Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heatherdowns Rehab & Residential Care Center during CMS and state inspections, most recent first.
Failure to notify family of ER transfer after change in condition. A resident with a PICC line, multiple chronic diagnoses, and intact cognition reported chest tightness after noticing air in the IV line while antibiotics were infusing. The ER workup was negative and the resident returned with a new PICC line, but the chart lacked documentation of the change in condition and family notification, and the DON verified the family was not informed.
PICC line dressing changes and site checks were not completed as ordered for a resident with a PICC and multiple chronic conditions. MAR/TAR review showed no documented dressing changes or shift-by-shift site monitoring, and observation found gauze under a TSM dressing blocking the insertion site. The resident later went to the ER after reporting chest tightness and air in the IV line while antibiotics were infusing, and the DON confirmed the dressing timing did not match policy or the post-insertion requirements.
The facility failed to maintain an adequate hot water supply on two halls, affecting multiple residents who experienced a lack of hot water for several days. After hot water was initially lost due to a faucet left running in a mechanical room, a maintenance assistant restored acceptable temperatures but did not continue monitoring. CNAs and an LPN later reported that there was still no hot water, and a resident’s family member reported that a shower could not be completed and that hot water had been out for several days. A central supply staff member stated she was not informed of the issue until contacted by the DON, and maintenance logs showed no work orders submitted for hot water concerns during this period. Plumbing records later confirmed one hot water tank was inoperable and another required a new gas valve, contributing to the ongoing lack of hot water.
A resident with intact cognition and multiple medical conditions, including lumbar spinal stenosis and acute cystitis, had documented care plan needs for assistance with ADLs and a stated preference that hygiene choices were very important. On one occasion, staff did not provide requested washing, citing lack of hot water in the resident’s room, even though hot water was available elsewhere in the facility. The resident’s family observed the lack of hot water, later received a call from the resident reporting that staff refused to wash her, and reported that staff dressed the resident without completing hygiene, causing the resident distress. This was inconsistent with facility policy requiring adequate nursing care and honoring reasonable resident requests.
A resident with lumbar spinal stenosis and recent hospitalization for back and leg pain was admitted with PRN oxycodone ordered and a care plan calling for analgesics and non-pharmacologic pain interventions. Over several days, pain assessments documented increasing pain levels, but oxycodone was never administered, the prescription was not initially faxed to the pharmacy, and staff did not obtain available oxycodone from the contingency box after being instructed to do so. The resident’s daughter repeatedly reported the resident’s pain to the DON, and when the resident requested an ice pack, staff stated none were available despite multiple ice packs being present on the units. As a result, the resident did not receive ordered pharmacologic or available non-pharmacologic pain interventions during this period.
A deficiency was cited when a CNA did not follow approved catheter care procedures for a resident with a urinary catheter, using soap and water instead of an alcohol pad to clean the drainage bag spout after emptying. This action was not in accordance with facility policy and state CNA procedure regulations, which require the use of an alcohol wipe to maintain infection control standards.
A resident who was dependent on staff for all transfers and required a mechanical lift, oxygen, and specialized equipment was discharged home without these essential supports. The resident was left in a standard wheelchair for several hours without care, resulting in a pressure ulcer and subsequent hospital admission. Facility staff did not coordinate with home health or community resources prior to discharge, and the discharge was arranged by a staff member who was no longer present at the facility.
The facility failed to follow proper hand hygiene, food handling, and sanitation practices. A CNA did not sanitize hands between assisting residents, and an employee prepared food without washing hands or changing gloves between tasks. Additionally, food items in residents' refrigerators were not labeled or dated, and the dish machine's chlorine concentration was not monitored, compromising sanitation.
The facility failed to label multiuse insulin pens and vials with the date opened, affecting four residents with diabetes. Observations revealed undated insulin pens and vials on medication carts, verified by LPNs. The facility's policy requires medications to be stored to maintain integrity, but this was not followed.
