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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norwood Towers Post-acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities was given several medications not prescribed for her when a medication technician, distracted during a med pass, administered drugs that had been pulled for another resident without properly verifying identity as required by facility policy. The resident received Clozapine, Depakote, Niacin, and Haldol, subsequently became lethargic, difficult to rouse, drooled, had tachycardia, and vomited multiple times, leading to notification of the provider and transfer to the hospital, where she was treated for unintentional ingestion of non-prescribed medications and returned to baseline mental status after about a day.
A resident with CKD, PVD, and a mood disorder had moderate cognitive impairment and required substantial assistance with bathing, but the facility did not consistently provide the resident’s preferred showers. Bathing records showed missed showers, bed baths, and missing documentation, and the resident stated staff were not giving him the option of a shower over a bed bath. The DON’s interview also reflected confusion about resident bathing preferences.
A resident with COPD, type I DM, and paranoid schizophrenia had a smoking incident when her coat smoldered from a cigarette butt she had previously smoked. Staff evacuated her, then later moved her to a secured Memory Care Unit because she was now a supervised smoker. The MD, NP, and Psychiatric NP were not promptly informed of the smoking incident or the move to the secured unit, despite the facility policy requiring prompt notification of the resident, attending physician, and representative when there is a change in condition or status.
Failure to protect residents from abuse: two residents were involved in a physical altercation after one resident was observed in the other resident’s doorway swinging his arms, and the other resident was found with facial redness, bruising, swelling, a bloody nose, and a head hematoma. One resident had severe cognitive impairment with a BIMS of 0, and the other had significant neurologic and mood-related diagnoses and was rarely/never understood. Staff notes and interviews described the event as physical aggression, while the incident was also described as unwitnessed or unclear.
A resident with COPD, DM I, and paranoid schizophrenia was found in bed with a smoldering coat after smoking, and staff later moved her to a secured Memory Care Unit because she was considered a supervised smoker. The DON said the secured unit was the only place for supervised smokers, while the PNP said he was not informed of the incident until later and was asked by phone to provide the housing order. The resident stated she was told about the move but did not agree to it.
Failure to follow the abuse policy after a resident-on-resident altercation. A resident with severe cognitive impairment sustained facial bruising, swelling, a bloody nose, and a head hematoma after another resident reportedly struck him in the face. Staff separated the residents and placed them on 1:1 observation, but the DON and Administrator stated they did not consider the event abuse and did not report it under the facility’s abuse policy.
Failure to Report Alleged Resident Abuse: Two residents were involved in an incident where one resident struck the other in the face, resulting in facial bruising, swelling, a bloody nose, and a head hematoma. The DON and Administrator stated they did not believe the event involved intent or met the threshold for abuse, so it was not reported to the state agency. Staff documentation and CNA testimony described the event as physical aggression, and both residents were placed on 1:1 observation.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse: The facility did not thoroughly investigate an alleged abuse incident between two residents. One resident with severe cognitive impairment sustained facial bruising, swelling, a bloody nose, and a head hematoma after a physical disturbance with another resident who had significant neurologic and psychiatric diagnoses. Staff documented that the other resident struck the injured resident in the face, and a CNA reported seeing the resident swinging his arms and making an aggressive statement. The DON and Administrator confirmed the incident was unwitnessed and that no thorough investigation was completed because they did not believe there was intent.
A resident with chronic pain syndrome and multiple serious conditions did not receive prescribed PRN oxycodone for nearly 24 hours due to the facility running out of medication. Despite repeated requests and reports of severe pain, staff did not notify hospice or obtain an emergency supply in a timely manner, and failed to document the resident's pain or communicate the shortage as required by facility policy. This resulted in actual harm, with the resident experiencing uncontrolled pain until an emergency supply was provided by hospice.
The facility did not provide residents with information about the grievance process or how to file a grievance. Multiple residents, including those who were cognitively intact and involved in resident council, were unaware of their rights or the process, and staff also lacked knowledge. No information was posted in the facility, despite policies requiring residents be informed and assisted in filing grievances.
Surveyors identified multiple deficiencies in the facility's environment, including unclean and damaged equipment in resident rooms, persistent odors in the memory care unit, and a dirty, poorly lit elevator. Staff confirmed these issues had not been addressed, resulting in a failure to provide a clean, comfortable, and homelike setting as required by facility policy.
