Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Park Center Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Failure to provide privacy during personal care: A resident with Alzheimer's disease, stroke, diabetes, depression, arthritis, and muscle weakness was observed being cleaned and changed after a BM with the bedroom door open, the privacy curtain not drawn, and the resident exposed while facing the door. The CNA confirmed she did not close the door or draw the curtain during the care.
Failure to assess and periodically reassess a seatbelt restraint for a resident. A resident with MS, chronic pain, anxiety, and depression was observed using a seatbelt on her wheelchair even though the MDS, physician orders, care plan, and progress notes did not document restraint use. The resident said she wore it for security and could self-release it, and an LPN and CNA confirmed staff knew about the seatbelt but had no assessment or direction tied to its use.
A resident with multiple diagnoses, including COPD and dementia, was identified as requiring supervision for smoking, and his care plan directed that he always be supervised. Staff gave conflicting accounts about his smoking privileges, and during observation he was smoking in the pavilion while an Activities Assistant stayed nearby but later left without bringing him inside. The Administrator confirmed there was no fire blanket or fire extinguisher in the smoking area, despite the facility policy requiring direct supervision for residents with restricted smoking privileges.
A resident with multiple chronic diagnoses, including kidney failure, dementia, heart failure, and psychiatric conditions, did not have ordered lab monitoring completed as scheduled. Orders included periodic Depakote levels, Hgb A1c, and LFTs, but the record showed the labs were not obtained at the required intervals, and an LPN/ADON confirmed the missed lab work.
Inaccurate Documentation of Splint Refusal: A resident with Alzheimer's disease, stroke-related right-sided weakness, and a right hand contracture had a physician order for a daytime right hand splint, but the care plan did not address the splint and the TAR documented daily use with no refusals. Observation found the splint not in use, staff stated the resident had refused it for about a year, and interviews confirmed refusals or unsuccessful attempts were supposed to be documented in the medical record.
Failure to use EBP during wound care was observed for a resident with a diabetic foot ulcer and diagnoses including vascular dementia and DM with hyperglycemia. During the dressing change, the ADON used gloves and hand hygiene but did not wear a gown as required, despite EBP signage and PPE being available nearby. The ADON confirmed the gown was not worn, and the facility policy stated that gowns and gloves are required for wound care.
The facility did not ensure food was served at palatable temperatures, affecting several residents. An LPN and residents reported issues with cold and unpalatable food, including spoiled milk and hard food. Observations confirmed inadequate food temperatures, with brussels sprouts being barely warm. The facility's policy lacked specific temperature guidelines.
A facility failed to involve a resident's Power of Attorney in care planning, affecting a resident with severe cognitive impairment and multiple diagnoses. Despite the facility's policy to include responsible parties in care conferences, the resident's representative was not contacted about changes in the resident's condition or invited to care meetings. Facility staff confirmed the lack of documentation for such invitations, and a care conference was missed.
A resident with Alzheimer's and other health issues experienced a significant decline in their ability to perform ADLs, including increased assistance needed for transfers and incontinence. Despite these changes, the facility failed to notify the resident's physician and responsible party in a timely manner, as required by their policy. Interviews with staff confirmed awareness of the decline, but communication with the family and physician was lacking.
A resident with Alzheimer's and other conditions experienced a decline in continence without a scheduled toileting program being implemented. Despite assessments indicating a need for such a program, facility staff did not establish one, and the resident's family was not informed of the incontinence issue. Interviews with staff confirmed the oversight, and the resident's decline in mobility was noted during therapy.
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, with issues such as holes in drywall, scuff marks, chipped paint, and dirt build-up in elevators and hallways. Residents expressed a desire for updates, and staff confirmed these observations, indicating non-compliance with the facility's policy on maintaining a homelike environment.
The facility failed to properly store and serve food, affecting all 92 residents. Undated food items were found in the refrigerator, and two dietary aides were observed without hair nets during tray service. The Director of Kitchen Operations confirmed these practices violated the facility's policies on food storage and dress code.
The facility failed to maintain a clean and homelike environment, affecting multiple residents. Observations revealed an overflowing sharps container, built-up dirt, and dried spit in a resident's room. Another hall had a black substance along baseboards, food and clothing on the floor, and uncleaned coffee spills. An LPN confirmed floors were not cleaned on weekends, despite policies requiring daily cleaning.
The facility failed to provide therapeutic activities as scheduled and in the evenings, affecting all 92 residents. Activity calendars showed a lack of scheduled activities after 4:00 P.M. and minimal weekend activities. Residents and staff reported dissatisfaction with the activity program, and the Activity Director admitted to not scheduling one-on-one visits or documenting refusals. The facility's policies on programming and preparation for activities were not followed.
The facility failed to store Tuberculin Purified Protein and Lispro Insulin properly, as both were found undated in the medication storage room. This deficiency affected a resident prescribed Lispro Insulin and had the potential to affect all residents in the facility.
The facility failed to ensure they had a qualified food service director, affecting all 92 residents who received food from the kitchen. The FSD had no formal dietary education, lacked necessary certifications or experience, and the quality of food was a significant issue. Interviews and record reviews confirmed the FSD did not meet the qualifications outlined in the facility's job description.
The facility failed to ensure a well-balanced menu in terms of calcium sources for all residents. Observations and interviews revealed that almost no residents were receiving milk with their lunch and dinner trays, and alternative calcium sources were not offered. The facility had communicated that milk would only be served at breakfast unless requested, but this information was not consistently provided to new residents. Dietary preferences were not consistently obtained or documented.
The facility failed to honor resident food preferences and provide appropriate substitutions, leading to widespread dissatisfaction with the food service. Residents were not routinely asked about their preferences, and alternate meal options were not provided if they disliked the scheduled menu items. The facility's policies on menus and resident rights were not being followed, contributing to ongoing issues with food quality and menu options.
The facility failed to follow proper sanitation practices in the kitchen and during meal tray delivery, including not washing hands, wearing artificial nails, improper sanitization of utensils, and delivering uncovered beverages. These actions were confirmed by the Food Service Director and violated the facility's policies.
The facility failed to maintain proper sanitation around the dumpster area, with one lid open and significant debris buildup, including medical gloves, plastic spoons, cigarette butts, and paper towels. The Food Service Director confirmed the area should be kept clean and the lids closed, as per facility policy.
The facility failed to administer its resources effectively and efficiently, impacting the well-being of all 92 residents. Issues included a lack of therapeutic activities, inadequate infection control measures, dietary issues, and environmental deficiencies. The Administrator and DON did not have effective systems in place to identify and correct these concerns, leading to substandard quality of care.
The facility failed to address ongoing food quality concerns, affecting all 92 residents. Food audits and Resident Council meetings revealed consistent dissatisfaction with food quality, lack of variety, and insufficient portions. Despite awareness of these issues, the administration and Food Service Director did not take effective corrective actions. The facility's QAPI plan was not effectively implemented to resolve the identified problems.
The facility failed to follow appropriate infection control procedures, including TBP and EBP, separation of clean and dirty linens, and proper storage of medical equipment. Staff lacked formal education on these precautions, and medical records showed no physician's orders for many residents. Additionally, the facility did not have an effective Legionella water management program.
