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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Otterbein Gahanna during CMS and state inspections, most recent first.
A resident with CVA sequelae, hemiplegia, DM2, MDD, and COPD repeatedly had another resident enter her room despite her clear objections. Staff and observations showed the other resident was found in her room multiple times, including late at night, and the resident said he would open the door and come in even when it was closed. Although a door sign had been used to deter entry, staff reported the behavior continued for weeks and occurred on most days.
Failure to provide routine hair care for a cognitively intact resident who was dependent for ADLs, including bathing and personal hygiene. The resident repeatedly reported matted, unwashed hair, and staff observed her hair to be uncombed and sticking up. A CNA and coach confirmed the hair should have been washed during the resident’s bed bath, but the shower sheet did not document hair care and the facility’s bath/shower tracking tools had no place to record it.
A resident with severe cognitive impairment, diabetes, CKD, malnutrition, and pressure-related skin issues did not receive skin integrity interventions as ordered: wound dressings were dated earlier than expected and ordered geri-sleeves were not in place during observation. Another resident with CKD, diabetes, depression, and neuropathy had a hospital discharge instruction for nephrology follow-up within one month, but the record did not show a nephrology appointment and the DON could not locate one.
A resident with severe cognitive impairment, diabetes, CKD, malnutrition, incontinence, and multiple pressure ulcers had an unstageable right knee wound with an order for daily calcium alginate with silver and foam dressing changes. The TAR showed missed treatments on four consecutive days, and the wound later increased in size; the wound nurse and regional nurse confirmed the missed documentation, and the wound NP acknowledged the gap in recorded wound care.
Failure to provide appropriate foot care for a resident with DM and other chronic conditions. The resident had intact cognition, required ADL assistance, and reported not having toenails trimmed for about a year; observation showed both great toenails extended about 1/2 inch past the toes. The SW confirmed podiatry had not occurred because a release from the son was not obtained, and the resident later reported broken toenails causing discomfort and scratching, while an LPN confirmed the nails were long and noted facility policy required a provider to cut them due to DM.
Missed and delayed medication administration affected two residents. One resident with diabetes was readmitted with an order for routine insulin, but the dose was held pending clarification and was not given routinely for several days while blood glucose readings remained elevated. Another resident with AFib had repeated missed Eliquis doses on the MAR. The DON confirmed the insulin was not routinely administered until later and could not explain the missed anticoagulant doses.
The facility failed to consistently prevent staff from serving allergen-containing foods to two residents with known food allergies/intolerances. One resident with a strawberry allergy was served strawberry ice cream and later strawberry-flavored juice, resulting in allergic reactions that required EMS and ED treatment. Another resident with lactose intolerance was observed being served menu items containing cheese, and the facility’s dining procedures and staff training did not include a clear process for checking allergies during meal prep or service.
A resident with ESRD, DM2, morbid obesity, and a below-knee amputation had a weekly skin assessment documented as completed even though the resident was at dialysis at the recorded time, and the assessment omitted skin areas noted in surrounding weeks. The facility also lacked documentation for a reported transport-related foot injury, including progress notes, skin checks, an incident report, and investigation details, despite an order for a foot x-ray and later reports of swelling and bruising.
Failure to Use PPE During Enhanced Barrier Precautions: A resident with a chronic foot wound, cognitive impairment, incontinence, and dependence for toileting and transfers was on enhanced barrier precautions. Two CNAs entered the room and provided toileting and pivot-transfer care without gloves or a gown, despite posted CDC signage and confirmation that PPE was required before direct care.
Two residents experienced deficiencies when staff failed to notify the physician and/or registered dietician after one resident did not receive ordered enteral nutrition and another had a significant, rapid weight loss. In both cases, required notifications and documentation were not completed as per facility policy, and these failures were confirmed through record review and staff interviews.
Two residents with pressure ulcer risk or history did not receive comprehensive and individualized care, including timely documentation, prompt treatment, and proper use of low air loss mattresses. One resident did not receive a recommended mattress, while another experienced delays in wound care and had a malfunctioning mattress set to the wrong weight, contrary to facility policy requirements.
Two residents did not receive appropriate nutrition and hydration monitoring as required. One resident, dependent on enteral nutrition, had a missed administration of tube feeding with no documentation or notification to the physician or RD, and staff provided conflicting accounts about whether the feeding was given. Another resident, identified as at risk for malnutrition, was not weighed weekly as ordered, with no documentation of weights after admission. Facility policies for enteral feeding and weight monitoring were not followed.
A resident with multiple chronic conditions received Dilaudid and other medications without proper documentation of pain or use of non-pharmacological interventions, as required by orders and policy. Medication records were inconsistent, and Dilaudid was administered even when the resident had no reported pain. The resident developed altered mental status and was hospitalized, where opioid toxicity and polypharmacy were identified as likely causes.
A resident with multiple chronic conditions had abnormal laboratory results, including elevated BUN and low hemoglobin, following orders for a CBC and BMP to assess causes of weakness. Despite documentation instructing nursing staff to notify the physician or CNP, interviews confirmed that neither were informed of the lab results.
The facility failed to maintain a clean kitchen environment, with observations revealing dirty cabinets, splattered substances, and grime on various surfaces across multiple houses. Staff interviews confirmed the unsatisfactory conditions, citing prioritization of resident care over cleaning due to time constraints and lack of housekeeping support. The Director of Nursing acknowledged the issue, indicating non-compliance with cleanliness standards.
A facility failed to prime insulin pens before administering insulin, affecting a resident with diabetes. During medication administration, an RN did not perform the required priming of the insulin pen, which was confirmed during an interview. Facility policy and manufacturer's guidelines specify that insulin pens require priming with two units to ensure accurate dosing, a step that was overlooked.
A facility failed to prime insulin pens before administering insulin to a resident, affecting their medication administration. A nurse was observed not priming the pens for Novolog and Lantus, and admitted to being unaware of the requirement. The resident, who had diabetes and was cognitively intact, was prescribed these insulins, which require priming according to facility policy and manufacturer guidelines.
The facility failed to sanitize glucometers between residents during medication administration, affecting three residents with diabetes. An RN confirmed using alcohol swabs but did not sanitize the glucometers between uses, contrary to the facility's policy. This was identified during a complaint investigation, indicating non-compliance with infection control protocols.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them, as observed during a survey. Residents with indwelling urinary catheters, diabetic foot ulcers, and enteral feeding lacked necessary PPE and signage. Additionally, the facility did not provide appropriate disposal bins for soiled PPE in an isolation room for a COVID-19 positive resident. Infection control policies were outdated, with no evidence of annual reviews, as confirmed by the DON.
The facility failed to store food in a sanitary manner, with proper labeling and dating, and allowed expired food to remain. Observations revealed improperly stored and labeled food items across multiple houses, including undated and past-date items, unclean refrigerators, and oven vents with buildup. Diet Tech confirmed these issues, indicating a lack of adherence to facility policies on food storage and labeling.
The facility failed to provide individualized activity programs for several residents, as evidenced by a lack of comprehensive activity assessments and insufficient documentation of activity participation. Residents were observed spending significant time without engagement in activities, despite having documented preferences and interests. The Activity Coordinator confirmed that comprehensive activity assessments were not completed, and residents were not provided with individual or one-on-one activities.
The facility failed to change and date oxygen tubing and supplies as ordered, affecting four residents. A resident with COPD had outdated oxygen tubing, while another with Alzheimer's lacked humidification and proper dating of equipment. Two other residents had undated oxygen tubing and improperly stored respiratory equipment. These issues were confirmed by staff and contradicted facility policy.
A facility failed to follow the planned menu for a resident on a pureed diet and did not have specific menus for residents on pureed and mechanically altered diets. A resident with dementia and dysphagia was served only mashed potatoes instead of the appropriate menu items. The facility's dietitian and diet tech confirmed the lack of specific menus for 11 residents on modified diets, relying on aides to substitute items without clear guidance.
