Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Otterbein North Shore during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, including HTN, was admitted on multiple ordered antihypertensive medications. Several scheduled doses of these medications were not administered, despite the drugs being available in the facility, and the resident’s BP readings were elevated, including a markedly high value later that day. There was no documentation that the physician or resident representative were notified of the missed doses or the elevated BP, contrary to facility policies requiring notification for changes in condition and withheld medications.
The facility failed to provide ordered nutritional supplements with meals for two residents who required assistance and monitoring for nutrition and hydration. One resident with dementia, dysphagia, and severe cognitive impairment, fully dependent on staff for feeding, had orders for a health shake with meals and a magic cup to be given with meals and alternated with bites of food, but was only given the regular breakfast items without the health shake and without the magic cup being offered as ordered. Another resident with hyperkalemia, chronic fatigue, and moderate cognitive impairment, who was at risk for altered nutrition and had an order for a magic cup supplement with each meal, was observed eating breakfast without being offered the supplement. A CNA reported being unaware of some of these supplement orders despite diet cards in the kitchen, and the Administrator reported there was no policy on supplemental orders.
The facility failed to administer ordered medications to three residents despite medications being available on site and clear physician orders. One resident with diabetes, CKD, and hypertension did not receive multiple antihypertensives, psychotropics, and insulin doses on admission and the following day, and blood glucose monitoring was not performed as ordered. Another resident with Parkinson’s disease did not receive several scheduled doses of carbidopa-levodopa, with no documentation of refusal, even though the drug was in stock. A third resident with acute systolic heart failure and hypertension did not receive an ordered evening dose of carvedilol, despite vital signs not meeting hold parameters and the medication being available. The DON confirmed in each case that medications were not administered per physician orders, contrary to facility policies requiring adherence to written orders and use of on-hand medication supplies.
Staff failed to administer multiple ordered medications, including antihypertensives, carbidopa-levodopa, and carvedilol, to three residents despite the drugs being available in the facility. One resident with severe cognitive impairment and a history of markedly elevated BP missed several doses of multiple antihypertensive agents shortly after admission, while BP readings remained elevated. Another resident with Parkinson’s disease and severe cognitive impairment did not receive several scheduled doses of carbidopa-levodopa, with no documentation of refusal. A third cognitively intact resident with acute systolic heart failure and hypertension did not receive an evening dose of carvedilol even though vital signs were within ordered parameters and the medication was on hand. The DON confirmed that these medications were not administered per physician orders, contrary to facility policies requiring administration as ordered and use of on-hand stock when needed.
Incorrect advance directive documentation was found for a resident with dementia, hypothyroidism, and major depressive disorder. The care plan and EMR identified the resident as DNRCC, but the nurse/CNA report sheet listed DNRCCA; the CNA and DON both confirmed the mismatch, and the facility policy required advance directives to be recorded in the medical record.
Failure to complete weekly skin and wound assessments led to delayed identification of new pressure injury development. A resident with severe cognitive impairment, incontinence, hospice status, and prior buttock pressure ulcer had a stage 2 wound documented, but the scheduled wound eval was rescheduled and not reattempted, and weekly skin assessments were not completed. Later, the prior wound was noted healed and a new stage 3 sacral/coccyx pressure ulcer was found.
Failure to use PPE during EBP care. A resident with impaired cognition and an unstable coccyx wound was identified as being on EBP, with a door sign indicating staff should wear gown and gloves for high-contact care. During incontinence care, two CNAs provided care without PPE and confirmed the resident was on EBP. The Administrator also confirmed there were no EBP orders in the resident's chart, despite the facility policy requiring gowns and gloves for residents with wounds.
A CNA was observed transferring a resident with severe cognitive and physical impairments using a mechanical lift without the required assistance of a second staff member, contrary to the resident's care plan and facility policy. Staff interviews confirmed that two-person assistance was mandated and that the CNA typically performed such transfers alone, resulting in non-compliance with established procedures.
Surveyors identified multiple instances of improper food storage, labeling, and dating in facility kitchens, including expired and unlabeled food items, lack of refrigerator thermometers, and food stored directly on the floor. These deficiencies were confirmed by staff and were not in accordance with facility policy, potentially affecting all residents receiving food from the kitchens.
