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 Main Street Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, wheelchair use, and a history of multiple skin issues, including prior pressure injuries, was care planned for skin integrity but developed an avoidable deep tissue pressure injury (DTPI) to the right knee associated with an undocumented knee immobilizer. After a fall and diagnosis of a right hip fracture, the resident’s right lower extremity was immobilized without a documented physician order for a knee immobilizer, and there was no evidence of skin assessment under or around the device. On readmission from the hospital, staff documented only a right knee abrasion, and no treatment orders were initiated until a wound CNP later identified a circumferential DTPI consistent with brace-related injury. Interviews confirmed no written order for the immobilizer, uncertainty about who applied it and for how long, and a delay in wound evaluation, demonstrating failures to recognize device-related pressure injury risk, monitor the device, and promptly treat the new wound.
A resident with dementia, Alzheimer’s disease, and multiple comorbidities was identified as high risk for falls and care planned for safety, including non-skid footwear and supervision in common areas, yet experienced multiple falls resulting in serious injuries over time. The facility repeatedly failed to provide or document comprehensive fall investigations, did not substantiate its claim that orthostatic hypotension caused one fall, and did not demonstrate that key interventions such as proper footwear and ordered safety checks were in place at the time of several falls. The resident fell in her room, while on C. diff isolation, near the nurses’ station, and in the secured unit dining room, sustaining an L3 compression fracture, head laceration requiring staples, a right hip fracture, and later multiple rib and wrist fractures and facial laceration. Staff interviews revealed gaps in supervision, incomplete communication about the resident’s restlessness and agitation, and lack of clear determination of fall causes, while the facility withheld fall investigations as QAPI and could not show that fall risks and behaviors were adequately assessed and addressed.
Meals were not kept at acceptable temperatures during tray line service. Steam table foods were observed at varying temperatures, and a test tray later showed ground beef, Spanish rice, and pureed items at temperatures that were warm but not hot enough for preference. The dietary staff member confirmed the Spanish rice and pureed items were not warm enough, and facility policy required food to be maintained and served at proper temperatures.
Improper Storage of Refrigerated and Expired Medications: A medication storage area contained an expired stock bottle of NAD tablets and a medication refrigerator that held resident meds alongside food items, including a frozen meal and an unidentified sandwich with fruit. The refrigerator stored multiple resident and facility-stock meds, including insulin, GLP-1 injectors, pantoprazole suspension, and suppositories, and an RN confirmed the findings.
Failure to follow the approved menu and therapeutic diet orders occurred when dietary staff did not provide all listed taco ingredients during meal service and ran out of tomatoes for several trays. An aide requested salsa for one resident, but none was available, and two residents on pureed diets did not receive the pureed cookie listed on the production sheet; staff instead reported giving a magic ice cream cup.
Kitchen staff failed to follow hand hygiene and personal hygiene practices during meal service. A cook with a beard was observed without a beard net, two cooks carried resident plates out of the kitchen and returned to the serving line without washing hands or changing gloves, and a dietary aide entered the kitchen area without a hair net. Facility policy required handwashing when entering or returning to the dietary department and hair restraints and beard coverings while serving or preparing food.
Delayed Access to Eyeglasses: The facility failed to ensure a resident received new eyeglasses in a timely manner after an optometry visit for blurry vision. The resident, who was cognitively intact and had DM and COPD, was observed waiting months for glasses and was using a damaged pair. The optometry note documented a new Rx and selected frames, but there was no timely follow-up by the SSD or evidence that insurance verification or private-pay notification was completed.
Hospice Care Plan and Care Conference Not Documented: A resident with lung cancer with metastasis, palliative care, and moderate cognitive impairment was receiving hospice services, but the facility did not have a hospice-provided care plan in the chart or hospice binder. A care conference was held with facility department managers and the resident, but hospice was not included, and staff confirmed hospice visit summaries were not in the medical record.
A resident with cognitive impairments was found outside the facility after an unwitnessed fall, having pushed through a window screen. Despite being assessed with no injuries, the incident was not reported to the State Agency as required. The facility's policy on elopement and reporting was not followed, as the incident was not reported as an elopement, and an investigation was not completed.
