Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hall Of Fame Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to provide timely meal service according to its posted mealtimes and written policy on meal frequency. Resident council minutes documented that meals were often late, and an observation confirmed that lunch trays arrived on one floor 55 minutes after the posted delivery time, as verified by an LPN. The dietary manager acknowledged that the posted schedule indicated when trays should be delivered, despite stating it reflected tray line start times. Multiple residents reported late meals as an ongoing concern, and the issue affected several residents and had the potential to affect nearly all individuals receiving meals from the kitchen, excluding one resident who was NPO.
Surveyors identified that the facility did not maintain clean and sanitary kitchen conditions or proper food storage for residents receiving meals. Two dietary staff serving breakfast had full beards without beard coverings, and equipment such as a floor‑stand mixer, stove shelf, and nearby walls had visible food splatter, grease, dust, and residue. An unlabeled and undated bag of vanilla wafers was found in dry storage, and the walk‑in refrigerator had a ripped, moldy gasket. The dish area had missing floor tiles. These conditions were inconsistent with the facility’s written policy requiring all food preparation and service areas to be kept clean and sanitary.
The facility failed to ensure DON duties were completed by an RN. Records showed an RN listed as DON and an LPN listed as ADON, but the ADON’s personnel file and Administrator interview confirmed the LPN was acting DON and performing all DON duties while the RN held the title only.
QAPI/QAA committee meetings were held monthly, but the facility did not document DON attendance at any of the meetings reviewed. An ADON stated the DON had attended some meetings, but the DON's signatures were absent from the sign-in sheets and the specific meetings attended could not be identified. The facility policy required the interdisciplinary QAA committee to include the DON and other specified members.
A facility failed to use appropriate PPE during care for residents on EBP or contact precautions and failed to ensure contact precautions were in place for a newly admitted resident. An RN did not use EBP during PICC-line medication administration, a CNA did not use EBP during Foley catheter care, a resident with contact precautions had staff sitting beside them without gown and gloves, and an LPN stated another resident should at least have been on EBP but was not. The facility policy and staff interviews confirmed EBP and contact precautions were required for invasive devices and direct contact.
The facility did not maintain a safe, orderly, and homelike environment in several resident rooms. One resident’s bathroom door had a hole, confirmed by a housekeeper. Another resident’s room had a urinal and a pair of scissors left on the floor, verified by an LPN. A third resident’s room had a long, deep gash in the lower part of the bathroom door and a trash bin with a large missing chunk on its rim, as confirmed by the DOM. These observations showed that housekeeping and maintenance services were not consistently ensuring a sanitary, comfortable environment as required by facility policy.
A resident’s code status was not accurately reflected in both the hard chart and EMR. The physician orders listed DNR-CCA, but the hard chart contained a Full Code document on the first page. The ADON verified the resident had a signed DNR-CCA that should have been in the hard chart.
Two residents received antipsychotic medications without appropriate documented diagnoses or rationale. One resident with dementia was given quetiapine for insomnia, and pharmacy reviews questioned the diagnosis and GDR while staff later confirmed insomnia was not an appropriate indication. Another resident was ordered Vraylar for MDD after the MD had said to hold it until psych evaluated the resident, and there were no documented behaviors or evidence supporting the request for the medication.
The facility failed to complete discharge MDS assessments for two residents. One resident with ESRD, pulmonary edema, bipolar disorder, morbid obesity, and immunodeficiency was transferred to the hospital/ICU with sepsis, and another resident with rib fractures, a fall, and DM2 discharged home after nursing reviewed paperwork and obtained vital signs; neither record contained the required discharge MDS assessment, and the MDSC verified the omissions.
Missing Contact Isolation in Care Plans: Two residents had physician orders for contact isolation, but their care plans did not include it. One resident was admitted with sepsis and had a Foley catheter, while the other was admitted with osteomyelitis of the left ankle/foot with MRSA; an LPN confirmed the omission for both residents. The facility policy required comprehensive person-centered care plans with measurable objectives and timeframes.
Unsafe smoking practices and delayed smoke breaks were observed for one resident and several others. A resident assessed as needing supervision for smoking was seen with a lighter on a tray table, later holding a lighter and using personal cigarettes kept in a jacket, even though staff said smoking materials were supposed to be stored by the facility. Five residents were also waiting at the courtyard door for a smoke break that was late, and an LPN said aides were giving report.
Failure to Honor Resident Food Allergies: A resident with documented food allergies was served a meal containing onions despite her diet ticket listing onion, peanut butter, and strawberry allergies. During tray line observation, dietary staff portioned beef tips over noodles for the resident, and the DM confirmed the resident said onions make her break out.
