Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sanctuary Wadsworth during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a sacral wound had an order for oxycodone before dressing changes, but during observed incontinence and wound care the RN continued the procedure while the resident repeatedly verbalized pain. The nurse did not stop to assess or treat the pain until care was complete, when the resident rated pain 10/10. The wound NP confirmed pre-medication was ordered for wound care, and the RN later acknowledged she did not reassess pain before continuing.
Dietary staff were observed with hair nets that did not fully contain their hair, including exposed hair at the hairline, ears, and neck. Resident room refrigerators also had missing or incomplete temp logs, unlabeled and undated drinks, unidentified liquids, and an expired salad. The RD confirmed the hair restraint and refrigerator food safety issues, and facility policy required full hair coverage, daily temp checks, and labeling/dating of stored food.
The DON falsified blood glucose monitoring QC logs and instructed staff to do the same, including placing nurses’ initials on records for days they did not work. Multiple nurses reported blank or incomplete glucometer logs, missing control fluid, and forged signatures, and staff also described the DON asking them to falsify shower sheets and charting. The Administrator was notified after the issue was discovered, and the DON admitted she completed the false logs to avoid survey penalties.
Unsafe parking lot conditions and inconsistent water temperatures were identified during survey. Large potholes remained in the parking lot and residents reported the issue had gone unaddressed for a long time, while the ADON and MDS nurse confirmed the problem had persisted for years. Environmental rounds also found a sink with cold hot water and showers with temperatures that were not consistently comfortable, and an LPN and RN reported that shower water could fluctuate between hot and cold.
Incomplete and inaccurate resident record documentation: The facility documented showers for one resident inconsistently, including missing shower sheets, entries outside the scheduled shower window, and documentation by a CNA who was not working; the resident said showers were not always offered and CNAs stated the DON asked them to complete false shower sheets. For another resident, MAR and TAR entries were completed while the resident was hospitalized. For a third resident with bowel and bladder incontinence, task sheets showed multiple missed two-hour checks across several shifts.
Failure to Provide Requested Medical Records: The facility did not ensure a resident's medical records were available when requested by the family. The resident had chronic respiratory failure, HF, anxiety, and depression, and staff interviews showed the request was not passed along after the prior medical records clerk left. An LPN could not produce an email request, and the SSD confirmed the family was directed to the former clerk, who did not relay the request to the Clinical Manager.
A resident’s advance directive was not accurately reflected in the medical record. The face sheet listed the resident as DNRCCA and the physician’s orders included DNRCCA, but no signed DNRCCA form was found in the EMR or paper chart. The DON verified the missing form and stated the resident should be documented as full code until the physician signed the DNRCCA form.
Failure to Report Injury of Unknown Origin: A resident with intact cognition, a Hoyer lift order, and anticoagulation therapy developed an unexplained skin tear to the lower leg. RN and ADON were notified and treatment orders were obtained, but no witness statements or investigation were completed, and the Administrator was unaware of the injury and did not report it to the State Agency as a self-reported incident.
Failure to Investigate Injury of Unknown Origin: A resident with intact cognition, a wheelchair, and warfarin therapy developed a skin tear of unknown origin that was noted by an RN during routine care. The injury was documented, but no witness statements were obtained and no investigation was completed. The ADON confirmed she did not ask other staff how it occurred, and the administrator stated the event was not reported as a self-reported incident to the State Agency.
Inaccurate MDS discharge assessment. A resident with CHF, A-fib, spinal stenosis, anemia, HTN, and HLD was discharged to home after meeting skilled goals, and the progress note documented a planned discharge in a private vehicle with a friend. However, the discharge MDS incorrectly coded the discharge as unplanned, and the MDS nurse confirmed the assessment should have reflected a planned discharge.
Care plans were not kept current for three residents. One resident’s plan did not add interventions after skin tears occurred during a Hoyer transfer and later on the leg, another resident’s plan listed smoking precautions but did not reflect vaping, and a third resident’s plan did not include the resident’s preference to recline while eating or swallowing-related interventions despite a pureed diet and dysphagia.
Failure to Provide and Accurately Document Scheduled Bathing: A resident with hemiplegia, hemiparesis, venous insufficiency, and a chronic ulcer was care planned for showers twice weekly, but the facility did not consistently provide bathing as scheduled. Shower documentation showed missing sheets, showers recorded outside the assigned shift, and entries completed by CNAs who were not working or did not provide the care. The resident said showers were not consistently offered, and staff reported the DON asked them to falsify shower records.
