Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schoenbrunn Healthcare during CMS and state inspections, most recent first.
Unsanitary food storage and improper glove use during food preparation. A box of rice was left open to air in dry storage, wet pans and wet warming bases were stored on racks, and a DDM prepared a toasted cheese sandwich while touching multiple surfaces and her clothing without changing gloves or washing hands before handling the bread. An expired box of iced tea was also found connected to the drink dispensing system.
The facility failed to follow the planned menu and did not notify residents of meal substitutions. During lunch tray line, a dietary staff member confirmed ham portions were only 1.5 oz instead of the ordered 3 oz, and the kitchen ran out of the planned vegetable. The DDM served unseasoned canned carrots to the last nine trays without informing those residents of the change.
Surveyors found that the facility failed to employ a qualified director of food and nutrition services and to ensure education of dietary aides, affecting all 86 residents. A contract company assumed operation of the kitchen and promoted a former cook to Dietary Manager despite her lacking required certification and relevant educational background. The previously credentialed Dietary Manager stepped down due to the complexity of the new computer system and informed the company that the new Dietary Manager was not credentialed. Although the company indicated it would fund certification training, the new Dietary Manager had not begun any classes at the time of the survey, resulting in non-compliance related to food and nutrition services oversight.
Food was not prepared in a manner that conserved flavor and appearance, as evidenced by a resident repeatedly receiving chicken noodle soup without broth, resulting in bowls of dry noodles that had to be eaten with a fork, and by broccoli consistently served in a mushy, watery state that did not hold its shape. Staff, including dietary personnel, acknowledged that the soup tin contained no broth and that the broccoli always became mushy due to the way it was cooked on the stovetop in a tin on low heat.
The facility failed to provide alternate meal choices of similar nutritional value and did not consistently honor resident food and beverage preferences during a period when the main kitchen was closed and meals were prepared from the dining room using limited equipment. Only a single entrée was offered at each meal, with peanut butter and jelly or deli sandwiches as the only substitutes, and several residents reported they could not order and were simply served whatever was prepared, including food they disliked or items that did not match their stated preferences. Residents also did not consistently receive requested beverages such as chocolate milk, 2% milk, cranberry juice, fruit punch, or ice with meals, and one resident reported being served burnt pizza with no alternative. The Dietary Manager confirmed there was no second meal option of similar nutritive value during the shutdown and that new dietary aides had not been fully trained on tray line duties.
Surveyors found that kitchen sanitation and milk handling practices were deficient. An uncovered, overflowing trash can was located next to a food prep area where a dietary aide was portioning fruit. Staff did not consistently monitor milk temperatures, and milk was sometimes served above the 41°F guideline despite a policy requiring cold potentially hazardous foods to be held at or below that temperature. Temperature logs showed many meals without recorded milk temperatures, and expired milk cartons remained in the milk chest, with expired milk served to a resident.
A cognitively intact, fully dependent and always incontinent resident received incontinence care from a CNA in a shared room without the privacy curtain being drawn, despite the roommate being present. During the care, the resident’s genital area and buttocks were exposed while the CNA removed the adult brief and cleaned the resident. The resident later reported that staff sometimes forget to pull the curtain and that this exposure sometimes bothers him, and the CNA acknowledged not using the privacy curtain, contrary to facility policy on resident privacy during personal care.
A resident with renal failure and legal blindness, who required set-up assistance for meals, had physician orders for a renal diet with specific food restrictions and the use of a blue scoop bowl and plate guard. During multiple observed meals, the tray line provided only a plate guard and no scoop bowl, despite the meal ticket indicating the need for both. Dietary staff reported that previously available scoop bowls could no longer be found anywhere in the facility, resulting in the resident not receiving the ordered adaptive equipment during the observed meal services.
Expired and unlabeled medications were found stored in the 2nd floor med room, including inhalers, Lovenox, a Cipro IV kit, and multiple vials of Acetylcysteine. An RN confirmed the meds were expired, and facility policy states unused meds with missing or illegible labels are to be destroyed.
Dishwasher and 3-compartment sink not functioning properly. The sink was leaking, with water running into the rinse compartment and sediment observed in the water while staff washed items used for pureed food. The dishwasher was labeled for high-temp sanitation, but observed wash and rinse readings and the temp logs showed multiple cycles below the required minimums, and the DM and MD confirmed they were unaware the machine was not meeting the required temps.
Infection control practices were not maintained during wound care, incontinence care, meal service, contact isolation, and med administration. An LPN and wound NP performed wound care for a resident on EBP without gowns, while PPE supplies were not readily available and isolation bins were improperly placed and uncovered. A CNA placed clean washcloths directly into a sink for perineal care, another CNA handled meal trays and food without hand hygiene, no isolation signage was posted for a resident on contact precautions for MRSA, and an RN moved between two residents’ med passes without hand hygiene.
A resident with dementia, anxiety, and depression received Seroquel for dementia without documented justification, and three other residents had PRN Ativan orders without required stop dates. Records showed one resident was stable with no behaviors, while the DON confirmed the antipsychotic indication was not appropriate and that the PRN psychotropic orders lacked the required stop dates.
