Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadow Wind Health Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and frequent incontinence had a urine culture ordered for altered mental status. The facility received an abnormal culture showing ESBL Klebsiella but did not report it to the NP for several days, and treatment was delayed until the resident was later found slow to respond with bradycardia and unresponsiveness and was sent to the hospital, where UTI, AKI on CKD, and IV antibiotics were documented.
Inaccurate MDS assessments were completed for two residents. One resident with respiratory failure, pneumonia, COPD, and diabetes was incorrectly coded as receiving insulin injections and not taking an antibiotic, even though the record showed Levaquin and no insulin orders. Another resident on hospice with chronic respiratory failure, quadriplegia, and depression was incorrectly coded on the MDS prognosis item as not having a life expectancy of less than 6 months, which an LPN confirmed was wrong.
A resident with a documented DNRCCA order had CPR started during a respiratory emergency before the code status was verified, despite staff records showing the resident was DNRCCA and cognitively impaired. Staff reports described confusion during the event, with CPR initiated while family members were present and code status confirmation occurring after compressions had already begun. In a separate record review, another resident’s chart showed DNRCCA in the EMR and care plan, but the hard chart lacked signed code status documentation.
Failure to Provide Scheduled Vision Services: A resident with ESRD, dialysis, HF, dysphagia, and use of glasses was consented for 360 Care vision services, but the scheduled vision visit did not occur as expected. The resident had also refused ophthalmic drops because they blurred vision, and the NP discontinued the medication. Staff reported the resident and daughter were waiting for the vision team, but the team was packing up and said the resident would not be seen; the visit record later stated the resident refused services, and follow-up emails sought another appointment.
A resident with stroke-related deficits, CHF, hypothyroidism, gastritis, and a GI bleed was identified as being at risk for altered nutrition and fluid imbalance. After the resident became fatigued and labs showed elevated BUN, creatinine, and a low GFR, a DT documented a recommendation for the NP to review the resident for IV fluids. However, the recommendation was not shown to have been relayed to the provider, and the NP later stated she was not aware of it.
Respiratory Tubing Not Maintained as Ordered The facility failed to keep oxygen tubing and set-up changed as ordered for three residents on mechanical ventilation with chronic respiratory failure and tracheostomy status. During observation and record review, tubing dates did not match the ordered change schedule, and the RT verified the tubing should have been changed as required. The facility could not provide a policy for respiratory staff changing oxygen tubing for residents on mechanical ventilation.
Licensed nursing staff did not have competencies completed on hire, and the facility did not ensure staff had the skills needed to carry out resident care and monitor changes in condition. One resident’s positive urine culture was not reported to the NP for days, and another resident did not receive ordered BID BG checks; abnormal lab results and a recommendation for IV fluids were documented, but no follow-up was found in the record. The facility assessment listed competency areas such as change in condition and BG testing, and the Regional RN confirmed new-hire competencies were not being completed.
Improper glove use and hand hygiene during incontinence care. Two CNAs provided perineal care to a resident with dementia, bowel and urine incontinence, and total dependence for care, but did not remove contaminated gloves or perform hand hygiene after cleaning stool before continuing to clean the labia area and reposition the resident. One CNA also touched the resident’s head with dirty gloves, and both CNAs restarted care without changing gloves or washing hands after the resident had another bowel movement. The DON could not confirm the proper procedure and stated she had not completed staff training on incontinence care.
The facility failed to adhere to infection control protocols, affecting 75 residents. A COTA exited a COVID-19 isolation room without hand hygiene, and an LPN conducted tracheostomy care without a sterile barrier. A housekeeper cleaned a contact isolation room without proper PPE, and a resident's blood sugar was checked in the dining room without a barrier. These actions compromised infection control measures.
A resident's dignity was compromised when their urinary catheter drainage bag was left uncovered, despite physician orders for a privacy cover every shift. Observations confirmed the bag was visible from the room's doorway, and staff acknowledged the oversight.
The facility failed to properly label enteral feeding bottles and water flush bags for a resident, and did not obtain necessary orders for another resident's feeding tube care. Observations showed unlabeled formula bottles and water flush bags, and a lack of orders for tube care and flushing was confirmed by staff. Both residents had complex medical histories and required assistance with feeding and medication administration.
A facility failed to establish parameters for administering pain medications, resulting in a resident receiving only Morphine, even for lower pain levels, without guidelines for using Acetaminophen. Interviews confirmed the absence of specific parameters, leading to unnecessary Morphine use.
