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 Manor during CMS and state inspections, most recent first.
The facility did not maintain required RN coverage for at least eight consecutive hours per day, seven days a week. Review of staffing schedules and the staffing tool, confirmed by interviews with the administrator, HR staff, and the scheduler, showed that on two separate days there was no RN on duty for the required duration, potentially affecting all 50 residents. The facility assessment stated that two RNs and/or LPNs would be scheduled for each shift but did not address the specific requirement for daily eight-hour RN presence, contributing to the deficiency cited under multiple complaint investigations.
A cognitively impaired female resident with Alzheimer’s disease and a BIMS score of 0 was involved in two separate incidents of sexual contact with cognitively impaired male residents, both of whom also lacked documented assessments of capacity to consent to sexual activity. In one event, a CNA found her in a male resident’s bed with him on top of her and both of their pants down; in another, staff found her naked in another male resident’s bed while he had his fingers in her vaginal area and stated she wanted it. Despite facility policies requiring evaluation of consent capacity when there is concern a resident may not be able to consent, no such evaluations were documented for any of the involved residents, and staff later acknowledged they relied only on BIMS scores to judge consent capacity. One of the alleged sexual abuse incidents was not reported to the state agency as required, law enforcement was not contacted, and the guardian of one male resident was not documented as being consulted about police involvement. Although 15‑minute checks were added to the female resident’s care plan, multiple CNAs and an RN on the unit reported they were unaware of any special monitoring and described only routine checks, indicating the enhanced supervision was not effectively implemented.
Two cognitively impaired residents were found in a male resident’s bed with both of their pants down, with a CNA observing the male on top of the female and immediately separating them and notifying an LPN and the DON. The female resident had Alzheimer’s disease with a BIMS score indicating severe impairment, and the male resident had dementia, hepatitis C, antisocial personality disorder, and a documented high-risk heterosexual behavior diagnosis, yet neither had any documented assessment of capacity to consent to sexual activity in their records or care plans. Facility leadership and clinical staff confirmed the physical circumstances of the incident, acknowledged that both residents were considered unable to consent based on BIMS scores, and confirmed that no report was made to the state survey agency, no SRI was filed, law enforcement was not contacted, and the male resident’s guardian was not consulted about police involvement. Review of facility policies showed requirements to evaluate capacity to consent when there is reason to suspect a resident may lack such capacity and to report alleged abuse and investigation results to the state survey agency within specified timeframes, which were not followed in this case.
The facility failed to assess and document sexual consent capacity and to implement effective protective monitoring for a cognitively impaired resident involved in two separate sexual incidents with two different male residents, both of whom also had cognitive impairment. In the first incident, a CNA found the female resident in a male resident’s bed with both of their pants down and the male on top of her; this male had dementia, a BIMS score indicating cognitive impairment, a diagnosis of high-risk heterosexual behavior, and a court-appointed guardian, yet no consent-capacity evaluation or related care plan interventions were in place. In the second incident, staff found the same female resident naked in another male resident’s room, with that resident naked and inserting his fingers into her vaginal area while stating she wanted it, again without any prior assessment of either resident’s capacity to consent. Although the female resident’s care plan later referenced 15-minute checks, multiple CNAs and an agency RN working on the unit reported they were unaware of any special monitoring, and leadership acknowledged they relied only on BIMS scores for consent decisions, had not completed formal consent-capacity assessments, had not reported the first incident to the state, and were not following a clear protocol for alleged sexual abuse as required by the facility’s abuse policy.
A resident with Alzheimer’s disease, major depression, and a BIMS score of zero had no healthcare POA or guardian, while the listed financial POA declined involvement in healthcare decisions. The care plan identified impaired cognition and behaviors but did not address the resident’s capacity to consent to sexual activity, despite two separate incidents in which the resident was found partially or fully undressed in bed with male residents and engaged in sexual contact. Staff and leadership acknowledged relying solely on BIMS scores to judge consent capacity, did not complete formal assessments of sexual consent capacity, and did not document any attempts to obtain guardianship, while the Social Service Designee and PCP both stated the resident could not make her own decisions or give informed consent.
