Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northwood Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Unsafe food storage and sanitation practices were observed when a Dietary Supervisor verified undated lemonade, expired chicken salad and coleslaw, and homemade croutons past their use-by date in the cooler/freezer. Surveyors also found a soda stored below raw meat, dented cans of pears, an opened undated bag of panko bread crumbs, and two knives with missing chips on the blade in the knife rack. Facility policy required food to be covered, labeled, and dated, and raw animal products to be stored separately and below ready-to-eat foods.
Pest Control Program Not Maintained in Kitchen Area: Several gnats were observed near the dish machine, and the Dietary Supervisor confirmed the facility had been having a problem with gnats in the dish washing area. Pest control reports also showed repeated fly activity in the kitchen, and the facility policy stated kitchen areas are to be kept clean and protected from rodents, roaches, flies, and other insects.
A facility failed to keep supervised smokers from having their own cigarettes and lighters, as a nurse scheduler handed out cigarettes and lit them while residents were later found hiding extra cigarettes and a lighter on their persons. The smoking blanket and box were rusted and damaged, with the box falling apart and the blanket showing rust across it. The facility also misassessed a resident with prior Uber-related elopement attempts, failed to include the wander guard in the care plan, and did not document the device on the TAR; the DON and MD were not fully aware of the order details.
Failure to Follow Pureed Diet Menu: The facility did not follow the menu for residents ordered a pureed diet, affecting five residents with that diet order. The lunch menu called for bread and Oreo cookie blondies, but the pureed menu spreadsheet required pureed bread and a pureed blondie. During observation, residents on the pureed diet were not served bread and were given applesauce instead of the cookie blondie. An LPN confirmed the issue, and the Dietary Supervisor stated the facility had the supplies to make the pureed items but had not prepared them.
A cognitively intact resident was left at a dining table without a meal while other residents were served, even though the dietary aide said the order had been taken and the meal was ready. Another cognitively intact resident with multiple diagnoses, including Parkinson's disease and dysphagia, was placed in a Wanderguard after Uber-related outings, but the device was not documented on the TAR or in the care plan. The resident said the device made him feel trapped, and the DON acknowledged the missing care plan and monitoring documentation.
Missing Consent for Psychotropic Medication: A resident with dementia, anxiety, and bipolar disorder, and with severe cognitive impairment, was ordered Olanzapine for bedtime use. The record contained no signed consent from the resident or representative and no progress note showing the responsible party was notified after the risks and benefits were explained, which the DON verified.
The facility failed to complete a PASARR when a resident developed a new mental health diagnosis of schizoaffective depressed type after admission for other medical conditions. The resident had intact cognition on MDS review, but the updated diagnosis was not reflected in a new PASARR, and the RDO confirmed the omission and stated the facility had no PASARR policy.
Failure to develop comprehensive care plans for multiple residents was identified. A resident with a Wanderguard had no care plan for the device or monitoring, a resident on hemodialysis had no dialysis care plan, a resident receiving risperidone and divalproex had no care plan for antipsychotic use or seizures, and a resident using CPAP had no care plan for CPAP use. The DON and other staff verified these omissions, despite the facility policy requiring individualized comprehensive care plans for each resident.
A resident with COPD, Type II DM, encephalopathy, and a right BKA had ongoing pain that affected sleep, therapy, and daily activities, with a reported pain level of 7. The care plan included pain interventions and a physician order for a pain clinic referral, but an LPN confirmed the appointment had not been made and was unsure which clinic to call; the DON stated there was no policy on scheduling appointments or following physician orders.
Failure to Address Pharmacist Medication Review Recommendations: A resident with schizoaffective disorder, epilepsy, and anxiety disorder had repeated MRR recommendations for phenytoin and digoxin monitoring, plus an AIMS test, but there was no physician response or signature on the reviews and the pharmacist’s recommendations were not implemented. Lab results later showed a digoxin level and no detectable phenytoin, and the Medical Director stated the results should have been followed up when received.
A resident with diagnoses including polyneuropathy, hypokalemia, and pneumonia had a physician order for a mechanical soft diet with extra gravies and sauces, but was served a regular texture meal instead. The resident stated meals were often the wrong texture, and the QA nurse and DS verified the meal ticket was incorrect and had not been updated after the diet change.
