Below average — CMS composite of the measures below.
The next survey window likely opens 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 Roscoe Gardens Skilled Nursing And Rehab during CMS and state inspections, most recent first.
A resident with dementia and impaired mobility declined sharply after a fall with a fibula fracture and became non-weight bearing, but the record showed no updated Braden assessment or documented heel offloading and turning before a new left heel DTI progressed to an unstageable pressure ulcer. Staff interviews confirmed the resident was largely bedbound, and the DON verified the heels were not documented as offloaded and the ordered pressure redistribution mattress was not in place. A second resident on hospice also had an air mattress left on the firm setting, which the DON verified was not the correct setting for the resident’s weight.
Unsanitary conditions were observed in the tray service area when two exhaust fans had a brown and gray fuzzy substance on them and the ceiling paint above the food serving area was chipping and bulging. In addition, hot food on the tray line was held below safe temperatures, with plain chicken and mechanical soft chicken observed in the temperature danger zone; staff confirmed the temperatures were out of range.
Smoking area not properly maintained. Surveyors observed 37 cigarette butts on the ground in the central enclosed courtyard, including three butts in a pine bush that had burned some of the needles. A cigarette receptacle was present, and the DM verified the findings. The Administrator stated smokers were expected to use the two fireproof cigarette receptacles, and the facility Smoking Policy required compliance with applicable smoking laws and safety rules.
Respiratory care was not provided and documented as ordered for one resident, who was receiving O2 without MAR documentation or recorded O2 sats, and oxygen tubing was left undated for several other residents receiving O2, nebulizer, or BiPAP therapy. Surveyors observed the missing tubing dates and uncovered BiPAP equipment, and an LPN confirmed the issues.
Infection control failures were observed involving meal service for two residents on contact precautions for C. diff, where CNAs entered the rooms without the required PPE and stood within one foot of the residents while setting up meal trays. An LPN also placed a glucometer on a resident’s overbed table and medication cart without a barrier and did not follow the wipe contact time directions. In addition, a resident on EBP had emergency rain ponchos available outside the room, but staff verified they were not appropriate PPE because they did not cover the arms.
A resident who was cognitively intact and needed substantial/maximal assistance for bathing was observed being transported to the shower room in a shower chair with the front covered by a gown, but the resident's buttocks and genitals were visible from the side. A CNA confirmed the exposure, and the facility policy required residents to be covered and privacy maintained during transport to and from the bath area.
Unsafe Call Light Box Condition: A resident with multiple diagnoses, including DM, dysphagia, CHF, COPD, and psychiatric conditions, was observed in a room where the bed was positioned near the door and the call light was attached to a partially covered call light box at the foot of the bed. The box had an uncovered section with unused wires visible and covered by a wire nut and electrical tape, and a CNA confirmed the setup.
A facility failed to provide a bed hold letter to a resident and failed to notify the Ombudsman when the resident was transferred to the hospital after a fall. The resident had vascular dementia and a displaced femur fracture, and the chart contained no evidence of the required bed hold notice or Ombudsman notification, which was confirmed by the BOM. Facility policy required written bed hold information to be given before transfer.
Failure to Maintain Fingernail Hygiene: A resident with cognitive impairment, hospice services, and dependence on staff for personal hygiene had long, untrimmed fingernails despite ADL care plans for grooming and hygiene. Bathing records repeatedly noted the fingernails were not trimmed, surveyors observed the long fingernails, and hospice staff stated aides did not trim fingernails as part of ADL care.
Delayed assessment after a fall and improper Foley catheter care were identified. A resident with dementia and intellectual disabilities fell, developed bruising and swelling, and was later found to have a right ankle fracture after an x-ray and subsequent CT showed a tri-malleolar injury; the resident’s mobility declined after the fall and the ankle was not fully assessed during an early NP visit. In a separate finding, an LPN/DON confirmed another resident’s Foley drainage bag was hung on the bed rail and left visible rather than properly secured per policy.
Failure to Provide Ordered Nutritional Supplements: Two residents with significant medical and nutritional risk factors did not consistently receive ordered nutritional supplements. One resident experienced marked weight loss, had a puree diet ordered, and had recommendations for increased house supplements and an appetite stimulant that were not initiated during the review period. Staff confirmed the facility had been out of Magic Cup supplements for a while, no substitution was provided, and the supplements were not consistently sent on meal trays or documented as offered.
Missing Parameters for PRN Pain Medications: A resident with vascular dementia and a displaced right femur fracture had orders for two PRN pain medications, Tylenol and oxycodone-acetaminophen, but neither order included pain-level parameters. The MAR showed both medications were given for varying pain scores, and an LPN and the DON confirmed the orders lacked guidance on when each medication should be used; the Administrator stated the facility did not have a pain medication management policy.
A resident with hemiplegia, chronic pain, and other chronic conditions had two PRN topical pain medications that the pharmacist recommended for discontinuation because they had not been used in 60 days. The NP signed the pharmacy note agreeing with discontinuation, but the signature was undated and the meds remained active on the MAR/TAR when reviewed by surveyors; the DON confirmed they had not been discontinued.
Medication administration errors occurred when an LPN gave an excessive dose of Pregabalin to one resident, and two other residents received duplicate doses after an RN failed to document medications on the MAR. The residents had diagnoses including chronic pain conditions and neuropathy, and the errors involved scheduled medications such as Pregabalin, Tramadol, Levaquin, and Prednisone. The DON verified the incorrect administration and the missing MAR documentation that led to the additional doses.
Pureed bread was not prepared or served as listed on the menu for two residents on pureed diets. Staff observed during meal prep that no pureed bread was made, and an LPN confirmed that no bread or substitute was served because it does not work well. The RD stated that a pureed bread substitute would be expected if the bread could not be prepared properly.
Call light not within reach. A resident with dementia, AFib, asthma, and anxiety disorder had a care plan intervention to keep the call light within reach, and the MDS showed severe cognitive impairment with independent mobility. Surveyors observed the call light between the bed and wall and later under the bed, and a CNA confirmed it could not be reached by the resident.
Staff were observed preparing and serving food without wearing facial hair coverings and by handling food with bare hands, including when preparing a mechanically altered diet for a resident with dementia and no teeth. These actions were not in accordance with the facility's food handling policy, and beard covers were available but not used.
A resident with multiple medical conditions did not receive weekly skin inspections as outlined in their care plan. Although initial and one follow-up inspection were documented, subsequent weekly inspections were missed prior to discharge, as confirmed by the DON.
The facility failed to provide alternate menu items, such as cottage cheese, as reported by several residents. Despite being listed on the alternative menu, cottage cheese had not been ordered since mid-September. The dietary department, contracted to an external company, was unaware of this oversight, leading to the deficiency.