Call Light Left Out of Reach: A resident with COPD, HTN, anxiety, depression with psychotic symptoms, muscle weakness, and moderately impaired cognition was observed up in a tilt-in-space wheelchair while the call light remained attached to a grab bar out of reach behind the wheelchair. The care plan identified the resident as a fall risk and included ensuring the call light was within reach, and CNA verification confirmed the call light was not accessible.
The facility failed to promptly notify the physician, responsible party, and hospice when one resident spilled soup and developed burns with large blisters to both inner thighs, and failed to document or notify the physician or responsible party when another resident sustained a skin tear to the right lower leg. Staff notes and interviews confirmed the notifications were not made at the time of the injuries, and the second resident’s skin tear was only later addressed with a dressing order and wound care documentation.
A resident with vascular dementia, HTN, anxiety disorder, and paranoid personality disorder had a PASARR on file that did not include a personality disorder. After the paranoid personality disorder diagnosis was added, there was no evidence of a new Level II PASARR submission to the state agency, and social services confirmed none was completed.
A resident with CHF, DM2, Afib, COPD, and HTN had PRN Norco and Tylenol orders and reported ongoing pain that was somewhat controlled. The MDS showed PRN pain med use and intact cognition, but the record contained no pain care plan, and the MDS nurse confirmed a comprehensive pain plan had not been developed as required by facility policy.
The facility failed to provide showers to two residents according to their care plans, schedules, and stated preferences. One resident with multiple chronic conditions, including COPD, CKD, diabetes, and legal blindness, had orders and care plans for showers three times weekly but received only bed baths and no documented showers during the review period. Another resident with ESRD, diabetes, legal blindness, and mobility issues was supposed to receive showers three times weekly, but documentation showed missed showers and staff confirmed the resident was only placed on part of the schedule. No refusals were documented for either resident.
The facility failed to obtain timely treatment orders for a resident’s bilateral thigh burns after a hot soup spill and failed to fully assess and document a second resident’s skin tear to the right lower leg. Staff observed the burn injury and later the skin tear, but records showed missing physician/RP notification, incomplete documentation, and no initial order for the skin tear until later. The DON and ADON confirmed the gaps in assessment and charting.
A resident with MS and other diagnoses had a physician order for a left resting wrist/hand splint, but the care plan did not include the splint and the MAR/TAR showed no documentation that it was applied as ordered. The DON confirmed it was a nursing order and staff should have been putting it on, and therapy observed the resident's left wrist contracted with no splint in place.
A resident with multiple diagnoses, including dementia, malnutrition, peripheral vascular disease, and a history of falls, had a care plan identifying fall risk, but the interventions did not include hipsters. Although the physician ordered hipsters to be worn at all times and removed each shift for skin checks, surveyors observed the resident in bed without them, and a CNA confirmed they were not on.
A resident with pneumonia and chronic respiratory failure had delayed respiratory treatment and incomplete medication administration. Prednisone was ordered for acute respiratory failure but started late and only 4 of 5 doses were given, a chest CT was completed but the results were delayed, and Rocephin for pneumonia was started late because the med was unavailable and only 6 of 7 ordered doses were administered. Pneumonia care plan interventions were also absent.
Incomplete dialysis monitoring and access documentation was identified for a resident with ESRD and multiple comorbidities, including DM2, COPD, AFib, and CHF. Although the resident received repeated HD treatments and weights were recorded at times, several dialysis communication forms were missing and there was no evidence of ordered fistula bruit/thrill checks; the DON verified the missing documentation.
A resident with diabetes, dementia, and urinary and bowel incontinence was started on Tobramycin after a urine culture showed E. coli and Proteus mirabilis with possible ESBL. The facility’s infection surveillance checklist showed the resident did not meet McGeer criteria for antibiotic use, and although the NP was notified, the antibiotic was not discontinued; the ADON confirmed the resident continued to receive it.
The facility did not maintain complete and accurate medical records for several residents, failing to document activity participation and medication administration as required. For multiple residents with complex medical and psychosocial needs, activity participation was not recorded in the official medical record for several months, despite care plans indicating its importance. Additionally, discrepancies were found between the controlled substance records and the MAR for a resident receiving oxycodone, with doses not properly documented as administered. These issues were confirmed by the Activity Director and DON during a complaint investigation.
A resident with multiple chronic conditions and cognitive impairment did not receive an individualized activity program tailored to her documented preferences for group activities, crafts, and socialization. Despite her ability to communicate and express interest in participating if reminded, staff did not consistently provide reminders or re-evaluate her activity plan, and activity participation logs were missing for two months. The activity calendar offered limited variety, and the resident was mostly observed in bed with passive engagement, leading to a deficiency in meeting her activity needs.
A resident experienced verbal and emotional abuse from an STNA who yelled, used profanity, and punched a wall during care. The incident was not reported to management until days later, allowing the STNA to continue working with the resident. The facility's delayed response and failure to adhere to abuse policies resulted in psychosocial harm to the resident.