The facility failed to provide adequate meal portions and did not follow the prescribed menu, affecting all residents except one. Observations revealed incorrect scoop sizes were used for serving, and wheat bread was not provided as indicated. Staff interviews confirmed these discrepancies, and the Dietary Manager was unable to determine the correct portion size for a #6 scoop.
The facility failed to ensure proper infection control during food preparation and wound care. A staff member prepared food with an open wound without wearing gloves, and an LPN did not change gloves between handling soiled and clean dressings for a resident with Alzheimer's and a fractured acetabulum. These actions violated the facility's hygiene and wound care policies.
The facility failed to maintain resident dignity for two residents. A resident with mild cognitive impairment had a full urinal placed on the overbed table next to his breakfast tray, causing discomfort. Another resident, who is cognitively impaired and dependent on staff for dressing, was observed with her breast exposed during feeding assistance, without the privacy curtain drawn. These actions were contrary to the facility's dignity policy.
A resident reported $2.00 stolen from her room to a CNA, but no resolution was offered, and the incident was not reported to administration. The DON was unaware of the theft until informed by surveyors, revealing a failure to follow the facility's policy on reporting and investigating misappropriation. Both the CNA and an LPN knew of the allegation but did not report it, violating the policy requiring staff to report such incidents within 24 hours.
A resident with paraplegia, who was always incontinent and required staff assistance for hygiene, was left with wet bedding after staff changed only the brief and chux pad. An LPN verified the wet pad and bottom sheet with a yellow stain, indicating a failure to provide adequate hygiene assistance as per the facility's ADL policy.
A resident with multiple health conditions, including acute kidney failure and osteoarthritis, experienced pain due to long, thick, and yellowed toenails with fungus. The resident, who was cognitively intact, reported being unable to trim her toenails and stated that staff were aware of the issue. The DON confirmed the need for podiatry care, which was not promptly provided as per facility policy.
The facility failed to maintain a medication error rate below five percent, with two errors observed in 26 opportunities, resulting in a seven percent error rate. A resident with hypertension received an incorrect dose of Lasix, and another resident with osteoarthritis received an incorrect dose of Tylenol. Both errors were confirmed by the respective LPNs involved.
A resident with paraplegia and multiple medical conditions experienced a fall due to improper repositioning by a CNA, who failed to follow the care plan requiring two caregivers. The resident, who was at risk for falls, was able to lower himself to the floor using a mobility bar, avoiding injury. The facility's fall prevention protocols were not consistently implemented, leading to non-compliance.
A facility failed to adequately prepare and coordinate services for a resident's discharge to home. The resident, with complex medical needs, was discharged without necessary wound care instructions or supplies, and the home health agency was not notified. This led to a delay in the resident receiving required care, as the home health agency was not contacted until several days post-discharge, and a physician evaluation was delayed.
The facility failed to provide ordered pressure ulcer treatments for three residents, leading to deficiencies in care. One resident with severe cognitive impairment did not receive prescribed treatments for heel ulcers, while another with paraplegia and stage 4 ulcers experienced missed treatments over several months. A third resident, at risk for pressure injuries, developed a pressure wound due to inconsistent application of preventive measures. The facility's policies on physician orders and wound care were not followed.
The facility failed to ensure medications were administered per physician orders and to maintain an accurate system of dispensing and administering controlled substances, affecting three residents. Discrepancies were found between the CSAR and MAR for various medications, indicating a lack of proper documentation and administration practices.
The facility failed to evaluate, provide care, and conduct ongoing assessments for a resident's skin alteration. Despite having a care plan for an open blister on the right leg, a scabbed area on the left leg was not documented or treated, as confirmed by the DON.
