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 Mayfair Village Nursing Care Center during CMS and state inspections, most recent first.
Surveyors found multiple breaches in dietary practices, including staff entering and working behind the service line without required hair nets or beard restraints, a staff member repeatedly adjusting a beard cover without performing hand hygiene, and an ice scoop stored directly inside an ice bin used for residents’ drinks. In addition, a dietary worker opened equipment doors and then handled and stabilized corned beef on a mechanical diet plate with a soiled gloved hand. These actions did not follow the facility’s policies on cross contamination prevention, resident dining services, safe food handling, and staff dress code.
A resident with multiple chronic conditions and frontotemporal neurocognitive disorder, who was dependent on staff to meet emotional, intellectual, physical, and social needs, did not receive individualized activities consistent with documented preferences. The activity assessment showed the resident was Catholic, valued pets and sports, and was interested in various group and leisure activities, yet observations found the resident repeatedly in a dark room with only television for stimulation. Activity staff reported the resident often refused activities but admitted they did not document what was offered or refused, had limited activity documentation, could not access the activity assessment and care plan, and were unaware of the resident’s religious affiliation and specific entertainment preferences.
A resident with mood disorder, depression, and other neurological conditions, who was cognitively intact and independent in ADLs, experienced escalating changes in mental status and behavior, including increased confusion, decline from baseline, refusal of medications and meals, hallucinations, and paranoid thoughts. Although the resident was under regular psychiatric care with a Psychiatric CNP and the CNP had instructed nursing to follow up if acute issues arose, facility staff, including the DON and a nursing supervisor, did not notify the Psychiatric CNP of these changes before contacting the Medical Director, completing an emergency hospitalization "pink slip," and involving police to transport the resident to the hospital. The Psychiatric CNP later confirmed she had not been informed of any behavior or condition changes or of the hospitalization, despite facility policy requiring provider notification of changes in a resident’s condition or status.
A resident with chronic kidney disease, vascular dementia, and frequent bowel/bladder incontinence reported dysuria, and a CNP ordered a UA with C&S. The initial urine specimen was picked up by the lab but later discarded, and there was no documentation of when the facility was notified or whether symptoms persisted. A repeat urine sample was collected and the culture later showed bacterial growth susceptible to antibiotics, yet the resident’s urinary symptoms, potential UTI, and lab results were not addressed in progress notes for an extended period, and antibiotics were only ordered after the positive culture was finally followed up. The resident’s care plan did not address UTI risk or recurrent UTIs, and the facility lacked UTI-related policies.
A resident with dementia and other comorbidities was ordered Metoprolol Tartrate 50 mg twice daily for HTN, with instructions to hold the dose if systolic BP was below a specified threshold. Review of the MAR and vital sign records showed the medication was routinely administered at scheduled times without documented BP checks around those administrations. The DON confirmed that BP was not monitored as ordered, despite facility policy requiring that medication administration parameters be noted, resulting in a deficiency related to unnecessary drug use.
A resident with a history of opioid abuse and chronic pain was maintained on PRN Oxycodone for pain management, with prior hospital and practitioner notes indicating concerns about narcotic tolerance and a plan to taper the dose. For a therapeutic leave of absence, nursing staff sent 17 Oxycodone tablets home with the resident from her controlled substance supply without a documented physician order or approval, and without following the facility’s LOA medication policy. Within less than two days, the resident reported she had used all of the pills and requested that her pain medication be available upon return, yet there was no documentation that the physician was notified of this rapid use of opioids outside the prescribed schedule, and her usual PRN Oxycodone regimen was resumed.
Surveyors found that the facility did not follow its own infection control policies for two residents requiring special precautions. A resident with an indwelling Foley catheter had orders and a care plan for Enhanced Barrier Precautions, yet a CNA provided a bed bath without donning required gown, gloves, or mask, despite facility policy identifying bathing as a high-contact activity requiring such PPE. Another resident receiving chemotherapy and on neutropenic precautions had signage on the door, but non-clinical staff, including a receptionist and a laundry assistant, entered the room without masks, later acknowledging they had not used PPE. The DON confirmed staff were expected to wear masks for neutropenic precautions, and facility policy called for protective precautions with appropriate PPE use.
Failure to report an allegation of sexual abuse involving two residents. One resident was cognitively intact, independent with ADLs, and ambulatory, while the other had intact cognition, needed minimal ADL assistance, and used an electric wheelchair. Staff accused the residents of sexual contact, both denied it, and the RR and administration acknowledged awareness of the allegation but did not initiate an investigation or report it to ODH despite facility policy requiring immediate reporting of reasonable suspicion of abuse.
Failure to Investigate Suspected Sexual Abuse: Staff accused two cognitively intact residents of sexual contact, but both denied the allegation and no investigation was started. The Ombudsman confirmed an open case, and the Regional Clinical Director stated the allegation was considered to have no merit after speaking with employees, so it was not reported to ODH or investigated further, despite policy requiring immediate reporting of suspected abuse.
Incomplete Care Plans for Multiple Residents: The facility failed to include key needs in the care plans for three residents. One resident with CHF had no care planning for that diagnosis, another resident using BiPAP had no care planning for the ventilator use, and a third resident receiving Ozempic had no care planning for the medication or its potential side effects. MDS staff confirmed the missing items were not addressed in the plans of care.
Failure to Update Care Plans After Falls, Behavioral Event, and Identified Fall Risk: The facility failed to revise care plans for three residents after changes in condition and events. One resident with parkinsonism, dementia, and mobility impairment had two falls, but no post-fall interventions were added to the care plan. Another resident with bipolar disorder, COPD, and chronic respiratory failure had a suicidal event requiring 911 and hospital transfer, yet the care plan lacked psych services interventions. A third resident with a high fall risk score and assistance needs did not have a falls care plan in place.
A medication error rate above five percent was identified when a resident with severe cognitive impairment was administered extended-release and electrolyte tablets in crushed form, despite clear 'do not crush' labeling. An LPN crushed and administered these medications in pudding, and a pharmacist later confirmed this was inappropriate. The facility's policies require adherence to proper medication administration procedures, which were not followed in this instance.
A resident with severe cognitive impairment and multiple chronic conditions was administered Metoprolol Succinate ER and Potassium CL ER tablets in crushed form, despite both being labeled 'do not crush.' An LPN crushed these medications and mixed them with pudding for administration, contrary to facility policy and manufacturer instructions. The error was confirmed by staff interviews and pharmacist consultation.
