Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Health Care Center Inc during CMS and state inspections, most recent first.
The facility failed to consistently provide and document scheduled showers and bathing assistance for multiple residents who depended on staff for ADLs. Several residents with complex medical and cognitive conditions had care plans and physician orders specifying shower frequency and required staff assistance, yet electronic records showed many missed shower days with few or no refusals documented. Some residents reported not receiving showers as often as scheduled or preferred. Staff, including CNAs, an LPN, and a corporate QA RN, confirmed that showers were documented only in an electronic system, that documentation was an ongoing issue, and that if a shower was not documented it was considered not done, contrary to the facility’s own bath/shower policy based on resident preferences.
Incomplete accounting of resident trust funds: The facility failed to keep complete and accurate records for resident account withdrawals, with multiple cash withdrawals lacking receipts for 9 residents. The affected residents had diagnoses including Parkinson's disease, MS, dementia, bipolar disorder, MDD, anxiety, diabetes, HTN, and hyperlipidemia, and the missing documentation involved a total of $822.00 from accounts managed by the facility.
A cognitively intact resident with Parkinson’s disease, muscle wasting, and muscle weakness, who required substantial assistance with dressing, was observed lying in bed with the door and curtain open, wearing only a t-shirt and incontinence brief and without any blanket or sheet available for coverage, leaving the resident exposed and uncomfortable. Staff confirmed the resident was visible from the hallway and should have been covered. The same resident’s care plan required that the call light be kept within reach, yet on multiple occasions the call light was placed near the resident’s shoulder, beyond the resident’s functional reach due to limited arm and hand mobility. Staff acknowledged they had not ensured the call light was accessible, and a family member reported repeatedly finding the call light out of reach during visits.
A facility failed to monitor unexplained bruising on one resident with severe cognitive impairment and a history of falls, failed to follow a physician-ordered bowel protocol for another resident with chronic constipation monitoring needs, and failed to change a PICC dressing as ordered for a third resident. Staff were unaware of the bruises when first observed, bowel protocol steps were not implemented despite gaps in BM documentation, and the PICC dressing remained unchanged past the ordered weekly schedule.
Failure to implement pressure-relieving interventions for a resident with a history of an unstageable heel pressure ulcer. The resident had orders for heel offloading in bed and a wedge cushion under the feet while in a Broda chair, but staff observed the left foot resting directly on the chair footrest and later on the mattress surface without a pressure-relieving device, while a boot was in place on the right foot.
Infection control failures occurred during medication administration for two residents. An RN dropped a pill during med pass for a resident with dementia, picked it up with a bare hand from the resident’s blanket, returned it to the cup, and continued administering the meds. In a separate event, an LPN administered IV vancomycin through a PICC to a resident with a chronic wound and osteomyelitis without wearing a gown, despite an EBP order and facility policy indicating EBP for central line IV access.
A resident with multiple risk factors for pressure ulcers did not receive comprehensive and individualized prevention and assessment, as staff failed to remove a protective dressing during weekly skin checks and did not document the condition of the skin beneath. This led to the development and infection of a Stage II pressure ulcer, which was only identified after the resident was hospitalized and required surgical intervention.
Staff failed to follow hand hygiene protocols during medication administration and incontinence care. An LPN administered oral medications to multiple residents without performing hand hygiene between each resident, and a CNA did not remove soiled gloves or sanitize hands after providing incontinence care before assisting a resident with other tasks. These actions were in direct violation of the facility's infection prevention and control policy.
A resident in an LTC facility, who was cognitively impaired and dependent on staff for all ADLs, was subjected to verbal and physical abuse by an STNA during incontinence care. The STNA forcefully rolled the resident, causing breathing difficulty, and repeatedly poked the resident's ear with dirty gloves. Two other STNAs present did not intervene. The incident was captured on video, leading to the termination of the involved staff.
A facility failed to re-admit a resident after hospitalization, despite having open beds and no documented reason related to the resident's welfare, health, or safety. The resident, who was cognitively intact and had multiple diagnoses, initially expressed a desire not to return but later attempted to come back. The facility did not collaborate with the hospital for alternate placement, and there was no evidence of a signed document stating the resident did not want to return. This action violated the resident's rights as outlined by CMS.
The facility failed to ensure adequate RN coverage for at least eight consecutive hours a day, seven days a week, affecting all 101 residents. Multiple days within the quarter had no RN present, and the Facility Annual Assessment did not reference the required RN coverage. The Regional Administrator confirmed the absence of RNs on the specified days.