Failure to Notify Family of ER Transfer After Change in Condition
Penalty
Summary
The facility failed to ensure the resident’s family was notified when the resident was transferred to the hospital emergency room with a change in condition. The resident was admitted with multiple diagnoses including absence of the left great toe, anemia, epilepsy, hypertension, low back pain, major depressive disorder, acute osteomyelitis of the left ankle and foot, psychoactive substance abuse, peripheral vascular disease, and type II diabetes mellitus. The most current MDS assessment indicated intact cognition, independent ambulation with a walker or wheelchair, partial to moderate assistance with ADLs, PRN pain medication use, and IV medications via access. The resident had a PICC line on admission, with physician orders to change the IV dressing every seven days and as needed, document the IV site every shift, and report changes to the physician. The record lacked documentation that the PICC dressing was changed or that the insertion site was monitored each shift until several days later. On the night of the emergency room transfer, the resident reported chest tightness after noticing air in the IV line while antibiotics were running. The ER workup was negative and the resident was to be transferred back to the facility with a new PICC line. The hospital record did not document family notification, the facility record did not document the change in condition or ER transfer, and the DON verified the family was not notified. The resident also stated that no family was informed and that he would have preferred they had been notified.
PICC Line Dressing and Site Monitoring Not Performed as Ordered
Penalty
Summary
The facility failed to ensure central venous catheter monitoring and treatments were provided in accordance with physician orders for a resident admitted with a PICC line. The resident had multiple diagnoses including anemia, epilepsy, hypertension, major depressive disorder, acute osteomyelitis of the left ankle and foot, peripheral vascular disease, and type II diabetes mellitus. The most current MDS described the resident as cognitively intact, independently ambulatory with a walker or wheelchair, requiring partial to moderate assistance with ADLs, and receiving medications via IV access. Physician orders dated 04/23/26 directed staff to change the IV dressing every seven days on Sundays and as needed for soiling, and to document the IV site appearance every shift using specified descriptors and report changes to the physician. Review of the MAR and TAR showed no documentation that the PICC dressing was changed, scheduled or as needed, throughout the resident’s stay until 05/03/26, and no documentation that the insertion site was monitored each shift. The care plan was revised on 04/27/26 to address the resident’s IV access and included interventions for monitoring for infiltration, bleeding, redness, swelling, drainage, heat, tenderness, and providing IV therapy as ordered. The resident was sent to the emergency room on 04/28/26 after reporting chest tightness and stating he noticed air in the IV line while antibiotics were running. Hospital documentation noted a negative cardiopulmonary workup and transfer back to the skilled nursing facility, but did not document family notification. On 05/06/26, observation showed the PICC dressing covered with a folded gauze under a transparent dressing, obstructing visualization of the insertion site and surrounding tissue. The LPN and DON verified the site could not be observed, and the DON confirmed the facility policy required gauze dressings to be changed every two days and within 24 hours after insertion, while the resident’s PICC had been replaced on 04/28/26 with no documentation of a dressing change until 05/03/26.
Failure to Maintain Consistent Hot Water Supply on Two Halls
Penalty
Summary
The deficiency involves the facility’s failure to maintain hot water temperatures at acceptable levels for residents on the Middle North and North Back halls. On one occasion, hot water was left running in Mechanical Room Five, which resulted in no hot water being available on those halls. A maintenance assistant responded, turned off the faucet, and confirmed that the hot water tank temperature returned to an acceptable range, with spot checks in two resident rooms and the nourishment room also within acceptable limits. However, there was no subsequent monitoring of water temperatures over the following days to ensure that hot water was consistently maintained. In the days that followed, staff and family reports indicated that there was no hot water on the affected halls for multiple days. The DON became aware of the initial hot water outage after CNAs reported the issue, and a group message was sent to management. Later, a resident’s family member reported that the resident’s shower could not be completed because there was no hot water and stated that staff had told them the hot water had been out for three days, including over a weekend. Nursing staff, including an LPN and a CNA who worked during this period, confirmed that there was no hot water on the Middle North and North Back halls on at least one of those days. Despite these conditions, review of the maintenance work order log for the period in question showed no evidence that staff had submitted any work orders regarding hot water concerns. A central supply staff member, who was present on some of the days when hot water was reportedly unavailable, stated that staff did not inform her of the problem until later, when the DON contacted her after receiving the family complaint. When she then investigated, she was told there had been no hot water for three days. Subsequent review of plumbing vendor documents confirmed that one hot water tank serving the affected halls was inoperable and another required a new gas valve, contributing to the lack of hot water for the identified residents on those halls.