The facility failed to provide knives on meal trays, affecting 64 residents, and did not ensure a privacy curtain for a resident, compromising their dignity and privacy. Despite having an adequate supply of knives and a request for a privacy curtain, the issues were not addressed, violating the facility's policies on resident rights and a homelike environment.
The facility failed to resolve ongoing food-related concerns expressed by residents, including repetitive meals, insufficient portions, and lack of alternatives for disliked items. Despite repeated complaints in Resident Council meetings and interviews, the Food Service Director's responses were unsatisfactory, and the Administrator was often too busy to address the concerns. The issues persisted due to inadequate follow-up and checks.
The facility failed to repair or replace broken window blinds for 14 residents and did not provide an adequately clean room for one resident. Observations revealed built-up visible dust and broken window blinds, which were confirmed by STNAs. The Director of Environmental Services acknowledged the issues but admitted that monthly audits for repairs or cleanliness were not conducted.
The facility failed to ensure proper storage and administration of oxygen and nebulizers according to physician's orders, affecting five residents. Observations revealed undated and improperly stored equipment, with staff confirming these deficiencies.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. One resident's call light was hanging out of reach, and another's call light had fallen behind a dresser, making it inaccessible.
The facility failed to maintain a resident's funds under the Medicaid limit and did not notify the guardian when the funds exceeded the limit. The resident had multiple diagnoses, including secondary Parkinsonism and schizophrenia.
The facility failed to document a resident's end-of-life wishes in the medical record, despite the resident being cognitively intact and having multiple diagnoses. An LPN confirmed the absence of a code status in the EMR, contrary to facility policy.
The facility failed to thoroughly investigate potential resident-to-resident abuse, affecting two residents with severe cognitive impairments. The investigation did not include interviews or skin assessments of other residents on the unit, and there was no evidence of staff education on abuse following the incident.
The facility failed to ensure accurate dental status documentation for two residents. One resident's MDS assessment did not reflect missing teeth, and another's MDS assessment inaccurately stated the presence of natural teeth despite the resident not having any. An LPN confirmed these inaccuracies.
The facility failed to update care plans for three residents to reflect their current needs, including psychosis, dementia, and significant weight loss. Interviews with staff confirmed the deficiencies.
The facility failed to provide consistent showers and nail care according to resident preferences, affecting two residents. One resident did not receive showers as per his preference and physician's orders, while another had long and dirty fingernails despite expressing a desire to have them trimmed. Interviews and observations confirmed these deficiencies.
The facility failed to ensure adequate supervision and safety measures for three residents, leading to deficiencies in accident prevention. One resident at risk for elopement was found unsupervised outside, another resident with cognitive impairment was observed smoking unsupervised without a required apron, and a third resident at high risk for falls was found without necessary fall prevention interventions in place.
The facility failed to ensure accurate weights were obtained as ordered for two residents, leading to a deficiency in maintaining proper nutrition and hydration. Both residents had gaps in their weight records, and staff interviews confirmed that weights were not consistently obtained despite reminders.
The facility failed to ensure accurate dialysis orders and complete pre and post dialysis assessments for a resident with end stage renal disease. The resident's medical record showed missing vitals and weights on several occasions, and staff interviews confirmed inconsistent assessment practices and unclear blood draw instructions.
The facility failed to ensure staff were aware of known PTSD triggers for three residents, leading to inadequate care plans and lack of specific interventions. Despite residents communicating their triggers, this information was not included in their care plans or made accessible to staff.
The facility failed to document appropriate justifications for declining a GDR recommendation for a resident. The resident, with multiple diagnoses including dementia, was on Olanzapine. A pharmacist recommended clarifying the diagnosis and updating the EMR, but this was not addressed by the psychiatric nurse practitioner. An LPN confirmed the recommendation was not addressed, contrary to facility policy.
The facility failed to ensure non-pharmacological interventions were attempted before administering pain medication to a resident with multiple diagnoses, including COPD and lung cancer. The resident received morphine even when reporting a pain level of zero, and the LPN confirmed that non-pharmacological interventions were not documented. The facility's pain management policy was not followed.
The facility failed to ensure appropriate diagnoses for medications and did not track behaviors for medication efficacy for three residents. Medications were prescribed without documented indications, and behavior tracking was not conducted as required by facility policy.
The facility failed to document daily weights for a resident with congestive heart failure, did not ensure a resident's diet order matched their dietary needs, and lacked documentation of weekly body audits for a resident with a Stage IV pressure ulcer. These deficiencies were confirmed by the ADON and RD.
The facility failed to ensure a functional call light system for three residents, affecting their ability to request assistance. Despite residents reporting non-functional call lights, no work orders were submitted, and the maintenance department did not conduct routine audits. This oversight compromised resident safety and care.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to ensure Resident #80 was provided privacy while being changed after a bowel movement. Resident #80 was admitted on 11/08/19 and had diagnoses including Alzheimer's disease, stroke affecting the right dominant side, diabetes, right hand contracture, depression, arthritis, and muscle weakness. The quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired and required varying levels of assistance with activities of daily living, including substantial or maximum assistance with toileting. During observation on 08/06/25 at 2:48 P.M., the resident's bedroom door was open while CNA #619 was assisting him with cleanup and changing after a bowel movement. The resident was rolled onto his right side, facing the door, with no clothing on, and the privacy curtain was not drawn. CNA #619 confirmed during interview that she was assisting in cleaning and changing the resident and did not close the door or draw the privacy curtain. The facility policy titled Dignity, dated February 2021, stated the facility would promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care.
Failure to Assess and Reassess Seatbelt Restraint Use
Penalty
Summary
The facility failed to ensure a comprehensive assessment and periodic reassessments were completed for a seatbelt restraint used by Resident #88. Resident #88 was admitted with diagnoses including MS, chronic pain syndrome, migraine, anxiety, and major depressive disorder. Her 07/04/25 quarterly MDS showed she was alert and oriented to person, place, and time, did not have any restraints including chair or trunk restraints, and was dependent on her wheelchair for movement around the facility. The current physician orders and care plan contained no order or mention of a seatbelt or trunk restraint, and progress notes before 08/06/25 did not mention her using one. During observation on 08/04/25, Resident #88 was seen in her wheelchair with a seatbelt fastened around her abdomen. The Administrator and Assisting Administrator later stated she did not have a seatbelt, and the Clinical Manager also confirmed she did not have one on her wheelchair. On 08/06/25, another observation showed a seat belt on her wheelchair, and Resident #88 stated she liked wearing it because it made her feel more secure and that she sometimes felt like she was going to slide out of her chair. She also stated she could easily take the seatbelt off and on herself. LPN #547 and CNA #562 said they knew she had a seatbelt and used it to feel more secure, and they acknowledged there was no assessment or direction to ask her to release it because it was her choice to wear it. The facility policy required a pre-restraining assessment and review, along with ongoing periodic review of the resident's ability to self-release the restraint.