The facility failed to maintain the ice machine and clean the cold air vents, potentially affecting all 57 residents. Observations revealed dusty air ducts and a clogged floor drainpipe causing stagnant water to back up into the ice machine drainpipe. These issues were confirmed with the District Manager, despite the contracted company's responsibility for cleaning and sanitizing.
A resident with anoxic brain injury and mental health disorders reported physical abuse by family, but the facility delayed reporting the allegation to the state survey agency by three days, contrary to policy requiring a two-hour reporting window.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in medication and diagnosis documentation. One resident's opioid use was not accurately recorded, and another resident's active diagnosis of anxiety was omitted. These inaccuracies were confirmed by interviews with nursing staff.
The facility failed to ensure accurate PASRR documentation for two residents. One resident's PASRR did not reflect an anxiety diagnosis despite being prescribed medication for it. Another resident's PASRR was outdated and did not include current mental health and intellectual disability diagnoses, which were confirmed by staff interviews.
A facility failed to maintain consistent communication with a dialysis center for a resident receiving hemodialysis. The resident, with end-stage renal disease and other conditions, had missing dialysis communication logs on several dates, which were crucial for managing their care. The facility's administrator confirmed the absence of these logs, highlighting a deficiency in maintaining essential records.
A facility failed to address pharmacy recommendations for a resident's pain management and lab work. The resident, with conditions including diabetes and hip pain, was prescribed acetaminophen and tramadol without proper pain parameters, as recommended by the pharmacy. Additionally, the facility did not conduct a recommended HbA1c test every three months. These deficiencies were confirmed by the Regional Care Consultant and the DON during a survey.
A resident with a spinal surgical wound infection did not receive scheduled doses of vancomycin due to unavailability and communication lapses. The facility's pharmacy adjusted the dosage without proper coordination with the infectious disease pharmacist, leading to further missed doses. The facility's policy on medication administration was not adhered to, resulting in significant medication errors.
The facility failed to ensure proper medication storage and administration. An LPN left a medication cart unlocked and unattended, and the DON found a resident's medications left on a bedside table, contrary to policy. Medications should be secured and administered when prepared.
A resident with hemiplegia and hemiparesis experienced significant dental pain after losing a filling, but the LTC facility failed to provide timely dental services. Despite multiple complaints and requests for pain relief, the resident's care plan lacked a dental plan, and the social worker did not secure an emergency dental appointment, mistakenly believing the resident did not meet emergency criteria. The facility's policy to assist in obtaining dental care was not followed.
A facility failed to provide a resident with the prescribed assistive eating device, a small maroon spoon, as ordered by a physician. The resident, who had hemiplegia and was receiving hospice services, was observed using a regular spoon instead. Interviews with staff confirmed the oversight.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic venous ulcer. The resident was observed without an EBP sign or available PPE, and there was no physician order for EBP, contrary to facility policy. The DON confirmed that EBP should have been in place.
The facility failed to lock three medication carts when unattended, potentially affecting 12 cognitively impaired and independently mobile residents. The carts were found unlocked outside the nurse's station, and a nurse confirmed leaving them unattended while going to the restroom. Facility policy mandates that medication supplies remain locked when not in use or attended by authorized personnel.
A resident with multiple health conditions was mistakenly given another resident's medication, including morphine and other drugs, due to a nurse's failure to follow the six rights of medication administration. The resident became lethargic but did not require Narcan. The incident was reported and investigated, revealing the error's root cause.
A nurse failed to perform proper hand hygiene during medication administration, affecting three residents. After administering medication to a resident, the nurse interacted with visitors and family members without washing her hands before preparing medication for another resident. She used her bare hand to handle medication and continued to administer medication to another resident without washing her hands, only doing so after completing the process. This deficiency was identified during a complaint investigation.
A resident was physically assaulted by another resident in the dining room where no staff were present, resulting in multiple injuries and psychosocial harm. The facility failed to provide timely medical care, notify the physician and authorities promptly, and implement appropriate interventions to ensure resident safety.
The facility failed to maintain an effective abuse prohibition program, resulting in an incident of resident-to-resident physical abuse. The investigation by the DON was inadequate, lacking comprehensive documentation and necessary notifications, leading to a delay in treatment for a resident and potential recurrence of such incidents.
The facility failed to ensure a complete and thorough investigation following an allegation of physical abuse involving two residents. The investigation lacked staff interviews, additional resident interviews, and proper documentation of the incident and injuries in the medical record. The facility's abuse policy was not adequately followed, leading to a deficiency in ensuring resident safety and thorough investigation of abuse allegations.
Failure to Prevent Pressure Injury Development and Ensure Proper Mattress Settings
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer prevention and skin care for a resident who had a significant decline in mobility after a fall with a right fibula fracture. The resident had diagnoses including dementia, anxiety, major depressive disorder, and intellectual disabilities, and was identified as at risk for impaired skin integrity due to incontinence and impaired mobility. Her care plan included barrier cream, turning and repositioning, skin inspections, and a pressure redistribution mattress, but the record showed no updated Braden Scale after she became non-weight bearing and no documented pressure ulcer interventions were in place after the fracture until an order for heel elevation was received on 10/22/25. After the fall, the resident was noted to have swelling and bruising to the right ankle, and x-ray findings confirmed an oblique nondisplaced distal fibula fracture. Emergency room documentation stated she had not been ambulatory for two days and was discharged with a splint and minimal weight-bearing instructions. Staff interviews confirmed that after the fall she refused to leave her room, required increased assistance, and was not getting out of bed. The DON verified there was no documentation that the resident’s heels were offloaded or that she was turned every two hours from after the fall until the wound was identified. On 10/24/25, the resident was found to have a new in-house acquired unstageable pressure ulcer to the left heel, later described as a DTI with necrotic tissue. The wound persisted over subsequent wound assessments and required debridement. Interviews with the NP, DON, ADON, and CNA staff confirmed the resident had a significant decline in function after the fall, that the heel wound was not reported before it was first identified, and that the resident did not have a pressure redistribution mattress in place despite the care plan calling for one. The facility also failed to ensure correct air mattress settings for another resident who was dependent for rolling and had hospice services; observations showed that resident’s air mattress remained on the firm setting, and the DON verified the setting should have been based on the resident’s weight.
Unsanitary Food Service Area and Improper Hot Food Holding Temperatures
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in the kitchen serving area. During observation of the over-the-tray foodservice area, two exhaust fans were noted to be dirty with a large amount of brown and gray fuzzy substance on them. The white paint on the ceiling over the food serving area was also observed to be chipping and bulging from the ceiling. An interview with the Dietary Director confirmed both the condition of the exhaust fans and the damaged ceiling paint. The facility also failed to maintain proper hot food holding temperatures on the tray line before food service. Plain chicken was observed at 130 degrees Fahrenheit and mechanical soft chicken at 153 degrees Fahrenheit, and on a later observation the plain chicken was 110 degrees Fahrenheit and the mechanical soft chicken was 128 degrees Fahrenheit. An interview with staff confirmed that the chicken items were in the temperature danger zone. The facility policy identified the danger zone for potentially hazardous foods as 41 degrees to 135 degrees Fahrenheit, and the USDA guidance reviewed stated that food held in warming trays should be kept above 140 degrees Fahrenheit.