A resident with multiple diagnoses, including dementia, was found outside the facility after an unwitnessed fall. Despite being high risk for falls, the incident was not documented as an elopement, and no report was filed with the State Agency. The resident was last seen in the dining room and later found on the grass outside, but the incident was not immediately reported to management. Documentation errors and miscommunications contributed to the deficiency.
A resident with moderate cognitive impairment and a history of dementia eloped from the facility by pushing through a window screen. The resident was found outside by staff after another resident reported hearing calls for help. The incident was not immediately reported to management, and the facility failed to follow its elopement policy, resulting in a deficiency in supervision and response.
A resident with Parkinson's disease experienced a significant medication error due to a transcription mistake by an RN, receiving only one-third of the prescribed Carbidopa/Levodopa dose. This led to a decline in the resident's condition, including altered mental status and decreased mobility, resulting in hospitalization for evaluation. The facility's policies on medication administration and physician orders were not properly followed.
A resident at high risk for pressure ulcers developed a deep tissue injury after being left on a bedpan for an unknown duration. Despite care plans and interventions, the resident was not consistently turned and repositioned, leading to a serious pressure injury. The facility's staff could not determine who was responsible, and the situation was described as mortifying by a nurse involved.
The facility failed to provide appropriate incontinence care for three residents, leading to potential harm and discomfort. A resident with moderate cognitive impairment expressed frustration over delayed care, resulting in a small abrasion. Another resident was found with wet incontinence products and irritated skin due to delayed care. A third resident with severe cognitive impairment had soiled liners and dried feces on her skin, causing redness and irritation. The use of multiple liners, against manufacturer's instructions, was observed in all cases.
A resident with a history of alcohol dependence was found inebriated after receiving vodka from a visitor, despite having a care plan and physician's order restricting leave of absence. The facility failed to implement care planned interventions, and staff were unaware of multiple incidents of alcohol use. The facility did not provide a substance abuse treatment policy for review.
A resident with Parkinson's and dementia was inappropriately placed in a secured unit without proper clinical indication or authorization, leading to distress and an elopement incident. Despite being cognitively intact, the resident was confined based on verbal communication and assumptions, rather than documented evidence. The facility failed to secure the environment, allowing the resident to exit through a window, highlighting lapses in safety and communication.
A resident experienced significant delays in receiving assistance after activating her call light due to incontinence. Despite multiple staff members entering her room for other tasks, her request for help was not addressed for nearly an hour, leading to distress and refusal of a meal. Staff interviews confirmed the delay in response.
Failure to Prevent and Timely Treat Device-Related Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to evaluate and identify risk factors for pressure injuries, implement appropriate preventive interventions, and initiate timely treatment for a new avoidable pressure injury. The resident involved had Alzheimer’s disease with late-onset dementia, severe cognitive impairment, used a wheelchair, and was dependent on staff for lower body dressing. Her care plan, initiated shortly after admission and later revised, identified a potential for impaired skin integrity with a history of deep tissue injury to the right buttock, MASD to the buttocks, pressure injuries to both heels, and a prior area to the right knee, with goals to maintain preventive measures and avoid new skin breakdown. Interventions included minimizing pressure on bony prominences, but the facility did not identify or document the presence of a right knee immobilizer or assess the skin under or around it during the relevant period. On one date, the resident fell and was evaluated by a CNP, who ordered x‑rays of the right lower extremity and hip. The following day, documentation indicated the resident complained of pain, was to remain in bed and non‑weight bearing, and that her right lower extremity was immobilized, but there was no physician order or documentation specifying a right knee immobilizer. Physician progress notes confirmed an acute hip fracture and continuation of non‑weight‑bearing status, with no recommendation for a knee immobilizer. From the date of the fall through the resident’s subsequent hospitalization for right hip fracture repair, there was no evidence in the medical record that a knee immobilizer was ordered, applied, or monitored, nor that the skin at the right knee was assessed. Upon readmission after surgery, a progress note described a right knee abrasion with specific measurements and no depth, marked as not staged and with no mention of a pressure injury or immobilizer. The following day, a progress note documented that the resident’s daughter questioned staff about markings on the resident’s right knee from an immobilizer that had been on when the resident went to the hospital from an orthopedic appointment. The daughter reported she had not known about the brace until the surgeon called her before hip surgery to ask why the resident had a knee brace on, and the facility’s medical record contained no order for such a device. Assessment at that time revealed linear, closed indentations on the medial, lateral, and posterior aspects of the knee, and the area was scheduled for evaluation by a wound CNP two days later. No treatment order for the new area was entered until that wound evaluation, when the wound CNP documented a circumferential deep tissue pressure injury of the right knee, appearing to be from a brace, with detailed measurements and description of purple and maroon discoloration and intact, non‑blanching skin. Interviews with therapy and wound staff confirmed there were no orders for a knee immobilizer, that therapy staff may have applied an immobilizer based on a verbal request with the expectation an order would follow, and that the wound CNP did not see the resident until several days after readmission, despite the presence of the knee wound. The survey referenced National Pressure Injury Advisory Panel guidelines stating that residents should be considered at risk for pressure injury when a medical device is applied and that staff should frequently evaluate, resize, or reposition such devices, and a facility policy requiring comprehensive skin assessment and preventive planning upon admission for residents at risk.