The facility failed to implement Contact Precautions for a resident diagnosed with E. coli and ESBLs in the urine. The resident was observed without the necessary precautions in place, including the absence of appropriate signage and being seen in a common area. An LPN confirmed the active order for Contact Precautions, highlighting a significant lapse in infection control measures.
The facility failed to implement their abuse policy and conduct thorough investigations for an injury of unknown origin for a severely cognitively impaired resident and an allegation of staff-to-resident abuse for a resident with ALS. Both investigations lacked critical documentation, including signed witness statements and skin assessments.
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and an allegation of staff-to-resident abuse for another resident. The investigations lacked proper documentation, witness statements, and skin assessments, contrary to the facility's policy on Resident Abuse Prevention Practices.
The facility failed to develop a comprehensive care plan for the care and maintenance of an enteral feeding tube for a resident with multiple diagnoses, despite having physician's orders for enteral feedings and flushes. This was confirmed by the Corporate QA Nurse.
A resident with severe cognitive impairment and hemiplegia was observed twice without the required pillow to elevate his left arm while in a wheelchair. An LPN confirmed the absence of the pillow, violating the facility's policy on wheelchair use.
The facility failed to ensure hearing aids were ordered and available for two residents. One resident, despite being recommended for hearing aids, never received them, causing distress. Another resident lost a hearing aid, and the facility did not follow up to replace it. The facility did not adhere to its policy on ensuring proper treatment and assistive devices for hearing.
The facility failed to complete dialysis assessments as ordered and ensure reliable transportation for two residents requiring dialysis. Both residents experienced missed or delayed dialysis appointments due to transportation issues, and multiple pre- and post-dialysis assessments were not completed. Interviews with QA nurses confirmed these deficiencies.
The facility failed to ensure clear instructions for narcotic pain medication use and did not attempt non-pharmacological interventions before administering pain medication to two residents, one cognitively intact and the other severely cognitively impaired, despite having a policy requiring such measures.
The facility failed to ensure appropriate diagnoses and rationale for prescribed medications for two residents. One resident was prescribed Klonopin for dementia, which is contraindicated, and another was prescribed Ativan without a documented diagnosis. This was confirmed by a registered nurse and violated the facility's policy on psychotropic medications.
A resident, admitted with major depressive disorder, anxiety, and muscle weakness, consented to receive the pneumococcal polysaccharide vaccine (PPSV 23). However, a review of the medical record revealed no documentation of the vaccination being administered. This was confirmed by the Corporate QA Nurse.
The facility failed to ensure staff spoke to a resident in a dignified manner. An STNA was observed hollering into a resident's room instead of entering, despite the resident's request for different incontinence briefs. The STNA cited the need to put on an isolation gown, although facility policy indicated that personal protective equipment was only necessary for direct personal care. This incident was verified by an LPN and highlighted a failure to adhere to the facility's policies on dignity and respect.
The facility failed to provide adequate oral care for a resident with chronic conditions and fingernail care for another resident with dementia. Despite requiring assistance, both residents were observed with unkempt personal hygiene, contrary to the facility's policies.