Failure to Apply Ordered Ted Hose: A resident with AFib, HTN, DM2, HLD, obesity, and edema had a physician order for ted hose to be applied in the morning and removed in the evening. Although the TAR showed the ted hose were applied on two mornings, surveyors observed the resident without ted hose, with puffy, purple ankles and later visibly swollen, purple legs. A CNA stated the ted hose had not been put on because staff were running behind that morning.
A resident who required a Hoyer lift was injured during transfer when the lift tilted after catching on a bedside table, and staff confirmed the incident was not fully investigated. Another cognitively impaired resident who was care planned for 2-person assist fell during incontinence care while only one CNA was providing care. A third resident with moderate cognitive impairment and limited ability to safely handle smoking items was observed vaping outside without the required smoking apron, and staff stated they did not apply the apron because there was no ash.
A resident with respiratory failure, quadriplegia, dysphagia, and ventilator dependence had a tube feeding ordered at 54 mL/hour for 20 hours, but it was observed running at 45 mL/hour. An LPN verified the feeding was not running at the ordered rate, and the facility policy required enteral feedings to be given according to the physician’s order.
A resident with ESRD and dependence on dialysis received HD treatments without an active physician order in place. Dialysis handoff forms documented multiple treatments, but the MAR/TAR had no pre- or post-dialysis vital signs, and an MDS nurse confirmed staff did not obtain vital signs after dialysis. The facility policy required physician orders for dialysis and nursing documentation of vital signs before and after treatment.
A resident with hemiplegia, bipolar disorder with psychotic features, anxiety, chronic headaches, and a TBI had Venlafaxine 75 mg BID ordered for depression and administered as ordered. Pharmacy review recommended changing the medication to Venlafaxine ER 150 mg daily and also noted the last GDR was over a year ago, but provider responses were inconsistent and not timely, with one recommendation marked agreed and another marked disagreed for the same medication issue.
A resident with chronic respiratory failure, COPD, heart failure, anxiety, and depression received Cresemba for aspergillosis, but nursing staff gave only one 186 mg capsule instead of the ordered 372 mg dose. The MAR showed the medication as administered daily, yet the facility investigation found 11 doses were given at half the prescribed strength, and an LPN stated the family reported there was still medication left because only half the dose had been administered.
Infection control standards were not maintained during incontinence care and wound care for two residents. During care for one resident with incontinence, diabetes, CKD, HF, and a stage III sacral wound, staff performed brief handwashing, left a soiled bed pad in place, and did not change gloves before moving from pericare to wound care. During wound care for another resident with necrotizing fasciitis and stage 3 buttock pressure ulcers, an LPN touched the resident with contaminated gloves after closing blinds, and an RN placed a 4x4 on the sterile field and did not sanitize scissors before cutting foam for the wound dressing.
The facility failed to provide required ADL assistance with oral hygiene and morning transfers for multiple dependent residents. Two residents who were care planned to receive oral care at least twice daily instead received oral care only once per day over the prior month, and both reported that staff did not assist or prompt them to brush their teeth; a CNA and an RN confirmed oral care was not consistently provided despite facility policy. Another resident with heart disease, CHF, cognitive impairment, and bilateral lower extremity impairment, who required a mechanical lift with two CNAs for transfers and preferred to be up and dressed before breakfast, was found still in bed after having already eaten, stating he had been waiting all morning to get up; a CNA confirmed he had to wait for available staff to complete the transfer.
Pain Not Assessed or Treated During Wound Care
Penalty
Summary
The facility failed to assess and treat a resident’s pain before or during wound care to the sacrum. The resident had multiple diagnoses including peripheral vascular disease, diabetes mellitus, anxiety, chronic kidney disease, heart failure, and polyosteoarthritis, and care plans identified altered comfort, risk for impaired skin integrity, and a sacral wound. The resident also had an order for oxycodone 5 mg every six hours as needed for pain and before dressing changes, and the record showed she had a stage III pressure ulcer to the sacrum that was later reclassified by the wound NP as an abscess. During observed incontinence care and wound care, the resident repeatedly verbalized pain by saying “ow” every four seconds throughout the 23-minute procedure. RN #504 and CNA #576 performed the care, but the nurse did not stop to assess the resident’s pain or offer pain medication before continuing with the dressing change. The resident continued to vocalize pain while the old dressing was removed, the wound was cleaned, and calcium alginate was placed on top of the wound rather than lightly packed into it. The wound care was completed at 11:00 A.M., and only after care was finished did the resident receive oxycodone for a pain rating of 10 out of 10. The wound NP confirmed the resident had an order to be pre-medicated prior to wound care because of the pain associated with the wound, and the nurse later acknowledged she did not reassess pain or offer medication before continuing. The nurse also stated the resident had refused morning medications and had behaviors of yelling out, which she used as the reason she did not stop the dressing change. The resident’s son reported that he had watched the video of the care and believed his mother was in pain during the procedure because he could hear her yelling loudly.