The facility failed to ensure that residents signing binding arbitration agreements understood the agreement. Two residents with non-Alzheimer's dementia and BIMS scores of 7, both residing in memory care, signed arbitration agreements. The Regional President of Operations confirmed memory care residents should not be signing binding arbitration agreements.
Nursing staff did not administer medications according to physician orders, resulting in multiple residents with complex medical conditions receiving their prescribed medications several hours late. Residents reported dissatisfaction with the timing of their medications, and staff interviews revealed that workload and lack of assistance contributed to the delays. The facility's policy requiring timely medication administration was not followed.
Surveyors identified multiple infection control deficiencies, including lack of clear EBP signage and instructions, inconsistent staff awareness of EBP protocols, failure to clean and disinfect DME between residents, and improper glove use and hand hygiene during resident care. These issues were observed among several residents and staff, with policies not being consistently followed or documented.
A resident with severe cognitive impairment and total dependence for toileting was found with a saturated incontinence brief that had leaked onto her pad, emitting a strong odor. Observation and CNA interview revealed that the resident had not received incontinence care for approximately four hours, despite the expectation of care every two hours.
A resident with severe cognitive impairment and multiple medical conditions experienced discomfort during incontinence care due to cold water, as staff were unable to obtain warm water from the bathroom. Staff confirmed ongoing issues with water temperature, and direct measurement showed the water was too cold. There was no policy available for managing water temperature.
A resident with impaired cognition and a history of elopement managed to leave a secured memory care unit unsupervised through a bedroom window. The resident was found 2.3 miles away in a busy area, highlighting inadequate supervision and intervention by the facility. Despite a previous elopement incident, the resident's care plan lacked specific interventions, and staffing was insufficient to monitor the resident effectively.
The facility failed to maintain a clean and sanitary kitchen, affecting all 71 residents. The kitchen lacked sanitizing solution for the three-compartment sink, and there was dirt, food debris, and a black substance under the sink and along the walls. The dishwasher was leaking, and trash cans had food debris and splattered substances. The facility's policy requires maintaining cleanliness and using sanitizing solutions, which was not followed.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
Food was not stored, prepared, and served in a safe and sanitary manner. During observation of the walk-in cooler, surveyors found lemonade that was undated, chicken salad with a discard date of 06/11/26, and coleslaw with a discard date of 05/26/26. The Dietary Supervisor verified that the lemonade did not have a date and that the chicken salad and coleslaw should have been discarded. In the same cooler, a can of Shasta cola was stored under raw meats, and the Dietary Supervisor confirmed it should not have been stored below raw meat. Additional observations in the walk-in freezer and food storage areas showed homemade bread croutons with a use-by date of 06/04/26 that should have been discarded, two knives with missing chips on the blade stored in the knife rack, two dented cans of pears stored on the can storage rack, and an opened bulk bag of panko bread crumbs that was undated. The Dietary Supervisor verified the condition of the knives and cans and stated the croutons should have been discarded and the panko bread crumbs should have been dated when opened. Facility policy required food in the refrigerator or freezer to be covered, labeled, and dated, and required raw animal products to be stored separately and below ready-to-eat foods.
Pest Control Program Not Maintained in Kitchen Area
Penalty
Summary
The facility failed to maintain an effective pest control program. During observation on 06/14/26 at 8:56 A.M., several gnats were seen flying around near the dish machine. During interview on 06/14/26 at 9:25 A.M., the Dietary Supervisor stated the facility had been having a problem with gnats in the dish washing area and that he was planning to have the pest control company come out to treat the area. Review of pest control reports since 02/19/26 showed fly activity was observed in the kitchen on 02/19/26, 04/10/26, and 06/02/26. Review of the facility policy titled, Sanitization, dated October 2008, stated all kitchen areas will be kept clean and protected from rodents, roaches, flies, and other insects.
