Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Ohio Living Sarah Moore during CMS and state inspections, most recent first.
The facility failed to maintain a sanitary kitchen. Surveyors observed brown spots and calcium buildup in the ice machine, dirt behind the soda machine, a black substance appearing to be mold behind the dishwasher area and by the soda dispenser, and dust buildup with a black substance over the food heater on the ceiling. A staff member confirmed the findings, and the Dietary Manager stated there were no cleaning schedule logs at that time.
Care plan not updated for a resident with dementia-related behaviors. The resident had confusion, looked for her deceased husband, and later had an outburst during a movie when she grabbed another resident she believed was her boyfriend. The MDS showed moderate cognitive impairment, but the care plan had no behavior plan in place, and an RN confirmed this during interview.
A resident with intact cognition and multiple chronic conditions, including OA, CHF, COPD, and impaired vision, was ordered to receive showers twice weekly and required supervision/touching assistance. Shower documentation showed missed scheduled baths/showers and only partial completion of the ordered routine, with the resident stating she was not receiving showers as scheduled. The DON confirmed only three showers were documented for one month and no additional records supported the missing care.
Failure to provide timely personal hygiene assistance: A resident with hemiplegia, muscle weakness, and moderate cognitive impairment required maximum staff help with ADLs, including shaving and other hygiene tasks, but was observed with visible chin hair on multiple occasions. Shower documentation showed the resident had not been shaved on several shower days, and staff confirmed the facial hair remained present despite expectations that it be removed when noticed or during shower care.
A resident admitted with a stage II coccyx pressure ulcer had a Braden score indicating skin risk, and the care plan included pressure relief measures and wound care. However, the wound treatment order was not entered when the ulcer was first assessed, and the MAR/TAR did not show documented zinc barrier cream treatments after incontinence care until the order was later placed; the DON confirmed the missing order and lack of evidence that daily treatments were completed.
Incomplete post-fall assessment after head injury: A resident with severe cognitive impairment and multiple fall-risk diagnoses was found on the floor after an unwitnessed fall. The RN documented that the resident denied hitting his head and noted only a skin tear, but did not identify a scalp hematoma or start neuro checks as required by policy when head impact is evident or the fall is unwitnessed. A PA later documented scalp swelling/contusion and that the resident was on anticoagulants, with later notes describing headaches and head/neck pain.
Medication administration errors exceeded the allowed rate, with 3 errors in 33 opportunities. An RN crushed an ER metoprolol tablet for a resident with dementia and HTN despite no order to crush it, another RN crushed a DR pantoprazole tablet for a resident with GERD, and an RN administered Tresiba insulin without priming the pen for a resident with DM and neuropathy. Manufacturer instructions and facility policy stated the medications should not be crushed and the insulin pen should be primed.
Insulin Pen Not Primed Before Administration: A resident with type II DM and diabetic neuropathy received a scheduled dose of Tresiba U-200 without the pen being primed first. An RN observed administering the insulin and later confirmed the pen had not been primed. The manufacturer IFU and facility policy both required priming the pen before use.
An LPN failed to use EBP PPE and proper signage during ostomy care for a resident with an ileostomy and suprapubic catheter, and also did not use sterile technique or keep the catheter bag in a sanitary position during catheter flushing. In a separate event, an RN did not perform hand hygiene after a blood glucose check before handling the glucometer, computer, and insulin pen for another resident.
Failure to monitor antibiotic use and apply antibiotic stewardship criteria affected three residents. One resident remained on chronic Macrobid prophylaxis for a history of UTIs without available urology notes to support the ongoing order, another resident with a suprapubic catheter received Macrobid despite an infection tracker showing no McGeer criteria met, and a third resident was continued on cephalexin after a hospital discharge even though the DON confirmed the UA did not support a UTI and the antibiotic was unnecessary.