Two residents experienced significant medication errors when ordered ATB therapy was not initiated or administered as prescribed. One resident with C-diff was discharged from the hospital on fidaxomicin twice daily, but multiple doses were missed after admission because the drug was not covered and considered too expensive, and the PCP was not documented as being notified until the family raised concerns and requested ER transfer. Another resident evaluated for sinus symptoms had Augmentin ordered twice daily by an NP, but staff did not recognize the order from the progress note, and weekend agency nurses did not access the emergency medication box or contact pharmacy, resulting in a two-day delay before the first dose was given, despite the facility’s policy requiring timely medication administration.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with complex medical and mental health needs was discharged to a homeless shelter without a comprehensive discharge plan, follow-up care, or involvement of their representative. The resident was not appropriate for the shelter, which lacked medical and support services, and was denied re-admission to the facility after expressing a desire to return.
Surveyors found that several residents with cognitive and physical impairments did not have their call lights within reach, despite care plans and facility policy requiring this accommodation. Observations and staff interviews confirmed that call lights were inaccessible, preventing residents from requesting assistance as needed.
The facility did not refund resident funds within the required 30 days after discharge for two residents, including one with a court-appointed guardian and another who transferred to a different facility. In both cases, the facility delayed closing the resident fund accounts and issuing refunds, despite facility policy requiring timely disbursement.
A resident with severe cognitive impairment and a history of falls was placed on a bed alarm without a documented assessment or device decision assessment, despite facility policy requiring such evaluation before implementing devices that may restrict movement. Observations and staff interviews confirmed the use of the bed alarm and the lack of required assessment.
Several residents and their representatives were not given the option to refuse a binding arbitration agreement during the admission process. The facility's electronic admission system required signatures on the arbitration agreement to complete admission paperwork, with no way to decline, despite the agreement being labeled as optional. Staff confirmed that this process had been in place for several months and affected multiple residents, including those who were cognitively intact, impaired, or had a guardian.
A resident with multiple medical conditions was discharged without a complete summary for continuation of care at home. The discharge summary lacked details on wound measurements, follow-up appointments, and necessary equipment. The facility did not make referrals for home-based services, assuming the resident had arrangements, but interviews revealed no such care was set up. The discrepancy between electronic and paper discharge summaries further complicated the issue.
The facility failed to maintain a sanitary environment, affecting all 26 residents. A food inspection report revealed dark colored growth on walls in the back storage room and kitchen area, likely due to water leaks. Observations confirmed mold-like growth on walls near resident service wear storage. The DON and Administrator were aware of these issues.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present in the facility for at least eight consecutive hours a day, seven days a week, as required. Review of staffing schedules from 01/01/26 to 04/21/26 showed there was no RN coverage for at least eight consecutive hours on 01/24/26 and 04/05/26. Review of the staffing tool for 04/05/26 to 04/11/26, conducted with the Administrator, Human Resources staff, and the Scheduler/HR Assistant, confirmed there was no RN coverage for at least eight consecutive hours on 04/05/26. During interviews, the Administrator, HR staff, and Scheduler/HR Assistant verified that, based on the staffing schedules and staffing tool, the facility did not have RN coverage for at least eight consecutive hours on those two days, potentially affecting all 50 residents in the facility. Review of the facility assessment dated [DATE] showed that the staffing plan specified there would be two RNs and/or LPNs for each shift, but it did not address the requirement to ensure an RN was present for at least eight consecutive hours a day, seven days a week. This omission in the facility assessment, combined with the documented gaps in RN coverage, led to the cited deficiency, which was investigated under Complaint Numbers 2966092, 2667528, and 2650567.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse and to Assess Consent Capacity
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to evaluate and document residents’ capacity to consent to sexual activity, as required by facility policy. One resident with Alzheimer’s disease and severe cognitive impairment, documented by a BIMS score of 0, had no assessment in the medical record regarding her capacity to consent to sexual activity. Her care plan addressed impaired cognition, impaired thought processes, tearful episodes, and crying out, but did not address capacity to consent to sexual activity. The Kardex for this resident included general behavior interventions but did not include information about sexual behaviors or the 15‑minute checks that were later added to the care plan. The same resident was involved in two separate incidents of sexual contact with male residents who also had cognitive impairment and no documented assessment of capacity to consent to sexual activity. In the first incident, a CNA found the cognitively impaired female resident in a male resident’s room, lying in his bed with him on top of her and both of their pants down. Witness statements and interviews confirmed that the male resident had dementia, a legal guardian, and a diagnosis including high‑risk heterosexual behavior, but there was no documentation that his capacity to consent to sexual activity had been evaluated. Facility staff, including the DON and ADON, later stated they relied solely on BIMS scores to determine consent capacity and believed both residents in this incident could not consent based on their