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 Northcrest Rehab And Nursing Center during CMS and state inspections, most recent first.
A dependent, severely cognitively impaired resident with paraplegia, contractures, trach and G-tube dependence, and a history of traumatic subdural hemorrhage was care planned and listed on the Kardex as requiring two-person assistance for all bed mobility due to use of a low air loss mattress with bolsters. During a night shift, a CNA provided incontinence and bed care alone, positioned the resident on her side, and left the bedside to obtain supplies, after which the resident fell from the bed to the floor and sustained a head laceration. Nursing documentation and an ED evaluation confirmed the fall and injury, and the facility’s fall investigation determined that the incident resulted from staff performing ADL care without the required two-person assist for bed mobility.
The facility failed to implement proper infection control practices for residents in droplet and contact isolation. A CNA did not use gloves or change an N95 mask when moving between residents, and another CNA did not wear a gown for a resident in contact isolation. These actions were inconsistent with the facility's infection control policies.
A facility failed to maintain clean and trimmed fingernails for a resident with a CVA and left-sided hemiplegia, who was dependent on staff for personal hygiene. Despite the care plan and facility policy requiring regular nail care, observations revealed the resident's nails were long and dirty, with debris under the nails. Documentation showed inconsistency in trimming the nails, and a CNA confirmed the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed care, including the application of a PRAFO brace and use of washcloths for hand positioning, as per physician orders. Observations revealed the absence of these interventions, and staff interviews confirmed a lack of awareness of the specific care requirements, despite documentation indicating completion.
The facility failed to implement fall interventions for two residents, leading to deficiencies in their care. One resident, who was moderately cognitively impaired, was observed with her bed not in the lowest position and missing nonskid strips. Another resident, with a history of falls and dementia, had a regular call light instead of a touch pad and lacked nonskid strips. Staff confirmed these discrepancies, noting room changes as a potential factor.
The facility failed to ensure proper medication storage and administration for two residents. One resident, unable to self-administer, had aspirin on her bedside cabinet, intending to use it for acne. Another resident was found with unattended medication on her overbed table, as she did not want to take all the pills at once. These incidents indicate non-compliance with the facility's medication policies.
A resident with multiple health issues, including urinary retention, experienced inadequate catheter care in an LTC facility. The resident's indwelling urinary catheter frequently leaked, leading to soiled bedding and refusal of care. Despite staff attempts to address the issue, there was a lack of documentation and communication with the urologist, contributing to the deficiency.
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 6.9%, exceeding the acceptable threshold of 5%. Two residents received their medications outside the prescribed times, as confirmed by the MAR and an LPN interview. The facility's policy requires medications to be administered within one hour of their prescribed time.
A facility failed to obtain a resident's blood glucose level at the scheduled time, as required by a physician's order for Novolog insulin administration via sliding scale. An LPN admitted to not checking the blood glucose level at 7:00 A.M. because the resident could not be located. The level was later checked, and insulin was administered based on the reading. The oversight was confirmed during a staff interview.
The facility failed to maintain sanitary conditions in the common showers used by residents on the 100 and 200 halls. Observations revealed black and orange substances in the 200-A and 200-B shower rooms, which the Environmental Services Director was unaware of. Non-operable exhaust fans may have contributed to the issue, as confirmed by interviews with staff.
A facility failed to follow physician orders for a resident's stage IV pressure ulcer treatment, resulting in a saturated dressing and soiled bed linen. The resident, with multiple health issues, had a care plan requiring specific wound care interventions. Observations showed the dressing lacked a foam border and was not changed as needed, contrary to facility policy.
A facility failed to administer and monitor nutritional supplements for a resident as per physician orders. The resident, with severe malnutrition and a stage 4 pressure ulcer, was supposed to receive Boost Breeze three times daily, but it was not provided during meals, and the amount consumed was not documented. Staff interviews confirmed the oversight, and the resident's preference for chocolate-flavored supplements was not honored.
