Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Health Care Center during CMS and state inspections, most recent first.
A resident at risk for skin breakdown developed seven new pressure injuries after limited skin monitoring, unclear repositioning documentation, and no evidence that ordered pressure-relieving devices or added interventions were in place. The resident later required hospitalization with sepsis, metabolic encephalopathy, and pressure injuries present on admission. In a separate case, an LPN confirmed ordered wound care was missed for another resident’s multiple terminal ulcers, and family reported dressings were not in place.
RN staffing coverage was not maintained for at least 8 consecutive hours per day, and the facility had a one-star PBJ rating for the quarter reviewed. The Facility Assessment listed RN, LPN, CNA, and IP coverage, but the PBJ Staffing Data Report showed no RN hours, and an undated facility list showed multiple days with no RN coverage. Regional HR staff confirmed the findings and stated the facility had hired five RNs since 03/2026.
Infection control procedures were not followed for blood glucose testing, respiratory equipment storage, and laundry handling. An RN used a glucometer for a resident with DM and then discarded the test strip in the trash and placed the meter away without cleaning it. Another resident with COPD had a nebulizer, oxygen tubing, and mask on the floor in the room, and soiled laundry with feces was observed dumped on the laundry room floor for sorting instead of being properly bagged and separated.
The facility failed to keep resident areas clean, sanitary, and in good repair. Surveyors observed dirty and sticky hallways, urine odors near several rooms, a dirty wheelchair with dried food and a spill, missing floor tile, patched and unpainted wall areas, mismatched and chipped floor tiles, duct tape on a windowsill, a loose heating unit cover, an empty barrier cream tube on the floor, and a dried brown substance on a wall. CNAs, the housekeeper, and the DOM verified several of the findings.
A facility failed to keep call lights within reach for two residents who were dependent on staff and had impaired cognition. One resident with hemiplegia, stroke history, and dementia was observed trying to get out of bed while the call light hung out of reach, and another resident with hemiparesis, chronic respiratory failure, diabetes, heart failure, and dementia was observed twice with the call light behind the bed or on the floor. Staff verified both call lights were out of reach, despite care plans directing that they be kept within reach.
Failure to honor a resident’s preference for arising. A resident with hemiplegia, stroke history, muscle weakness, vascular dementia, and dependence for transfers was observed trying to get out of bed with the call light out of reach and a mat on the floor nearby. He stated he wanted to get up for breakfast, but the CNA said a mechanical lift was needed and no clean lift pad was available, so he remained in bed until the pad returned from laundry.
A facility failed to provide a resident’s medical records after the POA requested current meds, MD visits, therapy notes, and a referral copy. The resident had Alzheimer’s disease, narcissistic personality disorder, and HTN, and the MDS showed intact cognition. Staff confirmed the email address used for requests was not valid, and the records had not been sent.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse: A resident with severe cognitive impairment was not protected from resident-to-resident sexual abuse by another resident with a known history of sexually inappropriate behaviors and an order for medication to manage sexual ideations. Staff observed the second resident in the first resident’s room with his brief down and near her bed, and the SRI witness statement described genital exposure and contact. The DON confirmed the care plan had not been updated to address the behavior before the incident.
A facility failed to complete and retain a full investigation for an allegation of resident-to-resident physical abuse after one resident was observed touching another resident’s breasts over her shirt. The incident was found unsubstantiated, but the facility could not provide the investigation, witness statements, or other supporting documentation. The residents involved had significant cognitive and medical impairments, including severe dementia in one resident and moderate cognitive impairment in the other.
The facility failed to complete required transfer and discharge paperwork for multiple residents. One resident with dementia and other chronic conditions had hospital transfers without bed-hold notices or LTC Ombudsman notification, another resident transferred by POA had no discharge summary or recapitulation, and a third resident with severe cognitive impairment had incomplete or missing bed-hold letters for hospitalizations.
Incomplete Care Conferences and Unupdated Care Plan: The facility failed to complete care conferences as required and did not include all required attendees for two residents. One resident with Alzheimer's disease and severe cognitive impairment had care conference forms that were incomplete or not done on schedule, and another resident with Lewy body neurocognitive disorder, diabetes, psychosis, and total ADL dependence had a quarterly care conference attended only by the RN and SSD, while the care plan was not updated to reflect a new blister on the right shoulder.
Failure to Provide Adequate Nail Care: A resident with dementia, impaired cognition, and ADL support needs was observed with long fingernails extending past the fingertips and dirt under the nails. Although nail care had been documented earlier, staff confirmed the resident’s nails were still long and dirty when observed, despite the care plan and facility policy calling for assistance with personal hygiene, including fingernail care.
A resident with severe cognitive impairment developed left leg pain that was later found to be a hip fracture, but the x-ray was not completed promptly and the resident was sent to the hospital after the initial evaluation. Another resident with severe cognitive impairment and multiple chronic conditions developed a new open blister on the shoulder, but the record showed no documented notification of the responsible party. The DON, ADON, and Regional RN confirmed the family was not notified of the new wound.