Surveyors found that three residents did not receive adequate privacy and dignity during personal care. One resident had visible facial hair that staff had not addressed despite her request. Another was left in a public area wearing a thin hospital gown that exposed her breast, with staff unaware of how long she had been exposed. A third resident was left exposed in bed with the door open while a CNA provided hygiene care, allowing direct hallway view. Staff confirmed these lapses in privacy and dignity.
The facility did not ensure that three residents with varying cognitive and physical impairments received necessary assistance with ADLs, including bathing and hygiene. One resident was found with unclean feet and bedding, another did not receive the required number of baths, and a third had to bathe independently despite needing help, with documentation and interviews confirming missed care.
Two residents with cognitive and physical impairments were observed smoking without the required protective smoking aprons during supervised smoke breaks. Staff were unaware of the need for these safety measures, and one resident had burns on his clothing. Facility policy and care plans specified the use of adaptive equipment and supervision, but these were not consistently implemented.
The facility failed to dispose of medications in a timely manner, potentially affecting all 110 residents. A room was found with a large quantity of medications, including blister packs and daily envelopes, stored improperly. The DON was unaware of who was responsible for disposal, and only two employees had access to the room. The facility's policy on medication disposal was not followed.
A facility failed to ensure medications were not left unattended at the bedside in a secured memory care unit, affecting a resident who was cognitively intact and required supervision. The resident was observed to have medications left on the bedside table, despite an LPN claiming to have witnessed the resident taking them. A medication technician later found the medications on the table, indicating they had not been taken. The facility's policy requires licensed individuals to administer and document medications, which was not followed in this case.
The facility failed to store medications properly, with unlocked doors and expired medications found in the storage room and central supply. An LPN confirmed the inability to lock the nurse's station and the presence of expired medications, violating the facility's policy requiring locked compartments for drugs and biologicals.
A resident with multiple health conditions, including diabetes, was observed with long, dirty fingernails despite being dependent on staff for personal hygiene. The care plan required weekly nail trimming, but staff interviews confirmed the resident did not refuse care, and his nails remained untrimmed over several days.
The facility failed to implement pharmacy recommendations for two residents, leading to deficiencies in medication management. A resident's orders for Rizatriptan and Diclofenac gel were not updated as recommended, and another resident continued receiving Ibuprofen and Benadryl despite agreements to discontinue. These oversights were confirmed by a Regional RN.
Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff administered multiple medications that were not prescribed for the resident. The resident had been admitted with diagnoses including cerebral infarction, type 2 diabetes, and dementia, and a recent MDS assessment documented severe cognitive impairment and dependence on staff for ADLs. During an evening medication pass, a medication technician pulled medications intended for another resident and, after becoming distracted by another resident, administered those medications to this resident at the medication cart. As a result of this error, the resident received Clozapine 200 mg, Depakote 250 mg, Niacin 250 mg, and Haldol (dose not specified), none of which were ordered for her. The facility’s own medication administration policy required the individual administering medications to verify the resident’s identity before giving medications and to check the label three times to ensure the right resident, medication, dose, time, and method. The medication technician acknowledged that she did not correctly verify the resident’s identity before administration and only realized the error after the medications had been given. Following the administration of the wrong medications, the resident developed lethargy, was difficult to rouse, was drooling, had an elevated heart rate, and experienced three episodes of emesis the next morning. Nursing staff notified the nurse practitioner, who contacted poison control, and the resident was sent to the emergency department for evaluation. Hospital records documented that the resident was admitted for unintentional ingestion of medications not prescribed for her, underwent a CT scan that showed no acute intracranial abnormality, and that her mental status returned to baseline after approximately 24 hours.
Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to accommodate a resident’s preference for showers over bed baths, affecting one resident reviewed for bathing. The resident was admitted on 08/26/25 and had diagnoses including chronic kidney disease, peripheral vascular disease, and a mood disorder. The quarterly MDS assessment showed moderate cognitive impairment with a BIMS score of 9 and need for substantial assistance with toileting, dressing, bathing, and transfers. Review of the bathing documentation for January and February 2026 showed multiple missed showers, bed baths, entries of “not applicable,” and one date with no documentation. During interview, the resident stated he was not getting his showers as required and later stated he preferred a shower over a bed bath but staff were not giving him the option. The DON stated another resident preferred a bed bath versus a shower, indicating confusion in resident preference.