The facility failed to provide a full set of utensils and napkins for residents during meals, affecting 19 residents. Observations showed residents were only given a spoon for meals requiring more appropriate utensils. Additionally, a resident was repeatedly left without food at the dining table while others ate, highlighting a lack of dignified dining experience.
The facility failed to provide adequate personal care and meal assistance to several residents, resulting in deficiencies such as unshaven facial hair, greasy hair, missed showers, and lack of meal assistance. Observations and interviews confirmed that residents with severe cognitive impairments and other health conditions did not receive the necessary support as outlined in their care plans.
The facility failed to follow physician orders and monitor skin conditions for several residents. A resident did not receive TED hose as ordered, another was not monitored for cellulitis, and a third did not receive wound care as prescribed. Additionally, a resident who fell did not receive a proper skin assessment upon return from the hospital.
The facility failed to implement fall interventions for several residents, including those with significant medical conditions, and did not complete sufficient fall documentation and neurological checks. A resident was left unsupervised during a transportation error, highlighting a lack of supervision and communication.
Several residents in the facility were not provided with adequate nutrition and hydration, as observed in multiple cases. A resident with dysphagia and dementia was often without fluids, despite needing encouragement to drink. Another resident with dementia and chronic kidney disease was frequently without fluids in common areas, not meeting daily fluid requirements. A third resident with a history of sepsis was observed without fluids, and a fourth resident was not offered food brought in by family as per their care plan. These deficiencies highlight issues in the facility's care practices.
A facility failed to document and provide necessary information for a resident's emergency transfer to a hospital. The resident, with multiple serious health conditions, was transferred due to a swollen left arm, but the change in condition evaluation was incomplete, and the hospital did not receive the required documentation. This was confirmed by the IDON.
A facility failed to update a resident's PASARR documentation to reflect new mental health diagnoses, including psychotic disorder with delusions and other hallucinations. The resident was initially admitted with chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. Despite the addition of new mental health diagnoses, the PASARR remained unchanged, as confirmed by a social worker.
The facility failed to accurately complete the PASARR for two residents, omitting mental health diagnoses. One resident was admitted with major depressive disorder and anxiety disorder, while another had bipolar disorder, yet their PASARRs did not reflect these conditions. Interviews confirmed these omissions.
A facility failed to notify the state mental health agency of significant changes in a resident's mental health condition. The resident, initially admitted with various diagnoses, was later diagnosed with psychotic disorder with delusions and other hallucinations. Despite this, the PASARR documentation was not updated to reflect these changes, as confirmed by a social worker.
A facility failed to complete a discharge summary for a resident with multiple medical conditions, including a compression fracture and pressure ulcer, who was discharged to an assisted living facility. The resident's medical record lacked documentation of the discharge and the receiving facility, and the discharge instructions were incomplete and unsigned. An interview with the LNHA indicated that information was faxed to the receiving facility, but no evidence of a completed discharge summary was provided.
The facility failed to timely assess and treat a UTI for a resident with multiple health issues, leading to delayed diagnosis and treatment. Additionally, another resident with an indwelling urinary catheter lacked physician orders and a comprehensive care plan. The Interim DON confirmed these deficiencies, indicating lapses in documentation and care planning.
A facility failed to label and date a tube feeding formula for a resident who received over half of her calories from a feeding tube. The resident's opened Glucerna bottle was found without any labeling, and interviews confirmed the oversight. The facility also lacked policies related to tube feeding.
The facility failed to address pharmacy recommendations for two residents, impacting medication management. A resident's Vitamin D test was delayed, and the physician did not justify continued Hydroxyzine use or address Seroquel recommendations. Another resident's pharmacy recommendations were undocumented for three months, confirmed by the interim DON.
A resident with chronic respiratory therapy, CHF, hypertension, and atrial fibrillation was not monitored for blood pressure or pulse before receiving Metoprolol, despite orders to hold the medication if systolic blood pressure was below 100 or heart rate was below 60. This lack of monitoring was confirmed by the Interim DON, indicating a deficiency in the resident's care plan execution.
A resident with COPD and other conditions was found with unsecured Ipratropium-Albuterol vials in their room without a physician's order or self-administration assessment. Interviews confirmed the lack of proper storage and assessment, leading to a deficiency.
The facility did not ensure pureed food was heated to a safe temperature for two residents on a pureed diet. An STNA prepared and served pureed carrots without heating them, as confirmed during an interview.
The facility failed to provide meals that met the dietary needs of two residents. One resident on a soft and bite-sized diet was served a whole sandwich, while another on a pureed diet received food with chunks. The facility lacked specific menus for these dietary requirements, leading to inappropriate meal substitutions.
A resident was not provided with the physician-ordered Kennedy cup for meals, as observed on two occasions. Despite the resident's care plan and physician orders specifying the use of this adaptive equipment due to health conditions, staff failed to comply. An STNA confirmed the lack of the required equipment, indicating a lapse in adherence to prescribed care interventions.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident's daily oxygen use was not documented, despite being observed using it. Another resident's worsening skin condition was not monitored or documented, resulting in hospitalization for cellulitis. These issues highlight significant gaps in record-keeping and monitoring practices.
The facility did not maintain a clean environment for a resident, with a room having splattered and chipped window ledges. Another resident experienced issues with a bathroom sink that did not drain properly and water that did not reach a hot temperature, confirmed by maintenance staff.
A resident with multiple health conditions did not receive showers according to her preferences, receiving only two showers in nearly a month. The care plan required moderate assistance for personal hygiene, but the task list lacked a scheduled shower day. Interviews confirmed the resident's desire for more frequent showers, revealing non-compliance with resident choice facilitation.
A facility failed to notify a resident's physician of vital signs outside specified parameters. The resident, with a complex medical history including CHF and hypertension, had orders to monitor vital signs and notify the heart failure clinic if certain thresholds were exceeded. Despite multiple instances of elevated pulse and systolic blood pressure, there was no evidence of physician notification. The Interim DON confirmed the oversight, which violated the facility's policy on change in condition notification.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. A resident with congestive heart failure lacked a care plan for oxygen therapy, another with a urinary catheter had no care plan for its management, and a third resident's care plan did not address self-care deficits or antidepressant use. The Interim Director of Nursing confirmed these deficiencies.
The facility failed to conduct quarterly care conferences with the required interdisciplinary team (IDT) members present for two residents. One resident with a complex medical history had their last care conference attended only by the Administrator, while another resident's conference lacked necessary IDT members, including nursing staff. This deficiency was noted under a specific complaint investigation.
Repeated Unwanted Entry Into Resident Room
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring interventions were in place, per the care plan, to prevent repeated uninvited and unwanted entry into a resident’s room. Resident #17 was cognitively intact and had diagnoses including sequelae of cerebral infarction, left-sided hemiplegia, type II diabetes mellitus with diabetic neuropathy, major depressive disorder, and COPD. Her care plan included an intervention, initiated earlier in the stay, to place a Velcro stop sign across her door to deter wandering elders from entering her room. Survey observations and interviews showed Resident #48 repeatedly entered Resident #17’s room despite the resident’s stated wishes. During observation, Resident #48 was found in Resident #17’s room in a wheelchair, and the resident stated she did not want him there, explaining that he would open the door and come in even when it was closed and that he would stay in her room when he said he was going to bed. Resident #17 also stated he talked in her room and interfered with her ability to hear her television. A care conference summary for Resident #17 documented that she wanted an elder to stay out of her room. Staff interviews confirmed the repeated nature of the issue. Coach #108 stated Resident #48 had been going into Resident #17’s room nightly about a month earlier and that staff were supposed to check hourly. CNA #186 stated he had seen Resident #48 in the room after 11:00 P.M. more than twice and had been told by management to tell him not to do that. CNA #188 stated Resident #48 had a habit of going into the room at least once per shift on most days for the past couple of months. The Administrator acknowledged prior discussion about Resident #48 entering the room, while the door sign intended to deter entry was observed inconsistently, including at one point when only an enhanced barrier precautions sign was on the door.