A facility failed to supervise smoking and secure smoking materials, and also failed to prevent a resident from leaving the building unnoticed. One resident with dementia and other chronic conditions was repeatedly found smoking without the required supervision, while another resident with cognitive impairment and multiple medical diagnoses caused a fire after a lit cigarette was placed in a brief. In a separate event, a resident with dementia and COPD exited through a door that staff said could be pushed open and whose alarm was too faint to hear, and was found outside on the sidewalk with civilians before being brought back inside.
Failure to provide timely incontinence care affected two residents. One resident with severe cognitive impairment was found in a urine-odorous room with soiled linens, gnats present, and clothing saturated with urine, while another resident with dementia and frequent bowel/bladder incontinence asked nightshift staff to use the bathroom but was treated as a check-and-change resident and not taken to the toilet at that time. The DON confirmed the resident should have been taken to the bathroom when requested.
Delayed Psychiatric Services: A resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety had psych consult orders that were not completed in a timely manner. Staff reported the delay was related to obtaining consent from the wife, limited psych NP availability, vacation coverage gaps, and caseload prioritization, resulting in the resident not being seen by psych until well after the orders were placed.
A resident with stroke-related deficits, vascular dementia, anxiety, and RA was receiving Sertraline and Trazodone. Pharmacy recommended considering a GDR trial for the psychotropic meds, but the recommendation was not addressed in a timely manner and was not signed by the PA until much later. The Regional RN confirmed the delay, and the facility policy required GDR for residents on psychotropic drugs unless contraindicated.
A resident with vascular dementia, bipolar disorder, and COPD was given two separate aspirin 81 mg orders daily for the same period. The MAR showed both aspirin orders were administered, and the DON confirmed the resident was documented as receiving two tablets daily.
A resident with alcohol abuse, difficulty walking, COPD, and intact cognition had Depakote orders that were not properly discontinued when a new dose was ordered for behaviors. The MARs documented that both the 250 mg and 375 mg Depakote orders were administered together, and the DON confirmed the duplicate administration; a valproic acid level was within normal range.
A resident with impaired cognition and diagnoses including HIV, bipolar disorder, and substance use disorders missed multiple HIV clinic appointments because of transportation problems, lack of staff escort, and missing documentation of attendance. The DON verified that not all appointments were attended, and the facility policy required support and facilitation of transportation to necessary medical appointments.
Meal Not Served Per Ordered Diet and Menu: A resident with Alzheimer's disease, DM, and HF was ordered a pureed diet with thin liquids and a divided dish, but an observed lunch tray contained mechanical-texture chicken, rice, green beans, and grape drink instead of the ordered pureed meal. CNA confirmation and the facility menu showed the meal was not provided as ordered or per the approved menu, and the resident also did not receive the ordered cake.
An LPN failed to perform hand hygiene before and after preparing and administering medications to two residents, including oral medications and eye drops. The LPN confirmed the omission during an interview, and facility policies require hand hygiene to prevent infection.
The facility failed to ensure that shift-to-shift narcotic count forms were signed by both oncoming and off-going nurses, affecting nine residents receiving narcotic medications. Observations revealed missing signatures on count sheets and logs, despite all narcotics being accounted for. Interviews confirmed the issue, with LPNs admitting to not consistently signing the sheets, contrary to facility policy.
The facility failed to maintain cleanliness of a refrigerator and microwave in the lounge area, affecting seven residents and their families who used these appliances. The microwave had burnt food debris and a sticky brown substance, while the refrigerator contained a brown sticky fluid and lacked a temperature log. The administrator confirmed the unsanitary condition and decided to reassign cleaning duties from kitchen to housekeeping staff.
The facility failed to maintain a sanitary environment, with dirty hallways and resident rooms containing food debris, medication tablets, and ants. Housekeeping and floor technicians' schedules contributed to the unsanitary conditions.
The facility failed to provide appropriate bed linens for four residents. Observations showed uncovered pillows and lack of blankets, despite sufficient linen inventory. An LPN confirmed the issue but had no explanation for the oversight.
The facility failed to complete quarterly smoking assessments for a resident with schizophrenia, bipolar disorder, and nicotine dependence. The resident's care plan required quarterly assessments and supervision during smoke breaks, but the last assessment was done in August 2023, with no assessment in 2024. The DON confirmed the oversight, and the facility's smoking policy did not specify assessment frequency.
A resident with dementia and Alzheimer's disease was observed with long and dirty nails, despite requiring assistance with personal hygiene. The Memory Care Coordinator confirmed the deficiency.
A resident with multiple diagnoses, including dementia and anxiety disorder, was not given opportunities to engage in activities or social interaction. The resident was observed seated alone in a hallway throughout the day, with no encouragement or assistance from staff to participate in activities, as confirmed by staff interviews.