scores. Despite this, there was no documentation of a formal capacity assessment for either resident. In the second incident, the same cognitively impaired female resident was found naked in another male resident’s bed, with her clothing and his clothing on the floor. Witness statements documented that the male resident had his fingers in her vaginal area while she lay with her legs open, and that he stated she wanted it. This male resident also had dementia and a low BIMS score, but again there was no documentation that his capacity to consent to sexual activity had been evaluated. The facility’s own policies on abuse and residents’ rights required that when there was reason to suspect a resident might lack capacity to consent to sexual activity, the facility would evaluate capacity and take steps to protect the resident from abuse. The survey found that such evaluations were not completed before or after either incident for any of the involved residents. The facility also failed to report one of the alleged sexual abuse incidents to the state survey agency as required by policy. Review of the state SRI database showed no self‑reported incident for the sexual encounter between the cognitively impaired female resident and the first male resident. Interviews with regional leadership and the ADON confirmed that the incident was not reported to the state agency and that law enforcement was not contacted, nor was there documentation that the male resident’s guardian was consulted about police involvement. Additionally, although the care plan for the female resident was updated to include 15‑minute checks after the second incident, multiple staff members working on the unit reported they were unaware of any residents on special monitoring, and they described only routine hourly checks, indicating that the enhanced monitoring interventions were not effectively communicated or implemented.
Failure to Report Alleged Sexual Abuse and Assess Residents’ Capacity to Consent
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the state survey agency and/or local law enforcement, and failure to evaluate and document the residents’ capacity to consent to sexual activity as required by facility policy. One resident, identified as having Alzheimer’s disease, hypertension, and major depression, was admitted in early June and had a BIMS score of 0 on her admission MDS, indicating severe cognitive impairment. Her care plan documented impaired cognition and thought processes related to Alzheimer’s disease, with interventions focused on yes/no questions, cueing, reorientation, supervision, and maintaining a consistent routine. There was no documentation in her medical record or care plan regarding an assessment of her capacity to consent to sexual activity, either before or after the incident. On a date in late July, prior to dinner, an agency CNA reported that she was looking for this cognitively impaired resident and, upon entering a male resident’s room, observed the male resident on top of her in his bed, with both residents’ pants down and no clothing below the waist. The CNA immediately separated the residents and notified an agency LPN, who then contacted the DON. Witness statements from the CNA and LPN consistently described the male resident on top of the female resident with both of their pants down. A subsequent assessment by the Infection Control/ADON documented a full body and vaginal assessment of the female resident, noting no blood, bruising, abrasions, lacerations, or signs of penetration, and that when asked if she was having pain or if it hurt, the resident only smiled. The male resident later told the former Administrator and an RN that the female resident had come into his room, sat on his bed, that he rubbed her leg, and that both of their pants were on, denying kissing and sexual contact. The male resident involved had dementia, viral hepatitis C, antisocial personality disorder, and a diagnosis of high-risk heterosexual behavior added shortly after the incident. He had a court-appointed legal guardian, but there was no documentation in his record or care plan regarding an evaluation of his capacity to consent to sexual activity. His quarterly MDS showed a BIMS score of 11, indicating cognitive impairment, and his care plan noted impaired cognition related to dementia. Interviews with regional leadership and the Infection Control/ADON confirmed that the male resident was on top of the female resident in his bed with both residents’ pants down, that the male resident had hepatitis C, and that lab testing was ordered for the female resident as a precaution. They also confirmed that the police were not contacted, there was no documentation that the male resident’s guardian was consulted about police involvement, and that no self-reported incident was filed with the state agency; only an internal investigation was completed. Further interviews with the DON and Infection Control/ADON revealed that no formal assessment of either resident’s capacity to consent to sexual activity was completed before or after the incident, that the facility relied solely on BIMS scores (with a threshold of 12) to determine consent capacity, and that they believed both residents could not consent based on their BIMS scores. Review of the state survey agency’s SRI database showed no SRI filed for this incident, and review of facility policies showed that the facility was required to evaluate capacity to consent when there was reason to suspect a resident might lack such capacity and to report alleged violations and investigation results to the state survey agency within required timeframes, which did not occur in this case. Additionally, interviews with staff and the primary care provider further underscored the lack of reporting and capacity assessment. The agency CNA who discovered the incident stated she no longer worked at the facility because the incident was disturbing and "just was not right," and reiterated that she found the male resident on top of the female resident with no clothing below the waist and that she was unsure if sexual activity had occurred because the male resident jumped up quickly when she yelled. The primary care provider for both residents stated she was aware of a potential sexual encounter and uncertainty about penetration, which led her to order hepatitis C testing for the female resident due to the male resident’s hepatitis C diagnosis. She stated that the female resident could not give informed consent, as