Unsafe smoking supervision and elopement assessment failures
Penalty
Summary
The facility failed to ensure a safe smoking environment for residents who were supervised smokers and were not allowed to have their own cigarettes or lighters. Resident #32, Resident #43, and Resident #68 each had care plans requiring supervision with smoking and storage of smoking materials per facility policy. During observation in the designated smoking area, a nurse scheduler handed each resident a cigarette and lit it for them, but later the same nurse scheduler observed those residents pull extra cigarettes from their shirts, and Resident #32 also pulled a lighter from her shirt. The nurse scheduler confirmed that residents buy cigarettes themselves or have family bring them in and hide them, and stated this happens all the time. The facility also failed to maintain the smoking blanket in good condition. During observation, the fire blanket was found in a rusted-out box that had fallen out of the bottom and onto the ground, and the blanket itself had an approximately 4-inch rusted area across it. The nurse scheduler stated the box had been rusted out for quite a while, and the Director of Housekeeping confirmed the box was rusted out at the bottom, the blanket fell out, and the blanket had rust across it. The smoking policy stated that the facility would establish and maintain safe resident smoking practices and that smoking materials must be handed in to the charge nurse to be secured. The facility also failed to accurately assess Resident #45 for wandering/elopement and did not maintain related documentation. Resident #45 was cognitively intact on the MDS and dependent on staff for multiple activities of daily living. Records showed he had previously left the facility with an Uber driver and later was found at an Apple Store in another city, where the store called the facility because he had no way back. The DON confirmed a wander guard was placed after these incidents, but the elopement risk assessment marked him as physically unable to leave the facility, no care plan addressed the wander guard, and the June TAR did not include monitoring or placement of the device. The physician stated he was not aware of the wander guard order until weeks later, and the facility policy required care plan strategies and interventions for residents at risk for wandering or elopement.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to follow the menu for residents ordered a pureed diet, affecting five residents (#28, #33, #37, #44, and #45) out of five identified with that diet order. Review of the 06/15/26 lunch menu showed garlic herb beef pot roast, mashed potatoes, Normandy vegetable blend, wheat bread, brown gravy, and Oreo cookie blondies, while the menu spreadsheet indicated that residents on a pureed diet should have received pureed pot roast, mashed potatoes, pureed veggie blend, pureed bread, brown gravy, and a pureed blondie. During observation at 12:00 P.M., residents on the pureed diet were not served bread and were given applesauce instead of the cookie blondie. An interview with staff member #258 confirmed that residents on a pureed diet were not being served bread or a cookie blondie, and the Dietary Supervisor stated at 12:05 P.M. that the facility had the supplies to make pureed bread and pureed cookie blondies but had not prepared those items according to the pureed menu.
Dignified Dining Experience and Resident Rights
Penalty
Summary
Resident #26, who was cognitively intact and required set up and clean up assistance with eating, was observed in the dining room without any food while the other residents had already been served. Dietary Aide #236 had delivered one food cart and then a second cart, but Resident #26 remained at a table by herself without a meal. During interview, the resident stated it bothered her that she was the only resident not served in the dining room. The Activities Director confirmed that Resident #26 was the only resident without a meal at that time. The dietary aide stated she had taken the resident's order with the others and had the meal ready, but did not have room on the cart to bring it out with the others. When the kitchen was checked, no meal had been made for Resident #26, and the aide was then observed plating the resident's meal. Resident #45, who was cognitively intact, had a history including Parkinson's disease, dysphagia, major depressive disorder, chronic kidney disease, hypertension, obesity, and chronic ulcer of the right calf. The record showed he left the facility on leave of absence and later returned, but there was no other documentation about that event. In April, he was found at the front entrance waiting for an Uber ride, was slightly confused and argumentative with staff about his right to leave, and the facility applied a Wanderguard to his ankle with the provider notified and no new orders. A later elopement risk assessment stated he was physically unable to leave the facility, and a physician order dated in May directed that the Wanderguard be placed and monitored twice daily. The June TAR contained no documentation of Wanderguard placement or monitoring, and the active care plans contained no care plan related to the device. During interview, Resident #45 stated the Wanderguard made him feel trapped in the facility. The DON stated the device was used after the resident had taken an Uber to another town to have his phone repaired and later had another Uber-related outing, but acknowledged there was no active care plan and the Wanderguard was not listed on the TAR. The resident's representative stated the family had not been aware of the Uber trip and was frustrated with the lack of communication and updates related to his care.
Missing Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication signed a consent for the use of the medication and that the risks and benefits were explained to the resident or the resident's responsible party. Resident #08 was admitted with diagnoses including non-Alzheimer's dementia, diabetes mellitus, anxiety, and bipolar disorders. The resident's MDS assessment showed a BIMS score of 07, indicating severe cognitive impairment, and the resident had verbal behaviors directed at others. Physician orders dated 04/06/26 included Olanzapine 5 mg at bedtime. Review of the medical record found no therapeutic consent signed by the resident or representative and no progress note documenting notification to the responsible party. During interview, the DON verified there was no documented evidence supporting consent or notification for the antipsychotic medication.