Failure to Provide and Document Scheduled Showers per Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers and bathing assistance according to resident care plans, physician orders, and stated preferences for multiple residents who required staff assistance. For one resident with major depressive disorder, hypertension, congestive heart failure, chronic kidney disease, and other conditions, the care plan required one-person assistance for bathing and use of a sit-to-stand lift, with showers scheduled twice weekly. Review of electronic shower documentation over a six‑month period showed that this resident received 21 showers and two bed baths out of 50 scheduled shower days, with only six refusals documented. Facility staff, including a CNA and an LPN, stated that showers were documented only in the electronic system and that if documentation was blank, the shower was not provided. The LPN and a corporate QA RN acknowledged that shower documentation had been an ongoing concern. Another resident with vertigo, anxiety disorder, muscle wasting and atrophy, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction, and muscle weakness had a care plan requiring two‑person assistance for bathing and a mechanical lift, with showers scheduled twice weekly. The annual MDS did not specify the level of assistance for showering/bathing, marking the item as not applicable. Review of shower records over a six‑month period showed this resident received eight showers and 11 bed baths out of 52 scheduled shower days, with only one documented refusal. The resident reported not receiving showers as often as desired. Staff interviews confirmed that showers were documented electronically, that documentation was problematic, and that if a shower was not documented, it was considered not done. A third resident with Alzheimer’s disease, dementia with psychotic disturbance, adjustment disorder with anxiety, muscle weakness, and a history of repeated falls had a care plan for one‑person assistance with bathing and transfers, and the MDS indicated a need for substantial or maximal assistance with showering/bathing. This resident was scheduled for showers twice weekly but received nine showers out of 13 scheduled days with no refusals documented, and reported not getting showers as scheduled. Another resident admitted with a periprosthetic fracture around a left knee prosthesis required two‑person assistance and was to receive showers twice weekly, with a documented preference for specific days. Over a 93‑day period with 26 scheduled shower days, this resident received only nine showers/bed baths with one refusal documented and reported having only one shower in the past month. Despite an in‑service on shower documentation, subsequent records still showed missed scheduled showers without refusal documentation. A fifth resident with severe cognitive impairment and multiple diagnoses, including major depressive disorder, GERD, generalized anxiety, aphasia, dysphagia, stroke, bone disorders, bradycardia, and obesity, had physician orders for showers three times weekly and a requirement to notify family if the resident refused. Progress notes indicated this resident often refused personal care, including showers and incontinent care. Review of CNA shower documentation over a six‑month period showed 79 scheduled showers, with 46 provided and three refusals documented. The resident’s daughter reported that the resident had not been receiving all ordered showers for several months. The Nurse Aide Supervisor verified that documentation did not show the resident received showers in accordance with physician orders. Across all five residents, the facility’s own policy stated that bath and shower frequency was to be based on resident preference as noted on the care plan, yet records and interviews demonstrated that scheduled showers and resident preferences were not consistently followed or documented.
Incomplete Accounting of Resident Trust Funds
Penalty
Summary
The facility failed to maintain complete and accurate records for resident funds accounts for 9 of 15 residents reviewed. Record review showed multiple cash withdrawals from resident trust accounts with no receipts available to verify the transactions, including residents with withdrawals ranging from $5.00 to $360.00. The missing receipts affected residents #16, #45, #49, #59, #63, #68, #124, #125, and #126, and the total amount involved was $822.00. The residents involved had varied medical histories, including Parkinson's disease, multiple sclerosis, bipolar disorder, anxiety disorder, major depressive disorder, dementia, Alzheimer's disease, diabetes, hypertension, hyperlipidemia, and cerebral infarction. Several residents had no cognitive impairment on MDS assessments, while residents #124 and #125 had severe cognitive impairment. The transaction histories for these residents documented cash withdrawals from accounts managed by the facility, but the corresponding receipts were not available. The facility's investigation of SRI tracking number 271333 found the same nine residents had cash withdrawals with no receipts documented. The Administrator stated the alleged perpetrator was interviewed and said there may have been bookkeeping errors related to health issues, but denied taking money from resident accounts. The facility was unable to locate receipts confirming the withdrawals occurred, and the Administrator stated the funds were replaced out of good faith despite no proof that the money had been misappropriated.
Failure to Maintain Resident Dignity and Ensure Accessible Call Light
Penalty
Summary
The deficiency involves the facility’s failure to maintain dignity, privacy, and appropriate coverage for a cognitively intact resident with Parkinson’s disease, muscle wasting, muscle weakness, and adult failure to thrive. The resident, admitted in late June 2025 and requiring substantial/maximal assistance with upper and lower body dressing, was observed lying in bed with the room door and privacy curtain open, wearing only a t-shirt and incontinence brief, and without any blanket or sheet available for covering. The resident stated he was not comfortable being uncovered and exposed and wanted to be covered. A personal care aide confirmed that the resident could be seen from the hallway, had no blanket or sheet, was only in a t-shirt and incontinence brief, and acknowledged the resident should have been covered. The facility also failed to ensure the resident’s call light was within reach, despite a care plan directive that staff ensure the call light remained accessible. On multiple observations, the resident was lying in bed with the call light placed near or over his right shoulder, which he confirmed he could not reach due to limitations in his hands and arms. One personal care aide confirmed at the time of observation that the resident could not reach the call light, and another aide admitted she had completed personal care and left the room without ensuring the call light was within reach. A physical therapist reported that, due to Parkinson’s disease, the resident’s ability to move his arms and hands varied by day but was limited on an ongoing basis. The resident’s uncle reported that on numerous occasions during visits he observed the call light was not within the resident’s reach.