Kitchen Hair Restraints and Resident Refrigerator Food Safety Lapses
Penalty
Summary
The facility failed to ensure a sanitary kitchen by allowing dietary staff to work with hair restraints that did not fully contain their hair. During lunch meal service, a dietary employee had a hair net on, but hair on the back of the neck was not restrained and the hair net sat about an inch above the exposed hair. The dietary manager confirmed the observation. Later that day, the dietary manager and other dietary staff were observed with hair nets pushed back or not fully covering the hairline, ears, and base of the neck, with hair exposed. The registered dietitian confirmed that all hair should be contained in the hairnet. The facility policy stated that hair shall be restrained to prevent physical contamination of food and that all employees in the kitchen shall wear hair restraints to cover all hair. The facility also failed to maintain resident room refrigerators in a sanitary manner and to ensure food was properly monitored. Several resident refrigerators had missing or incomplete temperature logs, including refrigerators with no log posted or logs not completed after a prior date. One resident’s refrigerator contained an uncovered, unlabeled, undated four-ounce glass of unidentified juice and an open, undated bottle of clear Gatorade, and another resident’s refrigerator contained two bottles with unidentified liquids, one of which had brown unidentified liquid inside. A different resident’s refrigerator contained an apple walnut salad with a use-by date that had already passed. The registered dietitian confirmed that temperature logs should have been completed, food items should have been labeled and dated, and outdated foods should have been discarded. The facility identified 12 residents with room refrigerators, and the policy required resident refrigerator food to be labeled with the prepared or opened date and expiration date, with temperatures documented daily and food items monitored three times a week.
Falsified Blood Glucose Monitoring Records and Directed Documentation Fraud
Penalty
Summary
The facility administration failed to maintain professional standards of practice when blood glucose monitoring quality control records were falsified and staff were instructed to falsify documentation. Review of the Director of Nursing’s job description showed she was responsible for organizing and directing nursing department activities to ensure proper resident care and for assisting in the development of performance policies and standards for nursing staff. The deficiency involved 21 residents who received blood glucose monitoring and had the potential to affect the clinical documentation of all 64 residents in the facility. Review of the original blood glucose monitoring system quality control logs for multiple medication carts showed the records were not fully completed from 07/01/26 through 07/08/26. Some logs were blank on multiple days, and some entries stated there was no control fluid available to perform glucometer checks. A separate set of logs for the same carts showed the records had been completed for those dates with the same handwriting used for nine different nurses, including staff whose schedules showed they were not working on those days. One LPN stated she discovered her initials had been forged on days she did not work and on carts she was not responsible for, and she reported that the DON told her it was not against the law to place nurses’ signatures on documents they had not completed. Additional interviews showed the DON had asked staff to falsify other records as well, including shower sheets and skilled nursing charting, and one CNA admitted she signed shower sheets for a resident even though she did not perform the showers. Another nurse stated the DON wanted her to write a progress note for a resident on a day she had not worked, and she refused. The facility investigation confirmed the DON admitted she had completed the falsified glucometer logs to avoid being penalized during the annual survey. The Administrator was informed of the issue, and interviews with multiple nurses verified their initials on the falsified records were not theirs.
