Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Majestic Care Of Middletown Llc during CMS and state inspections, most recent first.
Verbal Abuse Toward a Resident During Smoking Incident: A cognitively intact resident with multiple medical diagnoses was identified as a supervised smoker after being observed smoking outside the designated area. The former DON yelled at the resident in front of others, followed her into the hallway, and threatened to take her cigarettes and lighter. Staff described the DON’s tone as aggressive, degrading, and belittling, and the resident was crying and embarrassed. The facility substantiated the allegation of staff-to-resident verbal/emotional abuse.
Surveyors found that food storage areas, including the kitchen refrigerator and dry storage, were dirty and not maintained according to professional standards, with uncovered and unlabeled food items and debris present. Additionally, a resident's refrigerator contained spilled juice and dead bugs. These conditions were confirmed by dietary and nursing staff and did not comply with facility policies for cleanliness and food safety.
Surveyors found that the facility did not have a Legionella prevention program in place and failed to ensure staff followed proper glove use and hand hygiene during incontinence care for a resident under Enhanced Barrier Precautions. A CNA provided catheter and incontinence care, then touched multiple surfaces and the resident's wheelchair without changing gloves or performing hand hygiene, in violation of facility policy.
Surveyors found that several resident rooms had damaged, discolored, and missing ceiling tiles above beds, compromising the required safe, clean, and homelike environment. The Maintenance Director confirmed these conditions during the inspection.
Surveyors found that two residents with significant cognitive and physical impairments had long, jagged, and dirty fingernails, indicating a failure by staff to provide necessary nail care. One resident was unable to communicate due to cognitive impairment, while the other expressed a desire for nail care to be completed by nursing staff. The DON confirmed the need for nail care during the survey.
A resident with multiple diagnoses was prescribed both an opioid and a benzodiazepine, prompting the pharmacy to recommend PRN Narcan for overdose risk. Although the recommendation was accepted with a verbal physician order, PRN Narcan was not actually ordered until nearly two months later, as confirmed by the DON. This delay represented a failure to act promptly on pharmacy recommendations.
Insulin pen-injectors for three residents were found in a medication cart without being dated when removed from refrigerated storage, as required by facility policy and professional standards. An LPN, the DON, and the consulting pharmacist all confirmed that insulin vials and pens must be dated upon removal from refrigeration, but this was not done for Lantus, Glargine, and Tresiba pens. The deficiency was identified during a survey of the medication cart.
A resident with a colostomy experienced inadequate care, resulting in frequent leaks and a rash due to improper appliance fitting and untimely pouch changes. Staff interviews and observations confirmed the issues, with the DON and Wound Nurse acknowledging the rash caused by gastric juices. The facility's policy on monitoring and addressing pouching problems was not adequately followed.
The facility failed to provide a reasonably accessible and weather-protected outdoor smoking area for residents. A resident, who was cognitively intact and required assistance with daily activities, struggled to open the manual door to the smoking area while using a wheelchair. The door lacked an automatic opener, and no communication devices were available for assistance requests. Additionally, the smoking area lacked weather protection as the canopy was removed for colder months, affecting multiple residents.
A facility failed to notify a resident's representative of a significant change in condition, including increased confusion and hallucinations, as well as new medical orders. The resident's condition worsened, leading to a hospital transfer, with the family only being informed shortly before the transfer. The ADON confirmed the notification should have occurred earlier, as per facility policy.
A facility failed to conduct required care conferences for a resident with multiple diagnoses, including heart failure and dementia. Despite the need for quarterly conferences and alignment with MDS assessments, only one care conference was held over a significant period. The DON confirmed the lack of adherence to the facility's policy, which mandates routine scheduling of care conferences. This deficiency was identified during a complaint investigation.
A resident with chronic respiratory failure and hypertension received Midodrine despite blood pressure readings exceeding prescribed parameters. The facility's failure to adhere to physician orders resulted in significant medication errors, as confirmed by the DON. This non-compliance was identified during a complaint investigation.
