Above 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 Pataskala Oaks Care Center during CMS and state inspections, most recent first.
The facility failed to complete a timely abuse investigation assessment for a resident who was unable to communicate after an allegation that a CNA pinched, slapped, and used an inappropriate name during a transfer. Although the incident was reported and staff interviewed, no timely skin or injury assessment was documented for the affected resident, who had severe cognitive impairment and multiple diagnoses including dementia, Alzheimer’s disease, and behavioral disturbance. The Administrator confirmed the assessment was not completed when the allegation was reported, despite the resident’s inability to communicate and the facility policy requiring a thorough investigation.
Incomplete informed consent for psychotropic medications: The facility failed to ensure residents receiving psychotropic meds were educated on the risks and benefits and that valid consent was obtained before use. Five residents had missing or incomplete consent documentation for meds such as antipsychotics, antidepressants, anti-anxiety meds, and sedatives; in several cases, the EMR had no signed consent or the form was blank for the medication, diagnosis, or risk/benefit sections. The DON confirmed the lack of documented education and consent, and the facility policy required residents or representatives to be informed before psychotropic meds were initiated or increased.
A resident with cognitive impairment and multiple chronic conditions was identified as an elopement risk after a wheelchair fall, and staff applied a wander guard to the wheelchair without a physician order. In addition, three residents with PICC lines had dressings that were not changed as ordered on a weekly Sunday-night schedule, and one dressing was not dated, with the DON confirming the timing did not match the order.
Pressure ulcer prevention interventions were not implemented for five residents with pressure injuries or high skin-breakdown risk. Several residents with orders for pressure-redistributing air mattresses were observed on beds set to firmness levels that did not match their weights, and one resident with a heel pressure ulcer was also found with heels not off-loaded despite an order for heel elevation. Staff, including an LPN, CNA, and RN, verified the incorrect mattress settings and the lack of heel off-loading.
Code status records were not accurately matched between the EMR and the emergency binder for two residents. One resident’s binder listed Full Code while the EMR showed DNR-CC, and another resident’s binder listed DNRCC-A while the EMR showed DNR-CC. Staff confirmed the binder was used for emergencies and that it had not been updated to reflect the current physician orders.
PASRR documents were not kept accurate for three residents with mental health and cognitive diagnoses. One resident’s PASRR omitted MDD, anxiety, and PTSD despite those diagnoses being in the chart, while another resident developed schizo-affective disorder and dementia but had no updated PASRR after the change in condition. A third resident’s PASRR was not updated after a dementia diagnosis and decline in cognition and ADLs, even though the resident’s MDS reflected schizophrenia and non-Alzheimer’s dementia.
A resident admitted with multiple psychiatric diagnoses and chronic pain syndrome was receiving Melatonin at bedtime for insomnia and Senna Plus plus FiberCon daily for constipation, but her comprehensive care plan did not address either condition. The DON confirmed the medications and the absence of care plans, and an LPN who developed the plans acknowledged the resident was receiving treatment for both issues without corresponding care plan entries.
Unsafe bed equipment and improper resident setup were observed for two residents. One resident, who was a fall risk and required assistance with bed mobility, sustained a skin tear from a sharp bedrail, and the maintenance log documented a sharp piece sticking out from the rail. Another resident, who was completely dependent on staff and ordered to keep the bed low when not receiving care, was found lying in a high bed with the Breath Call device out of reach and no staff present in the room.
A facility failed to administer O2 via NC per physician orders for three residents. One resident ordered for 2 L continuous was observed at 4 L, another ordered for 3 L continuous was observed at 3.5 L, and a third ordered for 2 L PRN was observed at 3 L. RN confirmation showed the flow rates were not set as ordered, and tubing was also found unlabeled.
Failure to assess and plan for trauma informed care: Two residents had documented mental health and neurologic conditions, including PTSD in one resident, but the facility did not complete trauma assessments or include trauma-specific care plan interventions. One resident disclosed a history of rape and continued to report distress and pain, while staff acknowledged there was no specific trauma screening tool or assessment process and that care plans did not address trauma history, triggers, or re-traumatization.
Failure to clean and disinfect shared resident-care equipment was observed when an RN used the same BP cuff on two residents without sanitizing it between uses and later cleaned a glucometer with one alcohol wipe before returning it wet to the cart drawer. The glucometer was used for multiple residents, and staff were unable to state the correct disinfectant wet time; one resident using the device had DM2, CKD, heart disease, and a chronic ulcer, with blood glucose checks ordered four times daily.
A resident with schizophrenia, psychotic disorder with delusions, dementia, and need for personal care was started on Macrobid for a suspected UTI before the U/A C&S results were available. The urine dip was positive and the specimen was sent for testing, but the NP ordered antibiotics before final results were received. When the culture later showed Klebsiella pneumoniae with only intermediate susceptibility to Macrobid, the NP changed treatment to Cipro. The DON confirmed the antibiotic was started before the culture report and that there was no evidence of sepsis to justify doing so.