Failure to Provide Routine Hair Care
Penalty
Summary
The facility failed to ensure adequate and routine hair care for Resident #17, who was cognitively intact and dependent for multiple activities of daily living, including bathing, dressing, toileting, and personal hygiene. The resident had diagnoses including sequelae of cerebral infarction, left-sided hemiplegia, type II diabetes mellitus with neuropathy, major depressive disorder, COPD, and atherosclerotic heart disease. Her care plan identified a need for staff assistance with bathing, personal hygiene, and oral care, and noted she preferred a sponge bath when a full bath or shower could not be tolerated. During multiple observations and interviews, Resident #17 repeatedly stated that her hair was matted and not being cared for, and staff observed her hair to be uncombed, unwashed, and sticking straight up. She reported that although she told staff her hair needed to be fixed when they washed it, it was not addressed. Review of the shower sheet for one of her bed bath days showed no mention of hair care. A CNA confirmed the resident appeared to have unwashed hair and stated it should have been cared for during the prior evening's bed bath, while a coach confirmed hair should be washed as part of bathing and that the facility's bath/shower tracking tools did not include a space to indicate hair washing. The facility procedure reviewed also contained no instructions regarding hair care.
Failure to Implement Ordered Skin Care and Arrange Required Follow-Up Appointments
Penalty
Summary
The facility failed to ensure skin integrity interventions were implemented as care planned and ordered for a resident with multiple comorbidities including metabolic encephalopathy, protein-calorie malnutrition, type II diabetes mellitus, chronic kidney disease, anxiety, pressure ulcers, and a history of falls. The resident’s MDS showed severe cognitive impairment, dependence on staff for all ADLs, risk for pressure injuries, and use of a pressure-reducing mattress with ongoing wound care. The care plan identified impaired skin integrity and risk for further impairment, with interventions to administer treatments as ordered and monitor effectiveness. Weekly skin observation documented a left antecubital skin tear, and subsequent physician orders directed wound cleansing, calcium alginate with silver, and bordered foam or gauze dressings. A later progress note documented a new skin alteration and an order for geri-sleeves to both upper extremities each shift, followed by another wound order for the right lower arm. During observation, bilateral arm dressings were present but dated earlier than expected, and the resident was seated without the ordered protective sleeves in place. The facility also failed to ensure medical appointments were scheduled and completed as required for a resident with chronic kidney disease, diabetes, depression, and neuropathy. The resident’s record showed intact cognition with a BIMS score of 14 and need for staff assistance with bathing and grooming. After discharge from a hospitalization, the after-visit summary directed follow-up with a nephrologist within one month, but nursing progress notes from the discharge period through the later hospitalization did not show any nephrology appointments. The DON confirmed she could not locate a nephrology or urology appointment for the resident during the period reviewed.
Missed Ordered Wound Treatments for Pressure Ulcer
Penalty
Summary
The facility failed to ensure ordered treatments for a pressure ulcer were completed for a resident with multiple comorbidities, including metabolic encephalopathy, protein-calorie malnutrition, type II diabetes mellitus, chronic kidney disease, anxiety, pressure ulcers, and a history of falls. The resident was severely cognitively impaired, dependent on staff for all ADLs, incontinent, at risk for pressure injuries, and had multiple unstageable pressure ulcers and diabetic foot ulcers. A wound physician note documented an unstageable right lateral knee pressure ulcer measuring 1.5 cm by 1.6 cm by 0.1 cm, and an order was entered for calcium alginate with silver and a silicone foam border dressing to be changed daily. The physician order directed staff to cleanse the right knee, apply calcium alginate with silver directly into the wound bed, and cover it with a bordered foam dressing. The treatment administration record showed missed right knee treatments on four consecutive days, and a later wound physician note documented that the ulcer had increased to 2.4 cm by 2.2 cm by 0.1 cm with a change in treatment ordered. The wound nurse and regional nurse confirmed the missed documentation of daily dressings, and the wound nurse practitioner acknowledged the lack of documentation for those treatments while stating he believed the dressing had been completed and that the wound enlargement was related to the resident's decline and hospice admission.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to ensure appropriate foot care for Resident #20, who was admitted with diagnoses including depression, diabetes mellitus, hypertension, congestive heart failure, Parkinson's disease, history of falling, and muscle weakness. The quarterly MDS showed the resident had intact cognition with a BIMS score of 13 and required assistance with toileting, bathing, upper body dressing, and lower body dressing. The care plan identified a self-care deficit related to congestive heart failure, heart disease, and hypertension and noted the resident required staff assistance with ADLs. During interview, the resident stated she had not had her toenails cut in about a year and denied any podiatrist visit during her stay. Observation showed the toenails on both big toes had grown about 1/2 inch past the toes. Care conference notes did not mention podiatry services. The SW confirmed the resident had not been seen for podiatry because her son had not signed a release, and stated she had sent the consent form to the son but had not followed up. When asked why the resident could not sign herself, the SW stated she had just noticed the resident's intact cognition and had not considered that option. Later, the resident told the LPN her toenails had broken from being so long and were scratching the skin on the sides of her toes; the LPN confirmed the toenails were long and said she would see about having someone cut them, noting that due to the resident's diabetes mellitus, the facility policy was that a provider must cut them.
Missed and Delayed Medication Administration
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in significant medication errors for two residents. One resident with encephalopathy, osteomyelitis of the left ankle and foot, type 1 diabetes mellitus, acute kidney failure, and a non-pressure chronic ulcer of the left foot with necrosis of bone was readmitted with an order for insulin 30 units every morning. On readmission, a nurse documented concern that the dose was high and held the insulin pending clarification, but the routine insulin was not administered from 04/25/26 through 05/03/26. During that period, blood glucose results remained elevated, including readings as high as 364 mg/dL, 319 mg/dL, 270 mg/dL, 257 mg/dL, and 345 mg/dL, and the record showed only later one-time sliding scale insulin doses before a routine insulin order was entered. A second resident with end-stage renal disease, type II diabetes mellitus, hypertension, and morbid obesity had an order for Eliquis 2.5 mg by mouth twice daily for atrial fibrillation. Review of the MAR showed missed administrations on multiple occasions, including one evening dose in January, two morning doses in February, one morning dose in April, and one morning dose in May. The care plan identified the resident as receiving anticoagulant therapy and at increased risk for bleeding, with interventions to administer medications as ordered and monitor for side effects and effectiveness. The DON confirmed that the first resident’s routine insulin was not followed up on after readmission until 05/04/26 and that blood sugars obtained before that date would have required insulin coverage per physician order. The DON also confirmed she was unable to obtain additional information regarding the missed Eliquis administrations for the second resident. The deficiency was cited as non-compliance under multiple complaint investigations.
Failure to Prevent Service of Allergen-Containing Foods
Penalty
Summary
The facility failed to ensure a thorough procedure was in place to prevent staff from serving food items to residents with known food allergies and intolerances. This deficiency affected two residents reviewed for food allergies and was identified through observation, record review, interviews, and review of menus, recipes, and dining procedures. One resident had a documented strawberry allergy and was cognitively intact. Her record showed the allergy in multiple places, including the nutritional screen, physician progress notes, and hospital documentation. Despite this, she was served strawberry-containing foods on more than one occasion. In March 2025, she ate strawberry ice cream and developed facial and throat symptoms, requiring emergency treatment with epinephrine, Benadryl, and prednisone. After returning to the facility, she was again exposed to strawberry-flavored juice and developed tingling of the tongue, slurred speech, and wheezing, leading to EMS transport and emergency department treatment with IV Benadryl, breathing treatment, Pepcid, and Solu-Medrol. Interviews with dietary and nursing staff showed that allergy checking depended on staff reviewing the binder or remembering the allergy, and several staff members stated they were not sure whether the allergy information had been checked before serving the resident. A second resident had documented lactose intolerance with nausea. Her care plan noted lactose allergy with exceptions, but there were no goals or interventions addressing the intolerance or non-dairy alternatives. During observation, she was served menu items that contained cheese, including pepperoni pizza casserole, cheesesteak, and lasagna. Review of the recipes confirmed these items contained mozzarella, cottage cheese, and parmesan cheese. The Administrator confirmed these menu items contained cheese, and staff acknowledged the resident had a lactose allergy. The facility’s family-style dining instructions and allergy orientation materials did not include a clear step-by-step process for checking allergies during food preparation or service.
