Below 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 Majestic Care Of Perrysburg during CMS and state inspections, most recent first.
Surveyors found that the facility did not carry out or document required Legionella control measures, including routine flushing of infrequently used water outlets and scheduled cleaning or replacement of shower heads, despite having a written water management plan and CDC guidance. In addition, enhanced barrier precautions (EBP) ordered for residents with abdominal wounds, tracheostomies, and diabetic foot ulcers were not followed: an LPN and an RN performed wound and trach care without gowns, without disinfecting bedside tables before placing supplies, and without appropriate hand hygiene between glove changes, and staff assisted a resident with a chronic foot wound in ADLs and transfers without PPE or EBP signage or supplies available, contrary to facility policy and physician orders.
Failure to check nurse aide registry before hiring staff. The facility did not verify newly hired employees on the nurse aide registry before they began working with residents. An LPN file showed no registry search before employment, and the HRM stated he did not perform these checks for applicants. The Administrator confirmed this had not been done for non-CNA staff hired since the HRM started, including RNs, LPNs, ADON, dietary, housekeeping, maintenance, and administrative staff.
The facility failed to maintain adequately warm water temperatures in the East Hall shower room, resulting in multiple residents with conditions such as CHF, Parkinson’s disease, COPD, anxiety, and diabetes reporting that the shower water was too cold, leading some to refuse showers and instead receive bed baths or wash at the sink. CNAs and an LPN confirmed ongoing resident complaints and described one shower stall as cold and the other as only barely warm. Direct measurements with the Maintenance Director showed shower and sink water temperatures well below the minimum required level, and review of water temperature logs revealed that weekly monitoring was not consistently performed, with several weeks lacking any recorded temperatures.
The facility failed to provide and/or document scheduled bathing and grooming for multiple dependent residents. One hospice resident with severe cognitive impairment and extensive ADL needs had only sporadic bed baths and showers documented, with no evidence of hair washing, nail care, or beard grooming, and was observed with greasy hair, unkempt facial hair, and long jagged nails amid conflicting statements between CNAs and a Hospice CNA about responsibility for care. Another cognitively impaired resident dependent for showering reported only weekly showers despite being scheduled for twice-weekly showers, and records showed several missed showers without refusals documented. Two additional cognitively intact residents requiring substantial assistance with bathing had incomplete shower documentation, with only some scheduled baths recorded and no evidence of refusals, despite staff acknowledging that shower sheets should be completed for all showers, bed baths, or refusals and a policy requiring provision of ADL care including bathing and grooming.
Surveyors identified multiple deficiencies involving resident safety and assessment practices. A resident with cognitive impairment, neurological history, and documented exit-seeking behaviors, who was care planned as an elopement risk with a wander management device, eloped twice from the building and was found outside on facility grounds and later across a street near a high-speed roadway, while the administrator acknowledged staffing was not adequate to maintain the needed level of supervision and 15‑minute checks had been discontinued without added interventions. Another cognitively intact resident, assessed as safe to smoke only with supervision and subject to a policy requiring all smoking materials, including e‑cigarettes, to be stored by the facility, was found to have a vape pen left on his bed on more than one occasion, contrary to facility policy and staff expectations. In a separate case, a resident with multiple comorbidities and high assistance needs who sustained an unwitnessed fall had post-fall neurological assessments documented over two days in which hand grasps and motor function checks were repeatedly omitted, and the administrator confirmed these neuro checks were completed inaccurately.
Inaccurate MDS Assessments for Behaviors, Oxygen Use, Wounds, and Refusals of Care. The facility failed to accurately code MDS assessments for multiple residents. One resident with cognitive impairment and elopement risk had an annual MDS that did not reflect wandering or elopement risk despite care plans, a wander management device order, and an elopement event. Another resident’s admission MDS did not show O2 use or hospice status even though the resident was on O2 and had elected hospice. A third resident’s admission MDS did not reflect wounds despite wound orders, care plan interventions, and documented wound measurements. A fourth resident’s admission and discharge MDS assessments did not show refusals of care even though progress notes documented repeated refusals.
A resident with a tracheostomy did not have the ordered spare trach tube and obturator at the bedside. Two residents were observed on O2 via nasal cannula and concentrator despite no physician O2 orders in the chart. Another resident with COPD had ordered BIPAP therapy that was not being applied, with undated tubing, missing parts, no recent cleaning, and a usage report showing no use for weeks.
Food was stored unsafely in multiple kitchen storage areas. Surveyors found boxes of food on the floor in the dry storage area and walk-in freezer, with other food stacked on top of them, and observed red stains on the walk-in cooler floor below stored meat. Expired food items were also found in the cooler, and the DNFS confirmed the observations and stated food should not be stored on the floor.
A resident with hemiplegia, dysphagia, dementia, and an ADL self-care deficit was care-planned to receive partial assistance from one staff member for eating and was dependent on staff for meals. While about 13 residents were in a secured dining area awaiting breakfast, a CNA, from the hallway, loudly referred to the resident as a “feeder” to another CNA in the dining room, in front of other residents. The CNA later confirmed she had used this term and acknowledged it was not dignified or respectful, contrary to the facility’s resident rights policy requiring staff to treat residents with kindness, respect, and dignity.
Surveyors found that the facility failed to develop and implement timely and complete baseline care plans for two newly admitted residents. One resident with multiple chronic conditions and extensive ADL assistance needs had no baseline care plan in place for nearly two weeks after admission, and monitoring for diabetes was not initiated until a comprehensive care plan was developed later. Another cognitively intact resident with multiple medical diagnoses had a baseline care plan that did not address oxygen administration, even though the resident was observed using oxygen via nasal cannula at 4 L/min and used oxygen as needed. Facility policy required the admission nurse to initiate a baseline care plan and required care plans to include objectives to meet medical needs.
A resident with diabetes, peripheral vascular disease, dementia, and a history of diabetic ulcers was care planned for skin integrity risks and had orders for weekly skin observations and heel off-loading. A scheduled weekly skin assessment was not completed, and the next day an LPN documented a new wound on the left great toe and heel but did not record measurements or a detailed description until a week later, when the ulcers were measured and noted to contain significant eschar. Despite orders for heel boots and later heel elevation, surveyors repeatedly observed the resident in bed with feet resting on the mattress, without pressure-relief boots, heel elevation, or a linen tent, and CNAs reported never seeing such devices in use. A later dressing change revealed yellow/green drainage from the toe wound. These omissions in timely assessment, documentation, and implementation of ordered off-loading measures resulted in a deficiency for inadequate diabetic foot care.