Unsafe Parking Lot Conditions and Inconsistent Water Temperatures
Penalty
Summary
The facility failed to provide a safe environment related to large potholes in the parking lot. Review of repair quotes showed the facility had received quotes on 09/16/24, 02/25/26, and 03/26/26, and an observation on 07/07/26 found 10 large potholes in the parking lot in front of the building. During the resident council meeting, Resident #25 stated the potholes had been there for a while and had not been addressed, and Residents #23, #28, #44, and #68 agreed. The Activities Director confirmed the parking lot needed to be fixed so large outdoor activities could be held, and the Administrator confirmed the first repair quote was dated 09/16/24 and that the facility was waiting for the owner to review the quotes and select one. The Maintenance Director stated the potholes had been present for quite a while, and an MDS Nurse stated the parking lot had started getting bad about three or four years earlier after a large carnival was held outside. The facility also failed to maintain water temperatures at a level a reasonable person would find comfortable. During environmental rounds, the hot water at the sink in an unoccupied room on the 100-hallway measured 68 degrees F, the shower in the 400-hallway shower room measured 100.2 degrees F, and the shower in the 200-hallway shower room measured 97 degrees F. An LPN reported a former resident had used the sink where the water was too cold, and another LPN stated showers were not hot at times and the water could get hot, then cold, and change quickly while residents were showering. An RN also reported concerns with shower temperatures, stating the water could be too hot or too cold and that there was a concern with water temperatures on the 200-hallway. The Maintenance Director verified the measured water temperatures were not reaching sufficient temperatures.
Incomplete and inaccurate resident record documentation
Penalty
Summary
The facility failed to maintain resident records in a complete and accurate manner for three residents reviewed. For one resident with hemiplegia, hemiparesis, venous insufficiency, and a chronic ulcer of the right foot/lower leg, the record showed a care plan for showers twice weekly and as needed, but the shower documentation was inconsistent. Shower sheets were missing for some scheduled showers, the task record showed showers documented at times outside the scheduled shower window, and some shower entries were recorded by a CNA who was not scheduled to work on those dates. The resident stated he was not always offered showers and had not received showers during the middle of the night, and CNAs stated they were asked by the DON to complete shower sheets for dates they did not work or for showers they did not provide. For another resident with ESRD, HTN, type 2 DM, and dialysis dependence, the record showed the resident was in the hospital, yet the MAR and TAR still contained documentation of completed vital signs and treatments on a date when the resident was not in the facility. The documented items included vital signs and multiple treatment tasks such as fistula assessment, behavior checks, offloading boot use, non-skid footwear, head-of-bed elevation, dialysis site monitoring, pressure cushion use, and wound care. The Administrator and MDS Nurse verified that the resident was hospitalized during that time and that the LPNs documented orders as completed while the resident was away. For a third resident with muscle wasting and atrophy, difficulty walking, dependence on a wheelchair, cognitive communication deficit, and bowel and bladder incontinence, the bladder and bowel task sheets were not completed as required. The resident’s care plan directed staff to check the resident every two hours, provide incontinence care as needed, and toilet the resident every two hours while awake. The task sheets showed multiple missed checks across day, evening, and night shifts over several days, including periods when the resident was not checked for eight hours or more and one day when no checks were documented on any shift. The MDS Nurse verified that the bladder continence task sheets were not completed every two hours per facility policy.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to ensure resident medical records were available upon request for one resident, Resident #72, who was admitted with diagnoses including chronic respiratory failure, heart failure, anxiety, and depression and was later discharged from the facility. Review of the closed medical record, interviews, and facility policy showed that the resident's family had asked for medical records, but the request was not provided to the staff member then handling medical records after the previous clerk left the facility. During interviews, the Clinical Manager stated she had started in the medical records office after the previous clerk left and had not been informed that Resident #72 wanted a copy of the records. An LPN stated she had corresponded with the family by email but could not provide an email showing a request for records, and said the request may have gone to the prior clerk who had not kept other staff updated. The SSD stated the family member asked for records and was told to speak to the previous medical records clerk, who did not relay the request to the Clinical Manager. The facility policy stated it would ensure timely, compliant access to residents' clinical records while protecting confidentiality and record integrity.
