Above 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 Omni Manor Nursing Home during CMS and state inspections, most recent first.
A facility failed to complete Dementia and Behavioral Health Questions evaluations for five residents with diagnoses including dementia, Alzheimer's disease, TIA, CKD, dysphagia, and type II DM. Several residents also had orders for secure unit placement due to elopement risk, yet the required evaluations were never completed, and the CQA confirmed the omissions.
The facility failed to document oxygen safety measures and weekly tubing changes for three residents receiving O2. One resident had intact cognition and extensive ADL needs, another had moderate cognitive impairment and moderate ADL needs, and a third had hemiplegia after CVA with moderate to stand-by ADL assistance. Although each resident had an O2 order, the care plans lacked complete oxygen-related focuses or interventions, and the DON confirmed staff did not document when tubing was changed even though it was reportedly done weekly.
PPE for droplet isolation was not readily available outside a resident’s room. The resident, who had COPD, chronic respiratory failure with hypoxia, supplemental O2 dependence, and an infection/inflammatory reaction related to a knee prosthesis, was placed on droplet isolation for symptoms potentially related to COVID-19 while awaiting testing. Observation found isolation signage on the door but no PPE in the hallway, and the door was open. An LPN confirmed PPE was not available outside the room, and the IP stated PPE and isolation supplies should always be available and the door should remain closed.
Failure to report alleged misappropriation of a resident’s property. A resident with dementia had a missing necklace after the resident’s son accused staff of taking it, but the LSW and admin verified no SRI was filed with the State Agency. The necklace was not on the inventory log, the concern was handled verbally, and the facility’s records showed the inventory log was not kept current as family brought in additional items.
Failure to thoroughly investigate an allegation of misappropriation of a resident’s property. A resident with dementia had a reported missing necklace after the resident’s son accused staff of taking it. The LSW reviewed the inventory log, noted no jewelry was listed, and only had verbal discussions with aides; no investigation documentation was available. Observation also showed several personal items in the room that were not on the inventory log, and staff confirmed the log was not kept current.
PICC Dressing Change Order Not Followed: A resident with a PICC line and significant orthopedic and infectious diagnoses had a dressing that was not dated, and staff could not identify when it was last changed. An LPN confirmed the issue, and the QA nurse stated the dressing should have been changed per the physician’s weekly order and facility policy.
A resident with atrial fibrillation, DM, and dementia missed multiple scheduled doses of Rivaroxaban 15 mg at bedtime because the medication was unavailable or pending pharmacy delivery. The MAR and nursing notes documented the missed administrations, but there was no evidence the physician was notified, and the DON confirmed the medication was not given as ordered and the MD was not updated.
A resident who required continuous tube feeding via G-tube was discharged without a tube feed pump or adequate arrangements for feeding supplies. The discharge summary lacked instructions regarding the absence of the pump, and the resident and family reported difficulty receiving nutrition and nausea from bolus feeds after discharge. Staff interviews confirmed delays in providing necessary equipment and incomplete education on alternative feeding methods.
Nine residents with various medical conditions, including cognitive impairment and dietary needs, did not consistently receive meals according to their documented preferences, such as requests for or against bread, rolls, or gravy. Direct observation and interviews confirmed that meal preferences were not honored during meal service, despite facility policy requiring accommodation of such requests.
A resident with multiple medical conditions reported hitting his head on the ceiling of a facility van during transport over speed bumps. Although staff were informed and referenced an assessment in witness statements, there was no documented evidence in the medical record of an injury assessment or a completed investigation, contrary to facility policy.
The facility failed to maintain a clean and sanitary kitchen and did not properly label, date, and store food. Observations included dirty utensil storage, unlabeled chicken stock and gravy mix, an open and undated bag of crispy onions, a staff member's water bottle in the refrigerator, and a ceiling fan with debris buildup. These actions were contrary to the facility's policy on food, equipment, and utensil storage.
The facility failed to maintain a clean and sanitary refuse area, affecting all residents. Observations revealed debris around the kitchen's garbage exit, an uncovered grey cart with bagged garbage, and an overflowing large dumpster. The Dietary Supervisor confirmed these findings, stating the dumpster was often full. The Regional Administrator noted the dumpster is emptied five times weekly, excluding weekends, and confirmed lids should cover the grey carts when the dumpster is full.