The facility failed to date a multi-dose vial of Tubersol tuberculin solution when it was opened for use. An LPN confirmed the absence of the opened date, and the manufacturer's guidelines and facility policy require that opened vials be dated and discarded after 30 days.
The facility failed to ensure that residents on a mechanically altered diet were served food at the appropriate texture, with chicken lasagna containing pieces larger than the required 1/4 inch size. This affected five residents with conditions such as dysphagia and Alzheimer's disease.
The facility failed to use appropriate hand hygiene during meal service, affecting all residents who consumed food from the kitchen. Dietary staff were observed performing various tasks and changing gloves without washing their hands, violating the facility's hand washing policy.
The facility failed to complete a bed hold notice within 24 hours for a resident discharged to the hospital. The resident, whose primary payer was Ohio Medicaid, did not have the required notification in their medical record. The Business Office Manager confirmed the notice was not sent due to the discharge occurring on a weekend, and by the following Monday, the resident's family had informed the facility that the resident would not be returning.
A facility failed to apply and document the use of a left elbow brace for a resident with cerebral palsy, despite a physician's order and staff education on its correct placement. Observations and interviews confirmed the brace was not consistently applied, and documentation was lacking due to a task option not being activated in the POC system.
A resident with multiple diagnoses, including quadriplegia and anoxic brain damage, experienced a fall due to inadequate assistance during routine care. The care plan required two-person assistance for bed mobility, but only one aide was present, leading to the incident. The interdisciplinary team noted changes in the resident's muscle tone and significant weight gain as contributing factors.
The facility failed to change oxygen and nebulizer tubing as ordered for a resident with severe cognitive impairment and respiratory issues. Observations on two consecutive days revealed that the tubing had not been changed as per the weekly schedule, and an LPN confirmed the dates were from a week ago, indicating non-compliance with physician orders and facility policy.
The facility failed to provide non-pharmacological interventions and properly document pain location and indicators of pain for a resident with complex medical conditions. The resident received as-needed pain medication multiple times without required documentation, as confirmed by the DON.
The facility failed to document an end date for an as-needed psychotropic drug, ensure non-pharmacological interventions were attempted, and complete AIMS assessments as scheduled for three residents. This resulted in improper monitoring and documentation of psychotropic medication use.
The facility failed to ensure that puree food was served according to the menu and at an appropriate texture for a resident on a puree diet. Dietary staff prepared puree chicken lasagna and chicken breast without following a recipe, resulting in a soupy consistency with visible chunks and a mixture that separated into thin liquid. The food did not meet the required 'pudding-like' consistency as per the facility's policy.
The facility failed to change the oxygen and nebulizer tubing for a resident as required by the physician's order. Despite the order being signed off as completed, observations revealed that the tubing had not been changed. An LPN confirmed the discrepancy, and the DON emphasized the expectation for accurate documentation.
The facility failed to perform proper hand hygiene during wound care for a resident with a sacrum pressure injury. An LPN did not follow the facility's wound care policy, neglecting to change gloves or wash hands during the dressing change process, despite handling heavily saturated dressings and applying new materials.
Failure to complete timely abuse investigation assessment
Penalty
Summary
The facility failed to complete a thorough and timely abuse investigation for one resident who could not communicate, after a self-reported incident alleged that a CNA pinched the resident’s arm during a transfer and also slapped and called the resident an inappropriate name. The incident report documented that the resident had a small faint bruise on the right outer forearm, complained of discomfort, and reported pain at a level two on a zero-to-10 scale. The resident was noted to feel safe at the facility and to appear at baseline. The Administrator interviewed the resident, the involved CNA, another CNA, and two nurses, and notified the Medical Director, DON, and the resident’s responsible party. The investigation also showed that the CNA involved in the allegation had been assigned to multiple residents, including two residents with BIMS scores below 8. Although the facility interviewed the other residents assigned to that CNA, documentation did not show that a skin assessment, injury assessment, or other assessment was completed for the resident who was rarely or never understood and had severely impaired decision-making. The resident’s record showed diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, anxiety disorder, dysphagia, apraxia, peripheral vascular disease, severe protein-calorie malnutrition, and sleep apnea. The resident’s MDS documented that the resident was rarely or never understood and that BIMS was not completed because of that condition. The facility’s skin check log did not include a skin assessment on the date the allegation was reported, and the next documented skin check occurred several days later. During interview, the Administrator confirmed the facility did not complete a skin assessment for the resident when the allegation was brought to its attention and stated staff did not do so sooner because they felt there was nothing to the allegation due to the reporting resident’s history and statements toward others. The facility policy required allegations of abuse to be reported and thoroughly investigated, including identifying involved residents and staff and assessing residents for injury or change in condition.