Smoking Area Not Properly Maintained
Penalty
Summary
The facility failed to ensure smoking regulations were followed in the designated smoking area in the central enclosed courtyard, as required by NFPA 101 - 2012 Edition, Section 19.7.4. During a tour with the Director of Maintenance, surveyors observed 37 cigarette butts on the ground, including three butts in a pine bush that had burned some of the needles. A cigarette receptacle was present in the area. The Director of Maintenance verified the findings at the time of observation. The Administrator stated that smokers were expected to use the two available fireproof cigarette receptacles to dispose of cigarette butts after smoking. Review of the facility's September 2022 Smoking Policy showed that the smoking area was to comply with applicable Federal, State, and local laws regarding smoking and smoking safety.
Respiratory Care and Oxygen Equipment Documentation Failures
Penalty
Summary
The facility failed to ensure Resident #7 received oxygen as ordered. Resident #7 was admitted with diagnoses including hypertensive heart disease with heart failure, a displaced right femur fracture, severe protein-calorie malnutrition, and anxiety, and had a care plan for impaired respiratory status with interventions to monitor vital signs and pulse oximetry and provide oxygen as needed for signs of breathing difficulty. The physician order dated 10/25/25 directed oxygen at 2 to 4 liters per minute via nasal cannula as needed to maintain oxygen saturation at 90% or greater and/or for shortness of breath, but the December 2025 MAR had no documentation of oxygen use as needed and no oxygen saturation documentation. During observations on 12/15/25 and 12/16/26, Resident #7 was receiving oxygen at 3 liters per minute via nasal cannula, and the DON confirmed oxygen was being administered without MAR documentation and without documentation of oxygen saturation levels before and after use or how many liters were being administered. The facility also failed to ensure oxygen tubing was dated for multiple residents receiving respiratory treatments. Resident #6, who had COPD, chronic kidney disease, and anxiety disorder and was assessed as cognitively intact, had an order for 4 liters of oxygen per minute via nasal cannula with titration to keep saturations at or above 91%, and a weekly tubing change order; however, on observation the oxygen tubing was not dated, which RN #92 confirmed. Resident #26, with diagnoses including COPD, diabetes, anemia, anxiety, hypertension, dementia, depressive disorder, dysphagia, and polyneuropathy, was observed with oxygen via nasal cannula and no date on the tubing, which LPN #135 confirmed. Resident #27, with COPD, acute and chronic respiratory failure with hypoxia, heart failure, chronic kidney disease stage four, and other cardiac diagnoses, was also observed receiving oxygen via nasal cannula with no date on the tubing, and LPN #135 confirmed this. Additional observations showed Resident #44, who had COPD, dementia, chronic respiratory failure with hypoxia, and other diagnoses, was lying in bed with oxygen via nasal cannula and no date on the tubing, which LPN #135 confirmed. Resident #70, who had COPD, cerebral infarction, morbid obesity, obstructive sleep apnea, heart failure, asthma, chronic kidney disease stage three, and acute respiratory hypercapnia, had BiPAP at bedtime and with naps as needed, plus an order for DuoNeb via nebulizer as needed; during observation, the nebulizer mask and tubing were on the nightstand attached to the machine with no date, and the BiPAP facemask was on top of the machine with no date on the tubing and was not covered. LPN #135 confirmed the missing dates and stated the facemask should be stored in a plastic bag when not in use. The NIH nebulizer instructions reviewed by surveyors stated nebulizer parts should be stored in a dry, clean plastic storage bag and kept in separate labeled bags.
Infection Control Failures During Contact Precautions, Glucose Monitoring, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow infection control procedures while serving meals to residents under contact precautions for C. diff infection. Resident #21 had diagnoses including C. diff infection and a care plan directing contact isolation with all meals provided in the room. During lunch meal pass, a CNA entered the resident’s room without PPE and stood within one foot of the resident while setting up the meal tray. The CNA confirmed that no PPE was worn before entering the room and approaching the resident. A similar failure occurred with Resident #26, who also had C. diff infection and physician orders for contact isolation. During lunch meal delivery, a CNA entered the resident’s room without gloves or a gown and was observed standing within one foot of the resident while setting up the meal. The CNA confirmed that PPE was not worn when entering the room and being close to the resident. The facility policy and CDC guidance reviewed in the report stated that gown and gloves are recommended for contact precautions and that PPE should be available for room entry. The facility also failed to properly handle a glucometer during a blood glucose check for Resident #60, who had type II diabetes and was ordered blood glucose monitoring before meals and bedtime. An LPN placed the glucometer on the resident’s overbed table without a barrier, then placed it directly on the medication cart after use and wiped it with bleach wipes without using a barrier. The LPN confirmed the device was placed on the overbed table and medication cart without a barrier, and the wipe directions required the device to remain visibly wet for three minutes. In addition, Resident #13 was on enhanced barrier precautions, but emergency rain ponchos were found in the PPE cart outside the room, and staff verified they did not cover the arms and were not appropriate PPE. The facility policy defined EBP as gown and gloves during high-contact care activities.
Resident Privacy Not Maintained During Shower Transport
Penalty
Summary
The facility failed to ensure privacy was maintained while Resident #17 was being transported to the shower room. Resident #17 was admitted with diagnoses including Parkinson's disease, diabetes, and anxiety disorder, and the annual MDS assessment indicated the resident was cognitively intact and required substantial/maximal assistance for showering and bathing. During an observation, a CNA was seen transporting the resident from the room to the shower room in a shower chair. Although the resident was wearing a gown that covered the front, a side view showed the resident's buttocks and genitals were visible below the hole in the shower chair seat. The CNA verified that the resident's buttocks and genitals were able to be seen when observed from the side. The facility's Shower/Tub Bath policy stated that residents should be covered and privacy maintained when transporting them to and from the bath area.
Unsafe Call Light Box Condition
Penalty
Summary
A safe environment was not maintained for Resident #4. The resident was admitted on 07/20/22, re-entered on 07/07/24, and had diagnoses including diabetes, dysphagia, heart failure, COPD, osteomyelitis, schizoaffective disorder, schizophrenia, peripheral vascular disease, anxiety disorder, major depressive disorder, and hypertension. The quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and that the resident was independent or needed set-up assistance with eating, bed mobility, transfers, and wheelchair mobility, with partial/moderate assistance needed for toilet hygiene and bathing. The resident also had an indwelling catheter and was occasionally incontinent of bowel. During an observation, Resident #4's bed was positioned to the left of the door with the head of the bed against the same wall as the door and about six inches from the wall on the left side. The resident's call light was attached to the call light box at the foot of the bed. The call light box was partially covered by a plastic cover, with approximately one-third uncovered, and unused wires covered by a wire nut and electrical tape were visible in the open area of the box. A CNA confirmed the position of the call light and the condition of the partially covered call light box with visible wiring.