Failure to Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the state mental health authority through the PASARR process when a resident had a significant change in condition that resulted in a new mental health diagnosis. Resident #03 was admitted with diagnoses including pleural effusion, epilepsy, and anxiety disorder, and later received a new diagnosis of schizoaffective depressed type. Review of the medical record showed the new diagnosis was entered on 07/16/25, but no PASARR was completed to reflect the updated mental health condition. The resident’s MDS assessment dated 04/23/26 showed a BIMS score of 15, indicating intact cognition. During interview, the RDO verified the new diagnosis and confirmed that a new PASARR was not completed for the change in condition, and stated the facility did not have a policy on the PASARR process.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to complete comprehensive care plans for four residents reviewed for care planning. The report states that the care planning/interdisciplinary team was responsible for developing an individualized comprehensive care plan for each resident within seven days of completion of the MDS assessment, but the facility did not have comprehensive care plans in place for the identified needs of the residents reviewed. Resident #45 was admitted with multiple diagnoses including lymphedema, chronic ulcer of the right calf, hypertension, chronic kidney disease, obesity, major depressive disorder, rhabdomyolysis, Parkinson’s disease, dysphagia, angina pectoris, and acute kidney disease. The record showed he left the facility with family on LOA and later returned, and another note documented that he was found at the front entrance waiting for an Uber, had slight confusion, and was argumentative about his right to leave. The facility applied a Wanderguard to his right ankle and the provider was notified, but the active care plan did not include a comprehensive plan related to the Wanderguard. The DON stated the resident required a wander guard after prior incidents involving leaving the facility and confirmed there was no active care plan for the device and it was not listed on the TAR for monitoring. Resident #02 had diagnoses including hypertension, bradycardia, hyperlipidemia, CHF, DM, adult failure to thrive, and COPD, and the MDS showed impaired cognition, dependence for ADLs, and dependence on hemodialysis. The active care plan did not include a comprehensive plan for dialysis, and the DON confirmed this omission. Resident #33 had anxiety, cognitive impairment, and active orders for risperidone and divalproex sodium, but the active care plan did not address antipsychotic medication use or seizures, and the DON verified the lack of a care plan for antipsychotic medication. Resident #09 had diagnoses including DM, malnutrition, and UTI, and an active order for an auto-adjusting CPAP at bedtime for sleep apnea, but the active care plan did not include CPAP use. The MD confirmed the CPAP order, and the Regional QA Nurse verified there was no comprehensive care plan for CPAP machine use.
Pain Clinic Referral Not Scheduled for Resident With Ongoing Pain
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services was not ensured for one resident. Resident #05 was admitted with diagnoses including COPD, Type II DM with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma, and encephalopathy. The Medicare 5-Day MDS indicated the resident was cognitively intact, had pain or hurting at times in the last 5 days, and experienced pain that occasionally made it hard to sleep, limited participation in rehabilitation therapy sessions, and limited day-to-day activities. The resident also had a reported pain intensity level of seven over the last five days. The care plan identified pain and altered comfort related to a right below the knee amputation and a history of DVT, with interventions to administer medications as ordered, assess effectiveness, use non-pharmacological interventions such as back rub, warm blanket, redirection, and repositioning, and monitor for increased pain and notify the physician. A physician order dated 05/04/26 included a referral to a pain clinic, but interview with the LPN confirmed the appointment had not been made. The LPN stated social services usually made appointments, but there was no current social worker, and he had not made the pain clinic appointment and was unsure which pain clinic to call. The DON confirmed there was no policy on scheduling appointments or following physician orders.
Failure to Address Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to act on pharmacist recommendations made during monthly medication regimen reviews for one resident with schizoaffective depressed type, epilepsy, and anxiety disorder, who also had a BIMS score of 15 indicating intact cognition. The resident’s MRRs repeatedly recommended monitoring phenytoin and digoxin levels on the next convenient lab day and every six months, and one review also recommended an AIMS test now and every six months. The record showed no physician response or signature on the MRRs, and the pharmacist’s recommendations were not reviewed or implemented. The resident’s lab results collected after the June review showed a digoxin level of 1.00 ng/mL and no phenytoin detected. On 06/03/26, the DON notified the nurse practitioner of the lab levels, and no new orders were received. During interview, the Medical Director stated the 06/02/26 lab results should have been followed up on at the time of results and that the repeat lab should not wait until December to be drawn. The Regional QA Nurse confirmed the pharmacy reviews for the resident had not been reviewed or implemented. The facility policy stated pharmacists’ recommendations will be addressed timely by the physician.