Failure to Notify Providers of Significant Change and Unit Transfer
Penalty
Summary
The facility failed to ensure physicians/providers were notified of a significant change in Resident #47’s status and failed to notify the physicians/providers when the resident was moved to the secured Memory Care Unit. Resident #47 was admitted on 01/13/22 and had diagnoses including COPD, type I DM, and paranoid schizophrenia. A quarterly MDS assessment showed moderate cognitive impairment with a BIMS score of 11, and the resident required supervision with eating, toileting, dressing, and transfers, and setup with bathing. On 01/24/26, staff found Resident #47 lying in bed with her coat smoldering from a cigarette butt she had previously smoked; she was evacuated to a safe place and educated about not bringing previously lit cigarettes into the building. A late entry note later that night documented that the resident was moved to the second floor secured unit because she was now a supervised smoker at all times. Interviews showed the Medical Director, NP, and Psychiatric NP were not informed of the smoking incident until days later, and they were not informed when the resident was moved to the secured Memory Care Unit. The DON stated the resident was moved because the Memory Care Unit was the only place the facility had supervised smokers.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse when two residents were involved in a physical disturbance that resulted in injury to one resident. Resident #111 had diagnoses including malignant neoplasm of the brain, hypertension, and metabolic encephalopathy, and had severe cognitive impairment with a BIMS score of zero. The record documented that Resident #111 sustained facial trauma, including redness, bruising, swelling, a bloody nose, and a hematoma on the head after an incident with Resident #65. X-rays of the skull, facial bones, and cervical spine were ordered, and later documentation described the event as physical aggression by Resident #65 toward Resident #111. Resident #65 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, mood disorder, and PVD, and could not complete a BIMS because he was rarely or never understood. The record and staff interviews stated that CNA #12 observed Resident #65 standing in Resident #111's doorway and swinging his arms, after which Resident #111 was found with a red face and nosebleed. Staff interviews also described the incident as unwitnessed or unclear, while later notes stated Resident #65 appeared to be the aggressor and that Resident #111 had been injured in the face. The facility policy required staff and management to investigate alleged abuse and address suspected or identified abuse in a timely manner, and the deficiency was cited under Complaint Number 2729914.
Involuntary Seclusion After Smoking Incident
Penalty
Summary
The facility failed to ensure Resident #47 was free from involuntary seclusion after a smoking incident led to the resident being moved to the secured Memory Care Unit. Resident #47 was admitted with diagnoses including COPD, type I DM, and paranoid schizophrenia. A smoking observation assessment initially identified the resident as an independent smoker with no cognitive impairment, while a later Quarterly MDS assessment documented moderate cognitive impairment with a BIMS score of 11 and need for assistance with several activities of daily living. On 01/24/26, staff found the resident lying in bed with her coat at the foot of the bed smoldering from a cigarette butt she had previously smoked, and she was evacuated to a safe place while the coat was extinguished. A late entry progress note documented that the resident was then moved to the second-floor secured Memory Care Unit because she was now considered a supervised smoker at all times. The DON stated that all residents on the first and third floors were independent smokers and that the secured Memory Care Unit was the only place the facility had supervised smokers. The Psychiatric NP stated he was not informed of the smoking incident until several days later and that he was asked by phone to provide an order for the resident to be housed in the secured unit. The resident later stated she was informed she was being moved to the secured Memory Care Unit but was not agreeable, and observations during the survey showed she remained housed there.
Failure to Follow Abuse Reporting Policy After Resident-on-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy after an allegation of abuse was reported involving two residents. Resident #111 had severe cognitive impairment with a BIMS score of zero and required assistance with eating, toileting, bathing, dressing, and transfers. Resident #65 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, mood disorder, and PVD, and could not complete a BIMS because he was rarely or never understood. According to the record, staff reported that Resident #65 struck Resident #111 in the face, and the residents were separated. Resident #111 was documented with facial trauma, redness, a bloody nose, a hematoma on the right side of the head, bruising, swelling, and a bump on the forehead. X-rays of the skull, facial bones, and cervical spine were ordered, and later documentation stated the injury appeared to have resulted from an unwitnessed incident involving Resident #65. Resident #65 was also placed on one-to-one supervision and later sent out for evaluation. During interviews, the DON stated the incident was unwitnessed and the facility did not feel there was intent between the residents, so it did not implement the abuse policy or report the incident to the state agency. The Administrator stated the facility used a state agency flow chart to decide whether to report the incident as abuse and did not feel it warranted abuse reporting. The facility policy required staff and management to investigate alleged abuse or neglect, address suspected or identified abuse, and report it in a timely manner to appropriate agencies consistent with applicable laws and regulations.