An LPN at a facility was found with medication packages belonging to 13 residents in her vehicle, leading to a misappropriation incident. The medications, including Mirtazapine and Metoprolol, were discovered by the LPN's family and reported to the police. The facility's investigation could not determine if residents missed doses, and the LPN was receiving treatment at the time of the report.
A resident reported an incident where an STNA punched a wall in frustration, causing fear. The incident was not reported to the Administrator until several days later, contrary to the facility's policy requiring immediate reporting of abuse allegations. Staff interviews revealed a misunderstanding about the nature of the incident and a delay due to the Administrator's unavailability.
A facility failed to develop a discharge plan of care for a resident with complex medical needs, including cerebral infarction and diabetes mellitus type-1. Despite communication between the resident's power of attorney and the Social Service Designee (SSD) about necessary home care products and services, no active discharge planning or referrals were made. The SSD did not create a discharge plan due to concerns about forgetting updates, and the facility's policy for discharge planning was not adhered to.
A facility failed to revise a resident's care plan to reflect their preference against male caregivers, despite being informed by the resident's power of attorney. The resident, who was cognitively intact and had specific preferences documented, received care from a male caregiver before the facility was notified and took corrective action.
The facility failed to provide tracheostomy care as ordered for two residents, leading to missed care and equipment changes. One resident with cerebral infarction and tracheitis did not receive tracheostomy care on multiple occasions, and their care plan lacked necessary interventions. Another resident with cerebral infarction and diabetes also experienced missed tracheostomy care and equipment changes, with their care plan similarly lacking interventions. The facility's policy required adherence to physician's orders and professional standards, which was not followed.
A facility failed to ensure proper gloving and hand hygiene during incontinence care for a resident with dementia and incontinence. An STNA did not change gloves or wash hands after cleansing the resident and before adjusting the resident's gown and bed linens. The facility's policies on hand hygiene and perineal care were not followed.
Unsanitary food storage and improper glove use during food preparation
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. During observation of the kitchen, a 25-pound box of rice was found open to the air in the dry storage room, stainless-steel pans stored under the microwave were wet, and plastic warming bases were stacked together wet on a storage rack. The District Dietary Manager verified the wet pans and wet warming bases and stated they should have been air dried before storage. Facility policy required dry goods to be stored in accordance with FDA Food Code standards and dishware, service ware, and utensils to be cleaned, sanitized, air dried, and properly stored. During meal preparation, the District Dietary Manager was observed making a toasted cheese sandwich while wearing rubber gloves, touching the stove knob, opening a drawer, touching her rear pant pockets, and then returning to the stove and handling bread without changing gloves or washing hands. The District Dietary Manager verified she did not change gloves or wash her hands before directly touching the bread. In the kitchenette off the main dining room, a box of iced tea connected to the drink dispensing system was observed with a best by date of 02/05/26, and a Dietary Aide verified the date. Facility policy for food preparation required staff to practice proper handwashing techniques and glove use.
Menu Not Followed and Residents Not Notified of Meal Substitutions
Penalty
Summary
The facility failed to ensure menus were followed as prepared in advance and failed to ensure residents were notified of substitutions in advance. The menu for Thursday lunch planned honey glazed ham, sauteed asparagus cuts, whipped sweet potatoes, a dinner roll, and butterscotch pudding, with zucchini listed as the alternate vegetable. The diet spreadsheet indicated residents were to receive either asparagus cuts or zucchini and three ounces of honey glazed ham. During meal service, a dietary staff member placed a quarter-sized slice of ham on a plate and later weighed it at 1.5 ounces, confirming it did not meet the three-ounce portion listed on the spreadsheet. The staff member confirmed the 1.5-ounce portions had been prepared as the portion size, and more ham and glaze had to be cooked during tray line because the facility ran out of honey glazed ham halfway through service. Later in the same meal service, the facility ran out of sauteed asparagus cuts for the last nine trays. The District Dietary Manager opened a can of cooked carrots, heated them in the microwave without seasoning, and served them to the last nine trays for Residents #14, #18, #25, #28, #31, #42, #46, #56, and #73. The District Dietary Manager verified the vegetable had been replaced with unseasoned canned carrots and that the nine residents were not notified of the substitution. After the meal, Resident #46 stated he did not really like cooked carrots, and Resident #73 stated she was tired of carrots because they had them all the time and did not like the carrots because there was no seasoning on them.
Unqualified Dietary Manager and Lack of Dietary Staff Education
Penalty
Summary
The deficiency involves the facility’s failure to employ a qualified director of food and nutrition services and to ensure appropriate education of dietary aides, affecting all 86 residents. The Administrator reported that a contract company, Health Care Services Group (HCSG), had been brought in to run the kitchen, using the facility’s existing kitchen staff while the facility retained oversight. Personnel credential review showed that the individual serving as Dietary Manager, identified as #217, did not meet the qualifications for the role: she was not certified and her degrees were not in fields that would qualify her as a Dietary Manager, despite her years of kitchen experience. Interviews with Dietary Manager #217 revealed that she had originally been employed as a cook and was promoted to manage the kitchen after HCSG took over operations. She stated that a previously credentialed Dietary Manager, identified as #100, stepped down from the role when the contract company assumed control, citing the complexity of the computer system, and recommended her, while informing HCSG that she was not credentialed. HCSG indicated they would pay for her to take classes to become a Certified Dietary Manager, but she confirmed she had not started any classes and believed the company might be waiting to see if she could handle the position before investing in her training. The survey identified this as a failure to employ a qualified Dietary Manager and to provide education to dietary aides, constituting non-compliance under Complaint Number 2701233.