Therapeutic Diet Not Followed for Resident
Penalty
Summary
The facility failed to provide Resident #1 a therapeutic diet as ordered by the physician. Resident #1 was admitted with diagnoses including polyneuropathy, hypokalemia, and pneumonia, and the MDS identified the resident as cognitively intact. The physician order dated 05/26/25 specified a regular diet with mechanical soft texture and regular consistency with extra gravies, sauces, etc. to further moisten foods. The care plan identified the resident as at risk for nutrition or hydration problems and included an intervention to provide and serve the diet as ordered. During interview, Resident #1 stated she had an order for a mechanical soft diet and was often given meals of the incorrect texture. Observation of the lunch meal showed the resident's ticket listed a regular diet and the resident was served a regular texture meal. The Regional QA Nurse verified the meal ticket was incorrect and that the resident should not have been served a regular texture meal. The Dietary Supervisor stated he was unaware of the mechanical soft order and verified the meal ticket had not been updated when the diet changed. Facility policy stated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care.
Failure to Ensure Understanding of Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure residents signing binding arbitration agreements understood the agreement. For Resident #48, the medical record showed an admission for non-Alzheimer's dementia, an MDS BIMS score of 7 indicating severe cognitive impairment, and a signed arbitration agreement; the resident was also confirmed by the Admissions Director to reside in memory care. For Resident #62, the medical record showed diagnoses of non-Alzheimer's dementia and hypertension, an MDS BIMS score of 7 indicating severe cognitive impairment, and a signed arbitration agreement; the resident was also confirmed by the Admissions Director to reside in memory care. The Regional President of Operations confirmed that memory care residents should not be signing binding arbitration agreements.
Failure to Administer Medications Timely as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as nursing staff did not administer medications according to physician orders. Medical record reviews, staff and resident interviews, and policy review revealed that six out of seven residents reviewed for late medications received their prescribed medications significantly past the scheduled administration times. The facility's policy required medications to be administered within one hour of the prescribed time, but medications were often given several hours late. Residents affected had various medical diagnoses, including acidosis, coronary artery disease, heart failure, renal insufficiency, chronic obstructive pulmonary disease, diabetes, dementia, and psychotic disorders. For example, one resident with heart failure and renal insufficiency received multiple medications, including anticonvulsants, cholesterol medication, and insulin, more than an hour late. Another resident with chronic obstructive pulmonary disease and diabetes received medications such as atorvastatin, divalproex, insulin, and antipsychotics up to three hours late. Several residents reported in interviews that their medications were consistently late and expressed a preference for receiving them on time. Staff interviews indicated that late medication administration was due in part to workload issues, such as responding to resident falls, and a lack of available assistance, as there was no unit manager present and other nursing staff were occupied with their own medication passes. The nurse practitioner confirmed that she was not informed of the late medication administration. The facility's policy on medication administration was not followed, resulting in non-compliance with prescribed medication schedules for multiple residents.
Deficiencies in Infection Control: EBP Signage, DME Cleaning, and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding enhanced barrier precautions (EBP), cleaning and disinfection of durable medical equipment (DME), and proper hand hygiene and glove use. Surveyors found that residents requiring EBP did not have clear signage or instructions indicating the required personal protective equipment (PPE) or which care activities necessitated specific PPE. Instead, rooms were marked only with a magnetic square labeled 'EP,' without further information. Staff interviews revealed inconsistent understanding of EBP requirements, with some staff unsure of what PPE to use or the meaning of the signage. Additionally, EBP was inconsistently documented, sometimes only in care plans and not in physician orders, and there was no clear indication at the door for which resident in a shared room was under EBP. Observations showed that staff did not consistently follow protocols for cleaning and disinfecting DME between residents. For example, an LPN used the same finger pulse oximeter, blood pressure cuff, and forehead thermometer on two different residents without cleaning the equipment in between, despite being aware of the policy requiring disinfection. The DON confirmed that all DME should be cleaned between uses, and the facility's policy also required this practice. Hand hygiene and glove use were also found to be deficient. During incontinence care, a CNA failed to change gloves and wash hands between caring for two different residents in the same room. The CNA admitted to not following proper procedure, stating it was not her normal practice. The facility's hand hygiene policy required handwashing or use of hand sanitizer before and after resident contact, after removing gloves, and after contact with bodily fluids, but this was not followed during the observed care.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, multiple medical diagnoses including disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident, was observed to have a saturated incontinence brief that had leaked onto the incontinence pad beneath her. The resident was dependent on staff for toileting and transfers, and was frequently incontinent of bladder and always incontinent of bowel. During an early morning observation, a CNA confirmed that the resident's brief was saturated and emitted a pungent odor, with leakage onto the pad. The CNA reported that the resident had last been changed approximately four hours prior, despite the expectation that incontinence care should be provided every two hours. This lapse in timely incontinence care was verified through medical record review, observation, and staff interview.