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report alleged abuse to the state agency after an incident involving two residents. Resident #111 had severe cognitive impairment with a BIMS score of zero, required assistance with eating, and was dependent for toileting, bathing, and dressing. Resident #65 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, mood disorder, and PVD, and could not complete a BIMS because he was rarely or never understood. According to the record, staff documented that Resident #65 struck Resident #111 in the face, and the residents were separated immediately. Resident #111 was noted to have facial trauma, redness, a bloody nose, swelling, and a hematoma/bump on the head. Staff assessments and late entries described the incident as physical aggression or an unwitnessed event involving Resident #65, and both residents were placed on one-to-one observation. Resident #65 was also sent out to be evaluated, while Resident #111 received assessment, first aid, and x-rays that were unremarkable. During interviews, the DON stated the incident was unwitnessed and that the facility did not feel there was intent between the two residents, so it did not report the incident to the state agency. The Administrator stated the facility used a state flow chart to decide whether to report the event as abuse and did not believe it was warranted as abuse, so it was not reported. CNA #12 stated she saw Resident #65 standing in Resident #111's doorway, swinging his arms, and observed Resident #111 with a red face and bleeding from the nose.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident involving two residents, #65 and #111. Resident #111 had diagnoses including malignant neoplasm of the brain, hypertension, and metabolic encephalopathy, and was assessed with severe cognitive impairment with a BIMS score of zero. Resident #65 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, mood disorder, and PVD, and could not complete a BIMS because he was rarely or never understood. The record showed that on 12/30/25, staff reported a physical disturbance between the two residents. Resident #111 was documented with facial trauma, redness to the face and nose, a small hematoma on the right side of the head, facial bruising, swelling, a bloody nose, and a bump/knot on the head. Resident #65 was documented as having struck Resident #111 in the face, and CNA #12 stated she saw Resident #65 standing in Resident #111’s doorway swinging his arms. CNA #12 also reported that Resident #65 said he "expletive him up." Both residents were placed on one-to-one observation, and Resident #65 was sent to the hospital for evaluation. Interviews with the DON and Administrator confirmed the incident was unwitnessed and that the facility did not complete a thorough investigation. The DON stated the facility did not feel there was intent between the two residents and therefore did not believe a thorough investigation was needed. The Administrator stated the facility used a state agency flow chart to decide whether to report the incident as abuse or not and verified that no thorough investigation was completed. The facility policy titled Abuse and Neglect - Clinical Protocol stated staff, with physician input, would investigate alleged abuse and neglect to clarify what happened and identify possible causes.
Failure to Provide Timely PRN Pain Medication for Resident with Chronic Pain
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate pain management for a resident with chronic pain syndrome and multiple serious diagnoses, including malignant neoplasm of the larynx, osteomyelitis, fibromyalgia, and a bowel rupture with colostomy. The resident was cognitively intact, independent in most activities of daily living, and under hospice care. Physician orders specified that oxycodone 10 mg tablets were to be administered every three hours as needed for pain. However, documentation revealed that the resident did not receive her PRN pain medication for nearly 24 hours, despite multiple requests and reports of severe pain. Medical record review and interviews indicated that the facility ran out of the prescribed oxycodone, and staff did not notify hospice or obtain an emergency supply in a timely manner. The controlled drug record showed the medication was depleted, and the resident reported to both staff and hospice that she was in significant pain and unable to receive her medication. The hospice nurse confirmed being notified by the resident via text message that the medication was unavailable, and subsequently arranged for an emergency supply, which was not administered until the following day. There was no documentation that the hospice nurse was notified by facility staff when the medication first became unavailable. Facility policy required that medication administration be based on resident need and that medication errors be documented and reported. The pain management policy also required immediate notification of the provider if pain was not adequately controlled. Despite these policies, staff did not ensure the resident received her ordered pain medication, did not document the resident's repeated requests for pain relief, and failed to communicate the medication shortage to hospice in a timely manner. This resulted in actual harm to the resident, who experienced severe, uncontrolled pain for an extended period.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide residents with information regarding the grievance process and how to file a grievance, as required by policy. Record review and interviews revealed that three residents, including one who was cognitively intact and served as the presiding president of the Resident Council, were unaware of their right to file a grievance or the process for doing so. These residents reported that the grievance process had never been explained to them individually or during resident council meetings. One resident with moderate cognitive impairment also indicated he was unaware of the process and could not recall it being discussed at meetings he attended. Further investigation showed that there was no posted information about the grievance process in the facility, and the Assistant Director of Nursing confirmed a lack of knowledge about how the process worked. Although the Administrator was able to provide a written policy and the names of the grievance committee members, there was no evidence that this information was communicated to residents. The facility's own policies stated that residents have the right to file grievances orally or in writing and that the facility should assist residents in exercising this right, but these procedures were not being followed or made known to residents.