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 Hanover Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep kitchen equipment and food service areas clean and sanitary and did not follow its own sanitation procedures. During observations, they noted dried food in a microwave, crumbs on prep surfaces, undated cereal containers, rusty refrigerator shelves, unlabeled and improperly wrapped butter and cheese, grease and food splatter on serving equipment, and dried food in multiple steam table wells and lids. The dish area had cracked floor tiles and dried food on the clean side of the dish machine drain board, while the cooking area contained a slicer with dried meat, a robot coupe with dried food around its base, and damaged tiles and a wall hole where food carts were stored. A dietary staff member was also seen rinsing the robot coupe in a three-compartment sink without proper wash and sanitize steps, despite policies and checklists requiring thorough cleaning and proper wrapping, labeling, and dating of food.
The facility failed to prevent accidents and follow required safety interventions for mechanical lift transfers and supervised smoking. A resident with multiple comorbidities, including morbid obesity and a recent fracture, experienced a fall when a mechanical lift lost balance while turning during a transfer from bed to a stretcher, causing the lift to tip over while the resident remained attached. In separate incidents, two supervised smokers with COPD and upper-extremity amputations, one using prostheses, were allowed to smoke without the required fire-resistant smoking aprons despite documented assessments and care plans mandating their use; in one case, ashes were observed falling onto the resident’s lap and thighs while staff assisted with smoking. CNAs involved confirmed that the smoking aprons were not used and that they were unaware of the requirement, contrary to the facility’s written smoking guidelines.
Failure to Provide Ordered Respiratory Care: Multiple residents with respiratory needs did not receive ordered care or equipment support. A resident on continuous O2 had no clear parameters for flow adjustment and was observed on room air without O2 equipment in the room. Another resident’s CPAP was broken and there was no documentation for cleaning or checking it. Two residents with trachs had incomplete trach-related care, including an empty humidifier bottle, increased phlegm, missing ordered trach supplies, and overdue humidifier changes.
Pureed foods were not consistently prepared to a smooth consistency for residents on pureed diets. A resident reported poor taste and incorrect texture, and staff observed pureed pasta and pureed ham with visible chunks during meal preparation and tray line service. The RDM and DM both tasted the items and confirmed they were not smooth, despite recipes directing that the foods be processed and blended until smooth.
The facility failed to provide a safe, clean, and homelike environment for several residents. One resident’s room was found in disarray with a strong urine odor, dirty clothes mixed with clean linens, trash on the floor, and the bed controller out of reach. Another resident’s room had soiled bed sheets, visibly dirty suction machines and an oxygen concentrator, and a refrigerator with dust and sticky residue; this resident reported having to change his own sheets and not having his clothes laundered despite repeated requests, leaving him in visibly soiled clothing. An LPN acknowledged not relaying the laundry request and was unsure who cleaned medical equipment, while a housekeeper described limited cleaning duties and also did not know who was responsible for equipment cleaning. A third resident reported two bathroom falls related to a loose toilet seat and also described a non-flushing toilet and a leaking sink; observation confirmed the toilet seat was loose and shifted when pressure was applied to the handrails.
A resident with dementia, COPD, and bilateral upper arm amputations, who was cognitively intact and had orders for bilateral prosthetic devices and OT recommendations for stand-by assist and a scoop plate, was observed eating meals by bending over the plate and scooping food into the mouth rather than using utensils. On multiple observed breakfasts, the resident either pushed away loosely strapped utensils on the prostheses or stopped using a spoon and continued eating with the mouth, while staff either provided only brief verbal encouragement or did not intervene to assist or promote utensil use. Staff later reported that the resident preferred not to use utensils and needed daily encouragement, and the therapy director clarified that specific utensils were intended for use without prostheses, while the resident could use thin-handled utensils with the grabber hooks, indicating a failure to consistently assist with eating as outlined in the facility’s routine care policy.
A resident with Alzheimer's disease, major depressive disorder, ataxia, severe cognitive impairment, and dependence in ADLs had documented preferences for music, social interaction, and favorite activities, and a care plan allowing participation in group and 1:1 activities as tolerated. Despite this, there was no evidence in the medical record or 1:1 activity lists that she received 1:1 visits, and she reported that activity staff did not visit her room. She remained in bed with the TV out of her view and had only one documented activity offer related to a holiday event, while both the AD and an activity assistant confirmed she was not included on their 1:1 visit lists, contrary to the facility’s activities program policy.
Surveyors identified that staff did not follow infection prevention and control practices for two residents. For a resident with a tracheostomy and multiple comorbidities, a used trach collar and attached tubing were left on a room tabletop without a protective barrier, contrary to standard precautions. For another resident receiving incontinence care, a CNA cleansed reddened skin under a panniculus, applied barrier cream, and cleaned the perineal and gluteal areas while failing to change gloves between clean and dirty tasks and performing hand hygiene only once during the entire process, despite facility policies requiring hand hygiene and glove changes at specific points in care.
Surveyors found that three residents with dementia, impaired cognition, mobility limitations, and other comorbidities did not have call lights within reach while in bed. In one case, a resident’s call light was attached to a privacy curtain across the room; in another, both call lights in a shared room were attached to the roommate’s bed, leaving the other resident without access. A third resident’s call light was wound up over the actuator box near a recliner and could not be reached from the bed, and the bed controller was on the floor out of reach. These conditions occurred despite a facility policy stating that call light or bell access will be within reach as a method for residents to communicate needs to staff.
PASRR records were not updated for two residents after changes in psychiatric condition. One resident had orders for Seroquel and Depakote, but the PASRR did not reflect antipsychotic use. Another resident’s PASRR listed only severe anxiety despite diagnoses including psychotic disorder with delusions and major depression. Social Services confirmed the PASRRs were not updated.
Failure to Provide Written Baseline Care Plans Within 48 Hours: The DON confirmed that two residents did not receive a written baseline care plan within 48 hours of admission. One resident had multiple serious diagnoses and moderate cognitive impairment, while the other was cognitively intact but also had complex medical needs including respiratory failure, ESRD on hemodialysis, DM, HF, and psychiatric conditions. The facility’s admission evaluation included initial care planning areas and immediate interventions, but there was no evidence the required care plan was printed and shared with the resident or representative as outlined in policy.
Failure to Complete Post-Dialysis Assessments: The facility did not complete required post-dialysis evaluations for two residents receiving HD. One resident with ESRD, DM, HF, and mental health diagnoses reported that nurses did not always check VS after dialysis, and the record lacked post-dialysis documentation after an emergency dialysis episode and on a later on-site treatment. Another resident with ESRD and DM had no post-dialysis assessment in the chart; staff said the facility used the dialysis center’s last VS and only checked the access site, despite the care plan calling for evaluation after dialysis.
Unsanitary resident room conditions and a broken bathroom toilet were observed for two residents. One resident’s bed side rails, bedside table, and bed frame had grime, dirt, dried food debris, and splatter marks, while an LPN and DON identified housekeeping responsibility for cleaning. Another resident reported a toilet had been broken for months and would flood the bathroom when used, and an RN confirmed the issue.
Several residents with complex medical conditions did not receive their prescribed restorative nursing programs at the required frequency due to insufficient staffing. Staff and documentation confirmed that restorative ambulation and range of motion programs were not consistently provided as ordered, affecting multiple residents who required these services to maintain their functional abilities.
A resident with multiple cardiac and respiratory diagnoses was given metoprolol and midodrine despite a critically low blood pressure, without prior notification to the NP or physician as required by facility policy. The nurse administered the medication based on previous informal guidance, and the resident subsequently experienced severe symptoms requiring emergency transfer.
A resident with multiple chronic conditions reported missing money from a locked box after a leave of absence. Although the LPN notified the DON and RN Unit Manager, and the police were contacted, the required report to the State Survey Agency was not made as per facility policy. Staff interviews confirmed the breakdown in communication and lack of timely reporting to authorities.
A resident with multiple chronic conditions reported that over $350 was missing from a locked box in their room after returning from a leave of absence. Although an LPN promptly informed the DON and RN Unit Manager, and the police were contacted, there was no evidence that the incident was reported to the State Survey Agency or that a timely investigation was initiated as required by facility policy. Communication lapses among staff and administration resulted in delayed action on the allegation of misappropriation.
Two residents with significant medical histories did not consistently receive restorative ambulation programs as ordered, due to staff shortages, unclear responsibilities, and lack of documentation. This resulted in the failure to maintain their functional abilities as outlined in their care plans.
A resident with complex cardiac and oncological conditions was given midodrine despite physician orders to hold the medication for systolic blood pressure readings above 120 mm Hg. The medication was administered on three occasions when the resident's blood pressure exceeded this threshold, and staff were unable to explain the deviation from the order.
A resident with hemiplegia and multiple comorbidities did not receive the prescribed passive range of motion (PROM) program at the frequency ordered by the physician and outlined in the care plan. Documentation showed the program was provided fewer than the required six times per week, and the DON confirmed this discrepancy, resulting in non-compliance with restorative care requirements.
A resident was administered incorrect doses of divalproex sodium and vitamin B-6 due to failure to follow physician orders and facility policy. An LPN gave a total of 1250 mg of divalproex sodium in the morning instead of the ordered 750 mg, and a whole 100 mg tablet of vitamin B-6 instead of the prescribed 50 mg. The errors were confirmed through staff interviews and review of medication packets, with the pharmacist noting that outdated orders led to both doses being sent and administered together.
The facility assigned an unqualified staff member to direct the activities program, with no evidence of required certification, licensure, or experience in her personnel file. Interviews with the staff member and facility leadership confirmed she did not meet the qualifications for the role, and she only began a certification course after assuming the position.