Improperly contained trash and recycling were observed in the dumpster area. Multiple unbroken cardboard boxes and about 20 wet boxes were left on the ground near the dumpsters, with some blown across the parking lot and against the fence. Trash, including latex gloves and unknown debris, had also accumulated near the air conditioning units. The Administrator stated the facility did not have a recycling dumpster and staff had been placing boxes on the ground outside the dumpster area.
The facility failed to follow proper handwashing and glove use protocols during lunch meal service. Cook #273 was observed handling food items and meal tickets with the same pair of gloves, without washing hands before donning new gloves. These actions were confirmed by the Director of Dietary Services and the Dietary Supervisor, who acknowledged that proper hand hygiene was not followed.
The facility failed to prepare pureed and mechanical soft foods to the appropriate consistency, affecting residents with specific dietary needs. Observations and staff interviews confirmed that the zucchini casserole contained chunks of food, which was not suitable for residents on pureed and mechanical soft diets.
The facility failed to follow infection control protocols for a resident with C. diff. A State tested Nursing Aide (STNA) did not perform hand hygiene or wear appropriate PPE while providing care. Interviews revealed staff were unaware of proper procedures, despite the resident's care plan specifying infection control measures. This deficiency had the potential to affect multiple residents.
A resident with multiple diagnoses, including dysphagia and protein-calorie malnutrition, did not receive her physician-ordered fortified ice cream nutritional supplement 18 times over a period of one and a half months due to unavailability. The kitchen substituted the supplement with other items but failed to notify the nursing staff, leading to a lack of proper documentation and communication.
Unsanitary Kitchen Conditions and Missing Cleaning Logs
Penalty
Summary
The facility failed to maintain a sanitary kitchen. During an initial tour of the kitchen, surveyors observed the ice machine with brown spots and calcium buildup inside and above the ice, dirt buildup behind the soda machine, a black substance that appeared to be mold behind the dishwasher area and by the soda dispenser, and dust buildup with a black substance over the food heater on the ceiling. A staff member confirmed these observations during interview. The Dietary Manager stated that there were no logs of cleaning schedules at that time and said he was starting a new cleaning schedule. Review of the facility policy titled General Sanitation of Kitchen showed that food and nutrition services staff were required to maintain kitchen sanitation through a written, comprehensive cleaning schedule with assigned tasks, defined frequencies, written cleaning and sanitizing methods, and staff initials and dates documenting completion.
Care Plan Not Updated for Resident With New Behaviors
Penalty
Summary
The facility failed to ensure Resident #20’s care plan was updated when she began to exhibit behaviors. Resident #20 was admitted with diagnoses including vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly care conference note documented that she had moments of confusion, looked for her deceased husband, and thought other residents were her husband, but was easily redirected. A later progress note documented a behavior outburst during an afternoon movie, when Resident #20 became upset and grabbed another resident whom she stated was her boyfriend. Review of the MDS 3.0 assessment showed moderate cognitive impairment and no behavioral symptoms directed toward others or not directed toward others during the review period. Review of the care plan showed no behavior care plan in place for Resident #20, and RN #106 confirmed this during interview. The facility policy stated the comprehensive care plan should include measurable objectives and time frames for behavioral health care and services.
Failure to Provide Ordered Bathing and Maintain ADLs
Penalty
Summary
The facility failed to ensure a resident received bathing as ordered and to maintain ADLs. Resident #1 was admitted with diagnoses including bilateral primary osteoarthritis of the knee, chronic diastolic CHF, COPD, and bilateral nonexudative age-related macular degeneration. The resident’s MDS showed intact cognition and that she required supervision or touching assistance with showering/bathing. The physician ordered baths/showers two times per week, on Wednesday and Saturday, and the ADL care plan identified the resident as having potential functional status deficits related to deconditioning, weakness, pain, impaired vision, hearing difficulty, and chronic pain, with staff support and supervision/touching assistance for showers/baths. Review of shower sheets from January and February 2026 showed the resident received only some of the ordered showers and missed multiple scheduled shower days. The record documented refusals on two occasions, but the shower sheets did not show that the resident refused personal hygiene on the days she accepted a shower, and there was no documentation supporting that she received showers on several ordered dates. The resident stated she was not receiving showers twice a week per schedule. The DON confirmed the resident received only three baths/showers in February 2026 and that there were no additional documents to support further showers. The facility policy stated residents are to be assisted to the extent necessary for completion of ADLs on a daily basis and as needed.