Failure to Maintain Safe Water Temperatures During Resident Care
Penalty
Summary
The facility failed to maintain water temperatures within normal limits, resulting in a deficiency affecting a resident with severe cognitive impairment and multiple medical diagnoses, including disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident. During incontinence care, staff were unable to obtain warm water from the resident's bathroom and had to leave the room to find water that was only lukewarm. The resident displayed discomfort during care, pulling away from the washcloth as aides attempted to wash her, and staff acknowledged that the water was cold. Review of facility records showed that a mixing valve for hot water had been replaced, but the issue persisted, requiring another replacement shortly after. Water temperature logs indicated that temperatures were within normal limits at one point, but direct measurement during the observed care showed the water was 93.7°F, which was confirmed by the DON to be too cold. Staff interviews revealed ongoing problems with water temperature, and there was no policy available for review regarding water temperature management.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and intervention to prevent a resident with impaired cognition and a history of elopement from leaving the facility unsupervised. The resident, who was housed in a secured memory care unit, managed to elope through his bedroom window without staff knowledge. This incident placed the resident at potential risk for serious life-threatening harm and/or injury, as he was found 2.3 miles away from the facility in a busy area of town. The resident had a history of elopement, having previously exited the facility through the same window in May 2023. Despite this history, the resident's care plan did not include specific interventions to address the risk of elopement through the window. On the day of the incident, the resident was observed pacing near the nurse's station and closely watching an LPN, which was not recognized as a potential sign of elopement risk. The staff on duty were insufficiently equipped to monitor the resident effectively, as one STNA was pulled to work on another unit, leaving only one nurse and one aide to care for twenty-three memory care residents. The facility's failure to implement effective interventions and provide adequate supervision allowed the resident to elope undetected. The resident was eventually located by the Director of Rehabilitation, who found him leaving a store and walking in a busy area. The resident was returned to the facility by EMS, and a head-to-toe assessment revealed abrasions on both knees but no pain or distress. Interviews with staff indicated that the memory care unit was challenging to manage with limited personnel, and the facility's management was unaware of the previous elopement incident.
Removal Plan
- LPN #110 identified Resident #01 was not in his room and the facility began searching for the resident.
- DOR #85 located Resident #01 at a Dollar General Store and the facility was notified.
- Resident #01 was returned to the facility by [NAME] EMS, accompanied by the [NAME] Police Department. ADON #405 initiated one to one safety supervision for Resident #01.
- Registered Nurse (RN) #109 completed a head-to-toe assessment on Resident #01 and the resident was free from any pain or psychosocial distress related to the incident. Resident #01 did have an abrasion noted to his bilateral knees.
- RQAN #403 reviewed progress notes for the last 30 days for all current facility residents for any like behaviors and no other concerns were identified.
- The Administrator installed metal L Brackets and additional upgraded hardware to prevent Resident #01's window from opening more than six inches or wide enough to prevent the resident from exiting the window.
- The Administrator audited all resident accessible windows and upgraded securement hardware throughout the facility. All windows were noted to be secured without any identified concerns.
- Unit Manager (UM) #134 completed elopement risk assessments for all current facility residents. There were no identified concerns from prior elopement assessments.
- Clinical Operations Specialist (COS) #121 completed wander risk assessments for all current facility residents. There were no identified concerns noted from the prior assessments.
- The Administrator audited all egress doors, alarm panels and the facility wander guard system to ensure proper alarm and functioning. There were no identified concerns noted.