Improper Food Preparation Affecting Soup Consistency and Vegetable Texture
Penalty
Summary
Failure to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature was identified through observations, test trays, and interviews. During a lunch meal, one resident on the Lifebridge Unit, which was the last hall to be served, received two bowls of what appeared to be pasta salad on his tray at approximately 1:25 P.M. The resident clarified that both bowls were supposed to be chicken noodle soup, but there was no broth in either bowl, and he was eating the contents with a fork. He stated that he requested two bowls of chicken noodle soup daily for lunch and that sometimes there was broth, but usually he had to eat the soup with a fork. A CNA confirmed that the resident had received two bowls of chicken noodle soup without broth. On a subsequent lunch observation, the same resident again received two bowls that were supposed to be chicken noodle soup; one bowl had no visible broth and the other had only a small amount of liquid at the bottom. The Dietary Manager, present during this observation, acknowledged that the noodles appeared to be soaking up the broth and verified that the soup tin in the kitchen contained no broth, only noodles and carrots, and appeared dry at the bottom. Additional observations during the dinner tray line showed that broccoli being served did not maintain its shape and appeared mushy and watery. When a test bowl of broccoli was served later in the meal service, it still did not hold its shape and had a mushy, watery texture. An interview with a dietary staff member revealed that the broccoli was cooked on the stovetop in a tin on low heat, and he confirmed that the broccoli always became mushy. These findings demonstrated that food was not being prepared by methods that conserved nutritive value, flavor, and appearance, affecting items such as chicken noodle soup and broccoli and having the potential to impact all 86 residents in the facility.
Failure to Provide Alternate Meal Choices and Honor Resident Food Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide appealing meal options of similar nutritive value and to honor residents’ food preferences during a prolonged kitchen shutdown and subsequent transition period. For 19 days while major plumbing repairs were performed in the kitchen and dry storage, the facility prepared meals out of the dining room using limited equipment such as roasters, crockpots, a microwave, a griddle, and a waffle maker. During this time, only one meal choice was offered at each meal, and the only substitutes available were peanut butter and jelly sandwiches or deli sandwiches. The Dietary Manager confirmed that there was no second meal option of similar nutritional value available during the kitchen shutdown. Multiple residents reported not being able to order or receive their preferred items. One resident stated there were no second options or substitute items and that he was simply given food he did not like, including peas, carrots, and rice. Another resident’s meal ticket indicated a preference for chocolate milk, which was not provided on the tray. A different resident reported she does not order and is just served whatever is given; her stated preferences for 2% milk, cranberry juice, and fruit punch resulted in her receiving only fruit punch. Another resident reported being served burnt pizza with no other option when the kitchen was down and stated that even when she tells staff what she wants, she usually does not receive it; her ticket also indicated she should receive ice with every meal and fruit punch at lunch, neither of which were delivered. The Dietary Manager further acknowledged that new dietary aides were still in training and had not been given sufficient time to learn their tray line duties during and immediately after the kitchen relocation.
