Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mt Airy Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including sticky substances on the floor, chipped and peeling flooring, brown debris under and along the walls, and standing water in uncovered pipes near the dishwasher. These findings were confirmed by the Administrator and affected all but three residents who did not receive food from the kitchen.
The facility did not ensure the kitchen was free of pests, as multiple gnats were observed around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the ongoing issue, which had persisted for several weeks, in violation of the facility's pest control policy. This affected all residents except for three who did not receive food from the kitchen.
The facility failed to serve appropriate portion sizes, affecting all 77 residents. A dietary staff member used a green-handled scoop for macaroni and cheese, providing only 2 and 2/3 ounces instead of the required 4 ounces. The Dietary Director confirmed the error, leading to a deficiency in portion control.
The facility failed to properly store and handle food, risking foodborne illness for all 77 residents. Observations revealed opened and undated food items not refrigerated, milk and cheese stored on the floor, expired sanitizer test strips, and unsanitary food preparation practices. Numerous unlabeled and improperly stored food items were found in nourishment rooms, violating facility policies.
The facility failed to cover catheter bags for two residents, compromising their dignity and privacy. One resident with severe cognitive impairment had a visible catheter bag, while another with a nephrostomy tube had an uncovered leg bag. Both instances were confirmed by nursing staff, violating the facility's catheter care policy.
A facility failed to provide a safe and homelike environment, as observed in a resident's room and the Heritage nursing unit's shower room. A resident's room had missing cove base, an unsecured sink, and exposed drywall, while the shower room had peeling drywall. These issues were confirmed by staff, and the facility's policy on Resident Rights was not upheld.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their care needs. A resident was discharged before a comprehensive MDS was completed, another's assessments did not reflect a fall or hospice admission, and a third's assessment missed documenting a hand contracture. These inaccuracies were confirmed by staff interviews and observations.
A facility failed to update the PASARR for a resident admitted to hospice care, despite completing a significant change MDS assessment. The resident had multiple diagnoses, including hemiplegia and schizophrenia. The Social Services Director confirmed the oversight, acknowledging that the PASARR should have been updated upon hospice admission.
A facility failed to update a resident's care plan to reflect the discontinuation of a g-tube, despite the resident being on a regular diet and able to eat independently. The care plan inaccurately included interventions for tube feeding, which were no longer applicable. Staff interviews confirmed the care plan was not updated to reflect the resident's current dietary status.
A facility failed to ensure timely suture removal for a resident with a history of traumatic brain injury and cognitive impairment. The resident sustained a laceration to the right eyebrow after a fall, and the hospital discharge summary lacked orders for suture removal. Observations and staff interviews confirmed that the sutures remained in place beyond the typical removal period, with no order for their removal, indicating a lapse in wound management protocol.
The facility failed to provide necessary care for residents with impaired mobility and contractures. A resident with peripheral vascular disease did not receive a prescribed hand orthotic, another with a shoulder injury was not encouraged to use a sling, and a third with hemiplegia had an undocumented hand contracture. Staff were unaware or unable to locate necessary equipment, leading to inadequate care.
A resident on hospice care with moderate protein-calorie malnutrition was found without fluids available at the bedside on multiple occasions. Despite being on a mechanically altered diet with regular liquids, the resident did not have a water pitcher or cup in her room. Staff interviews revealed the absence was due to the resident's behavior of throwing the pitcher or taking it to other rooms. The DON confirmed fluids should have been available, and the NP stated there was no medical reason to withhold water. The facility did not provide a hydration policy when requested.
The facility failed to monitor adverse effects of psychoactive medications for three residents. One resident on Seroquel did not receive required AIMS assessments quarterly. Another resident on Invega Sustenna had no AIMS assessments conducted. A third resident on Depakote and Rexulti had no Depakote levels monitored and lacked quarterly AIMS assessments. These oversights were confirmed by facility staff.
A resident with complex medical conditions did not receive a Lidocaine patch as ordered, which was found undated and unsupervised on the bedside table. The LPN confirmed the patch was not applied, and the facility lacked a medication administration policy.
A facility failed to collaborate with a hospice agency to develop a comprehensive care plan for a resident with dementia and malnutrition. The hospice plan included nursing and aide visits, but lacked coordination with facility staff. Interviews confirmed unsuccessful attempts to engage the hospice agency in care planning, and the facility's care plan did not reflect hospice services.