Failure to Monitor Bruising, Follow Bowel Protocol, and Change PICC Dressing
Penalty
Summary
The facility failed to identify and monitor bruises for a resident with a history of repeated falls, a right hip replacement, a displaced right femur neck fracture, and severe cognitive impairment. On 03/02/26, ecchymotic areas were observed on the resident’s left upper arm and right wrist, but no documentation could be located related to the bruises. When an LPN was asked about the bruising, she stated she was unaware of it and that there was no documentation in the medical record. The resident was later observed again with bruises on both upper extremities and the right wrist, and a nursing note documented small bruises to both upper arms and the right wrist. The bruising was reassessed the next day with an RN and the resident’s son-in-law present. The resident was observed with a light purple quarter-sized area to the left bicep, a light purple/green half-dollar sized bruise to the right bicep, and a light/medium purple area to the right wrist described as petechiae. The bruises on both arms were directly in line with the edges of the underlying Hoyer pad in the Broda chair. The son-in-law reported the resident had a history of bruising related to very fragile skin, and the note indicated a plan to implement a larger Hoyer pad for transfers. The facility also failed to implement a bowel protocol and physician orders for another resident with chronic pain and vascular dementia who was severely cognitively impaired and incontinent of bowel. The physician ordered a stepwise bowel regimen if the resident did not have a bowel movement in 48 hours, including high fiber juice or prune juice, Milk of Magnesia, and Dulcolax suppository with abdominal evaluation. Bowel movement records showed gaps in documented bowel movements, but as of the morning of 03/03/26 there was no evidence that the ordered bowel protocol had been carried out. Corporate QA RN later verified that staff did not implement the bowel protocol, and another RN stated the facility expected floor nurses to follow the protocol based on a daily report. The facility further failed to change a resident’s PICC line dressing weekly as ordered. The physician ordered the PICC dressing to be changed weekly on Mondays, starting 03/02/26, but observations on 03/02/26 and again on 03/04/26 showed the dressing was still dated 02/23/26 with dried blood under the sterile dressing. An LPN confirmed the dressing had not been changed as ordered.
Failure to Implement Pressure-Relieving Interventions
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for one resident with diagnoses including chronic anemia, dementia, and right hip fracture. The resident was admitted with an unstageable pressure ulcer to the right heel, and the record showed orders to offload heels in bed for preventative skin care and later to use a wedge cushion under the feet while in the Broda chair. A plan of care also identified the resident as having potential or actual impairment to skin integrity related to incontinence, muscle wasting and atrophy, muscle weakness, fracture, hypertension, hypothyroidism, dementia, deep vein thrombosis, depression, and anemia, with interventions to identify and eliminate or resolve causative factors where possible. Although the right heel pressure ulcer was later documented as resolved, the orders for heel offloading in bed and the wedge cushion in the Broda chair remained in place. During observation, the resident was seen sitting in a Broda chair with the left foot resting on the foot of the chair and no wedge observed, despite signs posted to apply a boot when up in the wheelchair. A CNA stated there was a boot on the right foot but no wedge or other device to relieve pressure on the left heel, and an LPN later verified that while the resident was lying in bed, the right foot had a boot but the left foot was resting directly on the mattress surface.
Infection Control Failures During Medication Administration
Penalty
Summary
The facility failed to implement appropriate infection control protocols during medication administration for one resident with impaired cognitive function and dementia. On 03/03/26 at 8:49 A.M., an RN was observed administering medications to the resident using a small plastic cup and a plastic spoon. During the process, one pill dropped onto the blanket on the resident’s lap. The RN picked up the pill with her bare hand, returned it to the plastic cup with the other pills, and then used the plastic spoon to administer the remaining medications. The RN later confirmed that she picked up the pill from the blanket with her bare hand and stated that this was not proper protocol. The facility also failed to wear appropriate PPE while administering IV medication to a resident with type two diabetes mellitus, a foot ulcer, local skin and subcutaneous tissue infection, acquired absence of right toe(s), and osteomyelitis of the right ankle and foot. The resident had an order for EBP during high-contact resident care activities while having an indwelling medical device or chronic wound, and had orders for IV vancomycin through a PICC line and for weekly PICC/midline cap and dressing changes. On 03/03/26 at 8:20 A.M., an LPN was observed administering vancomycin through the PICC without wearing a gown. The LPN later verified that she did not wear a gown during the administration. The facility policy reviewed stated that EBP was indicated for indwelling medical devices including central line IV access.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Assessment
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident who was at high risk for pressure ulcers due to multiple comorbidities, including severe protein-calorie malnutrition, diabetes mellitus, and limited mobility. The resident was dependent on staff for most activities of daily living, was always incontinent of urine, frequently incontinent of bowel, and had a history of a healed pressure ulcer to the coccyx. Despite these risk factors, the facility's plan of care and physician's orders included preventative measures such as pressure-reducing devices and a protective dressing to the coccyx, but there was a lack of effective ongoing monitoring and documentation regarding the condition of the skin under the dressing. Weekly skin assessments were documented as completed by nursing staff, but interviews and record reviews revealed that the dressing on the coccyx was not removed during these assessments, and there was no actual evaluation of the skin beneath the dressing. The wound nurse confirmed that the assessments were incomplete and that she was not notified of any new pressure ulcer development. The staff documented that dressing changes were performed as ordered, but there was no description of the skin's condition under the dressing throughout the resident's stay. The deficiency resulted in actual harm when the resident experienced an acute change in condition and was hospitalized. Upon hospital admission, the resident was found to have a Stage II pressure ulcer with extensive gas-forming soft tissue infection at the lower back, requiring surgical intervention. The hospital assessment indicated that the pressure ulcer had become infected during the resident's stay at the facility, and the facility's own staff and quality assurance nurse acknowledged that adequate and ongoing assessments were not completed.