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure residents receiving psychotropic medications were educated on the risks and benefits of those medications and that informed consent was obtained from the resident and/or representative before use. This deficiency affected five of five residents reviewed for unnecessary medications: Resident #1, Resident #5, Resident #27, Resident #30, and Resident #35. Resident #35 had diagnoses including schizo-affective disorder, bipolar disorder, and anxiety disorder and was receiving aripiprazole, lorazepam, trazodone, and desvenlafaxine. Her EMR did not contain signed consents for psychotropic medication use, and there was no evidence she had been educated on the risks and benefits of the medications. The DON confirmed there was no documented evidence of informed discussion or signed consent, and the SSD stated she did not have signed consents. A consent later provided by the facility was obtained only after the DON was asked about it, and it listed only the resident’s signature and date without identifying the medications, diagnoses, or risks and benefits. Resident #5 had diagnoses including major depressive disorder and other significant medical conditions, and the MDS showed moderately impaired cognition. She was receiving aripiprazole, sertraline, and trazodone. Her consent form for psychoactive medication use was signed, but the sections indicating that she had been informed of and understood the reason for and risks of use were blank, and the medication and diagnosis sections were also blank. Resident #30 had diagnoses including dementia, anxiety disorder, and schizophrenia, with severely impaired cognition on the MDS, and was receiving escitalopram, mirtazapine, and buspirone. Her EMR contained no evidence of the facility’s psychoactive medication consent form, and the DON confirmed there was no documented evidence of education or signed consent. Resident #1 had a BIMS score of 15 and required total dependence for ADLs. He was prescribed paroxetine, but the informed consent form for psychoactive medication use had blank sections for the resident’s understanding of the reason for and risks of use, as well as the diagnosis. Resident #27 had a BIMS score of 13 and was prescribed duloxetine and buspirone, with additional monitoring orders for antidepressant effects and serotonin syndrome. His consent form was signed, but the medication, diagnosis, and witness sections were incomplete, and the DON confirmed there was no documented evidence that he had been informed of the risks and benefits associated with the psychotropic medications he was receiving. The facility policy required residents, families, or representatives to be informed of the benefits, risks, and alternatives before initiating or increasing psychotropic medications, including black box warnings for antipsychotics.
Failure to Obtain Order for Wander Guard and to Timely Change PICC Dressings
Penalty
Summary
The facility failed to obtain an assessment and physician order for a wander guard for one resident with diagnoses including nontraumatic chronic subdural hemorrhage, cerebral infarction, hypertension, diabetes mellitus, major depressive disorder, anxiety disorder, PTSD, hemiplegia and hemiparesis, and congestive heart failure. The resident’s annual MDS showed a BIMS score of 09 out of 15, indicating moderately impaired cognition. After the resident fell from his wheelchair while outside on the patio and was transferred to the ER, the care plan dated the next day identified him as an elopement risk and included interventions to apply a wander guard to his wheelchair, check the bracelet at bedtime, and observe for exit-seeking behaviors. The resident later stated he wanted to go outside whenever he chose, and nursing staff confirmed that the wander guard had been applied without a physician order and then removed from the wheelchair. The facility also failed to timely change PICC line access dressings as ordered for three residents. One resident with dependence on a respirator, a sacral pressure ulcer, MRSA infection, and type 2 diabetes had a physician order to change the PICC dressing every Sunday night, but observation showed the dressing dated several days earlier, and the DON confirmed it had been changed on a day other than the ordered weekly schedule. A second resident with multiple sclerosis, muscle weakness, and peripheral vascular disease had the same weekly Sunday-night PICC dressing order, but observation showed the dressing dated earlier than the required change date, and the DON confirmed it was not changed per order. A third resident with chronic kidney disease, a sacral pressure ulcer, type 2 diabetes without complications, and sepsis also had a weekly Sunday-night PICC dressing order. Observation showed the PICC dressing was not dated, and the DON confirmed it was unknown when the dressing had been changed because the facility’s practice is to date dressings when changed. The facility policy stated PICC, midline, or CVAD dressings are to be changed weekly or if soiled.