Failure to Provide Timely Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure Resident #14, who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene, including removal of facial hair. Resident #14 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, cerebral infarction, muscle weakness, and COPD. The admission MDS showed moderate cognitive impairment, and the care plan identified a need for maximum staff assistance with personal hygiene tasks such as combing hair, shaving, applying makeup, and washing and drying the face and hands. Review of shower sheets showed Resident #14 had not been shaved on multiple documented shower dates, and there were no shower sheets available for several days afterward. During observations, Resident #14 was seen sitting in a wheelchair with multiple white facial hairs on the chin, and the resident stated she would not have chin hair if at home. The spouse stated the resident typically removed the chin hair herself when able. CNA #200 confirmed the facial hair was present, and LPN #112 stated facial hair on women should be trimmed or shaved if the resident allows and completed on shower days and as needed. The DON stated facial hair on females should be cleaned up unless the resident refuses or it is resident preference, and that it should be removed when noticed even if it is not a shower day. The facility policy stated residents would be assisted to the extent necessary for completion of ADLs on a daily basis and as needed.
Delayed Treatment of Stage II Coccyx Pressure Ulcer
Penalty
Summary
Failure to provide timely wound treatment for a resident with a stage II pressure ulcer on the coccyx was identified. The resident was admitted with diagnoses including fracture of the right pubis, osteoporosis, fracture of the sacrum, and a stage II pressure ulcer of the sacral region. The admission care plan identified an ulcer on the coccyx and included pressure-reducing devices, surgical wound care, and a turning and repositioning program. The resident’s Braden Scale score was 15, indicating risk for skin impairment, and the physician noted the resident should be offloaded and receive daily zinc barrier cream. The record showed that from admission until the physician order was entered, there was no order to treat the stage II pressure ulcer. The physician order for cleansing and applying zinc barrier cream after each incontinence care every shift was not entered until later, and the medication and treatment records showed no documented treatments were provided during the earlier period, except for one date noted by the DON. The skin assessment later documented the wound as improving, but the DON confirmed the order had not been placed when the wound was initially assessed and that evidence of daily skin treatments from the earlier period could not be provided.
Incomplete post-fall assessment after head injury
Penalty
Summary
The facility failed to complete a thorough post-fall investigation for a resident who fell and was found on the floor next to the bed. The resident had multiple diagnoses including spinal stenosis, moderate dementia with agitation, chronic systolic heart failure, chronic atrial fibrillation, COPD, and bilateral age-related macular degeneration, and was identified in the care plan as a high fall risk due to advanced age, vertigo, atrial fibrillation, CHF, spinal stenosis, incontinence, high fall-risk medications, visual and auditory impairments, moderate cognitive impairment, and need for assistance with mobility and transfers. The Minimum Data Set reflected severe cognitive impairment. The fall investigation documented that the resident was unable to explain how he ended up on the floor and that he denied hitting his head, with a skin tear to the right elbow noted. However, the investigation did not identify a hematoma on the scalp and did not initiate neurological checks, despite the facility policy requiring a physical assessment, physician and responsible party notification, and neurological checks when there is evidence of head impact such as a bump, redness, or hematoma, or when the fall is unwitnessed. A PA later documented scalp hematoma, right posterior scalp swelling and tenderness, and that the resident was on Plavix and Eliquis; subsequent notes also referenced headaches and head and neck pain after the fall.