Failure to Honor Resident’s Personal Hygiene Preferences
Penalty
Summary
The facility failed to honor a resident’s stated preferences for daily personal care and hygiene. The resident was admitted with diagnoses including lumbar spinal stenosis with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression. An admission MDS dated 01/08/26 documented intact cognition with a BIMS score of 15 and indicated that hygiene choices were very important to the resident. The resident required supervision or touching assistance with ADLs, including bathing, and the care plan dated 01/04/26 identified ADL self-care needs related to deconditioning and weakness, with interventions to assist with personal hygiene. On 01/04/26, the resident requested to be washed, but staff did not provide the requested hygiene care, citing a lack of hot water in the resident’s room, despite hot water being available elsewhere in the facility. According to the DON, the resident’s family called on 01/05/26 with concerns that the resident had not been washed as requested the previous day due to the hot water issue. The family reported that during their visit they noted there was no hot water, and later the resident called them stating staff would not wash her for that reason. The family further stated that staff dressed the resident without completing any hygiene, which upset the resident. Facility policy on Resident Rights and Facility Responsibilities stated that residents had the right to adequate and appropriate nursing care and to have all reasonable requests honored.
Failure to Provide Timely Pharmacologic and Non-Pharmacologic Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pain management interventions for a resident admitted with significant back and leg pain and diagnoses including lumbar spinal stenosis with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression. The resident was discharged from the hospital to the facility with an order for oxycodone 5 mg by mouth every eight hours as needed for pain for up to three days, and physician orders at the facility directed staff to assess pain and discomfort every shift and administer oxycodone 5 mg PO every eight hours as needed. The resident’s care plan identified risk for pain due to lumbago with sciatica and neuropathy, with interventions to administer analgesics as ordered, offer non-pharmacological pain interventions, and notify the physician if interventions were unsuccessful or if the pain complaint represented a significant change. Pain assessments documented pain levels ranging from two to six over several days, yet the Medication Administration Record showed that oxycodone was not administered from the date of admission through several subsequent days. The DON confirmed that the oxycodone prescription was not faxed to the pharmacy upon admission, so the medication was not received in the regular delivery, and that this omission was not identified until several days later. During this period, the resident’s daughter frequently reported to the DON, in person and by phone, that the resident was in pain. The DON stated that once the missing prescription was discovered, nursing staff were instructed to obtain the medication from the contingency box, where oxycodone was available, but an LPN did not contact the pharmacy for authorization to remove the narcotic from the contingency supply, and the medication was not accessed. The DON also reported that when the resident requested an ice pack to help ease pain, nursing staff told the resident there were no ice packs available, despite multiple ice packs being present at each nurses’ station. The DON verified that from admission through several days afterward, the resident did not receive ordered pain medication or non-pharmacological interventions such as cold compresses, contrary to the facility’s pain management policy, which required provision of pain management services and allowed for non-pharmacological measures including cold compresses.
Failure to Follow Approved Catheter Care Procedures
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow approved procedures for urinary catheter care for a resident with a history of urinary tract infection, urine retention, and hydronephrosis. The resident had a physician's order for a 16 French urinary catheter with a 10 ml balloon and required catheter care every shift and as needed. During an observation, the CNA donned personal protective equipment, placed a barrier under the graduated cylinder, emptied the urinary drainage bag, and wiped the tip of the spout with a wet wash cloth before returning it to the holder. Upon interview, the CNA confirmed that the correct procedure was to clean the urinary bag spout with an alcohol pad, as outlined in both facility policy and state CNA procedure regulations, but admitted to using soap and water instead. The facility's policy and resource documents specified the use of an alcohol wipe for cleaning the spout after emptying the bag. This failure to adhere to established infection control procedures constituted the deficiency.