Failure to Maintain Sanitary Food Service and Proper Milk Handling
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions, affecting the entire census of 86 residents. Surveyors observed that a large garbage can located near a prep table and three-compartment sink in the kitchen did not have a lid and was repeatedly overflowing with trash, including large cans piled above the rim, on multiple observations over two days. During one observation, a dietary aide was portioning pineapple into cups and covering them with plastic wrap on the prep table adjacent to the uncovered, overflowing trash can. The dietary manager confirmed that the garbage can was not covered with a lid. Surveyors also found that milk temperatures were not consistently monitored and that milk was not always maintained at or below the facility’s policy guideline of 41°F. During a supper tray line, milk temperatures were not initially taken, and when requested, a milk sample measured 40°F. On another meal service, pre-poured milk cups were left on the three-compartment sink before being placed in the milk chest, and later a glass of milk taken from the chest measured 46.9°F; staff confirmed that milk temperatures were not obtained before the tray line started. Review of March food temperature logs showed that milk temperatures were missing for 47 of 71 meals, and the dietary manager acknowledged inconsistent monitoring. Additionally, surveyors found multiple cartons of 1% milk in the milk chest past their use-by date, and a staff member reported using two expired cartons for resident trays, with one expired milk serving provided to a resident. The facility’s written policy required potentially hazardous cold foods to be kept at or below 41°F and verified with a clean, sanitized, and calibrated thermometer.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The deficiency involves a failure to maintain privacy during incontinence care for Resident #3. The resident was admitted with multiple diagnoses including lung disease, heart failure, diabetes, anxiety, gastric reflux, hypertension, arthritis, and a gastric bleed. A quarterly MDS assessment dated 01/14/26 documented that the resident was cognitively intact, dependent on staff for personal hygiene, toileting, bathing, dressing, transfer, and mobility, and was always incontinent of bowel and bladder. Facility policy on Resident Rights stated that residents have the right to privacy and confidentiality, including personal privacy during personal care. On 03/25/26 at 8:58 A.M., a surveyor observed CNA #137 gather supplies and enter the double-occupancy room of Resident #3, closing the door while the resident’s roommate remained in the room in his wheelchair. Although a privacy curtain divided the room, the CNA did not draw the curtain at any time during the incontinence care. The CNA removed the resident’s adult brief, exposing his genital area for cleaning, and then had him roll to his left side toward the wall, which exposed his buttocks to his roommate while care continued. During an interview at 9:04 A.M. the same day, the resident stated that CNAs sometimes forget to pull the curtain during incontinence care and that it sometimes bothers him to be exposed to his roommate when present. CNA #137, present during the interview, acknowledged she had not pulled the privacy curtain.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered adaptive eating equipment for a resident who required it. The resident was admitted with diagnoses including hypertensive urgency, renal dialysis, glaucoma, and legal blindness. A quarterly MDS assessment documented that the resident was independent in daily decision making but required set-up assistance for meals. Physician orders specified a renal diet with regular texture and thin liquids, double protein, several food restrictions, an 1800 milliliter fluid restriction, and the use of a blue scoop bowl and plate guard related to renal failure. During a supper meal observation, the resident’s meal ticket indicated the need for both a blue scoop bowl and a plate guard, but the tray was prepared with only a plate guard. Further observations of subsequent meal tray lines showed that the required scoop bowl continued to be unavailable for the resident’s meals. At one lunch service, staff confirmed there were no scoop bowls available for the resident’s tray, despite the order specifying their use. Dietary staff interviews revealed that the facility previously had multiple scoop bowls but they could no longer locate them, and that only three had recently been available before they also went missing. Multiple staff, including dietary aides and the dietary manager, reported they were unable to find any scoop bowls in the kitchen, resident rooms, or on the units at the time of the observations. As a result, the resident did not receive the ordered adaptive equipment during the observed meals.
Expired and Unlabeled Medications Stored in Medication Room
Penalty
Summary
The facility failed to dispose of expired and unlabeled medications stored in the second floor medication storage room. Observation of the room revealed two Incruse Ellipta inhalers in a sealed foil package that had been removed from the box with expiration dates of 10/24 and 02/25 and no label attached, Lovenox 100 mg/ml injection with an expiration date of 05/25 and no label attached, a Cipro 400 mg 2 mg/ml IV kit with a dispensed date of 03/14/19 and a discard-after date of 04/18/25, and 23 vials of Acetylcysteine 20% 200 mg/ml with an expiration date of 5/2025. An RN verified that the medications were expired and stored in the medication room. Facility policy stated that unused medications are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels, and that these medications are destroyed in accordance with the facility's Destruction of Unused Drugs policy.
Dishwasher and Three-Compartment Sink Not Functioning Properly
Penalty
Summary
The facility failed to ensure the dishwasher and three-compartment sink were in proper working order to prevent the potential spread of food borne pathogens. During observation, the three-compartment sink was leaking, water was running down the hoses and faucet into the second compartment, and sediment was observed in the water. The Dietary Manager confirmed the sink was used for items that could not be run through the dishwasher, and a blender was being washed in the sink for the next pureed food item. The Maintenance Director confirmed the sink was leaking and that there was sediment in the rinse water. Observation of the dishwasher showed it was labeled as a hot temperature dishwasher, with the posted wash cycle listed as 155-160 degrees Fahrenheit and the rinse cycle as 180-195 degrees Fahrenheit. However, the observed wash temperatures were 110 degrees Fahrenheit on the first check and the same on the second and third checks, while the rinse temperature was 186 degrees Fahrenheit. Review of the dishwasher temperature logs from 07/27/25 through 07/30/25 showed multiple instances where wash and rinse temperatures did not meet the manufacturer’s required minimums. The Dietary Manager and Maintenance Director both confirmed they were not aware the dishwasher temperatures were not meeting recommendations, and the Maintenance Director stated the filters in the dishwasher and three-compartment sinks had been cleaned the prior night due to no water pressure.