A resident dependent on staff for all ADLs and incontinent of bladder and bowel received incontinence care during which a CNA failed to change soiled gloves and perform hand hygiene after cleaning stool and urine, and before applying barrier cream and a new brief. The CNA, as well as the RN and DON, confirmed that gloves should have been changed and hands washed according to facility policy.
The facility submitted inaccurate staffing data to CMS, as revealed by discrepancies between staffing sheets and time punches for several dates. The administrator identified missing time punches for former employees, which may have led to incomplete data submission. This issue was found during a complaint investigation.
A resident with severe cognitive impairment and mental health diagnoses did not receive daily surgical wound care as ordered by the physician. Observations showed that dressings on the resident's wounds were not changed daily, as required, with the last change occurring three days prior. The ADON confirmed the lapse in care, which was contrary to the facility's wound care policy.
A resident with chronic anemia and low hemoglobin levels experienced delays in obtaining stool samples for occult blood testing. Despite multiple physician orders and the resident having bowel movements, the facility failed to collect and test the samples in a timely manner. Interviews confirmed the delay, which was expected to be completed within two weeks.
A resident with severe cognitive impairment and surgical wounds did not receive documented wound care as per physician orders. The TAR inaccurately showed completed wound care on two days, despite unchanged dressings. This was confirmed by the ADON and an RN, who noted an LPN documented treatments without performing them, violating the facility's documentation standards.
The facility failed to protect residents from abuse, resulting in Immediate Jeopardy. An STNA was witnessed forcibly placing a resident into a tilt-in-space wheelchair and inverting it, causing distress. Another STNA was physically abusive during a shower, leading to bruises and fractures. Both incidents were not promptly reported or investigated, and the STNAs continued working without removal. The deficiency was exacerbated by inadequate staff training on abuse prevention and reporting.
The facility failed to report allegations of abuse immediately, resulting in Immediate Jeopardy. An STNA was observed forcibly placing a resident in a tilt-in-space wheelchair, causing distress, and another resident alleged physical abuse during a shower, resulting in injuries. These incidents were not reported to leadership or authorities promptly, allowing the STNAs to continue working with residents.
The facility failed to implement its abuse policy, resulting in two incidents of alleged abuse. In one case, a resident was forcibly placed in a tilt-in-space wheelchair by an STNA, causing distress. In another, a resident suffered bruises and fractures during a shower with a male STNA. Despite reports, no immediate investigations were initiated, and the STNAs continued working, risking further harm to residents.
The facility failed to screen new employees for TB before their first day, did not sanitize a BGT machine between uses, and neglected proper infection control during wound and tracheostomy care. An LPN did not clean the BGT machine due to a lack of sanitizing wipes, and an RN did not change gloves during wound care. Additionally, an LPN did not wear a gown during tracheostomy care, contrary to enhanced barrier precautions.
The facility failed to provide adequate care and assistance for residents dependent on staff for daily activities. A resident with severe cognitive impairment had untrimmed, dirty fingernails, while another resident did not receive a breakfast meal due to insufficient staff. Additionally, a resident was instructed to use an incontinence brief instead of being assisted to the bathroom. These deficiencies were confirmed by the DON and staff interviews.
The facility failed to investigate allegations of a staff member taking unauthorized photos of a resident and did not follow up on a missing electric razor reported by another resident. Despite complaints and corroborating witness statements, the facility's investigation was inadequate, affecting two residents who filed formal concerns.
A resident with severe cognitive impairment and a risk for constipation did not receive timely administration of a prescribed laxative, Milk of Magnesia, despite not having a bowel movement for several days. The delay in treatment led to symptoms of nausea and vomiting, requiring further medical interventions. The DON confirmed the oversight, noting that the nursing staff were alerted when a resident did not have a bowel movement for three days, yet the laxative was not administered until four days after the last small bowel movement.
A resident with multiple diagnoses, including dementia, experienced ongoing visual difficulties despite receiving new eyeglasses. The resident expressed concerns about worsening cataracts and requested further vision services. However, no follow-up care was provided after a referral was made to the NP, resulting in a failure to meet the resident's vision care needs.
A resident at risk for skin impairment developed multiple pressure ulcers due to the facility's failure to implement a comprehensive prevention program. Despite interventions in the care plan, the resident developed Stage II and III pressure ulcers, which were not promptly identified or treated. Discrepancies in wound assessment and documentation further delayed appropriate care.
A resident with severe cognitive impairment and specific dietary needs did not receive timely meal assistance due to staffing shortages in the secured memory care unit. The resident was not provided breakfast in their room because only two STNAs were available, which was insufficient to observe or feed residents in their rooms. The LPN Unit Manager was unaware of the situation.
A resident with dementia and a history of elopement risk managed to exit a secured unit without staff knowledge due to inadequate supervision and failure to implement new safety interventions. Despite expressing a desire to leave, the facility did not update interventions or monitor the resident effectively, leading to the resident's elopement and subsequent hospitalization for injuries.
A facility failed to accommodate a resident's preference for side rails on their bed, despite the resident's representative signing a form requesting them. The request was not reflected in the Bed Safety Evaluation, and the facility did not have the necessary side rails available. The Assistant Director of Nursing confirmed the resident should have had side rails per their preference, but the referral to apply them was delayed.
A resident with multiple medical conditions experienced ineffective pain management due to the facility's failure to timely follow a telehealth NP's directive to change pain medication. Miscommunication among nursing staff led to a delay in contacting the medical director for a new narcotic order, resulting in inadequate pain relief.
A facility failed to document timely blood sugar checks for a resident with diabetes, end stage renal disease, and congestive heart failure. The resident's physician ordered blood sugar checks before meals and Insulin Lispro administration per a sliding scale. However, the MAR lacked documentation for the 7:00 A.M. check, and a progress note showed it was done later than ordered. The DON confirmed the lapse, contrary to the facility's policy requiring timely medication administration.
The facility failed to ensure a clean and sanitary kitchen, affecting 104 residents. Observations revealed expired and undated food items, a heavily soiled Robot Coupe, and incomplete temperature logs for refrigeration and dishwashing equipment. These findings were confirmed by staff, and the facility's policies were found to be inconsistent with observed practices.
Failure to Maintain Sanitary Kitchen Conditions and Follow Food Service Sanitation Procedures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain the kitchen in a clean and sanitary condition and to follow its own sanitation policies. During an early morning kitchen tour, they observed dried food inside a microwave and food crumbs on the table beneath it, as well as undated containers of various cereals on a shelf. In a reach-in refrigerator, five shelves were rusty, shredded cheese was not labeled or dated, and butter stored in a hotel pan was not properly wrapped, labeled, or dated. In the serving area, there was grease on the table under the toaster, food splatter on the plate warmer and pellet warmer, and dried food in seven of ten steam table wells with five dirty lids containing dried food and gravy. In the dish area, floor tiles were cracked, and the clean side of the dish machine drain board had dried food and a salt packet on it. In the cooking area, the slicer had dried meat near the blade, the robot coupe had dried food around its base, and there were cracked tiles and a hole in the wall where food carts were stored. These conditions were verified by a staff member. Further observation showed that a dietary staff member rinsed the robot coupe in the three-compartment sink without following proper washing and sanitizing procedures, stating that she only rinses it out. Review of the facility’s “Operation and Sanitation” policy indicated that operating instructions and cleaning procedures are developed for all dining services equipment, and the closing checklist required that all equipment be cleaned and all food wrapped, labeled, and dated. The facility’s failure to follow these established procedures and checklists resulted in multiple areas and pieces of equipment in the kitchen not being properly cleaned, sanitized, labeled, or maintained, affecting food storage, preparation, and service for nearly all residents who received meals from the kitchen.
Failure to Prevent Lift-Related Fall and Enforce Smoking Safety Interventions
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and follow safety interventions related to mechanical lift use and supervised smoking. One resident with a right foot fracture, morbid obesity, back pain, diabetes mellitus type 2, and bipolar disorder was care planned as a total mechanical lift transfer and identified as at risk for falls. While being transferred from bed to a stretcher for an orthopedic follow-up appointment, the mechanical lift lost balance while turning, tipped over, and the resident fell to the floor while still connected to the lift. A CNA witness confirmed that the lift tipped over during the transfer and that the resident had to be lifted from the floor. The facility’s mechanical lift and transfer policy stated that resident safety was a primary concern. The deficiency also includes failures to follow smoking safety interventions for two supervised smokers. One resident with COPD, respiratory failure, heart disease, and right-hand amputation was assessed as a supervised smoker requiring a smoking apron due to dexterity problems; however, during a smoking time, staff did not provide the required smoking apron, which was confirmed by both the resident and the CNA involved. Another resident with dementia, bilateral traumatic arm amputations with prostheses, COPD, and nicotine use was care planned and assessed to require adaptive equipment, one-on-one supervision, and a smoking apron. During an observed smoking period, this resident smoked without a smoking apron while a CNA distributed and lit cigarettes; ashes were seen falling onto the resident’s lap and upper thighs as he scraped the cigarette ashes off with his prosthesis. The CNA confirmed the resident did not use a smoking apron and stated she was unaware of anyone needing one, despite the facility’s Resident Smoking Guidelines defining and requiring smoking aprons for safety.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for multiple residents with respiratory-related orders and devices. Resident #126 was admitted with acute respiratory failure, lung disease, and other chronic conditions, and had an order for oxygen at 1-4 L/min via nasal cannula continuously. The record contained pulse oximeter readings from 03/09/26 through 03/17/26 showing oxygen levels between 90% and 99% on room air without oxygen use. The clinical manager confirmed there were no parameters on the oxygen order, the facility did not have standing orders for oxygen adjustment, and staff did not always request clarification from providers. The resident was observed without oxygen in the room after a room transfer, denied shortness of breath, and stated she did not always wear oxygen and only used it when she felt she needed it. Staff also confirmed the oxygen equipment was not in the room at that time. Resident #12 had diagnoses including obstructive sleep apnea, heart failure, muscle weakness, and morbid obesity, and used a CPAP machine at night. The physician order for CPAP did not include orders to clean the machine, mask, or tubing. The MAR and TAR from 02/01/26 through 03/16/26 lacked documentation that the CPAP was cleaned or checked for working order. The resident reported the CPAP machine had been broken for multiple weeks, and an RN verified that the CPAP was not in working order. An LPN stated there should have been a physician order to clean CPAP machines weekly and that cleaning should have been documented on the TAR, but the order and documentation were absent. Resident #44 had diagnoses including acute respiratory failure, epilepsy, kidney failure requiring hemodialysis, tracheostomy, and gastrostomy. The resident had orders for tracheostomy care every shift, cool air mist via trach collar every shift with oxygen titrated at 6 liters, and checking and refilling the humidification bottle every 4 hours. During observation, the trach collar was attached to an empty humidifier bottle, and RN #526 performed trach suctioning several times because of increased phlegm. The RN confirmed the humidifier bottle was empty and stated that without humidified air the resident would have increased phlegm production and nurses should monitor the water level. Resident #6 had orders for trach care every shift and as needed, daily inner cannula replacement, and to have the same-sized trach and one size smaller at bedside at all times. Observation of the room showed no 5XL cuffed Shiley ETT, only a 5XL cuffless Shiley, and no smaller ETTs were present. The humidifier had last been changed 13 days earlier. The LPN confirmed the ordered cuffed trach was not in the room, there were no smaller tubes available, and the humidifier had not been changed since the earlier date. The resident stated he had difficulty getting supplies from the facility and had been doing his own ETT care because he believed staff did not understand how to care for it.