Therapeutic diets were not followed for two residents during lunch tray line service. One resident ordered a dysphagia mechanical soft diet but was served regular textured beef tips instead of ground meat, and another resident ordered a CCD but did not receive the baked apples listed on the meal spreadsheet. A dietary aide stated he missed the items, and the CDM verified the correct diet items on the spreadsheet.
Daily nursing staff information was not posted. Observation showed the required staffing information was missing, and the ADON stated it was usually kept at the receptionist desk and confirmed she had not put it up.
Surveyors found that food service staff failed to prevent food contamination by not changing gloves between tasks and directly handling food items, leading to cross-contamination during meal service. Additionally, the facility did not maintain an adequate emergency food and water supply, with expired items and insufficient quantities to meet policy requirements.
Surveyors found that the facility did not ensure a clean and sanitary environment, as evidenced by mold or mildew under a resident's bathroom sink and unsanitary conditions in a second-floor shower room, including exposed pipes and a toilet with dried stool. Staff confirmed these issues and were unaware of how long some problems had persisted, despite facility policies requiring routine cleaning and disinfection.
The facility did not provide a sufficient variety of activities to meet all residents' needs and interests, with scheduled events limited to weekdays, ending by mid-afternoon, and weekends and holidays offering only activity packets and television. Several residents reported boredom and a lack of engaging options, especially in the evenings and on weekends. The sole activities staff member worked only weekdays, had no formal training or certification for the role, and there was no evidence of additional staff support.
A resident with cognitive deficits and a history of combative behavior was observed with extremely long, thick, and curled toenails after repeatedly refusing nail care from staff and a podiatrist. Staff and medical record reviews revealed a lack of documentation regarding family notification and care conference discussions about the refusals, despite facility policy requiring proper foot care and communication.
A resident with cognitive deficits and a history of combative behavior was not provided with adequate podiatry care due to repeated refusals, lack of family notification, and insufficient documentation by untrained social services staff. The staff member responsible had not received formal training or a job description, resulting in prolonged neglect of the resident's toenail care.
The facility failed to properly store and maintain supplemental oxygen equipment for three residents, as required by their policy. Observations showed that oxygen tubing and nasal cannulas were not stored in protective bags, and equipment changes were not conducted weekly as mandated. The DON confirmed these lapses, affecting residents with conditions like COPD and congestive heart failure.
The facility failed to implement a water management program to prevent Legionella growth, lacking a comprehensive plan and documentation. Additionally, an LPN did not maintain infection control during medication administration by handling a pill with bare hands, contrary to facility policy. The resident involved had Alzheimer's, diabetes, and chronic kidney disease.
The facility failed to conduct required smoking assessments for residents who smoked, affecting four out of twelve residents. Despite being observed smoking with staff, two residents had not been reassessed since May, and two others had never been assessed since admission. An LPN confirmed the assessments were not completed quarterly as per policy.
A facility failed to ensure that a resident's advance directives were filed in the electronic medical record. Despite the resident's admission packet indicating a DNR CCA status, the signed document was found unfiled, contrary to facility policy. The resident had multiple diagnoses, including type II diabetes and Alzheimer's dementia.
A facility failed to create a comprehensive care plan for a resident with behavioral health needs, including schizophrenia and bipolar disorder. Despite the resident's moderate depression and other mental health issues, no psychosocial care plan was developed, contrary to facility policy. Staff confirmed the oversight, highlighting a lapse in adhering to the required assessment and care planning process.
A facility failed to monitor a resident on Ativan for side effects, despite the resident's complex medical history including anxiety and schizoaffective disorder. Interviews with staff confirmed the absence of a monitoring system, contrary to the facility's policy requiring ongoing evaluation of psychotropic medication effects.
The facility failed to maintain proper sanitation for resident refrigerators, affecting two residents. One resident's refrigerator contained unlabeled hamburgers, while another's had expired and moldy dip containers. Staff interviews revealed confusion over responsibility for monitoring and cleaning the refrigerators, contrary to facility policy.
A facility failed to maintain a complete and accurate medical record for a resident receiving antipsychotic medications, as required by their policy. Despite pharmacy recommendations, the facility did not document necessary AIMS assessments in the resident's medical record for over six months. Interviews confirmed that assessments were conducted by a CNP but were not included in the facility's records.