Surveyors found that medications and biologicals were not properly labeled or stored. An LPN was observed with opened but undated bottles of Thiamine B1, Famotidine, and MiraLAX, and several expired medications were found in the medication storage room. The ADON confirmed the presence of expired items, which were not separated as required by facility policy.
Two residents dependent on staff for bathing and shaving did not receive assistance according to their preferences or scheduled needs. One resident, with multiple medical and mental health conditions, received infrequent bed and sponge baths and was not shaved as desired, while another resident with severe cognitive impairment received only minimal bathing. The DON confirmed concerns with the completion of scheduled bathing and shaving for both residents.
A resident with severe cognitive impairment and a history of falls was not thoroughly assessed for range of motion after a fall, and the physician was not notified promptly. Staff documented a head-to-toe assessment and provided pain medication, but delayed physician notification and omitted a full assessment, as confirmed by the DON and a CNP.
A resident with cognitive impairment and a recent hip fracture experienced multiple falls and reported ongoing pain, but did not receive prescribed pain medication in a timely manner. Staff failed to administer pain relief as ordered, and stronger medication was only provided after further assessment revealed a new fracture. Facility policy for pain assessment and management was not followed.
A resident with a history of acute medical conditions and drug use was admitted to a facility without proper physician orders or supervision, leading to neglect. The resident did not receive necessary medications and experienced a rapid decline, resulting in death. The facility also failed to provide timely post-mortem care, leaving the body in the facility for over 11 hours. This incident resulted in Immediate Jeopardy due to significant lapses in care and communication.
A facility failed to update a resident's care plan to include interventions for aggressive behaviors and racial expletives as indicated in a self-reported incident. The resident, with multiple diagnoses and moderate cognitive impairment, had their silverware changed to plastic, but this was not reflected in the care plan. The DON confirmed the oversight, and nursing staff were unaware of the intervention.
The facility failed to provide comprehensive tracheostomy care for two residents, as there were no physician orders or documentation of care in their medical records. One resident, with chronic respiratory failure and tracheostomy, was dependent on staff for daily activities and always incontinent. Another resident, with hemiplegia and tracheostomy, required assistance with daily activities and was occasionally incontinent. The DON confirmed the lack of documentation for tracheostomy care.
An LPN left a medication cart unattended, with several medications on top, posing a security risk for seven cognitively impaired and independently mobile residents. The facility's medication policy did not address leaving medications unlocked and unattended.
A facility failed to maintain proper infection control during tracheostomy care for a resident with multiple health conditions, including chronic respiratory failure and a tracheostomy. An LPN did not wash hands between glove changes during the procedure, contrary to the facility's hand hygiene policy. The resident's medical record lacked physician's orders and documentation for tracheostomy care.
A facility failed to protect a resident's medical privacy by posting a sign with private medical information in a hallway. The sign, visible to other residents, included details about the resident's medical instructions and surgery. Staff confirmed this was against protocol and had been displayed since the morning shift.
The facility failed to maintain the dignity of two residents with indwelling urinary catheters by not covering the catheter drainage bags, as required by physician orders. Observations revealed that the drainage bags were visible from the doorway and hallway, and an LPN confirmed this oversight.
A medication administration error occurred when a resident was given Zyprexa 10 mg intended for another resident. The medication, initially refused by one resident, was not returned to the pharmacy and was later administered to another resident experiencing escalated behaviors. This error was confirmed by the RN Unit Manager.
A facility failed to document the justification for administering an antipsychotic medication to a resident with impaired cognition and schizoaffective disorder. The medication was given for reported increased agitation, but there were no progress notes or documentation to support the need for the medication. The DON confirmed the lack of documentation, which is required by the facility's policy.
The facility failed to have a carbon monoxide detector in the main kitchen where a gas stove was present, potentially affecting all 90 residents. An observation revealed the absence of the detector, and the Food Service Director confirmed it was missing and was unaware of how long it had been absent.
A resident with quadriplegia and other conditions was found with a lighter and cigarettes at his bedside while receiving oxygen therapy, contrary to facility policy. A nurse confirmed the presence of these items and confiscated them, as the resident was not allowed to store smoking materials at his bedside.
The facility failed to protect the privacy of two residents' medical records. A resident's electronic medical record was left open and unattended on a medication cart, visible to passersby. Similarly, another resident's treatment record was left open on a treatment cart, visible to several individuals. The facility's policy on safeguarding electronic health information was not followed.
A facility failed to complete required PASRR documentation for a resident with multiple diagnoses, including mood and anxiety disorders. The resident was cognitively intact, but the first PASRR document was completed months after admission and inaccurately indicated it was for an expiring respite stay. The DON confirmed this was the only PASRR document and that the resident had not been discharged or received respite services.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite her history of sexual assault and identified triggers. The resident, with an intact cognitive status, reported that people entering her room was a trigger, yet no trauma-informed care plan was developed. This deficiency was confirmed through interviews and a review of the facility's policy, which mandates a multi-pronged approach to trauma care.
The facility failed to conduct quarterly care conferences for three residents, as required by their policy. Interviews confirmed that residents were not invited to participate, and the DON verified the lack of evidence for quarterly interdisciplinary care conferences. The facility's policy mandates comprehensive care plans be developed and reviewed by an interdisciplinary team, including the resident and their representative, to ensure person-centered care.
A facility failed to monitor and document skin abnormalities for a resident on anticoagulant therapy, leading to unreported bruising and a scratch. Despite orders to monitor for bleeding signs, the MAR inaccurately showed no adverse reactions. Observations confirmed bruising and a scratch, which were not documented, violating facility policies requiring daily anticoagulation management and weekly wound assessments.
A facility failed to assess a resident for PTSD, missing a history of sexual assault in their trauma-informed care plan. Despite the resident's intact cognitive status and a policy requiring comprehensive trauma assessments, the facility did not identify PTSD triggers or develop a care plan. The resident reported feeling safe but was triggered by room entries, a detail not captured in the assessment.