A resident with impaired cognition and complex neurological and ventilator-related diagnoses was discharged to a hospital, but the EMR contained no documentation of the discharge, no alert charting, and no change in condition assessment. Although an MDS Discharge Return Anticipated was completed and the facility’s Admission, Discharge, and Transfer Report showed the hospital discharge, progress notes for the relevant period lacked any information about the reason for discharge or the resident’s condition at the time. The interim DON and ADON confirmed the absence of required documentation, despite a facility policy requiring each medical record to accurately represent the resident’s experience and progress.
Delayed and missed wound care orders and treatments were identified for two residents. One resident with multiple complex diagnoses, including diabetes and CKD, had abdominal incision and drain site care started late, with several missed drain-output recordings. Another resident with CHF, AFib, lymphedema, and chronic respiratory failure had RLE wound care delayed for weeks and several treatments missed. Both residents were cognitively intact and dependent for much of their care, and the facility policy required timely assessment and treatment of impaired skin integrity.
Dialysis Access Site Not Properly Assessed: A resident with ESRD and a left arm AV fistula returned from HD and stated he had not been assessed by a nurse. Although an LPN documented the post-dialysis access check and monitoring for complications as completed, interview and observation confirmed the fistula site was not actually assessed, and the LPN only touched the dressing without observing the site or checking for a bruit.
Medication Administration Not Given Per Orders: An LPN administered several meds to a resident outside the ordered time frames, including antibiotics, psych meds, metoprolol, and insulin glargine. The LPN also did not check the resident’s blood sugar before giving the insulin, despite an order to hold it if BG was below 100 mg/dL. Review of the MAR and facility policy confirmed the meds were not given in accordance with the physician orders.
An LPN administered a resident’s insulin glargine outside the ordered morning time frame and did not check the blood sugar before giving it, despite an order to hold the dose if blood sugar was below 100 mg/dL. The resident also received other scheduled meds outside their prescribed time frames, and the LPN later obtained a blood sugar of 167. Facility policy required meds to be given within the ordered time window unless otherwise ordered.
Medications Left Unattended at Bedside: An LPN prepared a resident’s multiple medications, placed them on the over-bed table, and left the room without observing the resident take them. The resident had intact cognition but was not assessed as independent with medication administration, and the DON confirmed this. Facility policy stated medications were not to be left unattended unless the resident had been assessed for safe self-administration.
Staff failed to ensure a call light was within reach for a resident with severe cognitive and physical impairments, despite care plan interventions and facility policy requiring accessibility. The call light was repeatedly found on the floor and out of reach, and CNAs confirmed it was not accessible as required.
A resident with severe cognitive impairment and total dependence on staff was found with unexplained scratches on the left arm. Staff did not document the origin of the injuries, initiate treatment orders, or report the incident to the State Agency as required. The incident was not investigated, and no Self-Reported Incident was filed, resulting in non-compliance with reporting and investigation policies.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained scratches on the left arm. Although the injury was assessed by an RN and noted in a skin evaluation, there was no documentation in progress notes, no treatment orders, and no investigation into the cause of the injury. The DON confirmed that the incident met the criteria for an injury of unknown origin and should have been investigated according to facility policy, but this was not done.
Two cognitively intact residents did not have comprehensive, resident-specific discharge care plans developed or implemented. One resident's care plan lacked details about their discharge preferences and potential for returning to the community, while another had no discharge planning care plan initiated. Staff confirmed these omissions, which did not align with facility policy requiring individualized, measurable care plans reflecting resident goals and preferences.
The facility did not thoroughly investigate or document falls, nor did it consistently implement immediate and appropriate interventions for three residents at high risk for falls. Multiple falls occurred without root cause analysis, and in some cases, interventions were either missing or duplicated, despite facility policy requiring comprehensive follow-up and documentation.
Two residents with specific dietary preferences, including avoidance of pork and beef due to health and religious reasons, did not have their preferences consistently honored. Nutrition assessments were not completed in a timely manner, and staff failed to accurately document and follow dietary restrictions, resulting in residents receiving meals with items they wished to avoid.
The facility did not ensure that wound care treatments and follow-up appointments were completed as ordered for three residents. Missed wound care treatments were documented for two residents with chronic ulcers, and another resident did not receive scheduled Unna boot changes or attend a wound clinic follow-up. Staff interviews and record reviews confirmed these deficiencies, despite residents not refusing care.
Two residents with significant wounds did not receive pressure ulcer treatments as ordered, with multiple missed wound care interventions documented in the TARs. Despite physician orders and care plans specifying daily and twice-daily wound care, the required treatments were not completed on several occasions, as confirmed by the DON. Facility policy required wound management to promote healing, but these protocols were not followed.
The facility failed to maintain a pest-free environment, with ants observed in multiple residents' rooms and hallways. Pest control services had not been conducted since August 2024, as confirmed by the Regional Director of Maintenance. Staff and residents reported frequent ant sightings, and temporary measures like disinfectant spray were used. The facility's pest control policy required routine monthly visits, which were not followed, resulting in this deficiency.
A facility failed to correctly identify and manage a resident's wound care, leading to improper treatment. The resident, with multiple health conditions, was initially noted to have a pressure ulcer on the left buttock, but a later assessment revealed a laceration on the left posterior thigh. The wound care orders were not entered into the electronic medical record promptly, resulting in missed daily dressing changes. The facility's wound care policy was not adhered to, leading to a deficiency in care.
A resident with multiple health conditions, including multiple sclerosis and vascular dementia, did not receive timely incontinence care, resulting in wet clothing and a saturated brief. The CNA responsible had not attended to the resident for several hours due to other duties, and the facility's policy lacked specific guidelines for care frequency. The DON confirmed that care should be provided every two hours.
A facility failed to clarify physician orders and administer medications as prescribed for a resident with multiple health conditions. The resident did not receive lactulose and ezetimibe until two days after admission, and pregabalin was not administered on the day of admission despite being available. Interviews confirmed the orders should have been clarified upon admission, highlighting non-compliance with facility policies.