Infection Control Practices Not Maintained During Wound Care, Incontinence Care, Dining, Isolation, and Medication Administration
Penalty
Summary
The facility failed to maintain infection control practices during wound care for a resident with peripheral vascular disease, above-knee amputation, heart failure, COPD, chronic kidney disease, non-pressure ulcers, neurogenic bladder, diabetes, legal blindness, and chronic pain. The resident had enhanced barrier precautions ordered because of wounds and an indwelling urinary catheter. During wound care, an LPN and a wound nurse practitioner were observed in the resident’s room without gowns while removing the old dressing, measuring the wounds, and assessing two open areas on the right foot and ankle. The LPN stated she was not aware she was required to wear a gown during wound care, and the DON confirmed staff were required to wear gowns and gloves for this resident’s wound care. The observation also showed the PPE cart outside the room did not contain gowns, and the isolation trash bins inside the room were not positioned near the exit door and were covered with clothing and blankets. The infection preventionist confirmed the gowns were not readily available, the bins were not located near the exit door, the bins should not have been covered with clothing and blankets, and the used PPE should have been contained in red biohazard bags. The facility policy for enhanced barrier precautions stated gowns and gloves were to be available immediately near or outside the resident’s room and that wound care was a high-contact activity requiring gown and glove use. The facility also failed to maintain infection control during incontinence care, dining service, contact isolation, and medication administration. A CNA providing perineal care to an incontinent resident placed clean washcloths directly into a sink to wet them and applied soap while they were in the sink before using them for care, and she confirmed she had not sanitized or cleaned the sink first. During meal service, a CNA delivered trays to residents and handled food items with bare hands while moving between rooms without washing her hands. For another resident on contact isolation for MRSA, isolation bins were present inside the room but no signage was posted at the doorway. During medication administration, an RN administered medications to one resident, removed gloves, returned to the medication cart, and then prepared and administered medications, insulin, and a lidocaine patch to another resident without performing hand hygiene between residents. The RN confirmed she did not perform hand hygiene between the two medication administrations.
Unjustified antipsychotic use and missing stop dates for PRN antianxiety medications
Penalty
Summary
The facility failed to ensure a resident had an appropriate justification for the use of an antipsychotic medication and failed to ensure residents had stop dates for antianxiety medications. For one resident with diagnoses including dementia, anxiety, and depression, Seroquel 12.5 mg at bedtime was continued after a short hospital stay and was documented as being used for dementia. The record showed no other medication ordered or administered to treat anxiety, depression, or dementia, and the psych note stated the resident was stable with no behaviors noted. The DON confirmed the facility continued Seroquel for dementia even though dementia was not an appropriate indication for its use, and the medication was later discontinued because the resident was not having behaviors. For another resident with diagnoses including intracranial injury, vascular dementia, traumatic brain injury, major depression disorder, mood disorder, generalized anxiety disorder, and impulse disorders, the physician's orders included Ativan 0.5 mg twice daily for restlessness/anxiety and Ativan 0.5 mg every 12 hours as needed for restlessness. The record did not contain a stop date for the as-needed Ativan. The quarterly MDS showed severely impaired cognition and indicated the resident received an antipsychotic and an antianxiety medication. The DON confirmed there was no stop date for the as-needed Ativan. A third resident with diagnoses including subarachnoid hemorrhage, dementia, anxiety disorder, and depression had an order for Ativan 0.5 mg every four hours as needed for anxiety, but the record did not include a stop date for the medication. The psychiatric progress note stated the plan was to continue the current psychotropic medication and that Ativan could be given at bedtime and every four hours as needed for anxiety, with GDR clinically contraindicated unless otherwise noted. A fourth resident with diagnoses including COPD, chronic respiratory failure, anxiety disorder, and major depressive disorder had an order for Ativan 0.5 mg every eight hours as needed for dyspnea or anxiety, and the record did not show the required 14-day stop. The DON verified the antianxiety medication did not have the required stop date.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure the call light was within reach of Resident #26. Resident #26 was admitted with diagnoses including chronic obstructive pulmonary disease, rhabdomyolysis, paroxysmal tachycardia, anxiety disorders, hypertension, major depressive disorder with psychotic symptoms, and muscle weakness. The care plan dated 08/18/20 identified Resident #26 as at risk for falls related to deconditioning, gait and balance problems, and psychoactive drug use, and included an intervention to ensure the call light was within reach and to encourage use for assistance as needed. The annual MDS assessment showed moderately impaired cognition and dependence for all ADLs. During observation on 07/28/25 at 11:18 A.M., Resident #26 was up in a tilt-in-space wheelchair beside the bed, but the call light remained attached to the left grab bar out of reach behind the wheelchair. This was verified with CNA #141 at 11:20 A.M. The facility policy stated staff would ensure the call light was within reach of each resident and secured as needed.
