Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakes Of Monclova Health Campus The during CMS and state inspections, most recent first.
A CNA failed to treat a resident with dignity during meal assistance by loudly referring to residents as "feeders" in the presence of other residents and staff. The resident was dependent on staff for eating assistance and had diagnoses including dementia, Alzheimer's disease, malnutrition, anxiety, and dysphagia. The CNA confirmed the term was used for residents receiving restorative feeding, and the Administrator verified staff should not use that language.
A resident was observed in bed with a medication cup containing seven tablets left on the bedside table while she waited to take her morning meds with food. The resident said she had left the meds there herself, and an LPN confirmed the meds should not have been at bedside; the LPN also stated the resident had the meds in her mouth during morning med pass. The facility’s Medication Storage policy gave no direction about leaving meds at bedside.
Pureed diet meals were not prepared and served according to the facility diet guide. A staff member blended goulash and egg noodles together, then plated a smaller amount for pureed trays than for mechanical soft trays. The DSAD confirmed the goulash and noodles were supposed to be blended and served separately, and that residents on pureed diets did not receive the correct amount of beef goulash mixture or protein.
Unsanitary meal assistance was observed when a CNA blew on a resident’s hot soup with her mouth before offering it to the resident, and repeated the action with a second spoonful. The resident had Alzheimer’s disease, dementia, protein-calorie malnutrition, anxiety, and dysphagia, and was dependent on staff for eating assistance. The AD of Dining Services confirmed that blowing on residents’ food is not a hygienic practice.
A resident with type one diabetes experienced multiple episodes of hyperglycemia and received several doses of Novolog insulin based on verbal orders from an on-call practitioner. However, the nurse did not enter these insulin orders into the electronic medical record, and a follow-up blood sugar check was performed but not documented. The DON and LPN confirmed the lack of proper documentation, which resulted in incomplete and inaccurate medical records.
The facility failed to provide scheduled bathing for three residents, with one resident receiving only half of the scheduled showers, another expressing dissatisfaction with bathing frequency, and a third experiencing a nine-day gap without a shower. This non-compliance with the facility's bathing policy was confirmed by the DON and Regional Nurse.
The facility failed to provide appropriate receptacles for PPE disposal in the rooms of residents in Enhanced Barrier Precaution isolation. Observations and staff interviews confirmed the absence of these receptacles, affecting two residents with multiple medical conditions. This was contrary to the facility's policy requiring PPE to be doffed and disposed of inside the resident's room.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week. A review of staffing schedules and an interview with the DON confirmed the absence of an RN on duty on two specific days, with RNs only on call. This deficiency had the potential to impact all 56 residents in the facility.
The facility failed to provide adequate portions of protein and vegetables for residents on mechanical soft and pureed diets. Observations revealed that staff used smaller scoop sizes than required, affecting 10 residents on a mechanical soft diet and 4 on a pureed diet. The Director of Food Service confirmed the discrepancy between served portions and menu requirements.
A facility failed to ensure proper PPE use and signage for infection control. Staff did not consistently wear PPE when caring for a resident with C. diff, despite contact precautions being in place. Additionally, a resident requiring Enhanced Barrier Precautions lacked appropriate signage. These lapses were confirmed by staff interviews and observations, indicating non-compliance with facility policies.
Two STNAs administered medications with expired CRMA licenses, affecting 21 residents. The issue was identified through a review of medical and staffing records, revealing multiple instances of noncompliance. Interviews confirmed the oversight, which was investigated under a specific complaint number.
A resident with chronic kidney disease and other health issues had critical lab results delayed due to a failure in communication at the LTC facility. Despite orders for lab tests, they were not drawn promptly, and when results were available, they were sent to the wrong nephrology clinic. This miscommunication prevented timely treatment for the resident's elevated potassium and creatinine levels.
A resident with moderate cognitive impairment and multiple medical conditions was not provided showers according to their preference, receiving only two showers since admission despite a preference for three per week. Staff interviews revealed inconsistencies in scheduling and documentation, with some showers missed without proper documentation or offering. The facility's policy required bathing at least twice a week unless otherwise preferred, which was not followed.
A resident with severe cognitive impairment and multiple health conditions experienced a delay in obtaining necessary laboratory tests due to incorrect entry of orders into the electronic system. Despite reminders, the tests were not conducted timely, leading to delayed identification of critical lab results, including high BUN, creatinine, and potassium levels.