Failure to Implement Legionella Controls and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its Legionella Water Management Plan and to follow its own policies and CDC guidance for Legionella control. The written plan, dated 12/01/25, required flushing hot and cold water for three to five minutes in empty rooms and less frequently used outlets, including soiled utility rooms, medication rooms, shower stalls, private room showers, and eyewash stations, as well as cleaning, disinfecting, or replacing shower heads on a six‑month cycle. Review of facility documentation showed no evidence that these flushing tasks or shower head maintenance were completed. The Maintenance Director stated that flushing of less frequently used outlets was performed and tracked in TELS but acknowledged he was unaware that documented evidence of task completion was required and confirmed that shower heads were not cleaned, disinfected, or replaced every six months as required by the plan. CDC Legionella control guidance reviewed by surveyors recommended maintaining hot water above 140°F and flushing low‑flow piping at least weekly and infrequently used fixtures regularly. The facility also failed to implement enhanced barrier precautions (EBP) for residents with wounds and indwelling devices as required by its own policies and physician orders. One resident with multiple diagnoses including bladder injury, septic shock, ascites, diabetes, and chronic kidney disease had an abdominal wound and a physician order for EBP during wound care. During observed wound care to the abdomen and closed‑suction bulb drain site, an LPN did not don a gown, did not disinfect the bedside table before placing wound care supplies on it, and did not perform hand hygiene between glove changes. The LPN and the Assistant DON confirmed these omissions and acknowledged that a gown should have been worn, the table disinfected, and hand hygiene performed between glove changes. Another resident with chronic respiratory failure, tracheostomy status, and dependence for all care had care plan interventions and physician orders for EBP every shift and tracheostomy care every 12 hours. During observed tracheostomy care, an RN did not perform hand hygiene before entering the room or between glove changes, did not don a gown, and did not disinfect the bedside table before placing sterile tracheostomy supplies on it; the RN confirmed these failures. A third resident with dementia, diabetes, peripheral vascular disease, and a diabetic foot ulcer had ongoing wound treatments to the left toes and heel, but no EBP were in place during observations of routine care and transfers, and CNAs providing ADL assistance wore no PPE. An LPN confirmed the resident had a current wound, that there was no EBP signage or accessible PPE outside the room, and that EBP should have been in place. The ADON later verified that EBP had not been implemented for this resident until the previous day, despite wound treatment orders being in place since late February. Facility policies required EBP, including readily available gowns and gloves, for residents with chronic wounds or indwelling medical devices and specified hand hygiene after glove removal.
Failure to Check Nurse Aide Registry Before Hiring Staff
Penalty
Summary
The facility failed to ensure newly hired staff were checked on the nurse aide registry to verify eligibility for employment before working with residents. Review of the personnel file for an LPN showed a hire date of 02/18/26, but there was no evidence that the LPN had been searched on the nurse aide registry before beginning work in the facility. The census was 52 residents, and the deficiency was identified through review of personnel files, staff interviews, and policy review. During interview, the HRM stated he did not perform nurse aide registry searches for applicants prior to hiring and believed the registry was checked through the corporation's comprehensive background check. The Administrator confirmed that the HRM had not completed nurse aide registry searches for staff, except CNAs, hired since he began the position on 10/06/25. The Administrator also provided a list of 22 non-CNA staff hired during that period, including ADON, RNs, LPNs, maintenance, activities, dietary, housekeeping, and administrative staff. The facility later completed nurse aide registry searches for those 22 employees, and the review showed no findings of abuse, neglect, or misappropriation. The facility policy stated that nurse aide registry checks were to be completed prior to hiring all potential new employees, licensed and unlicensed, and new volunteers.
Failure to Maintain Adequately Warm Shower Water Temperatures in East Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequately warm shower water temperatures in the East Hall shower room, resulting in residents not receiving safe, comfortable, and homelike bathing conditions. Multiple residents who required staff assistance for showers reported that the shower water was too cold, leading some to avoid showers and instead receive bed baths or wash at the sink. One resident with congestive heart failure, weakness, and parkinsonism stated he rarely used the shower because the water was too cold and instead received bed baths. Another resident with Parkinson’s disease, asthma, and depression reported that the shower water was chilly but bearable and acknowledged refusing showers in the past due to cold water. A resident with congestive heart failure, anxiety, and atrial fibrillation described the East Hall shower room as so cold she felt like she had icicles coming off her body and avoided showers, receiving bed baths instead. A closed record review for a resident with COPD, anxiety, Type II diabetes mellitus, and restless legs showed documentation that the shower water was too cold, leading the resident to wash up at the sink rather than shower. Staff interviews with CNAs and an LPN confirmed that residents complained about cold water in the East Hall shower room and that one shower stall was cold while the other was only barely warm. Direct observation with the Maintenance Director showed shower stall temperatures of 83°F and 88°F after several minutes of running, and the sink reaching only 90°F, all below the stated minimum requirement of 105°F and the facility’s intended range of approximately 109°F to 115°F. Review of water temperature logs revealed that required weekly monitoring for the East Hall shower room was not consistently performed, with no temperatures logged for several weeks and only two recorded readings showing compliant temperatures shortly before the survey. The Maintenance Director verified the low temperatures, acknowledged the lack of recorded monitoring during the specified periods, and confirmed that the water temperatures did not meet the minimum requirement.
Failure to Provide and Document Scheduled Bathing and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure dependent residents received appropriate bathing, showers, grooming, and fingernail care in accordance with their assessed needs, care plans, and facility policy. One resident with severe cognitive impairment, multiple complex diagnoses, and on Hospice care required substantial to maximal assistance with ADLs and was care planned for showers on specific days with assistance for bathing and grooming. Documentation showed only intermittent bed baths and showers, with no recorded refusals, and no evidence of hair washing, fingernail clipping, or beard grooming. On observation, this resident was noted to have greasy long hair, unkempt facial hair, and long jagged fingernails. CNAs stated Hospice was responsible for showers and hair care, while the Hospice CNA stated facility CNAs were responsible, and confirmed the resident’s unkempt condition. Another resident with severe cognitive impairment, dependence on others for showering and personal hygiene, and multiple medical conditions reported only receiving showers once a week and wanting more frequent showers. Facility shower sheets and nurse aide task checklists showed showers were scheduled twice weekly, but documentation reflected that showers were only completed on some of the scheduled days, with only one documented refusal. The Interim DON confirmed that shower sheets were expected to be completed for each scheduled shower day, regardless of whether the resident accepted a shower, received a bed bath, or refused, and verified there was no evidence that several scheduled showers had been provided. Two additional residents, both cognitively intact and requiring substantial to maximal assistance with bathing, also lacked documented showers according to their schedules. For one resident, who was dependent for mobility and ADLs, shower sheets showed bathing on only three of eight scheduled opportunities, with no documentation of refusals in nursing notes. For the other resident, admitted and discharged within the review period, shower sheets showed no evidence of showers during the initial days after admission, including a scheduled shower day, and staff interviews confirmed that shower sheets should be completed for all showers, bed baths, or refusals. The IDON and other staff confirmed that the facility had no additional documentation to show that these residents were offered or received scheduled bathing, despite a facility policy stating that ADL care and services, including bathing, dressing, grooming, and oral care, would be provided.