Pureed Foods Served With Chunks Instead of Smooth Consistency
Penalty
Summary
The facility failed to serve pureed foods at a smooth consistency for safe swallowing for residents on pureed diets, including Residents #4, #15, #66, #73, #77, and #104. Resident #15 stated that the food tasted bad, the texture was not correct, and that the pureed food could sometimes be consumed through a straw. During observation of puree preparation, a staff member pureed pasta and placed it in a hotel pan while it still contained chunks; the Regional Dietary Manager tasted it and confirmed the chunks, and the pasta had to be pureed more. Review of the pureed pasta recipe showed it should be processed and blended until smooth. During lunch tray line observation, pureed ham was also found with dark chunks in it; the Dietary Manager tasted it and confirmed the chunks, and the tray line was stopped so the ham could be pureed more. Review of the pureed ham recipe showed it should be processed and blended until smooth.
Failure to Maintain Safe, Clean, and Functional Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for multiple residents. One resident’s room was observed in disarray, with a strong urine odor, dirty clothes on a chair with clean linen placed on top, soiled underwear in a corner, trash on the floor, and the bed controller on the floor out of the resident’s reach. The DON confirmed the urine smell and the general disarray, including dirty linens, dirty clothes, and trash in the room. Another resident’s room had bed sheets soiled with a dark substance at the head of the bed, and medical equipment including two suction machines and an oxygen concentrator splashed with dark substances, with fluid remaining in one suction canister. The refrigerator in the room had a layer of dust on top and sticky substances covering most interior surfaces. This resident reported that he usually changed his own sheets if they were changed at all and that he had requested laundry service for over a week without response, leaving him with only one visibly soiled shirt and pair of pants while dirty clothes accumulated in his closet. An LPN verified the room conditions, acknowledged the resident’s request for laundry that she had not communicated, and was unsure who was responsible for cleaning medical equipment. A housekeeper stated she had cleaned the room about an hour earlier, described housekeeping tasks as floors and dusting, and indicated CNAs were responsible for linens but was also unsure who cleaned medical equipment. A third resident reported falling twice in the bathroom due to a toilet seat not being attached, and also reported a non-flushing toilet requiring a plunger each time and a leaking sink. Observation of this bathroom showed a loose toilet seat that slid to the side when pressure was applied to the handrails, which the DON confirmed.
Failure to Provide Appropriate Self-Feeding Assistance for Resident With Prosthetic Arms
Penalty
Summary
The facility failed to provide appropriate assistance and accommodation for self-feeding to a resident with bilateral upper arm amputations who used prosthetic arms. The resident, admitted with diagnoses including dementia, traumatic amputation at both elbows, and COPD, was cognitively intact with a BIMS score of 14 and required staff setup assistance for eating per the MDS. Physician orders directed that bilateral upper arm prosthetic devices be applied before breakfast and removed after dinner, with skin checks each shift. OT notes from 12/03/25 to 02/06/26 documented discharge recommendations for self-feeding that included stand-by assist from staff and use of a scoop plate. During breakfast observations on two separate days, the resident was seen eating without appropriate use of utensils or assistive devices, despite the documented needs and therapy recommendations. On one morning, the resident sat in the dining room with bilateral prostheses and grabber hooks in place; red and white plastic utensils were loosely strapped to the prostheses. The resident pushed the utensils up out of the way and bent over the plate, scooping French toast into his mouth without using utensils, despite an activities assistant encouraging him to use the utensils. On another morning, the resident initially used a regular spoon to eat cereal but then put the spoon down and bent over the plate to eat scrambled eggs with his mouth, without staff coming to assist or encourage utensil use. The therapy director later clarified that the red and white utensils were intended for use when the prostheses were not on, and that the resident preferred thin-handled utensils that could be held with the grabber hooks. A CNA confirmed that the resident typically did not use utensils, preferred to scoop food with his mouth, and required daily encouragement to use a spoon or fork. The facility’s routine care policy included assisting residents with eating and hydration, but staff actions did not consistently reflect this for the resident.
Failure to Provide Individualized 1:1 Activities for Bedbound Resident
Penalty
Summary
The facility failed to provide individualized activities of interest to a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, major depressive disorder, and ataxia. The resident’s annual MDS assessment documented severe cognitive impairment, dependence in ADLs, and that music, doing things with other people, and engaging in favorite activities were important to her. An activity preference assessment indicated she enjoys talking. The resident’s care plan stated she may continue to participate in group and/or 1:1 activities of her choice as tolerated. However, review of the medical record showed no evidence that she participated in 1:1 visits, and the activity department’s 1:1 list did not include her. During observation, the resident was found lying in bed with the bed against the wall and the TV positioned on the opposite wall, out of her view. She reported that activity staff do not visit her in her room. The Activity Director stated that activities are documented in the electronic chart and that she conducts 1:1 visits two to three times per week, and acknowledged that the resident had previously attended bingo but had been staying in bed due to pain in recent weeks. The Activity Director further revealed that activities staff did not conduct 1:1 visits with the resident while she was staying in her room, and there was no documentation that she was offered activities except for a Valentine’s Day celebration. The Activity Assistant confirmed she kept her own list of residents receiving 1:1 visits and verified that this resident was not on her list. The facility’s undated Activities Program policy stated that the facility will provide resident-centered care that meets the psychological, physical, and emotional needs and concerns of residents.
Failure to Follow Infection Control Practices During Trach and Incontinence Care
Penalty
Summary
The deficiency involves failure to maintain infection prevention and control practices during tracheostomy care for one resident. The resident was admitted with diagnoses including acute respiratory failure, epilepsy, kidney failure requiring hemodialysis, tracheostomy, and gastrostomy, and had a physician’s order for tracheostomy care every shift. During an observation of trach care, surveyors noted a used trach collar with attached tubing lying directly on a tabletop in the resident’s room without any barrier underneath it, and a white washcloth placed on top of the used trach collar. In an interview, the RN confirmed the used trach collar and tubing were on the table without a barrier and stated the nurse must have removed the trach collar and tubing prior to the resident going to dialysis. Facility policy on Infection Prevention and Infection Control required standard precautions to be universally applied in the care and treatment of all residents. A second deficiency involved failure to follow hand hygiene and glove-use standards during incontinence care for another resident. During observed perineal care, a CNA cleansed under the resident’s panniculus, where the skin was reddened with chunks of old skin and powder, while wearing gloves, then applied barrier cream and proceeded to clean the perineal area without performing hand hygiene or changing gloves. The CNA then assisted with removing the resident from a bedpan, cleaned the bedpan, washed her hands, and changed gloves, and completed the remainder of incontinence care, including cleaning the gluteal area, without further hand hygiene until all care was completed. In an interview, the CNA confirmed she performed hand hygiene only once during the care and could not recall when she was last educated on hand hygiene. Facility policies on Perineal Care and on Standard Precautions and Transmission-Based Precautions required hand hygiene before applying gloves, after completing skin care, and after glove removal, and required gloves to be changed between clean and dirty tasks and after contact with materials that may contain high concentrations of microorganisms.
Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident call lights were within reach for multiple residents, contrary to facility policy stating that call light or bell access will be within reach as a method for residents to communicate needs to staff. One resident with dementia, depression, high blood pressure, impaired cognition (BIMS score of 3/15), and a self-care deficit related to language barrier and impaired mobility was observed lying in bed asleep with the bed positioned against the wall while the call light was attached to the privacy curtain across the room, out of the resident’s reach. A RN confirmed that this resident’s call light was attached to the privacy curtain across the room rather than being accessible from the bed. Another resident with Alzheimer’s disease, depression, anxiety, high blood pressure, impaired cognition (BIMS score of 5/15), functional incontinence, impaired communication related to dementia, and impaired mobility requiring staff assistance was observed sleeping in bed with no call light in reach; both call lights in the room were attached to the roommate’s bed. The RN confirmed that this resident’s call light was attached to the roommate’s bed and not within reach. In a separate observation, a third resident’s call light was found wound up over the call light actuator box near the recliner, not reachable from the bed, and the bed controller was on the floor at the foot of the bed, also out of reach. These observations showed that three residents reviewed for call light use did not have accessible call systems as required by facility policy.