Failure to Provide Timely Meal Service According to Posted Mealtimes
Penalty
Summary
The deficiency involves the facility’s failure to ensure meals were served in a timely manner in accordance with residents’ needs, preferences, and the facility’s own posted mealtimes and policy. Resident Council minutes from two separate meetings documented that meals were often late. The facility’s posted mealtime information at the second-floor nurses’ station indicated that the second-floor meal cart was to be delivered at 11:50 A.M. During an observation on 03/23/26 at 12:45 P.M., lunch trays arrived on the second floor, and an LPN confirmed that the trays were 55 minutes late compared to the posted delivery time of 11:50 A.M. The facility’s written mealtime policy titled “Frequency of meals” stated that three regular mealtimes would be scheduled comparable to normal mealtimes in the community. During interviews conducted in conjunction with the survey, the Dietary Manager stated that the posted times represented when tray line started for the food cart, but then acknowledged that the posted mealtimes indicated trays were to be delivered to the second floor at 11:50 A.M. In a resident council meeting held during the recertification survey, five residents reported that late meals were a concern. The deficiency affected five residents reviewed for frequency of meals and had the potential to affect all 47 residents who received meals from the kitchen, with one resident identified as NPO. This issue was investigated under Complaint Number 2693841.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors found that the facility failed to maintain the kitchen in a clean and sanitary manner and to store food to prevent contamination and spoilage for 47 of 48 residents who received food, with one resident identified as NPO. During a kitchen tour, two dietary staff members serving breakfast were observed to have full beards without beard coverings. The floor‑stand mixer had food splatter on the backsplash, white mix on top, and dried food residue on the stand. In the dry storeroom, a bag of vanilla wafers was found open without any label or date. The walk‑in refrigerator had a ripped gasket with mold present. In the cooking area, the stove shelf had grease, dust, and food residue, the wall near the microwave had food splatter, and there were grease drippings on the stove. In the dishwashing area, floor tiles were missing. The dietary staff member interviewed confirmed these observations. Review of the facility’s kitchen sanitation policy, titled “Environment” and revised in June 2015, stated that all food preparation, service, and dining areas would be maintained in a clean and sanitary condition, which was not followed as evidenced by the unsanitary conditions and improper food storage identified during the survey conducted under Complaint Number 2693841.
DON Duties Performed by LPN Instead of RN
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) duties were completed by an RN. Review of the key personnel list showed RN #419 listed as the DON and LPN #423 listed as the Assistant Director of Nursing (ADON). However, review of the ADON’s personnel file included an employee action form dated 10/21/22 with a handwritten note stating that effective 10/09/22 the ADON was "currently acting DON and all clinical lead," approved by the Administrator. During interview, the Administrator confirmed he wrote the note and stated that as of 10/09/22 the ADON LPN #423 was the acting DON with all clinical leads, while RN #419 was DON only by title and the ADON performed all DON duties.
QAPI/QAA Committee Lacked Required DON Attendance
Penalty
Summary
The facility failed to ensure that all required members attended the QAPI and QAA meetings at least quarterly. Review of the sign-in sheets for QAPI/QAA meetings from 03/20/25 through 02/19/26 showed the committee met monthly, but there was no documented evidence that the DON attended any of the meetings. During interview on 03/26/26 at 3:37 P.M., the ADON stated the DON had attended some but not all of the QAA/QAPI meetings, but also verified that the DON's signatures were not on any of the sign-in sheets and could not identify which meetings the DON had attended. Review of the facility's undated Quality Assurance and Performance Improvement policy showed the QAA committee was required to be interdisciplinary and include, at minimum, the DON, the medical director or designee, and at least three other facility staff members, including the administrator, owner, board member, or other leadership role, as well as the infection preventionist.
Failure to Use PPE and Precautions During Resident Care
Penalty
Summary
The facility failed to maintain infection control by not using appropriate PPE during care for residents on enhanced barrier precautions (EBP) or contact precautions, and by not ensuring contact precautions were in place for a newly admitted resident. Resident #47 had diagnoses including osteomyelitis of the vertebra and an order for EBP due to a PICC line, but the comprehensive care plan did not include EBP as an intervention for IV medication administration. During medication administration via the PICC line, RN #400 did not use EBP, and later confirmed this after the observation. The Infection Preventionist stated that EBP were to be used with wounds, Foley catheters, IVs, and other invasive medical devices, and the facility policy called for EBP for wounds and indwelling medical devices to prevent transmission of MDRO. Resident #63 was admitted with pyelonephritis and had an order for EBP due to a Foley catheter, but the care plan did not list EBP as an intervention. During catheter care, CNA #442 did not use EBP and confirmed this after the observation. Resident #65 was admitted with diagnoses including fracture of the left femur, conjunctivitis, and diabetes mellitus, and had physician orders for contact precautions and a Foley catheter. The resident was observed in bed with a Foley catheter, and an LPN stated the resident should at least have been on EBP but was not, likely because of the recent admission. Resident #1 had diagnoses including COPD, generalized anxiety disorder, and emphysema, was diagnosed with sepsis due to other specified staphylococcus, and had contact precautions ordered; however, a staff member sat next to the resident without PPE despite signage on the door stating gowns and gloves must be worn. The ADON confirmed staff should wear PPE when a resident is on contact precautions.