Elopement Supervision, Smoking Material Storage, and Post-Fall Neuro Checks Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for residents at risk of elopement, improper storage of smoking materials, and incomplete neurological assessments after a fall. One resident with traumatic subdural hemorrhage, diabetes, alcohol withdrawal history, dysphagia, cognitive communication deficit, slurred speech, anxiety, and unsteadiness on his feet had been assessed as an elopement risk and care planned for exit-seeking behaviors. His care plan and physician orders required a wander management device with daily functional checks, and elopement risk assessments consistently identified him as at risk. Despite this, he experienced an elopement incident in which he was found outside near the employee access door after door alarms were activated, and a subsequent elopement in which he was found on a lawn across a two-lane street and near a four-lane state route. The administrator later stated that staffing was not adequate to provide the level of supervision necessary for this resident and that 15‑minute checks, initiated after the first elopement, were discontinued without additional interventions while he remained an elopement risk. Another deficiency involved a resident who was cognitively intact, used a manual wheelchair with supervision, and required maximal assistance with transfers and ADLs. This resident had a care plan focus area for smoking, with interventions to orient him to smoking policies and procedures, and a smoking assessment indicating he was safe to smoke with supervision. Facility policy defined smoking to include electronic cigarettes and required that smoking supplies be stored by the facility. However, a vape pen was documented as being found in the resident’s bed by an LPN, and on subsequent observation a red vape pen was again seen on the resident’s bed while he was not in the room. Staff, including a CNA, ADON, and LPN, confirmed that the vape pen was not allowed to be stored in the resident’s room and should have been secured with other smoking supplies, and the resident himself acknowledged that all smoking materials, including vape pens, were required to be stored in a locked box maintained by the facility. A further deficiency concerned the facility’s completion of neurological assessments following a fall. A resident with COPD, anxiety, Type II diabetes mellitus, heart disease, and restless legs, who required substantial to maximal assistance for mobility, transfers, toileting, and personal care and did not ambulate due to medical or safety concerns, had an unwitnessed fall documented on the incident log. The neurological assessment flowsheet for the period following this fall showed that hand grasps and motor functions were not completed at multiple required assessment time points over two days, even though other parameters such as level of alertness and pupil response were documented. In an interview with the administrator, concurrent review of the flowsheet confirmed that these neurological assessments were completed inaccurately and should have included hand grasps and motor function at all assessment times.
Inaccurate MDS Assessments for Behaviors, Oxygen Use, Wounds, and Refusals of Care
Penalty
Summary
The facility failed to ensure accurate MDS assessments for four residents. Review of the records, observations, and interviews showed that the assessments did not consistently reflect residents’ actual status for behaviors, oxygen use, hospice status, wounds, and refusal of care. The report also states that the facility followed the CMS LTC Facility RAI User’s Manual for guidance on accurate completion of MDS assessments. For one resident with diagnoses including traumatic subdural hemorrhage, diabetes, alcohol use, dysphagia, cognitive communication deficit, slurred speech, and unsteadiness, the annual MDS dated 03/20/26 did not identify elopement risk, even though care plans described exit-seeking behavior and elopement risk, a wander management device was ordered, elopement risk assessments consistently showed risk, and the resident had an elopement from the facility on 03/29/26. The Administrator later confirmed the resident had another elopement on 04/17/26, and the RRN confirmed the MDS was inaccurate regarding elopement risk. For another resident admitted with multiple cancers and neurogenic bladder, the admission MDS did not indicate oxygen use or hospice status, although the resident was observed wearing an oxygen nasal cannula connected to an oxygen concentrator at 4 lpm, the Administrator confirmed oxygen was used as needed, and hospice paperwork showed hospice benefits were elected on admission and continued throughout the stay. A third resident’s admission MDS did not reflect wounds, despite admission orders for wound care to the right lower extremity, treatments to the left lower extremity and coccyx, care plan interventions for wound management, and documentation of a right lower extremity wound measuring 6.5 cm by 5.8 cm by 0.1 cm. For a fourth resident with COPD, arthritis, abscess, bacteremia, hypertension, difficulty walking, and GERD, both the admission and discharge MDS assessments incorrectly indicated no refusals of care, even though progress notes documented multiple refusals on numerous dates during the stay.
Respiratory Equipment and Therapy Orders Not Followed
Penalty
Summary
Emergency respiratory equipment was not kept at the bedside for a resident with a tracheostomy. The resident had diagnoses including chronic respiratory failure with hypoxia and tracheostomy status, and the care plan and physician orders required a spare tracheostomy tube and obturator at the bedside, including one tube the same size and one size smaller. During observation, the extra tracheostomy tube, obturator, and smaller tube were not present at the bedside, and both an LPN and the ADON confirmed the supplies were missing and should have been there. Two residents were receiving oxygen without physician orders. One resident had diagnoses including COPD and lung cancer, was cognitively intact, and was observed wearing an oxygen nasal cannula connected to an oxygen concentrator running at four lpm even though the medical record contained no oxygen order. A second resident with diagnoses including neurogenic bladder and multiple cancers was also observed wearing an oxygen nasal cannula connected to an oxygen concentrator running at four lpm, while the record likewise had no order for oxygen administration. An LPN verified both residents were receiving oxygen, and the Administrator confirmed the absence of oxygen orders. BIPAP therapy was not initiated as ordered for a resident with COPD, and BIPAP equipment maintenance was not completed as required. The resident had physician orders for BIPAP settings, monthly tubing changes, and weekly cleaning of the mask and machine. During observation, the BIPAP machine was at the bedside, but the resident stated it had not been placed on her in approximately two months, the tubing was undated, no water was in the humidification chamber, and she reported the machine had not been cleaned or had parts changed in about two months and was missing parts. Staff interviews confirmed the BIPAP was not applied during the night because equipment was not available in the room, the tubing was undated, and the resident had not worn the BIPAP for two months. The machine usage report showed no use since 02/15/26 and a compliance summary of 44 of 90 days, or 48.9% application.