Incomplete Skin Assessment and Incident Documentation
Penalty
Summary
The facility failed to ensure weekly skin assessments were accurately documented in the medical record for one resident. The resident was admitted with diagnoses including end-stage renal disease, type II diabetes mellitus, morbid obesity, and an acquired absence of the right leg below the knee. The record showed the resident had a physician order for weekly skin assessments, a care plan addressing potential impairment of skin integrity, and a pressure injury risk assessment indicating moderate risk. On 04/22/26, a weekly skin observation tool documented the assessment as completed and noted no skin irregularities or new areas, but the DON later confirmed the resident was at dialysis at the documented time and the nurse could not have completed the assessment then. The DON also confirmed the assessment omitted skin areas documented the week before and the week after, and the facility’s skin care management procedure required weekly skin assessments to be completed and documented to identify new or potential areas of concern. The facility also failed to maintain a complete medical record related to a resident incident. The record contained progress notes, a diagnostic foot scan order for a swollen foot and toes, and a radiology report showing no acute fracture, but there was no documentation of a foot scan, swelling, injury, skin check, or incident report in the progress notes or incident and accident log for the relevant period. The resident later reported that while staff were attempting to transport her to dialysis, she struck her foot against a vehicle and developed significant swelling and bruising. Facility leadership confirmed the medical record contained no documentation of the incident, including skin assessments, physician notes, an accident report, interviews, or investigation, and the Administrator stated the record should have contained detailed information regarding the event.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure infection control measures were used for a resident on enhanced barrier precautions. Resident #13 was admitted with diagnoses including encephalopathy, osteomyelitis of the left ankle and foot, type 1 diabetes mellitus, sepsis due to Escherichia coli, peripheral vascular disease, and a non-pressure chronic ulcer of the left foot with necrosis of bone. The care plan identified impaired skin integrity related to a chronic vascular wound of the left great toe and directed staff to use enhanced barrier precautions, including proper hand hygiene and wearing gloves and a gown during high-contact care activities. The MDS showed the resident was cognitively impaired, dependent for toileting, required substantial to maximal assistance for sit-to-stand transfers, was frequently incontinent of bowel and bladder, and had one venous/arterial ulcer. Observation showed two CNAs entering the resident’s room without PPE despite a posted sign instructing staff to put on PPE before entering. The CNAs were observed inside the room without PPE after removing the resident from the toilet and while preparing to complete a pivot transfer into bed. They completed the hands-on transfer without wearing PPE, with their hands and lift belt in direct contact with the resident’s clothing. The CNAs confirmed the signage was posted and that PPE, including gloves and a gown, was required before providing care. The SW confirmed PPE should be applied before entering the room, and the DON later stated the resident’s isolation status was incorrect but that staff were still required to follow enhanced barrier precaution guidance because of the wound.
Failure to Notify Physician and Dietician of Missed Enteral Nutrition and Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and/or registered dietician when a resident did not receive physician-ordered enteral nutrition and failed to report significant weight loss for another resident. In the first instance, a resident with diagnoses including nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia was ordered nothing by mouth and was to receive Osmolite 1.5 via enteral feeding as their sole source of nutrition. On a specific date, the Osmolite was not available and was not administered, and there was no documentation that the physician or registered dietician was notified of the missed feeding. Interviews with the LNHA, RD, and DON confirmed that the enteral nutrition was not given and that appropriate notifications were not made, contrary to facility policy requiring immediate notification and documentation when there is a need to alter treatment significantly. In the second case, a resident with senile degeneration of the brain and vascular dementia, who was at risk for malnutrition, experienced a significant and rapid weight loss according to the medical record. The resident's weights showed a drop of 10 pounds in one day and 12 pounds in seven days, with no evidence that staff were made aware of the weight loss or that the registered dietician was notified. The DON confirmed that the EMR reflected this weight loss and that the last nutrition/dietary note was dated prior to the weight changes. The facility's policy required reweighs and notification of the dietician for significant weight changes, but there was no documentation that these steps were taken. Both deficiencies were identified through record review, interviews, and policy review, and involved failures to follow the facility's own policies regarding notification of changes in condition. The issues affected two of three residents reviewed for change in condition, and the facility census at the time was 54.
Failure to Provide Comprehensive Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide comprehensive and individualized pressure ulcer care and prevention for two residents with a history or risk of pressure ulcers. For one resident admitted with multiple fractures, osteoporosis, and a surgical wound, documentation revealed the presence of a pressure ulcer to the coccyx upon admission. However, there was no detailed description or measurement of the area in the initial care plan, and no treatment was documented until several days after admission, following evaluation by a wound physician. Although a low air loss mattress was recommended for this resident, there was no physician order for it, and observations confirmed that the mattress was never provided during the relevant period. For another resident with diagnoses including atrial fibrillation, malnutrition, and bone density disorders, a physician order for a low air loss mattress was in place, and the care plan included interventions for skin integrity. Despite this, documentation showed that after a resolved Stage III pressure ulcer, the resident developed new open areas to the coccyx, which were not promptly documented or treated. There was a delay of several days between the identification of the open areas and the implementation of wound care treatment. Additionally, the low air loss mattress in use was found to be malfunctioning and set for an incorrect weight, which was not addressed until after surveyor intervention. Policy review indicated that thorough skin assessments were required upon admission, weekly, and with any significant change, and that staff were to document and notify physicians of any skin concerns. The facility did not consistently follow these procedures, as evidenced by incomplete documentation, delayed treatment, and failure to implement recommended interventions for pressure ulcer prevention and care.
Failure to Provide and Monitor Nutrition and Hydration for Residents
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered treatment plan to address the nutritional needs of residents requiring enteral nutrition and did not maintain appropriate parameters to accurately assess nutritional status. For one resident with a history of nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia, the medical record showed that the resident was ordered nothing by mouth and relied solely on enteral nutrition via Osmolite 1.5. On a specific date, documentation indicated that the prescribed enteral nutrition was not administered because it was reportedly unavailable, and there was no evidence that the physician or registered dietician was notified of the missed administration. Subsequent interviews revealed confusion regarding staff identity and documentation, with conflicting accounts about whether the nutrition was actually given, and no supporting documentation to confirm administration. Another resident, admitted with multiple diagnoses including osteoarthritis, hypertension, diabetes, and neurocognitive disorder, was identified as being at risk for malnutrition. The care plan required weekly weights for four weeks to monitor nutritional status. However, the medical record did not contain evidence that the resident was weighed after the initial entry, despite a clear order and facility policy requiring weekly weights to establish a baseline. The DON confirmed that the required weekly weights were not performed as ordered. Facility policy for enteral tube feeding required documentation of any problems or complications, including practitioner notification and prescribed interventions, and the weight policy mandated weekly weights for new admissions. In both cases, the facility failed to follow its own policies and physician orders, resulting in a lack of proper monitoring and documentation for residents' nutritional needs.