Failure to Perform Hand Hygiene During Medication Administration and Incontinence Care
Penalty
Summary
Staff failed to perform proper hand hygiene during medication administration and incontinence care, as observed and documented in the facility. An LPN administered oral medications to multiple residents consecutively without performing hand hygiene between residents. Specifically, after administering medications to one resident, the LPN did not sanitize or wash hands before preparing and administering medications to the next resident, only stopping when prompted by an observer. The LPN confirmed during an interview that hand hygiene was not performed between these tasks. In a separate incident, a CNA provided incontinence care to a resident with multiple medical conditions, including bowel and bladder incontinence, without removing soiled gloves or performing hand hygiene after cleaning the resident. The CNA then assisted the resident with additional tasks, such as donning clothing and preparing for transfer, while still wearing the same soiled gloves. The CNA acknowledged during an interview that gloves should have been removed and hand hygiene performed after completing the incontinence care. The facility's hand hygiene policy, based on CDC guidelines, requires staff to perform handwashing or use alcohol-based hand rubs at specific times, including before and after resident contact, after glove removal, and after contact with potentially contaminated surfaces. The observed failures to follow these procedures directly contravened the facility's established infection prevention and control protocols.
Resident Abuse by Staff in LTC Facility
Penalty
Summary
The facility failed to protect Resident #16 from abuse, resulting in an incident of verbal and physical abuse by staff. On the date of the incident, Resident #16, who was cognitively impaired and dependent on staff for all activities of daily living, was subjected to rough handling during incontinence care by STNA #434. The resident's face was forcefully pushed into a pillow, causing him to struggle to breathe and yell for help. Additionally, STNA #434 repeatedly poked the resident in the ear with dirty gloves, further agitating him. Two other STNAs, #435 and #436, were present during the incident but did not intervene or report the abuse. Resident #16 had a complex medical history, including hemiplegia, dysphagia, anxiety, and chronic obstructive pulmonary disease, and was receiving hospice services. The resident's care plan noted a tendency for verbal aggression and outlined interventions to manage such behavior, including medication administration and calm engagement. Despite these measures, the staff's actions during the incident were inappropriate and abusive, as evidenced by the video footage reviewed by the facility and the Ombudsman. The abuse was substantiated through multiple interviews and video evidence, which showed STNA #434's inappropriate behavior and the failure of other staff members to act. The resident's family had installed a camera in the room due to the resident's cognitive impairment, which captured the incident. The video showed STNA #434's rough handling and verbal abuse, as well as the lack of intervention by STNAs #435 and #436. The facility's policy on abuse prevention was not followed, leading to the termination of the involved staff members.
Facility Fails to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after being sent to the hospital, violating the resident's rights. The resident, who was cognitively intact, had been admitted with multiple diagnoses including a displaced fracture and bipolar disorder. Upon requesting to go to the hospital due to severe cramps, the resident initially expressed a desire not to return to the facility. However, when the resident attempted to return from the hospital, the facility refused re-admittance, despite having open beds and no documented reason related to the welfare, health, or safety of the resident or others. The facility did not collaborate with the hospital for alternate placement, nor was there evidence that the resident signed a document stating she did not want to return. The resident contacted the Ombudsman, who confirmed the facility's failure to take appropriate action. The facility's actions were not in compliance with the resident's rights as outlined by CMS, which state that a resident cannot be made to leave unless specific conditions are met, none of which were applicable in this case.