A facility failed to provide full visual privacy in a resident's room, affecting a resident with severe cognitive impairment and multiple diagnoses. The room's window curtains allowed visibility from the parking lot, were damaged, and lacked a privacy curtain despite having tracking in place. The Housekeeping Director confirmed these issues, which violated the facility's policy on resident rights to personal privacy.
The facility failed to maintain a safe, clean, and comfortable environment for residents, as observed in multiple rooms. A resident with severe cognitive impairment lived in a room with potentially moldy drywall, while other rooms had issues like torn curtains, peeling wallpaper, and unsanitary bathrooms. These deficiencies were confirmed by staff and the Administrator.
A resident with a complex medical history was discharged from the hospital with new medication orders, which were not transcribed or administered upon their return to the LTC facility. The oversight was discovered when the resident was readmitted to the hospital with health complications. The error occurred because the discharge orders were misplaced, and the responsible LPN did not verify the physician orders, leading to a significant medication error.
The facility failed to prevent a high-risk resident from eloping and did not provide adequate supervision for residents who smoked. A resident left the facility unsupervised and was found walking in a busy street. Additionally, several residents were observed smoking in non-designated areas without staff supervision, contrary to the facility's policy.
The facility failed to maintain elevators in good working order and did not provide appropriate containers for cigarette disposal. Observations revealed numerous cigarette butts around the entrance, and residents were seen smoking and disposing of butts improperly. One elevator was out of order, and the other frequently malfunctioned, confirmed by staff, residents, and the Ombudsman. The facility lacked a policy for elevator maintenance.
A resident with dementia and cognitive impairments eloped from the facility and was found on a main road by a housekeeper. The nursing staff was unaware of the elopement, and the resident's representative was not notified until two days later, contrary to the facility's policy.
The facility failed to ensure that an interdisciplinary team was present during care conference meetings for four residents with varying cognitive impairments and multiple diagnoses. Care conferences were attended only by the SSD and, in some cases, an additional nurse, contrary to the facility's policy requiring full interdisciplinary team participation.
Unsanitary Kitchen Conditions Identified During Survey
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen, as required for food procurement and service. During an inspection, a sticky substance was found on the floor at the kitchen entrance, and the floor by the walls was chipped and peeling. There was a brown substance on the floor under the dishwasher and along the kitchen walls, as well as brown debris in two black rubber mats. Additionally, an uncovered pipe with standing water and a rag was noted near the dishwasher, and a second pipe nearby contained standing brown water. These unsanitary conditions were confirmed by the Administrator during a concurrent interview. The deficiency affected all residents except for three who did not receive food from the kitchen, with a facility census of 91.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to maintain a kitchen environment free of pests, as required by its pest control program policy. During an observation of the kitchen, multiple gnats were seen around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the presence of gnats in these areas, with the Dietary Aide stating that the issue had persisted for several weeks. The facility's pest control policy indicated an obligation to eradicate and contain common household pests, but the ongoing presence of gnats demonstrated non-compliance with this policy. This deficiency affected all residents except for three who did not receive food from the kitchen.
Inadequate Portion Control in Meal Service
Penalty
Summary
The facility failed to ensure appropriate portion sizes were served to residents, which had the potential to affect all 77 residents in the facility. During an observation, a dietary staff member was seen using a green-handled scoop to serve macaroni and cheese, which was not the correct size according to the facility's portion control chart. The dietary spreadsheet specified a 4-ounce serving for macaroni and cheese, which required a dark gray-handled scoop. However, the green-handled scoop used provided only 2 and 2/3 ounces. The Dietary Director confirmed the incorrect scoop was used, leading to the deficiency in portion control.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to store and handle food in a manner that prevents the potential spread of foodborne illness, affecting all 77 residents. Observations in the kitchen revealed several issues, including a jar of grape jelly and a jug of barbeque sauce that were opened, partially used, and not dated, which should have been refrigerated according to manufacturer labels. Additionally, milk cartons and a box of cheese were stored directly on the floor in the walk-in cooler and freezer, respectively. The use of expired sanitizer test strips for the dishwasher was also noted, compromising the sanitation process. Further observations in the food preparation area showed unsanitary practices, such as draining green beans against the inside of a sink, which was not considered sanitary. In the nourishment rooms on both the first and second floors, numerous food items were found unlabeled, undated, and improperly stored, including a jar of applesauce with mold, opened bottles of chocolate syrup and coffee creamer, and various sandwiches and beverages. These items were not in compliance with the facility's policy, which requires all foods to be labeled, dated, and stored properly to prevent contamination. Interviews with staff, including the Dietary Director, Dietary Aid, and Licensed Practical Nurse, confirmed the deficiencies in food storage and handling practices. The facility's policies on food storage and personal food brought in from outside sources were not adhered to, as evidenced by the numerous unlabeled and improperly stored food items. The facility's failure to follow these policies posed a risk of foodborne illness to all residents.