Pressure ulcer prevention interventions not implemented
Penalty
Summary
The facility failed to implement preventive pressure ulcer skin interventions for five reviewed residents who were at risk for skin breakdown or already had pressure injuries. The report identified that residents with orders for pressure-redistributing air mattresses were observed on mattresses that were not set according to their weights, and one resident with a heel pressure ulcer was not having the heels off-loaded as ordered. Resident #33 had diagnoses including chronic kidney disease, a sacral pressure ulcer, diabetes, and sepsis. The resident was assessed as totally dependent for several activities of daily living and at high risk for pressure ulcers, with a Braden score of 12. Although the physician ordered an air mattress and the care plan included that intervention, observations on multiple days showed the air mattress set to firm, which the patient weight guide indicated was for 400 pounds, while the resident’s weight was 151.2 pounds. LPN #39 verified the mattress was set to firm instead of matching the resident’s current weight. Resident #2 had diagnoses including respiratory dependence, a sacral pressure ulcer, MRSA infection, and diabetes. The resident was assessed as totally dependent for bed mobility, toileting, bathing, and transfers, and had stage 3 and stage 4 pressure injuries present on admission/reentry. The physician ordered a pressure-reducing mattress, but observations showed the air mattress set to firm, indicating 400 pounds, while the resident weighed 120.8 pounds. LPN #39 verified the incorrect setting. Resident #18 had an air mattress order, was totally dependent for all ADLs, had a pressure ulcer to the right gluteus, and had a Braden score of 9. Observations showed the mattress set first to medium and later to firm, while the resident weighed 238.6 pounds, and LPN #39 verified the mattress was set to firm instead of the resident’s current weight. Resident #4 had diagnoses including a left heel and midfoot ulcer, diabetes with foot ulcer, venous insufficiency, and osteomyelitis. The resident was assessed as needing assistance with bed mobility and transfers and was at risk for pressure ulcer injuries. Despite an order and care plan for an air mattress, observations showed the mattress set to medium, indicating 170 pounds, while the resident weighed 322.2 pounds, and LPN #39 verified the mismatch. Resident #63 was admitted with dementia, weakness, need for personal care, and palliative care, and had an unstageable left heel pressure ulcer on admission. The resident had orders for an air mattress and heel elevation, but observations showed the heels were not elevated and were in direct contact with the mattress, heel boots were unused on the nightstand, and the air mattress was set to 350 pounds despite the resident weighing 148.2 pounds. CNA #10 and RN #23 confirmed the heels were not off-loaded and the mattress was not properly set.
Code Status Records Were Inconsistent Between EMR and Emergency Binder
Penalty
Summary
The facility failed to accurately reflect residents’ code status in both the electronic medical record and the paper code status binder kept at the nurse’s station for emergencies. For one resident admitted with chronic obstructive pulmonary disease, diabetes with neuropathy, hypertension, major depressive disorder, anxiety, insomnia, heart disease, and chronic kidney disease, the binder listed the resident as Full Code while the EMR and active order summary identified the resident as DNR-CC, with a provider-signed order scanned into the record. The care plan also contained an incorrect code status entry for that resident. A charge nurse stated the binder should match the current order, and the unit manager acknowledged the binder had not been updated as frequently as it should be. For another resident with diagnoses including COPD, CHF, OSA, adult-onset diabetes, and chronic kidney disease, the active physician’s order in the EMR identified the resident as DNR-CC, while the code status binder listed the resident as DNRCC-A. The resident’s DNR order form in the EMR showed the provider signed the DNRCC-A form earlier, but the order was later changed to DNR-CC and the binder was not updated to match. Staff interviews confirmed that the EMR was used to determine code status and that the code status book was maintained by management, but the binder still contained the outdated status.
PASRR Documents Did Not Match Resident Diagnoses
Penalty
Summary
The facility failed to ensure Pre-admission Screening and Resident Review (PASRR) documents accurately reflected resident diagnoses. Review of records, interviews, and the facility policy showed that PASRR information was not updated or completed accurately for three residents whose records contained mental health or cognitive diagnoses that were not reflected on the PASRR documents or were not reassessed after later changes in condition. One resident was admitted with diagnoses including major depressive disorder, anxiety disorder, and PTSD, but the PASRR dated 06/06/24 did not identify any of those mental health diagnoses. The resident’s annual MDS showed a BIMS score of 09 out of 15, indicating moderately impaired cognition. During interview, the SSD confirmed the PASRR was not accurate and did not include anxiety, PTSD, or MDD. A second resident was admitted with multiple mental health diagnoses, and the most recent PASRR completed before admission identified mood disorders, panic disorder, severe anxiety disorders, and insomnia. The resident later received new diagnoses of schizo-affective disorder, delirium due to a known physiological condition, and unspecified dementia without behavioral disturbances, and the quarterly MDS later selected schizophrenia and non-Alzheimer’s dementia. The SWD confirmed no updated PASRR had been completed for the new diagnoses. A third resident had PASRR documentation completed in 08/18/22 that identified schizophrenia and a mood disorder, but after a later diagnosis of dementia, no new PASRR was completed even though MDS assessments showed a decline in cognition and functional status around that time.
Missing Care Plans for Insomnia and Constipation
Penalty
Summary
The facility failed to ensure Resident #35’s comprehensive care plan addressed all diagnoses for which she was receiving scheduled medications. Resident #35 was admitted with diagnoses including schizo-affective disorder, bipolar disorder, anxiety disorder, and chronic pain syndrome. Her physician’s orders included Melatonin 10 mg by mouth at bedtime for insomnia, Senna Plus 8.6 mg-50 mg daily, and FiberCon 625 mg, two tablets daily, for constipation. Review of the resident’s active care plans showed no care plan in place for insomnia or constipation, despite the scheduled use of medications to manage both conditions. The DON verified that the resident was receiving Melatonin nightly for insomnia and Senna Plus and FiberCon daily for constipation, and confirmed that these diagnoses were not addressed in the comprehensive care plans. An LPN stated she developed the care plans and indicated the resident had regular bowel movements and did not have an official diagnosis of constipation, but acknowledged the resident was receiving medical intervention for constipation and Melatonin for insomnia without corresponding care plans.