An LPN at an LTC facility failed to follow infection control policy by administering a pill that was dropped on the floor to a resident with a history of COVID-19 and other conditions. The DON confirmed the medication should have been destroyed and replaced.
The facility failed to perform timely incontinence care and did not follow physician orders for four residents, resulting in them remaining in heavily soiled briefs for extended periods. Staff interviews confirmed that incontinence care was not performed as required, with some staff admitting to completing rounds every four hours instead of the mandated two hours.
The facility failed to notify the physician of significant weight loss for a resident and did not inform the nurse practitioner of wound treatment refusals for another resident, despite clear directives in the care plans and physician orders.
The facility failed to provide two residents with meals that were palatable and served at appropriate temperatures. Both residents reported that the food was cold and unappetizing, which was confirmed by a sample food test tray showing significantly low temperatures for the food items. The facility's policy on providing a nourishing and well-balanced diet was not adhered to.
A facility experienced significant coordination and communication failures in managing hemodialysis treatments for residents with end-stage renal disease (ESRD). One resident missed four consecutive dialysis sessions, leading to cardiopulmonary arrest and death. The facility staff were unaware of the missed appointments, failed to arrange transportation, and did not notify the physician. Additionally, three other residents faced risks due to similar communication lapses, including missed appointments and inadequate documentation. These events highlight systemic issues in ensuring continuity of dialysis care.
The facility failed to notify a resident's physician when a diabetic medication was unavailable due to a national shortage. The resident missed three doses, and there was no documentation of physician notification. This issue was confirmed by the DON and RNC and represents continued non-compliance from a previous survey.
A facility failed to prevent physical abuse when a resident, who was cognitively intact and had multiple diagnoses, was involved in a verbal and physical altercation with an RN. The RN allegedly used profane language and attempted to force the resident into her room, resulting in the resident's foot being injured. The incident was reported to local police, and the RN was suspended and resigned.
Verbal Abuse Toward a Resident During Smoking Incident
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse. Resident #152 was admitted with diagnoses including nontraumatic intracranial hemorrhage, dysphagia, lymphoid leukemia, anxiety disorder, COPD, hypertension, and insomnia. Her MDS assessment dated 02/26/25 described her as cognitively intact and dependent on staff for medication administration, with set-up assistance needed for several activities of daily living. Smoking-related assessments identified her as a safe smoker, and her smoking care plan directed staff to complete smoking assessments, instruct her on smoking risks and the facility smoking policy, and notify the nurse if she violated the smoking policy. On 12/23/25, Resident #152 was observed smoking outside the designated area and was identified as a supervised smoker. During the incident, the former DON approached her and yelled at her in a loud, aggressive voice about smoking unsupervised. Multiple staff members reported that the former DON shouted at the resident in front of others, followed her into the hallway, and continued to yell at her near the nurse’s station. Staff also reported that the former DON threatened to take the resident’s cigarettes and lighter and spoke to her in a degrading manner. Resident #152 was upset, crying, embarrassed, and stated she did not know she was a supervised smoker. The facility’s investigation substantiated the allegation of verbal/emotional abuse by the former DON. Staff interviews consistently described the former DON’s behavior as inappropriate, belittling, and degrading toward the resident. The former DON denied yelling or belittling the resident and stated her intent was to keep the resident safe, but the facility determined the incident was staff-to-resident verbal abuse. The facility policy stated residents have the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and sanitation practices. In the kitchen refrigerator, food storage shelves were found to be dirty and covered in debris, with spots of a blackish green substance present. Several milk cartons were stored in a plastic tub containing water, but no ice, which is not in accordance with proper food storage practices. In the dry storage area, a large plastic container of dry cereal was left uncovered on a roll cart, and the surrounding area, including the floor, was dirty and covered in debris. Several plastic bowls containing dry cereal were also found on the cart without labels or dates. The Dietary Manager confirmed these observations during the survey. Additionally, a resident's personal refrigerator was found to have spilled cranberry juice at the bottom, along with multiple dead, black bugs in the spilled liquid. This was verified by a Certified Nursing Assistant at the time of observation. Review of facility policies indicated that food storage areas should be neat, clean, and organized, with all foods stored in covered, labeled, and dated containers to prevent cross-contamination, and that all food preparation and service areas should be maintained in a clean and sanitary condition. The observed conditions did not meet these standards.