Missed Pressure Injury Prevention and Wound Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized pressure ulcer prevention program for a resident who was admitted with severe cognitive impairment, diabetes, abnormal gait and mobility, chronic pain, and dependence on staff for all ADLs. The resident was assessed as at risk for skin breakdown, was incontinent of bowel and bladder, and had physician orders for a pressure redistribution mattress, heel offloading, and frequent repositioning. Although the care plan included pressure injury prevention interventions, the record showed only one weekly skin observation in June and no further skin assessments until new wounds were identified in early July. The MAR/TAR documented only general encouragement to offload heels and reposition once per shift, with no specific frequency recorded, and there was no evidence that the ordered pressure-reducing devices for the bed and chair were documented as being in place. On 07/03/26, CNA documentation noted the resident’s skin was not intact with red buttocks and skin tears, and an LPN documented a sacral wound that was cleansed and covered pending wound team assessment. A subsequent skin grid described a new sacral skin tear measuring 6.5 cm by 5.0 cm. The record then showed no evidence of new treatments, nutritional supplements, or pressure-reducing interventions being implemented over the next two days. On 07/06/26, wound care identified seven new in-house acquired pressure injuries, including an unstageable sacral wound extending to both buttocks, suspected deep tissue injuries to the left hip, left ischium, right hip, and left lateral foot, a stage III pressure injury to the left heel, and an unstageable pressure injury to the left first digit/medial foot. The resident was later noted to have functional decline, increased confusion, changes in skin condition, fatigue, pressure injuries, and pain, and was sent to the emergency room. Hospital records showed admission for lethargy with severe sepsis, metabolic encephalopathy, and pressure injuries present on admission. An infectious disease specialist documented multiple potential sources of sepsis, including a urinary tract infection, cellulitis of the right hip and buttock area, and dry gangrene of the left foot. The resident’s spouse stated she had been told about only one wound and was unaware of the multiple newly identified wounds. The facility also failed to complete wound treatments as ordered for another resident with multiple terminal ulcers. That resident had orders for wound care to the left hip, right ischium, sacrum, and left buttock using cleansing, Santyl or other ordered dressings, and super absorbent dressings on a daily or shift basis depending on the order. Review of the MARs showed missed wound care on multiple dates for the left hip, right ischium, and sacrum/left buttock wounds. The wound nurse confirmed the wound care was not completed as ordered, and the resident’s granddaughter reported seeing wounds without dressings during a visit, stating the wound care had not been completed as ordered.
RN Staffing Coverage and PBJ Rating Deficiency
Penalty
Summary
The facility failed to ensure RN staffing coverage of at least eight consecutive hours per day and had a one-star rating on the PBJ for the second quarter of 2026. Review of the Facility Assessment dated [DATE] showed nursing services included RNs for approximately 12 hours per day, RNs with administrative duties for approximately two hours per day Monday through Friday, LPNs for approximately six hours per day, LPNs with administrative duties one hour Monday through Friday, CNAs at approximately 150 hours per day at a census of 75, and an Infection Preventionist eight hours per day Monday through Friday. Review of the PBJ Staffing Data Report for 01/01/26 to 03/31/26 showed the facility had one star and no RN hours. During interview on 07/07/26 at 10:40 A.M., Regional HR #830 and Regional HR #31 confirmed the findings, and Regional HR #830 stated the facility had hired five RNs since 03/2026. Review of the undated list provided by the facility showed no RN coverage on multiple dates in January, February, and March 2026. Review of the Nursing Services and Sufficient Staff policy dated 09/26/25 showed the facility’s policy was to provide sufficient staff with appropriate competencies and skill sets to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, with census acuity and diagnoses considered based on the facility assessment.
Infection Control Failures with Glucometer Use, Respiratory Equipment, and Laundry Handling
Penalty
Summary
The facility failed to ensure proper infection control procedures were implemented related to glucometer use. Resident #8 had diagnoses including vascular dementia, type II diabetes, hypertension, alcohol abuse, gout, and chronic kidney disease stage three, and the quarterly MDS indicated impaired cognition and insulin use. During an observation of blood glucose testing, an RN gathered supplies, donned gloves, wiped the resident’s finger with alcohol, used the facility glucometer, and then disposed of her gloves and washed her hands. The RN threw the used testing strip in the trash and placed the glucometer into a basket on the medication cart without cleaning it. The RN later verified that the used testing strip should have been placed in the biohazard box and that the glucometer was not cleaned. The facility policy stated glucometers are to be cleaned and disinfected after each use according to manufacturer instructions. The facility also failed to maintain proper infection control for respiratory equipment and laundry handling. Resident #4 had diagnoses including vascular dementia, bipolar disorder, COPD, type 2 diabetes, osteomyelitis, chronic kidney disease, syncope, and PTSD, and the care plan addressed altered respiratory status related to COPD. Observation of the resident’s room showed the nebulizer was on the floor next to the television, with oxygen tubing and mask also lying on the floor; the resident stated the nebulizer had been on the floor because there was no plug available, and a CNA confirmed it should not be on the floor. In the laundry room, a housekeeper aide was observed washing clothing while multiple soiled washcloths with feces and other soiled laundry were lying on the floor in front of the washers, with dried feces noted on the floor. The aide stated he had dumped the soiled linens on the floor to sort them because other laundry personnel had quit, and the interim administrator stated the facility was trying to catch up on laundry. The infection prevention and control program required clean linen to be separated from soiled linen at all times and soiled linen to be bagged and placed in the soiled utility room.