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to provide a homelike environment for its residents, as evidenced by multiple observations of unclean and damaged equipment and furnishings in resident rooms. Specific findings included tube feeding poles with dried brownish substances, broken window blinds, privacy curtains with brown stains or hanging off tracks, and walls with brown splashes and holes. Housekeeping and maintenance staff confirmed these issues had not been addressed. Additionally, the elevator was observed to be dirty, with stains on the floor, dirt in the corners, dim lighting, and light panels containing bugs and a black substance. The memory care unit (MCU) was also found to have persistent, pungent odors of urine and feces in the hallway and resident rooms, with staff unable to immediately identify or resolve the source of the smell. The facility's own policy requires a clean, comfortable, and homelike environment, but these conditions were not met for several residents and areas, affecting both the safety and comfort of residents, staff, and visitors.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
Surveyors identified that the facility failed to provide privacy and dignity for three residents out of seven reviewed for dignity. One resident with moderate cognitive impairment and multiple diagnoses, including dementia and depression, was observed to have noticeable facial hair under her chin. The resident stated that staff had previously addressed this issue and expressed a desire for staff to remove the facial hair. An LPN confirmed the presence and visibility of the facial hair. Another resident with severe cognitive impairment and a history of stroke and diabetes was observed sitting in a lounge area wearing a thin hospital gown, pants, and shoes. The gown was so worn that the resident's breast was visible through the fabric, and several other residents were present in the area. A CNA confirmed the visibility of the resident's breast and stated she was unaware of how long the resident had been exposed in this manner, noting that the resident had no other clothes available at the time. A third resident, who required substantial assistance with personal hygiene due to multiple medical conditions, was observed lying in bed with the door wide open while a CNA applied deodorant under his arms. The resident's chest was exposed, and the open door allowed direct view from the hallway. The CNA acknowledged that the resident was exposed with the door open, and the resident confirmed that privacy was not maintained during this care activity.
Failure to Provide Required Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents who required varying levels of support. One resident with severe cognitive impairment and multiple medical conditions, including diabetes and cerebrovascular attack, was found lying in bed with feet encrusted in a yellow substance and a dirty mattress, indicating a lack of proper hygiene care. Staff confirmed the resident's condition and the failure to maintain cleanliness. Another resident, who was cognitively intact but required supervision or assistance for bathing, did not receive the required twice-weekly bathing as documented, with staff confirming the missed care opportunities. A third resident, admitted with multiple diagnoses such as atrial fibrillation, diabetes, and cancer, required moderate assistance with bathing but reported having to perform showers independently after regaining some strength through therapy. Initially, this resident received no regular bathing, and both the resident and a family member expressed uncertainty and concern about the bathing schedule and lack of assistance when the resident was too weak to bathe independently. Documentation revealed several periods where the resident was not scheduled for any showers, further confirming the deficiency in providing necessary ADL support.
Failure to Ensure Safe Smoking Practices for Supervised Residents
Penalty
Summary
The facility failed to ensure safe smoking practices for residents who required supervision and adaptive equipment during smoking breaks. Two residents with cognitive and physical impairments, including visual impairment and dexterity issues, were observed smoking without the required protective smoking aprons, despite care plans specifying the need for supervision and use of adaptive devices. One resident was noted to have burns on his clothing, and neither resident was offered or wearing a smoking apron during supervised smoke breaks. Staff interviews confirmed a lack of awareness regarding the requirement for smoking aprons for these residents. Review of facility policy indicated that residents should be evaluated for safe smoking practices and that care plans should reflect any restrictions or necessary adaptive equipment. However, observations and interviews revealed that these protocols were not consistently followed, resulting in residents with identified risks smoking without appropriate safety measures in place. The facility had identified fifteen residents requiring assistance with smoking, but the deficiency was observed in the two residents reviewed.
Failure to Timely Dispose of Medications
Penalty
Summary
The facility failed to ensure timely disposal of medications, which could potentially affect all 110 residents. During an observation, a room on the second floor was found to contain a large quantity of medications, including individual blister packs and daily envelopes, stored in an overflowing cardboard box and plastic tubs. A large trash bag was also noted to be half full of empty plastic bottles and envelopes. The Director of Nursing (DON) indicated that these medications were not taken back by the pharmacy after residents were discharged or medications were discontinued. The DON was unaware of who was responsible for disposing of these medications and believed they had been in the room for two to three weeks. Further investigation revealed that only two employees, the Maintenance Director and Central Supply, currently had keys to the room, with a new Administrator set to receive a key soon. A review of the facility's policy on discarding and destroying medications showed that medications should be mixed with an undesirable substance and placed in a sealable container to prevent leakage. However, this procedure was not followed, as evidenced by the medications found in the room, some of which had fill dates as far back as October of the previous year.
