Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowbrook Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage, labeling, and sanitation, including open and undated food items in refrigerators and dry storage, incomplete temperature logs, improper drying of dishware, and staff failing to follow proper glove use and hand hygiene. Additionally, several dietary staff with facial hair did not wear beard restraints during food preparation, all contrary to facility policy. These failures had the potential to affect all residents in the facility.
Surveyors found that washers in the laundry room had visible build-up and that water was leaking from the water reserve tank, causing water to pool on the floor. The Housekeeping Supervisor confirmed these issues and stated the tank had been overflowing for over a week, potentially affecting all residents.
The facility did not document or follow up on concerns raised by residents during Resident Council meetings, as shown by blank 'Old Business' sections in meeting minutes and confirmed by resident and staff interviews. Issues such as staffing, call lights, medications, laundry, and menus were not addressed, despite facility policy requiring documentation and resolution of these concerns.
A resident with severe cognitive impairment and dependent on staff for ADLs did not have adequate lighting in their room during wound care, requiring staff to sometimes use a flashlight. Additionally, an LPN confirmed the presence of brown skid marks and an unidentifiable brown substance in the C Hall shower room, which was accessed by multiple residents.
The facility did not provide required bed hold notices or notify the Ombudsman when several residents, including those with heart failure, hip fracture, and chronic illnesses, were transferred or discharged to the hospital. Medical record reviews and staff interviews confirmed that these notifications and documents were missing for multiple residents during their hospitalizations.
Six residents with physician-ordered pureed diets were served incorrect food portions when staff used the wrong scoop sizes, contrary to the Registered Dietitian's plan and facility guidelines. The Dietary Manager confirmed the error, and facility policy required staff to be trained in proper portioning.
Staff did not inform a resident's medical provider of a significant weight loss, despite facility policy requiring such notification. The resident, who had chronic medical conditions and an order for daily weights, lost over 9% of body weight in two days. Both the dietician and NP confirmed that the provider was not notified of this change.
The facility did not accurately complete MDS assessments for three residents, resulting in incorrect documentation of dental status and range of motion. One resident was not coded as edentulous despite having no natural teeth, another was not coded for a left-hand contracture despite therapy records and observation, and a third was not coded for broken teeth despite clear evidence. The MDS RN confirmed these inaccuracies.
A resident admitted with a hospital exemption and a diagnosis of intellectual disability did not have a PASARR completed within 30 days as required. The resident's medical record and staff interview confirmed the absence of the PASARR, despite facility policy and hospital documentation indicating the need for timely completion.
A resident with multiple chronic conditions began receiving hospice services following a physician's order, but facility staff did not complete an updated PASARR assessment after this significant change in condition. This lapse was confirmed through medical record review and staff interview.
The facility did not develop complete care plans for two residents, omitting necessary interventions for one resident's use of a hypnotic medication and another resident's edentulous status. These omissions were confirmed through record review, observation, and staff interviews.
The facility did not conduct quarterly care conferences as required for three residents, including individuals with dementia, Parkinson's disease, and chronic obstructive pulmonary disease, all of whom required staff assistance with ADLs. Social Services Directors confirmed the absence of these care conferences, and facility policy requiring resident and/or representative involvement in care planning was not followed.
A resident with multiple chronic conditions was not reassessed for nutritional status after returning from a hospital stay for volume overload, during which a significant amount of fluid was removed. Facility dietary staff were unaware of the hospitalization and did not update or complete a nutrition assessment upon the resident's readmission.
A resident with multiple medical conditions did not have weights obtained according to physician orders, with several days and weeks missed despite clear instructions for daily, weekly, and monthly monitoring. Staff confirmed the failure to follow the prescribed schedule.
A resident with a gastrostomy tube was found with a partially used bag of Jevity 1.5 formula hanging on the pump, and a piece of paper towel was inserted into the end of the g-tube tubing to prevent spillage. Nursing staff confirmed the formula should have been discarded after the feeding was stopped, and facility policy required proper handling and timely disposal of enteral feeding formulas.
A resident with multiple chronic conditions and severe cognitive impairment refused the influenza vaccine, but there was no documentation of vaccine consent or declination, nor evidence that education on the vaccine's benefits and risks was provided, as required by facility policy. The DON confirmed the absence of this documentation.
A resident with multiple chronic conditions and severe cognitive impairment was not offered the COVID-19 vaccine as required, and there was no documentation of vaccine consent or declination in the medical record. The DON confirmed the lack of documentation regarding the vaccine offer or administration.
Staff failed to protect resident privacy by posting a resident's photo on social media without consent, providing incontinence care without closing the window curtain, and performing a blood sugar check in a public dining area without visual privacy. These actions involved residents with severe cognitive impairment and violated facility policies regarding confidentiality and resident rights.