Food Stored on Floor and Expired Items Found in Storage Areas
Penalty
Summary
The facility failed to store food in a safe and sanitary manner. During observation of the dry food storage area, an opened box on the floor contained six 104-ounce cans of applesauce, with an unopened box of six five-pound pouches of cornbread mix stacked on top of it, and an opened box containing two sealed 10-pound bags of elbow macaroni stacked on top of the cornbread mix. Nearby on the floor were an unopened box of six 57-ounce cartons of mashed potato flakes and an unopened box of four 35-ounce bags of frosted flakes. In the walk-in freezer, a box of cracked wheat pull-apart rolls was on the floor with boxes of chicken breast fillets, pork breakfast sausage crumbles, and buttermilk biscuits stacked on top of it, and nearby on the floor were an unopened box of chocolate protein shakes, a box of [NAME] Creek Meats, and a box of sliced strawberries. In the walk-in cooler, surveyors observed two oval red stains, each about 12 inches wide, on the floor below boxes of meat stored on a bottom shelf. Expired food was also found on a shelving unit, including beef stew, pork, egg, orange pineapple, ham slices, and fresh fruit, with expiration or prepared dates ranging from 04/05/26 to 04/12/26. The DNFS confirmed the observations in the dry storage area, freezer, and cooler, and stated that food should not be stored on the floor and that the items in the dry storage area and freezer had been there since delivery late in the afternoon on 04/10/26. The facility policy titled Kitchen Sanitation, dated 12/01/25, stated storage areas would be free of spills and all food would be stored at least six inches off the floor.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
The deficiency involves a failure to maintain resident respect and dignity in accordance with resident rights and facility policy. Resident #5, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, and dementia without behavioral disturbance, was admitted on an unspecified date. A comprehensive MDS assessment dated 04/15/26 documented that the resident was rarely or never understood and was dependent on staff for eating. The revised care plan dated 04/01/26 identified an ADL self-care performance deficit and included an intervention for partial assistance of one staff member to eat. On 04/14/26 at 8:22 A.M., surveyors observed approximately 13 residents in the secured unit dining area awaiting breakfast while CNA #110 passed out breakfast trays. As CNA #110 exited the secured unit, she turned back from the hallway and yelled to another CNA in the dining room that Resident #5 was a “feeder,” referring to the resident’s need for assistance with eating. During an interview at 8:35 A.M. the same day, CNA #110 confirmed she had yelled out that the resident was a feeder and acknowledged that referring to the resident in this manner was not dignified or respectful. Review of the facility’s Residents Rights policy, dated 02/20/26, stated that care team members would treat each resident with kindness, respect, and dignity, which was not followed in this instance.
Failure to Develop and Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement baseline care plans within the required timeframe and to provide them to the resident’s representative. One resident was admitted with multiple diagnoses including COPD, anxiety, Type II diabetes mellitus, heart disease, and restless legs, and required substantial to maximal assistance with ADLs such as toileting, bathing, dressing, transfers, and mobility. Review of the nursing admission/readmission evaluation showed that this resident needed physical assistance for ambulation, transfers, toileting, and bathing and used a walker and manual wheelchair. However, no baseline care plan was initiated at admission. The MDS Coordinator confirmed that no baseline care plan was in place from admission until nearly two weeks later, with the first care area initiated 13 days after admission and monitoring for diabetes mellitus not started until 14 days after admission. A second resident was admitted with diagnoses including peptic ulcer, schizoaffective disorder, bipolar disorder, rheumatoid arthritis, anxiety disorder, COPD, and lung cancer. Social services documentation indicated this resident was cognitively intact, had adequate vision and hearing, could be understood, and did not display behaviors or refusals of care. A baseline care plan was in place, but it did not address the administration of oxygen. Observation showed the resident wearing an oxygen nasal cannula connected to an oxygen concentrator running at 4 L/min, and the Administrator confirmed there was no care plan developed to include oxygen administration, despite the resident using oxygen as needed. Facility procedures stated that the baseline care plan would be initiated by the nurse conducting the admission assessment, and facility policy required care plans to include objectives to meet residents’ medical needs.
Failure to Provide Timely Assessment and Preventive Care for Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and preventive interventions for a diabetic foot ulcer in a resident with multiple risk factors. The resident had Type II diabetes mellitus, a history of diabetic ulcers, peripheral vascular disease, dementia, and impaired mobility, and was care planned for potential skin integrity impairment and an existing diabetic foot ulcer. The care plan and physician orders included weekly skin observations on day shift every Wednesday, encouragement and assistance with off-loading heels, turning and repositioning, use of a low air loss mattress, monitoring and documenting skin injuries, and referral to a podiatrist or foot care nurse. A skin risk assessment identified the resident as at risk for skin breakdown due to age and dementia. Despite these identified risks and interventions, the weekly skin observation scheduled for a Wednesday in late February was not completed, and there was no documentation of that required assessment. On the following day, a change in condition evaluation documented that the resident had developed a new skin wound or ulcer to the left great toe and second toe, described as a new onset grade two or higher pressure ulcer/injury or progression of an ulcer despite interventions, with a black scab on the great toe and a scarred heel. A wound/scab was also noted on the left heel. At that time, no wound measurements or detailed description of the toe wound were documented, and the only recorded intervention was an order to apply betadine every shift and obtain bilateral arterial Doppler studies. The DON and ADON later confirmed that no description or measurements of the wound were obtained until a week later, when a skin condition evaluation documented an in-house acquired diabetic foot ulcer on the left great toe measuring 5 cm by 4 cm with undetermined depth and mostly eschar, and a second diabetic foot ulcer on the left heel measuring 1 cm by 1 cm with undetermined depth. Subsequent documentation and observations showed that preventive off-loading interventions were not consistently implemented. Although there were physician orders to encourage off-loading heel boots/protectors every shift and later to elevate/float heels when resting in bed, surveyor observations on multiple occasions found the resident in bed with socks on, feet resting directly on the mattress, without pressure relief boots, heel elevation, or a tent to keep bed linens off the lower extremities. CNAs interviewed confirmed that the resident did not have heel elevation or pressure relief boots in place when in bed and that such boots had not been observed. Later observation of the left great toe dressing revealed it had not been changed since the prior day and showed a moderate amount of yellow/green drainage when removed. The facility’s own wound management policy stated that residents with impaired skin integrity would be recognized and treated timely, with systems in place for early identification and monitoring of new skin impairments, but the documented lapses in weekly skin assessment, initial wound measurement and description, and consistent implementation of off-loading interventions led to the cited deficiency.