Unsanitary and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary resident environment that was also in good repair. During a tour of the facility, the entire unit smelled like dirty mop water, and the area around several residents’ rooms smelled like urine. The hallway floor was dirty and sticky. A resident’s wheelchair was observed dirty with dried food all over and a dried spill on the seat, and the tile in front of the nurses station was missing. CNAs verified these observations during the tour. Additional observations showed multiple environmental and maintenance concerns in resident rooms. One resident’s room had a white patched-over crack running from the top to the bottom of the window, and another resident’s room had floor tiles in different colors with several chipped tiles near the bathroom. A different resident’s room had half of the windowsill covered with silver duct tape and a strong urine odor, which the resident stated had been present for six months. Another resident’s room had the top cover of the heating unit pulled away, an empty tube of barrier cream on the floor, and walls that were patched white and not painted. A separate room had a brown substance dried on the wall above the trash can. The facility policy stated housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents who had impaired cognition and required extensive assistance with activities of daily living. One resident had diagnoses including hemiplegia and hemiparesis on the right side, cerebral infarction/stroke, muscle weakness, vascular dementia, anxiety, and rheumatoid arthritis, and was dependent on staff for toileting, showering, and transfers. The care plan directed staff to keep the call light in reach while the resident was in bed. During observation, the resident was trying to get out of bed with a mat on the floor beside the bed, while the call light was hanging from the light above the bed and out of reach; the resident stated he wanted to get up and go to breakfast, and a CNA verified the call light was not in reach. The second resident had diagnoses including hemiparesis, chronic respiratory failure, obesity, type II diabetes, heart failure, depression, dementia, asthma, lymphedema, and dysphagia, and was dependent on staff for toileting, showering, and transfers. The care plan directed staff to keep the call light in reach while in bed and assist with daily hygiene and showering. On two observations, the resident was lying in bed with the call light hanging behind the bed and later on the floor, both times out of reach. An LPN verified the call light was out of reach and stated the resident was non-verbal but able to use the call light. The facility policy stated staff must ensure the call light is within reach of the resident and secured as needed.
Failure to Honor Resident Preference for Rising
Penalty
Summary
The facility failed to accommodate Resident #28’s preference for arising and getting up for breakfast. Resident #28 was admitted with diagnoses including right-sided hemiplegia and hemiparesis, cerebral infarction/stroke, muscle weakness, vascular dementia, anxiety, and rheumatoid arthritis. The quarterly MDS indicated impaired cognition and dependence on staff for toileting, showering, and transfers, and the care plan noted the resident needed assistance with ADLs related to hemiplegia, falls, and dementia, with the call light kept in reach while in bed. During observation, Resident #28 was trying to get out of bed, had a mat on the floor next to the bed, and his call light was hanging from the light above the bed out of reach. He stated he wanted to get up and go to breakfast. The CNA stated staff usually got him up for breakfast, that he required a mechanical lift for transfers, and that he could not be transferred because there was no clean mechanical lift pad available; staff would get him up once the pad returned from laundry.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to ensure Resident #37’s medical records were provided in response to a family request. Resident #37 was admitted with diagnoses including Alzheimer’s disease, narcissistic personality disorder, and essential hypertension, and the quarterly MDS assessment indicated intact cognition. An email from the prior administrator directed record requests to [email protected], and the resident’s POA used that email to request records for current medications, doctor’s visits, therapy notes, and a copy of the referral. During interview, the Regional RN confirmed the email address was not valid and stated the family was supposed to request records directly through the facility using a form, but the requested records had not been sent as of the survey date. The prior administrator stated he did not remember a record request for Resident #37. The facility’s Release of Medical Records policy stated medical records would be released with a valid request and in accordance with state and federal laws.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility did not ensure Resident #24 was free from resident-to-resident sexual abuse by Resident #26. Resident #24 was admitted with diagnoses including Alzheimer's disease with early onset, severe dementia with behavioral disturbance, bipolar disorder, and major depressive disorder, and was severely cognitively impaired and dependent on staff for oral hygiene, toileting hygiene, showers, dressing, and personal hygiene. Resident #26 was admitted with diagnoses including dementia, mild, anxiety disorder, and major depressive disorder, and his transferring paperwork included an order to monitor for sexually inappropriate behaviors. He was also prescribed cimetidine for sexual ideations, but his care plan was absent of interventions addressing his sexually inappropriate behaviors at the time of the incident. On the morning of the incident, CNA #811 observed Resident #26 in Resident #24's room standing near the head of her bed with his incontinent brief pulled down to his ankles, and Resident #24 was observed moving her hands around his pelvic region. CNA #784 also observed Resident #26 standing over Resident #24's bed with his brief down at his ankles. The DON stated she was notified that Resident #26 had been found in Resident #24's room with his pants down and that he was removed from the room. The witness statement for the SRI reported Resident #26 had his penis in Resident #24's face while she touched it. The facility's abuse policy stated it would implement policies and procedures to prevent and prohibit abuse and to identify, correct, and intervene in situations where abuse was more likely to occur.
Incomplete Investigation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure a complete and accurate investigation was completed for an allegation of resident-to-resident physical abuse involving two residents. Review of the self-reported incident showed that one resident was seen touching another resident’s breasts over her shirt, and the facility determined the allegation was unsubstantiated. However, the facility was unable to provide the investigation for the incident, including witness statements and the complete investigation documentation. The resident who was touched had vascular dementia, mild protein calorie malnutrition, hypertensive emergency, toxic encephalopathy, a history of transient ischemic attack, and cerebral infarction, and was severely cognitively impaired and dependent on staff for all ADLs. The other resident had hyperosmolality, hypernatremia, CHF, cardiac arrhythmias, pulmonary fibrosis, and type II diabetes, and had moderately impaired cognition with varying levels of assistance needed for ADLs. During interview, the Regional RN confirmed the facility could not locate or provide the investigation or additional information related to the incident.