Advance Directive Not Properly Documented
Penalty
Summary
The facility failed to ensure a resident’s advance directives were accurately reflected in the medical record. Resident #80 was admitted with diagnoses including cellulitis and malignant neoplasm of the prostate. The resident’s face sheet identified him as DNRCCA, and the physician’s orders included an advance directive for DNRCCA. However, review of the medical record found no signed DNRCCA form in either the electronic medical record or the paper chart. During interview, the DON verified that no signed DNRCCA form was present in the resident’s records and stated the resident should be documented as full code until the DNRCCA form was signed by the physician.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an injury of unknown origin was timely reported to the State Agency for Resident #20. Resident #20 was admitted on 05/11/22 and had diagnoses including encephalopathy, obstructive hydrocephalus, chronic respiratory therapy, moderate protein-calorie malnutrition, hypokalemia, and anemia. The resident had a BIMS score of 14, used a wheelchair, required maximum assistance for upper dressing and rolling, and was dependent for toileting, bathing, lower body dressing, and transfers. Physician orders included a Hoyer lift for all transfers and Warfarin Sodium, and the care plan identified the resident as at risk for bleeding and bruising due to anticoagulation therapy. On 06/26/26, RN #547 entered the resident’s room to give medications and apply lotion to the legs and observed a skin tear on the left lower leg. The resident was unsure how the injury occurred. RN #547 notified the ADON and an NP, and treatment orders were obtained. The facility incident log documented the injury, and skin assessments later described the tear as one inch by one inch with no depth and a dry scab. The injury was later documented as healed on 07/07/26. Interviews showed no witness statements were obtained and no investigation was completed for the injury. MDS Nurse #515 confirmed that staff were supposed to complete a risk management assessment and investigation, with DON review, when a skin injury or fall occurred. The Administrator stated she was not aware of the injury and therefore did not report it as a self-reported incident to the State Agency. RN #547 and the ADON/Wound Nurse #516 both confirmed they did not ask other staff how the injury occurred, and the resident also could not recall how or when the skin tear happened.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an injury of unknown origin was timely and thoroughly investigated for one resident with intact cognition who used a wheelchair, required extensive assistance with ADLs, and had orders for a mechanical lift for all transfers and warfarin therapy. The resident was also identified as being at risk for bleeding and bruising due to anticoagulation therapy. On 06/26/26, a RN found a skin tear on the resident’s left lower leg while giving medications and applying lotion. The resident was unsure how the wound occurred, and the RN notified the ADON and NP and obtained treatment orders. The injury was documented in the facility incident log and skin assessments, but no staff witness statements were obtained and no investigation was completed. The MDS nurse confirmed that when a skin injury or fall occurs, staff are supposed to complete a risk management assessment and investigation, with DON review of the findings, but that did not occur for this event. The ADON/wound nurse stated she observed the skin tear, noted it appeared scabbed over, and confirmed she did not ask other staff whether they knew how it occurred. She also confirmed she did not follow up on the risk management assessment or notify anyone further besides the wound NP. The administrator stated she was not aware of the injury and therefore did not report it as a self-reported incident to the State Agency and did not initiate an investigation. The resident later stated he did not recall how he got the skin tear. The facility policy required all incidents, accidents, and injuries to be reported immediately, documented, investigated, and reviewed by management, including witness statements and identification of contributing factors and root cause when appropriate, but those steps were not completed for this injury of unknown origin.
Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to complete an accurate MDS assessment for a resident admitted with congestive heart failure, atrial fibrillation, spinal stenosis, anemia, hypertension, and hyperlipidemia. The closed record showed the resident was admitted on 05/06/26 and discharged on 05/28/26, with a discharge planning review indicating the resident had met skilled goals and would discharge to home or community. The NOMNC dated 05/21/26 identified the last covered day as 05/27/26, and the progress note dated 05/28/26 documented a planned discharge to home, with the resident leaving in a private vehicle with a friend. However, the discharge MDS assessment indicated an unplanned discharge to home or community. During interviews on 07/07/26 and 07/08/26, the MDS Nurse confirmed the assessment should have indicated a planned discharge and stated she had opened a revision for it.