Failure to Cover Catheter Bags
Penalty
Summary
The facility failed to ensure that catheter bags were covered, affecting two residents. Resident #235, who was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus type two, and chronic kidney disease, was observed with a full catheter bag visible from the hallway, which was not covered with a dignity bag. This observation was confirmed by a registered nurse, who acknowledged that catheter bags should be covered. The resident had severe cognitive impairment and was dependent on staff assistance for activities of daily living. Similarly, Resident #236, who was admitted with diagnoses including complications of an incontinent external stoma of the urinary tract, chronic kidney disease, and cerebral infarction, was observed with a nephrostomy tube and a leg bag pinned to the outside of his pajama pants. The leg bag contained visible urine and was not covered with a dignity bag, contrary to the resident's plan of care, which required the nephrostomy bag to be covered at all times. This was confirmed by a licensed practical nurse. The facility's policy on catheter care, dated 2024, stated that privacy bags should be available and catheter drainage bags should be covered at all times to maintain resident dignity and privacy.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions observed in Resident #59's room and the Heritage nursing unit's shower room. Resident #59, who was cognitively intact and required supervision with activities of daily living, expressed dissatisfaction with the physical state of his room. Observations revealed a missing section of cove base by the bathroom door, an unsecured sink, a wide gap without grout between the countertop and backsplash, exposed drywall needing repair, and an extra cable wire on the floor. Resident #59 could not recall if he had reported these issues, but the Housekeeping Director confirmed the concerns. Additionally, the shower room on the Heritage nursing unit was found to have a ceiling with damaged drywall that was peeling and required repair or replacement and painting. This condition was confirmed by the Housekeeping Director and a Registered Nurse, who noted that two residents on the unit had the ability to use the shower room. The facility's policy on Resident Rights emphasizes the right to a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their care needs and conditions. Resident #77 was admitted with multiple diagnoses, including atherosclerosis and diabetes mellitus, and was discharged before the comprehensive MDS assessment was completed. The assessment was inaccurately dated after the resident's discharge, and the Minimum Data Coordinator confirmed the need to deactivate the incorrect submission. Resident #8, who had dementia and was admitted to hospice, had MDS assessments that failed to reflect a fall and the initiation of hospice services, as confirmed by the reviewing nurse. Resident #51, diagnosed with cerebral infarction and other conditions, had an MDS assessment that did not document contractures or limitations in range of motion, despite observations of a contracted left hand and the presence of a hand splint. The Rehab Director was unaware of the contracture, and the nurse confirmed the inaccuracy of the MDS assessment. These deficiencies highlight the facility's failure to maintain accurate and timely assessments, impacting the quality of care provided to the residents.
Failure to Update PASARR for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Preadmission Screening and Resident Review (PASARR) for a resident following their admission to hospice care. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hypertension, congestive heart failure, unspecified dementia, and schizophrenia, had a physician's order for hospice admission dated 07/18/24. Although the facility completed a significant change Minimum Data Set (MDS) assessment due to the hospice admission, they did not update the PASARR as required. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the PASARR should have been updated on the date of the hospice admission.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for a resident, which did not accurately reflect the resident's current health care status. The resident, who had a history of schizophrenia, subdural hemorrhage, traumatic brain injury, and a gastrostomy (g-tube), was admitted with orders to flush the g-tube every shift. However, the care plan continued to include interventions related to tube feeding, despite the resident not using the g-tube for nutritional support. The care plan included various interventions for tube feeding, such as monitoring tube placement and patency, which were no longer applicable. The deficiency was identified when a nurse practitioner noted that the g-tube was no longer in use and recommended its discontinuation. Despite this, the care plan was not updated to reflect the resident's ability to consume meals orally and the absence of g-tube use. Interviews with facility staff confirmed that the care plan was inaccurate and not updated to reflect the resident's current dietary status, as the resident was on a regular diet and able to eat independently.