Improper Hair Restraints, Utensil Storage, and Food Handling in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices related to hair/beard restraints, utensil storage, and safe food handling. The Food Service Director confirmed that dietary workers are required to wear hair nets or hats and beard restraints if they have facial hair. However, an aide from the assisted living area was observed behind the service line requesting food without wearing a hair net or beard restraint, and this was verified by another staff member. Another care aide from assisted living was also observed entering the service area and walking behind the service line with to-go meal containers, likewise without any hair or beard covering, which was confirmed at the time of observation. Additionally, during lunch service, a staff member with a beard covering was observed repeatedly pulling the covering up from his neck to his chin to ensure his beard was covered, using his hands and not performing hand hygiene afterward. Further observations showed improper storage and handling of food and utensils. In the main residents’ dining room, the ice bin contained a large serving utensil used to place ice into residents’ drinking cups, and the utensil was stored inside the ice bin itself, contrary to the facility’s policy that ice scoops be stored in a designated holder. In the kitchen, a staff member walked away from the stovetop and then opened the oven and steamer doors with gloved hands before preparing a mechanical diet plate of corned beef. With the same gloved hand, the staff member held the corned beef on the plate while cutting it, resulting in direct contact with food using a soiled glove. These practices were inconsistent with the facility’s written policies on prevention of cross contamination, resident dining services, safe food handling, and associate conduct and dress code, which require sanitary ice handling, avoidance of bare-hand contact with food, proper handwashing after touching hair or soiled equipment, and the use of hair and beard restraints.
Failure to Provide and Document Individualized Activities for a Dependent Resident
Penalty
Summary
The facility failed to ensure that one resident received appropriate, individualized activities and that activity offerings and refusals were properly assessed, care planned, and documented. The resident was admitted with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, chronic heart failure, type 2 diabetes mellitus, and frontotemporal neurocognitive disorder. A quarterly MDS assessment indicated the resident was rarely or never understood, and the plan of care documented that the resident was dependent on staff to meet emotional, intellectual, physical, and social needs, with interventions such as introducing the resident to others with similar interests, inviting to scheduled activities, and providing a program of activities of interest. An activity evaluation identified that the resident was Catholic, actively participated in religion, and that pets and sports were very important, while board games, community outings, current events, cultural events, educational programs, visits, group discussions, movies, music, television, and radio were somewhat important. The evaluation also noted the resident was interested in activities and was cooperative and cheerful. Observations over multiple days showed the resident in a dark room with no entertainment on one morning and only watching television at other times, with no evidence of other activities being offered that matched the documented preferences. During interviews, an activities assistant stated the resident refused many activities and did not like what was offered, but acknowledged that the activities offered and refused were not documented and that there was limited activity documentation overall. In a subsequent interview, two activities assistants reported they knew the resident liked trivia but were unable to access the activity assessment and care plan and were unsure of specific preferences such as what television and music the resident enjoyed. They were also unaware of the resident’s Catholic faith, despite the activity evaluation documenting this and noting that Catholic visitors came to see residents, indicating the resident had not been added to that list.
Failure to Notify Psychiatric Provider of Resident’s Acute Behavioral Change Before Emergency Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Psychiatric Certified Nurse Practitioner (CNP) of significant behavior and mood changes prior to initiating an emergency hospitalization process. The resident was admitted with a BIMS score of 15, indicating no cognitive deficits, and had diagnoses including Arnold Chiari Syndrome, hydrocephalus, mood disorder, depression, benign neoplasm of the brain, and adult failure to thrive. The resident’s care plan documented that he was independent with activities of daily living, ambulated independently in the facility and community, and received psychological services from a contracted counseling group, including visits from a Psychiatric CNP every two weeks and a nurse visit every other week. On a psychiatric visit dated 01/30/26, the Psychiatric CNP documented that nursing should follow up with the provider in 2–4 weeks unless an acute issue or concern arose. On 02/03/26, progress notes documented that the interdisciplinary team observed escalating changes in the resident’s mental status and behaviors, including multiple recent hospitalizations related to increased confusion, significant decline from baseline, refusal of medications and meals despite encouragement, and active hallucinations and paranoid thought processes. The facility’s Medical Director was notified and, by telephone, directed that the resident be sent to the hospital via an Application for an Emergency Hospitalization. The previous DON, a Nursing Supervisor, and a Regional Representative participated in completing the “pink slip,” and the police were contacted and arrived to facilitate transport. The resident reported that the DON informed him he was being “pink slipped” and that he agreed to go to the hospital after speaking with the police, but he was unaware he had a change in condition or different behaviors. The previous DON and Nursing Supervisor confirmed that the Psychiatric CNP was not notified of the behavior or mood changes at any time before the emergency hospitalization application and police notification. The Psychiatric CNP confirmed she had last seen the resident on 01/30/26, did not believe he then required hospitalization, was not notified of any subsequent behavior or condition changes, and only learned of the hospitalization at a later visit. Facility policy on “Changes in Resident’s Condition or Status” required notification of the resident, primary care provider, and resident/resident representative of changes in condition or status.
Failure to Timely Address UTI and Care Plan Recurrent Infections
Penalty
Summary
The facility failed to timely address a resident’s urinary tract infection (UTI) and to provide appropriate care for bowel/bladder continence and incontinence, catheter care, and UTI prevention. The resident was admitted with multiple diagnoses including chronic kidney disease, osteoarthritis, cognitive communication deficit, adult failure to thrive, delirium, and vascular dementia, and was frequently incontinent of bowel and bladder with moderately impaired cognition. On 03/03/26, the resident complained of pain with urination, and the on-call nurse practitioner ordered a urine specimen for urinalysis with culture and sensitivity. A progress note on 03/04/26 documented that the CNP evaluated the resident for dysuria, noted a history of recurrent UTIs, and that a urinalysis was pending; another note that morning stated the urine had been picked up by the lab. A urinalysis dated 03/04/26 showed the urine was collected and results were pending. From 03/04/26 to 03/15/26, progress notes did not address the resident’s potential UTI, urinary symptoms, or laboratory results. Documentation later showed that urine was collected again on 03/09/26, with culture results reported on 03/13/26 identifying bacteria susceptible to certain antibiotics, but treatment was not initiated until 03/16/26 when the CNP followed up on the positive culture and ongoing dysuria and ordered antibiotics. Interviews revealed the lab had discarded the 03/04/26 urine specimen and that there was no documentation of when the facility was notified, nor of whether the resident continued to have symptoms during that period. The CNP reported multiple issues with the lab, including reports that samples would not be run, and confirmed this occurred in this case. The resident’s care plan did not address her risk for UTIs or her recurrent UTIs, and the facility did not have policies related to UTIs. A Regional MDS staff member verified that the resident’s recurrent UTIs should have been addressed in the plan of care.