Care plans not updated for injuries, vaping, and swallowing preferences
Penalty
Summary
The facility failed to keep resident care plans current with changes in condition and resident preferences for three residents reviewed. For one resident with encephalopathy, obstructive hydrocephalus, chronic respiratory therapy, malnutrition, hypokalemia, and anemia, the care plan last reviewed on 05/05/26 identified anticoagulation-related bleeding risk and impaired transfers with use of a mechanical lift, but it was not revised to include interventions to prevent skin tears. The resident had a Hoyer lift order and later received warfarin, and the record showed a skin tear to the right hand during a Hoyer transfer and another skin tear to the left lower leg later in the month. Nursing notes documented the injuries, and the resident stated the hand injury occurred during transfer and that his skin had been pulled back on his hand. For another resident with progressive multiple sclerosis, myalgic encephalomyelitis/chronic fatigue syndrome, and depression, the smoking and safety assessment noted balance problems, poor fine motor skills, and inability to safely hold or extinguish tobacco products. The care plan last updated on 06/15/26 identified the resident as a smoker who should wear an apron and be supervised when smoking, but it did not reflect that the resident also vaped. During observation, the resident was seen outside using a disposable vape without an apron, and the resident stated staff usually did not put on the smoking apron when he vaped, only when he smoked cigarettes. The DON confirmed the resident smoked but was not aware he vaped, and confirmed the care plan did not reflect vaping. For a third resident with CHF, severe protein-calorie malnutrition, and dysphagia, the care plan last reviewed on 05/12/26 addressed nutritional risk, limited mobility, and a pureed diet with supplements, but it did not include the resident’s preference to recline while eating or specific swallowing-related interventions. The resident’s MDS showed moderate cognitive impairment, and physician orders included a pureed diet with thin liquids. During lunch, the resident was observed reclining in a wheelchair at about a 30-to-40-degree angle while eating a pureed meal. The RD confirmed the positioning was a potential choking hazard, and RN staff confirmed the resident preferred to recline while eating and that the care plan did not show that preference or specify safe swallowing interventions.
Failure to Provide and Accurately Document Scheduled Bathing
Penalty
Summary
The facility failed to ensure bathing was provided as required for one resident who required moderate assistance with bathing and was care planned for showers two times a week and as needed. The resident had diagnoses including hemiplegia and hemiparesis, venous insufficiency, and a chronic ulcer of the right foot and lower leg. The June 2026 shower schedule showed the resident was to receive showers on Tuesdays and Fridays during day shift, but the shower sheets provided by the facility documented only 7 showers for the month and did not include sheets for 06/05/26 and 06/23/26, which were scheduled shower opportunities. The facility shower task record contained multiple entries showing showers documented at times outside the scheduled day shift, including several in the middle of the night, and some shower sheets were completed by staff who were not working on those dates. The MDS nurse confirmed showers during the middle of the night should not have been documented and confirmed one CNA did not work on several dates she signed. The resident stated he was not being offered showers consistently and had not received showers during the middle of the night. A CNA stated the DON asked her to falsify shower sheets, and another CNA confirmed she completed a shower sheet for a date she did not provide a shower and said she was asked by the DON to fill out the sheets.
Failure to Apply Ordered Ted Hose
Penalty
Summary
The facility failed to apply ted hose as ordered for Resident #28, who was admitted with diagnoses including atrial fibrillation, hypertension, type 2 diabetes mellitus, hyperlipidemia, and obesity. The physician ordered ted hose to be put on in the morning and removed in the evening for edema, and the care plan addressed cardiovascular disease with interventions to administer medications and treatments as ordered and to notify the physician of edema and changes in skin color. The TAR showed ted hose were applied on the mornings of 07/08/26 and 07/09/26, but during observation on 07/08/26 the resident was wearing pants ending above the ankles and her ankles were puffy and purple with no ted hose observed. On 07/09/26, a CNA stated she had not had a chance to put the resident's ted hose on because staff were running behind that morning, and a later observation confirmed the resident was not wearing ted hose and both legs were visibly swollen and purple in color.
Unsafe Transfers, Incontinence Care, and Smoking Supervision
Penalty
Summary
The facility failed to ensure a safe transfer for a resident who required a mechanical lift for all transfers. The resident had diagnoses including encephalopathy, obstructive hydrocephalus, chronic respiratory therapy, malnutrition, hypokalemia, and anemia, and the MDS indicated intact cognition but dependence for transfers and toileting. During a Hoyer lift transfer, staff reported that the lift began to tilt when it caught on the edge of a bedside table as the resident was being lowered into a wheelchair. Staff stabilized the lift and completed the transfer, but the resident was found to have a skin tear to the hand with bleeding. The resident later stated the injury occurred during the transfer and described the cut as about 1-1/2 inches long. The incident was documented as a skin injury, and nursing notes described a right hand skin tear with steri-strips applied. Interviews with the aides involved confirmed that two staff members were assisting with the transfer and that the lift tilted during the maneuver. One aide stated the resident was in the air when the lift started to tilt, and both aides used their bodies and arms to prevent it from tipping. The RN confirmed she was notified after the injury, but the investigation did not include witness statements from both aides involved. The MDS nurse confirmed no investigation was completed to determine the root cause of the lift tilting and no new interventions were put into place. The facility also failed to ensure safety during incontinence care for another resident who was cognitively impaired, dependent in all ADLs, and care planned for two-person assist for all care. A falls investigation showed the resident had a witnessed fall from bed and was lowered to the ground during incontinence care. The investigation and CNA interview confirmed that only one CNA was providing care at the time of the fall, despite the resident's care plan calling for two-person assistance. In addition, the facility failed to ensure a safe smoking environment for a resident with progressive multiple sclerosis, moderate cognitive impairment, balance problems, and inability to safely hold or extinguish tobacco products. The smoking assessment stated the resident could not safely hold tobacco or other smoking products and could not extinguish them, and the care plan required a smoking apron and staff supervision. However, staff observed the resident outside using a disposable vape without a smoking apron. The CNA confirmed the apron was not applied because there was no ash, and the DON and MDS nurse stated they were aware the resident smoked but did not recognize vaping as requiring the same precautions, despite the facility policy stating electronic cigarettes were permitted but must follow smoking guidelines.