Unsafe Smoking Supervision and Missing Fire Safety Equipment
Penalty
Summary
The facility failed to ensure safe smoking practices for Resident #83, who had diagnoses including traumatic brain injury, schizoaffective disorder, COPD, dementia, alcohol use, depression, cocaine abuse, and tobacco use. His smoking evaluation identified him as requiring supervision for smoking, and his care plan directed that he always be supervised while smoking. However, staff interviews showed conflicting understanding of his smoking status, with one LPN stating he could smoke without supervision but was expected to do so only at designated smoke times, while the resident stated he could smoke whenever he chose and did not believe he needed supervision. The Activity Director confirmed he was a supervised smoker. During observation, Resident #83 was seen smoking in the pavilion while an Activities Assistant remained in the area with him and other residents for about 20 minutes. The Activities Assistant later confirmed she had been supervising smokers but left without asking Resident #83 to come inside, stating he was often noncompliant with the policy. The Administrator confirmed there was no smoke blanket or fire extinguisher in the smoking pavilion. The facility policy required residents with restricted smoking privileges to have direct supervision at all times while smoking.
Lab Orders Not Completed as Ordered
Penalty
Summary
The facility failed to ensure lab work was obtained as ordered for one resident. Resident #5 was admitted on 10/18/21 and had diagnoses including respiratory failure, kidney failure, dementia, heart failure, schizoaffective disorder, bipolar disorder, and depression. The quarterly MDS assessment identified the resident as cognitively intact, independent in eating, requiring supervision or touch assistance for oral and personal hygiene, and needing partial to moderate assistance for showering and toileting. Physician orders for August 2025 included a Depakote level and Hemoglobin A1c every six months, beginning 06/20/24, and LFTs every three months, beginning 04/09/24. Review of the lab record showed the Hemoglobin A1c was last completed on 12/23/24, and both the Depakote level and LFTs were last drawn on 04/11/25. During interview on 08/07/25, the LPN/ADON confirmed the labs had not been drawn as ordered for Resident #5. The facility policy stated that staff would process test requisitions and arrange for tests and lab results.
Inaccurate Documentation of Splint Refusal
Penalty
Summary
The facility failed to ensure Resident #80's medical record accurately reflected refusal of the right-hand splint. Resident #80 was admitted with diagnoses including Alzheimer's disease, stroke affecting the right dominant side, diabetes, right hand contracture, depression, arthritis, and muscle weakness. The quarterly MDS described him as moderately cognitively impaired with functional limitations in range of motion on one side. His physician's order required a right hand splint during the day and removal at night for contracture management, but the care plan did not include the splint order or related interventions, and the July 2025 TAR documented the splint as applied each day and removed each night with no refusals recorded. Observation on 08/04/25 found Resident #80 lying in bed with his right hand contracted and no splint in use. Staff interviews confirmed the resident had not worn the splint for at least one year because he refused it, and the splint was found in the top drawer of his bedside table. A CNA stated she had no knowledge of the splint and had never assisted with applying it, while another CNA and the staffing coordinator acknowledged that refusals or unsuccessful attempts to apply the splint should be documented in the medical record. The resident stated the splint was uncomfortable and he would not wear it if asked, and the Rehab Director confirmed staff should be documenting attempts and refusals and that splint use should be included in the care plan.
Failure to Use EBP During Wound Care
Penalty
Summary
The facility failed to utilize enhanced barrier precautions (EBP) during wound care for one resident who had a diabetic ulcer to the left lateral foot. The resident had diagnoses including vascular dementia and diabetes mellitus with hyperglycemia, and the wound required dressing changes three times weekly. Physician orders directed staff to cleanse the wound, apply betadine, place calcium alginate, and cover with an abdominal dressing and gauze wrap. During observation of wound care, the Assistant Director of Nursing entered the room with EBP supplies available nearby and performed the dressing change using gloves, glove changes, and handwashing, but did not don a gown for EBP at any point during the procedure. The wound care included removal of the soiled dressing, cleansing of the wound, and application of the ordered clean dressings without the required gown. The ADON confirmed during interview that a gown was not worn as required. The facility policy stated that EBP apply when a resident has a wound and that gloves and a gown are to be worn before high-contact resident care activity, including wound care.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at appropriate temperatures, affecting four out of six residents reviewed for food and nutrition. Interviews with an LPN and several residents revealed complaints about food being served cold and not being palatable. One resident reported receiving spoiled milk, and another mentioned that the food was sometimes too hard. These issues were corroborated by observations during a tray line inspection, where food temperatures were recorded as being below the expected levels for hot food, with pasta and brussels sprouts not reaching adequate temperatures. The facility's policy on Food and Nutrition Services, dated October 2017, stated that residents should be provided with a nourishing and palatable diet, but it did not specify a temperature range to maintain palatable food temperatures. During the inspection, the Dietary Manager verified that the temperatures of various food items, including iced tea, milk, mandarin oranges, pasta with sausage, and brussels sprouts, were not within acceptable ranges, with the brussels sprouts being barely warm. This deficiency was investigated under Complaint Number OH00160967.
Failure to Involve Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's responsible party was included in the development and revision of the care plan. This deficiency affected a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, anxiety disorder, chronic ischemic heart disease, and type two diabetes. The resident required assistance with certain activities of daily living (ADLs) and had a care plan that included interventions for neurological deficiencies and ADL self-care deficits. Despite these needs, the facility did not involve the resident's Power of Attorney (POA) in care planning discussions. The facility's records showed that the resident's care plan was reviewed and updated, and the resident and family were informed of changes. However, there was no evidence that the resident's representative was included in the quarterly assessments related to care planning. The resident's POA reported not being contacted about changes in the resident's condition or invited to care conferences, except for one near the time of admission. The POA expressed difficulty in communicating with facility staff and a desire to discuss the resident's placement in a secured unit. Interviews with facility staff revealed that care conferences were supposed to occur every three months and that responsible parties were to be invited via phone calls or emails. However, the staff confirmed that there was no documentation of such invitations for the resident's care conferences, and a care conference that should have occurred in October did not take place. The facility's policy emphasized the importance of involving residents and their representatives in care planning, but this was not adhered to in this case.
Failure to Notify of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a change in condition for a resident, identified as Resident #45, to both the resident's primary care physician and responsible party. Resident #45, who had a history of Alzheimer's disease, white matter disease, anxiety disorder, chronic ischemic heart disease, and type two diabetes, experienced a significant decline in their ability to perform activities of daily living (ADLs). This included increased assistance needed for transfers, incontinence of bladder, and extensive assistance required for feeding. Despite these changes, there was no evidence that the resident's physician or responsible party were notified in a timely manner. On January 12, 2025, progress notes indicated that Resident #45 required increased assistance with ADLs and was incontinent of bladder, yet there was no documentation of notification to the physician or responsible party. The following day, the resident appeared fatigued and lethargic, prompting a call to the on-call Nurse Practitioner, who ordered laboratory tests. However, the responsible party was still not informed of these developments. Interviews with facility staff, including a Certified Nursing Assistant and a Registered Nurse, confirmed awareness of the resident's decline, but communication with the family member or physician was lacking. The facility's policy on notification of significant change in resident condition mandates prompt communication with family members or designated Power of Attorney within a reasonable timeframe, typically within 24 hours. Despite this policy, the responsible party, identified as Family Member #672, reported not being informed of the resident's condition changes, including incontinence and the need for incontinence briefs. Interviews with facility staff, including the Social Services Director and Clinical Director, revealed lapses in communication and documentation, contributing to the deficiency identified during the investigation of Complaint Number OH00161689.