The facility inaccurately reported staff hours for the PBJ report, potentially affecting all 75 residents. During the third quarter of 2024, the facility used agency staff to cover shifts, but this data was not submitted to the corporate office, leading to inaccurate reporting. A review revealed insufficient direct care staff on certain dates, failing to meet the minimum required hours of care per resident.
The facility failed to accurately assess, document, and treat a new onset of a diabetic ulcer for a resident with type two diabetes mellitus, Alzheimer's disease, and other conditions. The resident's scabbed area was identified on the right lateral dorsal foot on 01/11/24, but no documentation, wound assessment, or treatment order was initiated until 01/12/24, resulting in a deficiency.
Delayed Reporting of Abnormal Urine Culture and UTI Treatment
Penalty
Summary
The facility failed to ensure Resident #44 received treatment and care in accordance with professional standards of practice for a urinary tract infection. Resident #44 was admitted with multiple chronic conditions, including stage three pressure ulcer, malnutrition, heart disease, dysphagia, weakness, and frequent bowel and bladder incontinence. Her care plan included monitoring for signs and symptoms of UTI, and a quarterly MDS showed she was cognitively intact but medically complex and dependent for toileting hygiene. On 06/03/26, a urine specimen was collected after a provider ordered a urinalysis with culture and sensitivity for altered mental status. The lab report, dated 06/07/26, showed the urine culture was positive for Klebsiella pneumoniae ESBL greater than 100,000 colony-forming units per milliliter. Although the facility received the result on 06/07/26 at 2:38 P.M., there was no evidence the abnormal result was reported to the NP or physician until 06/16/26 at approximately 9:51 P.M. Progress notes from 06/07/26 through 06/15/26 did not show that the culture result was communicated to the provider. After the delayed report, new orders were entered for nitrofurantoin. Later that evening, Resident #44 was found during medication pass to be slow to respond, not opening her eyes, and not responding to sternal rub, with a pulse of 44 and blood pressure of 108/63. She was transferred to the hospital shortly after midnight and admitted for bradycardia and unresponsiveness. Hospital records showed acute kidney injury on chronic stage three kidney disease and UTI, with urine testing positive for E. coli and Klebsiella pneumoniae. She required a nine-day hospitalization, infectious disease consultation, PICC placement, and IV antibiotics.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents. For Resident #9, the medical record showed an admission with diagnoses including acute and chronic respiratory failure, COPD with exacerbation, pneumonia, dysphagia, weakness, and type 2 diabetes mellitus. Review of medication orders showed no insulin injections ordered, and Levaquin 750 mg daily was ordered on 05/23/26 for bilateral pneumonia. However, the quarterly MDS dated 05/26/26 incorrectly coded Section N as if the resident had been receiving insulin injections for the past seven days with no changes, while also failing to identify the resident as taking an antibiotic at the time of the assessment. The MDS Nurse confirmed the assessment was coded incorrectly and stated the resident had been on Levaquin and had never received insulin injections during the stay. For Resident #11, the record showed admission with chronic respiratory failure, quadriplegia, and depression, and that she was admitted to hospice on 08/22/24. The comprehensive and quarterly MDS assessments reviewed both indicated the resident was on hospice, but Section J, question J1400, was answered incorrectly to show that she did not have a life expectancy of less than six months. An interview with the LPN confirmed the MDS assessments dated 01/22/26 and 04/20/26 were incorrect in Section J because the resident was on hospice and the prognosis question should have been answered yes.
Advance directives not honored during CPR event and code status documentation incomplete
Penalty
Summary
The facility failed to honor advance directives for a resident with a documented DNRCCA order when CPR was initiated during a respiratory emergency. Resident #91 was admitted with acute respiratory failure with hypoxia, pulmonary embolism, and tracheostomy status, and the record showed the resident was cognitively impaired, totally dependent for ADLs, and had a physician order and care plan identifying DNRCCA status. During the event, staff were alerted that the resident was having trouble breathing, and the respiratory therapist entered the room, found the resident not breathing, and began CPR before the code status was verified. According to the facility investigation and staff statements, multiple staff members responded to the room, the crash cart was brought in, and CPR continued while EMS was called. One witness stated the family was asked if they wanted life support and said yes, while another witness stated the resident’s spouse and son were present and that the spouse was removed from the room. The regional nurse confirmed CPR was initiated when it should not have been because the resident had a DNRCCA order. The DON stated staff believed someone was sent to verify the code status while the code continued, and the respiratory therapist stated she did not have time to look in the chart before starting compressions. The facility also failed to ensure advance directive documentation was accurate in the medical record for another resident. Resident #28 had physician orders and a care plan indicating DNRCCA, but the record did not contain signed documentation verifying that status in the hard chart. A review of the electronic chart showed DNRCCA, while the regional nurse stated there was no signed code status paper in the medical record and reported that the resident had said he wanted to be a full code. The facility policy required advance directives to be maintained in the medical record and readily retrievable, and to be followed.