Plan Of Correction
Facility Name: Majestic Care of Middletown Survey Date: 06/02/2025 Plan of Correction Tag: F0812 - Failure to store, prepare, distribute, and serve food under sanitary conditions. All residents potentially affected by the deficient practice were assessed by DNS/designees on 06/06/2025. No residents exhibited signs or symptoms of foodborne illness. The affected food storage and preparation areas were immediately cleaned and sanitized by the Regional Dietary Manager on 06/03/2025. All improperly stored food items were discarded. A facility-wide audit of all food storage, preparation, and service areas was conducted by the ED on 06/03/2025. No additional concerns were identified. Staff were interviewed and observed to ensure compliance with sanitary food handling practices. All dietary staff were educated on proper food handling, storage, and sanitation procedures per CMS and Ohio Department of Health guidelines by the Executive Director on 06/06/2025. The DON or designee will audit the resident refrigerators weekly to ensure that they are clean and there is no expired food. The dietary manager, Executive Director/designee will conduct random weekly audits of food storage and preparation areas. The Dietary Manager or Executive Director will complete weekly sanitation audits for 4 weeks. Results will be reviewed during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. The DON or designee will audit the resident refrigerators three times a week for 4 weeks to ensure they are clean and contain no expired food. Any issues identified will be addressed immediately with appropriate corrective action. The facility alleges compliance date: July 10, 2025.
Failure to Implement Legionella Prevention and Proper Infection Control During Incontinence Care
Penalty
Summary
The facility failed to establish and implement a Legionella prevention program as part of its infection prevention and control program. Review of the facility's water management documentation showed no evidence of an active Legionella prevention plan, no designated team members responsible for managing such a plan, and no documentation of control measures to prevent Legionella. During interviews, both the Maintenance Supervisor and the Administrator confirmed the absence of an implemented Legionella prevention plan and related control measures, despite the facility's policy outlining the need for a comprehensive water management program. Additionally, the facility did not ensure proper infection control practices during incontinence care for a resident under Enhanced Barrier Precautions. Observation revealed that a CNA provided catheter and incontinence care to a resident, then touched multiple surfaces and the resident's wheelchair without changing gloves or performing hand hygiene. The CNA also left the resident's room without washing or sanitizing hands, contrary to posted signage and facility policy requiring hand hygiene before leaving the room. The CNA later confirmed not changing gloves or sanitizing hands during and after care. The resident involved had a history of intracerebral hemorrhage, hemiplegia, morbid obesity, encephalopathy, and depression, and was always incontinent of bowel and bladder, requiring significant assistance with activities of daily living. Facility policies on Enhanced Barrier Precautions and hand hygiene were reviewed and found to require proper glove use and handwashing, which were not followed during the observed care event.