Failure to Ensure Timely Suture Removal
Penalty
Summary
The facility failed to ensure timely suture removal for Resident #73, who was admitted with a history of physical injury, traumatic brain injury, and altered mental status. The resident, who was cognitively impaired, sustained a two-centimeter laceration to the right eyebrow after falling from a stretcher in the emergency room. The hospital discharge summary did not include orders for suture removal, and the physician's orders only instructed monitoring of the sutures twice daily without specifying removal. Observations and interviews revealed that the sutures remained in place beyond the typical removal period of seven to ten days. The Licensed Practical Nurse confirmed the absence of an order for suture removal, and the Assistant Director of Nursing acknowledged that the Wound Nurse Practitioner was not following the resident for the sutured wound. This oversight resulted in the resident having sutures in place without a plan for their removal, highlighting a lapse in the facility's care protocol for wound management.
Failure to Provide ROM and Contracture Care
Penalty
Summary
The facility failed to provide appropriate care and services for residents with impaired mobility and contractures, affecting three residents. Resident #9, who had diagnoses including peripheral vascular disease and schizophrenia, was ordered to wear a left-hand orthotic to maintain joint integrity. However, observations revealed the resident was not wearing the brace, and staff confirmed they had never applied it nor could they locate it. The resident indicated a willingness to wear the splint, but it was not provided as ordered. Resident #72, with a history of traumatic brain injury and shoulder injury, was supposed to wear a sling for his right arm and shoulder. Despite orders to encourage sling use, observations showed the resident was not wearing it, and staff were unable to find the sling. Interviews with staff confirmed the resident had not been seen wearing the sling, and it was not present in his room, indicating a failure to follow the care plan. Resident #51, diagnosed with cerebral infarction and hemiplegia, was found to have a contracted left hand, which was not documented in the care plan or MDS assessment. A splint was found in the resident's belongings, but staff were unaware of the contracture, and the MDS assessment was inaccurate. This oversight highlights a lack of proper assessment and documentation for the resident's condition, leading to inadequate care.
Failure to Provide Fluids at Bedside for Resident
Penalty
Summary
The facility failed to ensure that a resident had fluids available at the bedside, which is essential for maintaining hydration. The resident, who was on hospice care with a diagnosis of moderate protein-calorie malnutrition, was observed on multiple occasions without any fluids available in her room. Despite being on a mechanically altered diet with regular liquids, the resident did not have a water pitcher or cup at her bedside during observations on two separate days. Interviews with staff revealed that the resident had a history of throwing the water pitcher at staff or taking it to other residents' rooms, which led to the absence of fluids in her room. The Director of Nursing confirmed that the resident should have had fluids available, and the Administrator was unaware of the situation. The Nurse Practitioner stated there was no medical reason for the resident not to have water at the bedside, and no laboratory tests were conducted regarding hydration due to hospice services. The facility did not provide a policy related to hydration when requested during the survey, indicating a lack of documentation or adherence to hydration protocols.