Failure to Follow Two-Person Assist Requirements Resulting in Fall From Bed
Penalty
Summary
The deficiency involves the facility’s failure to follow the care plan and Kardex instructions for a dependent resident who required two-person assistance for all bed mobility and used a low air loss mattress with bolsters. The resident had been admitted with multiple serious diagnoses, including traumatic subdural hemorrhage with loss of consciousness, chronic respiratory failure, paraplegia, contractures, heart failure, tracheostomy dependence, gastrostomy tube dependence, and aphasia. A quarterly MDS documented that the resident was severely cognitively impaired, dependent for all care, incontinent of bowel and bladder, and required special care for tracheostomy, suctioning, oxygen, and tube feeding. The care plan and Kardex both specified that the resident needed two staff for bed mobility and that the low air loss mattress with bolsters required two-person assistance due to the resident’s dependent status. On the night of the incident, two CNAs were scheduled to work the night shift on the relevant halls. According to the facility’s fall investigation and staff statements, one CNA entered the resident’s room to provide evening and incontinence care and proceeded to perform bed mobility and care alone, despite the resident’s documented need for two-person assistance. The CNA positioned the resident on her side and then walked away from the bedside to obtain washcloths from the bathroom. While the CNA was away from the bedside, a crash was heard, and the resident was found on the floor between the side of the bed and the nightstand, with blood on the floor near the back of her head. Nursing documentation indicated that the resident was found lying on her back on the floor, alert with eyes open, grinding her teeth, and tracking the nurse with her eyes. A nursing note recorded that the resident had sustained a fall from bed and had a laceration to the back of her head. Emergency room records confirmed that the resident reported a fall from bed and had a head laceration that did not require sutures or staples; CT scans of the head, neck, brain, spine, and pelvis showed no acute findings. The facility’s fall investigation concluded that the fall occurred because a staff member performed ADL care independently when the resident required two-person assistance for all bed mobility due to her condition and the use of a low air loss mattress. The incident was reviewed by the interdisciplinary team and documented on the facility’s Clinical Checklist as part of routine review of clinical concerns, including falls.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement proper infection control practices related to COVID-19 droplet isolation and contact isolation, affecting several residents. Resident #37, who was in droplet isolation for COVID-19, was observed to have improper PPE usage by CNA #771. The CNA entered the resident's room without gloves, did not perform hand hygiene upon exiting, and failed to change the N95 mask before attending to another resident, Resident #28, who was not in isolation. This indicates a lack of adherence to the facility's infection control policies. Resident #56, also in droplet isolation for COVID-19, was similarly affected by improper PPE practices. CNA #771 entered the room without donning the required PPE, including a gown and gloves, and was preparing to assist the resident with eating. This was observed by LPN #664, who intervened and instructed the CNA to wear the appropriate PPE. This further highlights the inconsistency in following infection control protocols. Resident #12, who was on contact isolation for MRSA, was also subject to improper infection control practices. CNA #604 entered the resident's room without wearing a disposable gown, despite the requirement to do so for any care provided to the resident. The Unit Manager confirmed the necessity of wearing a gown and gloves for residents in contact isolation. The facility's policies clearly state the need for PPE and hand hygiene, yet these were not consistently followed, leading to the deficiencies noted in the report.
Failure to Maintain Clean and Trimmed Fingernails for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident's fingernails were kept clean and trimmed, as required by their policy. The resident, who was admitted with a diagnosis of cerebral vascular accident (CVA) resulting in left-sided hemiplegia and hemiparesis, was noted to have moderate cognitive impairment and was dependent on staff for personal hygiene. Despite the care plan indicating the need for assistance with personal hygiene due to self-care deficits, observations on two consecutive days revealed that the resident's fingernails were long and dirty, with black and yellow debris caked under the nails, particularly under the right thumbnail. The facility's policy on nail care, dated October 2010, outlines the necessity of cleaning the nail bed, keeping nails trimmed, and preventing infections. However, documentation from the resident's shower sheets indicated that while the resident's fingernails were cleaned, they were not consistently trimmed. Interviews with a Certified Nurse Aide confirmed the observations of the resident's long and dirty fingernails, indicating a lapse in the facility's adherence to its own nail care policy.