the resident only gave a blank stare and did not communicate when questioned, while she believed the male resident could verbalize a desire for sex and give consent. Despite these observations and the facility’s own policies defining sexual abuse as non-consensual sexual conduct and requiring evaluation of capacity to consent and reporting of alleged abuse to the state survey agency, the facility did not complete or document a capacity-to-consent evaluation for either resident and did not report the allegation to the state survey agency or law enforcement. Review of the facility’s policies "Identifying Types of Abuse" and "Residents Right to Freedom from Abuse, Neglect, and Exploitation" showed that sexual abuse includes non-consensual sexual conduct of any type, including unwanted intimate touching and all types of sexual assault or battery, and that sexual contact is non-consensual if a resident appears to want the contact but lacks cognitive ability to consent. The policies state that when there is reason to suspect a resident may not have capacity to consent to sexual activity, the facility must take steps to protect the resident from abuse, including evaluating capacity to consent, and that when abuse is identified, the facility must report alleged violations and investigate within required timeframes, reporting investigation results to the Administrator and to officials including the state survey agency within five working days. In this incident, despite the female resident’s severe cognitive impairment, the male resident’s cognitive impairment and high-risk sexual behavior diagnosis, the observed physical positioning and state of undress of both residents, and staff and provider concerns, the facility did not perform the required capacity evaluations and did not report the allegation and investigation results to the state survey agency or law enforcement as required by its own policies and applicable regulations.
Failure to Assess Sexual Consent Capacity and Implement Protective Monitoring After Repeated Sexual Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement preventative measures to protect residents from sexual abuse, including failure to evaluate and document residents’ capacity to consent to sexual activity. One resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 0), and care plan problems for impaired cognition and tearful episodes was involved in two separate incidents of sexual contact with male residents. Her medical record did not contain any assessment of her capacity to consent to sexual activity, and her care plan did not address sexual consent capacity or sexually inappropriate behaviors. Despite her severe cognitive impairment and behaviors such as wandering and crying out, there was no documentation that anyone was making healthcare decisions for her, and facility leadership acknowledged that nobody was doing so at that time. The first incident occurred when a CNA, after noticing the cognitively impaired resident was not in the dining room, searched rooms and found her in a male resident’s bed with both residents’ pants down and the male resident on top of her. This male resident had dementia, a BIMS score of 11, a diagnosis including high-risk heterosexual behavior, and a court-appointed guardian, yet his record also lacked any evaluation of his capacity to consent to sexual activity and his care plan did not address sexual consent capacity. Witness statements from the CNA and LPN confirmed that the residents were found in this position and immediately separated. Facility leadership later verified that the male resident was on top of the cognitively impaired resident with both of their pants down and that the incident was not reported to the state agency, no self-reported incident was made, and the police were not contacted, nor was there documentation that the male resident’s guardian was consulted about police involvement. The second incident involved the same cognitively impaired female resident and another male resident with dementia, agitation, and a BIMS score of 3. His record also contained no evaluation of his capacity to consent to sexual activity. During rounds, CNAs could not find the female resident in her room and discovered her in this male resident’s room behind a pulled curtain. Witness statements and a nursing note documented that both residents were naked, their clothing was on the floor, and the male resident had several fingers in the female resident’s vaginal area while stating that she wanted it. Both residents were separated. A self-reported incident was completed for this event and later unsubstantiated by the facility. Interviews with multiple CNAs and an agency RN who routinely worked on the unit revealed they were unaware of any residents on special monitoring or 15-minute checks, despite the care plan for the cognitively impaired resident indicating such checks after the prior incident. Facility leadership and the DON acknowledged that no assessments of capacity to consent to sexual activity were completed for the involved residents, that they relied solely on BIMS scores for consent determinations, and that they were not aware of or did not implement a specific protocol for alleged sexual abuse as described in the facility’s own abuse policy, which required evaluation of capacity to consent and systemic actions to protect residents when abuse was suspected. The facility’s written policy on residents’ right to freedom from abuse, neglect, and exploitation stated that residents had the right to engage in consensual sexual activity, but that when there was reason to suspect a resident might lack capacity to consent, the facility would evaluate capacity and take steps to protect the resident from abuse. The policy also required the development of written procedures to determine whether the resident was protected, identify contributing risk factors, and determine the need for systemic actions and tracking of similar occurrences. Despite this policy, there was no documented evaluation of capacity to consent for any of the three involved residents, no documented implementation of the policy’s required procedures following the incidents, and no consistent implementation or communication of monitoring interventions such as 15-minute checks to staff on the unit. Interviews with the DON, ADON, and regional nurse confirmed the absence of a known protocol for alleged sexual abuse incidents and the lack of standardized monitoring measures following these events.