Failure to Implement Toileting Program for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #45, was provided with appropriate toileting assistance to maintain their ability to perform activities of daily living, specifically toileting. Resident #45, who had diagnoses including Alzheimer's disease and chronic ischemic heart disease, was initially assessed to have high restorative potential for bowel and bladder continence. However, subsequent evaluations showed a decline to moderate restorative potential, indicating a need for a toileting program, which was not implemented. Despite the resident's care plan indicating the need for supervision and verbal cues for toileting, there was no evidence of a scheduled toileting program or trial to manage the resident's continence. Interviews with facility staff, including a registered nurse and the clinical director, revealed that although the resident was assisted to the bathroom, it was not done on a schedule. The clinical director acknowledged the lack of a scheduled toileting program and could not provide a reason for the oversight. The resident's family member, who was also the power of attorney, was not informed about the resident's incontinence or the use of incontinence briefs until it was mentioned by an aide. The director of nursing confirmed that no scheduled toileting program was implemented, despite the resident's decline in continence. The occupational therapist working with the resident was not informed of incontinence issues, and the resident's decline in mobility was noted during therapy sessions.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple physical environment concerns observed during a survey. On the 300 hallway, there were 12 holes in the drywall, and the elevator near the activities room had excessive scuff marks, chipped paint, and dark debris in the corners. Similar issues were noted with the elevator entrance on the 300-hall. The flooring on the 200 and 300 halls had noticeable dark scuff marks and a build-up of a black, dirt-like substance along the baseboards. Additionally, the 300 hall unsecured unit had a PVC pipe protruding from the wall, and the secured unit had a PVC pipe and metal brackets extending from the wall at shoulder height. Further observations included a detached door frame in a resident's room, a build-up of dark dirt-like substance in the corners of the elevator near the rehab entrance, and a missing corner piece on the hand railing in the 200 hall, exposing a sharp edge. Interviews with several residents revealed a desire for the environment to be updated, and the Housekeeping Supervisor and Maintenance Director confirmed the observations. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, leading to this deficiency, which was investigated under multiple complaint numbers.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and serving of food, which could potentially affect all 92 residents. During a kitchen tour, it was observed that a two-quart container of chicken noodle soup, slices of bologna, sliced ham, hard-boiled eggs, and a package of cake mix were stored without dates in the refrigerator. The Director of Kitchen Operations confirmed these items should have been dated. Additionally, during tray service observation, two dietary aides were found not wearing hair nets, which was verified by the Director of Kitchen Operations as a requirement according to the facility's dress code policy. The facility's policies on food storage and dress code were not adhered to, leading to these deficiencies.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, affecting multiple residents across different halls. During a tour of the building, surveyors observed an overflowing sharps container with used razors in the shower room on Hall 2A, and razors were also found on top of the container. In Resident #42's room, there was built-up dirt in the bathroom corners, and dried spit was found on the floor, wall, and register. These findings were confirmed by a registered nurse and state-tested nurse aides present during the observations. Further observations on Hall 3B revealed a black substance along the baseboards, and Resident #72's room had food and clothing on the floor, along with built-up dirt at the door threshold. In the room shared by Residents #52, #62, and #65, dried and wet coffee was found on the floor, and a garbage can was without a bag. Clothing was also found on the floor. These findings were verified by an LPN, who noted that floors were not cleaned on weekends. The Director of Environmental Services confirmed that resident rooms were supposed to be cleaned daily, as per the facility's housekeeping checklist and room cleaning policy, which were not dated. The facility's Quality of Life-Homelike Environment policy, dated August 2009, emphasized providing a safe, clean, and homelike environment.
Failure to Provide Therapeutic Activities for All Residents
Penalty
Summary
The facility failed to ensure that all residents were provided with therapeutic activities as scheduled and in the evenings to meet their needs and preferences. The activity calendars for several months revealed a lack of scheduled activities after 4:00 P.M. and minimal activities on weekends. Additionally, there were no religious services scheduled for any of the months reviewed, and no specific activity calendar was provided for residents residing on the secured behavior unit (unit 3A). This deficiency affected all 92 residents in the facility, as evidenced by the lack of documented activity attendance and one-on-one visits for many residents. Interviews with residents and staff revealed dissatisfaction with the current activity program. Residents expressed that they were not asked for input on the activities they would like to see offered and that outings had been canceled for several months due to the lack of a driver for the facility van. Several residents reported that they had not received activity packets or one-on-one visits, and some activities listed on the calendar were either canceled or not conducted as scheduled. Staff members also confirmed that the secured unit did not receive updated activity calendars and that residents on this unit were not engaged in meaningful activities. The Activity Director (AD) admitted to not scheduling one-on-one visits and confirmed that the activity staff did not document refusals from residents. The AD also revealed that there was no specific training provided when she took over the position and that the facility did not have a formal checklist for activity director training. The Administrator confirmed that the facility had an operational van, but the AD was not comfortable driving it, resulting in the cancellation of social outings. The facility's policies on programming for residents with cognitive impairments and preparation for activities were not being followed, leading to a significant deficiency in providing meaningful and therapeutic activities for all residents.
Failure to Properly Date and Store Medications
Penalty
Summary
The facility failed to store Tuberculin Purified Protein and Lispro Insulin in a manner that ensures the efficacy of the medications. During an observation of the medication storage room, it was found that an open container of Tuberculin Purified Protein and an open vial of Lispro Insulin for a resident were undated. The package inserts for these medications indicate that Tuberculin Purified Protein should be discarded if in use for more than 30 days, and Lispro Insulin should be used within 28 days of opening. The facility's policy requires that the date of opening be recorded on multi-dose containers, which was not followed in this instance. This deficiency affected one resident prescribed Lispro Insulin and had the potential to affect all residents in the facility, which had a census of 92 at the time of the survey. An interview with the RN confirmed that both vials were undated, and a review of the facility policy corroborated that the date should be recorded on multi-dose containers when opened. The failure to date these medications could lead to the use of degraded or ineffective drugs, compromising resident care.
Unqualified Food Service Director
Penalty
Summary
The facility failed to ensure they had a qualified food service director, which had the potential to affect all 92 residents who received food from the kitchen. The Food Service Director (FSD) #499, who had no formal dietary education and had previously worked as the housekeeping director, was found to be unqualified for the position. The FSD had only a food protection manager certificate and lacked the necessary certifications or experience required for the role. Interviews with the FSD, a resident, and the registered dietitian revealed that the dietitian was not regularly involved in the kitchen, recipes were not always followed, and the quality of food was a significant issue at the facility. The personnel file review confirmed that FSD #499 did not meet the qualifications outlined in the facility's job description for the food service director position. The job description required a certified dietary manager or similar national certification, an associate degree in food service management or hospitality, or at least two years of experience as a director of food and nutrition services in a nursing facility. The FSD's certificate as a food protection manager was deemed equivalent to the ServSafe program but did not meet the higher qualifications required for the role. This deficiency was identified through interviews and record reviews conducted over several days, highlighting the facility's failure to employ a qualified individual to oversee the dietary department and ensure the quality of food service provided to residents.