A resident was given Ambien for sleep assistance without a documented sleep disorder or related diagnosis, and the care plan did not address or monitor the use of this hypnotic medication. The DON confirmed the absence of both an appropriate indication and a care plan, contrary to facility policy requiring clinical justification and monitoring for psychotropic medications.
The facility did not adequately assess or document pressure ulcers for two residents at high risk, failing to measure and describe new wounds and not following physician orders for wound care. Required treatments were not consistently recorded or completed, and staff did not always use the correct wound care products as ordered. These deficiencies were confirmed by interviews and review of facility policies.
A nurse failed to verify a resident's identity and administered medications intended for another resident, resulting in the resident being hospitalized for altered mental status and accidental drug overdose. The error was discovered after administration, and the resident required monitoring and treatment before returning to baseline.
Surveyors found that insulin pens for three residents with diabetes were not dated when removed from refrigeration or placed in medication carts, as confirmed by LPNs and the DON. The facility lacked a specific policy for insulin storage and dating, and the consulting pharmacist confirmed the requirement for dating insulin upon first use.
A resident with end stage renal disease, CHF, and diabetes was not provided with the prescribed renal diet, including limits on juice, milk, and sugar intake. Despite clear physician orders and meal ticket instructions, the resident was repeatedly served and consumed excessive amounts of milk and juice, as well as regular sugar syrup, due to errors by dietary and nursing staff. Interviews confirmed the resident was unaware of dietary restrictions and consistently received incorrect items.
Staff did not adhere to infection control protocols, including enhanced barrier precautions and proper hand hygiene, during care of two residents. An LPN failed to perform hand hygiene before tracheostomy care, used a non-disinfected surface for sterile supplies, and compromised aseptic technique. In a separate incident, a CNA wore the same gloves while moving a resident from their room to the dining area without changing gloves or performing hand hygiene.
A facility failed to implement its abuse policy when two residents were found in bed together, one undressed. The male resident, with moderate cognitive impairment, was confused and mentioned the female resident's odor. Despite the situation, no formal investigation was conducted, and the incident was not reported immediately to the DON or Administrator, as required by policy. Staff accounts were inconsistent, and a Self-Reported Incident was not completed.
A facility failed to timely report an alleged abuse incident involving two residents in a secured memory care unit. One resident was found undressed in another's bed, and staff inconsistencies delayed reporting to the DON and Administrator. The facility did not conduct a formal investigation or complete a Self-Reported Incident (SRI) as required by state regulations.
A facility failed to ensure staff wore appropriate PPE during high-contact care for a resident under Enhanced Barrier Precautions (EBP) due to Candida Auris. An STNA provided incontinence care without a gown, despite signage and policy requirements. The STNA was unaware of EBP protocols, leading to noncompliance with infection control measures.
A resident with hemiplegia and moderately impaired cognition was left without access to a call light, despite facility policy requiring it to be within reach. Staff failed to ensure the call light was accessible during multiple visits, leading to a deficiency finding.
A resident with multiple health conditions did not receive wound care as ordered after sustaining a skin tear. Despite a physician's order for daily dressing changes, the dressing was not updated for several days, as confirmed by an LPN. This noncompliance with the facility's wound care policy was identified during a complaint investigation.
A resident with chronic pain did not receive a one-time dose of Oxycodone in a timely manner due to a nurse leaving the floor without notice. The resident had difficulty finding a nurse for pain relief, and the medication was administered hours after the order was placed. The facility's policy requires timely medication administration, and the incident led to a deficiency finding.
The facility failed to administer medications as ordered, resulting in a 13.3% error rate. Two residents did not receive their prescribed medications due to unavailability, despite the facility's policy requiring adherence to prescriber orders. This deficiency was identified during a medication pass observation.
A facility failed to ensure a pressure ulcer dressing change was completed per physician orders for a resident with a stage four pressure ulcer. The LPN on the night shift did not perform the treatment and falsely documented it as completed, despite the resident not refusing the care.
The facility failed to ensure proper colostomy care for a resident, as an LPN did not follow hand hygiene protocols during the procedure. The LPN did not change gloves or perform hand hygiene when moving from dirty to clean tasks, resulting in improper care.
The facility failed to ensure the attending physician completed visits every 60 days, affecting two residents who had no physician visits from December 2023 through May 2024. Both residents were severely cognitively impaired, and the MD confirmed the oversight.