Failure to Provide Scheduled Vision Services
Penalty
Summary
The facility failed to ensure vision services were provided to a resident admitted with end-stage renal disease, renal dialysis, heart failure, dysphagia, and a dialysis fistula. The resident’s admission packet included consent for 360 Care ancillary services for audiology, vision, and podiatry, and the initial MDS indicated the resident used glasses and required hearing aids. In April 2026, the resident was treated with ciprofloxacin ophthalmic drops for conjunctivitis, but the resident refused the drops because they affected vision and made the eyes blurry; the NP discontinued the medication after the refusals and later prescribed lubricating eye drops after discussing treatment options with the resident’s family. An email from the Social Service Director requested that 360 Care add the resident for a vision visit and marked the resident as a priority, but there was no evidence of confirmation before the scheduled visit. The resident was listed as not seen on the 360 Care visit report, which noted the resident refused services. The Social Service Director later emailed again stating the resident had not been seen despite the family being present and reporting that the resident was not seen, and followed up again the next day seeking an emergent appointment. During interviews, the Social Service Director and Administrator stated the resident and daughter were waiting for the vision team, but the team was packing up and said they would not see the resident. The Administrator also reported that 360 Care management later stated the resident had refused, while the daughter had already left upset after the missed visit.
Failure to Communicate Dietary Recommendation for IV Fluids
Penalty
Summary
The facility failed to inform the nurse practitioner of a dietary recommendation to review the need for IV fluids for a resident with multiple medical conditions, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic congestive heart failure, hypothyroidism, mild gastritis, and a gastrointestinal bleed. The resident’s care plan identified risk for altered nutrition and fluid imbalance related to these conditions, along with episodes of meal intake less than 50 percent, significant weight loss, fluid shifts, and frequent urinary incontinence. On 05/19/26, the resident was seen by an NP for fatigue and was described as very tired during the exam. A chest X-ray, CBC, BMP, and TSH were ordered, and the NP noted there was no suprapubic tenderness and would hold off on IV fluids. The next day, labs showed elevated BUN, creatinine, and a reduced GFR. A dietary note documented a recommendation for the NP to review the resident for IV fluids, and nursing was aware and would contact the NP. However, there was no evidence that the dietary recommendation was relayed to the provider. A nursing note stated lab results were reported and new orders were received, but it did not show that the IV fluid recommendation was communicated. The NP later documented follow-up for pneumonia and additional antibiotics, but there was no indication she had been advised of the dietary recommendation. During interviews, the LPN stated she did not recall speaking with the DT or a dietitian about IV fluids, and both NPs stated they were not aware of the recommendation.
Respiratory Tubing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure respiratory equipment was maintained in a sanitary manner for three residents receiving respiratory care. Resident #35 had diagnoses including chronic respiratory failure, tracheostomy status, and dependence on a respiratory ventilator. His physician’s order required his oxygen tubing and set-up to be changed every Thursday and as needed, but the June 2026 TAR showed the tubing was due to be changed on 06/18/26 and staff had not completed it. During observation on 06/22/26, the tubing was dated 06/12/26, and the RT verified it should have been changed on 06/18/26. Resident #67 also had chronic respiratory failure, tracheostomy status, and dependence on a respiratory ventilator. His order required oxygen tubing and set-up changes every Thursday and as needed, but the June 2026 TAR showed the tubing was due to be changed on 06/18/26 and it had not been completed. On observation, the tubing was dated 06/12/26, and the RT confirmed it should have been changed on 06/18/26. Resident #70 had similar respiratory diagnoses and an order for oxygen tubing and set-up changes every Thursday and as needed. The June 2026 TAR documented the tubing as changed on 06/04/26, but on 06/22/26 the tubing was observed dated 05/14/26. The RT verified it should have been changed on 06/04/26 and again on 06/19/26 after the resident returned from the hospital. The facility could not provide a policy and procedure for respiratory staff changing oxygen tubing for residents on mechanical ventilation.