Failure to Notify Physician and Responsible Party of Resident Injuries
Penalty
Summary
The facility failed to ensure the resident, the resident’s physician, and the responsible party or hospice were notified when a resident spilled soup on herself and later developed burns with large blisters to both inner thighs. The resident had diagnoses including heart failure, atherosclerotic heart disease, dysphagia, glaucoma, urinary retention, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder, and hypertension, and a Significant Change MDS showed moderately impaired cognition. During incontinence care, staff observed two large blisters on the resident’s right and left inner thighs, and the RN stated the blisters were from spilling soup on herself the day before. The nurse’s note documented that the resident spilled soup on her lap while seated for lunch, clothing was pulled away, and cold cloths were applied, with the area described as slightly pink and later without redness or burning. A later note documented blisters to the bilateral inner thighs from the soup spill and education to keep the blisters intact, but there was no documentation that the physician, hospice, or responsible party was notified at that time. An RN later verified that the physician, responsible party, and hospice had not been notified of the burns. The facility also failed to document and notify the physician or responsible party when another resident sustained a skin tear to the right lower leg. That resident had diagnoses including pain due to an internal orthopedic prosthetic device in the left hip and knee, osteoarthritis, dementia, anxiety disorder, cataracts, and weakness, and had moderately impaired cognition on the Quarterly MDS. The resident stated an aide threw her into bed, she hit her shin on the bedrail, and she got a skin tear; staff later confirmed there was no investigation, assessment, family or physician notification, incident report, or documentation of the skin tear in the medical record.
Failure to Update PASARR After New Psychiatric Diagnosis
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed after a new psychiatric diagnosis was added for one resident. The resident’s record showed an admission date of 07/15/22 with diagnoses including vascular dementia, hypertension, anxiety disorder, and paranoid personality disorder, and the last PASARR submitted on 07/08/22 did not indicate a personality disorder. Record review showed that on 05/30/23, paranoid personality disorder was added to the resident’s diagnoses, but there was no evidence of a subsequent PASARR submission to the state agency for Level II consideration that included the new psychiatric diagnosis. Social services staff verified that no PASARR was submitted after the paranoid personality disorder diagnosis was added.
Failure to Develop a Comprehensive Pain Care Plan
Penalty
Summary
The facility failed to develop a comprehensive plan of care for pain management for one resident. Resident #38 was admitted with diagnoses including chronic systolic heart failure, type 2 diabetes, atrial fibrillation, chronic obstructive pulmonary disease, and hypertension. The 5-day MDS assessment showed the resident received PRN pain medications and had intact cognition. Physician orders included Norco 5/325 mg every 6 hours as needed and Tylenol 650 mg every 6 hours as needed. During interview, the resident stated he always has pain and that it is somewhat controlled. Review of the medical record found no evidence of a pain care plan, and the MDS Nurse confirmed that a comprehensive pain plan of care had not been developed for the resident. Facility policy stated the comprehensive care plan would be developed within 7 days after completion of the comprehensive MDS assessment.
Missed showers for two residents despite care plans and preferences
Penalty
Summary
The facility failed to ensure residents who required staff assistance with activities of daily living received showers according to their schedules and preferences. Resident #4, who had diagnoses including peripheral vascular disease, above left knee ambulation, heart failure, COPD, chronic kidney disease, non-pressure ulcers, neuromuscular dysfunctional bladder, diabetes, legal blindness, and chronic pain, had orders for showers on Monday, Wednesday, and Friday per preference, and care plans documenting a preference for showers and extensive assistance with bathing three times weekly. However, bathing documentation for 07/01/25 through 07/31/25 showed no evidence that Resident #4 received a shower during that period, and there was no documentation that the resident refused showers. The resident stated she had only been receiving bed baths lately and preferred showers, and the MRC confirmed the resident had not been provided showers per preference, orders, and plan of care during the last 30 days. Resident #46, who had diagnoses including end stage renal disease, diabetes, legal blindness, difficulty walking, weakness, and history of falls, had care plans stating the resident required partial to moderate assistance with bathing and would participate in choosing a bathing schedule that met preferences and needs. Quarterly MDS documentation showed no evidence of refusal of care, yet shower documentation for 07/2025 showed the resident did not receive showers on 07/06/25, 07/20/25, and 07/27/25. The resident stated his shower days were Tuesday, Thursday, and Sunday, but staff did not provide showers three times a week and forgot about him. The MRC confirmed the resident was only on the shower schedule for Tuesday and Thursday and that there was no documented evidence of showers on the missed Sundays.
Failure to Obtain Treatment Orders and Document Skin Injury Assessments
Penalty
Summary
The facility failed to ensure treatment orders were received for burns to one resident’s bilateral inner thighs after the resident spilled hot soup on her lap while in a chair for lunch. The resident had diagnoses including heart failure, atherosclerotic heart disease, dysphagia, glaucoma, urinary retention, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder, and hypertension, and a Significant Change MDS showed moderately impaired cognition. Nursing documentation stated the soup spill caused the area to be slightly pink and later noted large blisters to both inner thighs, but there was no documentation that the physician, hospice, or responsible party was notified at the time of the incident. An observation during incontinence care showed two large blisters on the resident’s right and left inner thighs, and the RN confirmed the resident had spilled soup on herself the day before. The RN later documented that hospice was notified and that the physician was okay with covering the blisters with Tegaderm, and a physician order was then written for Tegaderm to the left and right thigh burn sites. The RN also verified that no treatment order had been written for the blisters before that time. The facility also failed to comprehensively assess a skin tear to another resident’s right lower leg. That resident had diagnoses including pain due to an internal orthopedic prosthetic device in the left hip and knee, osteoarthritis, dementia, anxiety disorder, cataracts, and weakness, and a Quarterly MDS showed moderately impaired cognition. The resident was observed with an undated dressing to the right lower leg and stated an aide had thrown her into bed after she said she did not want to go to bed, causing her shin to hit the bedrail and result in a skin tear. The medical record contained an order for wound care, but there was no documentation of a skin tear, physician notification, responsible party notification, investigation, or assessment in the record. The DON and ADON both confirmed the lack of documentation and stated the nurse had not written an order, documented the event, completed an incident report, or notified the family or physician.