Failure to Apply Brace/Splint Per Physician Order
Penalty
Summary
The facility failed to apply a brace/splint per physician order for a resident with severe cognitive impairment and multiple medical conditions, including traumatic subdural hemorrhage and a displaced fracture of the second cervical vertebra. The resident was dependent on staff for activities of daily living and had specific physician orders for a left lower extremity PRAFO brace to be worn in the morning and removed at bedtime, along with passive range of motion exercises and the use of rolled-up washcloths in both hands to be removed every six hours to check skin integrity. However, observations on multiple occasions revealed that the resident did not have the prescribed splints or washcloths in place, and the PRAFO boot was not consistently applied as ordered. Interviews with facility staff, including a Certified Nursing Assistant (CNA), confirmed the absence of the required splints and washcloths, and the CNA was unaware of the specific orders for the resident's care. The facility's policy on Rehabilitative/Functional Maintenance Nursing Care emphasized the importance of assisting residents with their prosthetic devices and following physician prescriptions, yet these protocols were not adhered to in the case of this resident. This deficiency in care was documented despite the Treatment Administration Record indicating that the interventions were completed, highlighting a discrepancy between recorded care and actual practice.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents, leading to deficiencies in their care. Resident #15, who was moderately cognitively impaired and dependent on staff for various activities, was observed on multiple occasions with her bed not in the lowest position, contrary to her care plan. Additionally, nonskid strips were missing from the designated areas around her recliner. Staff interviews confirmed these observations, and it was noted that the room had been rearranged, which may have contributed to the oversight. Similarly, Resident #48, who had a history of falls and dementia, was found to have a regular push button call light instead of the touch pad call light specified in her care plan. Furthermore, nonskid strips were absent from the designated areas around her bed. Staff interviews verified these discrepancies, and it was mentioned that Resident #48 had recently changed rooms, which might have led to the failure in implementing the prescribed interventions.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, affecting two residents. Resident #22, diagnosed with chronic obstructive pulmonary disease and dementia, was observed with a bottle of aspirin on her bedside cabinet, despite being unable to self-administer medications. The Unit Manager confirmed the presence of the aspirin and removed it, noting that Resident #22 intended to use it as a skin treatment for acne. The aspirin was later stored in the medication room, but the Unit Manager had not yet consulted with the physician regarding the resident's request. Resident #16, with a history of ovarian and breast cancer and mild cognitive impairment, was found with a medication cup containing four unidentified pills on her overbed table. The Registered Nurse verified that the medication cup was left unattended, as Resident #16 did not want to take all the medications at once. The nurse stated she would return to ensure the resident took the medication. Both incidents highlight a failure to adhere to the facility's policy on safe medication storage and administration.
Failure to Maintain Effective Catheter Care
Penalty
Summary
The facility failed to maintain effective and sanitary care for a resident with an indwelling urinary catheter. The resident, who was admitted with multiple diagnoses including type II diabetes mellitus, neurofunction dysfunction of the bladder, and urinary retention, was dependent on staff for activities of daily living and utilized an indwelling urinary catheter. The care plan required catheter care every shift and monthly changes by the Director of Nursing (DON). However, there was no documentation indicating that the urologist was informed of the catheter's function, and the medical record lacked evidence of the catheter being changed as ordered in September 2024. Observations and interviews revealed ongoing issues with the resident's catheter care. The resident experienced frequent leaking of the catheter, resulting in soiled bedding, and refused care on multiple occasions. Despite attempts by staff to change the linens and provide catheter care, the resident's refusal persisted. The DON confirmed that the catheter was changed on October 1, 2024, but it continued to leak, and no additional interventions were implemented to address the issue. Furthermore, there was no documentation of the catheter change in the medical record, and the urologist had not been contacted since the resident's admission. The deficiency was further highlighted by the lack of communication and documentation regarding the resident's catheter care. Interviews with staff, including the DON and LPNs, confirmed the ongoing concerns with the leaking catheter and the resident's refusal of care. The facility's failure to document catheter changes and notify the urologist contributed to the deficiency, as did the absence of interventions to address the leaking catheter. This deficiency was investigated under Complaint Number OH00157794.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, resulting in a medication error rate above five percent. This deficiency was observed during a medication administration process involving two residents. One resident was administered Cymbalta, an antidepressant, at 10:22 A.M., which was outside the prescribed administration time of 7:00 A.M. as per the physician's order. The medication administration record (MAR) confirmed the prescribed times, and the error was verified through an interview with the LPN responsible for the administration. Another resident was administered budesonide-formoterol fumarate inhalation aerosol at 10:36 A.M., which was also outside the prescribed administration time of 8:00 A.M. as documented in the MAR. The LPN confirmed the deviation from the prescribed schedule during an interview. The facility's policy, revised in April 2019, mandates that medications be administered within one hour of their prescribed time unless otherwise specified. The observed errors resulted in a medication administration error rate of 6.9%, exceeding the acceptable threshold of five percent.
