Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Pickerington Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with complex medical conditions, intact cognition, and dependence on assistance for ADLs lost insurance coverage and was informed of appeal options and potential nonpayment but had no documented assistance from facility staff in applying for or changing Medicaid coverage. After an unsuccessful insurance appeal, the administrator and social services issued a 30‑day discharge notice for nonpayment, and no further social service notes were documented. The resident was later sent to the hospital for severe diarrhea and discharged from the facility the same day; the hospital social worker and the resident’s family reported the facility stated the resident owed a large balance, would not be accepted back, and did not provide an itemized bill or assist with Medicaid changes, despite a policy stating residents appealing discharge would be allowed to return from the hospital.
A dependent, severely cognitively impaired resident with multiple comorbidities, including post-CVA hemiplegia, contractures, HTN, anemia, diabetes, depression, and chronic pain, required staff assistance with all ADLs except eating. Documentation showed the resident refused hair washing on several shower days, but there was no documentation of refusals for hair care on non-shower days. On multiple observations, the resident’s hair was found matted to the back of the head, and a CNA acknowledged the hair was matted and needed to be combed, resulting in a cited deficiency related to inadequate hair care.
A resident with severe cognitive impairment, hemiplegia, and multiple chronic conditions was found to be living in a room where a brown stain on the floor under a small bedside dresser and a dry, crumbly brown substance on the dresser’s lower front and corner were observed on two separate occasions the same day. A CNA confirmed the presence of these soiled areas. Review of the facility’s routine cleaning and disinfection policy showed that visibly soiled surfaces were to receive detailed cleaning, but this was not done, resulting in a failure to maintain a clean and comfortable environment.
A resident with intact cognition and significant medical needs was given a discharge notice for nonpayment, but the record showed limited documented discharge planning and no documented help with changing Medicaid or finding alternate placement. The resident appealed, was hospitalized before the appeal was resolved, and the facility told the hospital SW she could not return because of nonpayment, despite policy stating residents who appeal may return from the hospital during the appeal process. The family reported the facility did not provide an itemized bill or meaningful assistance, and the resident ultimately went to another facility.
Two residents' room flooring was found peeling and in disrepair, and facility carpeting throughout hallways and common areas was observed to be dirty and stained. The Maintenance Director confirmed both issues, noting slow progress on repairs and unsuccessful cleaning efforts, with no documentation of steps taken toward carpet replacement.
Survey Results Binder Not Easily Accessible: A survey results binder was found chained to the wall in a front hallway, positioned high enough that a resident in a wheelchair would have difficulty lifting it out and reviewing it. The DON said she did not know why it was chained up and acknowledged residents would have to stand in the hallway to read it, while a regional nurse was also unsure why it was placed that way. Facility policy stated residents have the right to examine recent state survey results and plans of correction.
Staff failed to follow infection control protocols during fingerstick blood glucose monitoring and meal service. An LPN did not perform hand hygiene between glove changes or properly disinfect a glucometer, and a CNA did not perform hand hygiene while serving and assisting with meal trays for three residents, all of whom had significant medical conditions.
Ordered ROM splints and orthotics were not applied for several residents with contractures and impaired mobility. Residents with diagnoses such as intracerebral hemorrhage, anoxic brain injury, respiratory failure, dementia, and contractures had physician orders and care plans for hand splints, palm protectors, or elbow orthotics, but repeated observations found the devices not in place. Staff also confirmed some devices were being charted as completed even when they were not on the resident, and in some cases the splints were found stored in room drawers.
Improper Storage and Labeling of Frozen Food: Surveyors observed opened frozen beef patties and frozen vegetables in the walk-in freezer stored in unsealed bags and exposed to the open air, with no open dates on the boxes. The DM confirmed the items should have been sealed, closed, and dated, and the facility policy required opened frozen food to be dated, labeled, and wrapped or sealed.
Staff failed to provide privacy during care and treatment for three residents with significant cognitive and physical impairments. In separate incidents, a nurse administered medications and a respiratory therapist performed trach care without closing doors or pulling privacy curtains, and a certified nursing aide left a resident exposed during incontinence care with the door open. Staff later acknowledged that privacy should have been maintained, in violation of facility policy.
Two residents with impaired cognition and high care needs were found in unsanitary conditions, including a dirty wheelchair and soiled wall padding, which remained unaddressed by staff despite multiple opportunities to clean or report the issues, contrary to facility policy.
Three dependent residents with cognitive and physical impairments were found to have long, dirty, or jagged fingernails and toenails due to staff not consistently providing nail care as required by facility policy. Documentation and observations confirmed that nail care was missed during multiple showers, and staff interviews acknowledged the issue.
A resident with a Foley catheter did not receive documented catheter care or urine output monitoring for several months, and when the catheter came out, staff did not replace it or notify the physician due to missing orders. Facility policy requiring regular catheter care, monitoring, and prompt physician notification was not followed, as confirmed by staff interviews and record review.
Missing Care Plan for Bilateral Hand Splints: A resident with severe cognitive impairment and total care needs had an active order for bilateral resting hand splints and skin/circulation checks each shift, with the TAR showing completion, but the comprehensive care plan did not address the splints. The DON confirmed the care plan was not in place at the time of review, despite facility policy requiring a comprehensive care plan for each resident.
Failure to update care plans for dental and vision changes affected three residents. One resident lost dentures during a hospital stay and had no documented care plan revision, another had broken teeth, mouth pain, and a request for full mouth extractions that were not reflected in the care plan, and a third had worsening cataracts with a surgery recommendation that was not added to the care plan. MDS staff confirmed the care plans were not updated.
Resident-centered activities were not provided consistently for a cognitively impaired resident with trach, PEG, and multiple dependent care needs. The resident enjoyed music and Haitian cultural stimulation, but activity documentation was intermittent, several entries listed sleeping, and observations showed no radio or music at times and a TV on ESPN in English. The AD confirmed the resident did not speak English, Haitian music was usually played, and no music had been heard for the prior three days.
Delay in Antibiotic Treatment for Pneumonia: A resident with COPD, pleural effusion, and pneumonia symptoms produced brown/tan sputum, prompting a chest X-ray and COVID-19 test. The X-ray showed bilateral lower lobe atelectasis with possible RLL pneumonia, but the NP/MedOne did not respond to repeated notifications for several days before Levaquin was ordered and given, resulting in a 6-day delay in antibiotic treatment.
Delayed Ophthalmology Follow-Up: A resident with DM2, cognitive communication deficit, and glasses use had an eye exam that recommended cataract surgery and follow-up in 4 to 5 months, but the facility had no evidence of timely ophthalmology follow-up or appointment attempts for several months. The resident later reported worsening cataracts and asked to see the eye doctor, and Social Services confirmed the lack of timely follow-up despite the facility policy to assist with vision services.
A resident with dementia, dysphagia, contractures, and impaired cognition was ordered a scoop plate and two-handled cup with lid for meals to support self-feeding, and the care plan identified the need for adaptive equipment. During observation, breakfast included a mix of non-adaptive and incomplete drinking items, including a single-handled mug without a lid, and a CNA confirmed the resident's liquids were not in the ordered adaptive cups. Facility policy required assistive and adaptive devices to be on the tray.