Failure to Ensure Safe Discharge with Required Equipment and Services
Penalty
Summary
A deficiency occurred when a resident, who was dependent on others for care and required a mechanical lift for transfers, was discharged home without the necessary equipment and services to meet her care needs. The resident had multiple diagnoses, including COPD with acute exacerbation, muscle weakness, schizophrenia, acute respiratory failure with hypoxia, chronic atrial fibrillation, hypertension, diabetes, and Parkinson's disease. The resident was cognitively intact but required total assistance for activities of daily living, including toileting, dressing, and transfers, and had an order for oxygen therapy. Prior to discharge, the care plan indicated the resident was at risk for self-performance deficits and was dependent for transfers, with no evidence of skin breakdown or pressure ulcers. On the day of discharge, the resident was sent home without oxygen, a working hospital bed, or a Hoyer lift, all of which were necessary for her care. The resident's husband was also ill and unable to provide assistance. The resident was left in a standard wheelchair for approximately six hours without any care, including incontinence care, resulting in the development of a pressure ulcer. EMS was called after the resident was found unable to care for herself, and she was transported to the hospital, where an open wound and saturated brief were noted. Hospital records confirmed the presence of a pressure ulcer and concerns about the lack of home care services and equipment. Interviews with facility staff and external care coordinators revealed that the facility did not coordinate with the resident's waiver service coordinator or home health services prior to discharge. The discharge was arranged by a social services designee who was no longer employed at the facility at the time of discharge, and the resident was discharged with only a standard wheelchair, as transportation could not accommodate her specialized chair. The facility's discharge policy required that discharge planning be based on the resident's needs and that all necessary resources be arranged, but this was not followed in this case, resulting in actual harm to the resident.
Deficiencies in Hand Hygiene, Food Handling, and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during meal service, as observed with a Certified Nursing Assistant (CNA) who did not perform hand hygiene between assisting two residents. The CNA assisted one resident back to their wheelchair and then immediately began feeding another resident without sanitizing her hands, despite acknowledging the presence of a hand sanitizer dispenser in the dining room. This oversight was confirmed during an interview with the CNA, who admitted to not following the facility's hand hygiene policy. Additionally, the facility did not maintain proper food handling and sanitation practices in the kitchen. An employee was observed preparing sandwiches without washing hands before donning gloves and touched multiple unsanitary surfaces with the same gloves used to handle food. The employee also failed to properly clean or sanitize utensils between uses, potentially contaminating food items. This was confirmed during an interview with the employee, who was unaware of any residents with peanut allergies, further highlighting the lack of adherence to food safety protocols. The facility also neglected to label and date food items stored in residents' refrigerators, as observed in both the North and South Hall refrigerators. Items such as leftover containers, hard-boiled eggs, and various meats and juices were found undated and unlabeled. Interviews with staff confirmed the oversight and acknowledged that the facility policy required labeling and dating of food items. Furthermore, the facility failed to monitor the chlorine concentration in the dish machine, which was found to be below the required level for proper sanitization. The Dietary Manager confirmed the lack of training for staff on using test strips to monitor chlorine levels, and the dish machine logs only recorded water temperatures, not chlorine concentrations, as required by facility policy.
Failure to Date Insulin Pens and Vials
Penalty
Summary
The facility failed to label multiuse insulin pens and vials with the date opened, which is necessary to ensure medication integrity. This deficiency was identified during an observation of the medication carts on two different units. Specifically, an opened and undated Lantus insulin pen for one resident, an opened and undated Humalog insulin pen for another resident, and an opened and undated Lantus multiuse vial for a third resident were found on the back north unit. Additionally, an opened and undated Humalog insulin pen for a fourth resident was found on the back south unit. These findings were verified by interviews with the respective LPNs present during the observations. The residents involved in this deficiency had diagnoses of diabetes mellitus and were receiving insulin as part of their treatment. The medical records revealed that two of the residents were cognitively impaired, while the other two were cognitively intact. The facility's policy on medication storage, which was undated, stated that medications should be stored in a manner that maintains the integrity of the product and ensures the safety of the residents, in accordance with Ohio Department of Health guidelines. However, the failure to date the insulin pens and vials upon opening indicates a lapse in adherence to this policy.