The facility failed to follow the planned menu, affecting 15 residents who did not receive the scheduled dinner items. The facility ran out of sloppy joes and sweet potato waffle fries, leading to substitutions with peanut butter and jelly sandwiches for 12 residents. Interviews and Resident Council notes revealed ongoing dissatisfaction with meal service, highlighting issues with food management and planning.
The facility failed to serve food at a palatable temperature, affecting potentially 119 residents. Observations revealed that staff were not using bases for hot pellets, and they ran out of these for multiple residents. A test tray showed food temperatures not within safe service range, with sauerkraut at 127°F and milk at 55°F. Resident Council notes indicated ongoing issues with food temperature and quality.
The facility failed to ensure call lights were within reach for two residents, both at high risk for falls due to cognitive impairments and physical limitations. Observations revealed that one resident's call light was wrapped around a guard rail, and another's was on the floor, both inaccessible. This was confirmed by a housekeeper, and the facility's policy required call lights to be conveniently positioned for residents.
The facility failed to refund funds within 30 days for two residents after discharge. One resident had a balance of $1485.33, and another had $1790.93, both of which were not refunded as required. The facility's policy mandates the conveyance of funds within 30 days, but this was not followed.
The facility failed to provide the required 48-hour notice to three residents regarding the termination of their Medicare coverage for skilled services. For one resident, the notification letter was signed and dated by staff, making it impossible to verify the notification date. Another resident signed their letter just one day before services ended, and a third resident's letter was also dated by staff, preventing date verification. A bookkeeper confirmed the lack of proper notice.
The facility did not update the posted nursing staff information daily as required. Observations on two separate occasions revealed outdated staffing information, which was confirmed by the DON. This deficiency had the potential to affect all 121 residents.
A facility failed to complete ordered wound care for a resident with a skin tear on the back of the right hand. Despite physician orders for daily treatment, the treatment administration record showed no documentation of wound care on three specific dates. A nurse confirmed the lack of evidence for wound care completion, resulting in a noted deficiency.
The facility failed to document wound care as ordered for two residents, affecting their medical records' accuracy. Despite residents confirming that treatments were performed, the treatment administration records lacked documentation for specific dates, which was verified by a registered nurse. This indicates a failure to maintain accurate medical records.
Missing Dementia and Behavioral Health Evaluations for Five Residents
Penalty
Summary
The facility did not ensure that Dementia and Behavioral Health Questions evaluations were completed for Residents #7, #13, #22, #37, and #38. Record review showed Resident #7 was admitted with diagnoses of Alzheimer's disease, dementia, and other abnormalities of gait, and had a physician order for admission to the secure unit due to risk of elopement, but the dementia and behavioral health evaluation was never completed. Resident #13 was admitted with diagnoses of transient cerebral ischemic attack, dementia, and Alzheimer's disease, had a secure unit order due to risk of elopement, and also did not have the evaluation completed. Resident #37, admitted with hypertensive chronic kidney disease, dementia, and mild cognitive impairment, likewise had a secure unit order due to risk of elopement and no completed evaluation. Resident #22 was admitted with diagnoses of transient cerebral ischemic attack, dementia, and Alzheimer's disease with late onset, and the record showed the Dementia and Behavioral Health Questions evaluation was never completed. Resident #38 was admitted with other Alzheimer's disease, dysphagia, and type II diabetes, and also lacked the completed evaluation. The Licensed Social Worker stated she was to complete the Dementia & Behavioral Health Questions evaluation upon admission for all new residents and when time permitted for existing residents. Corporate Quality Assurance confirmed that the evaluations were not completed for these five residents.