Deficiency in Providing Calcium Sources in Resident Meals
Penalty
Summary
The facility failed to ensure that the menu was well-balanced in terms of calcium sources for all residents. This deficiency was identified through observations, interviews, and policy reviews. Specifically, it was noted that almost no residents were receiving milk with their lunch and dinner trays, despite the menu indicating that milk should be provided at all meals. The facility had sent letters to residents stating that milk would only be served at breakfast unless requested otherwise, but this information was not included in the admission packet or consistently communicated to new residents. Additionally, alternative calcium sources such as yogurt or cottage cheese were not offered to residents who did not want milk. Interviews with residents and staff revealed that dietary preferences were not being consistently obtained or documented, and residents were not aware of their options for calcium intake. The dietary cook confirmed that beverage carts were stocked with Kool-Aid and coffee, but not milk. The dietitian acknowledged the lack of documentation regarding residents' preferences for milk or calcium alternatives. The administrator admitted that the facility had not offered other calcium options at lunch and dinner and was unsure how new residents would be informed about the milk policy. The facility's policy stated that menus should provide a variety of foods from the basic daily food groups and offer alternatives if a food group was missing, but this was not being followed in practice.
Failure to Honor Resident Food Preferences and Provide Appropriate Substitutions
Penalty
Summary
The facility failed to ensure resident food preferences were honored and appropriate substitutions were made per resident preferences. Observations and interviews revealed that residents were not offered alternate vegetables or meal options if they disliked the scheduled menu items. For instance, during a meal service, no alternate vegetable was prepared, and residents who disliked the main dish were not provided with suitable alternatives. The Food Service Director confirmed that the facility did not offer a select menu, and residents were served whatever the kitchen prepared, which often did not align with their preferences. Additionally, the number of meal item dislikes that could be listed on a resident's tray card was limited, leaving staff to memorize multiple dislikes, which was not always feasible. Interviews with residents and staff highlighted ongoing dissatisfaction with the food quality and menu options. Residents reported that they were not routinely asked about their food preferences and that substitutions were not offered if they disliked certain items. For example, if a resident did not like peas, no alternate vegetable was provided. The Dietary Supervisor admitted to not preparing alternate vegetables and stated that requests for specific items like grilled cheese sandwiches were sometimes refused due to staffing issues. The Dietitian confirmed that food preferences were not routinely documented or honored, and there was no system in place to offer calcium alternatives when milk was not served at lunch and dinner. The facility's policies on menus and resident rights were not being followed. The Resident Council was supposed to be included in menu planning, and menus were to provide a variety of foods from the basic daily food groups. However, residents were not being offered alternate means of meeting their nutritional needs when certain food groups were missing from their diet. The Administrator acknowledged that residents were not happy with the menu and that the facility had not effectively communicated changes in meal service, such as the decision to serve milk only at breakfast unless requested. This lack of communication and failure to honor resident preferences contributed to widespread dissatisfaction with the food service at the facility.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure proper sanitation practices in the kitchen and during meal tray delivery, potentially affecting all 92 residents. Observations revealed that Dietary Cook and Dietary Aide did not wash their hands upon returning to the kitchen after delivering meal trays. Additionally, the Dietary Cook was observed wearing artificial nails with three-dimensional art, which is against the facility's dress code policy. The Food Service Director confirmed these observations and acknowledged that staff should wash their hands upon re-entering the kitchen and that artificial nails are not permitted for dietary employees. Further observations showed that the Dietary Supervisor did not follow proper sanitization procedures while preparing pureed food, as items were only washed and rinsed but not sanitized. Additionally, state-tested nursing assistants were seen delivering uncovered beverages, such as coffee and Kool Aid, down the hallway, which the Food Service Director confirmed should be covered or delivered using a beverage cart. These actions were in direct violation of the facility's policies on preventing foodborne illness, employee hygiene, and sanitation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility did not maintain garbage and refuse properly in a closed dumpster free of surrounding litter. During an initial kitchen tour, it was observed that one lid of the dumpster was open while the other was closed. There was a significant buildup of debris around the base of the dumpster, including approximately 20 blue medical examination gloves, numerous plastic white spoons, numerous cigarette butts, a broken blue storage bin, a small unidentifiable white plastic bottle with a lid, and numerous dried-up white papers, which appeared to be paper towels or napkins. This lack of sanitation was confirmed by the Food Service Director, who acknowledged that the dumpster lids should be closed when not in use and the area around the dumpster should be kept clean. The facility's policy on food-related garbage and rubbish disposal, revised in December 2008, mandates that outside dumpsters be kept closed and free of surrounding litter.
Facility Fails to Administer Resources Effectively and Efficiently
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the well-being of all 92 residents. The Administrator and Director of Nursing (DON) did not have effective systems in place to identify and correct quality, care, and environmental concerns. This included a lack of therapeutic activities, inadequate infection control measures, dietary issues, and environmental deficiencies. The activity calendars lacked religious services, specific activities for the secured behavior unit, and evening activities. Residents and staff confirmed the absence of therapeutic activities, and the Activity Director admitted to not receiving proper training from the Administrator. The facility's infection control program was ineffective, with multiple concerns noted during the survey. Residents on contact and enhanced barrier precautions were not accurately identified, and staff were not formally educated on these precautions. Nebulizer equipment was improperly stored, and laundry practices did not follow infection control protocols. Additionally, the facility did not conduct Legionella testing, and multi-use glucometers were not properly sanitized. The DON was unaware of these issues, indicating a lack of oversight and follow-up on infection control concerns. Dietary staff did not follow proper infection control measures, and residents' dietary preferences were not consistently met. Observations revealed staff not washing hands, recipes not being followed, and milk not being provided with meals as indicated. Residents' food preferences were not obtained, and dietary concerns raised during resident council meetings were not addressed. The facility also failed to maintain a clean, safe, and homelike environment, with non-functioning call lights and broken window blinds in multiple residents' rooms. Maintenance staff did not conduct routine audits to ensure call lights were functioning, and work orders for repairs were not consistently made or addressed.
Failure to Address Ongoing Food Quality Concerns
Penalty
Summary
The facility failed to develop and implement a system to address, analyze, monitor, and resolve quality assurance and performance improvement related to ongoing food quality concerns. This deficiency had the potential to affect all 92 residents, as none were identified as not eating by mouth (NPO). Food audits conducted from January to April revealed consistent dissatisfaction with the food quality among residents. Resident Council meeting minutes from September to March also documented ongoing dietary issues, with residents repeatedly voicing concerns about the food quality, lack of variety, and insufficient portions. Despite these complaints, no effective corrective actions were taken by the facility's administration or the Food Service Director (FSD). Interviews with the Ombudsman, FSD, Dietary Supervisor (DS), and residents confirmed the persistent food quality issues and the lack of adherence to standardized recipes. The Dietitian acknowledged the problem but had not reviewed the upcoming menu changes. The Director of Nursing (DON) and Senior Administrator were aware of the ongoing kitchen concerns but had not conducted a root cause analysis or implemented a performance improvement plan. The facility's Quality Assurance Performance Improvement (QAPI) meetings discussed the food issues, but no substantial actions were taken to resolve them. The facility's policy on QAPI, revised in April 2014, mandates the development and maintenance of an ongoing plan to monitor and improve care quality, which was not effectively implemented in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate infection control procedures were followed regarding transmission-based precautions (TBP) and enhanced barrier precautions (EBP). Observations revealed that several residents who were supposed to be on TBP or EBP did not have the necessary signage or personal protective equipment (PPE) outside their rooms. Interviews with staff confirmed a lack of formal education on these precautions, and medical records showed no physician's orders for TBP or EBP for many residents. This affected multiple residents and had the potential to impact all residents in the facility. The facility also failed to separate clean and dirty linens as required. Housekeepers admitted that both clean and dirty laundry entered and exited the laundry room through the same door, contrary to facility policy. This practice increases the risk of cross-contamination and infection spread among residents. Additionally, the facility did not have an effective Legionella water management program in place. The Director of Environmental Services was unaware of any documented evidence that the policy had been implemented. Furthermore, observations revealed improper storage of nebulizer masks and oxygen tubing, and multiuse glucometers were not cleaned according to facility policy. These lapses in infection control procedures were observed in multiple residents' rooms, further compromising the facility's infection prevention efforts.