PASRR Not Updated for Changes in Psychiatric Condition
Penalty
Summary
The facility failed to update Preadmission Screening and Resident Review (PASRR) information when residents had changes in condition. For one resident admitted with diagnoses including schizoaffective disorder, anxiety, bipolar disorder, and major depressive disorder, the medical record showed physician orders for Seroquel 50 mg twice daily for schizoaffective disorder and Depakote 125 mg two capsules twice daily for bipolar disorder, but the PASRR dated 05/05/2017 did not mark antipsychotic medication use. During interview, Social Services confirmed the PASRR was not updated to reflect the antipsychotic medications. For another resident admitted with diagnoses including psychotic disorder with delusions, dementia with psychotic disturbance, major depressive disorder, and anxiety, the PASRR dated 11/25/25 listed panic or other severe anxiety disorder as the only diagnosis. Social Services confirmed this resident did not have an updated PASRR reflecting the diagnoses of psychotic disorder with delusions and major depressive disorder. The facility policy titled PASRR - Pre-admission Screening and Resident Review was reviewed as part of the findings.
Failure to Provide Written Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to provide a written baseline care plan to Resident #125 and Resident #126 within 48 hours of admission. Resident #125 was admitted with diagnoses including aftercare for surgical amputation of the left leg above the knee, heart failure, high blood pressure, end stage renal disease with dialysis, atrial fibrillation, lung disease, anxiety, gastric reflux, and delirium. A brief mental status interview completed on admission showed a score of 08/15, indicating moderate cognitive impairment. The record also showed a care conference with the resident’s daughter and other staff, but there was no evidence that a baseline care plan was provided in writing to the resident or representative within 48 hours. Resident #126 was admitted with diagnoses including acute respiratory failure, lung disease, bipolar disorder, depression, anxiety, smoking, diabetes, heart failure, end stage renal disease with hemodialysis, and fibromyalgia. A brief mental status interview showed a score of 15/15, indicating cognitive intactness. The Nursing admission Evaluation-V 13 for this resident included initial care planning areas and immediate interventions, and the DON stated the interdisciplinary team met within 72 hours of admission and that the evaluation contained the baseline care plan embedded within it. The DON also confirmed there was no evidence that a care plan was provided to Resident #126 within 48 hours, and the facility policy stated the baseline care plan would be printed and shared with the resident or representative.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide appropriate post-dialysis evaluations for two residents receiving hemodialysis. Resident #126 was admitted with multiple diagnoses including end stage renal disease with hemodialysis, diabetes, heart failure, bipolar disorder, depression, anxiety, and lung disease. The resident was cognitively intact on a brief mental status interview and confirmed during observation that she was receiving dialysis at the facility and was not always assessed after returning from dialysis, including not having vital signs checked after treatments. For Resident #126, the record showed refusal of dialysis on two occasions, followed by emergency dialysis at the hospital after a critical potassium level of 6.2 and return to the facility the same day. The treatment administration record for that day did not contain post-dialysis vital signs or assessment, and the dialysis communication hand-off form also lacked documentation in the section for the nursing home nurse to record post-dialysis vital signs, weight, and assessment findings. Staff interviews confirmed that the resident had returned from emergency dialysis and that the facility only completed post-dialysis assessment notes for residents who received dialysis off site. Resident #55 was admitted with diagnoses including left femur fracture, end stage renal disease, dependence on renal dialysis, and diabetes mellitus type 2. The resident’s MDS showed cognitive intactness and receipt of dialysis, and the care plan included evaluating the resident following dialysis treatment. However, the record contained no physician order for post-dialysis assessment, no post-dialysis assessment documentation in progress notes, MAR, or TAR, and the dialysis communication sheets only showed access site checks without a resident assessment. Interviews with the DON and an LPN confirmed the facility did not assess residents’ vital signs post-dialysis and instead used the last vital signs from the dialysis center, while only checking the access site after treatment.
Unsanitary Resident Room and Broken Bathroom Toilet
Penalty
Summary
The facility failed to maintain the environment in a sanitary and working manner for two residents, including Resident #71 and Resident #12. For Resident #71, observations on 03/09/26 and again on 03/11/26 showed grime and dirt on the bed side rails. A later observation on 03/11/26 also found extensive dried food debris on the legs and post of the bedside table, the same grime and dirt on the side rails, and a bed frame that was visibly soiled with a large amount of splatter marks. During interview, an LPN stated that any staff member could clean messes on the floor, side rails, bedside table, and bed frame, and verified the findings. The DON stated housekeeping was responsible for cleaning the resident room, bedside table, and side rail. The facility policy stated rooms would be cleaned regularly, with attention to high-use surfaces such as bed rails, and visible soil would be removed prior to disinfection. For Resident #12, an observation of the bathroom showed a sign on the toilet stating DO NOT USE. The resident stated the toilet had been broken for several months and that when it was used it would flood the entire bathroom. The resident reported maintenance had been in several times but the issue was never corrected. An RN confirmed this information during interview. The deficiency was cited as non-compliance under Complaint Number 2691714.
Failure to Provide Consistent Restorative Nursing Programs Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to consistently deliver restorative nursing programs as ordered for residents requiring these services. Three residents reviewed for restorative services did not receive their prescribed programs at the frequency and duration specified in their care plans. For example, one resident with a history of cerebrovascular disease, diabetes, and generalized weakness was supposed to participate in a daily ambulation program but only received the service once in a 30-day period. The lack of consistent restorative care was confirmed by both staff and documentation, with staff citing insufficient time and staffing to complete these programs as ordered. Another resident with hemiplegia, diabetes, and other chronic conditions was on a restorative ambulation program intended to be provided daily, six to seven times per week. However, records showed the program was inconsistently offered, with some weeks showing only three to five sessions and other weeks with no documentation of the program being offered or completed. The Director of Nursing acknowledged that the records did not reflect the program being provided according to the care plan. A third resident, also with hemiplegia and multiple comorbidities, was prescribed a daily passive range of motion (PROM) program for the affected upper extremity. Documentation revealed the program was delivered only four to five times per week, rather than the ordered six to seven times. The Director of Nursing confirmed that the program was not provided at the required frequency. In total, the facility had identified 41 residents with orders for one or more restorative programs, indicating a broader issue with staffing and program delivery.
Failure to Notify Practitioner Before Administering Anti-Hypertensive Medication to Resident with Critically Low Blood Pressure
Penalty
Summary
The facility failed to ensure that a nurse practitioner or physician was notified prior to administering a medication with anti-hypertensive properties to a resident with a critically low blood pressure. The resident had a complex medical history, including hypertensive heart disease, paroxysmal atrial fibrillation, atherosclerotic heart disease, malignant neoplasm of the scrotum and prepuce, and pleural effusion. On the morning in question, the resident's blood pressure was recorded at 70/50 mm Hg and pulse at 59 bpm, yet both midodrine and metoprolol tartrate were administered. The facility's policy required consultation with the medical practitioner when there was a change in condition, such as a deterioration of health status or a need to alter treatment, but this was not followed. Nursing documentation showed that the nurse practitioner was only notified after the medications were given. The nurse who administered the metoprolol stated she did not contact the physician or nurse practitioner beforehand, citing past instructions to administer the medication to other residents with similar vital signs, though she could not provide specifics. The nurse practitioner confirmed that she should have been contacted prior to administration, as the medication could further lower blood pressure, and stated she would have instructed the nurse to hold the medication. The resident subsequently experienced severe symptoms, including hypoxia, lethargy, and critically low oxygen saturation, requiring emergency transfer to the hospital.
Failure to Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of money to the State Survey Agency as required. A resident with multiple diagnoses, including congestive heart failure, atherosclerotic heart disease, type 2 diabetes, bipolar disorder, and anxiety disorder, reported to an LPN that $350.37 was missing from his locked box after returning from a leave of absence. The resident stated the box had been locked in his room and the key was with him, but also mentioned there were times he left the key in his bag or in the lock. The police were informed and took a report from the resident. Documentation in the medical record and social service notes confirmed the resident's concerns were voiced and documented, but there was no evidence that the incident was reported to the State Survey Agency. Interviews with facility staff revealed that the LPN promptly informed the DON and RN Unit Manager about the missing money, and the RN Unit Manager communicated the allegation to the Administrator via text. Despite this, the Administrator stated he was not aware of the incident until several days later, and the DON could not explain why the State Survey Agency was not notified. Review of the facility's policy indicated that allegations of misappropriation should be reported to supervisors and required agencies immediately, but this protocol was not followed in this case.
Failure to Investigate and Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to initiate a thorough investigation into an allegation of stolen money from a resident's lock box, despite being informed by staff. The resident, who had multiple diagnoses including congestive heart failure, atherosclerotic heart disease, type 2 diabetes, bipolar disorder, and anxiety disorder, reported missing $350.37 from his lock box after returning from a leave of absence. The resident stated the box was locked in his room and the key was with him, but also mentioned occasions when the key was left in his bag or in the lock. The police were notified and took a report, and the resident's concerns were documented by social services. Despite facility policy requiring timely investigation and reporting of misappropriation allegations, there was no evidence that the incident was reported to the State Survey Agency or that a formal investigation was initiated promptly. Interviews revealed that the LPN informed the DON and RN Unit Manager shortly after the allegation, and the RN Unit Manager communicated with the Administrator. However, the Administrator stated he was not aware of the allegation until several days later, at which point he submitted a Facility Reported Incident and began an investigation. Documentation and communication gaps led to a delay in the required investigative and reporting actions.