Failure to Ensure Drug Regimen Was Free from Unnecessary Drugs and Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs and that medications were administered according to physician orders and facility policy. A review of records showed discrepancies between the hospital discharge prescription, physician orders, the medication administration record (MAR), and the medication monitoring/control record for Dilaudid, a narcotic pain medication. The resident was admitted with multiple diagnoses, including osteoarthritis, hypertension, diabetes, neurocognitive disorder with Lewy Bodies, and dementia. The resident was prescribed several medications, including Dilaudid, Flexeril, hydroxyzine, Buspar, Cymbalta, Celebrex, Abilify, Effexor, and Trazodone. The MAR and medication monitoring/control record showed inconsistent documentation of Dilaudid administration, with doses given without supporting documentation of pain or non-pharmacological interventions being attempted prior to administration, as required by the care plan and physician orders. Further review revealed that Dilaudid was administered multiple times without documentation of the resident experiencing pain, except for one instance. There was also no evidence that non-pharmacological interventions were attempted before administering the narcotic, and the MAR did not reflect all administrations recorded in the medication monitoring/control record. The facility’s policy required that medication orders be verified and that discrepancies be clarified with the physician, but this was not done. The DON confirmed that the order was incorrectly entered and that the discrepancies between the order, MAR, and controlled record were never clarified. Additionally, the resident received Dilaudid for zero out of ten pain on several occasions. The resident subsequently experienced increased lethargy and altered mental status, leading to hospitalization. Hospital records indicated a positive opioid screening and a diagnosis of acute metabolic encephalopathy likely due to narcotic pain medication use, with polypharmacy also suspected as a contributing factor. Several medications, including Dilaudid, were discontinued in the hospital, and the resident’s pain was managed with Tylenol. Interviews with facility staff confirmed the medication order entry error and lack of documentation for pain or non-pharmacological interventions prior to administration of Dilaudid.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or certified nurse practitioner (CNP) of laboratory results for one resident. The resident was admitted with multiple diagnoses, including osteoarthritis, hypertension, type 2 diabetes, shortness of breath, seizures, major depressive disorder, neurocognitive disorder with Lewy Bodies, dementia, chronic obstructive pulmonary disease, and urinary retention. The resident was cognitively intact at the time of the incident. Laboratory tests were ordered, including a complete blood count (CBC) and a basic metabolic panel (BMP), to establish a baseline and investigate causes of weakness such as anemia or electrolyte imbalance. The laboratory results showed several abnormal values, including elevated blood urea nitrogen (BUN), elevated carbon dioxide, low red blood count, low hemoglobin, and low hematocrit. Despite these findings, interviews with the Director of Nursing and the physician confirmed that neither the physician nor the CNP were notified of the laboratory results. Documentation indicated that the nurse was advised to ensure all follow-up was completed and that the specialist and CNP were notified, but this did not occur.
Facility Fails to Maintain Clean Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean kitchen environment, which was observed during multiple visits across different houses within the facility. On several occasions, kitchen cabinets were found dirty with splattered substances, and the stainless steel areas around stoves appeared unclean. Broken cabinet hinges and grime on various surfaces, including refrigerators and trash cans, were noted. These observations were consistent across different houses, indicating a widespread issue with cleanliness and maintenance in the kitchen areas. Interviews with staff, including CNAs and a Diet Technician, confirmed the unsatisfactory condition of the kitchens. CNAs expressed that they prioritized resident care over cleaning due to time constraints and the absence of a dedicated housekeeper. The Director of Nursing also acknowledged the unclean and unsanitary conditions in the kitchens of houses #1 and #2. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with maintaining a clean kitchen environment.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure that insulin pens were primed before administering insulin to residents, specifically affecting one resident. During an observation of medication administration, a registered nurse prepared an insulin pen for a resident with a history of type two diabetes mellitus, among other conditions. The nurse attached a needle to the insulin pen and prepared the dose but did not perform the required priming of the pen before administering the insulin. This oversight was confirmed during an interview with the nurse, who admitted to being unaware of the priming procedure and the amount of insulin needed for priming. The facility's policy and the manufacturer's guidelines both specify that insulin pens require priming with two units of insulin to ensure accurate dosing. The guidelines also recommend a priming test to ensure a drop of liquid appears on the needle tip, indicating proper priming. The failure to follow these procedures was identified as a deficiency during the investigation of a complaint, highlighting a lapse in adherence to established protocols for medication administration.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure that insulin pens were primed before administering insulin to residents, specifically affecting one resident who was reviewed for insulin pen priming. During a medication administration observation, it was noted that a registered nurse did not prime the insulin pens for both Novolog and Lantus before administering them to the resident. The nurse admitted to being unaware of the requirement to prime the pens, which is a necessary step according to the facility's policy and the manufacturer's guidelines. The resident involved had a medical history that included chronic obstructive pulmonary disease and diabetes, and was cognitively intact according to a recent assessment. The resident was prescribed Lantus and Novolog insulin, which required priming before administration. The facility's policy and the manufacturer's guidelines both specify that two units should be used to prime the needle before injecting insulin. This deficiency was identified during an investigation of a complaint, indicating non-compliance with proper medication administration procedures.
Failure to Sanitize Glucometers Between Residents
Penalty
Summary
The facility failed to ensure proper sanitization of glucometers between residents, as observed during medication administration for three residents. Resident #14, diagnosed with Alzheimer's Disease and diabetes, had their blood sugar taken without the glucometer being wiped with sanitizing wipes by RN #171. Similarly, Resident #15, who had a cerebrovascular attack and diabetes, also had their blood sugar checked without the glucometer being sanitized. Resident #23, with chronic obstructive pulmonary disease and diabetes, experienced the same issue during their blood sugar check. The facility's policy on cleaning and disinfecting medical devices, dated 11/05/21, requires that shared equipment be cleaned or disinfected between uses for different residents. However, RN #171 confirmed that alcohol swabs were used to clean the glucometers, but they were not sanitized between residents #14, #15, and #23. This oversight was identified during an investigation of a complaint, indicating non-compliance with the facility's infection prevention and control program.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Protocols
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents who required them, as observed during a survey. Residents with conditions such as indwelling urinary catheters, diabetic foot ulcers, and enteral feeding were not provided with the necessary personal protective equipment (PPE) like gowns and gloves, nor was there signage indicating the need for EBP in their rooms. Staff interviews confirmed the absence of EBP, and some staff members were unaware of what EBP entailed, despite physician orders and care plans indicating the necessity for such precautions. Additionally, the facility did not provide appropriate disposal bins for soiled PPE and laundry in an isolation room for a resident who tested positive for COVID-19. The lack of isolation-specific trash cans and linen hampers was confirmed by staff, indicating a failure to adhere to proper infection control protocols for residents under transmission-based precautions. This oversight was noted during an interview with a resident who expressed concern about their health condition after testing positive for COVID-19. The facility's infection control policies and procedures were found to be outdated, with no evidence of annual reviews as required. Policies related to infection prevention, antibiotic stewardship, and vaccination protocols had not been revised in several years, and there was no local infection control committee to oversee these processes. The Director of Nursing, who also served as the infection preventionist, confirmed the lack of updated policies and procedures, which could potentially impact the overall infection control measures within the facility.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored in a sanitary manner, with proper labeling and dating, and that expired food was not kept. During an observation, it was noted that various food items were improperly stored and labeled across multiple houses within the facility. In House 403, hot dog buns and a rotisserie chicken were found with past dates, and there were undated, unidentifiable food items. Additionally, a bag of frozen peas was open and undated, and both the kitchen freezer and pantry refrigerator were dirty. In House 401, cheddar slices were poorly wrapped, and cut vegetables were left unwrapped in a drawer with food debris. The refrigerators and freezers in this house were also unclean. In House 400, an open box of instant potatoes and a ketchup bottle with a broken lid were found, exposing the contents to air. House 402 had oven vents with a thick black buildup, and several bread packages were past their dates. The refrigerators were unclean, with a large food stain in one. House 404 also had oven vents with a buildup, and various food items were either undated or past their expiration dates. An interview with Diet Tech #123 confirmed these observations, and she indicated that housekeepers or aides were responsible for cleaning the refrigerators, while maintenance was supposed to clean the oven vents. The facility's policies on food storage and labeling were not adhered to, contributing to these deficiencies.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide individualized activity programs for six residents, as evidenced by a lack of comprehensive activity assessments and insufficient documentation of activity participation. Resident #51, who is moderately cognitively intact, was observed multiple times sitting in a common area without any form of entertainment or interaction from staff. Despite having a coloring book, it was kept in her room, and she was unable to see the television from her usual seating position. The Director of Nursing confirmed that the only documented activities for Resident #51 were watching TV or listening to music, with minimal engagement in other activities. Resident #32, with a moderate cognitive deficit, had no documented activity assessment and limited participation in activities. Observations revealed that the resident spent significant time in a Broda chair without engagement in activities, despite having interests such as listening to music and looking at pictures of farm equipment. The Activity Coordinator confirmed that a comprehensive activity assessment was not completed, and the resident was not provided with individual or one-on-one activities. Similarly, Resident #34, who has a moderate cognitive deficit, was not provided with activities from August to mid-September. Despite having a plan of care that included various activity preferences, the resident was observed at bedrest with the television on, without any in-room activities. The Activity Coordinator verified that a comprehensive activity assessment was not completed, and the resident was not provided with individual or one-on-one activities. Other residents, including Resident #19, Resident #22, and Resident #35, also experienced similar deficiencies in activity provision, with outdated or incomplete activity assessments and limited engagement in activities.