Failure to Investigate and Prevent Recurrent Falls in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess and address the causes of repeated falls for a resident at high risk for falls, and to ensure that fall-prevention interventions were consistently implemented. The resident was admitted with Alzheimer’s disease, dementia, anxiety disorder, atrial fibrillation, and other comorbidities, and was care planned early on for safety concerns and fall risk, including use of non-skid footwear and encouragement to stay in common areas while awake. A falls risk assessment identified the resident as at higher risk for falls. Despite this, the facility did not complete or provide comprehensive fall investigations, did not document orthostatic blood pressure assessments when claiming orthostatic hypotension as a cause, and did not demonstrate that existing interventions such as non-skid footwear were in place at the time of multiple falls. On one occasion, the resident was found on the floor in her room after reporting she heard voices in the hall and went to check; the facility later stated the fall was related to orthostatic hypotension, but there was no evidence in the medical record that orthostatic blood pressures were obtained at the time of the fall. The resident was sent to the ER and diagnosed with a closed compression fracture of the L3 vertebra. Subsequent falls occurred when the resident was restless and trying to stand up alone, including while on C. diff isolation, and when she was observed on camera walking around her room, sitting on the arm of a recliner, and falling to the floor. In these instances, the record did not show that the facility verified whether non-skid footwear was in use, and interviews confirmed that at least one fall occurred when the resident had nothing on her feet. The facility’s comprehensive fall investigations and witness statements were withheld as QAPI, and no documentation was provided to show thorough investigation, confirmation that interventions were in place, or determination of root causes. Additional falls included an unwitnessed fall where the resident was found on the floor next to her rollator with a head laceration requiring staples, and another fall near the nursing station where she was found sitting on the floor in front of her wheelchair and later diagnosed with an intertrochanteric right femoral fracture. The facility reported that the resident was last seen 10–20 minutes before some of these falls, but did not provide evidence that ordered safety checks (such as every 15-minute checks during isolation) were actually completed. The final fall occurred in the secured unit dining area, where the resident was assisted to a padded wheelchair in a semi-reclined position and left in the dining room while the LPN passed medications and CNAs provided morning care to other residents. Within approximately 5–15 minutes, the resident was found on the floor with facial injury, multiple fractures, and extensive ecchymosis. Staff interviews indicated the resident had been restless and scooting in her chair the prior day, but this was not communicated in report, and the facility could not identify the cause of the fall. The death certificate later listed the manner of death as accident, with the underlying cause being sequelae of blunt impacts to the head, trunk, and left arm with fractures and soft tissue injuries due to falls.
Meals Served at Improper Temperatures
Penalty
Summary
Food and drink were not maintained at palatable, attractive, and safe appetizing temperatures during meal service. During observation with the dietary staff member, steam table temperatures showed ground beef at 150 degrees Fahrenheit, Spanish rice at 173 degrees Fahrenheit, pureed ground beef at 145 degrees Fahrenheit, pureed Spanish rice at 166 degrees Fahrenheit, and gravy at 160 degrees Fahrenheit. Tray line service then began, with resident room tray carts leaving the serving station at different times for the 500-hall, 200-hall, and 100-hall, and the 200-hall dining room resident meals were finished at 12:52 P.M. A test tray completed afterward showed lower temperatures at the point of service, including ground beef at 118 degrees Fahrenheit, Spanish rice at 115 degrees Fahrenheit, pureed ground beef at 125 degrees Fahrenheit, and pureed Spanish rice at 117 degrees Fahrenheit. After tasting the items, the dietary staff member stated the Spanish rice was warm but would have preferred it warmer, the pureed beef was well seasoned but not warm enough, and the pureed Spanish rice was also not warm enough for preference. The facility policy stated food should retain flavor, appearance, and nutrients, and be maintained and served at proper and acceptable temperatures.