Failure to Provide Restorative Ambulation Programs as Ordered
Penalty
Summary
The facility failed to provide restorative nursing programs as ordered to maintain residents' ability to ambulate, affecting two of three residents reviewed for restorative services. For one resident with a history of cerebrovascular disease, diabetes, and generalized weakness, the care plan required daily ambulation with staff support. However, documentation showed the resident only received the ambulation program once in the prior 30 days. Interviews revealed that after the retirement of the restorative aide, no other staff consistently provided the program, and aides reported insufficient time and unclear assignments regarding restorative care responsibilities. Another resident with hemiplegia, diabetes, and other chronic conditions was also on a restorative ambulation program intended to be provided daily. Records indicated inconsistent delivery, with the program offered or provided fewer times than ordered and some refusals not consistently documented. The DON acknowledged that records did not reflect the program being offered in accordance with the care plan or assessments. These findings demonstrate a failure to implement restorative nursing programs as planned, resulting in non-compliance with requirements to maintain residents' functional abilities.
Medication Administered Outside Physician-Ordered Parameters
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including hypertensive heart disease, paroxysmal atrial fibrillation, atherosclerotic heart disease, malignant neoplasm of the scrotum and prepuce, and pleural effusion, received medication outside of physician-ordered parameters. The resident had an order for midodrine HCL 5 mg three times daily, with instructions to hold the medication if the systolic blood pressure was greater than 120 mm Hg. Despite this, the medication was administered on three separate occasions when the resident's systolic blood pressure readings were above the specified threshold (137/78, 137/74, and 138/74 mm Hg), as documented in the June Medication Administration Record. Interviews with the registered nurse who administered the medication and the Director of Nursing revealed that neither could provide an explanation for why the medication was given outside the ordered parameters. A nurse practitioner acknowledged that while administration outside parameters might be acceptable on dialysis days in some cases, it could still pose issues depending on the resident's overall condition. The report notes that there were no adverse consequences from these incidents, but the administration of medication was not in accordance with the physician's orders.
Failure to Provide Restorative ROM Program as Ordered
Penalty
Summary
A deficiency was identified when the facility failed to provide restorative range of motion (ROM) programs in accordance with physician orders for a resident with hemiplegia affecting the right dominant side, type two diabetes mellitus with diabetic neuropathy, morbid obesity, and other conditions. The resident's care plan required passive ROM to the right upper extremity in all planes once a day, six to seven days per week, for 15 minutes each session, with quarterly reassessment. The resident was cognitively intact, did not reject care, and required maximal assistance with minimal verbal cues. Review of restorative program delivery records showed that the program was not consistently provided as ordered, with documentation reflecting delivery only four to five times per week over several weeks, rather than the minimum six times per week specified in the care plan and physician order. The DON confirmed that the program was not offered at the required frequency, resulting in non-compliance with the resident's prescribed restorative program.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 7.4% (2 errors out of 27 opportunities). One resident was observed receiving an incorrect dose of divalproex sodium and vitamin B-6. Specifically, the resident was administered three 250 mg tablets and one 500 mg tablet of divalproex sodium in the morning, totaling 1250 mg, despite physician orders specifying 750 mg in the morning and 500 mg in the evening. Additionally, the resident received a whole 100 mg tablet of vitamin B-6 instead of the ordered 50 mg, as only 100 mg tablets were available and the tablets were not scored for splitting. Interviews with nursing staff confirmed the administration of incorrect doses, and review of medication packets and physician orders corroborated the errors. The pharmacist identified that a previous order for divalproex sodium 500 mg twice daily had not been discontinued when a new order for three 250 mg tablets in the morning was received, leading to both doses being sent and administered together. Facility policy required medications to be administered as prescribed, prohibited splitting unscored tablets, and instructed staff to contact pharmacy for correct dosages, but these procedures were not followed.
Unqualified Staff Assigned to Direct Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by the position description and regulatory standards. Review of the personnel file for the current Activities Director showed that she was originally hired as a Certified Nursing Assistant and later became an activity assistant before assuming the role of Activities Director. However, there was no evidence in her employee file to demonstrate that she met any of the required qualifications for the position, such as being a qualified therapeutic recreation specialist, a licensed activities professional, having the necessary experience, or having completed a state-approved training course. The Activities Director herself confirmed during interview that she did not possess the required qualifications and had been serving in the director role for several months. Further review revealed that the Activities Director only began a certified activities director course after assuming the position, and there was no indication that she had completed it. Interviews with the Divisional Director of Activities and the Regional Administrator confirmed that the Activities Director was not certified and did not meet the qualifications outlined in the job description. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
During incontinence care for a resident with Alzheimer's Disease, quadriplegia, tracheostomy status, and dysphagia, two CNAs gathered supplies, provided privacy, washed their hands, and donned gloves. One CNA removed a soiled brief and provided peri care, but then, without changing her gloves or performing hand hygiene, touched the barrier cream container, applied the cream to her gloves, and then to the resident's peri area. She continued care to the resident's buttocks and applied a new brief, all while wearing the same soiled gloves. The CNA only removed her gloves and washed her hands after completing all care tasks. Interviews with the CNA, a unit manager RN, and the DON confirmed that the CNA should have removed her soiled gloves and performed hand hygiene before touching the barrier cream container and before applying the cream to the resident. Facility policy on standard precautions also requires hand hygiene after contact with body fluids or excretions and after glove removal.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the accuracy of direct care staffing information submitted to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. During a review of the PBJ report for the fourth quarter of 2024, it was found that the facility had a one-star staff rating and excessively low weekend staffing. A detailed examination of staffing sheets and time punches revealed discrepancies on several dates, where the time punch detail report did not match the schedules. The administrator identified an issue with time punches of employees no longer working for the facility not appearing in the time punch detail. The administrator, who was not employed during the fourth quarter of 2024, indicated that the time punches submitted to corporate accountants were used for PBJ submission, and it was possible that some employee hours were not submitted. This deficiency was discovered incidentally during a complaint investigation.
Failure to Perform Daily Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that surgical wound treatments were completed according to physician orders for a resident with severe cognitive impairment and multiple mental health diagnoses. The resident, who required substantial assistance with bathing, had surgical wounds that required specific daily treatments. Physician orders dated 10/02/24 specified that the resident's mid-upper back wound should be cleansed with normal saline, have skin prep applied to the surrounding tissue, silver alginate applied to the wound base, and be secured with boarded foam. Similarly, the right lateral shoulder wound required cleansing, skin prep, silver alginate application, and coverage with boarded gauze dressing. On 10/17/24, an observation revealed that the dressings on both the right lateral shoulder and mid-upper back were dated 10/14/24, indicating that the prescribed daily wound care had not been performed as ordered. The Assistant Director of Nursing, who also served as the facility wound nurse, confirmed that she had applied the dressings on 10/14/24. The facility's undated wound care policy stated that residents with skin integrity issues should receive treatment as indicated, yet this was not adhered to in the case of this resident. This deficiency was investigated under specific complaint numbers.
Delayed Laboratory Testing for Occult Blood in Stool
Penalty
Summary
The facility failed to ensure timely laboratory testing for a resident who required stool samples for occult blood testing. The resident, who had a history of peripheral vascular disease, amputations, hypertension, duodenal ulcer, and chronic anemia, was admitted to the facility with low hemoglobin levels. Physician orders for three stool samples were initially made on July 22, 2024, with subsequent orders on August 15, 2024, and September 12, 2024. However, only one test was completed on September 16, 2024, indicating a delay in obtaining the necessary samples. Despite the resident having bowel movements from September 26 to September 29, 2024, there was no evidence that the stool specimens were collected or tested as ordered. Further orders for stool specimens were made on September 30, 2024, and the samples were eventually obtained on October 1 and October 6, 2024. Interviews with the Director of Nursing and the physician confirmed the delay in obtaining the stool samples, which should have been completed within two weeks according to the physician's expectations. This deficiency was investigated under Complaint Numbers OH00158714 and OH00158447.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to maintain accurate medical records related to resident care, specifically affecting a resident with severe cognitive impairment and surgical wounds. The resident had physician orders for daily wound care on the mid-upper back and right lateral shoulder, which were to be performed every day shift and as needed. However, during an observation, it was found that the dressings on both wounds were dated three days prior, indicating that the wound care had not been performed as documented. The Treatment Administration Record (TAR) inaccurately reflected that the wound care was completed on two consecutive days, despite the dressings not being changed. This discrepancy was confirmed by the Assistant Director of Nursing, who was also the wound nurse, and a Registered Nurse who acknowledged that an LPN had documented the treatments without performing them. The facility's policy on clinical documentation standards requires timely and accurate documentation, which was not adhered to in this case.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in Immediate Jeopardy and potential for serious harm. On September 5, 2024, an Activity Director witnessed a State Tested Nursing Assistant (STNA) forcibly placing a resident into a tilt-in-space wheelchair and inverting it, causing the resident distress and fear. Despite the incident being reported to the Human Resource Manager, the STNA continued to work at the facility without removal or further investigation. Another incident occurred on September 7, 2024, involving a different STNA who was physically abusive to a resident during a shower. The resident reported being forcefully grabbed and undressed, resulting in multiple bruises and fractures. The incident was not reported to leadership staff, and the STNA continued to provide care to residents, including the victim, without immediate removal or investigation. The facility's failure to report and investigate these incidents promptly, as well as the continued employment of the involved STNAs, contributed to the deficiency. The lack of proper training and awareness among staff regarding abuse prevention and reporting protocols further exacerbated the situation, leading to the facility being out of compliance with regulations designed to protect residents from abuse.