Missing oxygen safety and tubing-change documentation
Penalty
Summary
The facility failed to document oxygen safety measures and weekly tubing changes in the orders or care plans for three residents who were receiving oxygen. Resident #54 had diagnoses including hyperlipidemia, hypertension, gastroesophageal reflux disease, and chronic pain syndrome, had intact cognition, and required extensive assistance with all activities of daily living. The physician order was for oxygen via nasal cannula at 2 liters per minute for oxygen level less than 92%, but the care plan had no focus or interventions related to oxygen use. Resident #100 had diagnoses including type 2 diabetes mellitus, a nondisplaced fracture of the head of the right radius, and malignant neoplasm of the prostate, had moderate cognitive impairment, and required moderate assistance with all activities of daily living. The physician order was for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, and the care plan only included providing oxygen as needed for shortness of breath without other oxygen-related focuses or interventions. Resident #123 had diagnoses including an intracapsular fracture of the left femur, hemiplegia and hemiparesis following cerebral infarction, alcohol abuse, and hypertension, and required moderate to stand-by assistance with all activities of daily living. The physician order was for oxygen at 2 liters per minute via nasal cannula every shift, while the baseline care plan only included providing oxygen at 2 liters continuous and did not include other oxygen-related focuses or interventions. Observation showed the oxygen tubing for Residents #54, #100, and #123 was dated 06/07/26. During interview, the Regional Clinical Supervisor and DON confirmed there were no orders or care plan focuses in the residents' charts for oxygen safety measures, and the DON stated staff did not document when oxygen tubing was changed, although it was completed every Sunday. The facility policy stated oxygen cannulas or masks should be changed weekly and as needed, and tubing should be kept off the floor.
PPE Not Available Outside Droplet Isolation Room
Penalty
Summary
The facility failed to ensure required PPE for droplet isolation precautions was readily available outside the room of Resident #93. Resident #93 was admitted with diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and chronic obstructive pulmonary disease with acute exacerbation. The admission MDS showed the resident was cognitively intact and required substantial to maximal assistance with activities of daily living. The resident was placed on droplet isolation precautions for symptoms potentially related to COVID-19 while awaiting diagnostic testing, with orders to continue isolation until negative results or symptom resolution. Observation showed droplet isolation signage posted on the resident’s room door, but no PPE was present or available in the hallway before room entry, even though the resident had been on droplet isolation for two days. The resident’s door was open at the time of observation. An LPN confirmed PPE was not available outside the room and stated the facility expectation was to keep a fully stocked PPE supply in a dresser or cart outside isolation rooms. The IP stated PPE and isolation supplies should always be available, doors should remain closed when a resident is under droplet isolation precautions, and PPE should be obtained and placed promptly when isolation orders begin. Facility policy required an isolation caddy, table, or cart containing a 24-hour supply of necessary PPE outside the resident’s room.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident’s personal property to the State Agency. Resident #80 was admitted with diagnoses of dementia and need for assistance with personal care. During a visit, the resident’s son accused staff of taking the resident’s gold necklace, and the licensed social worker documented that the necklace was not listed on the resident’s inventory log. The resident’s representative later stated the son had given the resident a necklace, but she had not seen it for a while and assumed he had taken it home. The administrator and licensed social worker both verified that the incident was discussed and that staff searched for the necklace, but no self-reported incident was filed with the State Agency. The administrator stated the necklace was not on the inventory log and that no investigation documentation could be provided. The licensed social worker also stated the concern was handled through verbal communication and that the facility’s concern log had no entry for the missing necklace. Observation of the resident’s room showed multiple personal items present that were not reflected on the inventory log, and staff confirmed the inventory log was not kept current as family members brought in items. The facility policy required alleged, suspected, or observed abuse, neglect, mistreatment, or misappropriation of a resident’s belongings to be reported immediately to the State Agency via an SRI.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident’s property. Resident #80 was admitted with diagnoses of dementia and need for assistance with personal care. After the resident’s son accused staff of taking a gold necklace, the licensed social worker reviewed the inventory log and noted that no jewelry was listed. The resident’s representative later stated the son had given the resident a necklace, but she doubted it was gold and believed it may have been taken home. The social worker documented that she updated the resident’s daughter and informed administration about the concern. The administrator stated the necklace was not listed on the inventory log and that staff discussed the allegation at morning meeting, but he was unable to provide documentation of an investigation. The licensed social worker stated she spoke verbally with aides on the unit and kept a concern log for missing items, but there were no entries related to the necklace. During observation, multiple personal items were found in the resident’s room that were not reflected on the inventory log, and staff confirmed the log was not kept current when families brought in items. The facility policy required alleged, suspected, or observed abuse, neglect, mistreatment, and belongings-related concerns to be thoroughly investigated by the Administrator and DON or designee.