Enteral feedings were left unlabeled and undated for three residents receiving tube feedings. Observations found formula bags and syringes hanging without resident identifiers or dates, and an LPN confirmed the issue for one resident. The residents had significant medical conditions including respiratory failure, malnutrition, stroke history, and impaired cognition in some cases, and the facility policy required formula labels to include initials, date, and time hung.
Pain management was not provided in accordance with orders for one resident, and two residents had no documented evidence that non-pharmacological interventions were offered before PRN opioid use. One resident received oxycodone outside ordered pain parameters and morphine for a pain score of 0, while another resident with multiple complex diagnoses and impaired cognition repeatedly received PRN oxycodone without documentation of attempted non-pharmacologic measures. The DON confirmed the missing documentation, and the facility policy required pain to be recognized, evaluated, and managed with non-pharmacological interventions such as repositioning, comfort measures, and diversional activities.
Delayed response to resident requests and call lights: A resident with impaired cognition and diagnoses including osteomyelitis and necrotizing fasciitis asked for pain medication and for an LPN to assess a leg wound, but after an AA answered and cleared the call light, no staff addressed the concerns for about 40 minutes. The LPN said she had not been told about the request, and other residents reported that call lights may be answered quickly but staff often return 30 to 60 minutes later to finish the task, or do not return unless the light is turned on again.
Delayed response to pharmacy medication review recommendations affected two residents. One resident with respiratory failure, COPD, seizures, schizoaffective disorder, and depression had antidepressant and hydroxyzine recommendations left unaddressed for weeks, while another resident with schizophrenia, Parkinson’s dementia, and other diagnoses had GDR recommendations for Seroquel, Buspirone, and Ativan delayed, along with a later delay in discontinuing Tizanidine. The DON confirmed the recommendations should have been addressed sooner.
A resident with impaired cognition and multiple medical diagnoses lost his dentures during a hospital stay, and the facility did not document follow-up for dental services after the loss. The resident remained without dentures, requested help from social services, and speech therapy evaluated him after he asked for a diet downgrade to mechanical soft. The RA confirmed there was no documentation of follow-up, and social services said she did not speak with the resident about replacement.
Resident mail was not made available on Saturdays because the receptionist only collected and sorted mail on weekdays, and no one checked the mailbox on weekends. Three residents reported they only received mail Monday through Friday, while the RA was unaware that the receptionist was the only person removing mail from the mailbox and placing resident mail in the Activities mailbox for distribution. Facility policy stated residents had the right to receive mail.
A resident with complex medical conditions developed a new sacral pressure ulcer due to inadequate care and inconsistent treatment documentation. The facility failed to follow proper protocols for pressure ulcer management, including inappropriate use of dressings and insufficient repositioning. Observations revealed improper dressing changes and failure to float the resident's heels, violating facility policies.
A facility failed to maintain accurate medical records for a resident with a sacral wound. Initially documented as a non-pressure wound, the wound was later identified by a physician as a chronic sacral ulcer. Despite this, nursing assessments continued to inaccurately record it as a non-pressure wound, and a progress note incorrectly stated the resident's skin was intact. Interviews with staff confirmed these documentation inaccuracies.
The facility failed to maintain infection control practices for two residents. One resident's air mattress pump was improperly placed and non-functional, causing discomfort. Another resident had an outdated droplet isolation sign, leading to a visitor entering without PPE. Staff confirmed these lapses in protocol.
The facility failed to post daily nursing staff data, affecting all 65 residents. On a specific day, the Daily Staffing Log was outdated, and the responsible staff was off due to a holiday. The Administrator confirmed the required information was not updated. This was found during a complaint investigation.
The facility failed to dispose of expired Covid-19 vaccine syringes, potentially affecting residents receiving vaccines. An opened box of Spikevax vaccine with expired syringes was found in the medication storage refrigerator. An LPN confirmed the expired syringes, stating they would be administered upon request. Manufacturer guidelines indicate syringes should be refrigerated for up to 30 days.
A resident with multiple health conditions, including Parkinson's and dementia, was observed inadequately dressed in a hospital gown, exposing his chest to passersby. Despite the facility's policy on resident rights, staff failed to ensure the resident was dressed in personal clothing, attributing the oversight to being busy and actions of the night shift.
The facility failed to complete initial comprehensive MDS assessments within 14 days for two residents with complex medical conditions. Additionally, a resident's oral status was inaccurately coded on the annual MDS, despite evidence of edentulous status. Interviews confirmed these deficiencies.
The facility failed to assess medication side effects for two residents on psychoactive medications. One resident exhibited involuntary mouth movements, while another had upper body tremors. Despite these observations, AIMS evaluations and medication records did not document these side effects. Staff interviews confirmed the presence of these movements, but assessments failed to capture them, indicating a gap in monitoring and documentation.
A facility failed to document the rationale for declining a gradual dose reduction (GDR) of antipsychotropic medications for a resident with a complex medical history. Despite pharmacist recommendations for GDR on medications like Lexapro and Buspar, the CNP disagreed without providing specific reasons or symptoms, contrary to facility policy. The Director of Nursing confirmed the need for documentation of the rationale for such decisions.
A facility failed to maintain proper infection control practices for a resident on droplet isolation due to human metapneumovirus pneumonia. Staff, including an RN and a housekeeper, were observed not using the required PPE, such as gowns, gloves, and properly worn masks, as per the facility's policy. This non-compliance was confirmed through interviews with the staff involved.
A resident, who was non-verbal and dependent on staff for daily activities, had their call light placed on the floor out of reach, preventing them from alerting staff for assistance. This was observed on two consecutive days and confirmed by STNAs, despite facility policy requiring call lights to be accessible to residents.
The facility failed to ensure proper orders for ventilator services and oxygen monitoring for a resident with multiple serious diagnoses. Observations and staff interviews revealed inconsistencies in oxygen rates and a lack of documented guidelines for titration and monitoring, leading to a deficiency in care.