Failure to Monitor BP Parameters Before Administering Antihypertensive Medication
Penalty
Summary
Surveyors identified that a resident with dementia, dysphagia, and peripheral vascular disease, who was rarely or never understood, did not have blood pressure monitored as required in relation to an ordered antihypertensive medication. The physician’s order dated 12/01/25 directed that Metoprolol Tartrate 50 mg by mouth be given twice daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 110 mmHg. Review of the Medication Administration Records for March 2026 and early April 2026 showed the medication was administered at 9:00 A.M. and 9:00 P.M., but there was no documentation that blood pressure was checked around those administration times. Review of the resident’s vital sign records likewise showed no evidence of blood pressure monitoring at or near the times the medication was given. In an interview, the DON confirmed that the resident’s blood pressure was not being monitored as ordered, despite facility policy stating that any parameters around drug administration should be noted when administering medications. This deficiency was cited as noncompliance related to ensuring each resident’s drug regimen is free from unnecessary drugs, based on the failure to follow ordered parameters for blood pressure monitoring before administering Metoprolol Tartrate.
Unapproved Opioid Supply and Unreported Overuse During Leave of Absence
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from significant medication errors during a leave of absence (LOA). The resident had diagnoses including opioid abuse, heart failure, anxiety disorder, bipolar disorder, depression, chronic hepatitis C, and an unspecified mood disorder, and was cognitively intact. Her care plan documented pain management needs related to necrosis of the right femur, right hip joint issues, and osteoarthritis, with interventions including administering analgesics as ordered, monitoring for side effects such as respiratory depression, and evaluating the effectiveness of pain interventions. Physician orders included Oxycodone 15 mg every four hours as needed, and prior hospital records and practitioner notes indicated concerns about narcotic tolerance and a plan to taper her opioid dosage. On a specific date, progress notes and the controlled substance record showed that the resident was sent home on LOA with 17 Oxycodone tablets from her in-house supply. The controlled substance record documented that one Oxycodone dose was given at 4:39 p.m. and that 17 pills were then sent with the resident, with signatures from staff and the resident. There was no documentation in the medical record that the physician had ordered or approved sending this quantity of Oxycodone with the resident for the LOA. The DON later confirmed there was no physician order authorizing the Oxycodone for that LOA, despite a nurse’s verbal claim of having obtained approval, and the Regional Clinical Director confirmed the LOA policy was not followed. Subsequent progress notes documented that within less than 48 hours the resident called the facility stating she was out of her pain pills and had not been given any other medication, and she planned to return and wanted to ensure her pain medication would be available. When she returned, she resumed receiving as-needed pain medication per her usual schedule. There was no evidence in the medical record that the physician was notified that the resident had used 17 Oxycodone tablets in less than 48 hours outside of the prescribed order. The CNP later confirmed she had not approved sending 17 Oxycodone tablets for the LOA, stated that the resident was supposed to receive a reduced frequency of Oxycodone while on LOA, and verified that the resident went through the 17 pills sooner than allowed by her schedule, but the facility simply resumed her normal Oxycodone regimen without physician notification.
Failure to Follow Enhanced Barrier and Neutropenic Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control procedures for a resident on Enhanced Barrier Precautions (EBP). One resident with obstructive uropathy, stage IIIA chronic kidney disease, chronic systolic congestive heart failure, and an indwelling Foley catheter had physician orders for EBP due to Foley catheter use and a care plan identifying EBP as an intervention to reduce infection risk. Facility policy defined EBP as targeted gown and glove use during high-contact resident care activities, including bathing, and specified that residents with indwelling medical devices are indicated for EBP. During an observation of this resident’s room, a CNA entered to provide bed baths to both occupants of the room carrying gowns and trash bags but did not don a gown, gloves, or mask from the PPE drawers outside the room. The CNA remained in the room for the duration of the care and exited carrying trash bags containing used gloves, confirming afterward that she had provided bed baths and had not worn a gown for the resident on EBP. The deficiency also includes the facility’s failure to ensure staff followed neutropenic precautions for another resident. This resident had multiple myeloma, agranulocytosis secondary to cancer chemotherapy, hypertension, peripheral vascular disease, obesity, and congestive heart failure, required staff assistance with ADLs, and had progress notes indicating orders for neutropenic precautions. The resident’s room door displayed neutropenic precautions signage, and the resident reported being on neutropenic precautions due to receiving chemotherapy twice a week, stating that sometimes staff wore masks and sometimes they did not, and that his door used to be kept closed. Observations showed a receptionist and a laundry assistant each entering the resident’s room without masks to deliver a package and laundry, respectively; both later acknowledged entering without PPE, with the laundry assistant stating she forgot to put on PPE. The DON confirmed that staff should wear masks when entering rooms of residents on neutropenic precautions and that they were aware staff had entered without masks. Facility policy on protective precautions (reverse isolation) stated that such precautions are initiated at the recommendation of a provider, that a private room with the door ideally closed should be used, and that PPE will be worn in the room as needed by associates and visitors.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents and did not initiate a report to the Ohio Department of Health after staff became aware of the allegation. Resident #41 was admitted with diagnoses including Arnold Chiari Syndrome, hydrocephalus, mood disorder, depression, benign neoplasm of the brain, and adult failure to thrive, and was documented as cognitively intact with a BIMS score of 15. Resident #61 was admitted with diagnoses including COPD, heart failure, anxiety disorder, bipolar disorder, depression, opioid abuse, chronic viral hepatitis C, and unspecified mood disorder, and her MDS showed intact cognition. Both residents were described as having intact cognition, and Resident #41 was independent with ADLs and ambulation while Resident #61 required minimal assistance and used an electric wheelchair. Resident #61 stated that staff accused her of having sexual relations with Resident #41 and that she was offended by the accusation; Resident #41 also confirmed he had been accused of having sexual relations with Resident #61 in her room while her roommate was present and denied the allegation. The previous DON confirmed she was approached to initiate a pink slip for Resident #61 due to escalating behaviors and inappropriate sexual behaviors around other residents. The RR confirmed she was told on night shift that Resident #61 was having inappropriate sexual behavior but did not start an investigation or report it to the Ohio Department of Health. The Regional Clinical Director stated administration was aware of the allegations but believed there was no merit and therefore did not report the incident or investigate whether inappropriate sexual activity had occurred. The facility policy defined sexual abuse as non-consensual sexual contact and required immediate reporting of reasonable suspicion of crimes against a resident.