Failure to Maintain Safe and Homelike Resident Room Environments
Penalty
Summary
The facility failed to ensure a safe and homelike environment as required by its policy that housekeeping and maintenance services will be provided to maintain a sanitary, orderly, and comfortable environment. For one resident, observation of the resident’s room showed a hole in the bathroom door, which was confirmed by a housekeeper. For another resident, observation of the room revealed a urinal and a pair of scissors lying on the floor, which was verified by an LPN. For a third resident, observation of the room showed a long, deep gash in the lower part of the bathroom door and a large missing chunk on the rim of the trash bin, which was confirmed by the Director of Maintenance. These conditions were identified during observations and staff interviews and affected three residents out of six reviewed for the physical environment, in a facility with a census of 48 residents.
Code Status Not Consistently Documented
Penalty
Summary
The facility failed to ensure Resident #63’s code status was accurately reflected in both the hard medical record and the electronic medical record. Resident #63 was admitted with diagnoses of pyelonephritis, diabetes mellitus, and major depressive disorder. The physician’s orders for March 2026 listed the resident as DNR-CCA, but a document on green paper marked Full Code was found in the hard chart on the first page. During interview, the ADON brought a copy of the resident’s signed DNR-CCA and verified that it should have been in the hard chart. The facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, stated that the facility supports and facilitates a resident’s right to request, refuse and/or discontinue medical treatment and to formulate advance directives.
Unnecessary Psychotropic Medications Without Appropriate Diagnosis or Rationale
Penalty
Summary
The facility failed to ensure that two residents’ antipsychotic medications had appropriate diagnoses or rationale for use. For one resident with dementia, protein-calorie malnutrition, and diverticulosis, the record showed quetiapine fumarate was ordered for insomnia, while pharmacy reviews twice asked the physician to evaluate the medication for an appropriate diagnosis and gradual dose reduction. The physician responded that the benefits outweighed the risks and that the medication would cause distress or increase behaviors, and staff later verified that insomnia was not an appropriate diagnosis for quetiapine. The psych NP also stated she had seen the resident twice, did not catch the diagnosis for Seroquel, and did not attempt a GDR because the resident was new to her. For another resident admitted with pyelonephritis, diabetes mellitus, and major depressive disorder, the record showed Vraylar was ordered at bedtime for major depressive disorder after the resident had only taken one dose in the community before hospitalization. The MD initially instructed staff not to order Vraylar until psych evaluated the resident, noting the resident had not truly started the medication and psych should determine whether it was needed. Despite that, the medication was later ordered, and progress notes from the following days documented no behaviors. The ADON verified there was no documented evidence that the resident requested a specific medication, and the psych NP stated she was scheduled to see the resident later.
Late or Missing Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure discharge MDS assessments were created in a timely manner for two residents. Resident #5 was admitted with diagnoses including end stage renal disease, acute pulmonary edema, bipolar disorder, morbid obesity, and immunodeficiency, and later was sent to the hospital after a nurse documented that the hospital reported the resident had been admitted to the ICU with sepsis; the record contained no discharge MDS assessment with return anticipated. Resident #6 was admitted with diagnoses including multiple left rib fractures, fall, and type 2 diabetes mellitus, and was discharged home after nursing documented that vital signs were obtained, paperwork was reviewed, and the resident voiced understanding and was happy to go home; the record contained no discharge no return anticipated MDS assessment. The MDS Coordinator verified both residents' discharge assessments were not created.