Missing transfer, discharge, and bed-hold documentation
Penalty
Summary
The facility failed to complete required transfer and discharge procedures for three residents who were transferred to the hospital or discharged from the facility. For Resident #38, who had diagnoses including Alzheimer's disease, hip fracture, vitamin B and D deficiencies, muscle weakness, mood disorder, depression, and dementia with behavioral disturbances, the record showed hospital transfers for a change in condition and for evaluation of chest x-ray findings. The record review and interviews found no evidence that bed-hold notices were completed for the hospital transfers and no evidence that the Long-Term Care Ombudsman was notified of the resident's hospitalizations. For Resident #36, who had diagnoses including congestive heart failure, type II diabetes mellitus, muscle weakness, and dementia with behavioral disturbances, the record showed the resident was transferred to another facility by the power of attorney. The nursing note documented that the resident was stable at the time of transfer, with a Foley catheter draining clear yellow urine, vital signs obtained, and personal belongings and paperwork sent with the POA. However, the medical record contained no discharge summary or recapitulation for the resident. For Resident #3, who had vascular dementia, mild protein calorie malnutrition, hypertensive emergency, toxic encephalopathy, history of transient ischemic attack, and cerebral infarction, the record showed hospitalizations with return to the facility after each stay. The bed-hold letter for one hospitalization was not completed or delivered to the guardian until the day of the hospital transfer, and no bed-hold letter was provided for another hospitalization. During interview, staff confirmed the bed-hold notices were not completed accurately and were unsure whether transfer notices were available.
Incomplete Care Conferences and Unupdated Care Plan
Penalty
Summary
The facility failed to ensure care conferences were completed as required and/or included the required attendees for two residents reviewed. For Resident #38, the closed medical record showed an admission date of 01/23/24 and a discharge date of 09/24/25, with diagnoses including Alzheimer's disease, hip fracture, vitamin B and D deficiencies, muscle weakness, mood disorder, depression, and dementia with behavioral disturbances. The quarterly MDS assessment indicated severely impaired cognition, no behaviors, no mobility devices, setup and clean-up assistance for eating, and dependence for toileting, shower/baths, and personal hygiene. The facility provided care conference forms dated 05/01/24 and 08/08/24, and one dated 09/12/25 that was not completed. During interview, the RRN stated care conferences were not done within 72 hours of admission and then quarterly. For Resident #5, the record showed an admission date of 03/04/26 and diagnoses including neurocognitive disorder with Lewy bodies, type II diabetes, hyperlipidemia, psychosis, anxiety, acute kidney failure, and hypertension. The care plan last updated 03/04/26 identified potential alteration in skin integrity and protective/preventative skin care, but it was not updated to reflect a new blister on the right shoulder present from 06/15/26 through 06/22/26. The quarterly MDS showed severely impaired cognition, dependence for all ADLs, and bowel and bladder incontinence. The care conference progress note dated 05/25/26 showed the quarterly care conference was held with only the resident's RN and SSD present, and did not include all required staff. The SSD stated dietary and activities staff did not attend care conference meetings and that concerns were passed on verbally without follow-up to confirm they were addressed; the ADON confirmed the care plan was not updated for the blister and stated it should have been.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for Resident #21, who had diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, cerebral infarction, adult failure to thrive, and type 1 diabetes. The quarterly MDS assessment showed impaired cognition and a need for set up with personal hygiene. The care plan identified the resident as at risk for decline in ADLs related to weakness, left hemiplegia, and abnormal gait, and included staff assistance as needed with daily hygiene and weekly showering per facility policy. Review of the resident’s activity log showed nail care was provided on 06/10/26. However, during observation on 06/28/26, the resident’s fingernails were long, extending over the fingertips, with brown dirt embedded under the nails. The resident stated the nails were long and needed to be cut. A CNA verified the nails were long and appeared dirty under the nails, and activity staff later confirmed nail care had been provided on 06/10/26 and again on 06/28/26 when identified by staff. The facility policy stated residents would receive nursing care and supervision based on individual needs and abilities, including cleaning and cutting of fingernails and toenails.