Failure to Monitor Adverse Effects of Psychoactive Medications
Penalty
Summary
The facility failed to ensure timely monitoring of adverse side effects of psychoactive medications for three residents. Resident #08, diagnosed with dementia and psychotic disorders, was prescribed Seroquel. However, the required Abnormal Involuntary Movement Scale (AIMS) assessments were not completed quarterly as mandated, with the last assessment recorded in June 2024. The MDS Coordinator confirmed the oversight, acknowledging that the assessments were not conducted during the specified periods in 2025. Resident #72, with diagnoses including schizophrenia and traumatic brain injury, was prescribed Invega Sustenna. The facility's records showed no evidence of AIMS assessments being conducted, which was confirmed by the Director of Nursing. The resident's care plan required AIMS assessments every six months, but this was not adhered to, indicating a lapse in monitoring for potential adverse effects of the medication. Resident #06, with multiple diagnoses including dementia and mood disorder, was on Depakote and Rexulti. The facility failed to monitor Depakote levels as ordered, with no records of such tests being conducted since the medication was prescribed in January 2022. Additionally, the last AIMS assessment was conducted in June 2024, contrary to the policy requiring quarterly assessments. The Director of Nursing and a Nurse Practitioner confirmed the lack of monitoring, highlighting a significant oversight in the resident's medication management.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored and administered in accordance with professional standards, affecting a resident who was admitted with multiple complex medical conditions, including acute respiratory failure, diabetes, schizophrenia, and opioid dependence. The resident had a physician's order for a Lidocaine patch to be applied topically for pain management. However, during an observation, it was noted that the patch was left on the resident's bedside table, undated and with the protective backing still attached, indicating it was not applied as ordered. The resident confirmed that the nurse did not apply the patch the previous evening as required. The LPN and ADON present during the observation verified that the patch was not applied and should not have been left unsupervised in the resident's room. Additionally, the facility was unable to provide a policy related to medication administration upon request, further highlighting the deficiency in medication management and storage practices.
Lack of Collaboration with Hospice Agency in Care Planning
Penalty
Summary
The facility failed to collaborate effectively with a hospice agency to develop a comprehensive plan of care for a resident receiving hospice services. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and psychotic disorders, had an advanced directive for do not resuscitate comfort care and was on hospice for moderate protein-calorie malnutrition. The facility's plan of care included dietary interventions and monitoring for swallowing difficulties, but there was no evidence of collaboration with the hospice agency to integrate their services into the care plan. The hospice plan of care outlined services such as skilled nursing visits, aide visits, and the provision of equipment, but did not indicate any coordination with the facility staff. Interviews with facility staff, including a CNA, the Administrator, the Social Service Director, and the MDS Coordinator, confirmed the lack of collaboration and communication with the hospice agency. The facility had attempted to contact the hospice agency for scheduling information and to involve them in care planning, but these efforts were unsuccessful. The hospice staff did not participate in a recent care conference, and the facility's plan of care did not include details of the hospice services being provided. Additionally, the facility was unable to provide a policy related to the development of the plan of care upon request during the survey.
Failure to Ensure Visual Privacy in Resident's Room
Penalty
Summary
The facility failed to ensure full visual privacy in the resident bedrooms, affecting one of the four residents reviewed for physical environment. The resident in question, admitted with diagnoses including Alzheimer's dementia, psychotic disorder with delusions, and depressive disorder, was observed to have severe cognitive impairment and was dependent on staff assistance for activities of daily living. During an observation, it was noted that the resident's room window overlooked the facility parking area, and the window curtains were made of a material that allowed observation from the parking lot into the room. Additionally, the curtains were ripped and torn, and there was no privacy curtain in place despite the presence of privacy curtain tracking. An interview with the Housekeeping Director confirmed these findings, and a review of the facility's Resident Rights policy indicated that residents have a right to personal privacy in their living accommodations.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Resident #8608, who had severe cognitive impairment and was frequently incontinent, was living in a room with exposed drywall that was black in color, potentially indicating mold. This issue was reported by the resident's family, but it remained unaddressed for approximately two weeks. Additionally, other residents' rooms were found to have various issues, such as torn privacy curtains, peeling wallpaper, missing ceiling tiles, and unsanitary bathroom conditions. During the initial tour, several deficiencies were noted in the rooms of other residents. These included a torn privacy curtain in the room of two residents, peeling wallpaper and a missing ceiling tile in an unoccupied room, and a toilet bowl covered in brown material resembling feces in another room. Furthermore, a large brown ring stain was observed on the bathroom ceiling tile in one room, and peeling wallpaper was noted in the bathroom of another room. These observations were confirmed by a State tested Nursing Assistant and the facility's Administrator, indicating a widespread issue with maintaining a safe and clean environment for residents.