- COS #121 audited all current facility residents with physician orders for wander guards. All wander guards were placed properly, functioning and within required expiration. No identified concerns were noted.
- UM #134 audited all current facility residents at risk of elopement, to ensure all those at risk have a care plan with appropriate interventions in place. There were no identified concerns in the audit.
- COS #121 audited to ensure all current facility residents with a wander guard were appropriately assessed for placement as ordered, had a physicians order and had a care plan in place. There were no identified concerns noted.
- UM #122, Dietary Manager #400, DOR #85, Environmental Services Director #450 and Nursing Administrative Assistant #79 began educating all current facility staff in person, on the missing resident procedure and the facility Abuse/Neglect policy and all remaining staff via phone. The education was completed.
- The Administrator held an elopement drill in person with staff on dayshift and night shift. Staff response was immediate and appropriate. There were no identified concerns noted.
- The facility held a Quality Assessment and Performance Improvement (QAPI) meeting with the Administrator, RQAN #403, ADON #405, UM #134, UM #122, COS #121, RDO #402 and Medical Director #501. Resident #01's elopement and the facilities corrective action plan was discussed. The facilities corrective action plan was approved by the QAPI committee.
- Maintenance Director #130 or designee will conduct elopement drills on each shift, twice weekly for a period of four weeks to ensure staff respond accordingly.
- All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. All findings will be reported to the facility's QAPI committee.
- Maintenance Director #130 or designee will conduct checks of exit doors/wander guard system once weekly, for a period of four weeks to ensure proper functioning. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Ongoing compliance will be further maintained through audits as dictated by the facility's QAPI committee.
- The DON or designee will complete elopement risk and wandering risk assessments on current residents weekly for a period of four weeks, to ensure no changes in behavior patterns are present, placing residents at risk for elopement and ensuring that appropriate and effective interventions are in place. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary.
- The DON or designee will review current resident progress notes in the clinical operations meeting five times weekly for a period of four weeks to monitor acute changes in behavior patterns that require further intervention. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary.
- The DON or designee will audit all current facility residents with physician's order for wander guard five times a week, for a period of four weeks to ensure proper functioning, placement and devices within stated expiration. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. All findings will be reported to the facility's QAPI committee.
- The Administrator or designee will conduct checks of window securement hardware, three times a week for a period of four weeks to ensure windows are secure and safety latches remain intact. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee.
- RDO #402 will review all audits weekly for a period of four weeks to ensure completion and compliance. All variances will be corrected immediately upon discovery and additional follow-up and education will be provided as deemed necessary.
- The DON or designee will educate new hires and/or agency staff working in the facility prior to working their shift on the Wandering elopement procedure and Abuse/Neglect policy for four weeks. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary.
Sanitation Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all 71 residents residing there. During an initial tour of the kitchen, it was observed that the three-compartment sink lacked sanitizing solution, and the Kitchen Supervisor confirmed that the facility had been out of sanitizer for several days. Additionally, there was dirt, food debris, and a black substance under the three-compartment sink and along the walls throughout the kitchen. The cove base covering was torn off the wall under the sink, and a tile was missing. Trash cans in the kitchen had food debris and splattered substances running down them, and there was unknown splatter and debris on the front of the dishwasher, with food debris along its top. Water was also dripping from the dishwasher into a large bucket placed underneath. Interviews with the Regional Dietary Director and the Customer Service Representative confirmed the lack of sanitizing solution in the three-compartment sink and the leaking dishwasher. The facility's policy on sanitization, dated October 2008, requires that the facility be maintained in a clean and sanitary manner, with all equipment washed to remove soils using hot water and sanitizing solutions. Kitchen waste should be kept in clean, leakproof, tightly closed containers, and sinks used for washing utensils, cooking equipment, or dishes should be cleaned between uses with an approved sanitizing agent. This deficiency was investigated under Complaint Number OH00153481.
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aventura At Oakwood Village | 0.5 mi | ★★★★★ | 8 | 0 |
| Forest Glen Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Allen View Healthcare Center | 1.2 mi | ★★★★★ | 5 | 0 |
| Villa Springfield Rehabilitation And Healthcare Ce | 1.3 mi | ★★★★★ | 1 | 0 |
| Springfield Nursing & Independent Living | 2.6 mi | ★★★★★ | 30 | 0 |
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