Failure to Investigate Suspected Sexual Abuse
Penalty
Summary
The facility failed to conduct an investigation when there was a report of suspected sexual abuse involving two residents. Resident #41 was admitted on 03/09/24 with diagnoses including Arnold Chiari Syndrome, hydrocephalus, mood disorder, depression, benign neoplasm of the brain, and adult failure to thrive. He was cognitively intact with a BIMS score of 15, independent with activities of daily living, and walked around the facility and in the community independently. Resident #61 was admitted on 01/03/25 with diagnoses including COPD, heart failure, anxiety disorder, bipolar disorder, depression, opioid abuse, chronic viral hepatitis C, and unspecified mood disorder. Her quarterly MDS showed intact cognition, minimal assistance with activities of daily living, and use of an electric wheelchair. Interviews with both residents showed that staff accused Resident #61 of having sexual relations with Resident #41, which both residents denied. Resident #61 stated she considered Resident #41 like her nephew and was offended by the accusation. Resident #41 stated he was accused of having sexual relations with Resident #61 in her room while her roommate was present and said he was hurt by the accusation. The Ombudsman confirmed an open case related to Resident #61 and that she reported being accused of inappropriate sexual contact. The Regional Representative confirmed she was told by night shift that Resident #61 was having inappropriate sexual behavior and confirmed she did not start an investigation. The Regional Clinical Director confirmed the administration was aware of the allegations but, after speaking with other employees, believed there was no merit to the allegation and did not report the incident to the Ohio Department of Health or investigate whether inappropriate sexual activity had occurred. The facility policy stated that sexual abuse is non-consensual sexual contact of any type with a resident and that associates are mandated to immediately report suspected resident abuse and/or neglect.
Incomplete Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents. Resident #04 was admitted with diagnoses including obstructive uropathy, chronic kidney disease stage IIIA, and chronic systolic congestive heart failure. The resident’s MDS assessment showed the resident was cognitively intact and had an active diagnosis of heart failure, but the care plan completed by the facility on 02/05/26 did not include care planning for congestive heart failure. The Nurse MDS Coordinator confirmed that the diagnosis of congestive heart failure was not included or addressed on the care plan. Resident #56 was admitted with diagnoses including COPD, incomplete paraplegia, and chronic respiratory failure. The resident’s MDS assessment indicated the resident was cognitively intact and used a non-invasive mechanical ventilator. Medical record review showed orders for oxygen with CPAP/BiPAP at night, and observation confirmed a BiPAP machine was present in the resident’s room and in use. However, the care plan completed on 01/15/26 did not address the BiPAP machine. Resident #61 was admitted with diagnoses including COPD, anxiety disorder, bipolar disorder, depression, opioid abuse, chronic viral hepatitis C, and unspecified mood disorder. The resident’s MDS assessment showed intact cognition, and physician orders showed regular use of Ozempic for morbid obesity over multiple periods. The resident’s plan of care did not address the weight loss medication or its potential side effects, and the Regional MDS staff confirmed Ozempic was a high-risk medication that should have been addressed in the plan of care.
Failure to Update Care Plans After Falls, Behavioral Event, and Identified Fall Risk
Penalty
Summary
The facility failed to revise resident care plans for three residents after changes in condition and events occurred. Resident #28 had diagnoses including parkinsonism, metabolic encephalopathy, dementia, severe protein-calorie malnutrition, muscle weakness, abnormal gait and mobility, cognitive communication deficit, dysphagia, dysarthria and anarthria, and overactive bladder. His MDS showed a BIMS score of 10 and he required assistance with self-care and mobility. His care plan addressed ADL deficits, impaired cognition, and fall risk, but the incident log showed falls on 3/18/26 and 3/27/26, and the care plan did not include post-fall interventions for either fall. The DON confirmed the care plan was not updated to reflect the fall interventions implemented by the facility. Resident #16 had diagnoses including bipolar disorder, COPD, chronic respiratory failure with hypoxia, and very hard of hearing, with a BIMS score of 9. Nursing notes documented an event on 12/18/25 in which he was found with his call light wrapped tightly around his neck and the bed remote cord wrapped around his arm, and he stated, "I want to die," prompting a 911 call and transfer to the hospital where he received psychological services. A psychiatric nurse practitioner note later stated he used psychotropic medication and staff were to monitor side effects, implement stress management techniques, and note symptom changes, but his care plan did not include interventions for psychological services. Resident #62 had diagnoses including CHF, obesity, GERD, and restless leg syndrome, a fall risk score of 20, and an MDS showing a BIMS score of 15 with assistance needed for incontinence care, toileting, showers, and personal hygiene. Her updated care plans did not include a falls care plan, and the MDS Regional Nurse confirmed the at-risk-for-falls care plan was missing.
Medication Error Rate Exceeds Five Percent Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less during observed medication administration, resulting in an error rate of 7.69%. During medication pass observations for six residents, two errors were identified out of 26 observations. One resident with multiple diagnoses, including severe cognitive impairment, was administered Metoprolol Succinate ER 100 mg and Potassium CL ER 20 mEq, both labeled 'do not crush,' in crushed form along with Eliquis. These medications were crushed and given in pudding by an LPN, despite clear labeling and facility policy instructions. The LPN confirmed the medications were crushed and administered, and a pharmacist later verified that these medications should not be crushed. The facility's medication administration policy requires staff to adhere to the 10 rights of medication administration, including verifying the correct form of the drug. The facility's policy on medication-related errors also outlines steps for notification and monitoring if a medication error occurs. The deficiency was identified through direct observation, record review, and staff interviews.
Crushing of Extended-Release and Labeled 'Do Not Crush' Medications
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical diagnoses, including dementia, chronic kidney disease, atrial fibrillation, and hypertension, was administered medications in a manner inconsistent with physician orders and manufacturer instructions. During a medication pass, an LPN crushed and administered Metoprolol Succinate ER 100 mg and Potassium CL ER 20 mEq tablets, both of which were clearly labeled 'do not crush,' along with Eliquis, by mixing them into pudding for the resident. The resident's Medication Administration Record (MAR) specified the use of these medications for hypertension and hypokalemia, with additional instructions to hold Metoprolol if systolic blood pressure was below 110. The resident was noted to have severely impaired cognitive skills and was rarely or never understood, as documented in the Minimum Data Set (MDS). The error was confirmed through direct observation, staff interview, and consultation with a pharmacist, who verified that both Metoprolol Succinate ER and Potassium CL ER tablets should not be crushed. Facility policy required staff to adhere to the '10 rights' of medication administration, including verifying the correct form of the drug, and to consult pharmacy or prescriber if there was any doubt. The facility's policy on medication-related errors also required notification of pharmacy and physician if a medication error occurred. The failure to follow these protocols resulted in the resident receiving medications in a form that was not intended, constituting a significant medication error.