Medications Left Unattended in Memory Care Unit
Penalty
Summary
The facility failed to ensure that medications were not left unattended at the bedside in a secured memory care unit, affecting a resident who was reviewed for accidents. The resident, who was cognitively intact and required supervision for activities of daily living, was observed to have medications left on the bedside table. The medications were supposed to be administered by an LPN, who claimed to have witnessed the resident taking them. However, a medication technician later found the medications on the resident's table, indicating that they had not been taken. The resident, who had a history of convulsions, schizoaffective disorder, mood disorder, vascular dementia, major depressive disorder, personal history of traumatic brain injury, and hypertension, denied pocketing or spitting out the medications, stating that he always takes them when given. The facility's policy requires that only licensed individuals administer medications and document their administration, which was not adhered to in this instance, as the medications were left unattended, posing a potential risk to the resident and others in the secured unit.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored in a proper and safe manner, which had the potential to affect all residents except those on the secure unit. During an observation of the medication storage room on the third floor, it was found that the door was unlocked and accessible to anyone. Expired medications were present, including two bottles of aspirin with an expiration date of January 2024, a bottle of Senna plus with an expiration date of June 2024 but marked as April 2023, and a bottle of stool softeners with an expiration date of August 2023. Additionally, the nurse's station on the third floor could not be locked, and a grey plastic bag containing daily medication packs for residents was stored under the desk. The LPN verified the inability to lock the door and the presence of expired medications. Further observation revealed that a room identified as central supply on the lower level was also unlocked and contained numerous bottles of over-the-counter medications, including aspirin, acetaminophen, stool softeners, and vitamins. The LPN confirmed that these medications were stored in an unlocked room. The facility's policy on the storage of medications requires that drugs and biologicals be stored in locked compartments, which was not adhered to in these instances.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for personal hygiene. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, type II diabetes mellitus, anxiety, schizophrenia, and major depressive disorder, was observed with long fingernails that extended approximately three-fourth inches beyond the fingertip, with brown debris underneath. Despite the care plan indicating that the resident's nails should be trimmed weekly and as needed, there was no documentation of the resident refusing care, and the resident expressed a desire to have his nails trimmed. Interviews with staff, including the Director of Nursing, a State tested Nursing Assistant, and a Licensed Practical Nurse, confirmed that the resident did not refuse care and that his nails should be trimmed by a nurse due to his diabetic condition. However, observations over several days showed that the resident's nails remained untrimmed and dirty, indicating a failure to follow the care plan and provide necessary assistance with activities of daily living as per the facility's policy.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to act timely on pharmacy recommendations for two residents, leading to deficiencies in medication management. For Resident #32, the pharmacist recommended adding a maximum daily dose to the order for Rizatriptan Benzoate and specifying the amount for Diclofenac gel application. Additionally, there was a need to establish a pain scale for administering Meloxicam and Oxycodone. Despite these recommendations being agreed upon by the prescriber, the necessary changes were not reflected in the medication administration record (MAR) or physician orders over several months. This oversight was confirmed by a Regional Registered Nurse during an interview. For Resident #16, the pharmacist suggested discontinuing Ibuprofen for a trial period and replacing Benadryl with an alternative sleep aid. Although the physician initially agreed to these recommendations, the Ibuprofen was not discontinued, and Benadryl continued to be administered until months later. The physician's change of mind regarding Ibuprofen was not documented, and the delay in discontinuing Benadryl was acknowledged by the Regional Registered Nurse. These lapses in following through with pharmacy recommendations resulted in deficiencies in the facility's medication management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woods Edge Rehab And Nursing | 1.5 mi | ★★★★★ | 5 | 1 |
| Astoria Place Of Cincinnati | 1.6 mi | ★★★★★ | 13 | 0 |
| Garden Park Health Care Center | 1.6 mi | ★★★★★ | 28 | 0 |
| Harmony Court Rehab And Nursing | 1.9 mi | ★★★★★ | 13 | 1 |
| Beechwood Home For Incurables | 1.9 mi | ★★★★★ | 1 | 0 |
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