Nursing Competency and Communication Failures
Penalty
Summary
Licensed nursing staff did not complete competencies on hire and did not demonstrate the skill sets needed to care for residents based on assessed needs. The facility assessment listed training and competencies for the nursing department, including monthly education, orientation and training for new hires, and competency skill sets such as identifying resident change in condition and diabetic blood glucose testing. Review of employee files showed RN #507 and LPN #518 did not have nursing competencies completed on hire, and the Regional RN confirmed the facility had not been ensuring all licensed nursing staff had nursing competencies on hire. For one resident with diagnoses including atherosclerotic heart disease, gastroenteritis and colitis, muscle weakness, a stage 3 sacral pressure ulcer, peptic ulcer, malnutrition, bradycardia, hypotension, and intestinal bypass status, a urine culture positive for infection was reported to the facility but was not communicated to the NP until 13 days later. The resident was later hospitalized and treated for bradycardia, unresponsiveness, and IV antibiotics for a UTI caused by ESBL Klebsiella pneumoniae and E. coli. For another resident with hemiplegia and hemiparesis following cerebral infarction, CHF, hypothyroidism, and a history of GI bleed, an order required blood glucose checks twice daily, but the MAR showed only one check on one day. A dietary technician documented abnormal BUN, creatinine, and GFR results and recommended review for IV fluids and change in condition, but progress notes showed no follow-up on that recommendation, and both an LPN and NP stated they were not aware of the IV fluid recommendation.
Improper glove use and hand hygiene during incontinence care
Penalty
Summary
The facility failed to ensure staff followed proper infection control procedures during incontinence care for a resident who was admitted with hemiplegia of the right side, dementia, bowel and urine incontinence, and dependence on staff for all personal care, transfers, mobility, and feeding tube nutrition. During observation of incontinence care, two CNAs donned gowns and gloves under enhanced barrier protocol and began cleaning the resident after she had a bowel movement. After cleaning stool from the resident with disposable cloths, one CNA cleansed the rectal area, applied barrier cream, and then continued care without removing gloves or performing hand hygiene before obtaining a clean washcloth to cleanse the pubic area and labia. The other CNA also did not remove gloves or wash hands after assisting with care and then touched the resident’s head while repositioning her and placing a C-shaped pillow. When the resident began moving her bowels again, both CNAs stated they would need to start the process again, but neither removed gloves nor washed hands before restarting perineal care. In interview, one CNA stated she had been taught that once gown and gloves were donned for enhanced barrier protocol, they could not be removed until leaving the room, and the other CNA stated she was in training and had never been taught to remove or change gloves during incontinence care. The DON stated she had not completed staff training on incontinence care since starting her position, was not sure what training had been used, and could not confirm the proper hand hygiene and glove procedure without referring to the facility policy. The facility policy for perineal care stated to wash the labia area first, then the rectal area, and to remove gloves and wash and dry hands after cleaning the rectum before touching the resident’s environment.
Infection Control Deficiencies in Isolation and Care Procedures
Penalty
Summary
The facility failed to implement proper infection prevention and control protocols, which had the potential to affect all 75 residents. In one instance, a Certified Occupational Therapy Assistant (COTA) was observed exiting a COVID-19 isolation room without performing hand hygiene after removing an N95 mask. The COTA then proceeded to obtain a new mask from another resident's isolation cart without disinfecting her goggles or performing hand hygiene. Additionally, the isolation trash was overflowing, and there was confusion among staff regarding responsibilities for mask changes and trash disposal in isolation areas. In another case, a Licensed Practical Nurse (LPN) was observed conducting tracheostomy care for a resident without using a sterile barrier sheet, placing supplies directly on the resident's bed. The LPN confirmed that the supplies should have been placed on a sterile field, as per the facility's policy. Furthermore, a housekeeper was found cleaning a room under contact isolation without wearing the required gown, as she was not informed of the resident's isolation status. Additionally, a resident with diabetes was observed having their blood sugar checked and insulin administered in the dining room without a barrier for the supplies. The LPN placed used alcohol wipes and the glucometer directly on the table, contrary to the facility's infection control guidelines. These actions demonstrate a lack of adherence to infection control protocols, potentially compromising resident safety.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not covering an indwelling urinary catheter drainage bag, as required by physician orders. The resident, identified as Resident #276, was admitted with an indwelling urinary catheter and had specific physician orders for a foley catheter bag cover every shift to maintain privacy and dignity. Despite these orders, observations on multiple occasions revealed that the urinary catheter drainage bag was hanging from the bed frame without a privacy cover or bag in place. Interviews with State tested Nursing Assistants and a Licensed Practical Nurse confirmed the deficiency, acknowledging that the drainage bag was uncovered and visible from the room's doorway. The staff members recognized that there should have been a privacy bag or a drainage bag with an attached cover over the drainage bag, but this was not done, leading to a failure in maintaining the resident's dignity as per the facility's obligations.