Improper Storage of Refrigerated and Expired Medications
Penalty
Summary
The facility failed to ensure refrigerated medications were kept in a safe and sanitary manner in accordance with accepted professional practices and failed to ensure expired medications were not kept past the recommended expiration date. During observation of the 200 Hall medication storage area, one stock bottle of Nicotinamide Adenine Dinucleotide (NAD) 1,000 mg tablets was found with an expiration date of 03/2026. The medication refrigerator in the same storage area also contained a large frozen meal in the freezer compartment and a large clear plastic bag with an unidentified sandwich and fruit placed alongside resident refrigerated medications. The refrigerated medications observed in the refrigerator included two Adalimumab injectors for Residents #32 and #51, one Mounjaro auto injector for Resident #19, four Pantoprazole suspension bottles for Resident #12, one Ozempic auto injector for Resident #19, five Lantus insulin auto injector pens for Residents #5, #12, #18, #96, and facility stock, nine Humalog insulin doses for Residents #9, #12, #38, and #40, one Lispro insulin auto injector pen for Resident #9, and facility stock supplies of Tylenol suppositories, bisacodyl suppositories, Novolog insulin, and Lantus insulin. RN #397 confirmed the expired NAD stock bottle and the presence of food in the medication refrigerator and freezer. The facility policy stated medications are maintained behind a locked door inaccessible to unlicensed personnel, and the medication administration policy stated medications are administered in a safe and sanitary manner.
Failure to Follow Menu and Therapeutic Diet Orders
Penalty
Summary
The facility failed to ensure residents received food according to the menu, recipe, and therapeutic spreadsheet. During lunch service, the menu listed soft shell beef tacos with lettuce, tomatoes, shredded cheese, salsa, Spanish rice, and a cookie, and the recipe also included sour cream and taco sauce. Observation and interview with dietary staff confirmed the facility was out of sour cream and salsa and was not sending those items with the trays. An aide requested salsa for Resident #19 and was told none was available at the serving station. Dietary staff also ran out of diced tomatoes for the last eight resident trays, and Residents #9, #22, #47, #53, #63, and #115 did not have the option to receive tomatoes; two additional residents were also affected but could not be identified. The facility also failed to provide the pureed dessert listed for residents on a pureed diet. The production sheet for the lunch meal indicated that pureed diets were to receive a #40 scoop of pureed peanut butter cookie, but Resident #14, who had a pureed diet order, was not given the pureed cookie. Dietary staff confirmed they did not make the pureed cookies and usually gave residents on a pureed diet a magic ice cream cup instead. The Dietary Manager confirmed physician-ordered diets were to be followed and that dietary staff were to provide the items listed on the dietitian-approved menus. Facility policy stated portion control was to be achieved through regular and therapeutic diet menus, and the mechanically altered diets policy stated pureed diets were to receive all food pureed until smooth according to the standardized recipe.
Kitchen Hand Hygiene and Personal Hygiene Lapses During Meal Service
Penalty
Summary
The facility failed to ensure staff followed proper hand hygiene and personal hygiene in the kitchen when serving food. During observation in the 200-hall dietary serving station, which serviced residents on the 100, 200, and 500 halls, Cook #407 was observed with a beard and was not wearing a beard net. He confirmed he was not wearing one and stated he had to go to the main kitchen to get it because none were available in the 200 serving station. Later observations showed Cooks #401 and #407 leaving the kitchen carrying three resident plates each with gloved hands to deliver to the dining room, then returning to the serving line and opening the kitchen door with the same gloves without performing hand hygiene or changing gloves. Both cooks confirmed they had not washed their hands or changed gloves before returning to their serving stations. Dietary Aide #333 was also observed entering the serving area and walking to the back of the room near the dish machine without putting on a hair net, and Cook #407 confirmed the aide was supposed to have a hair net on in the kitchen.