Missing Contact Isolation in Care Plans
Penalty
Summary
The facility failed to ensure contact isolation was included in the care plans for two residents, affecting 2 of 23 resident records reviewed for care plans in a census of 48. Resident #01 was admitted with a diagnosis of sepsis. The medical record showed a physician order for contact isolation due to a Foley catheter each shift, and the MDS indicated a re-entry assessment was in progress. Review of the care plan dated 01/05/26 showed no care plan for contact isolation, and an LPN confirmed this during interview. Resident #15 was admitted with a diagnosis of osteomyelitis to the left ankle/foot with MRSA. The medical record showed a physician order for contact isolation each shift, and the MDS indicated an MRDO infection, intravenous medication, and isolation. Review of the care plan dated 03/04/26 showed no care plan for contact isolation, and an LPN confirmed during interview that contact isolation was not included in the resident's care plan. The facility policy for comprehensive care plans stated that each resident should have a comprehensive person-centered care plan with measurable objectives and timeframes to meet medical and nursing needs.
Unsafe Smoking Practices and Late Smoke Breaks
Penalty
Summary
The facility failed to ensure safe smoking practices for Resident #26. Resident #26 was admitted with diagnoses including hypertension, type 2 diabetes mellitus, muscle weakness, morbid obesity, and chronic systolic congestive heart failure. The smoking safety screen identified the resident as safe to smoke only with supervision and required the facility to store the resident’s lighter and cigarettes. The care plan also identified the resident as a smoker and included instructions about the facility’s smoking policy, locations, times, and safety concerns. However, during interview and observation, Resident #26 stated smoke breaks were not timely, especially at 7:00 A.M. during shift change, and a cigarette lighter was observed on the resident’s tray table. Later, the resident was observed with a lighter in hand and then using her own cigarettes from her jacket to light a cigarette in the courtyard. Staff interviews confirmed that smoking materials were supposed to be kept in a tote behind the nurse’s station, but one staff member stated the resident kept her own smoking materials and was treated as an independent smoker, while the ADON verified the assessment required supervision and facility storage of smoking materials. The facility also failed to provide timely smoke breaks for Residents #26, #51, #53, #56, and #69. During observation, these residents were waiting by the courtyard door at 7:30 A.M. and complained that staff were late for smoke break. An LPN verified the late time and stated the aides usually took residents to smoke but were giving report. The facility policy stated residents were not permitted to keep smoking materials on their person or in their rooms, and smoking was permitted only during posted smoke times under staff supervision.
Failure to Honor Resident Food Allergies
Penalty
Summary
The facility failed to ensure resident food allergies were honored. Resident #63 was admitted with diagnoses of pyelonephritis, diabetes mellitus, and major depressive disorder, and her physician’s orders showed a regular diet. Her diet ticket identified allergies to onion, peanut butter, and strawberry. During interview, Resident #63 stated that the kitchen does not honor her preferences. During lunch tray line observation, a dietary employee portioned beef tips over noodles for Resident #63, and when the tray was reviewed, it was noted that the meal contained onions. The Corporate District Manager asked whether the onion issue was an actual allergy or a dislike, and the Dietary Manager stated that Resident #63 said onions make her break out.
Therapeutic Diet Orders Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered for two residents. One resident had diagnoses including schizophrenia, bipolar disorder, and diabetes mellitus, and the quarterly MDS showed severely impaired cognition and dependence on staff for ADLs except eating, with set-up assistance only. The physician’s order for March 2026 specified a regular diet with dysphagia mechanical soft texture and regular fluid consistency, but during lunch tray line service a dietary aide portioned regular textured beef tips over noodles for the resident instead of ground meat. The tray was placed in the food cart, and the dietary aide stated he missed it. The Corporate District Manager told the aide to read the tickets louder and stated the tray assembler should read the tickets before placing the plate on the tray. The meal spreadsheet showed that dysphagia mechanical soft diets were to receive ground meat. A second resident was admitted with diagnoses including hypertension and diabetes mellitus, and the admission MDS was in progress. The physician’s order for March 2026 specified a consistent carbohydrate diet with regular texture and regular fluid consistency. During lunch tray line service, the same dietary aide portioned the resident’s meal but did not include baked apples for dessert. The aide stated he missed the CCD dessert because he does not usually put desserts on residents’ trays. The Corporate District Manager verified that a CCD should have received baked apples according to the spreadsheet.
Daily Nursing Staff Information Not Posted
Penalty
Summary
The facility failed to ensure that daily nursing staff information was posted. On 03/24/26, observations showed the daily nursing staff information was not posted. During an interview on 03/24/26 at 10:01 A.M., the ADON stated the posted daily nursing information was usually kept at the receptionist desk and verified that she had not put it up.