Inadequate RN Coverage
Penalty
Summary
The facility failed to ensure there was adequate Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week as required. This deficiency had the potential to affect all 101 residents residing in the facility. Review of the Payroll Based Journal (PBJ) Staffing Data Report and Nursing Assignment forms revealed multiple days within the quarter where no RN was present in the facility. Specifically, the facility had four or more days with no RN coverage and a one-star staffing rating. The Facility Annual Assessment did not reference the requirement for at least eight consecutive hours of RN coverage daily. Interviews with the Regional Administrator confirmed the absence of RNs on the specified days and verified the accuracy of the PBJ Report.
Failure to Implement Contact Precautions
Penalty
Summary
The facility failed to implement Contact Precautions as ordered for a resident diagnosed with Escherichia coli (E. coli) and extended-spectrum beta-lactamases (ESBLs) in the urine. The resident, who was moderately cognitively impaired and required substantial assistance for daily activities, was observed without the necessary Contact Precautions in place. Specifically, there was no sign indicating Contact Precautions on the resident's door, and the resident was seen in a common area, contrary to the requirements for such precautions. An LPN confirmed that the order for Contact Precautions was still active, despite the resident not being in isolation. The facility's policy and CDC guidance require the use of gown and gloves on every entry into the resident's room and restrict the resident to their room except for medically necessary care. However, these protocols were not followed, as evidenced by the resident's presence in a common area and the absence of appropriate signage. This oversight had the potential to affect all residents on the East Wing, as the necessary infection control measures were not properly implemented for the resident in question.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement their abuse policy regarding thoroughly investigating an injury of unknown origin for Resident #8 and an allegation of staff-to-resident abuse for Resident #77. Resident #8, who was severely cognitively impaired and required assistance for daily activities, was found with a bruise under her right eye and later a missing tooth. The investigation concluded that the resident had likely injured herself while trying to use the restroom, but it lacked signed and dated witness statements, interviews or skin assessments of other residents, and an assessment of Resident #8. The Administrator confirmed the absence of these critical elements in the investigation process. Resident #77, diagnosed with ALS and other conditions, alleged that a State tested Nurse Aide (STNA) had purposely pulled her hair while removing her glasses strap. The facility's investigation was incomplete, as the STNA avoided interviews and eventually had her employment terminated. The documentation consisted only of the SRI report form, a statement from Resident #77, and partial documentation of staff interviews. No skin assessments were completed for Resident #77, and the Administrator verified the lack of thorough documentation in the investigation. The facility's policy on Resident Abuse Prevention Practices required immediate and thorough investigation of any alleged, suspected, or observed abuse, including written statements and interviews with all involved parties. However, the facility failed to adhere to this policy in both cases, resulting in incomplete investigations and a lack of proper documentation and assessments.
Failure to Investigate Injury and Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and an allegation of staff-to-resident abuse for another resident. The first resident, who had diagnoses including dementia and acute kidney failure, was found with a bruise under her right eye and later lost a tooth. The investigation did not include signed and dated witness statements, interviews or skin assessments of other residents, or an assessment of the injured resident. The administrator confirmed the lack of documentation and witness statements during the investigation process. The second resident, diagnosed with ALS and major depressive disorder, alleged that a staff member purposely pulled her hair while removing her glasses strap. The staff member avoided the administrator's attempts to contact her and eventually did not show up for work, leading to her termination. The facility's investigation documentation was incomplete, consisting only of the SRI report form, a statement from the resident, and partial documentation of staff interviews. No skin assessments were completed for the resident involved in the incident. The facility's policy on Resident Abuse Prevention Practices requires thorough investigations, including immediate examination of the resident, appropriate medical attention, and written statements from all involved parties. However, the facility did not adhere to these procedures in both cases, resulting in incomplete investigations and insufficient documentation of the incidents.
Failure to Develop Comprehensive Care Plan for Enteral Feeding Tube
Penalty
Summary
The facility failed to develop a comprehensive care plan for the care and maintenance of an enteral feeding tube for Resident #92. The resident, who was admitted with diagnoses including muscle wasting and atrophy, dysphagia, dementia, and chronic kidney disease, had physician's orders for enteral feedings and flushes since 12/18/23. Despite these orders, the comprehensive care plan revised on 04/25/24 did not include any plan for the enteral feeding tube. This was confirmed during an interview with the Corporate Quality Assurance Nurse on 05/01/24, who verified the absence of a care plan for the enteral feeding tube.