Inadequate Meal Portions and Menu Non-Compliance
Penalty
Summary
The facility failed to ensure that meal portions served to residents met the nutritional guidelines as outlined in their menu and USDA standards. During an observation of the lunch meal service, it was noted that residents on a regular diet received a four-ounce scoop of pork vegetable stir fry instead of the prescribed #6 scoop, which is approximately five and one-third ounces. Similarly, residents on mechanical soft and pureed diets received inadequate portions of pork chops, with mechanical soft diets receiving a total of four ounces and pureed diets receiving only two ounces, contrary to the menu's specifications. Additionally, the facility did not provide wheat bread as part of the meal, as indicated in the menu. Interviews with the dietary staff confirmed these discrepancies. The staff member responsible for plating the meals acknowledged using incorrect scoop sizes and was unable to measure the portion of broccoli served due to the use of slotted spoons without measurement lines. The Dietary Manager confirmed the failure to follow the menu and was unable to determine the correct portion size for a #6 scoop. This deficiency had the potential to affect all residents in the facility, except for one resident who did not receive nutrition from the kitchen.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control during food preparation and meal service. During an observation, a staff member was seen preparing food without wearing disposable gloves, despite having an actively bleeding hand. Blood was observed on the serving utensil used to portion broccoli. The staff member washed her hands and applied a bandage but continued to handle food without gloves, even after the bandage was applied. This was in violation of the facility's personal hygiene policy, which requires employees with open sores to wear appropriate personal protective equipment. Additionally, the facility did not adhere to proper hand hygiene protocols during wound care for a resident with Alzheimer's disease and a fractured acetabulum. An LPN was observed removing a soiled dressing from the resident's heel without changing gloves before cleansing the wound and applying a new dressing. This was contrary to the facility's wound care policy, which mandates hand hygiene and glove changes between handling soiled dressings and applying new ones. The failure to follow these procedures was confirmed by the LPN during an interview.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity for two residents, as observed during a survey. Resident #42, who has mild cognitive impairment and is continent of bladder, was found in bed with a full urinal of dark-colored urine placed on the overbed table where his breakfast tray was also delivered. This situation was confirmed by a CNA, and the resident expressed discomfort with the urinal being on the table where he ate. Resident #43, who is cognitively impaired and dependent on staff for dressing, was observed with her left breast exposed while being assisted with feeding by a CNA. The resident was in a semi-private room, and the privacy curtain was not drawn, making her exposed breast visible to her roommate. The CNA confirmed the exposure and did not take action to cover the resident. The facility's policy on dignity, which emphasizes treating residents with respect and maintaining their quality of life, was not adhered to in these instances.
Failure to Report and Investigate Misappropriation Allegation
Penalty
Summary
The facility failed to implement its policies and procedures related to reporting and investigating allegations of misappropriation, affecting one resident. Resident #16, who was cognitively intact, reported to a CNA that $2.00 was stolen from her room within the past six months. Despite this report, no resolution was offered, and the money was not returned. The Director of Nursing (DON) was unaware of the incident until informed by the survey team, indicating a lapse in communication and procedure adherence by the staff. Further investigation revealed that both the CNA and an LPN were aware of the allegation but did not report it to the administration for investigation. The facility's policy, dated 07/01/20, mandates that staff report alleged violations of misappropriation to the administrator within 24 hours, with final investigation results reported within five business days. This policy was not followed, as evidenced by the lack of awareness and action by the administration until the survey team intervened.