Failure to Treat Residents with Dignity During Dining
Penalty
Summary
The facility failed to ensure residents were treated with dignity during dining. Resident #3, admitted with diagnoses including Alzheimer's disease, dementia, protein-calorie malnutrition, anxiety, and dysphagia, was documented on the quarterly MDS as rarely/never understood and dependent on staff for eating assistance. During observation in the restorative dining room, a CNA was providing meal assistance to Resident #3 while four other residents, another CNA, and an RN were present. The CNA was observed talking loudly to co-workers and referring to the residents as "feeders," and she confirmed she called the residents feeders and said they received restorative feeding. In a later interview, the CNA stated she had heard other staff use the term and had picked it up from them, and the Administrator verified staff should not refer to residents as feeders. The facility policy stated residents have the right to be treated with dignity and respect and treated fairly, courteously, and with respect by all staff.
Improper Medication Storage in Resident Room
Penalty
Summary
The facility failed to properly store medications. During observation and interview, Resident #64 was found awake and lying in bed with a bedside table near her, and a medication cup containing seven tablet medications was sitting on the table. Resident #64 stated she had left her morning medications there so she could take them with food. The resident’s medical record showed she was admitted with cellulitis of both lower limbs, was cognitively intact on admission MDS, and had a care plan noting high risk medications related to congestive heart failure, edema, and hypertension. At 8:45 A.M., an LPN confirmed Resident #64 should not have medications at bedside and entered the room to ask about the medications. Resident #64 again stated she was waiting to take them with food. The LPN explained that medications could not be left at bedside and said she would bring them back when breakfast arrived. The LPN also stated the resident had the medications in her mouth before walking out of the room during morning medication administration. Review of the facility policy titled Medication Storage, dated 10/01/23, gave no direction regarding medications being left at bedside.
Pureed Diet Portions Were Not Prepared and Served per Diet Guide
Penalty
Summary
The facility failed to follow instructions for the preparation and serving of residents receiving pureed textured food to ensure accurate portion sizes. During lunch meal preparation, a staff member was observed blending goulash mixture and egg noodles together. Later, the same staff member plated one four-ounce scoop of the pureed goulash and noodle mixture for pureed diet trays, while mechanical soft trays received two four-ounce scoops of the goulash and noodle mixture. During interview, the staff member confirmed the food items had been blended together and stated the pureed noodles were more ground down, so one four-ounce scoop of the pureed mixture was equal to two four-ounce scoops of the mechanical soft mixture. Review of the facility's Diet Guide Sheet with the Dining Services Assistant Director showed that the goulash mixture and egg noodles were to be blended separately and served separately. The Diet Guide Sheet also indicated residents on a pureed diet should have received one four-ounce scoop of goulash mixture and one three-ounce scoop of egg noodles. The Dining Services Assistant Director verified that residents on a pureed diet did not receive the correct amount of beef goulash mixture and therefore did not receive the correct amount of protein.
Unsanitary Meal Assistance
Penalty
Summary
Food was not fed to a resident in a sanitary manner during meal assistance. Resident #3 had diagnoses including Alzheimer's disease, dementia, protein-calorie malnutrition, anxiety, and dysphagia, and was documented as rarely or never understood and dependent on staff for eating assistance. During observation in the restorative dining room, a CNA provided meal assistance to the resident and stated the soup was very hot. The CNA scooped soup, blew on it with her mouth to cool it, and then offered it to the resident; this was repeated with a second spoonful, and the resident consumed the soup. The CNA later confirmed she often had to blow on the soup to cool it, and the Assistant Director of Dining Services stated that blowing on residents' food was not a hygienic practice and staff should not do it.
Incomplete Documentation of Insulin Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure the completeness and accuracy of a resident's medical record in relation to the management of elevated blood sugars. A resident with type one diabetes mellitus experienced multiple episodes of hyperglycemia, during which three separate doses of Novolog insulin were administered in response to high blood sugar readings. Although the on-call practitioner provided verbal orders for these insulin doses, the nurse did not enter these orders into the resident's physician orders in the electronic medical record. Additionally, a follow-up blood sugar check, as ordered by the physician, was performed but not documented in the medical record. Interviews with the Director of Nursing (DON) and the LPN involved confirmed that the insulin administrations and the follow-up blood sugar result were not properly recorded according to facility policy. The DON also acknowledged that the interdisciplinary team was not fully aware of the extent of insulin administered overnight due to incomplete documentation. Review of facility policies indicated that all entries, including telephone orders, should be promptly and accurately recorded in the electronic medical record, but this was not done in this case.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure that residents were provided with scheduled bathing, affecting three residents out of five observed for activities of daily living. Resident #20, with a severely impaired cognition and dependent on personal hygiene, was scheduled for showers twice a week but only received seven out of the 14 scheduled showers between January 17 and March 5. The Director of Nursing and Regional Nurse confirmed this discrepancy. Resident #35, who was cognitively intact but dependent on personal hygiene, was scheduled for showers twice a week but only received eight out of the 12 scheduled showers during the same period. The resident expressed dissatisfaction with the frequency and type of bathing received. Resident #52, also cognitively intact and requiring substantial assistance with bathing, was scheduled for 18 showers but only received 15, with a notable gap of nine days without a shower between February 14 and February 23. The facility's policy stated that residents should receive baths at least twice a week unless otherwise specified by the resident. The failure to adhere to this policy was verified by the Director of Nursing and Regional Nurse, indicating non-compliance with the facility's guidelines for bathing preferences.