Failure to Maintain Respiratory Equipment Standards
Penalty
Summary
The facility failed to adhere to its policy regarding the timely change and dating of oxygen tubing and supplies, as well as the proper storage of respiratory equipment, affecting four residents. Resident #11, diagnosed with conditions such as COPD and chronic respiratory failure, was observed with oxygen tubing that had not been changed weekly as per facility policy, with the last change dated nearly a month prior. This was confirmed by a registered nurse during an interview. Resident #21, who has Alzheimer's disease and other health issues, was found to have undated nasal cannula tubing and lacked humidification on the oxygen concentrator, contrary to physician orders. The resident's treatment administration record indicated that the oxygen tubing was changed, but observations contradicted this, and the registered nurse confirmed the discrepancies. Resident #31, with a history of congestive heart failure and other conditions, had oxygen tubing that was not dated, and the interim director of nursing verified this oversight. Similarly, Resident #38, who has chronic respiratory therapy needs, was observed with undated oxygen tubing and a dusty nebulizer mask stored improperly. The registered nurse confirmed that the equipment had not been changed weekly as ordered. The facility's policy mandates regular changes and proper dating of respiratory equipment, which was not followed in these cases.
Failure to Provide Appropriate Menus for Residents on Modified Diets
Penalty
Summary
The facility failed to adhere to the planned menu for a resident on a pureed diet, as well as failed to have a planned menu for residents on pureed and mechanically altered diets. Specifically, Resident #19, who has diagnoses including dementia, dysphagia, and muscle weakness, was served only mashed potatoes and a beverage for lunch, instead of the menu items listed for that day. The resident's physician had ordered a pureed texture diet with slightly thick liquids, but the menu for the lunch meal included items that were not suitable for her dietary needs. Additionally, the facility's menus for September 2024 did not include specific plans for residents on soft and bite-sized, minced and moist, or pureed diets. The dietitian and diet tech confirmed that there were 11 residents on these diets, but the facility only had a regular diet menu. They acknowledged that some items on the regular menu could not be appropriately modified for textured diets, and the aides were expected to substitute items based on the IDDSI guidelines. However, the guidelines only indicated which foods to avoid without providing equivalent replacements.
Failure to Provide Proper Dining Utensils and Timely Meals
Penalty
Summary
The facility failed to provide a full set of utensils and napkins for residents during meals in houses 400 and 404, affecting 19 residents. Observations revealed that residents were only given a spoon to eat meals that included items like sandwiches and soup, which required more appropriate utensils. Interviews with residents and staff confirmed the lack of proper utensils and napkins, with one resident reporting having to use a spoon to eat applesauce. The dietitian acknowledged that while residents could request additional utensils, they should not have to. Additionally, the facility failed to ensure a dignified dining experience for one resident, who was observed multiple times sitting at the dining table without being served food while others around her were eating. On two separate occasions, this resident was left without food for extended periods, even after other residents had finished their meals. The administrator was unaware of the situation until it was brought to her attention, and it was confirmed that the resident's meal was still being prepared. This deficiency was investigated under a specific complaint number.
Deficiencies in Personal Care and Meal Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for several residents, leading to deficiencies in personal care and meal assistance. Resident #45, who has severe cognitive impairment and multiple health conditions, was observed with significant facial hair and greasy, matted hair, indicating a lack of routine personal hygiene care. Despite her care plan requiring substantial assistance, she did not receive adequate bathing or grooming services, as confirmed by both observation and interviews. Resident #35, diagnosed with Alzheimer's disease and other health issues, did not receive showers as scheduled, which was verified by the Interim Director of Nursing. Similarly, Resident #52, who requires substantial assistance with eating due to severe cognitive impairment, was observed feeding herself without the necessary help, resulting in inappropriate food combinations. This lack of assistance was acknowledged by the Interim Director of Nursing. Additionally, Resident #25 and Resident #32 experienced neglect in nail care and shaving. Resident #25 had long, jagged nails with chipped polish, and it was confirmed that she had not received nail care for approximately a month. Resident #32, who has a moderate cognitive deficit and requires extensive assistance, was not provided with scheduled showers and had long, unshaven facial hair and untrimmed nails. These deficiencies were confirmed through observations and staff interviews, highlighting a pattern of inadequate personal care across multiple residents.
Failure to Follow Physician Orders and Monitor Skin Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs, affecting multiple residents. Resident #11, who had a history of hypertensive heart disease with heart failure, was not provided with Thromboembolism-Deterrent (TED) hose as ordered by the physician. Despite orders to apply the TED hose in the morning and remove them at bedtime, observations revealed that the resident did not have the TED hose on, and the resident confirmed that the nurse had measured her legs but never returned with the hose. Resident #31, with a history of cellulitis and other significant health issues, was not properly monitored for skin conditions. The resident developed a large erythema and cellulitis on the left back, axilla, and chest, which was not identified or treated by the facility before the resident was transferred to the emergency department. Additionally, the facility failed to notify the heart failure clinic of vital signs that were outside the specified parameters as ordered by the physician. Resident #48 did not receive wound care as ordered for a wound under the right big toe on several occasions, as documented in the Medication Administration Record. Furthermore, Resident #19, who had a fall resulting in a hematoma and bruise, did not receive a proper skin assessment upon return from the hospital, and the facility failed to monitor the hematoma. These deficiencies highlight the facility's failure to adhere to physician orders and adequately assess and monitor residents' conditions.
Deficiencies in Fall Interventions and Supervision
Penalty
Summary
The facility failed to ensure fall interventions were in place for several residents, including those with significant medical conditions such as diabetes, hypertension, and dementia. For instance, Resident #52, who was at risk for falls due to a cerebrovascular accident and weakness, was found on the floor without injuries, but the prescribed fall mat was not in place during multiple observations. Similarly, Resident #8's fall mat was not in place as required by the care plan, and Resident #28's bed was not in the lowest position, and the fall mat was not consistently beside the bed. Additionally, the facility did not complete sufficient fall documentation and neurological checks for some residents. Resident #110 experienced an unwitnessed fall, and the neurological checks were not completed as per policy. The Interim Director of Nursing confirmed that the timeline for these checks was not followed, and an additional undocumented fall occurred. Resident #19 also had incomplete neurological checks following a fall, and the fall investigation forms lacked necessary details and signatures. The facility also failed to provide adequate supervision for Resident #48, who was left unsupervised during a transportation error. The resident, who had moderately impaired cognition, was left alone at an appointment due to a scheduling mistake. The transportation employee assumed the resident was appropriate to be alone, which was not the case, as confirmed by the resident's family. This lack of supervision and communication led to the resident being left unattended at the appointment location.
Deficiencies in Nutrition and Hydration for Residents
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for several residents, as observed in the cases of Residents #19, #22, #32, and #34. Resident #19, who has multiple diagnoses including dysphagia and dementia, was observed multiple times without access to fluids, despite her care plan indicating the need for encouragement to drink fluids. Her fluid intake records showed consistently low consumption, often below the required daily amount. Interviews with staff confirmed that there were no set parameters for providing fluids to her, and she was often left without fluids within reach. Resident #22, diagnosed with dementia and chronic kidney disease, also faced similar issues with hydration. His care plan highlighted the risk of malnutrition and dehydration, yet observations revealed he was frequently without fluids in common areas. His fluid intake records indicated he was not meeting his daily fluid requirements. Staff interviews corroborated that fluids were not consistently available to him unless he specifically requested them. Resident #32, with a history of sepsis and other health issues, was observed without fluids on several occasions, despite his care plan's emphasis on encouraging fluid intake. His fluid consumption was significantly below the estimated needs. Additionally, Resident #34, who has a history of cerebrovascular accident and other conditions, was not offered food brought in by family or sweet potatoes as per his care plan. This lack of adherence to care plans and failure to provide necessary nutrition and hydration affected the residents' well-being and highlighted deficiencies in the facility's care practices.