Inadequate Hygiene Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hygiene assistance for a dependent resident, identified as Resident #31, who was affected by this deficiency. Resident #31, who was admitted with a diagnosis of paraplegia, was cognitively intact and always incontinent of bowel and bladder, requiring staff assistance for toileting and personal hygiene. The care plan for Resident #31 included staff assistance with cleaning following toilet use. However, during an interview and concurrent observation, Resident #31 reported being incontinent of urine and soaked through his bedding. Although staff changed his brief and chux pad, they left the bedding wet underneath him. This was verified by an LPN, who observed the wet pad and bottom sheet with a yellow stain. The facility's policy on Activities of Daily Living (ADLs) required appropriate care and services for residents unable to carry out ADLs independently, including support and assistance with elimination and incontinence care.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to ensure that a resident's podiatry needs were met, affecting one resident reviewed for podiatry services. The resident, who was admitted with diagnoses including acute kidney failure, essential hypertension, bipolar disorder, anxiety disorder, bilateral primary osteoarthritis of the hip, and muscle weakness, was found to have long, thick, and yellowed toenails with fungus, causing her pain. The resident, who was cognitively intact, reported being unable to trim her toenails herself and stated that the staff were aware of the condition. An interview with the Director of Nursing confirmed the resident's toenails were long and required trimming by a podiatrist. The facility's policy on Ancillary Services, revised in August 2024, states that the facility will assist residents in obtaining prompt podiatry care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by two medication errors observed during 26 medication administration opportunities, resulting in a seven percent error rate. This deficiency affected two residents. Resident #1, who was cognitively intact and diagnosed with hypertension, was prescribed 40 mg of Lasix daily. However, on the observed date, LPN #668 administered only 20 mg of Lasix, which was confirmed during an interview with the LPN. Similarly, Resident #51, who was also cognitively intact and suffered from osteoarthritis with frequent pain, was prescribed two tablets of Tylenol 650 mg twice daily. During the medication administration observation, LPN #634 administered two tablets of Tylenol 500 mg instead. This error was also confirmed in an interview with the LPN. The facility's policy on medication dispensing requires verification of the right drug, dose, route, time, and customer prior to administration, which was not adhered to in these instances.
Failure to Safely Reposition Resident Leads to Fall
Penalty
Summary
The facility failed to ensure that a resident was repositioned in bed safely, leading to a fall incident. The resident, who was paraplegic and had multiple medical conditions including stage four pressure ulcers and osteoarthritis, required extensive assistance with bed mobility and was totally dependent on staff for transfers and toilet use. Despite being cognitively intact, the resident was at risk for falls due to incontinence and the need for assistive devices. The care plan indicated that the resident should be repositioned with the assistance of two caregivers, but this was not consistently followed. On the day of the incident, the resident was being assisted by a CNA when he lost his balance and was lowered to the floor using the bed's mobility bar. The CNA was turning the resident to his right side when his weak leg gave out, causing him to slide off the bed. The resident was able to hold onto the bar and lower himself to the floor, avoiding injury. The incident was witnessed, and the resident was assessed with no injuries noted. However, it was documented that the resident had been repositioned 63 times in the last month by only one staff member, contrary to the care plan's requirement for two caregivers. Interviews with the resident and staff revealed that the CNA responsible for the incident was no longer working at the facility. The Director of Nursing confirmed that the resident had been repositioned improperly, leading to the fall. The facility's policy on managing falls and fall risk was not adhered to, as the interventions to prevent falls were not consistently implemented. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's fall prevention protocols.