Enteral Feeding Not Administered at Ordered Rate
Penalty
Summary
Resident #63, who was admitted with respiratory failure, quadriplegia, dysphagia, and dependence on a mechanical ventilator, had a physician’s order for enteral tube feeding to run at 54 mL/hour for 20 hours. During observation, the resident’s enteral tube feeding was found running at 45 mL/hour instead of the ordered rate. An LPN later observed the feeding and verified that it was not running at the correct rate per the physician’s order. The facility’s Enteral Feeding Policy stated that residents requiring enteral nutrition would receive feedings according to the physician’s order.
Missing dialysis orders and post-treatment assessment
Penalty
Summary
The facility failed to ensure a resident with end stage renal disease and dependence on renal dialysis had physician's orders in place for dialysis treatments. The resident's record showed an admission diagnosis of end stage renal disease, hypertension, type two diabetes mellitus, and dependence on renal dialysis, and the care plan indicated the resident required hemodialysis. However, the physician's orders showed no active order for dialysis treatments as of 07/09/26, and the most recent dialysis order had been discontinued on 06/18/26 due to hospitalization. There were also no orders to assess vital signs before and after dialysis. Dialysis handoff communication forms documented that the resident received dialysis treatments on 06/26/26, 07/02/26, 07/06/26, 07/07/26, and 07/08/26 even though no physician's orders were in place for those treatments. The forms included a post-dialysis assessment section for facility staff, but it did not include vital signs, and the MAR/TAR contained no documentation of vital signs before and after dialysis on the days dialysis was received. An MDS Nurse confirmed the resident received dialysis without a physician's order and confirmed that facility staff did not obtain vital signs after dialysis. The facility's SNF Dialysis Policy stated physician's orders for dialysis treatment would be obtained and nursing responsibilities included obtaining and documenting vital signs before and after dialysis.
Delayed Response to Pharmacy Medication Review
Penalty
Summary
The facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner for one resident. The resident had diagnoses including hemiplegia and hemiparesis, severe bipolar disorder with psychotic features, anxiety disorder, chronic post traumatic headaches, and a history of traumatic brain injury. The resident’s record showed an order for Venlafaxine (Effexor) 75 mg by mouth twice daily for depression, and the medication was administered as ordered during January and February 2026. The quarterly MDS indicated the resident required moderate assistance with most ADLs and had no noted behaviors. The pharmacist issued a recommendation to review the Venlafaxine order and suggested changing it to Venlafaxine ER 150 mg once daily in the morning for depression; this recommendation was marked agreed and signed by the provider. A second pharmacy recommendation stated the last gradual dose reduction for Venlafaxine 75 mg BID was greater than one year, and this recommendation was signed by a nurse practitioner as disagreed, with a note that additional attempts would likely cause increased distressed behavior. The nurse practitioner later stated he must have made a mistake and intended to attempt the GDR, and the MDS nurse confirmed pharmacy recommendations should be acknowledged in less than 30 days and that the physician did not respond timely. The facility policy stated the attending provider would review pharmacist recommendations and document acceptance or clinical rationale for declining recommendations within 30 days.