Failure to Obtain Guardianship and Assess Consent Capacity for Severely Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to ensure a resident with severe cognitive impairment had appropriate decision-making support, including guardianship, to attain the highest practicable well-being. The resident was admitted with diagnoses of Alzheimer’s disease, hypertension, and major depression, and had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. Her care plan identified impaired cognition and thought processes related to Alzheimer’s disease, with interventions such as yes/no questioning, reorientation, supervision, and consistent routines. She had a friend listed as POA for finances who, according to the facility, did not want involvement in healthcare decisions, and there was no POA for healthcare or guardian documented. The record shows that the resident was involved in two separate incidents of sexual activity with male residents. In the first incident, staff found her in another resident’s bed with both residents’ pants down, and they were separated. In the second incident, staff found her naked in another resident’s bed with a male resident, who had his fingers in her vaginal area while she lay with her legs open allowing access; both residents were again separated and placed on 15‑minute checks. The facility’s care plan for the resident included interventions for tearful episodes and crying out, and later added frequent observation and 15‑minute checks, but there was no care plan documentation addressing her capacity to consent to sexual activity. The Kardex listed behavior interventions such as distraction from wandering and behavior monitoring, but did not include the 15‑minute checks or any information about sexually inappropriate behaviors. Interviews with facility leadership and staff confirmed that there was no assessment or evaluation of the resident’s capacity to consent to sexual activity either before or after the incidents, and that the facility relied solely on BIMS scores to determine consent capacity. The DON and RN staff stated they believed both involved residents could not consent based on their BIMS scores, yet no formal consent-capacity assessment was documented. The Social Service Designee stated the resident could not make her own decisions, that the financial POA refused involvement in healthcare decisions, and that the resident needed a guardian, but there was no documentation of any attempts to obtain guardianship. She further stated that, in practice, the facility made the resident’s healthcare decisions because there was no one else to do so. The PCP reported that the resident could not give informed consent, describing a blank stare and lack of communication when questioned, and stated that the resident almost required one‑on‑one supervision due to constant ambulation, but this information had not been communicated to facility leadership. Overall, the facility failed to initiate or document efforts to secure a guardian or other appropriate decision-maker for a resident known to be unable to make informed decisions.
Delayed and Missed Antibiotic Therapy for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not providing ordered antibiotic (ATB) therapy in a timely manner and as prescribed. One resident with enterocolitis due to Clostridium difficile (C-diff), hypertension, malignant neoplasm of the prostate, and chronic kidney disease was admitted with a hospital discharge order for fidaxomicin 200 mg by mouth every morning and at bedtime for five days. The last hospital dose was given on the morning of admission, but the facility’s MAR showed that the bedtime dose on the day of admission, both doses the following day, and the next morning dose were not administered. Nursing documentation showed the resident had severe cognitive impairment and was rarely or never understood, and there was no documentation that the primary care physician (PCP) was notified of the missed doses. Interviews and record review revealed that staff were aware the fidaxomicin had not been started because the medication was not covered by insurance and would have cost over two thousand dollars for ten tablets. The Infection Control/Assistant Director of Nursing (ADON) reported that pharmacy had indicated the cost issue, and she contacted the PCP to discuss changing the medication, but this occurred after the resident’s daughter discovered the ATB had not been started and requested transfer to the emergency room (ER). The ER physician documented that the resident had not received his ATB for C-diff for two days because the nursing home stated it was too expensive to be given, and the ER administered a dose of fidaxomicin and discharged the resident with a prescription for the remaining doses. A second resident with chronic obstructive pulmonary disease with acute exacerbation, schizoaffective disorder, bipolar disorder, intact cognition, and delusions was evaluated by a nurse practitioner (NP) for sinus symptoms and acute cough. The NP documented an order for Augmentin 500-125 mg by mouth twice daily for seven days for acute frontal sinusitis. The physician orders reflected this ATB order the next day, but the MAR showed no doses were given for the first two days after the order, with the first documented dose administered on the third day. The DON and Infection Control/ADON confirmed the delay, explaining that the NP’s order was in the progress note and not recognized by staff initially, and that weekend staffing with agency nurses, who did not have access to the emergency medication box and did not contact pharmacy, contributed to the failure to start the ATB on time, despite the medication being available in the emergency box. The facility’s medication administration policy required medications to be administered in a safe and timely manner as prescribed but did not address physician notification for withheld doses.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Unsafe Discharge to Homeless Shelter Without Adequate Planning