Failure to Properly Label and Store Medications and Biologicals
Penalty
Summary
Surveyors observed that medications and biologicals in the facility were not properly labeled or stored according to accepted professional standards. During medication administration, an LPN was found with several facility stock bottles, including Thiamine B1, Famotidine, and MiraLAX, that had been opened but were not labeled with the date they were opened. Other stock medication bottles in the medication cart had open dates written on the lids, but these specific bottles did not. The LPN confirmed the lack of labeling and was seen labeling the bottles during the observation. Further inspection of the medication storage room revealed several unopened but expired items, including Fiber Powder Psyllium husk, Vitamin A, B2 Riboflavin, nasal moisturizing spray, and nasal decongestant, all with past expiration dates. The ADON confirmed that these medications were expired. Facility policy requires that expired, contaminated, or deteriorated medications be stored separately until destroyed or returned, but these expired items were not separated as required.
Failure to Provide Assistance with Bathing and Shaving
Penalty
Summary
The facility failed to provide adequate assistance with bathing and shaving for residents who were unable to perform these activities independently. One resident, admitted with multiple diagnoses including schizoaffective disorder, dementia, and severe protein-calorie deficiency, was documented as requiring supervision for bathing and expressed a preference for showers over bed baths. Over a 30-day period, this resident received only two bed baths and one sponge bath, and refused bathing once with occupational therapy. The resident was observed with a short beard and stated a dislike for facial hair, expressing a desire to be shaved. Both the resident and a family member confirmed a preference for showers, and the family member reported having to take the resident home to provide a shower due to infrequent bathing at the facility. The DON confirmed that bathing and shaving were not being provided according to the resident's preferences and schedule. Another resident, with severe cognitive impairment and dependent on staff for bathing, received only a sponge bath and one shower in the past 30 days. The DON acknowledged concerns with the completion of scheduled bathing for this resident as well. These findings were based on record reviews, resident and family interviews, and staff interviews, and were investigated under a specific complaint number.
Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident after a fall and did not notify the physician in a timely manner. The resident, who had a history of cognitive communication deficit, dementia, depression, anxiety, and a previous femur fracture, was found on the floor by his roommate after a fall. The resident was unable to explain what happened, had severely impaired cognition, and complained of left hip pain. Although a head-to-toe assessment was documented with no visible injuries, the resident was unable to stand, and staff assisted him back to bed and provided pain medication. The facility's fall investigation revealed that the resident's range of motion was not assessed following the fall, and the physician was not notified until several hours later. Interviews with the DON and a CNP confirmed that the range of motion assessment was omitted and that the physician notification was delayed, both of which should have occurred immediately after the incident. This deficiency was identified during a review of falls and related care for residents at risk.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to ensure timely and appropriate pain management for a resident with a history of cognitive impairment, dementia, depression, anxiety, and a recent left femur fracture. The resident experienced multiple falls, including one unwitnessed fall where he was found on the floor, unable to stand, and complaining of left hip pain. Despite a care plan identifying the resident as at risk for pain and discomfort, and physician orders for acetaminophen suppositories for pain, staff did not administer pain medication as ordered following the fall and during subsequent reports of pain. After the fall, the resident was given acetaminophen 325 mg, which was ordered only for fever, not for pain, and not the prescribed acetaminophen suppository for pain. The resident continued to report pain and had difficulty with activities of daily living, but no pain medication was administered from the day after the fall until two days later, despite ongoing complaints. It was only after further assessment and review of hospital records, which revealed a new hip fracture, that a stronger pain medication (oxycodone) was ordered and administered. Interviews with facility staff confirmed that pain management interventions were not implemented as per the care plan and physician orders. The CNP was unaware that acetaminophen had not been used for pain, and the DON verified that nursing staff did not attempt to give the prescribed pain medication during the period when the resident was experiencing pain. Facility policy required timely assessment and management of acute pain, but this was not followed in the resident's case.
Neglect in Resident Admission and Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident, who had been hospitalized prior to admission, received adequate, timely, and appropriate treatment and continuity of care. Upon admission, the staff did not obtain physician orders for medications or treatments, nor did they contact the physician or medical director regarding the resident's admission. This resulted in the resident not receiving necessary medications, including blood pressure medication, blood thinners, and insulin, which were critical given the resident's medical history of acute respiratory failure, cardiomyopathy, and polysubstance abuse. The resident, who had a history of illegal drug use, was not adequately assessed or provided with comprehensive and individualized interventions to maintain safety. Despite the resident's known comorbidities and recent hospitalization for acute conditions, the facility did not implement appropriate supervision or care plans to address these issues. The resident's condition deteriorated rapidly, leading to a call for emergency medical services and subsequent cardiopulmonary resuscitation, but the resident was pronounced deceased shortly after. Following the resident's death, the facility failed to provide timely and appropriate post-mortem care. The resident's body remained in the facility for over 11 hours before being transported to the morgue, as staff were unsure of the procedures to follow. This incident highlighted significant lapses in the facility's admission process, communication with medical professionals, and post-mortem care procedures, resulting in a situation of neglect and Immediate Jeopardy.
Removal Plan
- Education was provided to the facility's 32 nurses on the facility's admission policies, notification of the physician on admission, and physician orders, including medications.
- One-on-one education was provided to RN #15 and RN #35 as they were responsible for Resident #82's care during admission.
- The initial Self-Reported Incident (SRI) was submitted by the Administrator based on the allegation of neglect.
- The admitting nurse for Resident #82, RN #35, was suspended pending the outcome of the investigation.
- A whole house audit of 23 residents admitted was conducted to ensure physician orders were consistent with hospital discharge orders and physicians were notified of admission.
- All new admissions and re-admissions will be audited to ensure physician notification and physician orders are included.
- Education was provided to all 32 licensed nurses to communicate with facility leadership regarding changes that may occur to a resident's admission to the facility or with the hospital discharge plan, to seek further instruction and guidance; that residents with a history of drug abuse have a care plan with appropriate interventions in place; administration of an opioid reversal agent in suspected opioid overdose; the policy for postmortem care and pronouncement of death to include timely notification for release of a deceased resident and notification of the police and/or coroner as necessary.
- A whole house audit for residents with a drug abuse history diagnosis was completed to ensure interventions were in place and care plans reflected updated interventions as needed.
- Audits of care plans will be completed to ensure care plans for all residents with a history of drug abuse are appropriate.
- Audits of residents who have expired in the facility were reviewed to ensure they were provided with timely and appropriate postmortem care with notifications of the coroner and police as appropriate.
- Audits will be completed to ensure compliance.
- An Ad Hoc Quality Assurance and Performance Improvement Plan meeting was held to discuss the removal plan and root cause analysis (RCA).
- The Medical Director was notified of and approved the QAPI plan.
- All audits will be conducted and results will be discussed at the monthly QAPI meeting.