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. Based on 3 medication errors out of 33 opportunities, the medication error rate was 9.09 percent, affecting three residents observed during medication administration. The cited errors involved crushing medications that were ordered not to be crushed and failing to prime an insulin pen before administration. Resident #24 had diagnoses including dementia and essential hypertension and was assessed as having severe cognitive impairment. The resident had an order for Metoprolol Succinate extended-release 25 mg, to administer 12.5 mg, with no order allowing the medication to be crushed. During observation, an RN removed the medication from the cart, stated the resident took pills crushed, and crushed the Metoprolol Succinate extended-release tablet into applesauce before administering it. The RN later confirmed the tablet had been crushed. The medication label stated the tablet should not be crushed or chewed. Resident #11 had GERD without esophagitis and an order for Pantoprazole delayed-release 20 mg once daily, with no order to crush it. During medication administration, an RN crushed all medications except Mucinex DM and gave the crushed Pantoprazole in applesauce; the RN confirmed this action. Resident #29 had type II diabetes with diabetic neuropathy and orders for Tresiba FlexTouch U-200 insulin and insulin lispro. During observation, an RN administered Tresiba without priming the pen, and the RN confirmed the pen had not been primed. The manufacturer instructions and facility policy both stated the insulin pen must be primed before use.
Insulin Pen Not Primed Before Administration
Penalty
Summary
Ensure that residents were free from significant medication errors was not met when Resident #29’s Tresiba Flextouch U-200 insulin pen was administered without being primed. Resident #29 was admitted on 03/10/26 and had diagnoses including type II diabetes with diabetic neuropathy. The physician orders included Tresiba Flextouch U-200 insulin pen, 20 units subcutaneously once daily early morning, and insulin lispro pen per sliding scale. The care plan identified the resident as at risk for complications related to diabetes mellitus with neuropathy and directed staff to administer medications as ordered. During observation on 03/19/26 at 7:25 A.M., RN #116 administered 20 units of Tresiba to Resident #29’s left arm without priming the pen first. In interview immediately afterward, RN #116 confirmed the pen had not been primed. Review of the manufacturer’s Quick Start Guide and Instructions for Use for Tresiba U-100 and U-200 FlexTouch pens stated the pen should be primed by selecting two units, pressing and holding the dose button until the dose counter shows zero, and ensuring a drop appears. The facility policy on Subcutaneous Insulin also stated that after attaching a new needle, the insulin pen must be primed.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during care for Resident #8, who had intact cognition, an ileostomy, and a suprapubic catheter related to obstructive reflux uropathy and urinary retention. The care plan and physician orders called for enhanced barrier precautions for the suprapubic catheter and routine ostomy care. During an observation, an LPN changed the resident’s ileostomy bag without wearing a gown. There was no enhanced barrier precaution signage on the resident’s door, and PPE was not available at the room entrance; instead, the PPE was located in the resident’s bathroom. The LPN confirmed she did not wear a gown and verified the signage and PPE placement were not visible to staff or visitors. The facility also failed to use sterile technique during suprapubic catheter care for Resident #8. During an observation, an LPN prepared a syringe and flushed the suprapubic catheter without using sterile technique. The resident’s catheter bag was observed hanging on the edge of a trash can and above the bladder. The LPN confirmed the bag’s placement and stated she did not use sterile gloves, a sterile towel, sterile antiseptic, eye protection, or a gown during the procedure. The DON stated the flushes were a clean procedure, then acknowledged learning during the survey that the flush was a sterile procedure. The facility policy for suprapubic catheter care stated that a nurse specially trained in sterile technique and suprapubic catheter care can perform the procedure. The facility further failed to perform hand hygiene after a blood glucose check for Resident #29. An RN performed a blood glucose check, removed gloves, left the room, placed the used glucometer on the medication cart, used the computer, and then obtained the resident’s insulin pen without performing hand hygiene. The RN confirmed she did not perform hand hygiene after the blood sugar check. The facility’s hand hygiene policy required hand hygiene after removing gloves, and the glucometer cleaning policy required hand hygiene immediately after glove removal and before touching other medical supplies intended for use on other persons.