Lack of Dining Utensils and Privacy Curtain
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by not providing knives on meal trays, affecting 64 residents receiving meals from the kitchen and 24 residents on the secured behavior unit. Observations revealed that residents were served meals that included items difficult to eat without a knife, such as a Hawaiian ham slice. Interviews with staff and residents confirmed that knives were typically not provided, despite the facility having an adequate supply. The Registered Dietitian had previously reported the issue to the administration, but the problem persisted. The facility's policy on resident rights emphasized treating residents with respect, kindness, and dignity, which was not upheld in this instance. Additionally, the facility did not provide a privacy curtain for Resident #45, who had been without one since admission. This resident, who had moderate cognitive impairment and various medical conditions, was unable to section off his bed and personal space for privacy. Despite the resident's request to the maintenance staff, no work order was placed for a privacy curtain. The facility's policies on maintaining a homelike environment and respecting resident rights were not followed, resulting in a lack of privacy for Resident #45.
Ongoing Food-Related Concerns Unresolved
Penalty
Summary
The facility failed to resolve ongoing food-related concerns expressed by residents during Resident Council meetings. Over several months, residents consistently reported issues with the quality and quantity of food, including repetitive meals, insufficient portions, and lack of alternatives for disliked items. Despite these repeated complaints, the Food Service Director's responses were unsatisfactory, and the Administrator was often too busy to address the concerns. Residents also reported not receiving milk at every meal, having to request alternatives an hour before meal service, and not being provided with knives during meals. These issues persisted despite being raised multiple times in Resident Council meetings and during interviews with surveyors. Interviews with the Dietary Supervisor and Registered Dietitian confirmed the residents' complaints, noting that the quality of food depended on the cook and that menu adjustments had not been adequately reviewed. The Director of Nursing acknowledged the ongoing kitchen concerns and stated that these issues were discussed during Quality Assurance Performance Improvement meetings but felt that resolving them was primarily the responsibility of the Administrator and Food Service Director. The facility lacked effective follow-up and checks to address the residents' food concerns, leading to continued dissatisfaction among the residents.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to repair or replace broken window blinds for 14 residents and did not provide an adequately clean room for one resident. Observations revealed built-up visible dust on the chair rail in one resident's room, which was verified by a State tested Nurse Aide (STNA). Additionally, broken window blinds were observed in the rooms of 14 other residents, and these were confirmed by STNAs during the survey. The Director of Environmental Services (DES) acknowledged the issues and mentioned that resident rooms are cleaned daily and deep cleaned monthly, but admitted that monthly audits for repairs or cleanliness were not conducted. The facility uses a computer program (TELLS) to input work orders for repairs, and housekeeping staff also maintain a list of needed repairs. Despite being aware of the broken blinds and having replaced several over the past three weeks, the DES could not provide a list of the replaced blinds. The facility's policies on daily housekeeping and room cleaning were reviewed, revealing that resident rooms are supposed to be dusted daily and cleaned according to a predetermined schedule. The policy on maintaining a homelike environment emphasized the importance of providing a safe, clean, and comfortable setting for residents.
Failure to Properly Store and Administer Respiratory Care Equipment
Penalty
Summary
The facility failed to ensure that oxygen and nebulizers were stored and administered according to physician's orders, affecting five residents. Resident #52, who had diagnoses including COPD and lung cancer, had orders for oxygen at four liters continuously and nebulizer treatments. However, observations revealed that the oxygen tank was set at six liters, and the oxygen and nebulizer tubing were undated. Resident #71, diagnosed with dementia and heart failure, had nebulizer masks on the floor and undated tubing, which was confirmed by staff during the observation. Resident #246, with COPD and chronic respiratory failure, had oxygen tubing dated 04/03/24 and undated nebulizer tubing, contrary to the weekly change order. Staff interviews confirmed the discrepancies in tubing dating and storage practices for these residents. Resident #45, with multiple diagnoses including COPD and heart disease, had an uncovered nebulizer mask and undated tubing. Resident #16, diagnosed with Alzheimer's and chronic respiratory failure, had a nebulizer mask on the floor and undated nasal cannula tubing, which was also unbagged as per the physician's orders. Staff confirmed these observations during the survey. The facility's policy on oxygen and nebulizer use did not provide adequate guidelines for proper storage to prevent contamination and infection spread.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #8, who had diagnoses including muscle wasting, irregular heartbeat, schizophrenia, emphysema, and repeated falls, was observed on 04/15/24 with his call light hanging from a box to the right upper side of his bed, out of reach. This was confirmed by an interview with STNA #429. The resident's care plan, dated 01/18/24, included interventions to minimize fall risks by ensuring the call bell was within reach, but this was not adhered to during the observation. Similarly, Resident #67, who had diagnoses including diabetes, hypertension, paralysis of the left dominant side due to stroke, and muscle weakness, was observed on 04/15/24 without her call light within reach. The resident confirmed she did not know where her call light was, and STNA #429 confirmed that the call light had fallen behind her dresser, making it inaccessible. The resident's care plan, dated 02/02/24, also included ensuring the call light was within reach to mitigate fall risks, but this intervention was not followed. The facility's policy on answering call lights, dated October 2010, was not adhered to in these instances.
Failure to Maintain Resident Funds Under Medicaid Limit
Penalty
Summary
The facility failed to ensure that resident funds were maintained under the Medicaid limit for one resident. Resident #8, who was admitted with diagnoses including secondary Parkinsonism, dysphagia, muscle wasting and atrophy, schizophrenia, anxiety, emphysema, and hypertension, had a balance in his resident fund account that exceeded the Medicaid limit on multiple occasions. Specifically, the balances were $4,253.24 on 09/30/23, $4,408.45 on 12/31/23, and $4,565.29 on 03/31/24. The Business Office Manager confirmed that Resident #8's guardian was not notified when the funds exceeded the Medicaid limit, which is a requirement for managing resident funds.
