Director of Nursing confirmed during interviews that the care plan was not revised to include the new intervention after the fall, and was unable to provide a copy of the fall investigation. Facility policy required that care plans be specific to each resident's needs, list all interventions, and be updated at least quarterly and within seven days of comprehensive assessments, but this was not followed in this instance.
Failure to Administer Ordered Nicotine Patch Due to Unavailability and Lack of Physician Notification
Penalty
Summary
The facility failed to administer a nicotine transdermal patch as ordered for a resident with diagnoses including spinal stenosis, depression, and anxiety disorder. The physician's order specified daily application of a 21 mg nicotine patch due to tobacco use, starting on 02/06/25. Medical record review showed that on three consecutive days, the patch was not administered because it was not available, as documented in the progress notes. There was no documentation that the physician was notified about the unavailability of the medication, and the DON confirmed that she was not informed of the issue. The same nurse was responsible for medication administration on all three occasions but could not recall the events when questioned.
Failure to Follow Up on Positive Urine Culture Results
Penalty
Summary
The facility failed to ensure appropriate follow-up and communication regarding a urine culture ordered for a resident with a history of urge incontinence and other significant medical diagnoses, including sepsis and acute respiratory failure. The resident was cognitively intact and had been occasionally incontinent of bowel and bladder. A urinalysis with culture and sensitivity was ordered, but the medical record did not indicate the reason for the order, nor did it contain documentation of any genitourinary assessments or concerns after the order was placed. The urine sample was collected, and the final laboratory report showed significant findings, including the presence of Escherichia Coli at a high concentration, as well as other abnormal urinalysis results. Despite these findings, there was no evidence in the medical record that the urine culture results were communicated to the resident, her medical provider, or her primary care physician. Interviews with the DON and an RN confirmed a lack of documentation or recall regarding the reason for the urine culture, as well as a lack of follow-up or notification to the appropriate parties. Facility policy required prompt notification of changes in resident status, including lab results that could indicate a need to alter medical treatment, but this was not followed in this case.
Failure to Address and Document Significant Weight Loss
Penalty
Summary
A resident with diagnoses including depression, muscle weakness, severe protein-calorie malnutrition, and type 2 diabetes mellitus experienced significant unplanned weight loss. The resident's weight dropped from 187.2 lbs. to 164.2 lbs. over a period of weeks, with a questionable weight entry on one date that was later crossed out by the Registered Dietitian (RD) due to suspected inaccuracy. The RD was not made aware of the significant weight loss that occurred prior to the resident's hospitalization, and there was no documentation that the physician was notified of this weight loss. The facility's policy required verification of significant weight changes, assessment by the dietitian, and physician notification, but these steps were not consistently followed or documented. Interviews revealed that the RD relied on nursing staff to input weights into the electronic medical record and to notify her of changes, but this communication did not occur as expected. The RD also stated that she typically notifies the physician of significant weight changes but does not always document this action. The Director of Nursing confirmed that the RD monitors weights and is responsible for physician notification, but there was no evidence that the required notifications or interventions were completed or documented for the resident's significant weight loss prior to hospitalization.
Failure to Ensure Safe and Appropriate Pain Management and Opioid Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple complex medical conditions, including congestive heart failure, COPD, osteoarthritis, and a history of fractures and neoplasm. The resident was on a scheduled pain regimen and received both acetaminophen and oxycodone as needed for pain and discomfort. However, the orders for oxycodone did not specify the type or severity of pain for which it should be administered, and the care plan lacked a focus on opioid use or interventions for monitoring opioid-related side effects. Documentation review revealed that after administration of both acetaminophen and oxycodone, the effectiveness of the medications was frequently recorded as "unknown," with no follow-up pain assessments or evidence of monitoring for adverse effects. This pattern was observed multiple times over two months, with no nursing assessments or documentation to indicate that the resident's pain was re-evaluated or that opioid side effects were monitored as required by facility policy. The care plan only included general interventions for monitoring pain medication effectiveness and notifying the provider if medication was ineffective, but did not address opioid-specific monitoring. Interviews with nursing staff and the DON confirmed that pain reassessment was required after analgesic administration and that "unknown" should not be selected unless the resident was no longer in the facility. Staff also confirmed there was no designated place in the documentation system to record monitoring for opioid side effects, and the care plan should have included such interventions. Facility policy required monitoring for medication effectiveness, adverse effects, and signs of overdose, as well as pain re-evaluation 30 to 60 minutes after administration, but these practices were not followed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in two medication errors out of 29 observed opportunities, for a total error rate of 6.9%. In one instance, a registered nurse prepared to administer 21 units of Humalog insulin to a resident using a Kwikpen device that was labeled for a different resident and had already been opened. The nurse also failed to prime the needle with two units of insulin before programming the dose, contrary to manufacturer instructions and facility policy. The surveyor intervened before the injection was given, and the nurse confirmed the errors during an interview. In another case, a licensed practical nurse administered only one tablet of cholecalciferol (vitamin D3) 1000 units to a resident, despite an active order for two tablets totaling 2000 units daily. The nurse confirmed during an interview that only one tablet was given, not the prescribed dose. These two incidents contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Provide Bathing Assistance per Resident Preferences and Care Plan
Penalty
Summary
The facility failed to ensure that a resident received assistance with bathing and showers according to her documented preferences and care plan. The resident, who had multiple diagnoses including COPD, diabetes with neuropathy, chronic pain, atrial fibrillation, gout, depression, psychosis, and mild cognitive impairment, required substantial assistance for bathing and toileting hygiene. Her care plan specified a preference for one bed bath and one shower per week, and the physician's order supported a shower schedule based on her preferences or facility protocol. However, review of the electronic medical record and shower schedules showed that the resident primarily received bed baths and not showers as scheduled, with several instances where there was no documentation of any bathing or refusals. There were also no paper shower sheets documenting refusals or completed showers after a certain date. Interviews with the resident, her representative, CNAs, and the DON confirmed that the resident was not receiving showers as planned, and that the shower in her room was often inaccessible due to equipment being stored in the bathroom. Staff interviews indicated that while shower schedules and documentation protocols existed, they were not consistently followed, and the resident mostly received bed baths instead of showers. The facility's policy required provision of ADL care in accordance with resident consent and care plans, but this was not adhered to for this resident.
Failure to Use Proper PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) during high-contact resident care activities. This deficiency was observed in the care of a resident with a chronic Foley catheter, who required catheter care every shift. The resident, who had intact cognition, was diagnosed with dementia, peripheral vascular disease, and neuromuscular dysfunction of the bladder. During an observation, a State Tested Nursing Assistant (STNA) did not wear a gown while performing catheter care, despite the facility's policy requiring both gown and gloves for such activities. The facility's policy on Enhanced Barrier Precautions, dated August 2022, mandates the use of gown and gloves during high-contact resident care activities, such as providing hygiene, changing linens, and changing briefs. The STNA confirmed awareness of the requirement to wear a gown but failed to do so during the observed care. This non-compliance was documented under a specific complaint number, indicating a breach in infection prevention and control protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pebble Creek Healthcare Center | 0.4 mi | ★★★★★ | 2 | 0 |
| St Luke Lutheran Community-portage Lakes | 2.9 mi | ★★★★★ | 0 | 0 |
| Pleasant View Health Care Center | 5.3 mi | ★★★★★ | 2 | 0 |
| Barberton Post Acute | 5.4 mi | ★★★★★ | 0 | 0 |
| The Pavilion At Canal Fulton For Nursing And Rehab | 7.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.