Plan Of Correction
F0880: Water Management Program Facility Name: Majestic Care of Middletown Survey Date: June 5, 2025 Tag Number: F0880 Deficiency: The facility failed to implement a Legionella prevention plan, designate responsible personnel, or document control measures. The facility completed a review of all water management plan engineering protocols, which were all in place as of 6/20/25 by the maintenance director. The infection control prevention team completed a review of all current residents with no findings related to the cited practice on 6/6/25. As a precaution, the ED and Maintenance Director conducted an immediate risk assessment and flushed all water outlets to reduce potential exposure. All members of the Water Management Program (WMP) will complete CDC Legionella Training by July 10. A Water Management Team has been established, including the Administrator, Maintenance Director, Infection Preventionist, and Environmental Services. The facility has developed and adopted a comprehensive Water Management Program (WMP) in accordance with CDC Toolkit and ASHRAE Standard 188. The WMP includes: a detailed building water system diagram, hazard analysis identifying areas at risk for Legionella growth, control measures such as temperature monitoring, flushing protocols, and disinfectant levels, monitoring procedures and corrective actions for deviations, and documentation and communication protocols. The WMP will be reviewed quarterly by the Water Management Team. Monthly logs will be maintained for all control measures by the Maintenance Director. The facility will conduct annual validation of the WMP, and Legionella testing if indicated. Findings will be reported to the QAPI Committee for oversight. Date of Compliance: July 10, 2025
Failure to Maintain Safe and Homelike Resident Room Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as required by federal regulations. During an inspection of resident rooms, it was found that three residents' rooms had significant issues with ceiling tiles. Specifically, one room had a damaged, brown and black discolored ceiling tile above the bed, another room had three damaged and discolored ceiling tiles, one broken ceiling tile with a portion missing, and one entire ceiling tile missing, while a third room had three damaged, brown and black discolored ceiling tiles above the bed. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the conditions of the rooms. The observations directly indicate that the facility did not provide the necessary housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior, as well as failing to maintain the physical environment in a manner that supports resident safety and comfort.
Plan Of Correction
Tag Number: F584 Deficiency: The facility failed to provide a homelike environment by having ceiling tiles that had brown stains on them. Residents #54, #81, and #116 were affected by this deficient practice, with no negative outcomes. Ceiling tiles for the affected residents were changed by maintenance staff on 6/6/2025. A facility-wide audit was conducted to identify any ceiling tiles with stains on them on 6/21/25 through 6/23/25 and replaced by the Maintenance staff. The ED/designee provided education to the Maintenance supervisor and staff on ceiling tiles and cluttered rooms on 6/9/25. Weekly rounds by the Maintenance supervisor/designee to ensure that ceiling tiles are in good condition will be conducted for 4 weeks, and then twice monthly for 2 months. Results will be reviewed by the QAPI Committee and used to guide continuous improvement. Date of Compliance: July 10th F 0584
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
Surveyors identified a deficiency in the provision of activities of daily living (ADL) care, specifically related to nail care for dependent residents. Two residents with significant cognitive and physical impairments were observed to have long, jagged fingernails with unknown material underneath. One resident, with diagnoses including Alzheimer's dementia, Parkinson's disease, and diabetes, was noted to be dependent on staff for most ADLs and unable to communicate due to cognitive impairment. The other resident, with diabetes, rhabdomyolysis, and metabolic encephalopathy, required moderate assistance with ADLs and expressed a desire for nursing staff to provide nail care. During observations, both residents were found in clean, seasonally appropriate clothing, but their fingernails were visibly unkempt and dirty. The Director of Nursing confirmed the condition of the residents' nails, verifying that they were long, jagged, and in need of care. The failure to provide necessary nail care services was documented through direct observation, record review, and interviews, affecting two of three residents reviewed for care and services.
Plan Of Correction
Facility Name: Majestic Care of Middletown F0677 ADL Care for Dependent Residents State: Ohio Residents #32 and #100 identified during the survey were immediately assessed by the DNS/designee on 6/2/2025, revealing no negative outcomes related to the cited deficient practice. Both residents immediately received nail care by DNS/designee. A facility-wide audit was conducted by DNS/designee on 6/18/2025 - 6/20/2025 to identify residents who need ADL/nail care to ensure nails are clean and trimmed to the resident's preference. Residents' care plans were updated based on their personal preferences. Any discrepancies were corrected immediately by DNS/designee, and appropriate interventions were implemented. All nursing/CNA staff received in-service training on ADL care per policy requirements, with emphasis on nail care. The DON educated staff on 6/18/2025. The DNS/designee will audit 5 random residents weekly for 4 weeks, then once weekly for 2 months. All findings will be reported to the QA committee for review. The committee meets monthly and as needed. Completion Date: July 10, 2025
Failure to Timely Implement Pharmacy Recommendation for PRN Narcan
Penalty
Summary
The facility failed to follow through on a pharmacy recommendation regarding medication safety for a resident with multiple diagnoses, including chronic pain syndrome, anxiety, and a tracheostomy. The resident was prescribed both an opioid (Oxycodone) and a benzodiazepine (Clonazepam), a combination that increases the risk of life-threatening overdose. On 04/08/25, the pharmacy recommended that PRN Narcan (a narcotic reversal medication) be available for this resident, and this recommendation was documented as accepted with a verbal order from the physician. Despite the acceptance of the pharmacy's recommendation, a review of physician orders showed that PRN Narcan was not actually ordered for the resident until 06/04/25, nearly two months later. The Director of Nursing confirmed that the order for PRN Narcan was not placed in a timely manner and was only completed after pharmacy recommendations were specifically requested. This delay in implementing the pharmacy's recommendation constituted a failure to act promptly on identified drug regimen irregularities as required by regulation.