Failure to Provide Bed Hold Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a bed hold letter to Resident #3 and failed to notify the Ombudsman when the resident discharged to the hospital. Resident #3 was admitted with diagnoses including vascular dementia and a displaced fracture of the neck of the right femur, and an MDS assessment showed a BIMS score of 14, indicating intact cognitive status. Nursing progress notes documented that the resident had a fall and was discharged to the hospital for evaluation, and the resident was hospitalized before returning. Review of the medical record found no documented evidence that a bed hold notice letter was provided to the resident or representative and no evidence that the Ombudsman was notified of the hospitalization. The Business Office Manager confirmed there was no evidence of either the bed hold notice or Ombudsman notification, and the facility policy stated that written information explaining the bed hold policy is to be given to residents and resident representatives prior to transfer.
Failure to Maintain Resident Fingernail Hygiene
Penalty
Summary
The facility failed to ensure Resident #7’s fingernails were trimmed and cleaned as part of assistance with activities of daily living. Resident #7 was admitted and later readmitted with diagnoses including hypertensive heart disease with heart failure, displaced fracture of the right femur, severe protein-calorie malnutrition, and anxiety. The care plan identified an ADL self-care performance deficit and directed staff to assist with dressing, grooming, personal hygiene, locomotion, and oral care. The resident’s significant change MDS showed cognitive impairment and dependence on staff for personal hygiene, and the resident was also admitted to hospice with hypertensive heart disease with heart failure. Bathing documentation showed Resident #7’s fingernails were not trimmed on multiple occasions, including entries on 12/03/25, 12/06/25, and 12/10/25. Although hospice bathed the resident and trimmed the fingernails on 12/10/25, the same documentation also stated the fingernails were not trimmed. Surveyor observations on 12/15/25 and 12/16/26 found the resident had long fingernails. Hospice staff stated hospice aides did not trim resident fingernails as part of ADL care, and the DON verified the resident had long fingernails that needed to be trimmed. Hospice RN #242 also verified hospice aides could not trim resident fingernails.
Delayed Assessment After Fall and Improper Foley Catheter Bag Positioning
Penalty
Summary
Timely care and services were not provided to a resident who fell and later was found to have a right ankle fracture. The resident had diagnoses including dementia without behavioral disturbances, anxiety, major depressive disorder, and unspecified intellectual disabilities, and the care plan noted impaired communication with instructions to allow ample time for understanding and use simple, direct communication. The resident was identified as high risk for falls and used a walker independently before the incident. After the fall, the resident was documented as standing with a rollator in the room, heading toward the bathroom, then stopping, shaking, and falling to the floor. Immediate bruising to the affected lower extremity was noted, and three staff members assisted the resident back to bed. Following the fall, the resident’s mobility declined from independent or one-person supervision to extensive assistance and then two-person assistance for transfers, with no further walking documented after the fall. A nurse practitioner examined the resident the next day for bilateral lower extremity edema and ordered furosemide, while the resident’s TED hose remained on during the examination and the ankle was not visibly assessed. The resident was later noted to be favoring the right ankle, refusing to stand to transfer, and having limited range of motion with pain when standing. An x-ray obtained after the delay showed an oblique nondisplaced fracture of the distal fibula, and emergency room documentation described significant swelling, bruising, and tenderness of the right ankle with discharge orders for a splint, minimal weight-bearing, and orthopedic follow-up. A later orthopedic evaluation and CT scan identified a right tri-malleolar ankle fracture involving the distal fibula, posterior malleolus, and medial malleolus. The facility also failed to ensure proper catheter care for another resident with an indwelling Foley catheter, as the drainage bag was observed hung on the adjustable bed rail and positioned on the side of the bed facing the door without a cover, and the DON confirmed this placement was not consistent with facility policy.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to ensure timely initiation of nutritional supplement recommendations and failed to ensure nutritional supplements were available and received as ordered for two residents, including a resident with dementia, anxiety, major depressive disorder, and intellectual disabilities, and another resident with vascular dementia, cerebral infarction, and type 2 diabetes mellitus. Both residents had care plans identifying risk for altered nutritional status and physician-ordered nutritional supplements intended to support intake and/or wound healing. For one resident, the record showed a progression from stable intake to significant weight loss and declining functional status. A speech evaluation recommended a puree diet with thin liquids and close supervision, and physician orders later included Magic Cup twice daily and house supplements. Nutritional notes documented inadequate intake, total dependence on staff for supplements, and recommendations to increase house supplements and start an appetite stimulant. However, the record showed that the recommended increase in house supplements and the appetite stimulant were not initiated during the period reviewed, and Remeron was not started despite being recommended. The resident’s weight declined from 163.4 pounds to 132.8 pounds over the reviewed period. The record and observations also showed that the resident did not receive ordered Magic Cup supplements because the facility did not have any in the building and no substitution was provided. On multiple observations, the supplement was absent from the meal tray, and staff confirmed it was not given. Interviews with staff confirmed the facility had been out of Magic Cups for a while, that no substitution had been sent, and that there was no documentation showing an alternative had been offered. The dietary director also confirmed the supplement was not on the diet slip at one point, meaning kitchen staff had not been sending it on the meal tray. For the second resident, the physician ordered Magic Cup three times daily, but MAR review and nursing notes showed multiple missed doses because the kitchen did not send the supplement. Observations confirmed the resident did not receive the supplement at breakfast or lunch, and staff confirmed no substitution was provided. The resident’s weight remained stable during the period reviewed, but the record still showed repeated failures to provide the ordered supplement as prescribed.
Missing Parameters for PRN Pain Medications
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident who had orders for two as-needed pain medications without parameters specifying when each medication should be given. The resident was admitted with vascular dementia and a displaced fracture of the base of the neck of the right femur, and his MDS assessment showed a BIMS score of 14 out of 15, indicating intact cognitive status. Physician orders dated 08/24/25 included Tylenol 650 mg by mouth every four hours as needed for pain, and orders dated 08/26/25 included oxycodone with acetaminophen 5-325 mg by mouth every four hours as needed for pain, but neither order contained pain-level parameters. The MAR showed that the resident received oxycodone-acetaminophen for pain levels ranging from three to five on multiple occasions, and Tylenol for pain levels of six on two occasions. An LPN stated she would expect as-needed pain medication orders for residents prescribed two pain medications to specify when each medication should be given based on a one-to-ten pain scale and the parameters in the order. The DON confirmed the resident did not have pain parameters for either medication and stated she would expect the non-opioid analgesic to be used typically for pain levels one to five and the opioid analgesic for pain levels six to ten, but the physician would need to write the parameters. The facility policy on administering medications stated medications shall be administered in a safe manner as prescribed, and the Administrator stated the facility did not have a pain medication management policy.