Delayed Access to Eyeglasses
Penalty
Summary
The facility failed to ensure a resident received eyeglasses in a timely manner. Resident #81 was admitted with diagnoses including chronic obstructive pulmonary disease and diabetes mellitus, and the care plan directed staff to encourage the resident to wear glasses when out of bed and assist with care of the glasses as needed. The resident was cognitively intact and could see adequately with an appliance per the annual MDS assessment, but the resident reported waiting for new glasses for months and was observed holding a pair of glasses missing a stem. The optometry note documented that the resident complained of blurry vision, a new glasses prescription was updated, and new frames were selected for bifocals, distance, and near vision. The note stated the glasses were to be ordered and shipped to the home once insurance was verified, with a self-pay option if insurance did not cover them. However, there were no follow-up notes in the record regarding the new eyeglasses for several months, the SSD was not aware the resident was waiting for glasses, and the eyewear coordinator verified there was no evidence the resident received a private pay notification after insurance denial. The SSD also stated she did not receive the optometry progress notes or follow up with the eyewear coordinator in a timely manner.
Hospice Care Plan and Care Conference Not Documented
Penalty
Summary
The facility failed to ensure hospice was included in the care conference and failed to maintain a hospice-provided care plan in the medical record for Resident #28. The resident was admitted with diagnoses including malignant neoplasm of an unspecified bronchus or lung and palliative care, and the MDS indicated moderate cognitive impairment and that the resident was receiving hospice services. The physician order dated 03/27/26 directed admission to hospice services for lung cancer with metastasis and a prognosis of six months or less to live. Review of the resident’s records showed the care plan did not contain a hospice-provided plan identifying specific care needs and who would provide the needed care. A social services progress note documented a care conference with facility department managers and the resident, but hospice was not noted as participating. The hospice binder contained a signed hospice agreement, but no hospice-provided care plan or visit summaries were found in the binder or the medical record. Interviews with RN #356, the DON, the hospice nurse, and the SSD confirmed that hospice visit notes were kept in the hospice’s own electronic record, that the facility did not have access to them, and that hospice was not part of the care conference for Resident #28.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an incident of possible neglect involving a resident to the State Agency as required. The resident, who had a history of cerebrovascular disease, vascular dementia, and other conditions, was found outside the facility after an unwitnessed fall. The incident occurred when the resident, who used a walker and wheelchair, was found lying on the grass outside a window after reportedly getting tangled in a window screen and pushing through it. Despite being assessed with no noted injuries, the incident was not immediately reported to the appropriate authorities. The incident was discovered when another resident heard someone yelling for help outside her window and informed a CNA. The CNA, along with an LPN and another CNA, went outside to assist the resident. The LPN confirmed that he should have notified management immediately but did not contact the ADON until several hours later. The DON was informed of the incident the following morning but was initially unaware that the resident had been found outside the facility. The facility's policy on elopement and reporting of key events was not followed, as the incident was not reported as an elopement to the State Agency. The DON confirmed that an elopement incident investigation was not completed, and no self-reported incident report was made. The facility's policy requires immediate notification of the charge nurse, Administrator, DON, and Quality Assurance in the event of an elopement, but this protocol was not adhered to in this case.