Failure to Administer Medications Post-Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident's medications were ordered and administered following a hospital discharge, resulting in a significant medication error. The resident, who had a history of myocardial infarction, transient ischemic attacks, HIV, and cerebrovascular disease, was discharged from the hospital with new medication orders for Ticagrelor, ferrous sulfate, and metoprolol. Upon returning to the facility, these medications were not listed on the Medication Administration Record (MAR) and were never ordered, leading to a lapse in the resident's prescribed treatment. The deficiency was discovered when the resident was readmitted to the hospital with symptoms of shortness of breath and abnormal vital signs. A subsequent review of the resident's records revealed that the medications ordered upon hospital discharge were not transcribed into the facility's system. Interviews with staff indicated that the discharge orders were misplaced among other paperwork, and the error was not identified until the hospital contacted the facility to reconcile the resident's medications. The Director of Nursing confirmed that the responsible LPN failed to check and implement the physician orders upon the resident's readmission, which led to the medication error. The Medical Director was not informed of the error due to being on vacation at the time. The facility's policy on administering medications requires adherence to physician orders, which was not followed in this case, resulting in non-compliance with the standard of care.
Failure to Prevent Elopement and Ensure Supervised Smoking
Penalty
Summary
The facility failed to ensure adequate supervision to prevent a high-risk resident from eloping. Resident #26, who had been assessed as being at high risk for elopement, left the facility unsupervised and was found by an off-duty employee approximately 0.1 miles from the facility, walking in the middle of a busy street. The facility did not have a care plan or interventions in place to prevent the elopement, and staff were unaware of the resident's absence until notified by the off-duty employee. The facility did not document the elopement in the medical record or complete an investigation into the incident, as they did not consider it an elopement. Additionally, the facility failed to provide adequate supervision for residents who smoked, allowing them to smoke in non-designated areas without staff supervision. Residents #32, #33, #40, and #68 were observed smoking less than 10 feet from the facility entrance, under a 'No Smoking' sign, and without appropriate receptacles for cigarette butts. The facility's policy required residents who needed supervision to always have a staff member present while smoking and to smoke only in designated areas. However, these residents were left unsupervised, and the facility did not adhere to its smoking policy. The facility's deficiencies in supervision and policy adherence placed residents at risk for potential harm. Resident #26's elopement and the unsupervised smoking incidents highlight the facility's failure to implement and follow appropriate care plans and safety measures for high-risk residents and those requiring supervision while smoking.
Removal Plan
- Certified Nurse Practitioner (CNP) #91 assessed Resident #26 with no negative findings.
- The DON completed the Secured Unit Screening and Resident #26 was moved to the secured unit.
- DOO #01 educated the DON and Administrator on the definition of elopement.
- The Administrator and DON completed elopement in-services to all staff in-person, by telephone, and by text notification. Education included whom to notify and how to identify if an elopement had occurred. Agency staff will be provided with a copy of the education, and it will be in the assignment binder that the agency staff report to for each shift.
- The Administrator began investigating Resident #26's elopement. It was discovered that Resident #26 met qualifications for placement on the secured unit when Resident #26 was assessed to be at a high risk of elopement, but the resident was not moved to the unit. Root cause analysis indicates the system failure was an Elopement Risk Assessment was completed with no follow up action.
- The DON and designee completed audits of all 88 residents for Elopement Risk with no negative findings. No additional residents were impacted by the Elopement Risk Assessments. All 16 high-risk residents were appropriately located on the secured unit. All high-risk residents had care plans reviewed to ensure elopement risk was included. Care plans were revised to reflect changes for Residents #04, #13, #14, #21, and #26.
- The Administrator provided verbal education to the DON, and two unit managers [Registered Nurse (RN) #345 and Licensed Practical Nurse (LPN) #165] on identifying high elopement risk residents and the appropriate placement of exit-seeking individuals onto the secured unit as applicable.
- Minimum Data Set (MDS) Nurse #340 initiated a care plan for Resident #26. The care plan included that Resident #26 was an elopement risk/wanderer with an intervention of placement on a secured unit. Other interventions included identifying the pattern of wandering: divert as needed and intervene as appropriate.
- The facility held an ad hoc Quality Assurance Performance Improvement (QAPI) meeting with Medical Director #90, the Administrator, DOO #01, DOO #02, and the DON. The long-term care Ombudsman was also notified of the Immediate Jeopardy situation involving Resident #26.
- The DON or designee completed education to the nursing staff regarding Elopement Risk assessments and their completion/accuracy to ensure all nursing staff are knowledgeable.