Failure to Notify Responsible Party and Timely Address Changes in Condition
Penalty
Summary
The facility failed to ensure notification of a change in condition to a resident’s responsible party and failed to timely address a change in condition for another resident. Resident #38 had diagnoses including Alzheimer’s disease, hip fracture, vitamin B and D deficiencies, muscle weakness, mood disorder, depression, and dementia with behavioral disturbances. On 08/22/25, the resident was observed with left leg discomfort during supper, was screaming out in pain when the left leg was moved, and could not explain how the injury occurred. The NP was notified and ordered an x-ray of the left hip and thigh along with neurological checks and vital signs every shift. The guardian was notified of the discomfort and x-ray order, but the x-ray was not completed that evening. The next day, the nurse informed the NP that the resident could not obtain the x-ray because he was unable to follow instructions and stay still, and the resident was then sent to the hospital for further evaluation. The resident was admitted with a left hip fracture, and the guardian was notified of the hospital admission. The facility also failed to notify the responsible party of a new wound for Resident #5. Resident #5 had diagnoses including neurocognitive disorder with Lewy bodies, type II diabetes, hyperlipidemia, psychosis, anxiety, acute kidney failure, and hypertension, and was dependent on staff for all ADLs with severely impaired cognition. On 06/17/26, a CNA reported an open blister on the resident’s right shoulder measuring 2 cm x 1.5 cm x 2 cm. The wound was cleansed, a dry sterile dressing was applied, the wound team was notified, and the DON was notified. The record contained no documented evidence that the resident’s responsible party was notified. During interview, the ADON and Regional RN confirmed the family was not notified of the new blister and stated they should have been.
Unsafe Smoking Supervision and Unsupervised Exit From Facility
Penalty
Summary
The facility failed to provide appropriate supervision for residents while smoking and failed to keep smoking materials secured from resident access. One resident with diagnoses including Alzheimer’s disease, narcissistic personality disorder, and hypertension was assessed as an independent smoker despite the facility being a locked unit and a policy stating all residents were to be supervised while smoking. The record showed multiple incidents in which the resident smoked without staff supervision, including being found on the patio through the dining room sliding doors, going out the patio doors to smoke, and later smoking in a bathroom near the kitchen. The notes did not show that the family or physician were notified after these incidents. Another resident with diagnoses including hyperosmolality, hypernatremia, CHF, cardiac arrhythmias, pulmonary fibrosis, and type II diabetes had smoking assessments and a care plan identifying smoking as a safety hazard and requiring direct supervision, staff or family assistance, and smoking materials kept at the nurse’s station. The resident was brought out to smoke by staff and assisted with lighting a cigarette, but later a CNA reported smoke coming from the resident’s room. The resident was found with a burning brief on the floor next to the bed, and the incident report and Fire Marshal report stated the resident had placed a lit cigarette in the brief, which caused the fire. The resident’s family stated they later instructed staff that the resident was no longer allowed to smoke with facility staff because of the lack of supervision. The facility also failed to ensure a resident did not exit the building without staff knowledge or supervision. A resident with dementia, COPD, diabetes, malnutrition, MI, repeated falls, hypertension, and unsteadiness on feet was documented as not being at risk for elopement, yet was found outside standing on the sidewalk with civilians after staff believed the resident had left through the front door. Staff noted the door could be pushed open, the alarm was not loud enough to be noticed, and the resident was assisted back inside. Interviews confirmed staff concerns that the unit was not secure and that the alarm was faint. The facility policy stated residents with wandering behavior or at risk for elopement were to receive adequate supervision to prevent accidents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for two residents. Resident #27 had diagnoses including alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder, and difficulty walking. The resident’s care plan included assistance with transfers and ambulation, and the quarterly MDS showed severe cognitive impairment with occasional urinary and bowel incontinence. On observation, the resident was found sleeping in a room with an odor of urine, soiled linens, gnats around the resident, and the resident stated he was cold. A second observation showed the resident’s brief and jogging pants were saturated with urine and the resident’s t-shirt was wet with urine up the right side to just under the armpit. CNA #714 confirmed the observation. Resident #18 had diagnoses including dementia, essential hypertension, and hyperlipidemia. The resident’s care plan directed incontinence care every two hours and as needed, and the quarterly MDS showed moderate cognitive impairment with frequent bladder and bowel incontinence and dependence on staff for toileting. During observation, Resident #18 asked nightshift staff to use the bathroom to urinate. CNAs #807 and #784 stated the resident was incontinent and was a check-and-change resident, and that asking to use the bathroom was a behavior. The DON later stated the resident was both check-and-changed and taken to the bathroom for toileting, and confirmed that if the resident requested to go to the bathroom, staff should have taken the resident to the bathroom.
Delayed Psychiatric Services
Penalty
Summary
The facility failed to ensure psychiatric services were provided timely and according to orders for one resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety. The resident’s quarterly MDS showed severely impaired cognition, dependence for all ADLs, and bowel and bladder incontinence. The medical record showed orders for psych services on 04/10/26 and again on 05/03/26, but the resident was not seen by psych until 06/28/26. The delay was discussed in interviews with facility staff. The DON stated the delay was related to obtaining consent from the wife and confirmed the psych consult orders. SSD stated verbal consent from the wife was not received until the care conference on 05/25/26 and was unsure why psych did not see the resident sooner after that. SSD also stated the psych NP only comes to the facility every two weeks and was on vacation with no coverage. The psych NP acknowledged awareness that the resident was not seen for approximately one month after consent to treat was received and stated new referrals are sometimes pushed back based on caseload.