A resident with severe cognitive impairment and multiple medical conditions was repeatedly observed without a call light pendant within reach while in bed and in a wheelchair. Staff, including an RN and the DON, confirmed the call light was not accessible to the resident during these times, despite facility expectations.
A resident with dementia, dysphagia, and severe cognitive impairment, who was dependent on staff for feeding and had a recent hospitalization for dehydration, did not have a care plan that included goals or interventions for dehydration prevention. Staff confirmed the absence of measurable goals and interventions addressing dehydration in the resident's care plan.
A resident with severe cognitive impairment and a physician order for daily stool softener did not have a recorded bowel movement for six consecutive days. During this time, nursing staff did not initiate interventions or notify the physician, and no bowel protocol was in place. The DON confirmed the lack of action and documentation.
A facility failed to implement a policy or educate staff on reverse isolation precautions for an immunocompromised resident with a physician's order for such measures. Staff inconsistently used PPE, and leadership was unclear on the requirements, resulting in inconsistent protection for the resident.
Two residents were not offered annual influenza immunizations during the 2024-2025 season, as confirmed by medical record review and staff interviews, despite facility policy requiring the vaccine to be offered each year.
Required postings with contact information for state agencies and advocacy groups, as well as a statement about filing complaints with the State Survey Agency, were not displayed in any common areas or hallways of one house, affecting all residents living there. The Administrator confirmed the absence of these postings.
Surveyors found that daily nurse staffing information was not posted in the Cornerstone Cottage, as required. This was confirmed by the Administrator and affected all residents living in that area of the facility.
The facility inaccurately submitted staffing data to the CMS PBJ for the first quarter of 2024, indicating insufficient licensed nursing coverage on several days. However, actual staffing schedules and time sheets showed sufficient 24-hour nurse coverage. The Administrator confirmed the error was due to the corporate agency missing data when agency nursing staff was used, potentially affecting all 17 residents.
A resident with severe cognitive impairment alleged being slapped by an STNA, but the facility failed to remove the accused staff member from the schedule during the investigation, contrary to its policy. The STNA continued working while the investigation was conducted, and the allegation was later found unsubstantiated. The facility's policy required immediate removal of accused staff, which was not followed.
Failure to Notify Physician and Representative of Missed Antihypertensives and Elevated BP
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a change in condition and missed medications for a resident with multiple comorbidities. The resident was admitted from the hospital with diagnoses including type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia, and had severe cognitive impairment and dependence on staff for activities of daily living. Hospital discharge orders included multiple antihypertensive medications (lisinopril, amlodipine, atenolol, hydralazine, and hydrochlorothiazide), which were continued in the facility’s physician orders. On the evening of admission, the resident did not receive the evening doses of atenolol and hydralazine, and the following morning did not receive hydrochlorothiazide, lisinopril, or the morning doses of amlodipine, hydralazine, and atenolol. There was no documentation that the physician or family were notified that these medications were not administered. Vital sign records showed elevated blood pressures, including readings in the 160s/80s and a later reading of 193/99, with no documentation of a morning blood pressure on the day after admission. There was no documentation that the physician was notified of the elevated blood pressure of 193/99 after the resident had not received ordered antihypertensive medications. A late-entry nursing note documented that the resident’s blood pressure was elevated, that medications had just arrived from the pharmacy, and that a family member at the bedside was concerned; however, facility records showed that the ordered antihypertensive medications were already available on hand. The DON confirmed that medications were not administered as ordered, that available medications should have been used, and that the nurse should have clarified pre-transfer medications and notified the physician and family of the missed doses and elevated blood pressure. Facility policies required notification of the physician and resident representative for changes in condition and physician notification when medications are withheld.