Deficient Food Handling and Inadequate Emergency Food Supply
Penalty
Summary
Surveyors observed that food service staff failed to follow proper food handling procedures during meal tray line service. One staff member wore gloves while plating food but used the same pair of gloves to handle serving utensils, touch and open baked potatoes, and arrange meat and creamed spinach on plates without changing or disposing of the soiled gloves. The staff member also touched food items directly with gloved hands and used the same gloves to handle containers, resulting in visible food residue being transferred to adjacent containers. These actions were confirmed by both the Regional Dietary Director and the Dietary Manager during the observation period. Additionally, the facility did not maintain a sufficient emergency food and water supply as required by policy. The emergency food supply was found to be inadequate, with some items expired and insufficient quantities to meet the needs of all residents. The Dietary Manager acknowledged the shortfall and noted that the issue had been identified previously, but the necessary restocking had not yet occurred. The facility's policies required maintaining a three to seven day supply of non-perishable foods and a three day supply of bottled water, but these standards were not met at the time of the survey.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment, specifically affecting one resident and potentially impacting twenty-five others residing on the second floor. During an inspection, a large area of what appeared to be mold or mildew was found underneath a resident's bathroom sink. The resident was not present at the time of observation. Additionally, the second-floor shower room was found to have a large hole behind the toilet with exposed pipes, a large hole in the ceiling with exposed pipes, and a toilet containing a significant amount of dried stool both inside and on the outside of the bowl and lid. The housekeeper present confirmed these findings and noted that the water may have been turned off, preventing the toilet from being flushed. The Maintenance Director was unaware of the water being turned off and could not confirm how long the issue had persisted. Further observations with an LPN confirmed the presence of mold or mildew in the resident's room. The facility's policy on routine cleaning and disinfection requires cleaning of walls and visibly soiled surfaces in both common areas and resident rooms, but these standards were not met at the time of the survey. The deficiency was identified during the investigation of multiple complaints and was confirmed through direct observation and staff interviews.
Failure to Provide Sufficient and Varied Resident Activities
Penalty
Summary
The facility failed to provide a variety of activities that met the needs and interests of all residents, as evidenced by a review of the activities calendar, resident interviews, and staff interviews. The activities calendar for December 2025 showed repetitive activities, with no scheduled events later than 3:00 P.M., and a lack of staff-led activities on weekends and holidays. Activities were limited to options such as True or False, Crafts, Book Club, Bingo, Yarn Club, Bible Study, Cards, Nails, Trivia, and occasional church services, with weekends and holidays primarily offering only activity packets and television. There were no activities scheduled before 10:00 A.M. or after 3:00 P.M., and the only staff member leading activities was the Activities Director, who worked weekdays and left by 4:30 P.M. each day. Interviews with residents revealed dissatisfaction with the lack of engaging activities, particularly in the evenings and on weekends. One resident expressed boredom during these times, another noted that television was the only available option and requested more activities for veterans, and a third resident also reported boredom. Staff interviews confirmed that the Activities Director was the sole activities staff member, with no additional support, and that weekend activities were limited to passive options. The Activities Director had recently been promoted without evidence of required training or certification for the role, and there was no documentation that she had received a job description for her current position.
Failure to Provide Adequate Foot Care Due to Incomplete Documentation and Communication
Penalty
Summary
The facility failed to provide adequate foot care for a resident with a history of traumatic brain injury, aphasia, and cognitive deficits. The resident was noted to have self-care deficits and was frequently resistive or combative during attempts at nail care, both by staff and an outside podiatrist. Despite repeated refusals, there was no documentation that the resident's family was notified of the ongoing issue, nor was there evidence that refusals were discussed during care conferences. Observations revealed the resident's toenails were extremely long, thick, and curled, and staff interviews confirmed awareness of the resident's refusal and the lack of a clear plan to address the situation. Medical record reviews showed multiple missed opportunities to document and communicate the resident's refusals and the resulting condition of her toenails. The facility's policy required ensuring proper foot care, but interventions such as reapproaching the resident or educating the family were not consistently documented or implemented. The podiatrist suggested the possibility of sedation to facilitate nail care, indicating the chronic nature of the problem, but there was no evidence that this recommendation had been acted upon or communicated to the family.