Plan Of Correction
F0756 - Drug Regimen Review The resident #135 during the survey had their medication regimen reviewed by the Nurse Practitioner on 6/4/24 in house who addressed the recommendation. PRN order implemented on 6/4/2024. A retrospective audit of all residents' monthly drug regimen reviews over the past 60 days was conducted on 6/25/25 by the consultant pharmacist. Any missed or undocumented irregularities were addressed, and physicians were notified to ensure appropriate follow-up and documentation on 7/2/25. Nursing leadership will be educated by RNC on ensuring timely follow-up to pharmacy recommendations by 6/18/2025. The DON or designee will audit 100% of pharmacist recommendations weekly for 4 weeks then monthly for 2 months. All findings will be reported to the QA committee for review, which meets monthly and as needed. Compliance date: July 10, 2025
Failure to Date Insulin Pens Upon Removal from Refrigeration
Penalty
Summary
Surveyors observed that insulin pen-injectors for three residents were not properly labeled with the date they were removed from refrigerated storage and placed in the medication cart for administration. Specifically, Lantus, Glargine, and Tresiba insulin pens were found in the Aspen medication cart without the required dating. This was confirmed during an observation with an LPN, who verified that none of the pens had been dated when removed from stock. The Director of Nursing and the consulting pharmacist both confirmed that facility policy and professional standards require insulin vials and pen-injectors to be dated when removed from refrigeration for use. A review of the facility's medication storage policy indicated that certain medications, including multiple dose injectable vials, require an expiration date shorter than the manufacturer’s date once opened, to ensure medication purity and potency. The failure to date the insulin pens upon removal from refrigeration affected three of the 26 residents with medications stored in the Aspen medication cart, out of a total facility census of 148.
Plan Of Correction
Plan of Correction for F0761 - Label/Store Drugs and Biologicals During the observation of the Aspen Med Cart, it was found that resident's #23, #29, and #128 insulin pen injectors were not dated when removed from the refrigerator and placed in the cart. Correction was made by the staff member at the time of observation. A full house audit of all medication carts was conducted by DNS/designee on 6/4/2025. Any expired, improperly labeled, or unsecured medications were discarded or corrected. Staff were educated by DNS/designee on 6/4/2025 on the facility medication storage policy to reinforce labeling standards, including expiration dates, and the proper way to store insulin and date. The DNS/designee will conduct weekly audits on medication carts for 4 weeks, then 2 times a month for 2 months. All findings will be reviewed by the QAA committee, which meets monthly and as needed. Compliance date of July 10, 2025.