Failure to Accurately Document Resident Discharge and Condition in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate documentation in a resident’s medical record in accordance with its own policy and accepted professional standards. A closed record review for Resident #59, who had diagnoses including traumatic subdural hemorrhage, intracranial abscess and granuloma, and dependence on ventilator status, showed an admission date of 11/21/25 and a discharge date of 02/10/26. The quarterly MDS dated 02/06/26 documented impaired cognition, and a Discharge Return Anticipated MDS was completed on 02/10/26. The facility’s Admission, Discharge, and Transfer Report indicated the resident was discharged to the hospital on that date. However, concurrent review of the progress notes from 02/05/26 through 02/11/26 with the Interim DON and ADON revealed there was no documentation in the EMR regarding the resident’s discharge. During interviews, the Interim DON and ADON, both recently employed at the facility, stated they were unfamiliar with the resident and the circumstances of the discharge. They confirmed there was no alert charting, no change in condition assessment, and no documentation in the medical record explaining the reason for the resident’s discharge, despite the MDS indicating a Discharge Return Anticipated. The ADON stated that a change in condition assessment and alert charting should have been completed if the resident left emergently. In a follow-up interview, the Interim DON reported that the Administrator later explained the resident had a scheduled surgical appointment at the hospital and was discharged from the hospital to another LTC facility, but this information was not reflected in the resident’s medical record. Review of the facility’s “Documentation in the Medical Record” policy, dated 01/02/24, showed the expectation that each medical record present an accurate representation of the resident’s experience and progress through complete and accurate documentation, which was not met in this case.
Delayed and Missed Wound Care for Two Residents
Penalty
Summary
The facility failed to ensure non-pressure ulcer wound care was initiated timely upon admission and completed as ordered for two residents. Resident #1 was admitted with diagnoses including subsequent encounter of bladder injury, septic shock, ascites, Type 2 diabetes mellitus, polyneuropathy, irritable bowel syndrome, cystocele, peritonitis, and stage 3 chronic kidney disease. Her admission MDS showed she was cognitively intact, had no behaviors or refusals of care, and required maximal assistance to full dependence for ADLs, bed mobility, transfers, and mobility. Her care plan included wound-related interventions for an abdominal wound, heels, sacrum, and panniculitis, with wound care as ordered. Although admission orders included wound care to the abdominal surgical incision and closed-suction bulb drain site, physician treatment orders were not entered until 11 days after admission, and wound care to the abdominal incision did not begin until 5 days after admission. Drain site cleansing did not begin until 12 days after admission, and drain output was not recorded on multiple ordered shifts and dates. Resident #55 was admitted with diagnoses including chronic heart failure, thrombophilia, atrial fibrillation, anxiety, depression, cellulitis of the left lower extremity, venous insufficiency, lymphedema, and chronic respiratory failure with hypoxia. Her admission MDS showed she was cognitively intact, had no behaviors or refusals of care, and required maximal assistance to dependence for ADLs, transfers, and mobility. Her care plan included wound management for both lower extremities, and admission orders included wound care to the right lower extremity. However, physician treatment orders were not entered until 34 days after admission, and wound care to the right lower extremity was not initiated until 30 days after admission. The TAR also showed missed wound care on several dates. The facility policy stated residents with impaired skin integrity should be assessed upon admission and treated timely.
Dialysis Access Site Not Properly Assessed
Penalty
Summary
The facility failed to ensure hemodialysis access sites were properly assessed and monitored for a resident with end stage renal disease, dependence on renal dialysis, an arteriovenous fistula, hypertension, malnutrition, hydronephrosis, hypotension, major depression, malignant neoplasm of prostate, and anemia. The resident’s care plan and physician orders required monitoring of the left arm fistula, including assessment for bruit/thrill, signs and symptoms of complications, and post-dialysis access site checks after each Tuesday, Thursday, and Saturday treatment. After the resident returned from hemodialysis, he stated he had not been assessed by a nurse. The TAR showed an LPN signed off that the post-dialysis access site dressing check and monitoring for complications had been completed, but interview and record review confirmed the access site had not actually been assessed. When the LPN later went to the resident’s room, she lifted the sleeve, exposed the left upper extremity with a white dressing covering the fistula, placed her fingers on the dressing, and concluded the assessment without attempting to observe the fistula site or assess for a bruit. The LPN then verified the fistula site was not properly assessed.
Medication Administration Not Given Per Orders
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames for 5 of 32 observed medications, resulting in a 15.63% medication error rate. This affected one resident out of four reviewed for medication administration, with the facility census at 52. During observation, an LPN prepared Resident #47’s medications, including cephalexin 500 mg, Austedo 12 mg, Risperdal 0.25 mg, metoprolol tartrate 50 mg, and insulin glargine 10 units, and then administered them at 11:25 A.M. after entering the resident’s room. Review of the resident’s medical record showed physician orders for cephalexin, Austedo, Risperdal, metoprolol tartrate, and insulin glargine with administration times between 7:00 A.M. and 10:00 A.M. for the morning doses and 8:00 P.M. and 11:00 P.M. for the evening doses. The LPN verified the medications were given outside the ordered time frames and also verified she did not check the resident’s blood sugar before giving insulin glargine, despite the order to hold the insulin if blood sugar was less than 100 mg/dL. The facility’s medication administration policy stated medications should be compared with the MAR and administered within 60 minutes before or after the scheduled time unless otherwise ordered.