Failure to Provide Appropriate Discharge Planning and Allow Return After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate discharge planning and to permit a resident to return following hospitalization after issuance of a 30‑day discharge notice. The resident was admitted with multiple complex diagnoses, including cervical spine fusion, Ehlers‑Danlos syndrome, secondary malignant neoplasm of the lung, depression, anxiety, and neoplasm‑related pain, and had a care plan goal to eventually discharge to an apartment with cancer support. The admission MDS showed intact cognition and a need for supervision or touching assistance with ADLs. On 11/10/25, social services documented that the resident’s insurance coverage ended with a last covered day of 11/08/25, discussed appeal options and upcoming cancer treatment, and noted the resident required assistance with dressing, meal setup, and incontinence care and could not return to her previous residence. There is no documentation that staff provided or documented assistance with Medicaid application or plan changes despite the resident’s dependence on a payor source. On 12/03/25, social services documented that the resident’s appeal of the insurance termination was unsuccessful, that the family was exploring other medical plans with LTC benefits, and that the resident was informed she might receive a 30‑day discharge notice if no payor was secured. The resident expressed that she felt at home and hoped to stay, and there is no documentation that staff offered or provided assistance with the Medicaid application or plan change process. On 12/23/25, the administrator and social services director issued a 30‑day discharge notice for nonpayment, citing failure to pay or to have Medicare or Medicaid pay on the resident’s behalf, with a planned discharge date of 01/22/26. No further social service progress notes were documented in the resident’s record after issuance of the notice. On 01/04/26, nursing documented that the resident was sent to the hospital for nonstop diarrhea, and the record shows the resident was discharged from the facility that same day, with no further documentation after transfer. A hospital social worker later documented that he contacted the facility multiple times and was told the resident owed $28,000, had been given a notice to leave before hospitalization, and that the facility was unable to take her back. The appeal decision dated 01/20/26 found the facility had not met its burden to prove the discharge and denied the facility’s request to discharge the resident. The resident’s daughter and the hospital social worker reported that the facility told the hospital the resident could not return due to nonpayment, that the family did not receive an itemized bill despite requesting it, and that the facility did not assist with changing Medicaid plans. The administrator confirmed there was no documentation that the resident or family did not want to return, no documented communication with the hospital regarding discharge planning, and that facility policy required allowing a resident to return from the hospital during an appeal, which did not occur in this case.
Failure to Provide Hair Care to Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to failure to provide hair care to a dependent resident. The resident was admitted with multiple diagnoses including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. An admission MDS initiated but not yet completed showed, through assessments dated 01/26/26, that the resident was severely cognitively impaired with a brief interview for mental status score of zero and was dependent on staff for all ADLs except eating, for which setup assistance was required. Review of shower sheets for several dates showed the resident refused to have her hair washed on those shower days. Record review revealed no documentation that the resident refused hair care on days other than scheduled shower days. On 01/27/26, surveyors twice observed the resident’s hair to be matted to the back of her head, first at 11:55 AM and again at 1:49 PM. During the second observation, a CNA confirmed that the resident’s hair was matted and acknowledged that it needed to be combed. This deficiency was cited as non-compliance and was investigated under Complaint Numbers 2727003 and 2678134.
Failure to Maintain Cleanliness of Resident Room Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and comfortable environment in a resident’s room, as required by its own routine cleaning and disinfection policy. The resident involved had been admitted with multiple diagnoses, including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. Assessment information completed in preparation for the admission MDS showed the resident was severely cognitively impaired, with a brief interview for mental status score of zero, and was dependent on staff for all activities of daily living except eating, for which setup assistance was required. On two separate observations conducted on the same day, surveyors noted a brown stain on the floor under the resident’s small two-drawer bedside dresser and a dry, crumbly brown substance adhered to the lower front and corner of the dresser. These conditions were observed in the resident’s room both late morning and early afternoon. A CNA interviewed at the time confirmed the presence of the brown stain on the floor and the dry, crumbly brown substance on the dresser. Review of the facility’s undated “Routine Cleaning and Disinfection” policy showed that routine surface cleaning and disinfection was to be conducted with a detailed focus on visibly soiled surfaces, which was not carried out in this instance. This deficiency was investigated under Complaint Numbers 2727003, 2685197, and 2678134.
Discharge Planning and Return After Hospitalization
Penalty
Summary
The facility failed to provide timely and appropriate discharge planning after issuing a 30-day discharge notice to a resident with intact cognition and assistance needs for ADLs. The resident was admitted with diagnoses including cervical spine fusion, Ehlers-Danlos syndrome, metastatic lung cancer, depression, anxiety, and neoplasm-related pain. Her care plan documented that she wanted to be discharged to an apartment with cancer support, and social services, nursing, and rehab were to discuss discharge planning weekly or as needed. Progress notes show the resident was told her insurance coverage had ended, that she needed to pay or obtain another payer source, and that she could not return to her previous residence, but there was no documentation that staff assisted her with applying for or changing Medicaid coverage. A 30-day discharge notice was issued due to failure to pay after reasonable and appropriate notice. The resident and family appealed the discharge, but the resident was hospitalized before the appeal was resolved. The facility’s policy stated that if a resident appeals discharge, the facility will allow the resident to return from the hospital during the appeal process. However, the record contained no documentation of ongoing discharge planning after the notice was issued, and the facility later told the hospital social worker that the resident owed $28,000 and could not return because of nonpayment. The resident’s daughter stated the family received no itemized bill despite requesting one, and that the facility did not help find another facility or assisted living option other than one that did not accept Medicaid. The hospital social worker confirmed the facility said the resident could not return and to find alternate placement. The administrator later verified there was no documentation that the resident or family did not want her to return, and the facility was unaware of the resident’s location until the family emailed that she had gone to another facility.
Failure to Maintain Safe and Sanitary Flooring and Carpeting
Penalty
Summary
The facility failed to maintain safe and sanitary flooring for two residents, as observed by surveyors. The flooring under and around the room air conditioner in these residents' room was peeling up about an inch off the floor, affecting approximately eight tiles. The Maintenance Director confirmed awareness of the issue and stated that the facility was working through a list of rooms needing flooring replacement, but progress had been slow, with only five rooms completed over several months. Additionally, the facility did not maintain carpeting in a clean and sanitary manner throughout the building. Observations revealed dirty carpeting in hallways, with grime, dark staining, and old moisture marks visible outside resident rooms, down hallways, and around offices and nursing stations. The Maintenance Director confirmed the carpet's condition and stated that cleaning attempts had been unsuccessful. There was no evidence of steps taken toward carpet replacement, such as obtaining quotes or order confirmations. The facility's policy requires maintaining a safe, functional, and sanitary environment, but these standards were not met in the areas observed.
Survey Results Binder Not Easily Accessible
Penalty
Summary
Facility failed to ensure the survey results binder was easily accessible to residents. During observation on 09/25/25 at 11:34 A.M., the survey book was found in the front hallway between the administration offices and the staff and visitor bathrooms, sitting in a folder shelf with the binder bolted to the wall. The shelf was positioned about chest high and pointed upward, requiring a person to lift the binder up and out of the shelf, which would be difficult for a resident seated lower to the ground in a wheelchair. The chain attached to the binder was about 18-24 inches long and would not allow a resident to review the binder without standing in the hallway against the wall. The DON stated she did not know why the binder was chained to the wall and believed it was likely to prevent residents from walking away with it or taking it to their rooms, and acknowledged it would be difficult for residents to access and read it in the hall. A regional nurse also stated she was unsure why the binder was chained in the front hallway. Facility policy stated residents had the right to examine the results of the recent state survey and any plans of correction.