Failure to Update Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that care plans were comprehensive and addressed problems as identified in a self-reported incident (SRI) involving a resident. The resident, who was admitted with diagnoses including idiopathic aseptic necrosis of the left femur, unsteadiness on feet, history of falling, type II diabetes mellitus, and memory deficit following a cerebral infarction, was moderately cognitively impaired. The SRI indicated that the facility had changed the resident's silverware to plastic and updated the care plan for aggressive behaviors and racial expletives. However, a review of the care plan revealed that these interventions were not reflected in the care plan. Interviews with the Director of Nursing (DON) confirmed that the aggressive behaviors should have been addressed in the care plan as indicated in the SRI. The DON also verified that the care plan was not updated for aggressive behaviors and racial expletives, and nursing staff were not aware of the intervention added in the SRI. The facility's policy on care planning emphasized the importance of updating care plans to promote continuity of care and communication among staff, but this was not adhered to in this case.
Failure to Document Tracheostomy Care for Two Residents
Penalty
Summary
The facility failed to provide comprehensive tracheostomy care for two residents, Resident #65 and Resident #66, as evidenced by the absence of physician orders and documentation of tracheostomy care in their medical records. Resident #65, who was admitted with diagnoses including chronic respiratory failure and tracheostomy, was found to have no documented plan of care or evidence of tracheostomy care being completed. Her quarterly MDS assessment indicated she was dependent on staff for various activities and was always incontinent of bowel and bladder. Similarly, Resident #66, admitted with conditions such as hemiplegia, dysphagia, and tracheostomy, also lacked physician orders and documentation for tracheostomy care. Her admission MDS assessment showed she required assistance with daily activities and was occasionally incontinent of urine and always incontinent of bowel. An interview with the Director of Nursing confirmed the absence of documentation for tracheostomy/stoma care, highlighting a deficiency in the facility's care practices.
Unattended Medication Cart Poses Security Risk
Penalty
Summary
The facility failed to ensure medications were secured to prevent unauthorized access, which had the potential to affect seven residents identified as cognitively impaired and independently mobile. During an observation of medication administration, an LPN left the medication cart unattended while preparing medication for a resident. Several medications, including hydroxide HCL, Potassium Chloride ER, Spironalactone, toresmide, Venlafaxine HCL, and a bottle of Miralax, were left on top of the cart, unattended and out of the LPN's sight. The LPN confirmed leaving the medications unattended. The facility's Administration of Medications policy did not reference leaving medications unlocked and unattended.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to maintain proper infection control guidelines during tracheostomy care for Resident #65. The resident, who was admitted with diagnoses including chronic respiratory failure, cerebral aneurysm, liver transplant, tracheostomy, dysphagia, and Hepatitis C, was dependent on staff for various activities of daily living. A review of the medical record revealed no physician's orders for tracheostomy care, no documented plan of care, and no evidence that tracheostomy care had been completed as part of the treatment record. During an observation of tracheostomy care, an LPN was noted to have washed her hands and donned gloves initially, but failed to wash her hands between all glove changes throughout the procedure. This was confirmed during an interview with the LPN. The facility's hand hygiene policy, revised in 2024, requires hand hygiene to be performed even if gloves are used, particularly after removing personal protective equipment. This deficiency was investigated under Complaint Number OH00163322.
Privacy Breach of Resident's Medical Information
Penalty
Summary
The facility failed to protect the privacy of medical information for a resident, affecting one of three residents reviewed for privacy. During a medication administration, a piece of paper with private medical information for a resident was observed on the wall in the hallway next to the resident's room. The sign included details about the resident's medical instructions and upcoming surgery. Another resident was seen reading the sign and inquiring about the surgery, indicating that the information was visible to others. Staff confirmed that it was not protocol to display such information publicly and that the sign had been posted since the morning shift began.
Failure to Maintain Resident Dignity with Catheter Use
Penalty
Summary
The facility failed to uphold the dignity of residents with indwelling urinary catheters by not covering the catheter drainage bags, as required by physician orders. Resident #5, who was cognitively intact and required assistance with activities of daily living, had a suprapubic catheter with an order for a dignity bag to cover the drainage bag. However, during an observation, the catheter drainage bag was found hanging from the bed frame, visible from the doorway and hallway, with urine clearly visible. Similarly, Resident #27, who also required assistance with activities of daily living, had an indwelling urinary catheter with an order for a dignity bag to cover the drainage bag at all times. An observation revealed that the drainage bag was uncovered and visible from the doorway and hallway. An LPN confirmed that the catheter drainage bags for both residents were uncovered and in view, which constituted a failure to maintain resident dignity as per the facility's obligations.
Medication Administration Error
Penalty
Summary
The facility failed to maintain professional standards of quality when a medication intended for one resident was administered to another. Resident #74, who had diagnoses including dementia, type two diabetes mellitus, bipolar disorder, and schizoaffective disorder, refused a one-time order for the antipsychotic medication Zyprexa 10 mg via intramuscular injection on 08/07/24. This medication was supposed to be returned to the pharmacy but was instead placed in a box for return and remained in the medication storage room. On 08/12/24, Resident #33, who had diagnoses including epilepsy, high blood pressure, schizoaffective disorder, and traumatic brain injury, was experiencing escalated behaviors. A one-time order for Zyprexa 10 mg via IM injection was received for Resident #33. However, due to the medication not being returned to the pharmacy, Resident #33 was administered the Zyprexa 10 mg that was originally ordered for Resident #74. This incident was confirmed by RN UM #101, who acknowledged that the medication intended for Resident #74 was used for Resident #33.
Failure to Document Justification for Antipsychotic Medication Administration
Penalty
Summary
The facility failed to prevent the administration of an unnecessary antipsychotic medication to a resident, identified as Resident #33, who was admitted with diagnoses including epilepsy, high blood pressure, schizoaffective disorder, and traumatic brain injury. The resident was assessed with impaired cognition, impaired decision-making, and physical behaviors towards others. On a specific date, a one-time order for the antipsychotic medication Zyprexa 10 mg was given via intramuscular injection due to reported increased agitation and behaviors. However, there was no documentation or progress notes in the resident's medical record to support the occurrence of these behaviors that warranted the administration of the medication. The Director of Nursing confirmed the absence of documentation related to the resident's reported escalating behaviors on the date the medication was administered. The facility's policy on nursing documentation requires that nursing documentation be consistent with professional standards of practice and state laws. The deficiency was identified during an investigation under specific complaint numbers, indicating non-compliance with the facility's documentation policy and the requirement to document resident behaviors and interventions attempted before administering PRN medication.