Failure to Monitor and Validate Antibiotic Use
Penalty
Summary
The facility failed to follow its antibiotic stewardship program to monitor antibiotic use for three residents reviewed. The report states that the facility did not appropriately evaluate whether antibiotic therapy met McGeer criteria or whether continued antibiotic use remained justified, and that staff relied on existing orders without confirming the clinical basis for treatment. The facility census was 42, and the deficiency affected three of three residents reviewed for antibiotic stewardship. Resident #19 had diagnoses including hydrocephalus and a cerebrospinal fluid drainage device, with no cognitive impairment noted on the MDS. The care plan focused on prophylactic antibiotics related to a history of UTIs, and a physician order dated 11/02/24 showed Macrobid 100 mg daily. Pharmacy recommendations later questioned continued prophylactic use beyond six months and asked for discontinuation, but the physician response stated that urology followed and no change was advised. The DON later stated she could not locate any urology notes and that the resident and spouse reported no urology visit in at least two years; the DON also stated the resident’s last UTI was when she admitted to the facility in 09/2024. Resident #25 had diagnoses including UTI, obstructive and reflux uropathy, BPH with lower UTI, and a suprapubic catheter, and the MDS showed severe cognitive impairment and need for staff assistance with toileting hygiene. After a UA and culture were obtained, the final urine results showed mixed organisms, and Macrobid was ordered for seven days. The infection tracker for the event showed no McGeer criteria checked, and the DON stated the resident did not meet McGeer criteria based on the catheter-change timing. Resident #23 had a chronic indwelling catheter and was receiving an antibiotic on the MDS. Hospital records showed hematuria and an acute UTI diagnosis, and cephalexin was ordered at discharge; however, the facility infection report documented that the resident did not exhibit the required clinical signs for a UTI, and the DON confirmed the hospital urinalysis did not indicate a UTI and that the antibiotic ordered at discharge was unnecessary. The DON also stated she typically continued hospital-ordered antibiotics without confirming whether they were appropriately ordered.
Improperly Contained Trash and Recycling in Dumpster Area
Penalty
Summary
The facility failed to ensure trash and recycling were properly contained in the dumpster area. During observation of the dumpster area, multiple unbroken cardboard boxes were seen scattered around the air conditioning units, and approximately 20 wet boxes that had not been broken down were sitting on the ground next to the dumpster area. Wind had spread some of the boxes across the parking lot, and several were positioned against the chain link fence in the parking lot area. Trash had also accumulated near the air conditioning units on the opposite side of the stairs from the dumpsters, including latex gloves and multiple pieces of unknown debris. A staff member confirmed the observations of unbroken cardboard boxes and trash accumulation, and the Administrator stated the facility did not have a recycling dumpster at that time and that staff had been placing boxes on the ground outside the dumpster area.
Improper Handwashing and Glove Use During Meal Service
Penalty
Summary
The facility failed to follow proper handwashing and glove use protocols during lunch meal service, as observed on 04/17/24. Cook #273 was seen handling food items and meal tickets with the same pair of gloves, without washing hands before donning new gloves. Specifically, Cook #273 lifted a metal lid, unwrapped tin foil from a baked sweet potato, and touched peas while plating them, all without changing gloves or washing hands in between tasks. Additionally, the cook handled a towel and then a resident's cheeseburger with the same gloves on. These actions were confirmed by the Director of Dietary Services (DDS) and the Dietary Supervisor (DS), who acknowledged that proper hand hygiene was not followed. The facility's policy on disposable gloves mandates that gloves should be used for only one task and discarded when soiled or when interruptions occur. Hand washing is required before putting on gloves and whenever gloves are changed or removed. The DDS confirmed that Cook #273 did not adhere to these guidelines, as she did not wash her hands before donning clean gloves and after removing gloves. The DDS also stated that the cook should not have touched any food items directly, even with gloves on.