Pharmacy Recommendations Not Implemented for Unused Pain Medications
Penalty
Summary
The facility failed to implement pharmacy recommendations signed by the provider in a timely manner for one resident reviewed for unnecessary medications. Resident #49 was admitted on 07/27/23 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction on the right dominant side, chronic pain, hyperlipidemia, hypertension, mood disorder due to a known physiological condition, and alcohol abuse uncomplicated. The resident’s quarterly MDS showed a BIMS score of 15, indicating cognitive intactness, and documented wheelchair use, continence of bowel and bladder, occasional pain rated 5/10, and receipt of opioid pain medication. The resident had physician orders for trolamine salicylate external cream 10% for left wrist pain and diclofenac sodium external gel 1% for pain. The pharmacist’s note to the prescriber stated both medications should be evaluated for continued need or discontinued because they had not been used in the past 60 days. The note was signed by NP #200 indicating agreement that both medications should be discontinued, but the signature was undated. When the note was reviewed by surveyors, both medications were still active on the MAR and TAR, and the DON confirmed they had not been discontinued.
Medication Administration Errors Involving Duplicate and Excess Doses
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for three residents reviewed for medication administration. Resident #28 had diagnoses including mononeuropathy of the right lower leg, pain in the right knee, and type 2 diabetes, and was ordered Pregabalin 150 mg three times daily. On 11/26/25 at 4:00 A.M., LPN #96 signed out five Pregabalin 150 mg capsules from the controlled drug record, and the MAR did not show the medication as administered at the scheduled 6:00 A.M. time. Later that morning, Resident #28 reported not feeling well and stated she thought the increased Pregabalin dose might be the cause; the DON verified that 750 mg of Pregabalin had been administered instead of the ordered 150 mg, and that the medication was not scheduled for 4:00 A.M. and was not signed off as administered. Resident #50 had diagnoses including vascular dementia, anxiety disorder, idiopathic peripheral autonomic neuropathy, polyneuropathy, and polyarthritis, and was cognitively intact per the quarterly MDS. Resident #50 was ordered Tramadol 50 mg twice daily, Levaquin 500 mg daily, and Prednisone 40 mg daily. The record showed RN #155 administered Tramadol at 5:50 A.M., but did not document it on the MAR. During the morning medication pass, the day shift nurse administered Tramadol, Levaquin, and Prednisone again at the scheduled 7:00 A.M. time. The facility investigation stated RN #155 believed she had signed the medication on the MAR, and the root cause was the failure to sign the MAR, which led the oncoming nurse to administer an additional dose. Resident #69 had diagnoses including osteogenesis imperfecta, a fracture of the lower end of the right femur, chronic pain syndrome, and osteoarthritis, and was cognitively intact per the quarterly MDS. Resident #69 was ordered Pregabalin 200 mg and Tramadol 50 mg twice daily at 7:00 A.M. and 7:00 P.M. The MAR showed the medications were administered by LPN #94 at the scheduled 7:00 A.M. time, but the controlled drug record showed RN #155 had already administered both medications at 6:10 A.M. and had not signed the MAR. During the morning medication pass, LPN #94 noticed the earlier narcotic sign-out and the facility investigation identified the failure to sign the MAR as the cause of the additional dose.
Pureed Bread Not Served as Planned
Penalty
Summary
The facility failed to provide and serve pureed bread as planned on the menu for residents receiving pureed diets. Review of the planned pureed diet spreadsheet for 12/18/25 showed that a #16 scoop of pureed bread was scheduled to be served with lunch. However, observations of pureed diet preparation from 10:02 A.M. to 10:17 A.M. showed that no pureed bread was prepared. An interview with staff member #117 at 11:51 A.M. confirmed that no pureed bread was made for lunch and that no pureed bread substitute was served, with the staff member stating that it does not work well. The deficiency affected two residents, Resident #8 and Resident #13, who received pureed diets. The Registered Dietitian stated at 12:22 P.M. that if bread could not be prepared properly, a pureed bread substitute would be expected instead.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #42's call light was within reach. Resident #42 was admitted with diagnoses including dementia, atrial fibrillation, asthma, and generalized anxiety disorder, and the care plan identified the resident as at risk for falls related to impaired cognition and psychotropic medication use, with interventions to keep the call light within reach. The quarterly MDS showed a BIMS score of 02, indicating severe cognitive impairment, and that the resident was independent with mobility. During observations, the resident's call light was found between the bed and the wall and later under the bed beneath the foot board, and a CNA verified that the call light was underneath the bed and could not be reached by the resident.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
During meal service, staff failed to maintain sanitary conditions in the kitchen by not wearing facial hair coverings and by handling food with bare hands. Specifically, one staff member was observed preparing a cheeseburger for a resident on a mechanically altered diet by placing bread and cheese on the plate using bare fingers, rather than gloves or utensils. This was confirmed by another staff member who witnessed the incident. Additionally, two staff members were observed behind the steam table preparing trays and serving food without covering their facial hair, despite beard covers being available in the kitchen. The affected resident had diagnoses including dementia, weakness, and indigestion, required assistance with activities of daily living, and was on a mechanically altered, soft-textured diet due to having no teeth. The facility's food handling policy required food to be stored, prepared, handled, and served in a manner that minimized the risk of foodborne illness. All residents in the facility received food prepared in the kitchen, indicating the potential for widespread impact.
Failure to Complete Weekly Skin Inspections as Care Planned
Penalty
Summary
The facility failed to complete weekly skin inspections for a resident as required by the resident's comprehensive care plan. Medical record review showed that the resident, who had a history of fall with nasal fracture, influenza A, cerebrovascular accident, and traumatic brain injury, was admitted and received a skin inspection upon admission and again on 01/15/25. However, no further weekly skin inspections were documented prior to the resident's discharge on 02/01/25. The care plan specifically included an intervention for weekly skin inspections, but these were not performed on 01/22/25 and 01/29/25. The DON confirmed during interview that the required weekly inspections were missed.
Failure to Provide Alternate Menu Items
Penalty
Summary
The facility failed to ensure that alternate menu items were available to residents, as evidenced by multiple interviews and observations. Residents reported that the facility did not honor food alternatives ordered, and specific items such as cottage cheese, lettuce, and orange juice were unavailable. The alternative menu listed items like tossed salad and cottage cheese, but the facility had not ordered cottage cheese since 09/17/24, as confirmed by the review of food invoices and interviews with staff. The dietary department, contracted out to an external company, was unaware that cottage cheese was on the alternative menu, leading to its unavailability. Resident #56, who had diagnoses including endocarditis, diabetes mellitus, and sepsis, also reported that alternate food items were not always available. The resident's medical record indicated an intact and independent cognition level. The facility's certified dietary manager confirmed that the last order of cottage cheese was on 09/17/24, and none was available at the time of the survey. The food service contract stipulated that all food and supplies would be prepared and served by the contracted company, including items on the alternative menu, but this was not adhered to, resulting in the deficiency.