Failure to Provide PPE Disposal Receptacles in Isolation Rooms
Penalty
Summary
The facility failed to ensure appropriate receptacles were placed inside the doorways of resident rooms for the disposal of personal protective equipment (PPE) for residents in Enhanced Barrier Precaution (EBP) isolation. This deficiency was observed in the cases of two residents, who were part of a group of five residents reviewed for isolation. The facility had identified a total of 11 residents in EBP isolation. During observations, it was noted that there were no receptacles available in the rooms of these residents to discard used PPE, which was confirmed by interviews with the nursing staff. Resident #7, who was admitted with multiple diagnoses including dementia, Alzheimer's disease, and chronic kidney disease, was observed to have no receptacle for PPE disposal in their room. Similarly, Resident #20, who had a range of medical conditions including osteomyelitis and sepsis, also lacked a receptacle for PPE disposal. Interviews with the nursing staff confirmed the absence of these receptacles, which contradicted the facility's policy that required PPE to be doffed and disposed of inside the resident's room. The facility's policy on Enhanced Barrier Precautions specified that such precautions should be in place for residents with chronic wounds or indwelling medical devices, yet the necessary equipment to support these precautions was not provided in the rooms of the affected residents.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to comply with the requirement of having a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This deficiency was identified through a review of staff schedules and posted staffing information, which revealed that there was no RN coverage in the facility on two specific days, 05/18/24 and 05/19/24. An interview with the Director of Nursing (DON) confirmed the absence of an RN on duty during these days, although RNs were on call. This non-compliance had the potential to affect all 56 residents residing in the facility, as the census was 56 at the time of the survey.
Inadequate Portion Sizes for Special Diets
Penalty
Summary
The facility failed to provide adequate portions of protein and mashed potatoes to residents on a mechanical soft diet, as well as adequate portions of protein and vegetables to residents on a pureed diet. This deficiency was identified through observations during meal service, staff interviews, and reviews of the resident diet list and menu spreadsheet. Specifically, during a meal service, staff used a #12 scoop (2 2/3 ounces) to serve mechanical soft Salisbury steak, pureed Salisbury steak, and mashed potatoes, and a #16 scoop (2 ounces) for pureed peas. These portions were insufficient compared to the menu spreadsheet requirements, which specified that the mechanical soft Salisbury steak portion should be 5 1/3 ounces, mashed potatoes should be 4 ounces, pureed Salisbury steak should be 4 ounces, and pureed peas should be 3 ounces. The deficiency had the potential to affect all 10 residents on a mechanical soft diet and all four residents on a pureed diet. The Director of Food Service confirmed the scoop sizes used and acknowledged the discrepancy between the served portions and the menu spreadsheet requirements. The facility census at the time was 56, indicating that a significant portion of the resident population was affected by this issue.
Inadequate PPE Use and Signage for Infection Control
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was consistently worn by staff while providing care to a resident under contact precautions for Clostridium difficile (C. diff). Observations revealed that multiple staff members, including a Licensed Practical Nurse (LPN), a State Tested Nurse Aide (STNA), and an Occupational Therapy Assistant (OTA), entered the resident's room without donning the required PPE, despite the presence of a Contact Precautions sign and PPE cart outside the room. Interviews with these staff members confirmed their understanding that the resident was under contact precautions, yet they believed PPE was only necessary when dealing with soiled areas, such as after a bowel movement. This misunderstanding led to non-compliance with the facility's policy, which required gloves and gowns to be worn before room entry and hand hygiene with soap and water after potential contact with C. diff. Additionally, the facility did not ensure proper signage for Enhanced Barrier Precautions (EBP) for another resident who required such precautions due to a wound with dressing changes. During an observation, it was noted that there was no EBP sign posted on or near the resident's door. A Registered Nurse (RN) confirmed the absence of the sign, which was contrary to the physician's order and the facility's policy that required staff to use gowns and gloves during high-contact care activities. The facility's policies for both contact precautions and enhanced barrier precautions were not adequately followed, as evidenced by the lack of PPE usage and missing signage. The Assistant Director of Nursing (ADON)/Infection Preventionist confirmed the expectations for PPE use and hand hygiene, highlighting a gap in staff adherence to infection control protocols. The failure to implement these precautions properly had the potential to affect other residents in the facility.