Failure to Document and Provide Transfer Information
Penalty
Summary
The facility failed to ensure that a resident's required information for an emergency transfer was documented and provided to the receiving facility. This deficiency affected a resident who was admitted with multiple diagnoses, including cellulitis, cardiomyopathy, hypertension, and other serious conditions. On a specific date, the resident's left arm was noted to be extremely swollen, prompting a Nurse Practitioner to order an emergency transfer to a local hospital. However, the change in condition evaluation was left blank, and there was no documented evidence that the hospital received written documentation detailing the resident's change in condition. This oversight was confirmed during an interview with the Interim Director of Nursing.
Inaccurate PASARR Documentation for Resident
Penalty
Summary
The facility failed to ensure that all resident Pre-Admission Screening and Resident Review (PASARR) documents were accurate and reflective of the residents' current conditions and diagnoses. This deficiency was identified during a review of medical records and staff interviews, specifically affecting one resident out of three reviewed for PASARR documents. The resident in question was admitted with diagnoses including chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. On a later date, additional diagnoses of psychotic disorder with delusions and other hallucinations were added. However, the PASARR completed by the facility did not include any mental health diagnoses, and no updated PASARR was completed after the new mental health diagnoses were added. This oversight was confirmed during an interview with a social worker, who acknowledged that the admission PASARR did not contain the updated mental health diagnoses.
PASARR Screening Deficiency for Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) for two residents, resulting in a deficiency. Resident #7 was admitted with diagnoses including chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. However, the PASARR completed by the facility did not reflect any mental health diagnoses. Similarly, Resident #28 was admitted with diagnoses such as senile degeneration of the brain, dementia, atherosclerotic heart disease, and bipolar disorder, but the PASARR completed by another facility also failed to include any mental health diagnoses. Interviews with the social worker confirmed the omissions in the PASARR forms for both residents.
Failure to Update PASARR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the appropriate state mental health agency of significant mental health changes in a resident, leading to a deficiency. Resident #7, who was admitted with chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension, was later diagnosed with psychotic disorder with delusions and other hallucinations on 06/14/23. Despite these additional mental health diagnoses, the facility did not update the PASARR documentation, which initially indicated no mental health diagnoses. This oversight was confirmed during an interview with social worker #139, who acknowledged that a new PASARR was not completed after the resident's mental health condition changed.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of a resident's stay, affecting one resident. The resident, who had a history of compression fracture, metabolic encephalopathy, hypertension, hyperlipidemia, hypothyroidism, anxiety disorder, major depressive disorder, and a Stage II pressure ulcer, was discharged to an assisted living facility. The resident's medical record showed they were alert and oriented to person only upon admission, with a later assessment indicating no cognitive deficit. However, there was no documentation of the resident's discharge or the facility they were discharged to in the progress notes. Additionally, the discharge physician orders did not specify an order to discharge the resident to an assisted living facility, and the discharge instructions were incomplete and unsigned by the resident, family, or nurse. An interview with the LNHA revealed that the facility had faxed information to the receiving facility, but there was no evidence of a completed discharge summary or recapitulation of the resident's stay being received.
Deficiencies in UTI Management and Catheter Care
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a urinary tract infection (UTI) for a resident diagnosed with dementia, type two diabetes mellitus, bipolar disorder, chronic kidney disease stage four, dysphagia, major depressive disorder, and muscle weakness. The resident exhibited increased lethargy and confusion, prompting a Certified Nurse Practitioner to suspect a UTI. Despite orders for a urinary analysis and blood work, the urine specimen was not collected promptly, leading to a delay in diagnosis and treatment. The resident's condition worsened, with complaints of nausea and stomach pain, necessitating a stat laboratory test and eventual antibiotic treatment. Additionally, the facility failed to ensure that another resident, who had diagnoses including sepsis, urinary tract infection, and dementia, had physician orders for the use of an indwelling urinary catheter. The resident's medical record lacked documentation of a comprehensive care plan addressing the catheter use. The Interim Director of Nursing confirmed the absence of necessary physician orders for the catheter, highlighting a lapse in the facility's adherence to proper documentation and care planning protocols.
Failure to Label and Date Tube Feeding Formula
Penalty
Summary
The facility failed to ensure that the tube feeding formula for Resident #52 was appropriately labeled and dated after opening. Resident #52, who had multiple diagnoses including type two diabetes mellitus, hypertension, and chronic kidney disease, was receiving more than half of her calories from a feeding tube. A physician's order required that each new bottle of formula be labeled with the resident's name, date, time, and the nurse's initials. However, during an observation, an opened bottle of Glucerna was found on the resident's bedside table without any labeling to indicate the date it was opened or who opened it. Interviews with the interim Director of Nursing and a Licensed Practical Nurse confirmed the bottle was opened and undated. Additionally, the facility lacked policies related to tube feeding.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician and followed through by facility staff for two residents. For Resident #35, the pharmacist made several recommendations regarding medication management, including obtaining a Vitamin D level, reviewing the necessity and duration of Hydroxyzine, and correcting the diagnosis for Seroquel to monitor its effectiveness and side effects. The physician either did not follow through with these recommendations or disagreed without providing adequate justification. Specifically, the Vitamin D test was delayed, and the physician did not provide a note justifying the continued use of Hydroxyzine or address the recommendation for Seroquel appropriately. For Resident #22, the facility failed to maintain evidence of the pharmacist's recommendations for three consecutive months. The interim Director of Nursing confirmed the absence of these records, indicating a lapse in the documentation and communication process between the pharmacy and the facility staff. This lack of documentation prevented the facility from ensuring that the pharmacist's recommendations were considered and acted upon, potentially impacting the resident's medication management.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring the resident's vital signs before administering medication. The resident, who had a history of chronic respiratory therapy, congestive heart failure, hypertension, atrial fibrillation, and chronic pain, was prescribed Metoprolol to manage hypertension. The medication was to be held if the resident's systolic blood pressure was less than 100 or if the heart rate was less than 60. However, there was no documented evidence that the resident's blood pressure or pulse was checked before administering the medication in July, August, and early September 2024. The deficiency was confirmed during an interview with the Interim Director of Nursing, who verified that the resident's blood pressure and pulse were not obtained prior to the administration of Metoprolol. This oversight affected the resident's care, as the facility did not adhere to the physician's orders regarding the monitoring of vital signs before medication administration. The facility's failure to document and monitor the resident's vital signs as required led to a deficiency in the resident's care plan execution.
Failure to Secure and Assess Self-Administration of Medication
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting a resident who was observed during medication administration. The resident, who had diagnoses including COPD, congestive heart failure, and chronic pain, had a physician's order for unsupervised self-administration of nebulizer treatments. However, the medical record lacked an assessment to determine the resident's capability to self-administer the medication Ipratropium-Albuterol. During an observation, three vials of the medication were found unsecured in the resident's room without original packaging or directions for use. Interviews with the RN and the Interim DON confirmed that the medication was stored unsecured without a physician's order to keep it at the bedside. Additionally, there was no self-administration medication assessment on file to evaluate the resident's ability to self-administer the medication. This oversight in securing and assessing the resident's ability to manage their medication led to the deficiency noted in the report.
Failure to Heat Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were properly cooked and brought back up to a safe temperature after being pureed, affecting two residents in the 400 house. On September 10, 2024, during the lunch meal preparation, a State tested Nursing Assistant (STNA) was observed preparing pureed carrots for two residents on a pureed diet. The STNA opened a can of carrots, pureed them to the appropriate consistency, and served them to the residents without heating, seasoning, or bringing them back to a safe temperature. This was confirmed during an interview with the STNA, who acknowledged that the carrots were not heated after being pureed.