Failure to Provide Proper Positioning in Wheelchair
Penalty
Summary
The facility failed to provide proper positioning in a wheelchair as ordered for Resident #10. Resident #10, who has severe cognitive impairment and multiple diagnoses including hemiplegia following a cerebral infarction, was observed on two occasions without the required pillow to elevate his left arm while in the wheelchair. On one occasion, his left arm was wedged between his body and the wheelchair, and on another, his left arm was resting on his lap without the pillow. An LPN confirmed the absence of the pillow during the observation. The facility's policy on wheelchair use mandates that all positioning devices be in place as ordered, which was not adhered to in this case.
Failure to Provide Hearing Aids for Residents
Penalty
Summary
The facility failed to ensure hearing aids were ordered and available as needed for two residents. Resident #3, who has Alzheimer's disease, chronic pain, depression, end stage renal disease, hypertension, and unspecified hearing loss, was recommended for hearing aids following an audiology visit. Despite being cognitively intact and having a care plan that included interventions for her hearing deficit, the facility did not follow up on the recommendation for hearing aids. The resident expressed distress over the delay, and the Registered Nurse confirmed that the recommendation was never acted upon by the facility. Resident #13, who has chronic obstructive pulmonary disease (COPD), muscle weakness, and anemia, was severely cognitively impaired and required hearing aids as per physician's orders. Despite the care plan specifying the use of bilateral hearing aids, the resident lost one of her hearing aids, and the facility did not follow up with the resident or her family to replace the device. The Registered Nurse confirmed the loss and the lack of follow-up. The facility's policy on ensuring proper treatment and assistive devices for hearing was not adhered to in these cases.
Failure to Ensure Timely Dialysis Assessments and Reliable Transportation
Penalty
Summary
The facility failed to complete dialysis assessments according to the physician's orders and ensure reliable transportation for residents requiring dialysis services. Resident #35, diagnosed with end-stage renal disease and other conditions, had multiple instances where the contracted transportation company failed to arrive on time or at all, leading to missed dialysis appointments. Additionally, pre-dialysis and post-dialysis assessments were frequently not completed as ordered on several dates from March to April 2024. Clinical QA Nurse #647 confirmed these issues during an interview, and the facility's agreement with the dialysis center indicated the facility's responsibility for obtaining timely and professional services. Resident #406, also diagnosed with end-stage renal disease and congestive heart failure, experienced similar issues with transportation and missed dialysis appointments. On one occasion, the resident had to be sent to the emergency room for dialysis due to the transportation company's failure to arrive. The resident also missed several hours of dialysis treatment due to late arrivals and missed appointments. The facility's dialysis assessments for this resident were also incomplete on multiple dates. Interviews with Clinical QA Nurse #647 and Corporate QA Nurse #648 confirmed the transportation issues and incomplete assessments. The facility's policy indicated that they would work with contracted transport companies and had access to a company wheelchair-accessible van for transportation needs. However, the policy also noted that the company's transport availability was limited and needed to be scheduled in advance. The facility's agreements with the dialysis centers for both residents stated that the facility was responsible for the development and implementation of the care plan, including ensuring timely and professional dialysis services.
Failure to Ensure Clear Instructions and Non-Pharmacological Interventions for Pain Management
Penalty
Summary
The facility failed to ensure clear instructions were in place for the use of narcotic pain medication and did not ensure non-pharmacological interventions were attempted prior to the administration of pain medication. This deficiency affected two residents, one of whom was cognitively intact and the other severely cognitively impaired. Both residents had multiple diagnoses, including heart failure, muscle wasting, hypertension, diabetes, depression, insomnia, chronic kidney disease, and dementia. For Resident #53, the medical record review revealed that the resident received multiple doses of Hydrocodone and Acetaminophen for varying pain levels over several months. However, there was no documented evidence that non-pharmacological interventions were attempted before administering these medications. An interview with an LPN confirmed that non-pharmacological interventions should be attempted and documented prior to administering prn pain medications, but there was no guidance or scale used to determine when to administer narcotic pain medications. Similarly, for Resident #64, the medical record review showed that the resident received multiple doses of Tramadol and Acetaminophen for varying pain levels. Again, there was no documented evidence that non-pharmacological interventions were attempted before administering these medications. The same LPN confirmed the lack of guidance or scale for administering narcotic pain medications. The facility's policy on pain management, which required the use of a 1-10 scale to determine pain intensity and the attempt of non-pharmacological interventions before administering pain medications, was not followed.