Ice Machine and Air Vent Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the ice machine and clean the cold air vents, which had the potential to affect all 57 residents residing in the facility. During an observation of the kitchen, it was noted that three cold air ducts and one unused duct were visibly dusty. Additionally, the bottom drainpipe for the ice machine was improperly installed, running directly into the floor drainpipe without a gap. The floor drainpipe was clogged, causing stagnant water to back up into the ice machine drainpipe. These findings were confirmed during an observation with the District Manager. The review of the food service contract from April 25, 2021, indicated that the contracted company was responsible for various tasks, including cleaning and sanitizing. However, the observed deficiencies in the maintenance of the ice machine and cleanliness of the air vents suggest a lapse in fulfilling these responsibilities.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency in a timely manner, affecting one resident. The resident, who had anoxic brain injury, schizoaffective disorder, and bipolar disorder, was admitted with an independent and intact cognition level. On a specified date, the resident reported an allegation of physical abuse by her family, claiming she was hit in the face. Upon assessment, no injuries or signs of abuse were found. However, the facility did not create a self-reported incident (SRI) until three days after the allegation was made, which was verified by the Director of Nursing and Administrator. This delay was contrary to the facility's policy, which required reporting any abuse allegation to the state survey agency within two hours of receipt.
Inaccurate MDS Assessments for Medications and Diagnoses
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the medication and pertinent diagnoses for two residents. For Resident #6, the medical record indicated that the resident was prescribed Tramadol, an opioid, and received it on specific dates in August and September 2024. However, the quarterly MDS assessment dated September 5, 2024, inaccurately reported that the resident received an opioid for zero days during the seven-day look-back period. This discrepancy was confirmed during an interview with the MDS/Registered Nurse. For Resident #9, the medical records showed that the resident had diagnoses including schizophrenia, bipolar disorder, major depression, and anxiety. A psychiatry progress note instructed staff to monitor anxiety and schizophrenia. Despite this, the MDS assessment dated June 5, 2024, did not reflect an active diagnosis of anxiety. This inaccuracy was also confirmed during an interview with a Registered Nurse. These findings indicate a failure in accurately documenting the residents' medication use and diagnoses in the MDS assessments.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) documents accurately reflected the diagnoses of two residents. Resident #6 was admitted with diagnoses including schizoaffective disorder, dysphagia, chronic kidney disease, low back pain, and muscle wasting and atrophy. Despite having a diagnosis of anxiety disorder and being prescribed Clonazepam for anxiety, the PASRR document did not indicate this diagnosis. This discrepancy was confirmed by the Social Services Director during an interview. Resident #9 was admitted with multiple diagnoses, including schizoaffective disorder, bipolar disorder, major depressive disorder, general anxiety, and intellectual disabilities. However, the PASRR document from 2018 did not reflect any mental illness or intellectual disability, and there was no evidence of a PASRR update since then. The resident's current diagnoses and treatment plan indicated serious mental illness and intellectual disabilities, which were not captured in the PASRR. This was confirmed by a social worker, who acknowledged that the resident would require a Level II PASRR screening based on current diagnoses.
Inconsistent Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. This deficiency affected a resident who was the only individual in the facility receiving dialysis treatments. The resident had been admitted with diagnoses including end-stage renal disease, essential hypertension, and type two diabetes mellitus with diabetic nephropathy. The resident's care plan included interventions for outpatient dialysis three times a week and required communication with the dialysis center regarding medication, diet, and lab results. Upon review, it was found that the dialysis communication logs for the resident were missing on several dates in September 2024. These logs were crucial as they contained vital information such as the resident's code status, transfer time, allergies, mental status, medications, skin issues, and pre and post-dialysis weights. The absence of these logs was confirmed by the facility's administrator, indicating a lapse in maintaining essential communication records necessary for the resident's dialysis care.
Failure to Address Pharmacy Recommendations for Pain Management and Lab Work
Penalty
Summary
The facility failed to address pharmacy recommendations regarding a resident's pain medication and lab work in a timely manner. The resident, who was admitted with diagnoses including type two diabetes mellitus, pain in the left hip, and a non-pressure chronic ulcer of the left foot, was prescribed acetaminophen and tramadol for pain management. However, the pharmacy recommended evaluating these medications and establishing proper pain parameters, which the facility did not implement. Additionally, the resident's October 2024 physician orders did not include pain parameters for the prescribed medications. Furthermore, the facility did not obtain a Hemoglobin A1C (HbA1c) test every three months as recommended by the pharmacy. This oversight was confirmed during interviews with the Regional Care Consultant and the facility's Director of Nursing (DON), who acknowledged that the lab work was not completed as required. These deficiencies affected the resident's care and were identified during a survey of the facility.