Failure to Provide Ordered Nutritional Supplements With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements to residents as specified in their physician orders and care plans. One resident with severe cognitive impairment, dementia, depression, dysphagia, and dependence on staff for feeding had care plan interventions for staff to feed all meals and snacks and physician orders for a regular diet with pureed texture and mildly thick liquids. The care plan and orders included a health shake with meals for weight gain and a magic cup with meals, to be offered alternating with bites of food per speech therapy. During a breakfast observation, the resident was fed oatmeal, eggs, fruit, and thickened juice by a CNA, but the magic cup was not provided in between bites of food, and the health shake was not provided at all. The CNA confirmed awareness that the resident should receive a magic cup but did not know it was to be given between bites and was unaware of the health shake order, despite diet orders being available in the kitchen. Another resident with hyperkalemia, chronic fatigue, weakness, moderate cognitive impairment, and risk for altered nutrition and hydration status had care plan interventions to offer substitutes when meal intake was less than 50%, monitor weights, and provide nutritional supplements as ordered. The resident’s diet had been changed from mechanically altered to regular with thin liquids, and there was a physician order for a magic cup supplement with meals. During a breakfast observation, the resident was seen eating eggs, bacon, and toast without being offered a magic cup. The CNA later confirmed that the diet card indicated the resident should receive a magic cup with each meal but acknowledged that the supplement was not offered and that they were unaware of the order. The Administrator stated there was no policy on supplemental orders. This deficiency was cited under a complaint investigation.
Failure to Administer Ordered Medications Despite Availability
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders for multiple residents, despite medications being available on site. One resident with type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia was admitted from the hospital with a history of chronically elevated systolic blood pressure up to the 190s and severe cognitive impairment, dependent on staff for activities of daily living. Hospital discharge orders and subsequent physician orders included multiple antihypertensives, insulin aspart on a low-dose sliding scale, and several other medications. On the evening of admission, the resident did not receive ordered doses of amlodipine, hydralazine, and trazodone, and blood sugar was not monitored and insulin was not administered. The following day, the resident did not receive hydrochlorothiazide, lisinopril, morning doses of amlodipine and hydralazine, atenolol, fenofibrate, pantoprazole sodium, pregabalin, and sertraline, even though the facility’s Medication Inventory on Hand report showed these medications were available. The DON confirmed the medications were not administered per physician orders and that the nurse should have used medications on hand and clarified which medications the resident had been receiving prior to leaving the hospital. Another resident with Parkinson’s disease with dyskinesia, hypertension, atrial fibrillation, and gait and mobility abnormalities, and with severe cognitive impairment, was admitted with hospital orders for carbidopa-levodopa 25/100 mg three times daily. The physician orders at the facility also reflected carbidopa-levodopa 25/100 mg three times daily. Review of the MAR showed that the resident did not receive the evening and bedtime doses of carbidopa-levodopa on one day, and did not receive the bedtime dose the following day. The Medication Inventory on Hand report indicated that carbidopa-levodopa was available for administration, and nursing notes contained no documentation that the resident refused the medication. The DON verified that the medication was not administered as ordered, despite being available in the facility. A third resident with acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension, and with intact cognition, was admitted with hospital discharge orders for carvedilol 6.25 mg twice daily. The facility’s physician order mirrored this, specifying carvedilol 6.25 mg twice daily for hypertension, to be held only if systolic blood pressure was less than 100 or pulse was less than 60 beats per minute. On the evening of admission, the resident’s vital signs showed a blood pressure of 116/59 and heart rate of 84, which did not meet the hold parameters. However, the MAR indicated that the evening dose of carvedilol was not administered, and nursing notes did not document any refusal. The Medication Inventory on Hand report showed carvedilol was available, and the DON confirmed that the medication was not administered per physician orders. Facility policies required medications to be administered according to written physician orders and allowed use of on-hand medication supply when pharmacy medications were not yet delivered, but these procedures were not followed in the cited instances.
Failure to Administer Available Ordered Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to not administering ordered medications despite their availability. One resident with type 2 diabetes, chronic kidney disease, hypertension, and hypokalemia was admitted with a history of chronically elevated systolic blood pressure up to the 190s and had multiple antihypertensive medications ordered from the hospital, including lisinopril, amlodipine, atenolol, hydralazine, and hydrochlorothiazide. Facility physician orders mirrored these medications, but the evening doses of atenolol and hydralazine on the day of admission were not given, and the following day the resident did not receive hydrochlorothiazide, lisinopril, or the morning doses of amlodipine, hydralazine, and atenolol. Blood pressure readings during this period showed elevated values, including 193/99, and a late-entry nursing note documented that the resident’s blood pressure was elevated and that medications had just arrived from the pharmacy, even though the facility’s Medication Inventory on Hand report showed all ordered antihypertensives were available. Another resident with Parkinson’s disease with dyskinesia, hypertension, atrial fibrillation, and gait abnormalities had a hospital order for carbidopa-levodopa 25/100 mg three times daily. The facility’s physician orders continued carbidopa-levodopa three times daily, though it was incorrectly indicated for convulsions. The MAR showed that this resident did not receive the evening and bedtime doses of carbidopa-levodopa on the first day and did not receive the bedtime dose the following day, despite the medication being available per the Medication Inventory on Hand report. Nursing documentation for those days did not indicate that the resident refused the medication, and the DON confirmed that the medication was not administered as ordered. A third resident with acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension was discharged from the hospital with an order for carvedilol 6.25 mg twice daily. The facility’s physician order matched this, including parameters to hold the dose if systolic blood pressure was less than 100 or pulse was less than 60. On the day of admission, the resident’s blood pressure and heart rate were within the parameters for administration, but the evening dose of carvedilol was not given according to the MAR. Nursing notes did not document any refusal of the medication, and the Medication Inventory on Hand report showed carvedilol was available. The DON verified that this resident’s medication was also not administered per physician orders. Facility policies required medications to be administered according to written physician orders and directed staff to use on-hand medication supplies when pharmacy medications were not yet available.