Infection Control Deficiencies During Blood Glucose Monitoring and Meal Service
Penalty
Summary
The facility failed to maintain proper infection control practices during fingerstick blood glucose monitoring for one resident, with the potential to affect three additional residents receiving similar care. During observation, an LPN placed a glucometer directly on a resident's overbed table without a barrier, used gloves to obtain a blood sample, and then placed the glucometer on a tissue. The LPN changed gloves multiple times without performing hand hygiene between glove changes, and cleaned the glucometer for only five seconds, despite manufacturer guidelines requiring a two-minute contact time for disinfection. The LPN also prepared medication after glove removal, using hand sanitizer only after several glove changes without prior hand hygiene. These actions were confirmed during an interview with the LPN, and a review of facility policy indicated that hand hygiene should be performed after glove removal. Additionally, the facility failed to ensure hand hygiene was performed during meal service for three residents in the main dining room. A CNA was observed serving and assisting with meal trays for these residents without performing hand hygiene before or during the process. The CNA confirmed during an interview that hand hygiene was not completed as required. Facility policy identifies hand hygiene as the primary means to prevent the spread of healthcare-associated infections. The affected residents had various medical conditions, including high blood pressure, dysphagia, dementia, respiratory failure, epilepsy, anxiety, depression, and heart failure.
Ordered ROM Splints and Orthotics Not Applied
Penalty
Summary
The facility failed to ensure that ordered splints and orthotics were applied for residents with decreased range of motion and contractures. Review of records, observations, and staff interviews showed that multiple residents had physician orders and care plans for hand splints, palm protectors, or elbow orthotics to be worn daily for limited periods, with skin integrity and circulation checks required each shift, but the devices were not in place during repeated observations. Resident #87 had diagnoses including non-traumatic intracerebral hemorrhage, acute respiratory failure, seizures, encephalopathy, dysphagia, tracheostomy, and gastrostomy, and was dependent for most ADLs with impaired cognition. Although the physician ordered bilateral resting hand splints up to six hours daily, staff documented the splints as applied on several dates, while observations on multiple shifts showed no splints in place. An LPN confirmed the resident did not have the splints on during the shift even though the electronic record showed they had been utilized. Resident #81 had diagnoses including acute respiratory failure, protein calorie malnutrition, metabolic encephalopathy, adult failure to thrive, depression, old myocardial infarction, contractures, and anoxic brain damage, and was dependent for care with impaired cognition. The care plan required bilateral elbow orthotics, a right rolling hand splint, and a left resting hand splint up to six hours daily each shift, but repeated observations over several days showed no splints in place, and an LPN confirmed they were not on the resident. Resident #76 and Resident #5 also had orders for bilateral resting hand splints or orthotics, and Resident #20 had an order for a right palm protector; in each case, observations found the devices not in use and, for Resident #5 and Resident #20, the splints were located in drawers in the room while the TARs showed the orders as completed.
Improper Storage and Labeling of Frozen Food
Penalty
Summary
The facility failed to store and label frozen food in a sanitary manner. During an initial kitchen tour, surveyors observed in the walk-in freezer an opened cardboard box of about 30 beef patties in a clear unsealed bag exposed to the open air, a cardboard box of frozen diced carrots in an unsealed opened blue plastic bag exposed to the open air, an opened cardboard box of frozen peas in an unsealed blue plastic bag located under the box of frozen diced carrots with the peas exposed to the bottom of the carrot box, and an opened cardboard box of frozen green beans in an opened unsealed blue plastic bag exposed to the air. None of the four cardboard boxes had open dates. The Dietary Manager confirmed the opened and undated frozen beef patties and vegetables and stated the bags inside the cardboard boxes should be sealed with a clip once opened, the boxes should be closed, and dates should be placed on the boxes once opened. The facility policy titled Food Handling and Storage, dated 12/10/24, stated all opened frozen food will be dated, labeled, and wrapped or sealed.
Failure to Provide Privacy During Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that residents were treated with dignity by providing adequate privacy during care and treatment, as evidenced by observations and staff interviews involving three residents. In one instance, a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, received medication administration via gastrostomy tube from a registered nurse who did not close the door or pull the privacy curtain during the procedure. The nurse later confirmed that privacy was not provided. In another case, a resident dependent on staff for all activities of daily living, including tracheostomy care, had trach suctioning and tie changes performed by a respiratory therapist with the door and blinds open and the privacy curtain not pulled. The therapist acknowledged that privacy should have been provided. Additionally, a resident with impaired cognition and dependence for toileting was observed receiving incontinence care with the curtain only partially closed and the door wide open, allowing the resident to be exposed and visible from the hallway. A soiled brief was also observed being tossed onto the floor by a certified nursing aide, who admitted that the door should have been closed but did not do so, mistakenly believing it was stuck. Review of facility policy confirmed that residents have the right to privacy and confidentiality during medical treatment and personal care.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by observations and staff interviews. One resident with impaired cognition and dependent on staff for bathing and hygiene was observed sitting in a wheelchair with a stained cushion, food particles in the seams, and rails and footrest pegs covered in a white substance and dried food. Staff confirmed the wheelchair was dirty and stated that while the night shift usually cleaned wheelchairs, they would clean them if visibly soiled. The facility's cleaning schedule indicated wheelchairs were to be cleaned weekly, but this was not adhered to in this instance. Another resident, also with impaired cognition and dependent on staff for personal hygiene, was found to have a navy-blue wall padding next to their bed that was smeared with a dried brownish material. Multiple observations over the course of a day showed the soiled padding remained uncleaned despite several staff entering and exiting the room to provide care. A CNA confirmed the presence of the dirty substance but did not take action to clean it or alert other staff. The soiled mat remained unaddressed until the following day when housekeeping staff cleaned it. Facility policy required all personnel to report and address unclean or defective equipment and furnishings, but this was not followed in these cases.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for dependent residents, as evidenced by record reviews, observations, and staff interviews. Three residents with significant cognitive and physical impairments, who were dependent on staff for activities of daily living (ADLs), were found to have long, dirty, or jagged fingernails and toenails. Documentation showed that nail care was not completed during multiple showers for these residents, and there were no refusals documented for some of the missed care. Observations confirmed the poor nail condition, including long nails with dark substances underneath and thick, jagged toenails. Staff interviews corroborated the findings, with CNAs acknowledging the residents' unkempt nails and stating that nail care should be performed after bathing or showering. The facility's policy required staff to provide care and services for ADLs, including grooming and personal hygiene, but this was not consistently followed for the affected residents. The deficiency was identified through a combination of medical record review, direct observation, and staff confirmation.
Failure to Provide and Document Required Catheter Care and Monitoring
Penalty
Summary
A deficiency was identified regarding the care and management of a resident with a Foley catheter. The resident, who had multiple diagnoses including cardiac arrest, open wound, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, and urinary retention, was admitted with a Foley catheter in place due to obstructive uropathy. The care plan indicated the need for regular catheter care, monitoring of urine output, and prompt physician notification of any changes. However, review of the medical record revealed no evidence that catheter care was provided or that urine output was measured and documented from July through September. Additionally, there were no documented physician orders for the catheter prior to late September. An incident occurred when the resident's catheter came out overnight. The resident reported waiting for a nurse to replace it, but staff interviews revealed that the night nurse did not attempt to replace the catheter or notify the physician. The following day, the LPN on duty discovered the lack of catheter orders and contacted the physician for clarification. The RN on duty also did not replace the catheter or notify the physician, citing the absence of orders. There was no documentation of the resident's urine output during the 16-hour period without a catheter, nor was there evidence of physician notification regarding the catheter's removal. Facility policy required prompt physician notification of significant changes, regular catheter care each shift, and comprehensive care planning. Interviews with the DON and other staff confirmed that catheter care was not documented for several months and that the lack of orders was an oversight. The deficiency was substantiated by the absence of documentation, lack of physician notification, and failure to provide required catheter care and monitoring as outlined in facility policy.