Deficient Food Storage, Sanitation, and Staff Hygiene Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and sanitation practices within the facility's dietary services. Open and undated food items, such as jars of jelly, pitchers of drinks, cartons of thickened beverages, and containers of sauces and dressings, were found in both the free-standing and walk-in refrigerators, as well as in the dry storage area. Temperature logs for the walk-in refrigerator were incomplete, and several food items in dry storage, including boxes and bowls of cereal and cornstarch, were also open, unlabeled, and undated. The facility's policy required all food to be covered, labeled, and dated, and for refrigeration temperatures to be monitored and documented, which was not followed. Additional deficiencies were noted in food preparation and handling. Insulated lids used to cover breakfast plates were stored in a way that allowed water to pool inside, rather than being stored upside down to dry properly. During meal preparation, a dietary staff member was observed wearing the same pair of gloves while touching various surfaces, utensils, and food items, and did not change gloves or wash hands as required by facility policy. Furthermore, several dietary staff members with facial hair were not wearing beard restraints while preparing food, contrary to facility policy. These actions and inactions had the potential to affect all residents in the facility, which had a census of 89 residents at the time of the survey.
Laundry Room Equipment Not Maintained in Clean and Safe Condition
Penalty
Summary
Surveyors observed that the facility's laundry room contained four washers with visible brown, blue, and white build-up on the tops and sides. Additionally, water was seen leaking from the water reserve tank located behind the washers, resulting in water pooling on the floor in front of the machines. During an interview, the Housekeeping Supervisor confirmed the presence of the build-up and the ongoing water leakage, stating that the water reserve tank had been overflowing onto the laundry room floor for over a week. These conditions were directly observed and confirmed by staff, and had the potential to affect all 89 residents in the facility. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Document and Follow Up on Resident Council Concerns
Penalty
Summary
The facility failed to document and follow up on concerns raised by residents during Resident Council meetings, as evidenced by a review of meeting minutes from May 2024 to April 2025. The section of the minutes designated for follow-up on previous concerns, labeled 'Old Business,' was consistently left blank and did not address issues previously brought up by residents, including topics such as agency staffing, call lights, medications, laundry, and menus. Interviews with residents who regularly attended the meetings, including the Resident Council president, confirmed that the facility had not provided any follow-up on concerns raised. Additionally, the Activities Director acknowledged that there was no documentation of follow-up to the concerns discussed in the Resident Council meetings during the specified period. Review of the facility's policy indicated that the facility was required to track and document responses and resolutions to concerns raised by Resident Council members, but this was not done.
Inadequate Lighting and Unclean Shower Room Environment
Penalty
Summary
The facility failed to provide adequate lighting in a resident's room, as observed during wound care performed by an LPN. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, did not have sufficient overhead lighting when the curtain was closed. The available light sources included a sink light, a bathroom light, and an over-the-bed light, but these were not adequate for performing wound care, leading staff to sometimes use a flashlight to provide care. Additionally, the facility did not maintain a clean environment in the C Hall shower room, which was used by 48 residents. Observations revealed brown skid marks of an unidentified substance on the wall by the toilet and a layer of brown unidentifiable material along the walls surrounding the shower area, approximately two inches up from the floor. An LPN confirmed the presence of these substances and that all residents on the C Hall had access to the affected shower room.
Failure to Provide Required Bed Hold Notices and Ombudsman Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation and notifications related to residents' needs, appeal rights, and bed-hold policies during instances of discharge or transfer to the hospital. Specifically, the facility did not issue appropriate bed hold notices to residents or their representatives and did not notify the Ombudsman when residents were transferred or discharged to the hospital. This deficiency was identified through medical record reviews and staff interviews, affecting four out of five residents reviewed for discharge and hospitalization. For example, one resident with acute on chronic diastolic heart failure was discharged to the hospital and did not return, but there was no documentation of Ombudsman notification. Another resident with right hip fracture and osteomyelitis was transferred to the hospital twice, with no Ombudsman notification documented for either transfer. Additional cases included residents with hypothyroidism, cardiomegaly, atrial fibrillation, diabetes, schizoaffective disorder, and chronic kidney disease, where bed hold notices were not provided and Ombudsman notifications were not documented. Staff interviews confirmed these failures in documentation and notification.
Failure to Serve Dietitian-Planned Pureed Food Portions
Penalty
Summary
The facility failed to serve food portions as planned by the Registered Dietitian (RD) for six residents who had physician's orders for a pureed diet. During a lunch observation, staff member #18 used a four-ounce scoop for pureed barbeque ham sandwiches and a three-ounce scoop for pureed potatoes, instead of the required five and one-half ounces for the sandwich and four ounces for the potatoes as indicated on the dietary spreadsheet. A poster in the kitchen provided coded measurement indicators for reference, but these were not followed. The Dietary Manager confirmed that the incorrect scoop sizes were used and that the staff member did not adhere to the spreadsheet planned and approved by the RD. Review of the facility's policy on kitchen weights and measures indicated that staff were to be trained on the appropriate measurement and type of serving utensil for each food. This deficiency affected six residents with pureed diet orders and was identified during the investigation of two complaint numbers.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
Staff failed to notify the resident's physician or medical provider of a significant weight loss experienced by a resident with diagnoses including COPD, panic disorder, and pulmonary hypertension. The resident had an order for daily weights, and records showed a drop from 187 pounds to 169 pounds over two days, amounting to a 9.3% loss. Despite facility policy requiring staff to report significant weight changes to the provider, interviews with the dietician and nurse practitioner confirmed that no notification was made regarding this weight loss. The nurse practitioner stated she was not informed and would have ordered lab work if notified.