PICC Dressing Change Order Not Followed
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #112’s weekly dressing changes for a PICC line. Resident #112 was admitted with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis, acute osteomyelitis of the left femur, methicillin-susceptible Staphylococcus aureus infection, and the presence of a left artificial hip joint. The physician’s order required the midline/PICC dressing to be changed within the first 24 hours after insertion and then weekly on Wednesdays and as needed. During observation, the resident’s PICC line dressing did not have a date showing when it was last changed. An LPN confirmed the dressing was not dated and could not identify when it had last been changed. The corporate QA nurse later confirmed the dressing was not dated correctly and stated it should have been changed on the scheduled weekly date according to the physician’s order. The facility policy for Midline/PICC/CVC catheter dressing changes also stated that dressings must be changed within 24 hours after insertion and then weekly or as needed if wet, soiled, or loose.
Missed Anticoagulant Doses Without Physician Notification
Penalty
Summary
The facility failed to ensure Resident #5 was free from significant medication errors when her prescribed Rivaroxaban 15 mg at bedtime was not administered on multiple occasions. Resident #5 was admitted on 01/14/22 with diagnoses including atrial fibrillation, diabetes mellitus, and dementia, and her care plan identified anticoagulant therapy with interventions to administer medications as ordered by the physician. Review of the MAR showed missed doses on 04/20/26, 04/23/26, 04/24/26, 04/25/26, and 04/26/26, with documentation directing staff to nursing progress notes for those administrations. The nursing progress notes documented that the medication was not given because it was not available, pending pharmacy delivery, or awaiting delivery from the pharmacy. The record contained no documented evidence that the physician was notified about the missed administrations. The DON confirmed in interview on 06/10/26 that Rivaroxaban was not administered as ordered and that the physician was not updated on the dates listed. The facility policy titled Medication Administration, revised March 2026, stated that if a resident's prescribed medication was unavailable for any reason, the attending physician must be notified for further instructions or orders.
Failure to Ensure Safe Discharge with Required Tube Feeding Equipment
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who required durable medical equipment, specifically a tube feed pump, upon leaving the facility. The resident had diagnoses including dysphagia, moderate protein-calorie malnutrition, and required continuous nutrition via a gastrostomy tube (G-tube) as ordered by the physician. The discharge summary did not include instructions regarding the absence of a tube feed pump or the need for bolus feeding until a pump was available. Documentation showed that the resident was educated on using the tube feed pump and administering medications via G-tube, but there was no evidence that education on bolus feeding was completed prior to discharge. The resident was discharged without the necessary tube feed pump, and the facility had not secured the required feeding supplies or arranged for home health services to provide them at the time of discharge. After discharge, the resident and family reported that the resident was unable to receive nutrition due to the lack of a pump and experienced nausea from bolus feeds. Facility staff continued to search for providers and feeding supplies after the resident had already left, and the resident's insurance eventually sent a month's supply of feeding. Interviews with staff confirmed that the resident was discharged without the pump and that there was a delay in obtaining all necessary equipment and supplies. The facility's policy required a written summary and verbal explanation of the resident's condition at discharge, but the documentation and actions taken did not ensure the resident's needs for continuous tube feeding were met at the time of discharge.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor residents' meal preferences as required, affecting nine out of ten residents reviewed for this issue. Record reviews showed that residents had documented dietary preferences, such as not receiving bread or rolls, requesting extra gravy, or wanting gravy on the side. Despite these documented preferences, observations during a lunch meal revealed that several residents did not receive meals according to their stated preferences. For example, some residents received bread or rolls when they should not have, did not receive extra gravy as requested, or received gravy when they had requested none or to have it on the side. These findings were confirmed by staff interviews at the time of meal service. Additionally, interviews with three residents indicated that meal preferences were not consistently honored, and review of the facility's policy confirmed that dietary preferences should be accommodated if requested. The affected residents had a range of medical conditions, including severe cognitive impairment, dementia, depression, diabetes, kidney disease, and dysphagia, with varying levels of assistance required for eating. The deficiency was identified during a complaint investigation and was supported by direct observation, record review, and staff and resident interviews.