Incorrect Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the correct advance directive status for Resident #7 was documented in the medical chart and on the nurse and CNA report sheet. Resident #7 was admitted with diagnoses including unspecified dementia, hypothyroidism, and major depressive disorder, and the quarterly MDS showed impaired cognition and the need for supervision or touching assistance with ADLs. The care plan identified the resident as DNRCC, and the EMR contained an order dated 09/11/25 for DNRCC. Despite this, the nurse and CNA report sheet listed Resident #7 as DNRCCA. During interview, CNA #360 confirmed the report sheet showed DNRCCA and stated the CNAs were instructed to call the nurse if a resident were found not breathing. The DON also confirmed the report sheet listed Resident #7 as DNRCCA and acknowledged the resident was actually DNRCC. The facility policy stated that on admission the facility will determine whether the resident has executed an Advance Directive and record it in the medical record.
Failure to Complete Weekly Skin and Wound Assessments
Penalty
Summary
The facility failed to ensure skin breakdown was timely identified and reported for a resident with Alzheimer’s disease, osteoarthritis, hypertension, anxiety disorder, severe cognitive impairment, incontinence, dependence for toileting, and substantial to maximal assistance needs for bed mobility and transfers. The resident was at risk for skin breakdown and had a stage 3 pressure ulcer, and later was admitted to hospice services. A skin risk assessment identified moderate risk for skin breakdown, but the nurses did not complete weekly skin assessments from 10/12/25 through 11/06/25. A physician wound progress note on 10/24/25 documented a stage 2 pressure ulcer of the left buttock with moderate drainage. The wound evaluation scheduled for 10/31/25 was rescheduled because the resident was asleep in the recliner and nursing requested to reschedule, and no follow-up wound evaluation was completed from 10/25/25 through 11/06/25. Body audit shower sheets dated 10/31/25 and 11/05/25 did not document new skin breakdown. On 11/07/25, the left buttock pressure ulcer was documented as healed, and a new stage 3 pressure ulcer to the sacrum/coccyx was identified and noted as present for greater than five days. The DON verified the facility had not reattempted the wound evaluation after rescheduling and that nursing staff had not completed a weekly skin assessment to identify new skin breakdown.
Failure to Use PPE During EBP Care
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) was worn during care for a resident on enhanced barrier precautions (EBP). Resident #18 was admitted with diagnoses including Alzheimer's disease, unspecified protein-calorie malnutrition, and occlusion and stenosis of an unspecified carotid artery. The quarterly MDS showed impaired cognition and a pressure ulcer dressing, and the care plan documented an actual unstable wound to the coccyx with interventions for turning and repositioning and weekly skin screening. The care plan dated 12/07/25 contained no care plan for EBP, and the physician's orders for Resident #18 also contained no orders for EBP. On 03/25/26, the resident's bedroom door had a sign stating EBP precautions, with staff to wear gown and gloves for high-contact resident care. During observation on 03/26/25, two CNAs provided incontinence care to Resident #18 without wearing PPE. Both CNAs confirmed during interview that Resident #18 was on EBP and that they were not wearing PPE. The Administrator later confirmed that Resident #18 was on EBP and also confirmed there were no orders in the resident's medical chart for EBP precautions. The facility policy titled Isolation Precautions Process stated that EBP would be used for residents with wounds during their entire stay and that gloves and gowns should be worn during high-contact resident care, including hygiene, dressing, and wound care.