Inaccurate MDS Assessments for Dental Status and Mobility
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents regarding dental status and range of motion/mobility. For one resident with benign prostatic hyperplasia, chronic kidney disease, and intellectual disabilities, the admission MDS did not indicate that the resident was edentulous, despite direct observation and resident/staff interviews confirming the absence of natural teeth upon admission. Another resident with cerebral infarction, asthma, and anxiety disorder had a left-hand contracture documented in therapy records and observed during the survey, but the quarterly MDS did not reflect any upper extremity impairment. Interviews confirmed the contracture and the use of a carrot splint, which was omitted from the MDS coding. A third resident with type 2 diabetes, peripheral vascular disease, and cerebral infarction was not coded for broken natural teeth on the admission MDS, even though both observation and resident interview confirmed the presence of a broken tooth and possible cavities. In each case, the MDS Registered Nurse acknowledged that the MDS assessments were not accurately completed, resulting in discrepancies between the residents' actual conditions and the documented assessments.
Failure to Complete PASARR Within Required Timeframe for Resident with Intellectual Disability
Penalty
Summary
A deficiency occurred when the facility failed to complete a Preadmission Screening and Resident Review (PASARR) within 30 days for a resident admitted with a hospital exemption. The resident was admitted with diagnoses including osteoarthritis, benign prostatic hyperplasia, chronic kidney disease stage three, and unspecified intellectual disabilities. The resident's intellectual disability, which manifested prior to age 22, was documented in both the hospital exemption and the facility's diagnosis list at the time of admission. The hospital exemption specifically indicated that the facility was responsible for electronically initiating a PASARR prior to the 30th day following admission. Despite these requirements, a review of the resident's medical record revealed that a completed PASARR was not present. The admission Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and required staff assistance with activities of daily living. Staff interview confirmed that the PASARR had not been completed for the resident, and facility policy stated that the PASARR should be provided prior to or upon admission.
Failure to Update PASARR Assessment After Significant Change in Condition
Penalty
Summary
Facility staff failed to update the Preadmission Screening and Resident Review (PASARR) assessment for a resident with multiple diagnoses, including cerebrovascular disease, chronic obstructive pulmonary disease, neurocognitive disorder, and diabetes, after a significant change in condition. The resident was admitted and later began receiving hospice services as ordered by a physician. Despite this change, the medical record review and staff interview confirmed that the facility did not complete an updated PASARR assessment when the resident was enrolled in hospice, as required. This deficiency was identified during a review of four residents for PASARR completion, affecting one resident out of a facility census of 89.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as required by policy. For one resident with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction, the care plan did not address the use of Ambien, a hypnotic medication, despite a physician's order for its use and documentation that the resident received the medication. The resident was cognitively intact and required staff assistance with activities of daily living. The Director of Nursing confirmed that a care plan for the use of Ambien had not been initiated. For another resident with benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities, the care plan did not address the resident's edentulous status, even though the resident was observed and confirmed to be edentulous upon admission. The admission MDS assessment did not correctly code the resident's dental status, and the dental care plan failed to include interventions specific to being edentulous. The MDS Registered Nurse confirmed these omissions during an interview.
Failure to Conduct Required Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences as required for three out of four residents reviewed for care planning. For one resident with severe cognitive impairment and multiple diagnoses including dementia, schizophrenia, bipolar disorder, and diabetes, there was no documented quarterly care conference for the first, second, and third quarters of the year, with only one care conference recorded in the fourth quarter. Another resident with Parkinson's disease and dementia, who had intact cognition and required staff assistance with ADLs, did not have any care conference conducted during the year. A third resident with chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, also with intact cognition and requiring staff assistance, did not have a care conference in the first quarter of the year. Interviews with the Social Services Directors confirmed that quarterly care conferences were not conducted as required for these residents. Review of the facility's policy indicated that care planning should include the resident and/or their representative and that meetings should be scheduled at a convenient time, but this process was not followed for the affected residents.
Failure to Reassess Nutritional Status After Hospitalization
Penalty
Summary
The facility failed to reassess the nutritional status of a resident following a hospitalization for volume overload. The resident, who had diagnoses including end stage renal disease, congestive heart failure, and diabetes mellitus, was admitted to the hospital where 44 pounds of fluid were removed. Upon return to the facility, there was no documentation of a nutritional assessment being completed, despite significant changes in the resident's weight and clinical status. Interviews with the Dietitian Technician and Registered Dietitian confirmed that neither had updated or completed a nutritional assessment for the resident after readmission. Both staff members were unaware of the resident's recent hospitalization and the substantial fluid loss, and acknowledged that a nutritional assessment should have been performed due to the nutritional significance of the hospitalization.