Unsafe Bed Equipment and Call Device Placement
Penalty
Summary
The facility failed to maintain safe equipment for a resident who was admitted with diagnoses including atrial flutter, pain, rhabdomyolysis after a fall, hypertension, heart failure, COPD, BPH, ventricular flutter, bladder cancer, and acute on chronic diastolic CHF. The resident’s MDS showed a BIMS of 13 and indicated he required assistance from one person for bed mobility, transfers, and toileting. His care plan identified him as a fall risk due to a history of falls, weakness, impaired mobility, pain, and difficulty ambulating, and it included interventions for wheelchair use, footwear, safety, and staff assistance with bed mobility, but it did not include an intervention for mobility bars. On 07/25/25, a therapist reported the resident had a skin tear from a sharp area of his bedrail, and the incident report documented an unwitnessed skin tear to the left arm with the resident stating there was a sharp place on his bed. The maintenance log also documented that the bed rail had a sharp piece sticking out. The facility also failed to maintain safety for a resident identified as a high fall risk who was completely dependent on staff for all care areas. The resident’s orders included keeping the bed in the low position when not providing care. During observation, the resident was lying in bed with the bed in a high position, no staff were present in the room, and the Breath Call device was out of the resident’s reach, positioned about 3 feet from the bed. An RN verified that the Breath Call was not within reach and that the bed was in a high position, then lowered the bed and placed the device within reach.
Improper Oxygen Flow Rates and Tubing Labeling
Penalty
Summary
The facility failed to properly administer oxygen via nasal cannula as ordered for three residents reviewed for oxygen use. Resident #12 had diagnoses including acute respiratory failure with hypercapnia, dyspnea, chronic diastolic heart failure, chronic kidney disease stage 3, and pneumonia, and was ordered oxygen at 2 L continuous; however, observations on 08/18/25 and 08/19/25 showed the concentrator set at 4 L, and the tubing was not dated. RN #30 confirmed the ordered flow rate should have been 2 L and that the tubing was not labeled. Resident #27, who had diagnoses including COPD with lower respiratory infection, heart failure, atrial flutter, and bladder cancer, was ordered oxygen at 3 L continuous, but observation showed the concentrator set at 3.5 L, which RN #30 confirmed should have been 3 L. Resident #61, who had diagnoses including sepsis, CKD stage 3, Alzheimer's disease, myasthenia gravis, and UTI, was ordered oxygen at 2 L via nasal cannula as needed to keep O2 saturation greater than 92%, but observations showed the concentrator running at 3 L. RN #30 confirmed the oxygen should have been at 2 L as needed. RN #30 also stated oxygen was managed by the RN on duty, tubing was to be changed every Sunday night and labeled with the date, time, and initials of the RN who changed it, and the flow rate was to be determined by physician order. The facility policy required oxygen to be administered under physician orders, with care plans identifying the oxygen delivery system, frequency, and discontinuation criteria, and required weekly tubing changes.
Failure to assess and plan for trauma informed care
Penalty
Summary
The facility failed to assess and implement trauma informed care for two residents reviewed for trauma informed care. One resident had diagnoses including chronic kidney disease, cerebral atherosclerosis, hearing loss, dysphagia, ADHD, dementia, diabetes mellitus type II, major depressive disorder, anxiety, mild cognitive impairment, insomnia, heart disease, and lung disease. Her MDS, psychiatric notes, counseling care plan, and care plan did not document a trauma diagnosis, trauma-related care, or trauma informed interventions, despite her later telling staff that she had been raped when she was younger and that the rape resulted in tubal pregnancies. During interview, she was crying, voiced frustration, punched her legs, and reported pain with urination and being unable to sleep because of the pain. Staff interviews showed the facility was aware of some behavioral and mental health concerns but did not have a specific trauma screening tool or assessment process. The SWD stated the resident was receiving on-site counseling and that there was no specific screening tool or assessment used to identify residents with a trauma history. The RN and unit manager reported the resident sometimes had behaviors, responded to praise and positive reinforcement, and could be referred to counseling or psychiatry, while the MDS coordinator verified the care plans did not include trauma informed care and was unaware of the resident’s trauma history. The resident continued to report her rape history during follow-up interview. For the second resident, the medical record showed diagnoses including nontraumatic chronic subdural hemorrhage, cerebral infarction, diabetes mellitus, major depressive disorder, anxiety disorder, PTSD, hemiplegia and hemiparesis, and CHF. The annual MDS identified PTSD, but the care plan did not address the cause of PTSD, possible triggers for re-traumatization, or interventions to reduce re-traumatization. The record also showed no assessment had been completed to identify the cause of PTSD or potential triggers. The SWD verified that such an assessment and related plan of care had not been completed, and the facility policy stated that trauma events such as rape would be addressed by minimizing triggers and/or re-traumatization and by using trauma-specific care plan interventions.