Failure to Investigate and Document Resident Injury During Transportation
Penalty
Summary
The facility failed to ensure a thorough investigation and proper documentation following an incident in which a resident reported hitting his head on the ceiling of a facility van while being transported over speed bumps to a medical appointment. The resident, who had diagnoses including malnutrition, osteomyelitis, muscle weakness, arthritis, kidney disease, and diabetes, was cognitively intact and independent in daily activities. According to progress notes and staff interviews, the resident reported the incident to social services the day after it occurred, stating he had to bend to avoid hitting his head and that there was little space between his head and the van ceiling. Despite the report, there was no documented evidence in the medical record that the resident was assessed for injury after the incident, nor was there a completed investigation as required by facility policy. While witness statements from staff referenced the incident and mentioned a head-to-toe assessment and normal neurological checks, these assessments were not documented in the medical record. The facility's policy required documentation of accidents, resident assessments, and investigation summaries, but these steps were not followed in this case.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen area in a clean and sanitary manner, and did not ensure that all food was labeled, dated, and stored properly. During an initial kitchen tour, several deficiencies were observed and verified with the Dietary Supervisor. These included visible dirt and grease in a utensil storage drawer, an open and unlabeled container of chicken stock, and an open and unlabeled bag of country gravy mix. Additionally, a bag of crispy onions in the dry storage area was found open and undated. A staff member's opened bottle of water was also found in the standup refrigerator. Furthermore, a ceiling fan in the kitchen had a heavy buildup of black debris, which dispersed when the fan was turned on. The facility's policy required that food, equipment, and utensils be stored in a clean and dry location, and that all food be labeled and dated, which was not adhered to in these instances.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain its refuse area in a clean and sanitary condition, which had the potential to affect all residents. During an observation of the outside kitchen area, numerous items of debris, including Styrofoam cups and plastic wear, were found around the door where garbage was taken out of the kitchen. A grey cart with wheels containing bagged garbage was uncovered, despite the presence of lids in the area. Additionally, the large dumpster for garbage was overflowing with bagged garbage, preventing the lid from being closed. The Dietary Supervisor confirmed these findings during the observation. In an interview, the Dietary Supervisor explained that the garbage in the small grey bin was not taken to the large dumpster because it was overflowing, leaving no room for additional garbage. The Regional Administrator stated that the large garbage dumpster is emptied five times weekly, but not on weekends, and is picked up mid-morning on Mondays. The Regional Administrator also confirmed that lids for the grey garbage carts should be used to cover the carts when the large dumpster is full.
Failure to Follow Menu and Provide Planned Meals
Penalty
Summary
The facility failed to adhere to the planned menu, affecting 15 out of 119 residents who received meals from the kitchen. On the evening of July 30, 2024, the dinner menu included sloppy joes, sweet potato waffle fries, and corn, with an alternative option of a hot ham and cheese sandwich with mashed potatoes. However, the facility ran out of sloppy joes and sweet potato waffle fries, resulting in 16 residents not receiving the planned meal. Four residents received the alternative meal, while the remaining 12 were given peanut butter and jelly sandwiches. This substitution was confirmed by the Food Service Director and the Registered Dietitian, who acknowledged the miscalculation of food quantities. Residents affected by this deficiency had various medical conditions, including dementia, diabetes, multiple sclerosis, and chronic obstructive pulmonary disorder, among others. Interviews with residents revealed dissatisfaction with the meal service, with reports of not receiving the menu items regularly and receiving cold food. The Resident Council notes from August 2023 to July 2024 also documented complaints about the food not matching the menu. The facility's failure to provide the planned meals as per the menu indicates a lack of proper food management and planning, impacting the nutritional needs and satisfaction of the residents.
Food Temperature Deficiency
Penalty
Summary
The facility failed to provide food at a palatable temperature, affecting potentially 119 residents, as observed during the annual survey. Interviews with several residents revealed concerns about the food often being served cold. During the trayline observation, it was noted that staff were not using bases for hot pellets until questioned by the surveyor. The Food Service Manager admitted to not using them, and it was observed that they ran out of bases and hot pellets for multiple residents across different units. Further observations during a test tray delivery showed that the food temperatures were not within the safe service range. The sauerkraut was measured at 127 degrees Fahrenheit, and the milk was at 55 degrees Fahrenheit, both verified by the Registered Dietitian and Corporate RD. The Resident Council notes from the past year also indicated ongoing issues with food being cold, inconsistent, and not matching the menu. The facility's policies require cold foods to be at 41 degrees Fahrenheit or below and hot foods to be at least 140 degrees Fahrenheit, which were not adhered to, leading to this deficiency.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which was identified during an observation. Resident #45, who has diagnoses including dementia, depression, COPD, and coronary artery disease, was found to have her call light wrapped around a plastic guard rail approximately 8 inches from the floor, making it inaccessible. Her care plan indicated she was at risk for falls due to poor safety awareness and Alzheimer's, with interventions including ensuring the call light was within reach. This deficiency was confirmed by a housekeeper during the observation. Similarly, Resident #53, who has Alzheimer's, muscle weakness, anemia, depression, and difficulty swallowing, was observed with her call light on the floor next to her bed, out of reach. Her care plan also highlighted a high risk for falls due to weakness and poor safety awareness, with interventions to ensure the call light was accessible. The facility's policy on call light use, dated March 2024, stated that call lights should be positioned conveniently for residents, which was not adhered to in these cases.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to refund resident funds within 30 days of discharge, affecting two residents. Resident #373 was admitted and later discharged, with a balance of $1485.33 remaining in their account. The resident had authorized the facility to hold and manage their personal funds, as confirmed by a document signed by the resident's son. Upon review, the bookkeeper verified that the funds were not refunded within the required timeframe, and the account remained active. Similarly, Resident #374 was admitted and discharged, with a balance of $1790.93 still in their account. The resident had also authorized the facility to manage their personal funds, as indicated by a document signed by the resident's daughter. The bookkeeper confirmed that these funds were not refunded within 30 days of discharge, and the account was still active. The facility's policy requires the conveyance of funds within 30 days upon a resident's death, but this was not adhered to in these cases.