Insulin Given Outside Ordered Time Frame Without Required Blood Sugar Check
Penalty
Summary
Resident #47 did not receive insulin glargine in accordance with the physician’s order. During observation, an LPN prepared and administered the resident’s medications, including 10 units of insulin glargine by subcutaneous injection to the right upper extremity at 11:25 A.M. The resident’s order specified insulin glargine 10 units every morning, to be given between 7:00 A.M. and 10:00 A.M., and to be held if the blood sugar was less than 100 mg/dL. Review of the medical record showed the resident also had orders for cephalexin, Austedo, Risperdal, and metoprolol tartrate, each with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M. The LPN confirmed the medications were administered outside the prescribed time frames and acknowledged that blood sugar was not checked before giving the insulin. The blood sugar was obtained afterward and was 167. The facility policy required comparison of the medication source with the MAR and administration within 60 minutes before or after scheduled times unless otherwise ordered.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure medications were not left unattended at bedside for one resident reviewed for medication administration. Resident #4 had an admission date of 01/25/21 and diagnoses including peripheral vascular disease, COPD, Type II diabetes mellitus, bipolar disorder, major depression, anxiety disorder, neuropathy, restless leg syndrome, anemia, chronic viral hepatitis C, transient ischemic attack, and hypertension. The MDS dated 03/26/26 showed the resident had intact cognition and required setup/clean-up assistance with activities of daily living, and the resident received multiple medications including antianxiety, antidepressant, anticoagulant, diuretic, opioid, antiplatelet, hypoglycemic, and anticonvulsant medications. During observation on 04/14/26 at 7:42 A.M., an LPN prepared the resident’s medications and entered the room, then placed the medications on the over-bed table in front of the resident and exited without observing the resident take them. The LPN confirmed she left the medications unattended at bedside and stated she believed the resident was independent with medications and that she was not required to stay during administration. The DON later verified the resident was not assessed as independent with medication administration, and facility policy stated that unless a resident had been assessed for safe self-administration, medications were not to be left unattended for later consumption.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to ensure that a call light was within reach for a resident with severe cognitive impairment and significant physical limitations, including hemiplegia affecting the non-dominant left side and non-ambulatory status. The resident was dependent on staff for activities of daily living except eating and was at risk for falls, as documented in the care plan. The care plan specifically included an intervention to ensure the call light was within reach and to encourage its use for assistance. During observations and interviews, it was found that the resident's call light was repeatedly out of reach, including being on the floor behind the bed and on the floor while the resident was in bed. The resident reported not having access to the call light most times and stated he could use it if it were accessible. Certified Nursing Assistants confirmed during interviews that the call light was not within reach and acknowledged it should have been. Facility policy required staff to ensure call lights were within reach and secured as needed.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of an injury of unknown origin to the State Agency, affecting one resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had multiple complex medical conditions including anoxic brain damage and dysphagia, was found to have multiple scratches on the left arm during a skin evaluation. There was no documentation in the medical record or progress notes regarding the origin of the scratches, and no physician orders were made for their treatment. An incident report was opened in error and not completed, and no Self-Reported Incident (SRI) was filed for this event. Interviews with facility staff revealed that the DON did not properly address the incomplete skin evaluation and could not locate documentation explaining the scratches. The RN who assessed the resident's scratches did not initiate treatment orders or complete the required risk documentation, and only notified the family, who were already aware. The DON confirmed that the incident was not investigated to determine the cause of the injury, which met the facility's definition of an injury of unknown origin and should have been reported and investigated according to policy. The facility's failure to report and investigate the injury constituted non-compliance as identified during a complaint investigation.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple complex medical conditions, including anoxic brain damage, gastrostomy and tracheostomy status, anxiety, and dysphagia. The resident was dependent on staff for all activities of daily living and had a care plan addressing skin integrity risks. On a skin evaluation, multiple scratches were noted on the resident's left arm, but the evaluation was marked incomplete and the incident report was opened in error. There was no documentation in the progress notes or physician orders regarding the scratches, and no treatment orders were initiated. Interviews with the DON and an RN revealed that the scratches were assessed, but no investigation was conducted to determine their origin, and the required documentation and reporting procedures were not followed. The facility's policy required immediate reporting and investigation of all injuries of unknown source, but this was not done. The DON confirmed that the incident met the criteria for an injury of unknown origin and acknowledged that it should have been investigated, but there was no supporting documentation or evidence of an investigation.
Failure to Develop and Implement Resident-Specific Discharge Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, resident-specific care plans were developed and implemented for two residents regarding discharge planning. For one resident with diagnoses including hypertension, congestive heart failure, chronic pain disorder, and major depressive disorder, the care plan included only a general intervention for social services to assist with discharge planning. The care plan did not specify the resident's preferences or potential for future discharge, nor did it document whether the resident's desire to return to the community was determined, despite the resident being cognitively intact. For another cognitively intact resident with diagnoses such as pneumonia, kidney transplant status, end stage renal disease, and anemia, there was no specific care plan initiated to address discharge planning. Staff interviews confirmed that care plans are updated at least quarterly or with significant changes, and that the two residents in question did not have completed, resident-specific discharge care plans. Policy review indicated that care plans should include measurable objectives, timeframes, and reflect the resident's goals and preferences, which was not followed in these cases.
Failure to Investigate and Document Falls with Immediate Interventions
Penalty
Summary
The facility failed to ensure that falls were thoroughly investigated to determine a root cause, were properly documented in the medical record, and that immediate and appropriate interventions were implemented. This deficiency affected three residents who were reviewed for falls. For one resident with severe cognitive impairment and multiple risk factors for falls, there were repeated incidents where the resident was found on the floor in various locations, including the dining room, activity room, and their own room. In several instances, there was no documentation of immediate interventions following the falls, and interventions such as non-skid socks were repeatedly implemented despite already being in place. There was also no evidence of a root cause analysis or thorough investigation for any of the falls during the review period. Another resident with severe cognitive impairment and a history of falls had multiple falls for which there was no nursing documentation or fall follow-up notes completed. The care plan for this resident included numerous interventions for fall prevention, but the medical record lacked documentation for some falls and did not include thorough investigations or root cause analyses for any of the falls that occurred during the review period. A third resident, who was cognitively intact but at high risk for falls due to cervical spine issues and weakness, experienced falls while attempting to transfer or ambulate. Immediate interventions were inconsistently documented, and in at least one instance, there was no documentation of an intervention following a fall. Interviews with facility leadership confirmed the lack of immediate interventions, duplicate interventions, and the absence of thorough investigations or root cause analyses for the falls. Facility policy required immediate interventions, thorough documentation, and root cause analysis for incidents such as falls, but these procedures were not followed.
Failure to Complete Timely Nutrition Assessments and Honor Dietary Preferences
Penalty
Summary
The facility failed to ensure that nutritional assessments were completed in a timely manner to determine dietary preferences and failed to honor food preferences for two residents. For one resident with multiple diagnoses including congestive heart failure, diabetes, and moderate cognitive impairment, the care plan and physician orders did not specify the resident's request to avoid pork and beef, despite documentation and interviews indicating these preferences. Observations confirmed that this resident received beef on his meal tray, and staff verified the presence of beef despite the resident's stated aversion. Another resident, with a history of kidney transplant, end stage renal disease, and diabetes, also reported a preference to avoid pork for religious reasons. Although the dietician was made aware of this preference, the resident continued to receive pork on meal trays and had to return them. Staff interviews revealed that dietary staff did not consistently review meal tickets thoroughly and relied on cheat sheets, which were incomplete regarding certain preferences. The facility's policy required interviews within 72 hours of admission to determine food preferences, but this was not completed for one of the residents involved.