Failure to Provide Adequate Social Services and Podiatry Care Due to Untrained Staff
Penalty
Summary
The facility failed to ensure that social services staff were adequately trained and performed their duties as required, specifically affecting one resident with a history of traumatic brain injury, aphasia, and cognitive deficits. This resident was rarely understood, had self-care deficits, and exhibited combative behaviors during personal care, including resistance to nail care by both staff and an outside podiatrist. Despite repeated refusals of podiatry care and ongoing issues with extremely long, thick, and curled toenails, there was no documentation that the resident's family was notified of these refusals, nor was there evidence that these issues were discussed during care conferences. Observations confirmed the resident's toenails had been neglected for an extended period, and the podiatrist noted the condition may have persisted for years. Further review revealed that the staff member responsible for social services, who also served as the Activities Director, had not received official training for the social services role, had not been provided with a job description, and was unaware of all required duties. The personnel file lacked a signed job description, and the staff member admitted to learning the role informally and not documenting care refusals or family notifications as required. Facility policy required proper treatment and care to maintain foot health, but this was not followed in the resident's case.
Improper Storage and Maintenance of Oxygen Equipment
Penalty
Summary
The facility failed to ensure that supplemental oxygen delivery devices were changed weekly and stored properly, affecting three residents who were reviewed for supplemental oxygen use. Resident #12, diagnosed with pneumonia, congestive heart failure, and hypertension, had physician's orders for supplemental oxygen and DuoNeb via nebulizer. Observations revealed that the oxygen tubing and nasal cannula were not stored in protective plastic bags, and the equipment was not changed as per the schedule. Similarly, Resident #24, with chronic obstructive pulmonary disease, diabetes mellitus, and vascular dementia, had oxygen equipment improperly stored and not in protective bags. Resident #28, dependent on supplemental oxygen, also had equipment not stored correctly, and the nasal cannula was not changed since the specified date. The Director of Nursing and Assistant Director of Nursing confirmed that the facility's policy required weekly changes of oxygen tubing and nebulizer equipment and that these should be stored in protective bags when not in use. However, they verified that the equipment for Residents #12, #24, and #28 was not stored correctly, and Resident #28's nasal cannula had not been changed as required. The facility's policy on oxygen administration was not followed, leading to this deficiency, which was investigated under Complaint Number OH00161386.
Deficiencies in Water Management and Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive water management program to prevent the growth of Legionella, as required by the Centers for Disease Control (CDC) guidance. The facility's documentation included a blank section in the CDC toolkit for identifying buildings at increased risk, and there was no water management plan or diagram available. Interviews with the Licensed Practical Nurse/Assistant Director of Nursing/Infection Preventionist and the Chief Operating Officer confirmed the absence of a legionella water management plan. The facility's policy stated that a water management team should be established to develop and implement the program, but this was not effectively executed. Additionally, the facility did not maintain proper infection control during medication administration for one resident. During an observation, an LPN was seen pushing medication out of a card, causing a pill to fall into the narcotic drawer. The LPN then picked up the pill with her bare hand and placed it into a medication cup before continuing to gather other medications for the resident. This action was verified by the LPN during an interview, and it was contrary to the facility's policy, which stated that staff should not touch medication with their bare hands. The resident involved in the medication administration deficiency had a medical history that included Alzheimer's disease, diabetes mellitus, and chronic kidney disease. The facility's failure to adhere to its own policies and CDC guidelines resulted in deficiencies related to both water management and medication administration, highlighting lapses in infection prevention and control practices.
Failure to Conduct Required Smoking Assessments
Penalty
Summary
The facility failed to ensure that smoking assessments were completed for residents who smoked, as required by their policy. This deficiency affected four residents out of the twelve who smoked at the facility. Resident #15, who was admitted with vascular dementia and a history of traumatic brain injury, had not had a smoking safety screen since May 23, 2023, despite being moderately cognitively impaired. Similarly, Resident #35, with diagnoses including muscle weakness and repeated falls, had not been reassessed for smoking safety since May 24, 2023. Both residents were observed smoking in the designated area with staff present, but their assessments were not updated quarterly as mandated by the facility's policy. Additionally, Residents #38 and #192 had not received any smoking assessments since their admission, despite their participation in smoking activities. Resident #38, with chronic kidney disease and mobility issues, and Resident #192, with psychoactive substance abuse and bipolar disorder, were both observed smoking in the designated area. Interviews with an LPN confirmed that smoking assessments were not conducted as required, highlighting a lapse in adherence to the facility's policy, which stipulates that smoking evaluations should be completed quarterly and with any change in condition.
Failure to File Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that advance directives were present in the electronic medical record for a resident. Specifically, Resident #37, who was admitted with diagnoses including type II diabetes with ketoacidosis, dementia, cardiomyopathy, congestive heart failure, and Alzheimer's dementia, did not have an advance directive order in their electronic medical record. Although the admission packet and baseline care plan indicated a Do Not Resuscitate Comfort Care Arrest (DNR CCA) status, the Director of Nursing confirmed that the signed DNR CCA was in a pile of unfiled papers and not in the medical record as required. This oversight was contrary to the facility's policy, which mandates that advance directives be placed in the chart and communicated to staff upon admission.