Deficiencies in Enteral Feeding Tube Management
Penalty
Summary
The facility failed to ensure proper labeling and documentation for enteral tube feeding bottles and water flush bags for Resident #176. Observations revealed that the formula bottles and water flush bags were not labeled with the flow rate, date, or time of administration. This was confirmed during an interview with an LPN. Resident #176, who was cognitively intact, had a percutaneous endoscopic gastrostomy (PEG) tube and required assistance with activities of daily living, including medication and tube feeding formula administration. The facility's policy required documentation of the date, time, and initials on the formula label, which was not adhered to in this case. For Resident #177, the facility failed to obtain orders for the care and flushing of an enteral feeding tube. The resident had a feeding tube and required supervision with eating, but there were no orders for tube care or water flushes. The resident reported using the feeding tube for some medication administration. This lack of orders was verified by a Unit Manager. Resident #177 had multiple diagnoses, including osteomyelitis, cellulitis, type two diabetes mellitus, and schizophrenia, and was on various medications that could be administered orally or through the feeding tube.
Lack of Pain Medication Parameters Leads to Unnecessary Morphine Use
Penalty
Summary
The facility failed to establish parameters for administering pain medications for a resident, leading to a deficiency in medication management. The resident, who was severely cognitively impaired and dependent on hospice services, had orders for both Acetaminophen and Morphine for pain management. However, the Medication Administration Record (MAR) showed that only Morphine was administered, even for lower pain levels, without any guidelines for when Acetaminophen should be used instead. Interviews with the LPN and the Director of Nursing confirmed the absence of specific parameters for administering Acetaminophen versus Morphine. The facility's policy required assessing pain levels before administering medication, but it did not provide clear guidelines for choosing between the two medications. This lack of clarity in medication administration led to the unnecessary use of Morphine, as there were no established criteria for using the less potent Acetaminophen.
Inaccurate PBJ Reporting Due to Unreported Agency Staff
Penalty
Summary
The facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report, which had the potential to affect all 75 residents residing in the facility. A review of the PBJ report revealed excessively low weekend staffing for the third quarter of 2024. Further examination of the staffing schedules for nurses and State tested Nurse Aides (STNA) during this period showed that on specific dates, there was insufficient direct care staff to provide a minimum of 2.5 hours of direct care per resident per day. An interview with the Administrator on October 10, 2024, disclosed that during the third quarter of 2024, the facility utilized agency staff to cover shifts, but this data was not submitted to the corporate office for the PBJ. As a result, the data reported for the third quarter of 2024 was inaccurate.
Failure to Assess and Document Diabetic Ulcer
Penalty
Summary
The facility failed to accurately assess, document, and treat a new onset of a diabetic ulcer for Resident #80, who was dependent on staff for care. Resident #80, who had diagnoses including type two diabetes mellitus, Alzheimer's disease, high blood pressure, and chronic kidney disease, was admitted on an unspecified date and discharged to the hospital on 04/18/24. The resident had impaired cognition, was non-ambulatory, and was dependent on staff for bed mobility and transfers. The resident was also known to be combative and aggressive during care. On 01/11/24, a scabbed area was identified on the right lateral dorsal foot, but there was no documentation, wound assessment, or treatment order initiated on that date. The wound care team later evaluated the area on 01/12/24, noting it as a diabetic ulcer measuring 2.0 cm by 0.7 cm with no depth, and initiated a treatment order for cleansing and dressing changes three times per week. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) #310 revealed that the initial scabbed area was reported to RN #310 by an unknown nurse on 01/11/24, but no progress notes, wound measurements, or assessments were completed at that time. The facility's policy required a full assessment and documentation of any skin impairment, including location, stage, dimensions, presence of exudate or necrotic tissue, pain assessment, resident's mobility status, and current treatment. The failure to follow this protocol resulted in a deficiency, as the necessary documentation and treatment were not provided for Resident #80's diabetic ulcer in a timely manner.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Massillon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hanover Healthcare Center | 1.1 mi | ★★★★★ | 16 | 0 |
| Laurels Of Massillon, The | 1.7 mi | ★★★★★ | 1 | 0 |
| Amherst Meadows Skilled Nursing And Rehab | 2.2 mi | ★★★★★ | 0 | 0 |
| Legends Care Rehabilitation And Nursing Center | 2.5 mi | ★★★★★ | 12 | 0 |
| Astoria Skilled Nursing And Rehabilitation | 4.2 mi | ★★★★★ | 8 | 1 |
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