Failure to Complete Wound Care Treatments and Follow-Up Appointments as Ordered
Penalty
Summary
The facility failed to ensure that wound care treatments and follow-up appointments were completed as ordered for three residents. For one resident with a history of atherosclerotic heart disease and an open chest lesion, daily wound care orders were not carried out on multiple specified dates, despite the resident being cognitively intact and not refusing care. Another resident with a non-pressure chronic ulcer of the right heel and midfoot did not receive daily wound care as ordered on several dates, and a change in wound care orders was also not implemented on the day it was prescribed. In both cases, the treatment administration records (TARs) confirmed the missed treatments, and the DON verified these omissions during interviews. A third resident, admitted with cerebral palsy, lymphedema, and cellulitis, had orders for Unna boots to be changed three times weekly, but these were not completed on two scheduled days. Additionally, this resident missed a scheduled wound clinic follow-up appointment, which was not documented in the electronic health record, and the resident was not transported to the appointment. Interviews with facility staff and wound clinic personnel confirmed these lapses. The facility's wound management policy required the promotion of treatment and healing of skin integrity impairments, but the documented failures show that wound care and follow-up were not consistently provided as ordered.
Failure to Complete Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered for two residents with significant medical conditions and wounds. For one resident with a non-pressure chronic ulcer of the right heel and midfoot, medical record review showed multiple missed wound care treatments on specific dates, despite physician orders for daily care involving cleansing, application of collagen, and appropriate dressings. The resident's care plan included interventions for impaired skin integrity, but the treatment administration records (TARs) documented that wound care was not performed on several occasions. Another resident with a history of traumatic brain injury, tracheostomy, and pressure injuries to both feet also did not receive wound care as ordered. Physician orders and TARs indicated missed daily and twice-daily wound care treatments for both the left and right foot on multiple dates. Staff interviews with the DON confirmed that wound care was not completed as required for both residents. Facility policy required the promotion of treatment and healing of skin integrity impairment, but the documented omissions in wound care represented a failure to follow these protocols.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, specifically regarding an ant infestation affecting multiple residents. Observations revealed ants in the rooms of five residents and in the hallways, with the potential to affect additional residents. The pest control service records indicated that the facility had not received preventative pest control treatments since August 2024, with no services provided in September, October, November, and the first half of December 2024. This lack of pest control services was confirmed by the Regional Director of Maintenance, who acknowledged the absence of services and stated that a request for pest control had been made. Interviews with staff and residents confirmed the presence of ants in various locations within the facility. Environmental Services Staff verified the ants in several residents' rooms and mentioned using disinfectant spray as a temporary measure. Residents reported frequent sightings of ants, particularly in bathrooms, and staff members, including a CNA, RN, and LPN, verified these observations. The facility's pest control policy, dated 2018, required routine monthly visits and additional visits if necessary, but this policy was not adhered to, leading to the deficiency.
Failure to Identify and Manage Wound Care Correctly
Penalty
Summary
The facility failed to correctly identify the type and location of a wound for a resident, leading to improper wound care management. The resident, who had multiple diagnoses including multiple sclerosis and vascular dementia, was noted to have an open area on the left ischium, but later documentation revealed a stage two pressure ulcer on the left buttock. However, a nurse practitioner later identified a laceration on the left proximal posterior thigh, which was not documented in the electronic medical record until several days later. This discrepancy in wound identification and documentation resulted in the resident not receiving the appropriate wound care treatment as per physician orders. The physician orders for the newly identified wound were not entered into the electronic medical record in a timely manner, leading to a failure to perform daily dressing changes as required. The Director of Nursing confirmed that the wound care orders had not been entered and that the daily dressing changes had not been completed. Additionally, there was no documentation that the previously ordered barrier cream was applied to the laceration on the posterior thigh. The facility's policy on wound care, which requires staff to verify physician orders and provide care accordingly, was not followed, resulting in a deficiency in wound care management for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, which was identified during a review of medical records, observations, staff interviews, and policy reviews. The resident, who was admitted with diagnoses including multiple sclerosis, vascular dementia, and hemiplegia, was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting and personal hygiene. The plan of care indicated that staff should change the resident per protocol, preference, and as needed. On a specific observation, the resident was found with wet pants and a saturated incontinence brief with a strong urine odor, indicating a lack of timely care. The CNA responsible for the resident's care admitted to not providing incontinence care since early morning due to being busy with other tasks. The DON confirmed that incontinence care should be provided every two hours, but the facility's policy lacked specific guidelines for the frequency of incontinence care and checks. This deficiency was part of a complaint investigation.
Failure to Administer Medications Per Physician Orders
Penalty
Summary
The facility failed to timely clarify physician orders and ensure medications were administered per physician orders for a resident with multiple diagnoses, including cirrhosis of the liver and cognitive impairment. Upon admission, the resident had orders for pregabalin, ezetimibe, and lactulose, but the lactulose order lacked a specified frequency. The physician orders were not clarified until two days after admission, resulting in the resident not receiving lactulose and ezetimibe until then. Additionally, pregabalin was not administered on the day of admission and was only given once the following day, despite being available in the contingency medication supply. Interviews with the Director of Nursing and the Regional Clinical Nurse confirmed that the physician orders should have been clarified upon admission, and the resident did not receive the medications as prescribed. The facility's policies on order processing and medication administration required timely clarification and administration of medications, which were not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's procedures.
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Illustrative
What surveyors actually found near you
We read the 618 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Perrysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor At Perrysburg | 3.6 mi | ★★★★★ | 29 | 0 |
| Three Meadows Post Acute | 3.6 mi | ★★★★★ | 13 | 1 |
| Avalon By Otterbein At Perrysburg | 3.6 mi | ★★★★★ | 23 | 0 |
| Kingston Health Center Of Perrysburg | 4.2 mi | ★★★★★ | 0 | 0 |
| Concord Care Center Of Toledo | 5 mi | ★★★★★ | 6 | 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.