Removal Plan
- Registered Nurse #315 assessed Resident #71 for pain.
- Unit Manager #105 completed a skin check for Resident #71.
- Resident #71 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360).
- State tested Nursing Assistant #200 was suspended pending investigation by the Administrator/Executive Director.
- The Administrator/ED notified the local police department of the incident that had occurred between Resident #71 and STNA #200.
- ADON #100 notified Medical Director #800 of the incident with Resident #71 and STNA #200 and of the incident with Resident #78 and STNA #300.
- The ED notified the local police department of the incident that had occurred between Resident #78 and STNA #300.
- STNA #300 was suspended pending investigation by the Executive Director.
- Resident #78 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360).
- LPN #226 reassessed Resident #78 for skin issues.
- Resident #78 had pain assessment completed by LPN #105.
- 61 residents with a Brief Interview for Mental Status Score (BIMS) score of 10 and higher were interviewed by ADON# 100, Clinical Manager #101, and RDCO #320 to identify any additional occurrences of abuse.
- Skin assessments were performed by LPN #430, ADON #100, Clinical Manager #101 and RDCO #320 on all other residents who had a BIMS under 10 or were not interviewable.
- All 102 residents were interviewed and/or assessed.
- The Administrator/ED sent a text message to all 121 staff members, to notify them of required in-service education that was being completed by RDCO #320.
- The education included a quiz. Elements of the education included: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse, staff removing perpetrators from the facility, reporting an incident to a supervisor immediately, phone numbers of department heads, including abuse coordinator, and proper steps/timelines in abuse investigation.
- Seventeen employees completed the education.
- Regional Director of Operations #750 educated HRM #600 on the policy and procedure for appropriate pre-employment checks to be completed prior to hire.
- RDCO #320 educated HRM #600 verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- HRM #600 was educated that if an employee reported abuse to her, she should first make sure the resident was safe and the perpetrator was out of the facility, and then report the incident to the facility Abuse Coordinator, who was the Administrator/Executive Director.
- Unit Manager #105 along with the interdisciplinary team were educated by RDO #750.
- Education was in-person and included a review of proper policy and procedures on the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- RDCO #320 educated Unit Manger #105 on Abuse Prevention, the use of restraints, and aggressive/combative behavior with emphasis on de-escalating catastrophic reactions, abuse investigation (including resident assessments & documentation) and reporting, and use of restraints.
- RDCO #320 educated LPN #102 on abuse reporting, including the identity of the abuse coordinator, timelines, and proper notifications in instances of abuse allegations.
- Elements of these policies that were emphasized include: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse.
- RDCO #320 educated the Director of Nursing verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- The remaining 104 staff including LPN #102 and Unit Manager #105 were educated in person or via telephone on the use of restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation by RDCO#320/designee.
- The facility indicated all new hires would be educated on the first day of orientation by social service staff.
- The facility Quality Assessment and Performance Improvement (QAPI) committee met to conduct a root cause analysis of the incidents involving Resident #78 and Resident #71.
- The QAPI committee included ED, RDO #750, RDCO #320, Medical Director #800, and the DON via telephone.
- The QAPI committee determined the root causes of the incidents included staff working in the memory care unit without proper training in Dementia Care and Aggressive/Combative Behavior, staff needed education on the Use of Restraints in terms of tilt-and-space chairs, and staff were unaware of the facility identified Abuse Coordinator, proper reporting protocols, and proper steps/requirements of an abuse investigation.
- Resident #71 went to the hospital to have labs performed.
- While in the hospital, Resident #71 reported the incident of abuse to hospital staff.
- The hospital performed x-rays and found three fractures in Resident #71's right wrist.
- Resident #71 returned to facility with an order for a splint to the right wrist.
- An appointment was set for the resident to see an orthopedist.
- The DON/designees reviewed care plans for additional residents with history of catastrophic reactions.
- Resident #71's care plan was reviewed by LPN #105.
- The care plan was updated for the resident to have two staff members during showers, and no males were to provide care during all showers.
- Additionally, the residents care plan was updated related to her fracture.
- Changes were communicated to staff through the resident's Kardex in Point Click Care.
- The Administrator or designee would interview two staff and three residents once a week for four weeks to ensure that no incidents of abuse had occurred.
- The DON/designee would perform two random skin assessments daily for four weeks to ensure care is being provided appropriately.
- The DON/Designee would audit the Connections (memory care) Unit five days a week for four weeks.
- Audits would include observation of activity of daily living assistance and meal service to ensure residents were receiving proper care.
- The ED/designee would audit Human Resources once a week for four weeks to ensure new hires were properly screened with Bureau of Criminal Investigations checks and reference checks.
- Audits would also ensure new hires were properly signed up for Relias for in-service training and receive proper abuse and dementia care training upon hire.
- The ED/designee would audit employee evaluations once a week for four weeks to ensure any issues mentioned in employee evaluations were followed with proper education or discipline by DON/designee.
- The results of all audits would be submitted to the QAPI committee for review upon completion and quarterly thereafter.
- STNA #300 was terminated.
- STNA #200 was terminated.
Failure to Report Abuse Allegations Immediately
Penalty
Summary
The facility failed to ensure that all allegations of physical and/or emotional abuse were reported immediately to the Administrator and State Survey Agency as required. This resulted in Immediate Jeopardy and the potential for serious harm beginning when an Activity Director witnessed a State tested Nursing Assistant (STNA) forcibly placing a resident into a tilt-in-space wheelchair and inverting the chair, causing distress to the resident. The incident was not reported immediately, allowing the STNA to continue providing care to residents, including the affected resident. Another incident occurred when a resident alleged physical abuse by a male STNA during a shower. The resident reported being forcefully undressed and thrown into the shower, resulting in multiple bruises and fractures. Despite the resident's report to a Licensed Practical Nurse (LPN) and her son, the allegation was not reported to leadership staff, allowing the STNA to continue working with residents. The facility's failure to report these incidents immediately to the appropriate authorities and remove the alleged perpetrators from resident care areas contributed to the deficiency. The facility's policies required immediate notification of the Director of Nursing and Executive Director of any abuse allegations, but these protocols were not followed. Staff members, including the Human Resource Manager and Unit Manager, were aware of the incidents but did not take appropriate action to report them or initiate an investigation. This lack of adherence to reporting procedures and failure to protect residents from potential harm led to the deficiency identified by the surveyors.
Removal Plan
- The Administrator/Executive Director created Self-Reported Incident regarding Resident #71's allegation of abuse.
- The Executive Director conducted interviews with Resident #71, STNA/Alleged perpetrator #200, Activities Aide #310, STNA #300, STNA #131, LPN#102 and RN# 315.
- The Administrator/ED notified the local police department of the incident with Resident #71 and STNA #200. The local police opened a case.
- ADON #100 notified Medical Director #800 of the incident with Resident #71 and STNA #200 and the incident with Resident #78 and STNA #300.
- Regional Director of Clinical Operations (RDCO) #320 created Self-Reported Incident regarding the incident between Resident #78 and STNA #300.
- The Executive Director conducted interviews with Activities Director #400, Activities Aide #310, Activities Aide #301, STNA/Alleged Perpetrator #300, STNA #131, Unit Manager #105, HRM #600, and STNA #340.
- The ED notified the local police department of the incident involving Resident #78 and STNA #300. The local police opened a case.
- 61 residents with a Brief Interview for Mental Status Score (BIMS) of 10 and higher were interviewed by ADON# 100, Clinical Manager #101, and RDCO #320 to identify any additional occurrences of abuse.
- Skin assessments were performed by LPN #430, ADON #100, Clinical Manager #101 and RDCO #320 on all other residents who had a BIMS under 10 or were not interviewable. All 102 residents were interviewed and/or assessed.
- The ED sent a text message to all 121 staff members to notify them of required in-service education being completed by RDCO #320. The education included a quiz.
- Unit Manager #105 along with the interdisciplinary team were educated by Regional Director of Operations (RDO) #750. Education included a review of proper policy and procedures on the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- RDCO #320 educated Unit Manager #105 on Abuse Prevention, the use of restraints, and aggressive/combative behavior with emphasis on de-escalating catastrophic reactions, abuse investigation (including resident assessments & documentation) and reporting, and use of restraints.
- RDCO #320 educated LPN #102 on abuse reporting, including the identity of the abuse coordinator, timelines, and proper notifications in instances of abuse allegations.
- RDCO #320 educated the DON verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- The remaining 104 staff including LPN #102 and Unit Manager #105 were educated in person or via telephone on the use of restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation by RDCO#320/designee.
- The facility indicated all new hires would be educated on the first day of orientation by social service staff.
- The facility Quality Assessment and Performance Improvement (QAPI) committee met to conduct a root cause analysis of the incidents involving Resident #78 and Resident #71.
- RDCO #320/designee would audit 24-hour reports daily for four weeks to see if any reportable incidents occurred.
- The RDCO/designee would also audit to ensure facility Self-Report Incidents (SRIs) were reported to the State (ODH) agency portal in a timely fashion.
- The facility completed and submitted their final Self-Reported Incident information which substantiated the incident of abuse involving Resident #78.
- The facility completed and submitted their final Self-Reported Incident information which substantiated the incident of abuse involving Resident #71.