Failure to Document Resident's End-of-Life Wishes
Penalty
Summary
The facility failed to ensure a resident's wishes regarding end-of-life measures were clearly identified in the medical record. This deficiency affected one resident of three reviewed for Advanced Directives, with a facility census of 92. The medical record for the resident revealed an admission date and diagnoses including end-stage renal disease, colitis, anxiety, and depression. The comprehensive Minimum Data Set (MDS) 3.0 assessment indicated the resident was cognitively intact and required varying levels of assistance for daily activities. However, a review of the physician orders for April 2024 showed no evidence of a code status. An interview with an LPN confirmed that the electronic medical record (EMR) for the resident did not have a code status, despite facility policy stating that advance directives should be prominently displayed in the medical record.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate potential resident-to-resident abuse as required, affecting two residents. Resident #33, who had severe cognitive impairment and various mental health diagnoses, was found with a new left-hand skin tear. Resident #346, also severely cognitively impaired with behavioral disturbances, wandered into Resident #33's room, leading to a physical altercation that resulted in minor scratches and a skin tear on Resident #33's hand. The facility's Self-Reported Incident (SRI) documentation revealed that while immediate actions were taken to separate the residents and notify relevant parties, the investigation was incomplete. The Director of Nursing (DON) confirmed that the investigation did not include interviews or skin assessments of other residents on the unit who could have been affected by unwitnessed behavior. Additionally, there was no evidence of staff education on abuse following the incident. The facility's policy required thorough and objective investigations of all alleged abuse, but this was not adhered to in this case, as the investigation lacked comprehensiveness and follow-up actions to ensure resident safety and staff awareness.
Inaccurate Dental Status Documentation
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected the dental status for two residents. For Resident #28, the quarterly Minimum Data Set (MDS) 3.0 assessment indicated that the resident had no broken or missing teeth, despite the care plan noting an oral health problem related to carious teeth. An observation and interview confirmed that the resident was missing some natural teeth, which was not accurately reflected in the MDS assessment. Licensed Practical Nurse (LPN) #451 confirmed the inaccuracy in the resident's dental status documentation. Similarly, for Resident #196, the comprehensive MDS 3.0 assessment stated that the resident had no broken or missing teeth, while the care plan indicated that the resident had no natural teeth and did not wear dentures. An observation and interview confirmed that the resident did not have her own natural teeth and chose not to wear dentures. LPN #451 also confirmed the inaccuracy in the MDS assessment for this resident. The facility's policy on charting and documentation requires that charting be complete and accurate, reflecting treatment and response to care, which was not adhered to in these cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were updated to accurately reflect residents' needs, affecting three residents. Resident #31, who was moderately cognitively impaired, had physician orders for Olanzapine and Namenda, but the care plan did not include interventions for psychosis or dementia. Similarly, Resident #71, who was severely cognitively impaired, had physician orders for an Exelon patch and Namenda for dementia, but the care plan did not address dementia care. An interview with LPN #451 confirmed the absence of dementia and psychosis care in the care plans for these residents. Resident #50, who had multiple diagnoses including pneumonia, acute kidney failure, and dysphagia, experienced a significant weight loss of 11 pounds over a short period. Despite this, the care plan did not reflect the significant weight loss. A dietary note confirmed the weight loss, and an interview with Dietitian #503 verified that the care plan had not been updated to address this issue. The facility's policies on care plans and documentation were not followed, leading to these deficiencies.
Inconsistent Shower and Nail Care
Penalty
Summary
The facility failed to ensure showers and nail care were provided consistently and according to resident preference, affecting two residents. Resident #28, who was moderately cognitively impaired and required substantial assistance for showering, did not receive showers as per his preference and physician's orders. Despite his preference for showers on Wednesdays and Saturdays, records showed inconsistent documentation of showers and no refusals were documented. Interviews with the resident and an LPN confirmed the inconsistency in providing and documenting showers for Resident #28. Resident #50, who was severely cognitively impaired and required maximal assistance for personal hygiene, had long and dirty fingernails despite expressing a desire to have them trimmed. Observations and interviews with the resident and staff confirmed that his nails were not trimmed as required. The facility's policy on ADLs, which includes providing appropriate support and assistance with hygiene, was not followed in this case, leading to the deficiency in care for Resident #50.
Failure to Ensure Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for three residents, leading to deficiencies in accident prevention. Resident #24, who was at risk for elopement due to severe cognitive impairment and a history of elopement, was observed outside the facility entrance unsupervised. Despite having a wanderguard and being identified as at risk for elopement, no follow-up elopement assessments had been conducted since 08/25/21. The facility policy required detailed monitoring for residents at high risk of elopement, which was not adhered to in this case. Resident #4, who had moderate cognitive impairment and visual deficits, was observed smoking outside unsupervised and without a required smoking apron. The resident's care plan and smoking risk assessment indicated the need for supervision and the use of a smoking apron during smoking breaks. The facility's policy mandated that all smokers be supervised and use safety aprons if they failed the smoking assessment, which was not followed for Resident #4. Resident #72, who was at high risk for falls due to severe cognitive impairment and a history of falls, was found without the necessary fall prevention interventions in place. Despite physician orders for a fall mat and a perimeter overlay mattress, these interventions were not consistently observed during the survey. The resident had experienced multiple falls, and the facility's policy required specific interventions to prevent falls, which were not adequately implemented for Resident #72.
Failure to Obtain Accurate Weights as Ordered
Penalty
Summary
The facility failed to ensure accurate weights were obtained as ordered for two residents, leading to a deficiency in maintaining proper nutrition and hydration. Resident #50, who had multiple diagnoses including pneumonia, acute kidney failure, and type two diabetes, was not weighed weekly for four weeks as required. The resident's weight was recorded on admission and then not again until 18 days later, missing the weekly weight checks. Interviews with the Registered Dietitian and Assistant Director of Nursing confirmed that weights were not consistently obtained despite reminders and emails sent to staff. The facility policy required weights to be taken on admission, the next day, and weekly for two weeks, but this was not followed for Resident #50. Similarly, Resident #196, who had diagnoses including end-stage renal disease and colitis, also did not have weights obtained weekly as ordered. The resident's weight records showed gaps in the weekly weight checks, and there was no evidence that the resident refused to be weighed. The Registered Dietitian confirmed that weights were not obtained weekly as ordered. The facility policy required weights to be taken on admission, the next day, and weekly for two weeks, but this was not followed for Resident #196 either.
Failure to Ensure Accurate Dialysis Orders and Assessments
Penalty
Summary
The facility failed to ensure accurate dialysis orders and complete pre and post dialysis assessments for Resident #196, who was diagnosed with end stage renal disease and required hemodialysis. The resident's medical record indicated that she was cognitively intact and required dialysis on specific days. However, the facility did not consistently perform pre and post dialysis assessments, as evidenced by missing vitals and weights on several occasions between January and April 2024. Additionally, the physician's order to avoid blood draws from a specific arm was not clearly specified, leading to potential confusion among the staff. Interviews with the resident and nursing staff confirmed these lapses in care, with staff admitting that pre and post dialysis assessments were not consistently completed and refusals were not documented properly. The facility's policy on caring for residents with end stage renal disease required daily or per shift documentation of the resident's condition and coordination with the dialysis facility. Despite this policy, the facility did not adhere to these guidelines, resulting in incomplete documentation and assessments. The resident reported that the facility did not perform the necessary assessments, and staff interviews corroborated this, revealing a lack of consistent practice in checking the resident's condition before and after dialysis sessions. The failure to document refusals and specify which arm to avoid for blood draws further highlighted the deficiencies in the facility's dialysis care procedures.