Failure to Accurately Document Elopement Incident
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #195, who was admitted with multiple diagnoses including cerebrovascular disease, vascular dementia, and type II diabetes mellitus with chronic kidney disease. On 12/24/24, Resident #195 experienced an unwitnessed fall and was found outside the facility, lying on the grass after reportedly exiting through a window. Despite being assessed as high risk for falls, the incident was not accurately documented as an elopement, and the necessary incident report was not filed with the State Agency. The incident occurred when Resident #195 was last seen in the dining room around 8:35 P.M. by CNA #59. Shortly after, CNA #56 was informed by another resident that someone was yelling for help outside her window. Upon investigation, CNA #56 found Resident #195 outside on the grass. The resident was brought back inside without noted injuries, but the incident was not immediately reported to management. LPN #58, who assisted in bringing the resident back inside, delayed notifying the ADON until after 2:00 A.M. the following day. The Director of Nursing (DON) was not informed of the resident being found outside until 4:00 A.M. on 12/25/24, and no elopement incident investigation was conducted. The DON mistakenly believed the event was a change in status rather than an elopement. Additionally, the ADON admitted to entering incorrect times for the fall risk and safety assessments, which were actually completed on 12/25/24. This series of documentation errors and miscommunications led to the deficiency being cited under Complaint Number OH00161157.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident #195, who was not initially assessed as being at risk for elopement. Resident #195 had a history of cerebrovascular disease, vascular dementia, and other conditions, and was noted to have moderate cognitive impairment. Despite these conditions, the resident's care plan did not indicate a risk for elopement or wandering. On the night of the incident, the resident was last seen in the dining room before being found outside the facility after falling through a window. The incident occurred when Resident #195 was found lying on the grass outside a window by a CNA after another resident reported hearing someone yelling for help. The resident had apparently pushed through a window screen and exited the building. Staff members, including CNAs and an LPN, assisted in bringing the resident back inside. The resident was assessed and found to have no injuries, but the incident was not immediately reported to management, and the LPN involved did not document the incident in a nursing progress note or complete a witness statement. The Director of Nursing (DON) was not informed of the resident being outside until hours after the incident. The facility's policy on elopement was not followed, as the incident was not treated as an elopement, and no investigation or self-reported incident report was completed. The DON confirmed that the incident should have been considered an elopement, but it was mistakenly viewed as a change in the resident's status. This oversight represents a deficiency in the facility's supervision and response to potential elopement risks.
Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, affecting one resident during a short respite stay. The resident, who had medical diagnoses including Parkinson's disease, dementia, and adjustment disorder, was prescribed Carbidopa/Levodopa to be taken in a specific dosage. However, due to a transcription error by RN #64, the resident received only one-third of the prescribed dose from 12/20/24 to 12/23/24. This error was identified when the Director of Nursing (DON) reviewed the admission paperwork and discovered the discrepancy in the medication order transcription. As a result of the medication error, the resident experienced a decline in their condition, including altered mental status, drowsiness, and decreased mobility, leading to hospitalization for evaluation. The facility's Medication Administration Policy and Physician Order Policy were not followed, as the error was not initially reported, and the correct dosage was not administered. The incident was documented in the Medication Error Log, and the resident's condition was monitored, but no actual harm was reported.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care to prevent pressure ulcers for a resident, resulting in a deep tissue pressure injury. The resident, who was at high risk for pressure ulcers due to her medical conditions, was left on a bedpan for an unknown duration, leading to a serious pressure injury on her bilateral buttocks. The resident's medical history included atherosclerotic heart disease, type two diabetes, a wedge compression fracture, and moderate protein-calorie malnutrition, all contributing to her vulnerability. Observations and interviews revealed that the resident was not consistently turned and repositioned as required, despite being at very high risk according to the Braden Scale. The resident was found on a bedpan by the wound nurse practitioner and a nurse, indicating that she had been left in that position from the night shift. The facility's staff, including agency staff, could not determine who was responsible for leaving the resident on the bedpan, and the situation was described as mortifying by the nurse involved. The facility's documentation and observations showed inconsistencies in the care provided to the resident. Despite care plans and interventions being in place, there was no evidence that the resident was turned and repositioned regularly, as required. The facility's policy on wound prevention and management was not effectively implemented, leading to the development of a deep tissue injury that progressed to an unstageable pressure ulcer. The deficiency was investigated under a complaint, highlighting the facility's non-compliance with care standards.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide appropriate incontinence care for three residents, leading to potential harm and discomfort. Resident #48, who had moderate cognitive impairment and was frequently incontinent, expressed frustration over delayed incontinence care, which caused her to miss activities she enjoyed. During an observation, it was noted that she had a small open abrasion on her buttocks, and she reported having to wait a long time for her incontinence products to be changed. She was found wearing two liners in her pull-up, contrary to the manufacturer's instructions, which stated that wearing multiple liners could cause skin damage and discomfort. Resident #56, who was dependent on others for toileting hygiene, was observed to have not received incontinence care for an extended period. When care was finally provided, it was discovered that she was wearing a wet incontinence brief with two liners, resulting in red and irritated skin. The STNA responsible for her care admitted that this was the first time she had checked on the resident since starting her shift. The Director of Nursing confirmed the inappropriate use of two liners, which was against the manufacturer's guidelines. Resident #43, with severe cognitive impairment and frequent incontinence, was also found to have received inadequate care. Observations revealed that her incontinence brief had not been changed since the beginning of the STNA's shift, and she was found with a soiled liner and dried feces on her skin, causing redness and irritation. The facility's policy and the manufacturer's instructions were not followed, as multiple liners were used, which is considered bad practice and can lead to skin damage.