Failure to Obtain Resident Weights as Ordered by Physician
Penalty
Summary
The facility failed to obtain resident weights as ordered by the physician for one resident with diagnoses including hypothyroidism, cardiomegaly, and atrial fibrillation. The physician's order specified that the resident's weight should be obtained upon admission, daily for the following two days, weekly for four weeks, and then monthly. Review of the Medication Administration Record showed that weights were recorded on the first, second, and fourth days after admission, but not on the third day as ordered, and no weights were recorded for the remainder of the month. This failure to follow the physician's order was confirmed by staff interview. The facility's policy indicated that the physician, with staff input, determines the appropriate intervals for weight assessments.
Unsanitary Administration of Tube Feeding
Penalty
Summary
Staff failed to administer tube feedings in a sanitary manner for a resident with a gastrostomy tube. The resident, who was cognitively intact and had a history of dysphagia following cerebral infarction, was observed lying in bed with a tube feeding pump that was not running. A partially used container of Jevity 1.5, dated the previous day, was hanging on the pump and connected to the g-tube tubing, which had a piece of paper towel stuck in the end to prevent the formula from spilling out. Interviews with nursing staff confirmed that the tube feeding had been disconnected earlier in the day and that the partially used bag of Jevity 1.5 should have been discarded after the feeding was stopped. Facility policy required that reconstituted formulas be refrigerated and discarded within 24 hours. The presence of the used formula and unsanitary paper towel in the tubing indicated a failure to follow proper procedures for tube feeding administration and formula handling.
Lack of Documentation and Education for Influenza Vaccine Refusal
Penalty
Summary
The facility failed to ensure that a resident and/or their representative received education regarding the benefits and potential side effects of the influenza immunization. Medical record review for a resident with diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease showed an order for the influenza vaccine, which the resident refused. However, there was no documentation in the medical record of an influenza vaccine consent or declination form, nor evidence that the required education was provided. The resident was noted to be severely cognitively impaired and required staff assistance with activities of daily living. The DON confirmed that the resident refused the vaccine, but the necessary documentation and education were not present in the record, contrary to facility policy.
Failure to Offer and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine in accordance with its policy and CDC guidance. Medical record review showed that the resident, who had diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease, was admitted to the facility after having received a COVID-19 booster prior to admission. Despite being severely cognitively impaired and requiring staff assistance with activities of daily living, there was no documentation in the resident's medical record from the time of admission through the review period indicating that the COVID-19 vaccine was offered, declined, or administered. Additionally, there was no consent or declination form present in the chart, and the DON confirmed the absence of such documentation.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information, affecting three residents. For one resident with severe cognitive impairment and multiple diagnoses, the facility posted the resident's picture on social media without obtaining written consent from the resident or their representative, despite the representative's explicit request not to do so. The facility's policy required explicit written consent prior to releasing or transmitting resident images, which was not followed in this case. Another resident, also with severe cognitive impairment, was provided incontinence care by staff without the window curtain being closed, exposing the resident to potential view from the staff parking lot. Staff confirmed the curtain should have been drawn to ensure visual privacy. In a separate incident, a resident with Alzheimer's disease and other conditions had her blood sugar checked by an RN in the dining room in the presence of other residents, without visual privacy or obtaining consent. These actions were in direct violation of the facility's policies and residents' rights to privacy.
Hypnotic Medication Administered Without Proper Indication or Monitoring
Penalty
Summary
A deficiency was identified when a resident was prescribed Ambien, a hypnotic medication, for sleep assistance without an appropriate diagnosis or medical indication documented in the medical record. The resident, who had diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction, did not have a documented sleep disorder or related diagnosis to justify the use of Ambien. The physician's order for Ambien was present, but the necessary clinical justification was absent. Further review revealed that the resident's care plan did not address the use of Ambien, nor did it outline any monitoring for the effects or adverse consequences of the hypnotic medication. Interviews with the DON confirmed both the lack of an appropriate diagnosis for hypnotic use and the absence of a care plan for monitoring. The facility's policy required that psychotropic medications be clinically indicated and that residents be monitored for adverse effects, but these requirements were not met in this case.