Missing Care Plan for Bilateral Hand Splints
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the use of bilateral resting hand splints for Resident #5, who was admitted with diagnoses including CHF, anoxic brain damage, respiratory failure, ventilator dependence, high blood pressure, and anxiety. The quarterly MDS showed the resident had severe impaired cognition and was dependent on staff for all care. A physician order dated 06/17/25 directed staff to don bilateral resting hand splints up to 6 hours daily as tolerated and to check skin integrity and circulation every shift, and the TAR dated 09/01/25 to 09/24/25 showed these tasks were marked completed every shift. Despite the active splint order and documented completion on the TAR, the comprehensive care plan did not include the use of the bilateral resting hand splints as of 09/23/25. During interview on 09/24/25 at 3:45 P.M., the DON confirmed the resident did not have a care plan for the bilateral resting hand splints at the time of record review and stated the care plan had been written and implemented on 09/24/25. Facility policy required a comprehensive care plan for each resident and stated it shall be reviewed and revised after each comprehensive and quarterly assessment.
Failure to Update Care Plans for Dental and Vision Changes
Penalty
Summary
Facility failed to revise the care plan within 7 days of the comprehensive assessment and have it prepared, reviewed, and revised by a team of health professionals for three residents with changes in dental and vision needs. The deficiency involved Resident #32, Resident #60, and Resident #82, and was identified through observations, resident and staff interviews, and record review. Resident #32 was admitted with multiple diagnoses including cardiac arrest, malnutrition, dysphagia, muscle weakness, intellectual disabilities, and urinary retention. The care plan identified impaired dental status and dentures, but after the resident returned from a hospital stay, progress notes and speech therapy notes documented that the dentures were missing and the resident was requesting a diet downgrade to mechanical soft. The record contained no documented update to the care plan regarding the missing dentures. The resident was observed and interviewed without dentures and stated they were lost at the hospital and that he had been asking to see social services. The Regional Administrator and MDS Nurse confirmed there was no documentation that the care plan had been updated after the dentures were lost. Resident #60 had diagnoses including schizophrenia, Parkinson's dementia, diabetes, dysphagia, and encephalopathy. The care plan addressed risk for dental or chewing problems, poor dentition, and oral hygiene, but did not include broken teeth, mouth infections, or the resident's request for full mouth extractions and dentures. Dental notes documented broken teeth causing discomfort and a recommendation for oral surgery and follow-up for extractions. Later dental documentation showed the resident decided against the procedure after being told anesthesia would be needed. The resident reported mouth pain and said she was supposed to have her teeth pulled, and the MDS Nurse confirmed the care plan was not updated to reflect the changed dental needs. Resident #82 had diagnoses including acute cystitis, sepsis, diabetes type 2, cognitive communication deficit, dysphagia, and muscle weakness. The care plan addressed visual decline and wearing glasses, but did not include changes in vision, increased blurring, or the recommendation for cataract surgery. An eye exam documented that cataract surgery was recommended and that glasses would need updating after surgery. Later progress notes showed the resident requested to see the eye doctor because cataracts were getting worse, and social services scheduled an appointment months later. The resident stated he had seen an eye doctor and was waiting for follow-up and new glasses, and the MDS Nurse confirmed the care plan had not been updated with the vision changes or cataract surgery recommendation.
Resident-Centered Activities Not Provided Consistently
Penalty
Summary
The facility failed to ensure an ongoing resident-centered activities program that incorporated a resident’s interests, hobbies, and cultural preferences. Resident #87 was admitted with diagnoses including non traumatic intracerebral hemorrhage, acute respiratory failure, seizures, encephalopathy, dysphagia, tracheostomy, and gastrostomy. The quarterly MDS showed he was cognitively impaired and dependent on staff for oral hygiene, toileting, showering/bathing, dressing, personal hygiene, and turning and repositioning. The activity assessment noted he enjoyed listening to music, and the plan of care stated he needed escorted or assisted participation in activities of interest, was dependent on staff for activities and cognitive stimulation, and required one-to-one bedside or in-room visits when unable to attend out-of-room activities. It also noted he was of Haitian descent and enjoyed cultural music therapy, with staff to offer music on echo in his room as desired by the resident and family. The activity record showed in-room activities were documented intermittently in July, August, and September, with several entries listing sleeping as an activity and family visits documented on two days. Observations on multiple days showed no television or radio activity being performed, and later the resident was observed in bed with the television on ESPN in English. During interview, the Activity Director confirmed the resident did not speak English and that Haitian music was usually played for him, sensory activities were to be completed twice a week, and a staff member read to him in his language on weekends. The Activity Director acknowledged that no music had been heard in the last three days and that the television had been on but was in English.
Delay in Antibiotic Treatment for Pneumonia
Penalty
Summary
The facility failed to provide timely treatment according to orders for a resident with diagnoses including pleural effusion, COPD, pneumonia, depression, high blood pressure, and anxiety. The resident showed the nurse brown/tan sputum in a medication cup, and the nurse notified MedOne, which resulted in orders for a chest X-ray and a SARS-CoV-2 test; the COVID-19 test was negative. The chest X-ray later showed bilateral lower lobe atelectasis with possible right lower pneumonia. The resident’s record showed the chest X-ray results were communicated to the NP and MedOne on multiple occasions, but no response was documented until an antibiotic order was received several days later. Levaquin was ordered for pneumonia and then administered as ordered on the MAR. The DON acknowledged there was a 6-day delay in receiving antibiotic treatment for the resident. The facility policy on Notification of Changes stated the facility must consult with the resident’s physician when there is a change requiring notification, including commencing a new form of treatment to deal with a problem.