Inadequate Colostomy Care Leading to Rash and Leakage
Penalty
Summary
The facility failed to provide appropriate and adequate colostomy care for Resident #10, who had a colostomy due to malignant carcinoid of the stomach and other health issues. The resident's medical records indicated a need for specific colostomy care, including cleaning the colostomy with soap and water, applying skin prep, and changing the pouch when it was one-third to one-half full. However, interviews and observations revealed that the colostomy pouch was not always replaced timely, leading to leaks and a rash on the resident's abdomen. Interviews with staff, including an LPN and a CNA, confirmed that the colostomy pouch often leaked, and the resident frequently needed cleaning upon their arrival. The LPN expressed concerns about the night shift not emptying the pouch timely, and the CNA acknowledged the rash was not a new finding. Observations showed the colostomy appliance was not fitting properly, with the hole in the wafer cut too big, and paste was used unnecessarily, which contributed to the leakage and skin irritation. The Director of Nursing and the Wound Nurse confirmed the presence of a rash caused by gastric juices contacting the skin, and the DON noted the improper fit of the appliance due to the stoma's position. Despite the ongoing issue with the rash and leaking, there was a lack of documentation regarding the rash's recurrence. The facility's policy required monitoring the skin for breakdown and making appropriate referrals for ongoing pouching problems, which was not adequately followed, leading to the deficiency.
Inaccessible and Unprotected Smoking Area for Residents
Penalty
Summary
The facility failed to ensure that the outdoor smoking area was reasonably accessible and protected from the weather for its residents. This deficiency was identified through observations, interviews, and record reviews. Specifically, Resident #110, who was cognitively intact and required assistance with various activities of daily living, was observed having difficulty opening the manual door to the smoking area while maneuvering a manual wheelchair. The door lacked an automatic opener, and there were no communication devices available for residents to request assistance when needed. Interviews with other residents confirmed that the door was heavy and challenging to pass through. Additionally, the smoking area, which was an enclosed courtyard, lacked adequate protection from the weather as the canopy had been removed for the colder months. The facility's policy on providing a safe and functional environment was not adhered to, as there was no area to protect residents from the weather. The deficiency was noted to have the potential to affect 26 unsupervised residents who smoke, out of a total of 33 residents who smoke, within a facility census of 134.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in health care status, affecting one resident out of three reviewed for change in condition. The resident, who had diagnoses including acute diastolic heart failure, vascular dementia, and anxiety, exhibited behaviors such as refusing care and medications. Despite a significant change in condition, including increased confusion and hallucinations, there was no documentation that the resident's representative was notified of these changes or the new medical orders. The resident's condition further deteriorated, with oxygen saturation levels dropping significantly, prompting the initiation of oxygen therapy and a subsequent transfer to the hospital. The family was only notified of the change in condition shortly before the transfer. The Assistant Director of Nursing confirmed that the family should have been notified earlier, as per the facility's policy, which mandates notifying the physician and resident/representative when a significant change occurs. This deficiency was investigated under a specific complaint number.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were conducted as required for Resident #137, who was admitted on 12/20/22 and discharged on 11/03/24. The resident had multiple diagnoses, including acute diastolic heart failure, venous insufficiency, vascular dementia, and anxiety. The Minimum Data Set (MDS) assessment indicated impaired cognition, requiring supervision for eating and total staff dependence for bed mobility, transfers, and toileting. The care plan noted behaviors such as refusing care and interventions included encouraging family involvement and maintaining a safe environment. However, a review of progress notes from 02/21/24 to 12/31/24 revealed only one care conference was held on 02/21/24, despite the requirement for quarterly conferences and alignment with MDS assessments. The Director of Nursing confirmed the absence of additional care conferences for Resident #137 since 02/21/24, which was a deviation from the facility's policy. The policy, dated 12/12/23, stipulated that care conferences should be scheduled soon after admission, routinely, and with any change in condition, with advance notice provided to the resident and their representative. This deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its care conference policy, affecting the quality of care provided to the resident.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physician orders for medication administration, resulting in significant medication errors for a resident. The resident, who was admitted with diagnoses including chronic respiratory failure, hypotension, and hypertension, had an order for Midodrine to be administered with specific blood pressure parameters. The order specified that the medication should be held if the systolic blood pressure exceeded 120. However, the medication administration record for December 2024 showed that Midodrine was administered on multiple occasions when the resident's systolic blood pressure was above the prescribed threshold. The Director of Nursing confirmed that the medication was administered despite the blood pressure readings being outside the ordered parameters. The facility's policy on medication administration required obtaining and recording vital signs and holding medications if vital signs were outside the physician's prescribed parameters. This deficiency was identified during an investigation under Complaint Numbers OH00160511 and OH00161077, indicating non-compliance with the facility's medication administration policy.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement its infection control policy during medication administration, affecting one resident. During an observation, an LPN was seen dropping a pill on the floor, picking it up, and then handing it to the resident, who subsequently ingested it. This action was contrary to the facility's policy, which mandates that medications be administered in a manner that prevents contamination or infection. The resident involved had a medical history that included COVID-19, an infection following a surgical procedure, type two diabetes mellitus, depression, and hypertension. The resident was cognitively intact and required staff assistance for certain daily tasks. The Director of Nursing confirmed that the medication should not have been administered after being dropped and should have been destroyed, with a replacement offered to the resident.