Failure to Provide Appropriate Texture Diets
Penalty
Summary
The facility failed to provide meals that met the dietary needs of two residents, leading to deficiencies in their care. Resident #40, who had diagnoses including diastolic heart failure and dysphagia, was on a soft and bite-sized diet. However, during a lunch observation, she was served a whole sandwich with lunch meat and tomato, which did not comply with her dietary requirements. The dietitian confirmed that Resident #40 should have received a meal with puree bread and ground meats, but there was no specific menu for a soft and bite-sized diet, leading to inappropriate substitutions. Similarly, Resident #52, with diagnoses including type two diabetes mellitus and gastro-esophageal reflux disease, was on a pureed texture diet. During a breakfast observation, her meal contained chunks of egg and meat, which were not suitable for her dietary needs. The Interim DON and an agency aide verified that the meal was not appropriately pureed. The facility lacked a puree menu, resulting in meals that did not meet the required texture standards for Resident #52.
Failure to Provide Physician-Ordered Adaptive Equipment
Penalty
Summary
The facility failed to provide a resident with the physician-ordered adaptive equipment for meals, specifically a Kennedy cup, which is a spill-proof handled cup with a lid and straw. This deficiency was identified during observations on two separate occasions, where the resident was served meals with regular drinking glasses instead of the prescribed Kennedy cup. The resident's medical record indicated a need for this adaptive equipment due to various health conditions, including osteoarthritis, dementia with behavioral disturbances, and being edentulous without appliance status, which placed the resident at risk for nutrition and dehydration issues. The resident's care plan and physician orders clearly specified the use of a Kennedy cup at all meals, yet the staff failed to comply with these orders. An interview with a State tested Nursing Assistant (STNA) confirmed that the facility did not provide the required adaptive equipment, as the only lidded cup available was for another resident. This oversight affected the resident's ability to consume fluids safely and effectively, as per the physician's directive, and highlighted a lapse in the facility's adherence to prescribed care interventions.
Deficiencies in Medical Record Accuracy and Monitoring
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, leading to deficiencies in their care. For Resident #11, the medical record did not reflect the resident's daily use of oxygen, despite observations showing the resident using oxygen via nasal cannula. The resident's care plan included interventions for respiratory issues, and physician orders specified oxygen use as needed. However, the Medication Administration Record (MAR) did not document the use of oxygen, indicating a lack of accurate record-keeping. For Resident #31, the facility did not document or monitor the resident's skin condition adequately. The resident had a history of skin tears and was seen for fatigue and swelling, but the medical record lacked evidence of monitoring or treatment for a large erythema and cellulitis prior to the resident's transfer to the emergency department. The resident reported worsening rash symptoms that were not addressed by nursing staff, and the change in condition assessment was left blank. This lack of documentation and monitoring contributed to the resident's hospitalization for cellulitis.
Facility Fails to Maintain Cleanliness and Proper Water Functionality
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident #45 and did not ensure proper water temperature and drainage for Resident #33. Observations on multiple occasions revealed that Resident #45's room had a bed positioned against the wall, with a window ledge that had unidentifiable splatters and was chipped in several spots. This was confirmed by an interview with Agency Aide #155. Additionally, Resident #33 reported issues with her bathroom sink not draining properly and the water not reaching a hot temperature, making it difficult for her to wash her face. Observations confirmed that the sink filled up quickly without draining, and the water temperature only reached 91.1 degrees Fahrenheit after running for several minutes. Maintenance #157 verified these issues during an interview.
Failure to Provide Resident-Preferred Bathing Schedule
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing bathing services according to her preferences. Resident #25, who has a medical history including congestive heart failure, hyperlipidemia, hypothyroidism, chronic kidney disease, atrial fibrillation, hypertension, gastro-esophageal reflux disease, macular degeneration, and protein calorie malnutrition, was affected by this deficiency. The resident's care plan indicated a need for moderate assistance with dressing, showering, and personal hygiene due to self-care and physical mobility deficits. Despite this, the resident's task list did not specify a scheduled day for showers, and documentation showed that she only received two showers over a period of nearly a month. Interviews with the resident's family member and the Interim Director of Nursing confirmed that the resident received only two showers in the past 30 days, supplemented by bed baths on three occasions. The family member expressed that the resident desired more frequent showers. This deficiency was identified during an investigation of complaints numbered OH00156906 and OH00156905, highlighting the facility's non-compliance with promoting and facilitating resident choice in personal care preferences.
Failure to Notify Physician of Vital Sign Deviations
Penalty
Summary
The facility failed to notify a resident's physician of vital signs that were outside the parameters specified in the physician's orders. The resident, who had a complex medical history including conditions such as cellulitis, cardiomyopathy, hypertension, and congestive heart failure, was admitted with specific instructions for monitoring vital signs. The care plan required notifying the heart failure clinic if the resident's weight increased by two pounds in a day or five pounds in a week, and if the systolic blood pressure was less than 100 or greater than 135. Additionally, the heart rate was to be monitored, with instructions to notify the clinic if it was less than 60 or greater than 85. Upon reviewing the Medication Administration Record (MAR) for August 2024, it was found that the resident's pulse exceeded 85 on multiple occasions, and the systolic blood pressure was above 135 on several days. Despite these deviations, there was no documented evidence that the physician at the heart failure clinic was informed of these vital signs. The Interim Director of Nursing confirmed that the physician was not notified as required. The facility's policy on Notification of Change in Condition mandates immediate consultation with the resident's physician or nurse practitioner when there is a significant change in the resident's status, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #31, who had multiple diagnoses including congestive heart failure and anxiety disorder, did not have a care plan that addressed the use of oxygen therapy, despite physician orders indicating its necessity. The Interim Director of Nursing confirmed the absence of a comprehensive plan for the resident's oxygen use. Resident #32, with a history of sepsis, urinary tract infection, and dementia, among other conditions, lacked a care plan for the management of an indwelling urinary catheter. Observations revealed that the resident was incontinent and required assistance with toileting, yet there were no physician orders or care plans addressing the catheter usage. The Interim Director of Nursing acknowledged the deficiency in care planning for the resident's catheter management. Resident #52, diagnosed with type two diabetes mellitus and cerebrovascular disease, had a care plan that failed to address her self-care deficits and the use of antidepressants. The resident was rarely understood and required assistance with activities of daily living, but the care plan did not specify the level of assistance needed. The Interim Director of Nursing verified the lack of a care plan for the resident's antidepressant use and assistance with daily activities. The facility's policy on comprehensive care planning was not adhered to, resulting in these deficiencies.
Failure to Conduct Proper Care Conferences with IDT
Penalty
Summary
The facility failed to ensure that quarterly care conferences were conducted with the required interdisciplinary team (IDT) members present, affecting two residents out of a sample of 24. For Resident #34, who has a complex medical history including cerebrovascular accident, diabetes mellitus, and vascular dementia, the last care conference was held on 05/21/24, with only the Administrator in attendance. This was confirmed by an interview with the Licensed Social Worker (LSW) #139, who acknowledged that the required care conference had not been conducted since that date and that not all necessary IDT members, including nursing staff, were present. Similarly, for Resident #25, who has diagnoses such as congestive heart failure, chronic kidney disease, and atrial fibrillation, the last care conference was held on 05/28/24. The LSW #139 confirmed that the required IDT members, including nursing staff, did not attend this care conference. This deficiency was investigated under Complaint Number OH00156905, indicating non-compliance with the requirement for comprehensive care planning and team involvement.
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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 Gahanna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Gahanna | 1.2 mi | ★★★★★ | 27 | 0 |
| New Albany Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Continuing Healthcare Of Gahanna | 2.4 mi | — | 29 | 0 |
| Taylor Springs Health Campus | 2.9 mi | ★★★★★ | 1 | 0 |
| Otterbein New Albany | 3.5 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.