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical and mental health diagnoses, including diabetes, COPD, hypertension, depression, anxiety, and cocaine dependence, was discharged from the facility to a homeless shelter without adequate discharge planning or ensuring a safe and appropriate transition. The resident required assistance with medication administration, supervision for activities of daily living, and ongoing medical and mental health management. Despite these needs, there was no evidence that the facility developed or implemented a comprehensive care plan to address the resident's discharge needs, nor did they ensure the resident's representative was involved in the discharge planning process or aware of the discharge destination. The facility issued a 30-day discharge notice to the resident, citing non-payment and improvement in condition, with the proposed discharge location being a local homeless shelter. Documentation revealed that the resident was discharged with her medications but without any referrals for follow-up care, access to transportation, or arrangements for ongoing medical oversight. The homeless shelter staff determined upon arrival that the resident was not appropriate for their facility due to her inability to ambulate independently and manage stairs, and the shelter did not provide medical, social, or transportation services. The resident expressed a desire to return to the facility, but the facility refused re-admission, citing non-payment and a policy against accepting discharged residents. Interviews and record reviews indicated that the facility did not follow up on the resident's stated preference to obtain her own housing or assist with the Home Choice program until prompted by the ombudsman. There was no documentation of communication with the resident's emergency contact regarding the discharge, and the facility did not attempt to place the resident in any other setting besides the homeless shelter. The lack of a comprehensive discharge plan, failure to ensure the resident's needs and preferences were met, and inadequate communication with both the resident's representative and the receiving shelter led to the resident being discharged to an unsafe and inappropriate environment.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, as required by their care plans and facility policy. Observations revealed that the call lights for these residents were either clipped to privacy curtains or cords coming out of the wall, making them inaccessible from the residents' beds. Staff interviews confirmed that the residents were unable to reach their call lights to request assistance when needed. The affected residents had significant medical and cognitive impairments. One resident had hemiplegia following a stroke and was dependent on staff for most activities of daily living, while another had severe cognitive impairment and an indwelling catheter. Additional residents had diagnoses including dementia, metabolic encephalopathy, and reduced mobility, with varying levels of independence but all identified as being at risk for falls. Their care plans specifically included interventions to ensure call lights were within reach and to encourage their use for assistance. Despite these documented needs and interventions, staff failed to position the call lights appropriately, as verified during multiple observations and staff interviews. The facility's own policy required that each resident be provided with a means to call staff directly for assistance from their bed, but this was not followed for the four residents reviewed.
Failure to Timely Refund Resident Funds After Discharge
Penalty
Summary
The facility failed to refund resident funds within 30 days of discharge for two residents. For one resident with a court-appointed guardian and severe cognitive impairment, the facility issued an initial check to the guardian to close the resident fund account, but continued to receive and process deposits from Social Security and other sources after discharge. The facility did not notify Social Security of the resident's discharge until several months later, resulting in additional deposits and delayed closure of the account well beyond the required 30-day period. For another resident who was their own responsible party and had a daughter as power of attorney, the facility issued a check to the new nursing facility where the resident transferred, but this was also completed past the 30-day post-discharge requirement. Facility documentation, including the Resident Admission Agreement and Resident Fund Authorization, specified that funds should be disbursed within 30 days of discharge, but this policy was not followed in these cases.