Delayed Action on Pharmacy Recommendation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure pharmacy recommendations were acted on in a timely manner for one resident reviewed for unnecessary medications. Resident #28 was admitted with diagnoses including right-sided hemiplegia and hemiparesis, cerebral infarction, muscle weakness, vascular dementia, anxiety, and rheumatoid arthritis. The resident’s quarterly MDS showed impaired cognition and use of an antidepressant and anticoagulant, and the care plan identified a potential for adverse side effects from psychotropic drugs with interventions to document side effects and notify the physician of mental status changes. Current physician orders included Sertraline 50 mg daily and Trazodone 50 mg at bedtime. A pharmacy recommendation dated 11/05/25 for Sertraline 50 mg and Trazodone 50 mg stated the provider should consider a gradual dose reduction trial, with the note that dose reduction was contraindicated because additional attempts would likely impair the resident’s function. The recommendation was not signed by the PA until 01/27/26. During interview, the Regional RN verified the recommendation was not addressed in a timely manner. Facility policy stated residents using psychotropic drugs shall receive gradual dose reduction unless contraindicated, in an effort to discontinue these drugs.
Duplicate Aspirin Administration
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when staff administered two aspirin orders daily to Resident #4. Resident #4 was admitted with diagnoses including vascular dementia with other behavioral disturbance, bipolar disorder, and chronic obstructive pulmonary disease, and the Quarterly MDS showed moderate cognitive impairment. The physician orders included one aspirin 81 mg order for heart maintenance and a second aspirin 81 mg order for a healthy heart, and the MARs documented that both aspirin orders were administered from 05/05/26 through 06/02/26. During interview, the DON confirmed the resident was documented as receiving two tablets of aspirin daily during that period.
Failure to Discontinue Duplicate Depakote Orders
Penalty
Summary
The facility failed to ensure Resident #27’s Depakote was discontinued as ordered. The resident was admitted with diagnoses including alcohol abuse, difficulty walking, and chronic obstructive pulmonary disease, and the Quarterly MDS indicated intact cognition. Physician orders showed Depakote 250 mg by mouth twice daily for bipolar disorder, followed by a later order for Depakote 375 mg by mouth twice daily for dementia with behaviors. Nursing Recommendations documented that the resident had a new order for Depakote 375 mg twice daily, but the existing Depakote 250 mg twice daily order was never discontinued. The record also showed that both Depakote orders remained active and were administered together from 08/26/25 through 09/12/25, with documentation in the MARs confirming administration of both the 250 mg and 375 mg doses. A valproic acid level drawn on 09/08/25 was 71, which was within the stated normal range of 50 to 100. The DON confirmed the medical record and MARs documented administration of both Depakote orders during that period.
Missed Medical Appointments Due to Transportation Failures
Penalty
Summary
The facility failed to ensure physician appointments were attended for Resident #27, who was admitted with diagnoses including alcohol dependence with alcohol-induced persisting dementia, anxiety, HIV, bipolar disorder, and cocaine abuse. The quarterly MDS showed impaired cognition and that the resident was independent with transferring and ambulation. The care plan identified the resident as non-compliant with care and treatment as ordered by the physician, with interventions to educate the resident on not following physician orders and to observe and document behavior changes. Review of the appointment schedule and HIV clinic records showed multiple missed, cancelled, or unverified clinic visits. The facility was unsure whether the resident attended some appointments because there was no documentation, several appointments were rescheduled or cancelled due to transportation issues, one appointment was missed because transportation arrived in a vehicle too small to transport the resident, and another was missed because no staff escort was available. The DON verified that the resident did not attend all appointments and stated some were missed due to transportation, while the facility policy required support and facilitation of proper transportation to necessary medical appointments.
Meal Not Served Per Ordered Diet and Approved Menu
Penalty
Summary
Facility failed to ensure Resident #15 received meals as ordered and in accordance with the approved facility menu. Resident #15 was admitted with diagnoses including Alzheimer's disease, diabetes, and heart failure. The resident's record showed orders for a regular diet with pureed texture, thin liquids, and a divided dish for all meals, along with a divided dish order dated 05/22/24. The resident's quarterly MDS assessment noted memory problems, and the care plan included an intervention for diet as ordered by the physician. During observation on 06/29/26 at 1:18 P.M., Resident #15's lunch tray contained rice, Italian style green beans, mechanical chicken with gravy, and grape drink, with a meal ticket showing the resident's name and "mech" written on it. CNA #821 confirmed at 1:20 P.M. that the resident did not receive the meal as ordered and that it should have been pureed; the CNA also confirmed the resident did not receive the cake as ordered. The Spring/Summer 2026 menu showed the lunch meal for that day was honey garlic chicken thigh, steamed white rice, broccoli, frosted cake, beverage, and coffee or hot tea. The facility's Therapeutic Diet Orders policy stated residents are to be provided food in the appropriate form and/or nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to perform hand hygiene during medication administration for two residents. Observations showed that the LPN did not wash or sanitize hands before preparing and administering morning medications to the first resident, nor after completing the task. The LPN then returned to the medication cart, again without performing hand hygiene, and proceeded to prepare and administer medications, including oral medications and eye drops, to a second resident. After administering medications to the second resident, the LPN exited the room without performing hand hygiene. During an interview, the LPN confirmed the observations and acknowledged that hand hygiene should have been performed prior to obtaining and after administering medications to both residents. Review of facility policies revealed that staff are required to perform hand hygiene to prevent the spread of infection and to wash hands before and after administering medications, in accordance with professional standards and facility protocols.