Failure to Clean and Disinfect Shared Blood Pressure Equipment and Glucometer
Penalty
Summary
The facility failed to provide proper cleaning and disinfection of resident-care equipment between uses. During observation on 08/20/2025, RN #33 obtained Resident #32’s blood pressure with an electronic blood pressure monitor and did not sanitize the cuff afterward. The same cuff was then used for Resident #12’s blood pressure shortly afterward without being cleaned between residents. When interviewed, RN #33 stated she did not sanitize the digital blood pressure monitor before use on Resident #32, before use on Resident #12, or after use on Resident #12. Resident #19’s record showed admission on 05/23/23 with diagnoses including hemiplegia and hemiparesis following a stroke, type II diabetes mellitus, chronic kidney disease, heart disease, and a chronic ulcer of the right lower leg. The order summary dated 08/21/25 showed blood glucose checks four times daily and an order for a FreeStyle Libre 2 Plus Sensor to start on 08/21/25. On 08/21/25, RN #33 was observed cleaning the Assure Prism glucometer with an alcohol wipe for less than one minute and then placing it back in the medication cart drawer while it was still wet. During interview, RN #33 stated she had been instructed to clean the glucometer with alcohol or Sani-Cloth Bleach Wipes, but she and LPN #34 were unable to correctly identify the required wet time for the disinfectant wipes. RN #33 confirmed she used only one alcohol wipe and returned the glucometer to the drawer immediately without allowing it to dry or meet the required contact time. The glucometer was being used for residents in rooms 17, 18, and 19, and Resident #19 was the only resident currently using that specific glucometer while awaiting arrival of a personal sensor.
Antibiotic Started Before Culture Results for Suspected UTI
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program when a resident with schizophrenia, psychotic disorder with delusions, dementia, and a need for assistance with personal care was started on Macrobid for a suspected UTI before the urinalysis culture and sensitivity results were received. Resident #8 was seen by the nurse practitioner for increased confusion and weakness after previously refusing ordered blood work, and a new order was given to dip the urine and send it for U/A C&S if positive. The urine dip was positive for leukocytes, protein, and blood, and the urine was collected and placed in the lab refrigerator awaiting pickup. The nurse practitioner was notified and ordered Macrobid 100 mg by mouth twice daily for seven days for a UTI before the final culture results were available. When the U/A C&S results were later received, the nurse practitioner reviewed them and changed the antibiotic from Macrobid to Cipro 500 mg twice daily for seven days. The culture showed greater than 100,000 colonies/mL of Klebsiella pneumoniae, and the susceptibility report showed the organism was only intermediate susceptible to Macrobid and more susceptible to Cipro. The DON confirmed the resident was started on Macrobid before the final culture results were received and acknowledged the antibiotic had to be changed after the results showed a more appropriate option. The DON also stated there was no evidence of a history of sepsis that would have supported starting an antibiotic before the culture and sensitivity results were available.
Failure to Date Multi-Dose Vial of Tubersol Tuberculin Solution
Penalty
Summary
The facility failed to date a multi-dose vial of Tubersol tuberculin solution when it was opened for use. An observation revealed an opened multi-dose vial of Tubersol tuberculin solution in the medication refrigerator without an opened date on the vial, sticker, or storage box. The storage box had a delivery date from the pharmacy, but no indication of when the vial was first used. An LPN confirmed the absence of the opened date and stated that the solution should be used within 30 days of opening. The manufacturer's guidelines and the facility's medication storage policy both require that opened vials be dated and discarded after 30 days of use.
Failure to Provide Appropriate Food Texture for Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that five residents on a mechanically altered diet were served food at an appropriate texture. Specifically, residents with diagnoses such as Alzheimer's disease, dysphagia, cerebral infarction, and diabetes mellitus were observed receiving chicken lasagna with large chunks of chicken, which did not meet the required texture standards. The facility's policy indicated that meat should be in pieces no larger than 1/4 inch, but the lasagna served contained pieces larger than this size. The Dietary Manager confirmed that the lasagna was used without alterations based on information from a previous cook and her own assumption that the meat size was appropriate. During the lunch meal observation, it was noted that the lasagna contained chicken pieces larger than a quarter, which was not suitable for residents on a mechanically altered diet. The Speech Language Pathologist confirmed that meat for such diets should be the size of a quarter or less. The Dietary Manager acknowledged that the facility policy required meat to be 1/4 inch or less and that the lasagna used did not comply with this requirement. This deficiency affected five residents out of the 15 on a mechanically altered or soft diet, compromising their dietary needs and safety.
Failure to Use Appropriate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to use appropriate hand hygiene during meal service, which had the potential to affect all 46 residents who consumed food from the kitchen. During an observation, Dietary Staff #466 was seen performing various tasks such as preparing puree food, handling oven mitts, setting up the steam table, obtaining food temperatures, and serving food without washing her hands. Although she changed gloves multiple times, she did not wash her hands throughout the observation period. Additionally, Dietary Staff #460 entered the kitchen from the dining room, put on gloves, and began preparing grilled cheese sandwiches without washing her hands. The deficiency was confirmed through an interview with Dietary Staff #466 and the Dietary Manager #459. The facility's 'Hand Washing' policy, which was undated, required employees to wash their hands in several instances, including when entering the kitchen, after handling soiled equipment or utensils, during food preparation, before donning disposable gloves, and after removing gloves. The observed actions of the dietary staff were in direct violation of this policy, leading to the identified deficiency.