Failure to Implement Abuse Policy Leads to Resident Harm
Penalty
Summary
The facility failed to implement its abuse policy effectively, leading to two separate incidents of alleged abuse involving residents. In the first incident, an Activity Director witnessed a State Tested Nursing Assistant (STNA) forcibly placing a resident into a tilt-in-space wheelchair and inverting the chair, causing the resident distress and fear. Despite the incident being reported to the Human Resource Manager, no immediate investigation was initiated, and the STNA continued to work in the facility, posing a risk to other residents. In the second incident, another STNA was reported to have been physically abusive to a resident during a shower, resulting in multiple bruises and fractures to the resident's wrist. The resident reported the incident to a Licensed Practical Nurse (LPN), who failed to escalate the allegation to leadership staff. Consequently, the STNA continued to work in the facility without any immediate investigation being conducted, further endangering the residents. Both incidents highlight a significant lapse in the facility's response to allegations of abuse, as staff members who were aware of the incidents did not follow the proper reporting protocols. The facility's failure to act promptly and remove the alleged perpetrators from the environment placed vulnerable residents at risk of further harm.
Removal Plan
- Registered Nurse #315 assessed Resident #71 for pain.
- Unit Manager #105 completed a skin check for Resident #71.
- Resident #71 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360).
- State tested Nursing Assistant #200 was suspended pending investigation by the Administrator/Executive Director.
- The Administrator/ED notified the local police department of the incident that had occurred between Resident #71 and STNA #200.
- ADON #100 notified Medical Director #800 of the incident with Resident #71 and STNA #200 and of the incident with Resident #78 and STNA #300.
- The ED notified the local police department of the incident that had occurred between Resident #78 and STNA #300.
- STNA #300 was suspended pending investigation by Executive Director.
- Resident #78 had an in-person assessment completed by the nurse practitioner of the facility psych services (Psych 360).
- LPN #226 reassessed Resident #78 for skin issues.
- Resident #78 had pain assessment completed by LPN #105.
- 61 residents with a Brief Interview for Mental Status Score (BIMS) score of 10 and higher were interviewed by ADON# 100, Clinical Manager #101, and RDCO #320 to identify any additional occurrences of abuse.
- Skin assessments were performed by LPN #430, ADON #100, Clinical Manager #101 and RDCO #320 on all other residents who had a BIMS under 10 or were not interviewable.
- All 102 residents were interviewed and/or assessed.
- The ED sent a text message to all 121 staff members, to notify them of required in-service education that was being completed by RDCO #320.
- The education included a quiz. Elements of the education included: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse, staff removing perpetrators from facility, reporting incident to supervisor immediately, phone numbers of department heads, including abuse coordinator, and proper steps/timelines in abuse investigation.
- 17 employees completed the education.
- Regional Director of Operations #750 educated HRM #600 on the policy and procedure for appropriate pre-employment checks to be completed prior to hire.
- RDCO #320 educated HRM #600 verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- HRM #600 was educated that if an employee reported abuse to her, she should first make sure the resident was safe and the perpetrator was out of the facility, and then report the incident to the facility Abuse Coordinator, who was the Administrator/Executive Director.
- Unit Manager #105 along with the interdisciplinary team were educated by RDO #750.
- Education was in-person and included a review of proper policy and procedures on the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- RDCO #320 educated Unit Manger #105 on Abuse Prevention, the use of restraints, and aggressive/combative behavior with emphasis on de-escalating catastrophic reactions, abuse investigation (including resident assessments & documentation) and reporting, and use of restraints.
- RDCO #320 educated LPN #102 on abuse reporting, including the identity of the abuse coordinator, timelines, and proper notifications in instances of abuse allegations.
- Elements of these policies that were emphasized include: Using a tilt-and-space (chair) as a restraint, dementia care, de-escalating a catastrophic reaction, abuse, securing resident safety in cases of suspected abuse.
- RDCO #320 educated the DON verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- The remaining 104 staff including LPN #102 and Unit Manager #105 were educated in person or via telephone on the use of restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation by RDCO#320/designee.
- The facility indicated all new hires would be educated on the first day of orientation by social service staff.
- The facility Quality Assessment and Performance Improvement (QAPI) committee met to conduct a root cause analysis of the incidents involving Resident #78 and Resident #71.
- The QAPI committee included ED, RDO #750, RDCO #320, MD #800, and the DON via telephone.
- The QAPI committee determined the root causes of the incidents included staff working in memory care unit without proper training in Dementia Care and Aggressive/Combative Behavior, staff needed education on the Use of Restraints in terms of tilt-and-space chairs, and staff were unaware of the Abuse Coordinator, proper reporting protocols, and proper steps/requirements of abuse investigation.
- Resident #71 went to the hospital to have labs performed.
- While in the hospital, Resident #71 reported the incident of abuse to hospital staff.
- The hospital performed x-rays and found three fractures in Resident #71's right wrist.
- Resident #71 returned to facility with an order for a splint to the right wrist.
- An appointment was set for the resident to see an orthopedist.
- The DON/designees reviewed care plans for additional residents with history of catastrophic reactions.
- Resident #71's care plan was reviewed by LPN #105.
- The care plan was updated for the resident to have two staff members during showers, and no males were to provide care during all showers.
- Additionally, the residents care plan was updated related to her fracture.
- Changes were communicated to staff through the resident's Kardex in Point Click Care.
- The Administrator or designee would interview two staff and three residents once a week for four weeks to ensure that no incidents of abuse had occurred.
- The DON/designee would perform two random skin assessments daily for four weeks to ensure care is being provided appropriately.
- The DON/Designee would audit the Connections (memory care) Unit 5 days a week for four weeks.
- Audits would include observation of activity of daily living assistance and meal service to ensure residents were receiving proper care.
- The ED/designee would audit HR once a week for four weeks to ensure new hires were properly screened with BCI checks and reference checks.
- Audits would also ensure new hires were properly signed up for Relias for in-service training and receive proper abuse and dementia care training upon hire.
- The ED/designee would audit employee evaluations once a week for four weeks to ensure any issues mentioned in employee evaluations were followed with proper education or discipline by DON/designee.
- RDCO #320/designee would audit 24-hour reports daily for four weeks to see if any reportable incidents occurred.
- The RDCO/designee would also audit to ensure facility Self-Report Incidents (SRIs) were reported to the State (ODH) agency portal in a timely fashion.
- The results of all audits would be submitted to QAPI committee for review upon completion and quarterly thereafter.
- STNA #300 was terminated.
- STNA #200 was terminated.
Infection Control Deficiencies in Employee Screening and Resident Care
Penalty
Summary
The facility failed to ensure that newly hired employees were screened for tuberculosis (TB) prior to their first day of work, as required by the facility's policy. A review of eight employee files revealed that the Human Resource Director, Clinical Manager RN, and Culinary Director were not screened for TB before starting their employment. This was confirmed through interviews with the HR Director, who acknowledged the oversight. The facility's TB Symptom Screen Policy mandates that all employees, healthcare workers, volunteers, and healthcare providers be screened for TB upon hire and annually. The facility also failed to maintain appropriate infection control practices during blood glucose testing (BGT) and wound care. An LPN did not sanitize and disinfect the BGT machine after use on a resident in the secured memory care unit, despite the facility's policy requiring cleaning and disinfection between each resident. The LPN admitted to not cleaning the machine due to the absence of sanitizing wipes on the medication carts. Additionally, during wound care for a resident, an RN did not change gloves or wash hands after removing the old dressing and before applying a new dressing, which was against the facility's infection control policy. Furthermore, the facility did not adhere to enhanced barrier precautions during tracheostomy care for a resident. An LPN provided tracheostomy care without wearing a gown, which is required by the facility's Enhanced Barrier Precautions policy for high-contact resident care activities involving indwelling devices. The LPN was unaware of the requirement, and the Director of Nursing confirmed that enhanced barrier precautions should have been used. The facility's policy and a memorandum from the Centers for Medicare and Medicaid Services emphasize the necessity of gowns and gloves during such procedures.
Deficiency in Resident Care and Assistance
Penalty
Summary
The facility failed to provide adequate and timely assistance to residents who were dependent on staff for activities of daily living, affecting four residents. Resident #4, with severe cognitive impairment and paraplegia, was observed with long, dirty fingernails despite being totally dependent on staff for personal hygiene. The Director of Nursing confirmed the need for nail care. Resident #64, who was cognitively intact but required substantial assistance for toileting and showers, was also observed with long fingernails and dark debris under them. The Director of Nursing verified the need for nail care. Similarly, Resident #214, with moderate cognitive impairment and dependent on staff for all activities of daily living, was observed with dark debris under their fingernails on multiple occasions, which was confirmed by the Director of Nursing. Resident #51, with severe cognitive impairment and always incontinent, did not receive a breakfast meal due to insufficient staff to assist with feeding. Additionally, when Resident #51 requested to use the bathroom, staff instructed the resident to use the incontinence brief instead of assisting with toileting. Interviews with staff confirmed these observations, indicating a lack of adequate care and assistance for the resident's needs.
Failure to Investigate Resident Complaints
Penalty
Summary
The facility failed to thoroughly investigate an allegation involving a staff member taking unauthorized photographs of a resident. Resident #102, who has diagnoses including chronic obstructive pulmonary disease, hypertension, and anxiety disorder, reported that a State Tested Nursing Assistant (STNA) took his picture with her cell phone without consent. Despite the resident's complaint and another resident corroborating the incident, the facility's investigation lacked documentation of interviews with other residents or staff. The Administrator's follow-up was limited to a phone conversation with the accused STNA, who denied the allegations, and the staff was only educated on HIPAA and resident rights. Additionally, the facility did not adequately investigate a missing electric razor reported by Resident #64, who has diagnoses including anxiety, major depressive disorder, and Alzheimer's disease. The grievance form indicated that the issue would be addressed in a staff meeting, but the Director of Plant Maintenance was not informed, and no follow-up investigation was conducted. The resident reported the missing item but received no further communication regarding efforts to locate it. These deficiencies affected two residents who filed formal concerns with the facility. The lack of thorough investigation and follow-up on these grievances highlights a failure in the facility's processes to address and resolve resident complaints effectively.