Failure to Ensure Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed transferring a resident using a mechanical lift without the required assistance of a second staff member. The resident involved had significant medical conditions, including macular degeneration, dementia, osteoporosis, arthropathy, abnormalities of gait and mobility, and muscle weakness. The resident was unable to speak, had severe cognitive impairment, and was dependent on staff for all care and transfers, as documented in her care plan and Minimum Data Set (MDS) assessment. The care plan specifically required the use of a mechanical lift with two staff members for all transfers. Despite facility policy and training that mandated two staff members for mechanical lift transfers, the CNA reported routinely performing these transfers alone. The administrator and director of nursing confirmed that staff were trained to use two-person assistance for mechanical lift transfers, and the manufacturer's instructions indicated that the facility was responsible for determining when two-assist transfers were necessary. The observation and staff interviews demonstrated non-compliance with both facility policy and the resident's care plan requirements.
Deficient Food Storage, Labeling, and Dating Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and labeling practices within the facility. In the Cornerstone Cottage, refrigerators and freezers contained numerous unlabeled and undated food items, including containers with unknown substances, pastries, cake, donuts, sausage patties, lunchmeat, bacon, potato casserole, oats, and cheese. Some items were also found to be expired. Additionally, there was no thermometer present in the refrigerator, contrary to facility policy. These findings were verified by a Certified Nursing Assistant during the inspection. Further observations in the [NAME] House revealed that boxes of nutritional shakes and tube feeding formula were stored directly on the floor in the dry storage area, and refrigerators and freezers contained more unlabeled, undated, and expired food items, including sausage patties, soup, cottage cheese, sliced peaches, coleslaw, bacon, and a paper bag with moldy bread. A Registered Nurse confirmed these findings. Facility policies required all prepared food to be covered, dated, and labeled, and for food containers to be stored at least six inches off the floor, which was not followed in these instances. The census at the time was 17 residents, all of whom could have been affected by these deficiencies.
Failure to Ensure Call Light Accessibility for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that the call light pendant was within reach for a resident who was severely cognitively impaired, used a wheelchair, and required moderate assistance with activities of daily living. Medical record review indicated the resident had multiple diagnoses, including Alzheimer's disease, osteoporosis, osteoarthritis, hyperlipidemia, heart failure, and anxiety. On multiple occasions, observations revealed the resident was either lying in bed or sitting in a wheelchair without the call light pendant within reach. Staff interviews, including those with the Wellness Director, RN, and DON, confirmed that the call light was not accessible to the resident during these times, despite the expectation that it should be.
Failure to Develop Dehydration Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to develop a care plan addressing dehydration for a resident with a known risk and history of dehydration. Medical record review showed that the resident, who had dementia, dysphagia, severe cognitive impairment, and was dependent on staff for feeding, was admitted with physician orders for a puree diet and thickened liquids. Following a hospitalization for dehydration, discharge orders specified a required daily water intake. Despite these risk factors and medical directives, the resident's comprehensive care plan did not include any goals or interventions for dehydration prevention. This omission was confirmed during a staff interview, which verified the absence of measurable goals and interventions related to dehydration in the care plan.
Failure to Provide Timely Bowel Care and Physician Notification
Penalty
Summary
A resident with diagnoses including dementia, generalized muscle weakness, thoracic disc degeneration, aphasia, and osteoporosis was admitted to the facility and had a physician order for Docusate Sodium 100 mg twice daily for constipation. The resident was severely cognitively impaired, required substantial to maximum assistance with toileting, and was continent of bowel according to the most recent MDS assessment. Medical record review revealed that the resident did not have a recorded bowel movement for six consecutive days. During this period, there was no documentation of nursing interventions or physician notification regarding the absence of bowel movements. Additionally, there was no bowel protocol in place for the resident. The DON confirmed that no interventions were initiated and acknowledged that six days without a bowel movement was excessive.