Failure to Assess, Document, and Follow Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to timely and adequately assess the skin of a resident at very high risk for pressure ulcers. Despite physician orders for preventative skin care and weekly skin checks, documentation revealed that when an open area was discovered on the resident's right hip by family, staff did not measure or describe the wound as required by facility policy. Subsequent documentation and observation confirmed the presence of a facility-acquired unstageable pressure ulcer, but initial assessments lacked necessary details such as measurements, staging, and wound description. Additionally, the facility did not follow physician orders for wound care for another resident admitted with multiple pressure ulcers. Wound care orders for cleansing and dressing changes were not transcribed onto the Treatment Administration Records (TAR) for several periods, and there was no evidence that the prescribed treatments were completed. Documentation was also missing for specific dates, and staff used wound cleanser instead of normal saline on a wound, contrary to the physician's order. Interviews with nursing staff and the Director of Nursing confirmed these lapses in assessment, documentation, and adherence to physician orders. Facility policies required full assessment and documentation of pressure ulcers and completion of wound treatments as ordered, but these protocols were not followed for the affected residents.
Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a registered nurse administered a set of medications intended for another resident to a resident with multiple chronic conditions, including chronic diastolic heart failure, anxiety disorder, acute respiratory failure with hypoxia, hypertension, chronic obstructive pulmonary disease, and chronic kidney disease. The resident had intact cognition and required staff assistance with activities of daily living. The nurse failed to verify the resident's identity before administering the medications, as required by facility policy, and did not ask the resident's name or attempt any identification. Approximately 20 minutes after the error, the nurse realized the mistake, notified management, and assessed the resident. Following the administration of the incorrect medications, the resident's physician and emergency contact were notified, and the resident was monitored per physician orders. The resident's family requested hospital transfer, and the resident was sent to the hospital, where she presented with altered mental status and was diagnosed with accidental drug overdose and altered mental status. Hospital evaluation included lab work and EKG, which showed no significant abnormalities, and the resident was treated with intravenous fluids and monitored until returning to baseline. The incident was documented in the medical record, medication error report, and hospital records.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of insulin pens for three residents with diabetes mellitus. Medical record reviews and observations revealed that insulin pens for these residents were not dated when removed from refrigeration or placed in the medication cart, as required by professional standards. Interviews with LPNs confirmed that the insulin pens were not dated, and staff acknowledged that insulin is to be dated upon removal from refrigeration or when placed in the medication cart. Further interviews with the Director of Nursing and the consulting pharmacist confirmed the expectation that insulin should be dated when removed from refrigerated storage or first used. The Director of Nursing also confirmed that the facility did not have a policy specific to the storage and dating of insulin. These findings were based on direct observation, staff interviews, and review of medical records and physician orders for the affected residents.
Failure to Provide Physician-Ordered Renal Diet
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, congestive heart failure, and diabetes mellitus, who was prescribed a renal diet with low concentrated sugar and a fluid restriction, was not provided with the specified foods according to physician's orders. Medical record review and meal ticket documentation indicated the resident was to receive limited amounts of juice and milk, as well as a low concentrated sugar diet. However, observations revealed the resident was served and consumed six ounces of orange juice and eight ounces of milk at breakfast, exceeding the prescribed limits. The resident also received and consumed regular sugar syrup instead of the required sugar-free syrup. Interviews with the resident, dietary manager, and registered nurse unit manager confirmed that the resident was not provided with the correct diet as ordered. The dietary manager acknowledged that both the CNA and kitchen staff made errors in serving the incorrect items. The resident was unaware of the dietary restrictions and consistently received and consumed the wrong items. Facility policy required therapeutic diets to be prescribed by the physician to support the resident's treatment plan, but this was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines during care of residents, specifically in the application of enhanced barrier precautions (EBP) and hand hygiene protocols. For one resident with a tracheostomy, an LPN did not perform hand hygiene with alcohol-based hand sanitizer or soap and water before entering the room and donning a gown. After donning the gown, the LPN washed hands for only eight seconds, which is less than the recommended duration. The LPN also failed to disinfect the overbed table before using it as a workspace for sterile tracheostomy supplies and compromised aseptic technique by placing a non-sterile gloved thumb inside the sterile tracheostomy kit. These actions were confirmed by both the LPN and the Director of Nursing during interviews. Facility policy required EBP, including targeted gown and glove use during high-contact care activities such as tracheostomy care, and specified that hand hygiene should be performed before aseptic tasks. The policy also outlined that handwashing should last at least 15 seconds and that gloves do not replace hand hygiene. The tracheostomy care policy required aseptic technique and sterile gloves during procedures, as well as hand hygiene before and after glove use. These protocols were not followed during the observed tracheostomy care event. In a separate incident, a CNA was observed entering a resident's room wearing gloves, then exiting the room and assisting the resident to the dining room without removing or changing gloves. The CNA confirmed that the same gloves were worn throughout both activities. This practice did not align with infection control standards, which require glove removal and hand hygiene between resident care activities to prevent cross-contamination.