Failure to Administer Vancomycin as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of vancomycin for a spinal surgical wound infection. The resident, who was admitted with diagnoses including infection and inflammatory reaction due to orthopedic prosthetic devices, did not receive scheduled doses of vancomycin on multiple occasions. On the day of admission, the resident missed the second dose of vancomycin, and the first dose the following day, due to the medication not being available in the emergency medication kit. Additionally, the resident missed another dose later in the month for the same reason. There was no documented evidence that the infectious disease physician or the facility's physician was notified of these missed doses. Further issues arose when the facility's pharmacy adjusted the vancomycin dosage without proper communication with the infectious disease pharmacist. The infectious disease pharmacist had recommended holding certain doses and re-drawing trough levels, but these instructions were not followed, and no orders were written to hold the medication. The Director of Nursing confirmed these lapses in medication administration and communication. The facility's policy on medication administration, which requires adherence to prescriber's written orders, was not followed in these instances.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as observed on two separate occasions. On the first occasion, a medication cart in the Sycamore Valley area was left unlocked and unattended while the LPN responsible was in a resident's room at the other end of the hall. This was confirmed by a State tested Nurse's Aide who noted the cart was not secured as per the facility's policy, which mandates that medication carts must be closed and locked when out of the nurse's sight. On the second occasion, the Director of Nursing observed a pill cup with several pills on a resident's bedside table. The resident explained that the nurse had left the medications there earlier because she preferred to take them with her breakfast. The DON confirmed that medications should not be left unattended and should be administered at the time they are prepared, as per the facility's policy. The medications involved included a range of prescriptions such as aspirin, budesonide, and metoprolol succinate, among others.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for a resident who was admitted with hemiplegia and hemiparesis following a cerebral infarction, among other conditions. The resident, whose primary insurance was Medicaid, lost a filling in a bottom right tooth and began experiencing significant pain. Despite multiple complaints of pain documented in progress notes from early September, the resident did not receive a dental appointment. The resident's care plan lacked any evidence of a dental plan, and the facility's social worker did not complete an emergency referral form, believing the resident did not meet the criteria for an emergency visit. The resident continued to experience pain, requiring Tylenol for relief, and expressed frustration over the delay in receiving dental care. The social worker was aware of the dental issues but did not attempt to secure an appointment with an outside dentist, mistakenly believing that the resident would have to wait for the facility dentist's next visit. It was only after further inquiry that the social worker discovered a local dental office would see Medicaid patients promptly. The facility's policy stated that they would assist residents in obtaining both routine and emergency dental care, which was not adhered to in this case.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide an appropriate assistive device for a resident, leading to a deficiency in care. Resident #5, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, muscle wasting, lack of coordination, and cognitive communication deficit, was affected by this oversight. The resident was cognitively intact and receiving hospice services, with a care plan indicating limited ability to eat and drink due to weakness and dysphagia. A physician's order specified the use of a small maroon spoon as an assistive device during meals. However, during an observation, the resident was seen using a regular spoon instead of the prescribed assistive device. Interviews with the Regional RN Consultant and the Dietary Manager confirmed the absence of the small maroon spoon, as ordered by the physician.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident admitted with a chronic venous ulcer. The resident, who had diagnoses including unspecified venous ulcer, cellulitis, morbid obesity, and peripheral vascular disease, was observed without an EBP sign on the door or available Personal Protective Equipment (PPE) near the resident's door. The medical record review revealed that there was no physician order for EBP, despite the facility's policy indicating that EBP should be in place for residents with chronic wounds. The Director of Nursing confirmed that EBP should have been implemented for the resident.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that three medication carts were locked when unattended, which had the potential to affect 12 cognitively impaired and independently mobile residents. During an observation on the Buckeye Unit, three medication carts were found outside the nurse's station, unlocked and unattended. An interview with a nurse confirmed that she had left the medication carts unlocked while she went to the restroom. The facility's policy on medication storage requires that medications and biologicals be stored properly and accessible only to authorized personnel, with medication supplies remaining locked when not in use or attended by authorized individuals. This deficiency was identified during a complaint investigation.
Medication Error Involving a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, resulting in a medication error involving Resident #58. The resident, who had multiple diagnoses including cellulitis, urinary tract infection, cognitive communication deficit, dysphagia, hypertension, dementia, atherosclerotic heart disease, chronic kidney disease, and atrial fibrillation with a pacemaker, was given another resident's medication. This error occurred on the morning of 06/13/24 when Nurse #100 administered the wrong medication to Resident #58, which included a combination of drugs such as mycophenolate, cyclosporine, famotidine, Ativan, magnesium oxide, morphine, nystatin, and prednisone. Following the medication error, the nurse reported the incident, and the Nurse Practitioner was contacted. Orders were given to administer Narcan if the resident's respirations fell below 10 per minute and did not improve with arousal, and to send the resident to the emergency room if Narcan was administered. The resident's vital signs were closely monitored, and additional tests were ordered to assess hepatic and kidney function. The resident was noted to be lethargic and drowsy but did not require Narcan administration as her condition did not deteriorate to that extent. The facility's investigation determined that the root cause of the medication error was the failure of Nurse #100 to adhere to the six rights of medication administration. The Director of Nursing confirmed the error and noted that the resident's only change in condition was a slight drop in oxygen levels. The facility's policy on medication discrepancies required documentation and reporting of such incidents, which was followed in this case. This deficiency was investigated under Complaint Number OH00154888.
Failure to Perform Proper Hand Hygiene During Medication Administration
Penalty
Summary
During a medication administration observation, Nurse #101 failed to perform proper hand hygiene, affecting three residents. After administering medication to Resident #51, the nurse hugged a visitor and shook hands with a family member without washing her hands before preparing medication for Resident #54. She used her bare hand to remove a gabapentin capsule from the medication card and placed it into a medication cup. The surveyor intervened, and a new capsule was administered. The nurse continued to set up medication for Resident #25 without washing her hands, only washing them after completing the administration. An interview with Nurse #101 confirmed the lack of hand hygiene during the medication administration process for Residents #25, #51, and #54. This deficiency was identified during a complaint investigation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure Resident #2 was free from an incident of resident-to-resident abuse. On 04/21/24, Resident #2 was physically assaulted by Resident #3 in the dining room where no staff were present. Resident #3 struck Resident #2 multiple times, resulting in two facial lacerations, a laceration to the lower lip, and multiple hematomas on the arms, upper breasts, and chest wall. Resident #2 also experienced psychosocial harm, expressing fear of reoccurrence and isolating herself from activities and meals. The facility did not provide timely medical evaluation, failed to notify the physician and authorities promptly, and did not implement appropriate interventions to ensure resident safety. Resident #2 had a history of schizoaffective disorder, bipolar type, anxiety, major depressive disorder, personality disorder, cognitive communication disorder, dysphagia, heart failure, muscle weakness, and seizure disorder. The care plan for Resident #2 included interventions for verbal behaviors and supervision during meals due to poor self-monitoring and impulsivity with eating. Despite these interventions, the incident occurred, and the facility's response was inadequate. The facility did not conduct a thorough investigation, failed to provide timely medical care, and did not offer psychosocial support to Resident #2 following the incident. Resident #3 had a history of diffuse traumatic brain injury, major depressive disorder, mood disorder, anxiety disorder, and muscle weakness. The care plan for Resident #3 included monitoring for anxiety, restlessness, poor impulse control, and fear/apprehension. Despite these interventions, Resident #3 exhibited aggressive behavior towards Resident #2. The facility did not provide adequate supervision in the dining room, failed to implement appropriate interventions to prevent further incidents, and did not conduct a comprehensive investigation following the altercation. The facility's failure to ensure resident safety and provide appropriate care resulted in Immediate Jeopardy and physical and psychosocial harm to Resident #2.
Removal Plan
- 1:1 supervision was initiated for Resident #3 with one staff member assigned for supervision of the resident. Additional staff were added to the shifts (as needed) to ensure monitoring occurred until the resident's discharge. The following staff provided 1:1 supervision through discharge: State tested Nursing Assistant (STNA) #130, #148, #160, and Activities Staff #160.
- An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. Regional DON #702 and VPCO #703 educated the Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, Activities Director #91 on the facility abuse policy, Centers for Medicare and Medicaid abuse reporting guidelines, future expectations with reporting abuse and completing investigations. Topics also discussed during the meeting were resident behaviors and care planned interventions as well as the facility removal plan. QAPI committee meetings would be held weekly for weeks, then monthly for recommendations and further follow-up regarding the removal plan based upon evaluation of audits and observations. Audits would continue to be submitted to the QAPI committee for review and to ensure compliance goals. QAPI committee reserved the right to modify or extend monitoring times according to outcomes. The Administrator was responsible for the oversight of this plan to ensure ongoing compliance. Any issues identified thru the audits would be reviewed and revised thru the facility QAPI process.