Expired CRMA Licenses Lead to Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that licensed staff were administering medications, which affected 21 residents out of 24 reviewed for medication administration. The issue arose when two State Tested Nursing Assistants (STNAs), identified as #433 and #407, administered medications with expired Certified Registered Medication Aide (CRMA) licenses. This noncompliance was discovered through a review of medical records, medication administration records, staffing assignments, and CRMA licenses. The expired licenses of STNA #433 and STNA #407 were identified during the survey, revealing that they had administered medications on multiple occasions with expired certifications. Interviews with the facility's Administrator and Regional Clinical Support Registered Nurse (RCSRN) confirmed the oversight and the subsequent identification of the issue. The facility census at the time was 56, and the deficiency was investigated under Complaint Number OH000154300.
Failure to Notify Nephrologist of Abnormal Lab Results
Penalty
Summary
The facility failed to timely notify the nephrologist of abnormal laboratory test results for a resident with a history of type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease stage 3, and hypokalemia. The resident, who had severely impaired cognition and required assistance for daily activities, had laboratory tests ordered by a Certified Nurse Practitioner (CNP) after a fall and elevated blood sugars. Despite the order for a Comprehensive Metabolic Panel (CMP) and other tests on 05/10/24, the tests were not drawn until 05/28/24, with results available on 05/30/24. The results showed critically high levels of BUN, creatinine, and potassium, indicating a need for urgent medical attention. The CNP requested that the laboratory results, along with the resident's medication list and vital signs, be sent to the nephrology clinic on 05/31/24. However, due to a failure in communication and verification, the results were sent to the wrong nephrology clinic. Interviews revealed that the Director of Nursing (DON) faxed the results without confirming the correct recipient, leading to a delay in the nephrologist receiving the critical information. The nephrology clinic confirmed that they did not receive the results and would have treated the resident's elevated potassium and creatinine levels if they had been informed in a timely manner.
Failure to Provide Showers Per Resident Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers according to the resident's preference. The resident, who had moderate cognitive impairment and required substantial assistance for bathing, was admitted with several medical conditions including atrial fibrillation and congestive heart failure. Despite the resident's preference for three showers per week, the facility's schedule only allowed for two showers per week, and the resident received only two showers since admission, with several scheduled showers missed without proper documentation or offering. Interviews with staff revealed inconsistencies in the shower schedule and documentation practices. A State tested Nursing Assistant was unsure of the resident's scheduled shower days, and a Registered Nurse confirmed that there were issues with staff not offering showers and incorrectly documenting refusals. The Director of Nursing and a Regional Clinical Support RN confirmed the resident's limited showers since admission. The facility's policy required bathing at least twice a week unless otherwise preferred by the resident, which was not adhered to in this case.
Delayed Laboratory Tests for Resident with Multiple Health Conditions
Penalty
Summary
The facility failed to timely obtain laboratory tests as ordered by a physician for a resident with multiple health conditions, including type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease stage 3, and hypokalemia. The resident, who had severely impaired cognition and required assistance for daily activities, was evaluated by a Certified Nurse Practitioner (CNP) after a fall and elevated blood sugars. The CNP requested several laboratory tests, including thyroid stimulating hormone (TSH), hemoglobin A1c (HbA1c), complete blood count (CBC), and a comprehensive metabolic panel (CMP). However, these tests were not conducted in a timely manner. Despite multiple reminders and orders for the tests, they were not drawn until significantly later, resulting in a delay in obtaining critical laboratory results. When the CMP was finally conducted, it revealed critically high levels of blood urea nitrogen (BUN), elevated creatinine, and high potassium levels, indicating potential health risks for the resident. The delay was attributed to the laboratory orders not being entered correctly into the electronic system, as confirmed by the Director of Nursing (DON).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Maumee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Otterbein Monclova | 1.1 mi | ★★★★★ | 4 | 0 |
| Addison Heights Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 44 | 0 |
| Ridgewood Manor | 1.6 mi | ★★★★★ | 8 | 0 |
| Elizabeth Scott Community | 2.7 mi | ★★★★★ | 0 | 0 |
| Lutheran Village At Wolfcreek | 3.2 mi | ★★★★★ | 17 | 0 |
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