Failure to Complete Bed Alarm Assessment Prior to Use
Penalty
Summary
The facility failed to ensure that a bed alarm assessment was completed prior to implementing a bed alarm for a resident with significant cognitive impairment and a history of falls. The resident, who had diagnoses including Alzheimer's disease, major depressive disorder, repeated falls, vascular dementia, and anxiety, was admitted with severe cognitive impairment and a recent history of falls. Physician orders and the care plan indicated the use of a bed alarm to remind the resident not to get up unassisted, but there was no documentation of a bed alarm assessment or device decision assessment for this intervention. Observations on two separate occasions confirmed that the resident was in bed with the bed alarm in use. Interviews with an LPN and the Administrator verified the ongoing use of the bed alarm and acknowledged that the required assessment had not been completed. Review of facility policy defined physical restraints as any device that restricts freedom of movement and requires assessment prior to use, but this process was not followed for the resident in question.
Failure to Inform Residents of Right to Refuse Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents and their representatives were explicitly informed of their right to refuse to sign a binding arbitration agreement upon admission. Review of admission paperwork for three residents revealed that the arbitration agreement was presented as part of the electronic admission packet, but there was no option provided to decline the agreement. The electronic system required a signature on the arbitration agreement in order to complete the admission process, effectively removing the choice to refuse. For one resident who was cognitively intact, the admission paperwork included an arbitration agreement that was signed electronically, but the resident later stated he was not aware he had signed such an agreement and would not have done so if given the choice. Another resident, who was severely cognitively impaired, had a responsible party sign the agreement, also without an option to decline. A third resident, with a guardian, had the guardian sign the agreement under the same circumstances. In all cases, the agreement stated it was optional, but the process did not allow for refusal. Interviews with facility staff, including the Admissions Director and the Administrator, confirmed that the electronic admission system did not provide an option to decline the arbitration agreement. Staff acknowledged that the system required the agreement to be signed in order to complete the admission paperwork, and this had been the practice since at least August 2024. This affected multiple residents, as identified in the facility's records.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for Resident #27, which was necessary for the continuation of care at home. Resident #27, who had multiple medical diagnoses including pressure ulcers, paraplegia, and sepsis, was discharged without adequate documentation of follow-up care and necessary equipment. The discharge summary lacked specific details such as measurements of wounds, follow-up appointments, and the recommended air mattress for home use. Additionally, there was a discrepancy between the electronic and paper versions of the discharge summary, with the electronic version missing the resident's signature and the paper version lacking attached treatment orders. Interviews revealed that the facility did not make referrals for wound care or other home-based services because Resident #27 left before discharge plans were finalized. The Director of Nursing and Social Service Designee indicated that the resident had threatened to leave against medical advice, prompting a quick discharge. The Administrator, who was acting as the interim social worker, did not document discharge planning in the electronic medical record but instead in a personal notebook, which was not part of the legal medical record. Further interviews with Resident #27's mother and healthcare professionals indicated that the resident did not have wound care or nurse care set up at home, contrary to what was assumed by the facility. The Occupational Therapist and Physical Therapist confirmed that Resident #27 would not be able to manage wound care independently, highlighting the facility's failure to ensure a safe and coordinated discharge process.
Sanitary Environment Deficiency Due to Mold Growth
Penalty
Summary
The facility failed to maintain a sanitary environment, which had the potential to affect all 26 residents residing in the facility. During a review of the State of Ohio Food Inspection Report dated 09/20/24, it was revealed that there were several spots on the wall in the back storage room, near the mop closet, and near the stairway that had dark colored growth. The inspector expressed concern that water leaking from the ceiling or walls caused this growth in the kitchen area. An observation on 10/08/24 at 11:24 A.M. with the Maintenance Director revealed a black-like substance resembling mold growth on the lower northwest wall leading into the kitchen. The facility stored resident service wear on plastic shelves, and a freezer was positioned in front of this wall. An interview with the Maintenance Director confirmed the presence of the black-like substance on the wall leading to the kitchen, as well as behind the plastic shelving and a freezer. The Director of Nursing and the Administrator were aware of the local county health inspection results since 09/20/24 regarding the dark colored growth on the wall leading into the kitchen.
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What surveyors actually found near you
We read the 504 citations issued within 25 miles in the last 12 months — including the 9 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 Fowler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concord Care Center Of Cortland | 3.8 mi | — | 0 | 0 |
| Addison Healthcare Center | 5.4 mi | ★★★★★ | 7 | 0 |
| O'brien Memorial Health Care C | 5.5 mi | ★★★★★ | 6 | 0 |
| Clepper Manor | 6.5 mi | ★★★★★ | 0 | 0 |
| Hermitage Nursing And Rehabilitation | 7.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.