Failure to Develop Comprehensive Behavioral Health Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was created for a resident with significant behavioral health needs. The resident, who was admitted with diagnoses including rhabdomyolysis, acute kidney failure, anxiety disorder, other psychoactive substance abuse, and bipolar disorder, was found to have no psychosocial care plan addressing these issues. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact but experiencing moderate depression, as evidenced by a Patient Health Questionnaire (PHQ-9) score of 10. Despite these findings, the baseline care plan did not identify any psychosocial problems or interventions related to the resident's schizophrenia and bipolar disorder. Interviews with facility staff, including a Registered Nurse and the Assistant Director of Nursing, confirmed the absence of a psychosocial care plan for the resident. The facility's policy on Behavioral Health Services emphasized the need for a comprehensive assessment and person-centered care plan, which was not adhered to in this case. The policy required the development of a comprehensive care plan within seven days after the completion of the MDS assessment, which was not fulfilled, leading to the deficiency.
Failure to Monitor Anti-Anxiety Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor a resident on anti-anxiety medications, specifically Ativan, which was prescribed at a dosage of 0.5 mg to be taken orally twice a day for anxiety. The resident, who was cognitively intact, had a medical history that included anxiety, schizoaffective disorder bipolar type, depression, falls, hypertension, and suicidal ideations. Despite the prescription, there were no orders in place to monitor the side effects of the anti-anxiety medication, which is a requirement according to the facility's policy on the use of psychotropic medications. Interviews with the LPN/ADON and the DON confirmed that the Certified Nurse Practitioner was responsible for monitoring resident medications and side effects, yet there was no system in place for the nursing staff to monitor potential side effects related to the resident's anti-anxiety medication. The COO/RN also verified the lack of monitoring. The facility's policy stated that the effects of psychotropic medications should be evaluated on an ongoing basis through various assessments, but this was not adhered to in the case of the resident.
Improper Sanitation of Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper sanitation for resident refrigerators, specifically for two residents out of eight reviewed. Resident #9's refrigerator contained two hamburgers on a Styrofoam plate that were neither labeled nor dated. Resident #17's refrigerator had multiple containers of Lays dip, some of which were expired, and one had a visible black thick layer of mold on top. These observations were made during a survey conducted with a registered dietitian, who confirmed the findings and noted previous concerns about the lack of monitoring of resident refrigerators. Interviews with housekeeping staff and a state-tested nurse aide revealed a lack of clarity regarding responsibility for monitoring and cleaning the inside of resident refrigerators. Housekeepers reported that they only cleaned the top and sides of the refrigerators, assuming that aides were responsible for monitoring them. Conversely, the nurse aide believed that housekeepers were responsible for cleaning the refrigerators. The facility's policy indicated that staff should assist residents with food brought in by family or visitors if the residents were unable to do so themselves, but there was no evidence of consistent monitoring or cleaning of the refrigerators.
Incomplete Medical Record Documentation for Antipsychotic Monitoring
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident diagnosed with anxiety, schizoaffective disorder bipolar type, depression, falls, hypertension, and suicidal ideations. The resident was cognitively intact and received routine antipsychotic medications, including Abilify and Geodon, which could cause involuntary movements. Despite pharmacy recommendations, the facility did not document an Abnormal Involuntary Movement Scale (AIMS) or other appropriate assessments in the resident's medical record within the previous six months. The last documented AIMS assessment in the facility's records was dated several months prior. Interviews with facility staff, including an LPN/ADON and the DON, confirmed the absence of additional AIMS assessments in the resident's medical record. The COO/RN revealed that AIMS assessments were completed by a CNP but were not part of the facility's medical records. Documentation provided indicated that the CNP had conducted AIMS assessments outside of the facility's records. The facility's policy required all assessments and services to be documented accurately and timely in the resident's medical record, which was not adhered to in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines Healthcare Center | 0.5 mi | ★★★★★ | 4 | 0 |
| Astoria Skilled Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 2 | 1 |
| Canton Christian Home | 1.3 mi | ★★★★★ | 14 | 0 |
| Mckinley Nursing | 1.6 mi | ★★★★★ | 45 | 0 |
| The Pavilion At Edgefield For Nursing And Rehabili | 2 mi | ★★★★★ | 38 | 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.