Failure to Ensure Proper Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that the shift-to-shift narcotic count forms were signed by both the oncoming and off-going nurses as required by their policy. This deficiency had the potential to affect nine residents who were identified as receiving narcotic medications. During an observation on December 9, 2024, it was noted that while all narcotics were accounted for, there were missing signatures on the shift-to-shift count sheets from September 18, 2024, to December 7, 2024, totaling 113 missing signatures. Further observations of the medication carts at two stations revealed that although the carts were locked and narcotics were accounted for, there were additional missing signatures on the Controlled Medication Shift Change Logs for various dates in November and December 2024. Interviews with the Director of Nursing (DON) and several Licensed Practical Nurses (LPNs) confirmed the missing signatures. The DON acknowledged the issue but could not provide an explanation for the missing signatures. The LPNs admitted to counting the narcotics after each shift but did not consistently sign the shift-to-shift sheets. The facility's policy, dated June 2017, requires that both the outgoing and oncoming nurses sign the Shift to Shift Narcotic Count Verification form at each change of shift, which was not adhered to, leading to this deficiency.
Unsanitary Conditions of Lounge Appliances
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards for a refrigerator and microwave located in the lounge area near station one. During an observation, the microwave was found to have burnt food debris and a sticky brown substance inside, while the refrigerator contained a brown sticky fluid and lacked a temperature log. The administrator confirmed the unsanitary condition of these appliances and acknowledged that they should be cleaned at least weekly. It was noted that the responsibility for cleaning these appliances was initially assigned to the kitchen staff, but due to their location in the lounge, the administrator decided to reassign this duty to the housekeeping staff. Seven residents and their families, as well as staff, used these appliances to store and heat food. This deficiency was identified during an investigation under Complaint Number OH00159111.
Sanitary Environment Deficiency
Penalty
Summary
The facility failed to ensure a sanitary environment for residents, as observed on 04/08/24. The floors in the two main hallways were found to have scattered dried brown and orange liquid stains, dirt, and various debris, along with a strong smell of urine. This was confirmed by an LPN. Housekeeping staff reported cleaning resident rooms and communal areas daily, but floor technicians did not work over the weekend, leading to dirty hallways. Resident #38's room had food debris, plastic bags, unidentified medication tablets, and a dinner roll under the sink, which was verified by an LPN. Resident #15's room had food, paper debris, ants, and unidentified medication tablets on the floor, confirmed by the Memory Care Coordinator. The deficiency was investigated under Complaint Number OH00151393.
Failure to Provide Appropriate Bed Linens
Penalty
Summary
The facility failed to ensure residents had appropriate bed linens, affecting four residents. Observations revealed that two residents were lying in bed with pillows that were not covered with pillowcases. Another resident was covered with two fitted sheets but had no blanket, and his pillow also lacked a pillowcase. A fourth resident was covered with a flat sheet and no blanket, and expressed a desire for a blanket. An LPN confirmed the observations and stated that the facility had sufficient inventory of linens but could not explain why appropriate linens were not provided.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments as care planned for a resident with schizophrenia, bipolar disorder, and nicotine dependence. The resident's care plan, dated 08/31/23, indicated the need for quarterly smoking assessments and supervision during smoke breaks. However, the last smoking assessment was completed on 08/15/23, and no assessment was conducted in 2024. The Director of Nursing confirmed the oversight and stated that smoking assessments are supposed to be completed annually and quarterly. The facility's smoking policy, dated 2021, did not specify the frequency for smoking assessments.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that a resident was provided with adequate nail care. Resident #23, who has diagnoses of dementia and Alzheimer's disease, was observed with long and dirty nails containing food and other brown debris. The resident's medical record indicated that they required assistance with personal hygiene, including nail care. This deficiency was confirmed through an interview with the Memory Care Coordinator, who acknowledged the condition of the resident's nails. The incident was investigated under Complaint Number OH00151393.
Failure to Engage Resident in Activities
Penalty
Summary
The facility failed to ensure all residents were given opportunities to engage in activities and have opportunities for social interaction other than routine activities of daily living. This deficiency affected one resident who had diagnoses including malignant neoplasm of the uterus, unspecified dementia, anxiety disorder, senile degeneration of the brain, and muscle weakness. The resident's care plan indicated a need for encouragement and assistance to participate in activities, but there was no documentation of refusal to attend activities in the nurse progress notes from March 2024 through April 2024. On the day of observation, the resident was seen seated in a wheelchair in the main hallway, facing a wall and later blocked by a linen cart, with no interaction from staff. The resident remained in the same location throughout the day and did not attend any organized activities. Interviews with staff confirmed that the resident was not invited or encouraged to participate in activities from 8:00 A.M. to 2:30 P.M., and there was no staff interaction during the resident's meal time.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,173 citations issued within 25 miles in the last 12 months — including the 8 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 Oakwood Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grande Oaks | 0 mi | ★★★★★ | 37 | 0 |
| Aventura At Walton Hills | 1.3 mi | ★★★★★ | 21 | 0 |
| Northfield Village Retirement Community | 2.2 mi | ★★★★★ | 10 | 0 |
| Solon Pointe At Emerald Ridge | 3.1 mi | ★★★★★ | 21 | 0 |
| Avenue At Macedonia | 3.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.