Failure to Implement Abuse Policy in Resident Incident
Penalty
Summary
The facility failed to implement its abuse policy when staff discovered a male and female resident in bed together. This incident involved two residents, one of whom was deemed incompetent and resided in a secured memory care unit. The male resident had moderate cognitive impairment and was generally independent in his activities of daily living, while the female resident had severe cognitive impairment and required varying levels of assistance for her daily activities. The incident occurred when a CNA found the female resident undressed in the male resident's bed, with the male resident sitting on the side of the bed. The male resident appeared confused and mentioned that the female resident had an odor. Despite the situation, the facility did not conduct a formal investigation or issue formal findings. Staff statements were collected, and it was noted that the incident was not reported immediately to the Director of Nursing or the Administrator, as required by the facility's policy. Interviews with staff revealed inconsistencies in their accounts of the incident. The CNA initially reported seeing the male resident on top of the female resident but later stated he was lying next to her. The Director of Nursing and the Administrator confirmed that they were not notified of the incident until the following day, and a Self-Reported Incident was not completed. The facility's policy mandates immediate reporting and investigation of such incidents, which was not adhered to in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged incident of abuse involving two residents in the secured memory care unit. Resident #4, who was admitted with Alzheimer's disease, dementia, and other conditions, was found undressed in Resident #41's bed. Resident #41, who has dementia and diabetes, was sitting on the side of the bed and appeared confused. The incident was initially observed by CNA #550, who reported seeing Resident #41 lying next to Resident #4. However, there were inconsistencies in the accounts provided by the staff involved, including LPN #415 and Medication Technician #575. The facility's policy on abuse and neglect requires immediate reporting of any suspected incidents to the Director of Nursing and the Administrator. However, the Director of Nursing was not notified until the day after the incident, and the Administrator was also informed late. The facility did not conduct a formal investigation or issue a formal report on the incident, and no Self-Reported Incident (SRI) was completed as required by state regulations. The staff involved did not follow the protocol for reporting and investigating the alleged incident, leading to a delay in addressing the situation. Interviews with the staff revealed a lack of clarity and consistency in their observations and actions. CNA #550 initially reported seeing Resident #41 on top of Resident #4 but later stated he was lying next to her. LPN #415 did not witness the incident but reported it to RN #320, who also delayed notifying the Director of Nursing. The facility's failure to adhere to its abuse and neglect protocol resulted in noncompliance with state regulations, as the incident was not reported within the required timeframe, and a formal investigation was not conducted.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when providing high-contact care to residents under Enhanced Barrier Precautions (EBP). This deficiency was identified during an observation where a State tested Nurse Aide (STNA) provided incontinence care to a resident without wearing a gown, despite the presence of a sign indicating the requirement for gowns and gloves for high-contact care. The resident in question had been admitted with diagnoses including hemiplegia, type II diabetes, and chronic viral hepatitis C, and was under EBP due to a positive Candida Auris test. The STNA involved in the incident sanitized her hands and donned gloves before entering the resident's room but did not wear a gown as required by the facility's EBP policy. During an interview, the STNA confirmed her lack of compliance with the gown requirement and admitted to not being aware of the specific EBP protocols or the reason for the resident's EBP status. The facility's policy, dated August 2022, clearly stated that gloves and gowns should be applied prior to high-contact resident care to prevent the spread of multi-drug resistant organisms.
Failure to Ensure Resident Access to Call Lights
Penalty
Summary
The facility failed to ensure that residents had access to call lights, affecting one resident out of five sampled. Resident #46, who was admitted with diagnoses including hemiplegia, hemiparesis, type II diabetes, and chronic viral hepatitis C, was observed without access to a call light. The resident had moderately impaired cognition and required staff assistance for activities of daily living. The care plan for the resident included keeping the call light within reach and encouraging its use for assistance. On the morning of the observation, a State Tested Nurse Aide (STNA) entered the resident's room, provided care, and left without ensuring the call light was within reach, leaving it on the floor. Another STNA later entered the room, removed breakfast dishes, and also failed to check the call light's accessibility. It was only after a subsequent visit that the call light was clipped to the resident's blanket. The facility's policy required call lights to be within easy reach, which was not adhered to in this instance, leading to the deficiency noted in the report.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care as ordered for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including ataxic cerebral palsy, morbid obesity, and type II diabetes, was at increased risk for pressure ulcer development. The care plan included administering treatments as ordered to prevent skin breakdown. However, after the resident reported hitting his leg on an air conditioning unit, a physician ordered daily dressing changes for a skin tear on the left shin. Despite this order, the dressing was not changed as required. On observation, the resident's dressing, dated three days prior, showed signs of drainage, indicating it had not been changed according to the physician's instructions. An LPN confirmed the dressing had not been updated since the date marked on it. The facility's wound care policy, which mandates wound care per physician's orders to promote healing, was not followed, resulting in noncompliance identified during a complaint investigation.