- The DON and Licensed Practical Nurse (LPN) #132 completed a record review for all 57 residents (the current census) for behavioral diagnosis including but not limited to traumatic brain injury (TBI), dementia and schizophrenia with no newly identified residents at risk for resident-to-resident abuse through diagnoses.
- LPN #132 reviewed residents (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) determined to be at risk for potential aggressive behaviors to ensure care planned interventions were appropriate.
- Resident #3 was placed in a private room by Plant Director #158 and Medical Records #126.
- The Director of Nursing spoke with Resident #6 (the resident who witnessed the incident between Resident #3 and Resident #2) to offer emotional/psychosocial support, but the resident declined.
- Facility resident profiles for residents at risk for potential aggressive behaviors (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) were updated to reflect care planned interventions to be followed when caring for a resident with a behavioral care plan by SSD #100, LPN #132 and/or the ADON.
- Resident #2 was evaluated by Physician #810 regarding the incident with Resident #3 via telehealth. The provider's progress note indicated there were no lasting effects from the incident. There were no current updates made to the resident's care plan and no new orders were received.
- All 82 staff (17 nurses, 23 STNA, two Activity Aides, 14 Department Managers, two Agency Nurses, 12 therapy, seven dietary and five housekeeping/laundry) were educated by the Administrator, DON or ADON either in-person or by phone regarding the facility abuse policy and reporting abuse to the Administrator (the facility abuse coordinator).
- All nursing staff (17 nurses, 23 STNA and two agency nurses) were educated either in person or via phone on access to resident care plans by SSD #100, LPN #132, the DON, or the Assistant Director of Nursing (ADON). A hand-out was also provided regarding how to access the information and the staff who received education via phone will receive the hand-out on their next scheduled shift. Staff will also be required to show a return demonstration or recite the process on their next scheduled shift. The resident profiles are in the electronic medical record (EMR).
- The facility implemented a plan that any facility initiated Self Reportable Incident(s) and facility investigation(s) would be escalated to regional support, Regional DON #702, and [NAME] President of Clinical Operations (VPCO) #703 for review to ensure the facility policy was followed.
- A plan for Social Services Designee (SSD) #100 to conduct weekly psychosocial follow-up with Resident #2 was implemented to ensure no lingering effects from the incident had occurred. Follow up would be completed for four weeks.
- The DON, ADON, and/or LPN #132 would review all new admissions for behavior risks.
- Auditing would be completed by the Director of Nursing/Assistant Director of Nursing and/or LPN #132 five days a week for the next eight weeks then three times a week for four weeks for all residents, which includes all new admissions.
- The Director of Nursing, ADON and/or LPN #132 would review/audit all nursing staff documentation including progress notes, events, observations, and Care Assist documentation to ensure all residents with behaviors have care planned interventions to ensure safety. Auditing would be completed on all current residents five days a week for eight weeks, then three times a week for four weeks.
- Resident #3 was discharged to a sister facility related to the resident's behavioral health needs.
- The Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, and Activities Director #91 conducted an audit (questionnaire) of current interviewable residents, whose Brief Interview for Mental Status (BIMS) score was eight and higher with no reported incidents of abuse and the residents interviewed indicated they felt safe within the facility.
- Non-interviewable residents (#27, #71, #47, #9 and #58), received a skin assessment.
Failure to Maintain Effective Abuse Prohibition Program
Penalty
Summary
The facility failed to maintain effective administrative services to provide a comprehensive abuse prohibition program, resulting in an incident of resident-to-resident physical abuse. The incident involved Resident #2 and Resident #3, where Resident #2 alleged that Resident #3 attacked her in the dining room. The initial investigation by the Director of Nursing (DON) was inadequate, as it did not include obtaining witness statements from all involved staff, conducting thorough resident interviews, or completing necessary skin assessments for non-interviewable residents. Additionally, the DON did not notify the psychiatric providers or the attending physician of the incident, resulting in a delay of treatment for Resident #2. The DON was administering medications at the time of the incident and was working as a floor nurse due to staffing needs. The DON's investigation concluded that the incident did not constitute abuse, as she believed Resident #3 did not act willfully to harm Resident #2. However, the investigation lacked comprehensive documentation, including staff statements and interviews, and failed to implement preventative interventions following the altercation. The facility's self-reported incident (SRI) indicated that Resident #2 had scratches on her face and later developed bruises on her chest and forearms, but the DON did not document these injuries in the resident's medical record or notify the physician. The Administrator, who was also the facility Abuse Coordinator, confirmed that the investigation should have included staff interviews and resident assessments. The facility's policy on abuse, neglect, and misappropriation of property required a thorough investigation and documentation of all allegations, which was not followed in this case. The failure to conduct a comprehensive investigation and implement corrective actions resulted in the potential for recurrence and compromised the safety and well-being of the residents in the facility.
Incomplete Investigation of Physical Abuse Allegation
Penalty
Summary
The facility failed to ensure a complete and thorough investigation following an allegation of physical abuse involving two residents. Resident #2 alleged that Resident #3 attacked her in the dining room, resulting in scratches and bruises. The only witness, Resident #6, corroborated Resident #3's account that Resident #2 had instigated the altercation by attempting to remove Resident #3's oxygen tubing. The facility's investigation, led by the Director of Nursing (DON), concluded that the allegation was unsubstantiated and did not suspect abuse. However, the investigation was incomplete, lacking staff interviews, additional resident interviews, and proper documentation of the incident and injuries in the medical record. The DON did not notify the psychiatric providers of the involved residents, and there was no follow-up from psychiatry for either resident following the incident. Additionally, the facility failed to provide evidence of a 72-hour psychosocial evaluation for Resident #2, who expressed fear and tearfulness when reminded of the incident. The facility's abuse policy was not adequately followed, leading to a deficiency in ensuring resident safety and thorough investigation of abuse allegations.
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Illustrative
What surveyors actually found near you
We read the 156 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Coshocton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Coshocton Inc. | 2.1 mi | ★★★★★ | 20 | 0 |
| Lafayette Pointe Nursing & Rehab Ctr | 7.1 mi | ★★★★★ | 1 | 0 |
| Riverside Manor Nrsg & Rehab Ctr | 15.2 mi | ★★★★★ | 4 | 0 |
| Oak Pointe Nursing & Rehabilitation | 15.2 mi | ★★★★★ | 0 | 0 |
| Majora Lane Ctr For Rehab & Nsg Care Inc | 18.8 mi | ★★★★★ | 12 | 0 |
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