Delayed Ophthalmology Follow-Up
Penalty
Summary
The facility failed to ensure timely follow up for ophthalmology services for Resident #82. The resident was admitted with diagnoses including acute cystitis, sepsis, diabetes type two, cognitive communication deficit, dysphagia, and muscle weakness. The care plan dated 04/21/22 identified the resident as at risk for visual decline and noted that he wore glasses, with interventions to encourage glasses use, keep the call light in reach, and keep the glasses in a safe space. The care plan did not mention changes in vision, increased blurring of vision, or recommendations for cataract surgery. An eye exam dated 04/17/25 recommended cataract surgery for the resident with follow up in four to five months and noted that glasses would need to be updated after surgery. Progress notes dated 08/15/25 documented that the resident was requesting to see the eye doctor and stated the cataracts were getting worse, and Social Services scheduled an appointment for 11/10/25. The resident told surveyors on 09/23/25 that he had seen an eye doctor about four months earlier and was wondering about the follow up, and said he was supposed to get new glasses as well. Social Services confirmed on 09/24/25 that the facility had no evidence of timely follow up or attempts to make appointments from 04/2025 until 08/2025. Facility policy stated the facility shall assist residents in obtaining routine and emergency ancillary services as needed, including vision services.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met when the facility failed to ensure dietary adaptive equipment was available for a dependent resident. Resident #20 had diagnoses including high blood pressure, depression, dementia, contractures, and dysphagia. The quarterly MDS showed impaired cognition with a BIMS score of 9 out of 15, and the resident required assistance with meal set-up and was dependent for cares. The physician ordered a scoop plate and two-handled cup with lid for all meals to increase functional independence, and the care plan identified the need for adaptive equipment at meals. A dietary progress note stated the resident used a scoop plate and two-handled cup with lids at meals to facilitate self-feeding per therapy. However, during observation the resident was sitting up in bed with breakfast on the bedside table, and the tray contained a two-handled cup with juice, a carton of chocolate milk with a straw, and a single-handled brown mug of coffee with no lid. A CNA confirmed the resident's liquids were not in a two-handled cup with a lid and stated all of the resident's liquids should be adaptive cups. The facility policy stated necessary non-food items, especially assistive and adaptive devices, should be on the tray and missing items should be reported or replaced.
Enteral feedings were left unlabeled and undated
Penalty
Summary
The facility failed to ensure enteral feedings were labeled and dated when initiated and hung for administration for three residents with tube feedings. Resident #10 had diagnoses including acute and chronic respiratory failure, COPD, heart failure, depression, anxiety, atrial fibrillation, tracheostomy, and gastrostomy, and was cognitively intact on the quarterly MDS. During observation, Isosource 1.5 running at 65 ml per hour via gastrostomy tube was not labeled with the resident’s name or date, and a syringe was also hanging without a date or resident name; an RN confirmed the feeding was unlabeled and undated. Resident #81 had diagnoses including acute respiratory failure, protein calorie malnutrition, metabolic encephalopathy, adult failure to thrive, depression, old MI, contractures, and anoxic brain damage, and was not cognitively intact and rarely/never understood. Observation showed Isosource 1.5 and a syringe were not labeled or dated. Resident #39 had diagnoses including history of stroke, hypertension, depression, and anxiety, and had an order for Diabetisource via PEG tube with daily hydration bag and set-up changes labeled with patient identifier and date. Observation found a feeding pump with a bag of Diabetisource and a clear water bag without a date or time when hung, and the resident was not receiving formula or water flushes at that time; an LPN confirmed both bags were not dated. Facility policy for continuous pump enteral feeding required the formula label to include initials, date, and time the formula was hung/administered.
Pain management orders not followed and non-pharmacological interventions not documented
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #61 when staff documented administration of pain medications outside the ordered parameters and did not show evidence that non-pharmacological interventions were offered before giving the medications. Resident #61 was admitted with diagnoses including pressure ulcer, diabetes, respiratory failure with hypoxia, lymphedema, and anxiety. Physician orders included oxycodone 5 mg every 4 hours as needed for pain rated 1-4, with a 30 mg daily maximum, and morphine sulfate 20 mg/ml, 0.5 ml every 12 hours as needed for pain rated 5-10. The MAR showed oxycodone was administered multiple times for pain scores ranging from 5 to 10, and morphine was administered once for a pain score of 0. The record also listed non-pharmacological interventions such as repositioning, fluids, one-to-one care, diversional activities, massage, food, and music therapy, but there was no evidence these were offered before the pain medications were given. The DON and Regional Nurse confirmed the medications were documented as given outside the ordered pain parameters, and the Administrator requested evidence of non-pharmacological interventions but none was provided. Resident #8 also did not have documented evidence that non-pharmacological interventions were attempted before receiving PRN oxycodone for pain. The resident was admitted with diagnoses including acute and chronic respiratory failure, tracheostomy, encephalopathy, COPD, seizures, dependence on respirators, schizoaffective disorder, and depression. The quarterly MDS showed moderately impaired cognition, dependence for several ADLs, and bowel and bladder incontinence. The physician ordered oxycodone 5 mg every 6 hours as needed for pain rated 5-10, and the care plan directed staff to attempt non-pharmacologic interventions prior to medicating and document those attempts. Review of the MAR across multiple months showed repeated oxycodone administration, but there was no documented evidence of non-pharmacological intervention attempted prior to medication administration. The DON verified that no such documentation was present.
Delayed Response to Resident Requests and Call Lights
Penalty
Summary
The facility failed to ensure resident requests were followed up on in a timely manner and did not have a licensed nurse in charge of the resident’s needs during the observed event. Resident #93 was admitted on 09/18/25 with diagnoses including osteomyelitis, necrotizing fasciitis, anorexia, and lack of coordination, and had an MDS BIMS score of 10 indicating impaired cognition. On 09/22/25 at 1:48 P.M., the resident told staff she wanted something for pain and wanted the nurse to look at a wound on her leg, and was asked to activate the call light to notify staff. At 1:51 P.M., an Activity Aide answered the call light and deactivated it, but no staff entered the room to address the resident’s concerns during continuous observation from 1:48 P.M. to 2:28 P.M. When the LPN was interviewed at 2:28 P.M., she stated she had not yet been informed of the resident’s request and then went to the room to address it. The Administrator stated call light audits only measured when the light was activated and deactivated, not how long it took staff to provide the requested item or care, and confirmed a resident should not have to wait 40 minutes for care. Additional resident interviews stated call lights were answered, but staff often returned 30 to 60 minutes later to complete the requested task, and sometimes did not return unless the resident turned the light back on.
Delayed Response to Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy medication regimen review recommendations were acted upon in a timely manner for two residents reviewed for unnecessary medications. For one resident with acute and chronic respiratory failure, tracheostomy, encephalopathy, COPD, seizures, dependence on respirators, schizoaffective disorder, and depression, the pharmacy review noted ongoing use of Effexor 75 mg twice daily and Trazodone 150 mg at bedtime, with a recommendation related to gradual dose reduction that was not addressed until weeks later. A separate pharmacy recommendation to taper and stop Hydroxyzine 25 mg was also not addressed by the physician until a later date. The resident’s quarterly assessment showed moderately impaired cognition, dependence for several activities of daily living, and bowel and bladder incontinence. For another resident with schizophrenia, Parkinson’s dementia, diabetes, dysphagia, and encephalopathy, pharmacy recommendations dated in November 2024 called for gradual dose reduction of Seroquel 100 mg twice daily and 50 mg at 2:00 P.M., as well as Buspirone 7.5 mg twice daily and Ativan 0.5 mg twice daily; these recommendations were not addressed until about a month later, when the physician/nurse practitioner documented disagreement due to psychiatric treatment and intermittent behaviors. A later pharmacy recommendation to discontinue Tizanidine 2 mg every eight hours as needed because it had not been used in 90 days was not addressed until nearly a month later, when it was marked agreed to discontinue. The DON confirmed the facility should have addressed the pharmacy recommendations sooner.