Inappropriate Psychotropic Medication Prescriptions
Penalty
Summary
The facility failed to ensure appropriate diagnoses and rationale for prescribed medications for two residents. Resident #22, who has dementia, depression, diabetes, breast cancer, and Parkinson's disease, was prescribed Klonopin for dementia, which is not an approved use and is contraindicated for her condition. This was verified by a registered nurse during an interview. The resident's medical record and physician's orders did not provide a valid rationale for this prescription. Similarly, Resident #53, who has heart failure, muscle wasting, hypertension, diabetes, depression, and insomnia, was prescribed Ativan for restlessness or anxiety without a documented diagnosis to support its use. This was also confirmed by a registered nurse during an interview. The facility's policy on psychotropic medications, which mandates that residents receive medications only for assessed and documented medical conditions, was not followed in these cases.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide a pneumococcal vaccination to Resident #77 after consent was given. Resident #77, who was admitted with diagnoses including major depressive disorder, anxiety, and muscle weakness, agreed to receive the pneumococcal polysaccharide vaccine (PPSV 23) on 03/07/23. However, a review of the medical record revealed no documentation that the vaccination had been administered. This was confirmed during an interview with the Corporate Quality Assurance (QA) Nurse, who verified that there was no evidence of the vaccine being given to Resident #77.
Failure to Ensure Dignified Communication with Resident
Penalty
Summary
The facility failed to ensure staff spoke to Resident #15 in a dignified manner. Resident #15, who was admitted with multiple diagnoses including chronic respiratory failure, congestive heart failure, diabetes mellitus type two, depression, anxiety, hypertension, and morbid obesity, was also on Enhanced Barrier Precautions (EBP). During an observation, a State tested Nurse Aide (STNA) was seen standing at the doorway of Resident #15's room and hollering into the room instead of entering. The resident requested different incontinence briefs and asked the STNA to come into the room, but the STNA refused, citing the need to put on an isolation gown. This interaction was verified by a Licensed Practical Nurse (LPN) who was present in the hallway at the time of the incident. The facility's policy on EBP indicated that personal protective equipment was only necessary when providing direct personal care and not needed for entering the room to talk. Additionally, the facility's policy on dignity, respect, and privacy emphasized that all residents should be treated with kindness, dignity, and respect whenever they are talked with, cared for, or talked about. The deficiency was identified during a complaint investigation and was found to affect one resident directly but had the potential to affect all residents in the facility. The facility census at the time was 101. The incident was documented under Complaint Number OH00152199, and it highlighted a failure to adhere to the facility's policies on both Enhanced Barrier Precautions and the treatment of residents with dignity and respect.
Failure to Provide Adequate Personal Care
Penalty
Summary
The facility failed to provide adequate oral care for Resident #23 and fingernail care for Resident #50. Resident #23, who was admitted with chronic kidney disease, acute kidney failure, diabetes mellitus type two, cerebral infarct, and muscle wasting, was observed on two separate occasions with a white buildup between his lower teeth. Despite being cognitively intact and requiring assistance for grooming and hygiene, there was no documented evidence that oral care had been provided or refused. The facility's policy required staff to assist with oral hygiene in the morning and evening, which was not adhered to in this case. Resident #50, admitted with unspecified dementia, depression, weakness, hypertension, and diabetes mellitus type two, was observed with long, dirty fingernails containing a black substance. Despite needing assistance for bathing and hygiene, the resident's fingernails remained unkempt over multiple observations. The facility's policy mandated that fingernail care be performed during or after the resident's shower and as needed, which was not followed. This deficiency was confirmed by a State tested Nurse Aide (STNA) who acknowledged the unkept fingernails during an observation.
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What surveyors actually found near you
We read the 545 citations issued within 25 miles in the last 12 months — including the 9 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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Youngstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor Jewish Hm For | 2.2 mi | ★★★★★ | 2 | 0 |
| Shepherd Of The Valley Liberty | 2.3 mi | ★★★★★ | 13 | 0 |
| Windsor Health Care Center | 3 mi | ★★★★★ | 1 | 0 |
| Park Vista Nursing And Rehab | 3.3 mi | ★★★★★ | 5 | 0 |
| Omni Manor Nursing Home | 4.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.