Improper Preparation of Pureed and Mechanical Soft Foods
Penalty
Summary
The facility failed to ensure that pureed and mechanical soft foods were prepared in an appropriate consistency for residents with specific dietary needs. During the lunch meal preparation on 04/17/24, the regular food processor was broken, and Cook #273 used a small blender to puree the zucchini casserole. Despite following the recipe, the pureed casserole contained visible chunks of zucchini and chicken, which was confirmed by both the surveyor and Cook #273. This affected three residents on a pureed diet, as the food was not completely smooth as required by their dietary orders. Additionally, the facility did not prepare the zucchini casserole to the appropriate texture for residents on a mechanical soft diet. Observations revealed that the casserole served to two residents contained chunks of chicken and zucchini, which led to one resident coughing after taking a bite. Interviews with staff, including the Speech Language Pathologist and the Director of Dietary Services, confirmed that the casserole was not prepared according to the mechanical soft diet requirements. The facility's policy on mechanically altered diets was not followed, resulting in the improper preparation of meals for residents with specific dietary needs.
Infection Control Protocols Not Followed
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control protocols during the care of a resident diagnosed with Clostridioides difficile (C. diff). Specifically, a State tested Nursing Aide (STNA) entered the resident's room without performing hand hygiene or donning a gown, and later exited the room without wearing any personal protective equipment (PPE). The STNA then disposed of dirty linens and trash without following proper hand hygiene protocols. Interviews with the STNA and other staff members revealed a lack of understanding and adherence to the required PPE and hand hygiene procedures for residents under contact precautions. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the resident was on contact precautions and identified the necessary PPE, but the staff did not consistently follow these protocols. The resident in question had been diagnosed with C. diff and required moderate to complete assistance from staff for activities of daily living. The resident's care plan included specific interventions for infection control, such as using gloves and gowns, practicing good handwashing, and using soap and water for hand hygiene. Despite these guidelines, the facility's staff failed to comply with the established infection control policies, as evidenced by the observations and staff interviews. This deficiency had the potential to affect multiple residents on the second-floor rehab unit and healthcare two, as the STNA was assigned to provide care to numerous residents on the day of the observation.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident with her physician-ordered nutritional supplements routinely. Resident #30, who had diagnoses including dysphagia, chronic obstructive pulmonary disease, Alzheimer's disease, and protein-calorie malnutrition, was supposed to receive a fortified ice cream nutritional supplement with lunch and dinner twice a day. However, the supplement was not administered 13 times in March 2024 and 5 times in the first half of April 2024 due to the item being unavailable. The facility's Medication Administration Record (MAR) indicated these instances, but there were no progress notes related to the missing supplements during this period. Interviews with the diet technician and the Director of Nutrition Services revealed that the kitchen had run out of the fortified ice cream nutritional supplement at times and substituted it with ice cream, yogurt, or pudding depending on the diet texture. However, the kitchen did not consistently notify the nursing staff about these substitutions. The Director of Nursing confirmed that there was no documentation in Resident #30's medical record to indicate whether a substitute was provided or if the resident received nothing. This lack of communication and documentation led to the deficiency in providing the necessary nutritional supplements to the resident as ordered by the physician.
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Illustrative
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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.
Illustrative
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Illustrative
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Nursing homes near Delaware
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Club Center V, Inc | 1.1 mi | ★★★★★ | 12 | 0 |
| Delaware Court Health Care Center | 1.6 mi | ★★★★★ | 18 | 0 |
| Cherith Care Center At Willow Brook | 2.1 mi | ★★★★★ | 0 | 0 |
| Arbors At Delaware | 2.7 mi | ★★★★★ | 35 | 0 |
| Capri Gardens | 8 mi | ★★★★★ | 8 | 0 |
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