Failure to Follow Up on Missing Dentures and Dental Services
Penalty
Summary
The facility failed to ensure timely follow-up for dental services for one resident who had impaired dental status and wore dentures. The resident was admitted with multiple diagnoses including cardiac arrest, malnutrition, dysphagia, muscle weakness, intellectual disabilities, and urinary retention. The care plan identified impaired dental status and noted interventions to arrange dental consults and follow-up visits as needed. A dental visit note documented that the resident wore dentures, and later progress notes stated that after a hospital stay the resident’s dentures were missing. After the dentures were reported lost, speech therapy evaluated the resident and noted he was requesting a diet downgrade to mechanical soft. The resident, who had a BIMS score of 11 indicating impaired cognition, told surveyors he was still missing his dentures and had been asking to see social services about them. The Regional Administrator confirmed there was no documentation that staff followed up with the resident regarding dental services after the dentures were lost. Social Services stated the facility was informed of the missing dentures when the resident returned from the hospital, but she did not speak with him about replacement because she thought he would not want them replaced. The facility policy stated it would assist residents in obtaining routine and emergency dental services as needed.
Resident Mail Not Available on Saturdays
Penalty
Summary
Residents did not have reasonable access to their mail on Saturdays because the facility did not ensure resident mail was retrieved and distributed on weekends. During the resident council meeting, Residents #13, #19, and #71 stated they did not receive any mail on Saturdays and reported that mail was only delivered Monday through Friday. The receptionist stated she worked Monday through Friday, collected mail from the mailbox in front of the building, placed resident mail in the Activities mailbox for distribution, and that no one checked the mailbox on weekends. She also stated Saturday and Monday mail would be collected on Monday and then placed in the Activities mailbox for residents to receive. The Regional Administrator stated activities staff worked on weekends and residents could go to the front desk for their mail, but was not aware that only the receptionist physically removed mail from the mailbox and sorted it for activities staff to pass out to residents. Facility policy stated residents had the right to receive mail.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a history of pressure ulcers, leading to the development of a new sacral pressure ulcer. The resident, who was admitted with multiple complex medical conditions including functional quadriplegia and ventilator dependence, was initially assessed to have a resolved sacral Stage IV pressure ulcer. However, subsequent assessments revealed the development of a right lateral sacrum abscess, which was not properly managed according to the facility's guidelines. The facility's records indicated inconsistencies in the treatment and documentation of the resident's pressure ulcer care. The treatment plan included the use of Calcium Alginate dressings, which were not appropriate for dry wounds, and there was a lack of documented evidence that wound treatments were completed on several occasions. Additionally, the air mattress settings were not specified, and the resident was observed lying on a static air mattress, which may not have provided adequate pressure relief. Observations and interviews with staff revealed further deficiencies in care, including improper dressing changes and failure to reposition the resident adequately. The resident's heels were not floated off the bed surface as required, and the soiled dressing was left in the resident's room, contributing to an unpleasant odor. These actions and inactions were in violation of the facility's policies on pressure injury prevention and management, as well as turning and repositioning protocols.
Inaccurate Medical Record Documentation for Resident's Sacral Wound
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #100, who was admitted with multiple diagnoses including aortic aneurysm, cerebral infarction, respiratory failure with ventilator dependence, functional quadriplegia, and encephalopathy. The resident's quarterly Minimum Data Set (MDS) assessment indicated severe impairment in daily decision-making and noted the presence of a pressure-relieving device on the bed, with no pressure ulcers reported. However, a nursing Skin Grid Non-Pressure assessment later documented a right lateral sacrum abscess, which was initially recorded as a non-pressure wound. Further review revealed discrepancies in the documentation of the resident's sacral wound. A physician's progress note indicated the presence of a chronic sacral ulcer, recommending evaluation by the wound team for possible debridement. Despite this, a nursing progress note inaccurately stated the resident's skin was intact, and subsequent weekly assessments continued to document the sacral pressure ulcer as a non-pressure wound. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse confirmed the inaccuracies in the documentation, highlighting a failure to accurately record the resident's medical condition.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two separate incidents involving residents. In the first case, Resident #103, who was admitted with multiple diagnoses including primary central nervous system lymphoma and depression, was found to have an air mattress pump sitting on the floor without a barrier, and the pump was not functioning because it had been unplugged. The air mattress was deflated, causing discomfort to the resident. The Occupational Therapist confirmed the absence of a footboard, which typically supports the pump, and the Registered Nurse acknowledged that the pump should not have been on the floor without a barrier. In the second incident, Resident #9, who was admitted with acute respiratory failure and other serious conditions, was observed with a droplet isolation sign on the door, despite the isolation precautions having expired. A visitor was seen in the room without personal protective equipment, which was required under the posted isolation precautions. The Assistant Director of Nursing verified that the isolation sign should have been removed after the precautions ended, indicating a lapse in updating the resident's status and ensuring compliance with infection control protocols.
Failure to Post Daily Nursing Staff Data
Penalty
Summary
The facility failed to ensure that daily nursing staff data was posted as required, which had the potential to affect all 65 residents residing within the facility. On December 26, 2024, at 8:10 A.M., an observation of the reception area revealed that the Daily Staffing Log posted was dated December 24, 2024. This was verified by the Business Office Manager (BOM) at the time of the observation. During an interview at 9:17 A.M., the BOM confirmed that the nursing staff information had not been posted on December 25 or December 26 because the staff responsible for posting the data was off on December 25 due to the holiday and had just returned to work. Later, at approximately 4:15 P.M., an interview with the Administrator revealed that the required nursing staff information was behind the posting dated December 24, 2024, but had not been flipped over on December 25. This deficiency was identified as an incidental finding during a complaint investigation.
Expired Covid-19 Vaccine Syringes Not Disposed
Penalty
Summary
The facility failed to properly dispose of expired Covid-19 vaccine syringes, which could potentially affect any resident receiving a Covid-19 vaccine or booster. During an observation, an opened box of Spikevax (Covid-19) vaccine was found in the medication storage refrigerator in the North unit's medication storage room. The box contained two pre-filled syringes from an original set of ten, with a lot number #3032713 and an expiration date that had passed. There were no opened dates on the box or syringes. An interview with an LPN Unit Manager confirmed the presence of the expired syringes, and it was stated that the vaccines would be administered upon resident request. The manufacturer's guidelines for the Moderna Spikevax vaccine indicate that single-dose pre-filled syringes may be stored refrigerated for up to 30 days prior to use.
Resident Dignity Compromised Due to Inadequate Dressing
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by multiple observations of the resident being inadequately dressed. The resident, who was dependent on staff for all activities of daily living due to conditions such as Parkinson's disease and dementia, was observed sitting in a Broda chair wearing only a hospital gown with a blanket covering his legs. On one occasion, the gown had fallen down to the resident's waist, exposing his chest to staff and passersby. This situation was not addressed by the staff, as evidenced by an interview with a State Tested Nursing Assistant (STNA) who acknowledged the resident should have been dressed in personal clothing but had not considered it due to being busy. The resident's medical record indicated a range of diagnoses, including human metapneumovirus pneumonia, pulmonary fibrosis, and generalized muscle weakness, which contributed to his dependency on staff for care. Despite the facility's policy on resident rights, which mandates that all direct care staff are educated on the rights of residents, the staff failed to uphold these rights by not ensuring the resident was dressed appropriately. The STNA attributed the resident's state of dress to the night shift's actions and did not take steps to rectify the situation, highlighting a lapse in the facility's adherence to its own policies regarding resident dignity and care.