Failure to Perform Timely Incontinence Care and Follow Physician Orders
Penalty
Summary
The facility failed to perform timely and adequate incontinence care and did not follow physician orders for the use of incontinence products for four residents. Resident #14, who was cognitively intact and required substantial assistance with toileting, was found with a heavily soiled incontinence brief. Resident #43, who was dependent on staff for toileting, also had a heavily soiled brief. Resident #116, who had memory problems and was dependent on staff for all care, was similarly found with a heavily soiled brief. Resident #108, who had severe cognitive impairment and required substantial assistance for toileting, was found with a heavily soiled brief despite having a physician order not to wear briefs while in bed. Staff interviews confirmed that incontinence care was not performed as required, with some staff admitting to completing rounds every four hours instead of the mandated two hours. Observations and staff interviews revealed that incontinence care was not performed in a timely manner, leading to residents remaining in wet and bulging briefs for extended periods. Specifically, STNA #342 admitted to not changing or completing peri-care for Resident #108 during her shift, and LPN #340 confirmed that Resident #108 was wearing a brief against physician orders. Additionally, LPN #355 and STNA #321 confirmed that Residents #14, #43, and #116 had not received incontinence care since the start of the shift. The facility's perineal care policy aimed to provide cleanliness, comfort, and prevent infections, but these standards were not met, resulting in non-compliance with care protocols and physician orders.
Failure to Notify Physician of Significant Changes
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of significant weight changes and wound treatment refusals for two residents. Resident #26 experienced an 18.39% weight loss over approximately six months, dropping from 223.0 lbs. to 182.0 lbs. Despite the care plan's directive to notify the physician of significant weight changes, there was no documentation in the progress notes indicating that the physician was informed. This was confirmed by the Regional Nurse Consultant during an interview. Resident #108, who had severe cognitive impairment and a stage four pressure ulcer, refused wound treatments on two occasions due to pain. The physician's order required the nurse practitioner to be personally notified of every treatment refusal. However, there was no documentation in the progress notes indicating that the nurse practitioner was informed of the refusals. This was confirmed by both an LPN and the Unit Manager during interviews. The facility's change in condition policy also mandates physician notification prior to the end of the shift, which was not adhered to in these cases.
Failure to Provide Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to provide residents with meals that were palatable and served at appropriate temperatures. Resident #69, who has diagnoses including acquired clubfoot, hemiplegia, hemiparesis, and mild protein-calorie malnutrition, reported that the food was not favorable and was usually cold when it should be hot. This was confirmed during an interview on 05/23/24. Resident #113, with diagnoses of heart failure and chronic obstructive pulmonary disease, also reported that the food was cold and unappetizing. Both residents were cognitively intact and able to communicate their dissatisfaction with the meal temperatures and quality. On 05/28/24, a sample food test tray revealed that the temperatures of the food items were significantly below the appropriate levels for serving. The barbequed meat was 121.0°F, baked beans were 110°F, spinach was 60.2°F, fruit was 60.3°F, and milk was 43.3°F. The Account Manager Healthcare Services (AMHS) #401 confirmed that these temperatures were not appropriate for serving. Both residents confirmed that they did not eat much of their lunch due to the cold temperatures, and Resident #113 mentioned that he always received his food tray last, resulting in consistently cold meals. The facility's undated food and nutrition services policy states that each resident should be provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering their preferences, which was not adhered to in these instances.