Failure to Administer Timely Laxative Treatment
Penalty
Summary
The facility failed to provide adequate and timely treatment for a resident experiencing constipation, as evidenced by the lack of administration of prescribed laxative medication. The resident, who had severe cognitive impairment and was dependent on staff for daily living activities, was at risk for constipation according to their care plan. Despite having a physician's order for Milk of Magnesia to be administered as needed for constipation, the resident did not receive the medication in a timely manner. Documentation revealed that the resident did not have a bowel movement for several days, and the laxative was not administered until the resident exhibited symptoms of nausea and vomiting. The Director of Nursing confirmed that the resident went without a bowel movement for an extended period, and the nursing staff were alerted when a resident did not have a bowel movement for three days. However, the laxative was not given until four days after the resident's last small bowel movement, leading to further complications. The delay in administering the prescribed treatment resulted in the need for additional medical interventions, including an abdominal x-ray and medications to address nausea and vomiting.
Failure to Provide Timely Vision Care
Penalty
Summary
The facility failed to provide timely vision care for a resident, identified as Resident #27, who was admitted with multiple diagnoses including schizophrenia, anxiety, major depressive disorder, intellectual disabilities, and dementia. The resident's plan of care, dated April 10, 2024, noted impaired visual function and included interventions such as arranging consultations with an eye care practitioner as needed. On April 26, 2024, the resident received new eyeglasses, but by April 30, 2024, the resident reported continued visual difficulties and expressed concerns about worsening cataracts. A request for further vision services was submitted to the nurse practitioner by the licensed social worker on the same day. Despite the request for additional vision services, the resident did not receive any follow-up care or see an eye doctor after the initial referral was made on April 30, 2024. Interviews conducted in August 2024 with the resident and the licensed social worker confirmed that no further action had been taken to address the resident's ongoing visual issues. This lack of follow-up care resulted in the facility's failure to meet the resident's vision care needs in a timely manner, affecting the resident's ability to communicate and manage sensory impairments effectively.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident, leading to the development of multiple pressure ulcers. The resident, who was admitted with several diagnoses including congestive heart failure and Alzheimer's disease, was identified as being at risk for impaired skin integrity due to impaired mobility and dependence on staff for most activities of daily living. Despite interventions in the care plan, such as regular skin assessments and repositioning, the resident developed eight Stage II pressure ulcers on the buttocks and sacrum, which were not initially identified or treated appropriately. On August 11, a nurse discovered the pressure ulcers and notified the physician, who ordered a treatment plan. However, the wound care team did not assess the resident the following day, and there was a lack of clarity and consistency in the documentation and assessment of the wounds. The Assistant Director of Nursing (ADON)/LPN initially disputed the presence of pressure ulcers, suggesting instead that the resident had moisture-associated skin dermatitis (MASD) on the mid-lower back, but did not assess the wounds until three days after they were first identified. Further observations and interviews revealed discrepancies in the assessment and documentation of the resident's skin condition. The ADON/LPN was unaware of the pressure ulcer on the sacrum until it was pointed out during an observation. The wound nurse practitioner confirmed the presence of a Stage III pressure ulcer on the sacrum only after assessing the resident on August 15, indicating a delay in appropriate wound care management and assessment by the facility's staff.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident, who required setup assistance with meals, received their breakfast meal and was assisted with setup in a timely manner. This deficiency affected one resident in the secured memory care unit (SMCU), which had a census of 34 residents. The resident in question was admitted with diagnoses including senile degeneration of the brain, anxiety disorder, and unspecified dementia with mood disturbance, and exhibited severe cognitive impairment according to their Minimum Data Set (MDS) 3.0 assessment. The resident's care plan specified a regular diet with dysphagia mechanical texture and thin liquids consistency, along with fortified pudding and cereal. On the day of the observation, the resident was not provided a breakfast meal while in their room because there were only two State Tested Nursing Assistants (STNAs) available, which was insufficient to observe or feed residents in their rooms. The resident was later moved to the hallway in a Broda chair without having received breakfast. An additional STNA arrived later in the morning, and alternative breakfast foods were offered to residents who were assisted out of bed. The Licensed Practical Nurse (LPN) Unit Manager was unaware that the resident had not been provided a breakfast meal. The facility's Routine Resident Care policy requires daily care by a certified nursing assistant under the supervision of a licensed nurse, including assistance with eating and hydration.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement risk, resulting in the resident exiting the secured unit without staff knowledge. The resident, who had a history of elopement attempts and was diagnosed with dementia with psychosis, expressed a desire to leave the facility multiple times. Despite these verbalizations, the facility did not implement new safety interventions or update existing ones to address the resident's exit-seeking behavior. The resident was admitted to the facility with several medical conditions, including a right clavicle fracture, vascular dementia with psychotic disturbance, and diabetes mellitus. The resident was placed on a secured unit for safety due to the risk of elopement. However, the facility's staff failed to monitor the resident adequately, as evidenced by the resident's ability to remove a window security device and use tied sheets to exit the building. The resident was later found by emergency services and transported to a hospital for treatment of injuries sustained during the elopement. Interviews with facility staff revealed that the resident frequently expressed a desire to leave the facility, yet the staff did not follow the facility's elopement prevention policy. The policy required individualized interventions and regular monitoring, which were not adequately implemented for this resident. The lack of appropriate monitoring and intervention allowed the resident to elope, resulting in injury and hospitalization.
Failure to Accommodate Resident's Preference for Bed Rails
Penalty
Summary
The facility failed to accommodate the preferences of a resident regarding the installation of side rails on their bed. The resident, who had a medical history of diabetes mellitus, end-stage renal disease, and congestive heart failure, was admitted and later discharged without having their request for side rails fulfilled. The resident's representative had signed a form requesting both right and left half side rails, but this request was not reflected in the facility's Bed Safety Evaluation completed by an LPN. The facility did not have half side rails available, and the request was not transferred to the assessment. Interviews with facility staff revealed that the resident's preference for side rails was acknowledged but not acted upon in a timely manner. The Assistant Director of Nursing confirmed that the resident should have had side rails per their preference upon admission, but the referral to therapy and maintenance to apply the side rails was delayed until over a month later. The facility's policy allowed for the use of bed rails if desired by the resident and with informed consent, but this policy was not followed in this case, leading to the deficiency.
Failure to Timely Address Pain Management
Penalty
Summary
The facility failed to timely follow the direction of a telehealth nurse practitioner for a change in pain medication for a resident, identified as Resident #113. The resident, who had a history of diabetes mellitus, end-stage renal disease, and congestive heart failure, was experiencing pain related to impaired mobility and other medical issues. Despite a new order for Oxycodone being received on 04/25/24, the resident continued to receive Norco, which was noted to be ineffective at times. The telehealth nurse practitioner had advised the facility nurse to contact the medical director for a new narcotic order, but this was not done promptly. The delay in addressing the resident's pain management needs was compounded by miscommunication among the nursing staff. RN #210 was instructed by LPN #209 not to contact the medical director after hours, contrary to the telehealth nurse practitioner's advice. This resulted in the resident's daughter being upset and the issue being deferred to the next shift. The facility's policy on pain management and assessment was not adhered to, as the resident did not receive timely and appropriate pain management in accordance with professional standards and the care plan.
Failure to Document Timely Blood Sugar Checks
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for medication administration, specifically affecting a resident with diagnoses including diabetes mellitus, end stage renal disease, and congestive heart failure. The resident was admitted and later discharged, with physician's orders requiring blood sugar checks before meals and administration of Insulin Lispro according to a sliding scale. However, the medication administration record (MAR) did not document the completion of the 7:00 A.M. blood sugar check as ordered. A nursing progress note indicated that the blood sugar was checked later than the physician's order. The Director of Nursing confirmed that the nursing staff did not document the blood sugar check per the physician's orders. The facility's policy stated that medications ordered for a specific time should be administered at that time.
Facility Failed to Maintain a Clean and Sanitary Kitchen
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen, which had the potential to affect 104 residents receiving meals. During an initial kitchen tour, several issues were observed, including expired and undated food items in the walk-in refrigerator and reach-in refrigerator. Specifically, there were containers of Sysco nectar thick lemon water, Sysco honey thick lemon water, ricotta cheese, barbecue pork, fruit cocktail, green beans, and tuna fish sandwich spread that were either expired, undated, or improperly stored. Additionally, the Robot Coupe in the kitchen preparation area was heavily soiled with dried food splatter, and there was no posted cleaning schedule for the kitchen. Temperature logs for the walk-in refrigerator, walk-in freezer, and reach-in refrigerator were incomplete, with missing temperatures for several dates. Similarly, the dishwasher machine log had no recorded temperatures for multiple dates. These findings were confirmed by Cook #19 and Corporate District Manager #109. The facility's policies on equipment cleanliness, food storage, and labeling and dating were reviewed and found to be inconsistent with the observed practices. The deficiency was investigated under Master Complaint Number OH00152582.
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What surveyors actually found near you
We read the 702 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Massillon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Wind Health Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Laurels Of Massillon, The | 2.1 mi | ★★★★★ | 1 | 0 |
| Astoria Skilled Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 2 | 1 |
| Amherst Meadows Skilled Nursing And Rehab | 3.1 mi | ★★★★★ | 2 | 0 |
| Legends Care Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 12 | 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.