Failure to Implement Substance Abuse Interventions
Penalty
Summary
The facility failed to implement care planned interventions for a resident with substance abuse issues, leading to a deficiency. The resident, who was cognitively intact, had a history of alcohol dependence with alcohol-induced mood disorder and bipolar disorder. Despite having a physician's order restricting leave of absence (LOA) except for medical appointments, the resident was found inebriated after a visit from his girlfriend, who provided him with vodka in a water bottle. This incident was reported to the nightshift nurse and the physician, but no further interventions were documented. The resident's care plan included interventions such as one-to-one visits, involving family, and making referrals as needed. However, after the incident of alcohol use, there was no evidence that these interventions were implemented. The care plan was revised to note the resident's non-compliance with alcohol use, but the goals and interventions remained unchanged. The facility's records did not show any further orders or actions taken to address the resident's substance abuse following the incident. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's alcohol use. The Director of Nursing was unaware of the second episode of inebriation, and the Social Services Designee did not offer additional psychological services due to being informed of only one incident. The physician involved stated that the resident's LOA should have been revoked for safety reasons, but there was confusion about who authorized the resident's LOA for a fishing trip. The facility did not provide a substance abuse treatment policy for review, only an illegal substance policy.
Inappropriate Secured Unit Placement and Lack of Proper Documentation
Penalty
Summary
The facility failed to ensure appropriate placement and interventions for a resident, leading to a deficiency in behavioral health services. The resident, who had Parkinson's Disease and dementia with agitation, was admitted to the facility for therapy and strengthening. Despite being cognitively intact and having a BIMS score of 14, the resident was placed in a secured unit without a clear clinical indication or proper authorization. This decision was based on verbal communication and assumptions rather than documented evidence or a formal order from the attending physician. The resident expressed frustration and confusion about being in the secured unit, which was not aligned with his cognitive status and personal capabilities. He was able to manage his finances and expressed a desire to leave the facility, indicating that he did not belong in the secured unit. The resident's family and physician were not adequately consulted about the placement, and there was a lack of proper documentation to justify the decision. The facility's staff, including the DON and LPN, acknowledged that the resident was independent and did not require the restrictions of a secured unit. The deficiency was further compounded by the facility's failure to secure the resident's environment properly. The resident was able to exit the facility through a window due to loose metal brackets, highlighting a lapse in safety measures. Interviews with staff revealed confusion and miscommunication regarding the resident's placement and the necessity of the secured unit. The facility's policy required a signed consent for secured unit placement, which was not appropriately obtained or documented, leading to the resident's inappropriate confinement and subsequent distress.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident call lights were answered in a timely manner, affecting at least one resident. Resident #59 reported that when she activated her call light due to incontinence, staff often did not respond promptly. On one occasion, a staff member entered her room, turned off the call light, and left without providing assistance, leaving the resident to wait for nearly an hour. During this time, Resident #59 repeatedly called for help and expressed frustration over the delay. Observations confirmed that Resident #59's call light remained activated for an extended period without appropriate response. Multiple staff members entered the room for other reasons, such as delivering meal trays, but did not address the resident's need for assistance. The resident eventually received help from a nurse after a significant delay, during which she became upset and refused her lunch. Interviews with staff verified the prolonged activation of the call light and the lack of timely response.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 612 citations issued within 25 miles in the last 12 months — including the 6 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Avon Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Mary Of The Woods | 2.7 mi | ★★★★★ | 11 | 0 |
| Woods On French Creek Nursing & Rehab Center The | 2.7 mi | ★★★★★ | 2 | 0 |
| Avon Oaks Nursing Home | 3.3 mi | ★★★★★ | 8 | 0 |
| O'neill Healthcare Bay Village | 3.6 mi | ★★★★★ | 23 | 0 |
| Avon Place Healthcare Center | 3.7 mi | ★★★★★ | 11 | 0 |
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