Coordination and Communication Failures in Hemodialysis Care
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD), identified as Resident #06, received scheduled hemodialysis treatments as ordered by the physician. This failure resulted in Immediate Jeopardy and potential serious harm, as Resident #06 went four days without dialysis due to communication and coordination failures within the facility. The resident ultimately suffered cardiopulmonary arrest and passed away in the facility. The facility's staff were unaware of the resident's missed appointments, failed to coordinate transportation to the dialysis center, and did not notify the physician of the missed treatments, leading to the tragic outcome. Additionally, the facility did not maintain proper communication with the dialysis center for three other residents (#07, #08, #139) receiving hemodialysis, placing them at risk for more than minimal harm. The deficiency extended to issues such as missed appointments, lack of documentation in the communication binder for dialysis, and failure to ensure continuity of care for residents requiring dialysis services. The report highlighted instances where staff were unaware of residents' dialysis schedules, missed appointments, and lacked essential communication with the dialysis center, indicating systemic failures in coordinating and monitoring dialysis care for residents. The investigation revealed specific events that contributed to the deficiency, including missed dialysis appointments, lack of physician notification, communication breakdowns between staff and the dialysis center, and inadequate documentation of dialysis treatments. The report detailed the circumstances surrounding Resident #06's missed appointments, the lack of transportation coordination, and the subsequent failure to provide necessary dialysis treatments. These events underscored critical lapses in communication, coordination, and oversight within the facility's dialysis care services, leading to severe consequences for the residents involved.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to ensure the physician was notified when medications were not available due to a national shortage, affecting one resident. Resident #65, who has type II diabetes, was admitted on an unspecified date and had a physician's order for Mounjaro subcutaneous pen-injector to be administered once a week for four weeks. The medication was not administered on three occasions due to the shortage, specifically on 03/15/24, 03/22/24, and 03/29/24. There was no documentation indicating that Resident #65's physician was informed about the unavailability of the medication. This deficiency was confirmed by the Director of Nursing and the Regional Nurse Consultant during an interview on 04/17/24. The issue represents continued non-compliance from a previous survey dated 02/14/24.
Failure to Prevent Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse involving a resident who was cognitively intact and had multiple diagnoses, including depressive mood disorder, anxiety disorder, and respiratory failure. The incident occurred when the resident was at the nurse's station and was asked by a registered nurse (RN) to move due to HIPAA concerns. The resident resisted and a verbal altercation ensued, during which the RN allegedly used profane language and attempted to force the resident into her room, resulting in the resident's foot being injured against the door frame. The resident responded by throwing water at the RN, who then left the room. The RN denied using profane language but confirmed the altercation and the resident's resistance. Interviews with staff and the resident confirmed the sequence of events, with the resident and a State Tested Nursing Assistant (STNA) reporting that the RN tried to pull the resident into her room against her will. The resident's care plan included interventions for managing her behavior, such as postponing care if the resident became combative, which the RN did not follow. The incident was reported to local police, and the RN was suspended and subsequently resigned. The facility's policy on abuse prevention defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish. The policy emphasizes that residents have the right to be free from abuse and that any instances of abuse must be reported and addressed. The deficiency was confirmed by the Director of Nursing (DON) and the Regional Nurse Consultant (RNC), who acknowledged that the RN did not follow the resident's care plan interventions during the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,016 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawthorn Glen Nursing Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Ohio Living Mount Pleasant | 3.2 mi | ★★★★★ | 3 | 0 |
| The Laurels Of Middletown | 3.5 mi | ★★★★★ | 2 | 0 |
| Arlington Pointe Care Center | 4.1 mi | ★★★★★ | 5 | 0 |
| Gateway Springs Health Campus | 5.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.