Failure to Obtain Blood Glucose Levels as Ordered
Penalty
Summary
The facility failed to obtain blood glucose levels as ordered for a resident, which was discovered during a complaint investigation. On the morning of October 1, 2024, an LPN was observed administering medications, including Novolog insulin, to a resident based on sliding scale blood glucose levels. However, the LPN admitted to not obtaining the resident's blood glucose level at the scheduled 7:00 A.M. time because the resident could not be located. The blood glucose level was eventually checked later in the morning, revealing a reading of 204 mg/dL, and the LPN administered four units of insulin accordingly. The resident's medical record indicated a physician's order for Novolog insulin administration via sliding scale, with specific units to be given based on blood glucose levels at designated times throughout the day. The order specified administration times at 7:00 A.M., 11:00 A.M., 4:30 P.M., and 8:00 P.M. However, the medication administration record for October 2024 showed no documentation of the blood glucose level being obtained at the 7:00 A.M. scheduled time on October 1, 2024. This oversight was confirmed during an interview with the LPN, who acknowledged the failure to obtain the blood glucose level as ordered.
Unsanitary Conditions in Common Showers
Penalty
Summary
The facility failed to maintain the resident common showers in a sanitary manner, affecting all 27 residents residing on the 100 and 200 halls. During an observation with the Environmental Services Director (ESD), a black substance was found clinging to the ceiling and corner of the wall above the shower stall in the 200-A common shower room, along with a black and orange residue on the shower stall baseboard. Similarly, an orange and black substance was observed clinging to the baseboard of the 200-B common shower stall. The ESD was unaware of these substances prior to the observation. Interviews with State tested Nurse Aides (STNAs) confirmed that residents from the 100 and 200 halls used these common showers. A follow-up interview with the ESD revealed that the exhaust fans in the shower rooms were not operable, potentially contributing to increased moisture and the presence of the substances.
Failure to Adhere to Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to ensure pressure ulcer treatments were completed in accordance with physician orders for a resident with multiple medical conditions, including a stage IV pressure ulcer. The resident was admitted with a stage IV pressure ulcer to the right flank area, and the care plan included specific interventions for wound care. However, observations revealed that the dressing on the resident's wound was saturated with drainage, which had penetrated the dressing and soiled the bed linen. The dressing did not include a foam border as required by the physician's orders, and no attempts were made to change the saturated dressing before it caused further soiling. The resident's medical record indicated a history of chronic obstructive pulmonary disease, intellectual disabilities, and other significant health issues. The wound specialist certified nurse practitioner had assessed the wound as stable, but the facility's staff failed to adhere to the prescribed treatment regimen. The facility's policy required wound care procedures to be completed per physician orders, including the application of dressings with initials, time, and date. The deficiency was identified during an investigation under a master complaint number.
Failure to Administer and Monitor Nutritional Supplements
Penalty
Summary
The facility failed to administer and monitor nutritional supplements for a resident in accordance with physician orders. The resident, who was moderately cognitively impaired and dependent on staff for activities of daily living, had multiple health issues including severe protein-calorie malnutrition and a stage 4 pressure ulcer. The physician had ordered Boost Breeze to be given three times a day, with the amount consumed to be recorded. However, the medication administration records showed that while the supplement was marked as administered, the amount consumed was not documented. Observations revealed that the resident did not receive the Boost Breeze supplement during meals, and instead, a different supplement, Thrive, was provided but not consumed. Interviews with staff confirmed that the Boost Breeze was not listed on the resident's diet card, and there was no documentation of the amount consumed. The dietary manager and nursing staff acknowledged the oversight, and it was noted that the resident preferred chocolate-flavored supplements, which were not provided. This deficiency was identified during an investigation under a specific complaint number.
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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 Napoleon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Fulton Manor Nursing & Rehab C | 9.6 mi | ★★★★★ | 13 | 0 |
| Ayden Healthcare Of Wauseon | 9.9 mi | ★★★★★ | 5 | 0 |
| Vancrest Health Care Ctr Of Ho | 10.2 mi | ★★★★★ | 6 | 0 |
| Fairlawn Haven | 12.6 mi | ★★★★★ | 0 | 0 |
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