Failure to Complete Bed Hold Notice Within 24 Hours
Penalty
Summary
The facility failed to complete a bed hold notice within 24 hours of a resident's discharge to the hospital. This deficiency affected one resident out of four reviewed for hospitalization. Resident #55, who was admitted to the facility and later sent to the hospital for evaluation of altered mental status, did not have a bed hold notice in their medical record. The resident's primary payer was Ohio Medicaid, which requires notification to the resident's representative about the option to hold the resident's bed following a hospital discharge. The Business Office Manager confirmed that the bed hold notice was not sent because the discharge occurred on a weekend, and by the following Monday, the resident's family had informed the facility that the resident would not be returning, so the notice was not completed. The facility's policy requires written information to be given to residents and their representatives prior to a transfer, explaining the rights and limitations regarding bed-holds.
Failure to Apply and Document Use of Elbow Brace
Penalty
Summary
The facility failed to apply and document the use of a left elbow brace for a resident with cerebral palsy, high blood pressure, and type two diabetes mellitus, who required assistance with personal care tasks and used a wheelchair for mobility. Despite a physician's order for the resident to wear a left elbow extension brace daily to prevent contracture, there was no documentation in the Treatment Administration Record (TAR) or Point of Care (POC) task documentation indicating that the brace was applied. Observations over two days revealed the brace was not applied and was instead found on furniture in the resident's room. Interviews with the resident and staff confirmed the inconsistency in applying the brace, and it was revealed that the task option for documenting the brace application was not activated in the POC system, leading to a lack of proper documentation and follow-through on the physician's order. The resident's medical record and care plan indicated the need for the brace, and staff had been educated on its correct placement. However, the failure to document and consistently apply the brace as ordered resulted in a deficiency in maintaining the resident's range of motion and preventing contracture. The facility's policy on resident mobility and range of motion, which mandates treatment to prevent a decrease in range of motion, was not adhered to in this case.
Failure to Provide Adequate Assistance Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure Resident #39 received the appropriate assistance, resulting in a fall. Resident #39, who had multiple diagnoses including quadriplegia, anoxic brain damage, and chronic respiratory failure, was dependent on staff for all activities of daily living. The resident's care plan indicated a need for two-person assistance for bed mobility and transfers. However, during routine care, a State tested Nursing Assistant (STNA) assisted the resident alone, leading to the resident being assisted to the floor when turned to the opposite side. The Director of Nursing (DON) confirmed that only one aide was providing care at the time of the fall, contrary to the care plan requirements for two-person assistance. The interdisciplinary team reviewed the incident and noted that Resident #39 had been receiving Botox injections, which changed his muscle tone, and had experienced significant weight gain over the previous six months. These factors contributed to the increased risk of falls. The team determined that a larger bed would decrease the risk of future falls by providing a safer environment for bed mobility, transfers, and positioning. Despite these observations, the deficiency occurred due to the failure to follow the care plan's directive for two-person assistance during bed mobility.
Failure to Change Oxygen and Nebulizer Tubing as Ordered
Penalty
Summary
The facility failed to change oxygen and nebulizer tubing as ordered for Resident #14, who was admitted with diagnoses including asthma, high blood pressure, dementia, and weakness. The resident had severe cognitive impairment and required staff assistance for personal hygiene, transfers, and bathing. Physician orders indicated that the oxygen tubing should be changed weekly on Sunday night shifts. However, observations on two consecutive days revealed that the oxygen and nebulizer tubing dated 04/14/24 had not been changed as per the order, despite the facility policy requiring weekly changes and the LPN confirming the dates were from a week ago. On 04/22/24, Resident #14 was observed sitting in a wheelchair receiving oxygen via nasal cannula with tubing dated 04/14/24. The nebulizer tubing was also dated 04/14/24. The following day, the same tubing was observed still in use, indicating it had not been changed. An interview with the LPN confirmed that the tubing should have been changed on the previous Sunday night, but it had not been done. This failure to follow physician orders and facility policy affected the resident's respiratory care and highlighted a lapse in adherence to scheduled medical equipment maintenance.