Deficiencies in MDS Completion and Oral Status Assessment
Penalty
Summary
The facility failed to complete an initial comprehensive, accurate standardized Minimum Data Assessment (MDS) within the first 14 days following admission for two residents. Resident #175, who was admitted with multiple complex diagnoses including pneumonia, Parkinsonism, and dementia, had an MDS assessment with an assessment reference date (ARD) that remained incomplete beyond the required 14-day period. Similarly, Resident #177, admitted with conditions such as metabolic encephalopathy and acute respiratory failure, also had an incomplete MDS assessment with an ARD that exceeded the 14-day requirement. Interviews with the MDS Coordinator confirmed that the assessments were not completed within the mandated timeframe. Additionally, the facility failed to accurately assess and code the oral status of Resident #30 on the annual MDS. Despite being documented as edentulous in dental consultations and observed without visible teeth, the MDS assessments inaccurately reflected the resident's dental status. The MDS nurse confirmed the discrepancy in coding, which did not align with the resident's actual oral condition as noted in previous assessments and consultations.
Failure to Assess Medication Side Effects
Penalty
Summary
The facility failed to comprehensively assess residents for possible medication side effects, affecting two residents. Resident #19, diagnosed with schizophrenia and Parkinson's disease, was on multiple medications, including antipsychotics and antidepressants. Despite observations of involuntary mouth movements, the AIMS evaluations and medication administration records did not document any side effects. Interviews with staff confirmed the presence of these movements, yet the assessments and progress notes failed to identify them. Resident #11, diagnosed with schizoaffective disorder, was also on several medications, including antipsychotics and anticonvulsants. Observations noted upper body tremors, but the AIMS evaluations and medication records did not reflect these findings. Although psychiatry progress notes documented fine hand tremors, there was no further assessment or documentation regarding the cause or treatment. Staff interviews confirmed the presence of tremors, but the assessments did not capture these involuntary movements. The facility's policy required routine monitoring for side effects using the AIMS assessment for residents on psychoactive medications. However, the assessments for both residents failed to identify involuntary movements, and there was a lack of documentation and reporting of these side effects. The deficiency highlights a gap in the facility's adherence to its policy for monitoring and documenting medication side effects.
Failure to Document Rationale for Declining GDR of Antipsychotropic Medications
Penalty
Summary
The facility failed to document the rationale for declining a gradual dose reduction (GDR) of antipsychotropic medications for a resident. The resident, who had a complex medical history including conditions such as muscular dystrophy, anxiety disorder, and depression, was receiving medications like Buspar and Lexapro via a peg-tube. Despite recommendations from the pharmacist for GDR on multiple occasions, the Certified Nurse Practitioner (CNP) disagreed with these recommendations without providing a rationale or symptoms for the denial. This lack of documentation was contrary to the facility's policy, which requires the attending physician to document the rationale for any decision not to change medication. The resident's medical record showed that the pharmacist recommended GDR for Lexapro and Buspar on several dates, but the CNP consistently disagreed, citing potential increased distressed behavior or worsening of target symptoms. However, the CNP did not provide specific reasons or symptoms to support these decisions. An interview with the Director of Nursing confirmed that the CNP should have documented the reason for declining the GDR. The facility's policy mandates that any irregularity identified by the pharmacist must be reviewed and documented by the attending physician, including the rationale for not making any changes to the medication regimen.
Inadequate Infection Control Practices in Droplet Isolation
Penalty
Summary
The facility failed to maintain proper infection control practices in the area of droplet isolation, affecting one resident who was admitted with human metapneumovirus pneumonia. The resident's care plan required droplet isolation due to the infection, with specific interventions outlined to manage the condition and prevent the spread of infection. However, observations revealed that staff did not adhere to the required personal protective equipment (PPE) protocols. A registered nurse was observed taking the resident's blood pressure without wearing the necessary PPE, including a gown, gloves, and surgical mask. Further observations showed a housekeeper cleaning the resident's room with a mask improperly worn under the nose and only wearing gloves, failing to utilize the full required PPE. Interviews with the staff members confirmed the lack of proper PPE usage. The facility's policy on transmission-based precautions required healthcare personnel to wear a facemask for close contact with infectious residents and additional PPE if there was a risk of exposure to respiratory secretions. The failure to adhere to these precautions was a direct violation of the facility's infection control policy.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a critical means for the resident to alert staff for assistance. The deficiency was observed when the call light for a resident, who had no speech and was dependent on staff for activities of daily living, was found on the floor out of reach. This was confirmed by two separate observations on consecutive days, where the call light was noted to be on a floor mat next to the resident's bed, rendering the resident unable to summon facility staff for needs. Interviews with State tested Nursing Assistants verified the resident's inability to access the call light, which was the only means to alert staff of any needs. The facility's policy requires that call lights be within reach of residents and secured as needed, but this was not adhered to in this instance.
Failure to Ensure Proper Ventilator and Oxygen Monitoring
Penalty
Summary
The facility failed to ensure proper orders for ventilator services and oxygen monitoring for Resident #23. The resident, who was admitted with multiple serious diagnoses including chronic obstructive pulmonary disease and malignant neoplasms, did not have a physician order specifying the rate of oxygen or guidelines for titrating oxygen levels. This lack of documentation persisted from December 2023 to April 2024, with no evidence of pulse oxygen levels being checked according to facility policy and professional standards. Observations on April 16, 2024, revealed inconsistencies in the resident's oxygen rate, which varied from eight liters per minute to approximately 3.5 liters per minute. Interviews with various staff members, including RNs, LPNs, and the respiratory therapist, confirmed that there were no documented instructions or guidelines in the resident's medical record for titrating oxygen or monitoring it after titration. The staff admitted that the orders for oxygen rate and titration were only added to the resident's medical records on the day of the surveyor's inquiry. The Director of Nursing and the Administrator acknowledged the lack of proper documentation and adherence to the facility's oxygen administration policy. The facility's guidelines require checking the resident's pulse oxygen level five minutes and one hour after titration, but these steps were not consistently followed. The respiratory therapist admitted to not documenting titration events specifically in progress notes, further contributing to the deficiency in care for Resident #23.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Pickerington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Violet Springs Health Campus | 2.3 mi | ★★★★★ | 19 | 0 |
| Embassy Of Winchester | 3.3 mi | ★★★★★ | 5 | 0 |
| Altercare Of Canal Winchester Post-acute Rc | 3.8 mi | ★★★★★ | 36 | 1 |
| Canal Winchester Care Center | 4 mi | ★★★★★ | 17 | 0 |
| Robert A Barnes Center | 4.9 mi | ★★★★★ | 0 | 0 |
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