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to ensure timely administration of pain medication for a resident, leading to a deficiency. Resident #75, who was admitted with multiple diagnoses including chronic pain, had a physician's order for routine Oxycodone 10 mg four times a day and a one-time dose for pain. However, the one-time dose was not administered until several hours after it was ordered. The resident reported difficulty in locating a nurse for pain relief, and it was discovered that a nurse had left the floor without notifying staff, resulting in a delay in medication administration. Interviews revealed that the nurse responsible for administering the medication had left the facility for an unspecified reason and was terminated following an investigation. The Director of Nursing confirmed the delay in administering the medication, and the facility's policy required medications to be administered timely according to prescriber orders. The deficiency was identified during a complaint investigation, highlighting a lapse in the facility's medication administration process.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that residents received medications as ordered, resulting in a medication error rate exceeding the acceptable threshold of 5%. Specifically, two residents were affected by this deficiency. Resident #41, who has multiple diagnoses including ataxic cerebral palsy, type II diabetes, and chronic heart failure, did not receive their prescribed medications, including Amlodipine, Cymbalta, and Pataday, due to unavailability. Similarly, Resident #51, diagnosed with Parkinsonism and dementia, did not receive their prescribed Rytary medication for Parkinson's. During a medication pass observation, an LPN administered only 26 out of 30 ordered medications to five residents, resulting in a 13.3% error rate. The LPN confirmed that the medications for Residents #41 and #51 were unavailable, leading to the failure in administration. The facility's policy on administering medications, dated April 2019, mandates that medications be administered according to prescriber orders, which was not adhered to in this instance. This deficiency was investigated under specific complaint numbers.
Failure to Complete Pressure Ulcer Dressing Change as Ordered
Penalty
Summary
The facility failed to ensure a pressure ulcer dressing change was completed per physician orders for Resident #93. The resident, who was cognitively intact and had a stage four pressure ulcer on her sacrum, was supposed to have her wound dressing changed every shift as per the physician's order dated 04/18/24. However, on 04/30/24, the dressing change was not performed during the night shift. The Treatment Administration Record (TAR) inaccurately documented that the treatment was completed. An observation on 05/01/24 revealed the dressing was undated, and the resident confirmed that the dressing was not changed on 04/30/24 and denied refusing the treatment. An interview with the agency Licensed Practical Nurse (LPN) who was responsible for the night shift on 04/30/24 confirmed that she did not complete the wound treatment. The LPN stated that the resident refused the treatment but admitted she did not document the refusal and instead falsely recorded that the treatment was completed. This deficiency was identified during an investigation under Complaint Number OH00152739.
Failure to Ensure Proper Colostomy Care
Penalty
Summary
The facility failed to ensure proper colostomy care for Resident #77, who was cognitively intact and required substantial assistance for toileting and moderate assistance for bed mobility and transfers. During an observation of colostomy care, LPN #140 did not follow proper hand hygiene protocols. Specifically, LPN #140 did not change gloves or perform hand hygiene when moving from dirty to clean tasks while providing colostomy care. This resulted in dried feces being present on the resident's skin, which was not properly cleaned before applying new dressings and wafers. The facility's policy on colostomy care, revised in October 2010, clearly outlined the steps for proper hand hygiene and glove use, which LPN #140 failed to follow. The policy required washing and drying hands thoroughly, removing gloves after handling dirty items, and putting on clean gloves before proceeding with clean tasks. LPN #140's failure to adhere to these procedures was confirmed during an interview, where he acknowledged not performing hand hygiene or changing gloves during the colostomy care for Resident #77.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure the attending physician completed resident visits every 60 days, affecting two residents. Resident #2, admitted with diagnoses including hypertension, hyperlipidemia, and dementia, had no evidence of a physician visit from December 1, 2023, through May 7, 2024. Similarly, Resident #3, admitted with diagnoses including hypertension, dementia, hyperlipidemia, and traumatic brain injury, also had no evidence of a physician visit during the same period. Both residents were severely cognitively impaired according to their quarterly Minimum Data Set (MDS) assessments. Interviews with the Nurse Practitioner and Medical Doctor revealed that the MD only visited the facility for new admissions or if a resident was sick, and confirmed that the MD had not seen Residents #2 and #3 since December 2023. The facility's policy required physician visits at least every 30 days for the first 90 days following admission and then at least every 60 days thereafter. This deficiency was investigated under Master Complaint Number OH00153494.
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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 Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Lakes | 1.6 mi | ★★★★★ | 0 | 0 |
| Montgomery Care Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Blue Ash Health & Rehab | 2.6 mi | ★★★★★ | 4 | 0 |
| Lodge Nursing & Rehab Center | 2.8 mi | ★★★★★ | 7 | 0 |
| Brookwood Care Center | 2.8 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.