Failure to Identify and Communicate PTSD Triggers
Penalty
Summary
The facility failed to ensure staff were aware of known triggers for three residents with a diagnosis of post-traumatic stress disorder (PTSD). Resident #81, who was cognitively intact, reported that being woken up by an unfamiliar nurse triggered his PTSD. Despite this, the care plan for Resident #81 included avoiding potential PTSD triggers, but no specific triggers were identified or communicated to the staff. Social Services and nursing staff confirmed they were unaware of Resident #81's specific PTSD triggers, and the information was not accessible to the staff who needed it. Resident #5, who was also cognitively intact, had a history of abuse by her ex-husband and experienced anxiety and fear when working with male aides. Although she had communicated this history to the facility, her care plan did not include any specific techniques or triggers related to her PTSD. An interview with a licensed practical nurse confirmed the absence of this critical information in her care plan. Resident #45, who was moderately cognitively impaired, had a history of substance abuse and exhibited aggressive behaviors. His care plan included interventions for his cognitive loss and aggression but did not address his PTSD or identify any specific triggers. Both the Social Service Designee and the MDS Registered Nurse confirmed that Resident #45's care plan lacked information on his PTSD triggers, which was against the facility's trauma-informed care policy aimed at creating a safe and supportive environment for residents with PTSD.
Failure to Address Pharmacist's Recommendation for Antipsychotic Medication
Penalty
Summary
The facility failed to document appropriate justifications for declining a gradual dose reduction (GDR) recommendation for Resident #31. Resident #31, who was admitted with diagnoses including acute kidney failure, hypothyroidism, diabetes, dementia, and cognitive communication deficit, was moderately cognitively impaired and required supervision for certain activities. A pharmacist recommended clarifying the diagnosis and justification for the use of Olanzapine, an antipsychotic medication, and updating the electronic medical record (EMR). This recommendation was noted by the Director of Nursing (DON) but was not addressed by the psychiatric nurse practitioner as intended. An interview with an LPN confirmed that the pharmacist's recommendation had not been addressed, and a review of the facility's policy indicated that the physician should follow up on medications by changing or stopping them when necessary or documenting why the benefits outweighed the risks.
Failure to Attempt Non-Pharmacological Interventions Before Administering Pain Medication
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #52. The resident, who had diagnoses including COPD, lung cancer, muscle weakness, depression, and insomnia, was cognitively intact and required varying levels of assistance for daily activities. The physician's orders included Morphine Sulfate and Tylenol for pain management, but there was no specific guidance on when to administer each medication. The Medication Administration Record (MAR) showed multiple instances where morphine was administered even when the resident reported a pain level of zero, indicating unnecessary use of the opioid medication. An interview with an LPN confirmed that non-pharmacological interventions were not documented in the progress notes and that the nurse used her judgment to decide between Tylenol and Morphine, generally opting for Morphine for pain levels of five or higher. The facility's policy on Pain Assessment and Management stated that specific strategies should be used for different levels and sources of pain, but this was not followed in the case of Resident #52. This deficiency affected one resident out of seven reviewed for unnecessary medication, in a facility with a census of 92.
Failure to Ensure Appropriate Diagnoses and Behavior Tracking for Medications
Penalty
Summary
The facility failed to ensure appropriate diagnoses for medications and did not track behaviors for medication efficacy for three residents. Resident #31, who was moderately cognitively impaired, was prescribed Namenda, Olanzapine, and Duloxetine without documented indications for their use. An interview with an LPN confirmed the absence of a diagnosis for Olanzapine and the lack of behavior tracking for this resident. Similarly, Resident #35, who was cognitively intact but had anxiety and depression, was prescribed Effexor, Hydroxyzine, and Klonopin without evidence of behavior tracking, as confirmed by the same LPN. Resident #71, who was severely cognitively impaired, was prescribed Exelon, Namenda, Depakote, and Olanzapine without documented indications for their use and without behavior tracking. The facility's policy on antipsychotic medication use, which requires documentation of targeted symptoms and specific conditions for medication use, was not followed. The LPN confirmed that behaviors were usually tracked as a result of medication orders but were not tracked for these residents.
Documentation Failures in Weight Monitoring, Diet Orders, and Body Audits
Penalty
Summary
The facility failed to ensure daily weights were documented per physician orders for a resident with congestive heart failure. Despite the physician's order for daily weights to monitor heart failure, there were numerous dates over several months where weights or refusals were not documented. This was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the lack of documentation for the specified dates. The facility's policy on charting and documentation requires daily treatment and vital signs to be recorded, which was not adhered to in this case. Additionally, the facility did not ensure that a resident's diet order accurately reflected their dietary needs. The resident, who had end-stage renal disease, was supposed to be on a liberalized renal diet, but the physician's orders incorrectly listed a regular diet. This discrepancy was confirmed by the Registered Dietician (RD), who verified that the diet order did not match the resident's actual dietary requirements. Furthermore, the facility failed to document weekly body audits for a resident with a Stage IV pressure ulcer as ordered by the physician. The ADON, who is also the wound care nurse, admitted that she was behind on inputting body audits and had no documented evidence to verify that the audits were completed on the specified dates. The facility's policy on the prevention of pressure ulcers requires timely and appropriate assessments, which were not documented in this instance.
Failure to Ensure Functional Call Light System
Penalty
Summary
The facility failed to ensure a functional call light system for three residents, affecting their ability to request assistance. Resident #82, who had multiple diagnoses including orthopedic aftercare and generalized muscle weakness, reported that her bathroom call light was not working. Despite informing aides months ago, no action was taken, and she resorted to carrying her cell phone for safety. Observations confirmed the call light was non-functional, and there was no work order for its repair. The facility's maintenance department only addressed call light issues when work orders were submitted, and no routine audits were conducted to ensure functionality. Resident #81, with diagnoses including a femur fracture and COPD, also had a non-functional call light. During an interview and observation, it was confirmed that the call light did not light up or sound when activated. Similar to Resident #82, there was no work order for the non-functioning call light until it was pointed out by the state surveyor. The maintenance department's lack of routine audits and reliance on work orders contributed to the oversight. Resident #27, who had paraplegia and other significant health issues, experienced a similar problem with a non-working call light. Observations confirmed that the call light did not activate, and there was no prior work order for its repair. The facility's policy required staff to report defective call lights to the nurse supervisor, but this was not effectively implemented. The maintenance department's failure to conduct routine audits and the reliance on staff-initiated work orders led to the continued malfunction of call lights, compromising resident safety and care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 563 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Youngstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beeghly Oaks Center For Rehabilitation & Healing | 1.6 mi | ★★★★★ | 0 | 0 |
| Maplecrest Nursing And Hta | 1.8 mi | ★★★★★ | 0 | 0 |
| Oasis Center For Rehabilitation And Healing | 2 mi | ★★★★★ | 16 | 0 |
| Greenbriar Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Shepherd Of The Valley-boardman | 2.7 mi | ★★★★★ | 21 | 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.