- The Administrator or designee will complete weekly audits for four weeks for elopement risk assessments for all admissions, readmissions, and any resident with a change in condition.
Elevator Malfunctions and Improper Cigarette Disposal
Penalty
Summary
The facility failed to ensure the elevators were maintained in good working order and failed to ensure cigarette butts were disposed of in appropriate containers. Observations over several days revealed numerous cigarette butts lying on the ground in front of the facility entrance doors, in the mulch, and in the rocks located beside the entrance doors. Residents were observed smoking within ten feet of the entrance doors and disposing of cigarette butts on the ground due to the absence of appropriate receptacles. The Director of Nursing (DON) confirmed the area was not a designated smoking area and that residents continued to smoke and dispose of cigarette butts improperly despite a 'No Smoking' sign being present. The facility's smoking policy, revised in January 2024, stated that smoking was only permitted in designated areas with appropriate containers, which was not adhered to in this case. Additionally, the facility had issues with elevator maintenance. One of the two elevators was out of order, and the other frequently malfunctioned, failing to open its doors on the second floor and returning to the first floor without allowing passengers to disembark. Interviews with staff, residents, and the Ombudsman confirmed the frequent malfunctioning of the elevators. The DON and the Administrator acknowledged the ongoing issues despite multiple repair attempts. The facility did not have a policy pertaining to elevator maintenance, and concerns about the elevators were documented in the Resident Council Meeting minutes from April 2024.
Failure to Timely Notify Resident's Representative of Elopement
Penalty
Summary
The facility failed to timely notify the resident's representative of a resident's elopement from the facility. This deficiency affected Resident #26, who had diagnoses including dementia, altered mental status, cognitive communication deficits, and high blood pressure. On 04/20/24, Resident #26 was found by a housekeeper ambulating on the main road in front of the facility with his wheeled walker, approximately 0.1 miles away, and in the middle of the road with vehicles swerving around him. The housekeeper alerted the nursing staff, who were unaware that Resident #26 had left the floor. The resident was then brought back to the facility by an unknown staff member and escorted to the second floor. However, there was no documentation or recollection of the events in the nursing notes for that day. The facility's policy required the Nurse Supervisor/Charge Nurse to notify the resident's family or representative when the resident is involved in any accident or incident. Despite this, the resident's representative was not informed of the elopement until two days later, on 04/22/24, when the Social Services Director called the resident's niece to discuss future placement on the secure unit. The Director of Nursing confirmed that the facility should have notified the resident's representative immediately following the elopement, verifying the lapse in timely notification.
Failure to Ensure Interdisciplinary Team Participation in Care Conferences
Penalty
Summary
The facility failed to ensure that an interdisciplinary team was present during care conference meetings for four residents. Resident #5, who had severe cognitive impairments and multiple diagnoses including seizures and dementia, had a care conference attended only by the Social Services Director (SSD) and the MDS Nurse. Similarly, Resident #7, with severe cognitive impairments and diagnoses such as hypertension and dementia, had a care conference attended only by the SSD and an unidentifiable Licensed Practical Nurse (LPN), with no documentation indicating if the resident representative was invited. Both instances were verified by SSD #200 during an interview, confirming that the interdisciplinary team was not fully present as required by facility policy. Resident #26, who had moderate cognitive impairments and diagnoses including cerebrovascular disease and anemia, had a care conference attended solely by the SSD. Resident #67, with minimal cognitive impairments and multiple diagnoses such as metabolic encephalopathy and atrial fibrillation, also had a care conference attended only by the SSD. These deficiencies were confirmed through interviews with SSD #200, who acknowledged that the care conferences did not include all members of the interdisciplinary team as mandated by the facility's policy. The facility's policy, revised in December 2008, clearly states that care plans should be developed by the entire interdisciplinary team based on each resident's comprehensive assessment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 931 citations issued within 25 miles in the last 12 months — including the 7 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 Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeridge Villa Health Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Ohio Living Llanfair | 1 mi | ★★★★★ | 4 | 0 |
| Twin Towers | 1.6 mi | ★★★★★ | 3 | 0 |
| Clovernook Health Care And Rehabilitation Center | 1.8 mi | ★★★★★ | 27 | 0 |
| Covenant Village Care Center | 2.2 mi | ★★★★★ | 6 | 0 |
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