Failure to Implement and Educate Staff on Reverse Isolation Precautions
Penalty
Summary
The facility failed to ensure there was a policy and procedure in place for reverse isolation, and staff were not knowledgeable about the requirements for reverse isolation as ordered by the physician for a resident who was immunocompromised. The resident, who had diagnoses including pancytopenia and immunodeficiency due to drugs, was admitted with a physician's order for reverse isolation following critically low white blood cell and platelet counts. Despite the order, staff actions were inconsistent: some staff entered the resident's room without donning personal protective equipment (PPE), and there was confusion among staff and leadership regarding what reverse isolation entailed. Observations confirmed that signage and PPE were inconsistently used, and staff interviews revealed varying interpretations of the reverse isolation order, with some staff believing PPE was no longer required and others unsure of the specific precautions needed. Further interviews with the DON, who also served as the facility's Infection Preventionist, and the Administrator confirmed that the facility did not have a policy covering reverse isolation and had not clarified the physician's order. The physician indicated that the use of PPE would depend on the facility's policy, but no such policy existed. This lack of clear policy and staff education resulted in inconsistent implementation of reverse isolation precautions for the immunocompromised resident.
Failure to Offer Annual Influenza Immunizations
Penalty
Summary
The facility failed to offer annual influenza immunizations to two of five residents reviewed for immunizations during the 2024-2025 influenza season, despite having a policy in place requiring annual influenza immunizations to be offered between October 1st and March 31st. Medical record reviews for two residents showed no evidence that they were offered the influenza vaccine for the specified season. Interviews with the Administrator and DON confirmed that these residents had not been offered the immunization as required by facility policy. The facility census at the time was 17 residents.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to display a list of names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, as well as a statement informing residents of their right to file a complaint with the State Survey Agency. This deficiency was identified through observation and staff interview, which revealed that the required postings were not present in any common areas or hallways of the Cornerstone Cottage, affecting all ten residents residing there. The Administrator confirmed that the necessary information was not posted, and the facility census at the time was seventeen residents. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted as required in the Cornerstone Cottage. Upon arrival and during subsequent observations, surveyors noted that there was no daily nurse staffing information displayed in any of the common areas or hallways of the Cornerstone Cottage. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the required nurse staffing information was not posted. The lack of posted staffing information affected all ten residents residing in the Cornerstone Cottage at the time of the survey, with the facility census being seventeen.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the CMS Payroll-Based Journal (PBJ) for the first quarter of 2024. Upon review, it was found that the facility was flagged for not having licensed nursing coverage 24 hours a day on multiple specific dates. However, the staffing schedule and time sheets indicated that there was indeed sufficient nurse staffing for 24 hours on each of the days identified as deficient in the PBJ. This discrepancy suggests that the data entered into the PBJ did not accurately reflect the actual staffing levels. The Administrator confirmed that the data entered into the PBJ was inaccurate, attributing the error to the corporate agency responsible for entering the data, which failed to include information when agency nursing staff was used. This oversight had the potential to affect all residents, as the facility census was 17 at the time. The Administrator acknowledged the issue and indicated that an audit of all facilities was underway to ensure the problem was corrected.
Failure to Remove Accused Staff During Abuse Investigation
Penalty
Summary
The facility failed to implement its policy regarding the removal of staff accused of abuse during an investigation. A resident, who was severely cognitively impaired and had a history of anxiety and delusions, alleged that a State Tested Nursing Assistant (STNA) slapped her. Although a skin assessment showed no marks and the resident's story changed, the facility's policy required the immediate removal of the accused staff member from the facility and the schedule pending the investigation's outcome. However, the STNA continued to work during the investigation period, contrary to the facility's policy. The Director of Nursing (DON) and the Administrator confirmed that the STNA was not removed from the facility but was instead moved to another building. The facility's investigation concluded that the allegation was unsubstantiated, but the failure to follow the policy regarding staff removal during the investigation was identified as a deficiency. The facility's policy, revised in October 2022, clearly stated that any staff member accused or suspected of abuse should be immediately removed from the facility and the schedule, which was not adhered to in this case.
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Illustrative
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lakeside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Care Center | 7.6 mi | ★★★★★ | 4 | 0 |
| Ohio Veterans Home | 9.1 mi | ★★★★★ | 5 | 1 |
| Concord Care And Rehabilitation Center | 9.6 mi | ★★★★★ | 0 | 0 |
| Edgewood Manor Rehabilitation & Healthcare Center | 9.7 mi | ★★★★★ | 2 | 0 |
| Parkvue Health Care Center | 10.4 mi | ★★★★★ | 11 | 0 |
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