Significant Medication Error With Antifungal Dosing
Penalty
Summary
Resident #72 was admitted with diagnoses including chronic respiratory failure, COPD, heart failure, anxiety, and depression, and was later discharged from the facility. An infectious disease consult ordered Cresemba 372 mg once daily for aspergillosis, and the physician’s orders reflected isavuconazonium sulfate (Cresemba) 372 mg daily for 30 days with the family to supply the medication. The medication was supplied in capsule form at 186 mg per capsule, meaning the resident should have received two capsules per dose. The MAR documented Cresemba 372 mg as administered daily from 05/08/26 through 05/22/26, but the facility investigation determined that 11 doses were given at half the strength ordered by the physician. The missed medication investigation stated the doses were not administered as ordered from 05/08/26 through 05/21/26. An LPN stated the family had brought in the medication and that nursing staff had only been giving one capsule instead of two, and that the family had alerted nursing management that medication was still left when weekly doses were brought in.
Infection Control Lapses During Incontinence and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control standards during incontinence care and wound care for two residents. Resident #10 had diagnoses including peripheral vascular disease, diabetes mellitus, chronic kidney disease, heart failure, anxiety, cognitive communication deficit, and polyosteoarthritis, and was dependent on staff for toileting with bladder and bowel incontinence. During observed incontinence care, the CNA placed supplies on a towel on the tray table, and the RN washed her hands for only 10 seconds before assisting with repositioning. The CNA removed the resident’s brief, left the soiled cloth bed pad under the resident, and performed pericare without separating the labia. After incontinence care, the CNA did not change gloves before assisting with wound care, and the RN repeatedly removed gloves and washed her hands for only 5 to 8 seconds before continuing the dressing change. Resident #58 was admitted with necrotizing fasciitis and stage 3 pressure ulcers of the left and right buttocks, and was cognitively intact. During the observed wound dressing change for the left gluteal wound, the LPN used a gloved hand to close the blinds and did not change gloves or perform proper hand hygiene before touching the resident again. The RN assisting with the treatment placed a 4x4 gauze pad from the resident’s drawer onto the sterile field over clean scissors and did not sanitize the scissors before cutting foam dressing for the wound. The wound was then packed with foam dressing, covered with clear drape, and connected per orders. The facility policies reviewed stated that staff should wash hands before and after patient care regardless of glove use, that handwashing should last at least 20 seconds after applying soap, and that handwashing is indicated after contact with inanimate objects to prevent healthcare-associated infections. Interviews with the RN and LPN confirmed the hand hygiene and glove-use issues observed during the care of both residents.
Failure to Provide Required ADL Assistance With Oral Care and Morning Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living (ADLs), specifically oral hygiene and getting out of bed, for dependent residents. One resident with impaired cognition and a documented self-care deficit in ADLs was care planned to receive daily and as-needed oral hygiene, yet ADL records for the prior 30 days showed oral care was provided on average only once per day. Another resident with cerebral infarction, diabetes, peripheral vascular disease, and intact cognition was care planned to receive mouth care and hygiene at least twice daily and as needed due to potential discomfort related to dentures, but ADL records likewise showed oral care was provided on average only once per day. Both residents, who shared a room, stated staff did not assist or prompt them to brush their teeth, and a CNA confirmed oral care was not provided daily, citing denture-related discomfort for one resident. An RN verified the lack of oral hygiene for both residents, despite a facility policy stating that ADL care and services, including oral care, would be provided. The deficiency also includes failure to assist another dependent resident with ADLs related to getting out of bed and dressing. This resident had diagnoses including atherosclerotic heart disease and chronic congestive heart failure, impaired cognition, bilateral lower extremity impairment, and physician orders and a care plan requiring a mechanical lift with two CNAs for all transfers. During observation and interview, the resident was found lying in bed, stating he had been in bed all morning waiting for staff to get him up, dressed, and transferred to his wheelchair, and that he preferred to be dressed before breakfast. A CNA confirmed the resident preferred to be out of bed before eating but stated that residents who required two staff and a mechanical lift had to wait if other staff were busy, and that this resident had already eaten breakfast and was still waiting in bed to get up. These findings were confirmed at the time of the interview and were investigated under a complaint number.
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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.
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Nursing homes near Wadsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Of Wadsworth | 1.9 mi | ★★★★★ | 0 | 0 |
| Doylestown Health Care Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Wadsworth Pointe | 3.8 mi | ★★★★★ | 15 | 0 |
| Autumnwood Nursing & Rehab Center | 4 mi | ★★★★★ | 2 | 0 |
| Pleasant View Health Care Center | 5.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.