Failure to Provide 48-Hour Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide residents with the required 48-hour notice regarding the termination of their Medicare coverage for skilled services. This deficiency affected three residents. For Resident #97, the Notice of Medicare Non-Coverage letter indicated that services ended on March 13, 2024, but the notification letter was signed by the resident and dated by facility staff, making it impossible to verify the accurate date of notification. Resident #107 signed their notification letter on July 24, 2024, which did not allow for the required 48-hour notice before services ended on July 25, 2024. Similarly, for Resident #122, the notification letter was signed by the resident but dated by facility staff, again preventing verification of the notification date. An interview with Bookkeeper #124 confirmed that the letters did not provide the necessary 48-hour notice of non-coverage.
Failure to Update Nursing Staff Information Daily
Penalty
Summary
The facility failed to ensure that the posted nursing staff information was updated daily, as required. On July 29, 2024, at 7:52 A.M., an observation revealed that the posted nursing staff information was dated July 26, 2024. This was confirmed during an interview with the Director of Nursing (DON) at 9:34 A.M. on the same day. Furthermore, on July 31, 2024, at 8:20 A.M., another observation showed that the posted staffing information was dated July 30, 2024, which was again confirmed by the DON during an interview at 9:33 A.M. This deficiency had the potential to affect all 121 residents in the facility.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to ensure that wound care was completed as ordered for a resident diagnosed with antineutrophilic cytoplasmic antibody vasculitis, calculus of the kidney, and an abnormal electrocardiogram. The resident's care plan included interventions for medication and treatment administration as ordered. The resident's Quarterly Minimum Data Set indicated intact cognition and the presence of skin tears, specifically a skin tear on the back of the right hand. Physician orders required daily wound care, including cleansing the area, applying betadine and Cuticerin, and covering with an ABD and kerlix until resolved. However, the treatment administration record for October 2023 showed no documentation of wound care on three specific dates. A registered nurse confirmed the lack of evidence for wound care completion on those dates, leading to the deficiency being noted under Complaint Number OH00153046.
Failure to Document Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that wound care was documented as ordered for two residents, affecting their medical records' accuracy. Resident #61, who has multiple diagnoses including congestive heart failure and chronic kidney disease, had physician orders for wound care on the sacrum that were not documented as completed on several dates across February, March, April, and May 2024. Despite the resident's report that wound care was performed daily, the treatment administration record (TAR) lacked documentation for specific dates, which was confirmed by a registered nurse. Similarly, Resident #101, with diagnoses including pressure ulcer and dementia, had physician orders for sacral wound care that were not documented on several dates in March, April, and May 2024. The resident confirmed that treatments were completed as scheduled, but the TAR did not reflect this, as verified by the same registered nurse. The lack of documentation for both residents indicates a failure to maintain accurate medical records in accordance with professional standards.
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What surveyors actually found near you
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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 Youngstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Austintown Healthcare Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Windsor Health Care Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Heritage Manor Jewish Hm For | 2.7 mi | ★★★★★ | 2 | 0 |
| Park Vista Nursing And Rehab | 3 mi | ★★★★★ | 4 | 0 |
| Briarfield At Ashley Circle | 3.1 mi | ★★★★★ | 0 | 0 |
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