Failure to Document Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide non-pharmacological interventions and properly document pain location and indicators of pain for a resident with multiple complex medical conditions, including ALS and chronic pain syndrome. The resident's care plan included various interventions for pain management, but the review of the medical record revealed that these interventions were not followed. Specifically, the resident received as-needed pain medication (Dilaudid) multiple times without any documentation of non-pharmacological interventions or descriptions of the pain's location and characteristics. The facility's 'Pain Assessment and Management' policy required staff to ask residents about pain and identify its characteristics, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that there was no indication that non-pharmacological interventions had been attempted and that descriptions of the pain should have been documented. This deficiency affected one resident out of the five reviewed for unnecessary medications, highlighting a significant lapse in the facility's pain management practices.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure an end date was documented for an as-needed psychotropic drug order, document behaviors, and ensure non-pharmacological interventions were attempted prior to the administration of as-needed psychotropic drugs for Resident #46. The resident, who had multiple diagnoses including anxiety disorder and amyotrophic lateral sclerosis (ALS), received Ativan multiple times without documentation of non-pharmacological interventions or behavior descriptions. The Director of Nursing confirmed that these steps should have been taken and documented for every as-needed administration of Ativan. For Resident #38, who had severe cognitive impairment and multiple psychiatric diagnoses, the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments as scheduled. The resident had only one AIMS assessment completed since the previous year, and the unit manager confirmed that the order for AIMS assessments was not carried over to the new system, leading to the oversight. The resident's psychiatric note indicated intermittent verbal aggression, but no further AIMS assessments were documented. Resident #19, diagnosed with Alzheimer's disease, depression, and dementia, was on Seroquel for dementia. The facility failed to document AIMS evaluations prior to April 24, 2024, despite the resident being on antipsychotic medication. The facility's policies did not address the frequency of AIMS evaluations, and the Resident Assessment Instrument (RAI) manual indicates that residents on antipsychotic medications should be monitored for potential adverse consequences at least quarterly. The facility's failure to follow these guidelines resulted in a lack of proper monitoring for potential adverse effects of the medication.
Failure to Serve Puree Food at Appropriate Texture
Penalty
Summary
The facility failed to ensure that puree food was served according to the menu and at an appropriate texture for a resident on a puree diet. The deficiency was observed when Dietary Staff #466 prepared puree chicken lasagna and chicken breast without following a recipe, resulting in a soupy consistency with visible chunks and a mixture that separated into thin liquid. The dietary staff added unmeasured amounts of milk, broth, and thickener, which did not achieve the required 'pudding-like' consistency as per the facility's policy. The dietary staff and manager confirmed that the food was thinner than pudding or mashed potatoes and did not meet the required texture for puree diets. The affected resident had severe cognitive impairment and was on a puree diet as per the physician's order. The lunch menu for the day included a BLT with potato cakes, green beans, and a cookie, with an alternate meal of chicken lasagna and a breadstick. However, the dietary staff's preparation did not adhere to the menu or the consistency guidelines, leading to the deficiency. The facility's policy on 'Consistency Modified Diets' stated that puree food should be homogenous, cohesive, and 'pudding-like,' which was not followed in this instance.
Failure to Change Oxygen and Nebulizer Tubing as Ordered
Penalty
Summary
The facility failed to accurately document a physician order by signing off that an order had been completed when it had not. Specifically, the facility did not change the oxygen and nebulizer tubing for a resident as required by the physician's order. This affected one resident who had severe cognitive impairment and required staff assistance for personal hygiene, transfers, and bathing. The resident had diagnoses including asthma, high blood pressure, dementia, and weakness. The physician's order required the oxygen tubing to be changed every week on Sunday night shift, but the tubing dated 04/14/24 was not changed as documented on 04/21/24. Observations on 04/22/24 and 04/23/24 revealed that the resident was using oxygen and nebulizer tubing that had not been changed since 04/14/24, despite the order being signed off as completed on 04/21/24. An interview with an LPN confirmed that the tubing had not been changed, even though the order was signed off. The Director of Nursing stated that the expectation is for nurses to accurately follow physician orders and only sign off when the task has been completed.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform proper hand hygiene during wound care for Resident #34, who was admitted with multiple diagnoses including a pressure injury to the sacrum, bacteremia, and bilateral above-the-knee amputations. During an observation, LPN #419 did not follow the facility's wound care policy, which mandates hand washing and changing gloves at specific steps in the procedure. LPN #419 placed wound dressing supplies directly on the bed without a barrier, washed her hands only before donning gloves, and did not change gloves or wash hands during the dressing change process. This included handling the heavily saturated dressing, cleansing the wound, and applying new dressing materials without changing gloves or performing hand hygiene in between steps. An interview with LPN #419 confirmed the failure to wash hands or change gloves during the dressing change. The facility's policy on wound care, dated October 2010, clearly outlines the need for hand washing and glove changes at multiple points during the procedure. The LPN admitted to only washing hands before starting and after completing the dressing change, neglecting the necessary steps in between. This oversight directly contradicts the facility's established protocols for infection prevention and control.
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 889 citations issued within 25 miles in the last 12 months — including the 8 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 Pataskala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tuscany Gardens | 1.3 mi | ★★★★★ | 25 | 0 |
| Robert A Barnes Center | 7.6 mi | ★★★★★ | 0 | 0 |
| Smiths Mill Health Campus | 8.3 mi | ★★★★★ | 20 | 0 |
| Otterbein At Granville | 8.7 mi | ★★★★★ | 5 | 0 |
| Violet Springs Health Campus | 8.7 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pataskala Oaks Care Center.
100% money-back within 48 hours.
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.