Inadequate Discharge Planning and Coordination
Penalty
Summary
The facility failed to ensure adequate preparation and coordination of services prior to the discharge of a resident to their home. The resident, who was cognitively intact, required substantial assistance with activities of daily living and had multiple complex medical conditions, including diabetic foot ulcers and a right below-knee amputation. The discharge plan was initiated with an undetermined plan to return home or remain in long-term care. However, upon discharge, the facility did not provide necessary wound care instructions or supplies, nor did they notify the home health agency of the resident's discharge. The physician's discharge orders included specific wound care treatments, such as negative pressure wound therapy and dressing changes, but these were not communicated to the home health agency. Consequently, the resident was not contacted for an initial visit by the home health agency until several days after discharge, and the required physician evaluation by the community primary care physician was delayed. The Director of Nursing confirmed that no education or supplies were provided to the resident or their representative for wound dressing changes at the time of discharge, and there was no evidence of notification to the home health agency.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for three residents, leading to deficiencies in care. Resident #60, who had severe cognitive impairment and was dependent for all activities of daily living, had unstageable pressure ulcers on both heels. Despite physician orders for daily treatment, the treatment records showed multiple instances where the prescribed care was not administered. The Director of Nursing confirmed that if treatments were not documented, they were not completed, indicating a lapse in following the treatment plan. Resident #64, diagnosed with paraplegia and stage 4 pressure ulcers, also did not receive the required wound care as per physician orders. The treatment records revealed numerous missed treatments over several months. An interview with the resident highlighted concerns about the inconsistency between the care provided and the physician's orders. Observations confirmed that the treatments did not align with the prescribed care, as different materials were used than those ordered by the physician. Resident #8, who was at risk for pressure injuries, developed an unstageable pressure wound due to the facility's failure to implement preventive measures. Despite orders for preventive skin preparation and heel boots, these interventions were not consistently applied. The Director of Nursing verified that the lack of documentation indicated non-completion of these preventive measures, resulting in the development of a facility-acquired pressure wound. The facility's policies on physician orders and wound care were not adhered to, contributing to these deficiencies.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered per physician orders and to maintain an accurate system of dispensing and administering controlled substances. This deficiency affected three residents. For Resident #77, there were discrepancies between the controlled substance administration record (CSAR) and the medication administration record (MAR) for lorazepam, morphine sulfate, and hydrocodone/acetaminophen. Medications were removed but not documented as administered on the MAR, and vice versa, indicating a lack of proper documentation and administration practices. For Resident #26, similar issues were observed. The CSAR and MAR did not match for tramadol, morphine sulfate, and lorazepam. Doses were removed from the CSAR but not documented on the MAR, and some doses were documented on the MAR but not on the CSAR. This inconsistency highlights a failure in the facility's medication administration process. Resident #18 also experienced discrepancies in medication administration. The CSAR showed doses of morphine sulfate and lorazepam being removed, but these were not consistently documented on the MAR. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that multiple nurses failed to document narcotic medications properly. The facility's policy on medication administration was not followed, leading to these deficiencies.
Failure to Document and Treat Skin Alteration
Penalty
Summary
The facility failed to evaluate, provide care and treatment, and conduct ongoing assessments for a resident's skin alteration. Resident #4, who had diagnoses including congestive heart failure, chronic kidney disease, type II diabetes mellitus, and dementia, was admitted with no initial skin breakdown but was at risk for skin issues. The care plan included interventions for an open blister from cellulitis on the right lower extremity, requiring regular monitoring and treatment. However, the facility did not document or treat a scabbed area on the resident's left lower leg, which was observed during a survey but not recorded in the medical records or weekly assessments. Observations and interviews revealed that the resident had a scabbed area on the left lower leg that had not been addressed or documented by the staff. The Director of Nursing confirmed the oversight and acknowledged that the scab should have been included in the resident's medical record for proper monitoring and treatment. The facility's policy on skin care mandates weekly skin evaluations to identify and assess new or existing skin alterations, which was not followed in this case, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 576 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Toledo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ohio Living Swan Creek | 1.3 mi | ★★★★★ | 17 | 0 |
| Foundation Park Care Center | 1.8 mi | ★★★★★ | 29 | 0 |
| Concord Care Center Of Toledo | 1.9 mi | ★★★★★ | 6 | 0 |
| Lutheran Village At Wolfcreek | 2.2 mi | ★★★★★ | 17 | 0 |
| Continuing Healthcare Of Toledo | 2.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.