Absence of Carbon Monoxide Detector in Kitchen
Penalty
Summary
The facility failed to have a carbon monoxide detector in the main kitchen where a gas stove was present, which had the potential to affect all 90 residents residing in the facility. During an observation, it was noted that there was no carbon monoxide detector in the designated spot in the kitchen area. An interview with the Food Service Director confirmed the absence of the detector and revealed that she was unaware of how long it had not been in place.
Failure to Maintain Safe Smoking Practices
Penalty
Summary
The facility failed to maintain smoking products safely, affecting a resident with quadriplegia, chronic obstructive pulmonary disease, and other conditions. The resident, who had intact cognition as per the Minimum Data Set 3.0 assessment, was observed with a lighter and a package of cigarettes at his bedside while receiving oxygen therapy at two liters per minute. This was confirmed by a Registered Nurse, who then confiscated the smoking materials and handed them to the Executive Director. The facility's policy on oxygen administration, which requires oxygen to be kept away from combustible materials, was not adhered to, as the resident was not permitted to store smoking materials at his bedside.
Failure to Protect Residents' Medical Record Privacy
Penalty
Summary
The facility failed to protect the privacy of two residents' medical records during an annual survey. Resident #18's electronic medical record was left open and unattended on a medication cart, making it visible to passersby. This occurred from 4:04 P.M. to 4:14 P.M. on 08/05/24, and was confirmed by both the RN Unit Care Coordinator and the LPN Unit Nurse, who admitted to leaving the record unattended. Similarly, Resident #12's electronic medical treatment record was left open and unattended on a treatment cart from 1:25 P.M. to 1:29 P.M. on 08/07/24. During this time, several individuals, including residents, staff, and visitors, passed by the visible record. The record remained viewable until it defaulted to a screen saver, and was later secured by the Executive Director and the RN Assistant Director of Nursing. The LPN Unit Nurse confirmed leaving the record unattended while performing treatments. The facility's policy on safeguarding electronic health information, which requires users to log off when leaving their workstation, was not followed.
Incomplete PASRR Documentation for a Resident
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) documents were completed as required for a resident. This deficiency affected one resident who was admitted with multiple diagnoses, including mood disorder, major depressive disorder, and anxiety disorder, among others. The resident was cognitively intact according to the Minimum Data Set (MDS) assessment. However, the first PASRR document for this resident was not completed until several months after admission, and it inaccurately indicated that it was for an expiring respite stay, which was not the case. The Director of Nursing confirmed that this was the only PASRR document available for the resident and that the resident had not been discharged or received respite services since admission.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, was assessed with an intact cognitive status and had a history of sexual assault. Despite this, the facility did not create a trauma-informed care plan that identified PTSD triggers or outlined how to monitor behaviors related to the resident's PTSD. The absence of such a care plan was confirmed during interviews with the resident and the Licensed Practical Nurse (LPN) MDS Nurse. The facility's policy on trauma-informed care requires a multi-pronged approach to identify residents with PTSD or a history of trauma, including assessing for trauma indicators upon admission and during changes in condition. However, the social services assessment for trauma-informed care did not include the resident's history of sexual assault, and no care plan was developed to address potential triggers. The resident expressed that people entering her room was a trigger, which was not addressed in her care plan, highlighting the facility's failure to adhere to its own policy and adequately support the resident's needs.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for three residents, as required by their policy. Resident #4, who has diagnoses including Parkinson's disease and cognitive communication deficit, was not invited to attend quarterly care conferences. The medical record showed only one interdisciplinary care conference was held in the past year. Similarly, Resident #65, with conditions such as type one diabetes mellitus and acute kidney failure, was also not invited to quarterly care conferences, with only one conference documented in the past year. Resident #40, who has acute and chronic respiratory failure among other diagnoses, was not invited to quarterly care conferences either, with only one conference held in the past year. Interviews with the residents confirmed they were not invited to participate in these conferences, and the Director of Nursing verified the lack of evidence for quarterly interdisciplinary care conferences for these residents. The facility's policy requires that comprehensive care plans be developed and reviewed by an interdisciplinary team, including the resident and their representative, to ensure person-centered care. However, the facility did not adhere to this policy, resulting in the deficiency.
Failure to Monitor and Document Skin Abnormalities
Penalty
Summary
The facility failed to properly monitor and document skin abnormalities for a resident who was at risk due to anticoagulant therapy. The resident, who was cognitively intact and at risk for pressure ulcers, was on anticoagulant therapy for atrial fibrillation, which increased the risk of bleeding. Despite physician orders and care plans requiring monitoring for signs of bleeding, including bruising, the facility's documentation did not reflect the presence of significant bruising observed on the resident's arms. The Medication Administration Record (MAR) inaccurately indicated no signs of adverse reactions, such as bruising, from the anticoagulant use. Observations revealed dark, scattered bruising on the resident's arms and a large scratch on the elbow, which were not documented in the medical records. Interviews with nursing staff confirmed the presence of these skin abnormalities and the lack of documentation or routine monitoring. The facility's policies required daily anticoagulation management and documentation, as well as weekly wound assessments, which were not adhered to in this case. This deficiency in monitoring and documentation of skin conditions and potential adverse reactions to medication was identified during the survey.
Failure to Assess PTSD in Resident
Penalty
Summary
The facility failed to effectively assess a resident for Post Traumatic Stress Disorder (PTSD) as part of their trauma-informed care approach. The resident, who had a history of PTSD and sexual assault, was admitted with multiple diagnoses including bipolar disorder and homelessness. Despite having a cognitive status indicating intact mental capacity, the facility's assessment on 03/13/24 did not acknowledge the resident's history of sexual assault, which was later confirmed in medical progress notes. This oversight resulted in the absence of a trauma-informed care plan that identified PTSD triggers and monitored behaviors related to the resident's past trauma. Interviews and medical record reviews revealed that the resident felt safe in the facility but was triggered by people entering her room, a detail not captured in the initial assessment. The facility's policy required a comprehensive approach to identifying trauma indicators and developing individualized care plans, which was not followed in this case. The LPN MDS Nurse confirmed the omission of the resident's sexual assault history in the trauma assessment, highlighting a gap in the facility's adherence to its own policies for trauma-informed care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 819 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Sanctuary At Tuttle Crossing | 1.5 mi | ★★★★★ | 4 | 0 |
| Crown Pointe Care Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Friendship Village Of Dublin | 1.7 mi | ★★★★★ | 0 | 0 |
| Trueman Pointe Care Center | 1.9 mi | ★★★★★ | 6 | 0 |
| Sapphire Rehabilitation And Care Center | 2 mi | ★★★★★ | 69 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mayfair Village Nursing Care Center.
100% money-back within 48 hours.
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.