Missing Treatment Plan and Documentation for Resting Hand Splint
Penalty
Summary
The facility failed to ensure a comprehensive treatment plan was in place for the use of a left resting wrist/hand splint to maintain or improve mobility for one resident. The resident was admitted with diagnoses including multiple sclerosis, marasmic kwashiorkor, hypertension, major depressive disorder, and obstructive and reflux uropathy. The annual MDS showed no restorative days or minutes for splint or brace assistance and no upper extremity impairment. Although the physician ordered a resting wrist/hand splint for the left hand once daily for up to four hours on dayshift, the care plan did not identify the splint, and July 2025 MARs and TARs contained no documentation that the splint was applied as ordered. The DON verified the splint was a nursing order and that staff should have been applying it, and an observation with therapy found the resident's left wrist contracted with no resting hand splint in place.
Failure to Use Ordered Hipsters for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure fall interventions were in place for Resident #12, who had diagnoses including atherosclerotic heart disease, severe protein calorie malnutrition, malignant neoplasm of the prostate, depression, peripheral vascular disease, adult failure to thrive, history of falling, transient ischemic attack, fracture of the fifth metatarsal of the left hand, emphysema, dementia, and hypertension. The resident’s plan of care identified a potential for falls related to history of falls, cachexia, and unsteady gait, but the interventions did not include wearing hipsters. The physician’s orders included hipsters to be worn at all times and removed every shift for skin checks. During observations on 07/28/25, the resident was in bed without the ordered hipsters on, and a CNA verified that the resident did not have the hipsters on while in bed. The quarterly MDS assessment also indicated moderately impaired cognition and one fall with injury.
Delayed respiratory treatment and incomplete antibiotic administration
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident with diagnoses including pneumonia, chronic respiratory failure with hypoxia, and diabetes. A chest x-ray showed opacities representing penumonitis and recommended a chest CT, but the CT ordered for pneumonia was not completed until later. The resident’s plan of care included two pneumonia care plans initiated without interventions, and the nurse practitioner noted respiratory failure with hypoxia and ordered the CT scan to be scheduled. The resident’s physician ordered Prednisone 20 mg daily for five days for acute respiratory failure with minimal improvement, but the order was not entered until the next day and the medication was not started until two days after it was ordered; only four of the five doses were administered. After the CT later showed right lower lobe pneumonia, multifocal bronchitis, and a probable subacute thoracic vertebra compression fracture, Rocephin 1 gm IM daily for seven days was ordered for pneumonia, but the first two doses were not given because the medication was not available, and only six doses were administered before it was discontinued without documentation of an additional day to complete the ordered seven-day course. The Infection Preventionist/ADON confirmed the delayed start of Prednisone, the delayed CT result, the delayed start of Rocephin, the incomplete Rocephin course, and the absence of pneumonia-related care plan interventions.
Incomplete Dialysis Monitoring and Access Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for Resident #39, who was admitted on 07/02/25 with diagnoses including c-diff infection, ESRD, type II diabetes, COPD, atrial fibrillation, chronic systolic heart failure, and malignant neoplasm of the prostate. Physician orders directed staff to weigh the resident before and after each hemodialysis treatment on Mon/Wed/Fri and to check for bruit and thrill to the left arm fistula. The resident received hemodialysis on multiple dates in July 2025, including 07/02/25, 07/04/25, 07/07/25, 07/09/25, 07/11/25, 07/14/25, 07/16/25, 07/18/25, 07/21/25, 07/23/25, 07/25/25, 07/28/25, and 07/30/25. Review of the July 2025 Dialysis Monitoring and Communication Forms showed incomplete or missing documentation for 07/04/25, 07/07/25, 07/11/25, 07/18/25, 07/23/25, and 07/25/25. The medical record contained multiple weights recorded before and after dialysis treatments, but there was no evidence of fistula monitoring as ordered. During interview on 07/31/25 at 11:07 A.M., the DON verified the missing dialysis communication forms, including the weights and documentation checking the fistula. Facility policy stated that the nurse will monitor and document the status of the resident's access site upon return from dialysis to observe for bleeding or other complications.
Inappropriate Antibiotic Use Without Meeting Infection Criteria
Penalty
Summary
The facility failed to ensure antibiotic use was appropriate according to its antibiotic stewardship protocols for one resident reviewed for antibiotic use. Resident #74 was admitted with diagnoses including type II diabetes, neuralgia and neuritis, depression, anxiety, and dementia, and the annual MDS showed intact cognition with frequent urinary incontinence and constant bowel incontinence. A urinalysis with culture and sensitivity was ordered due to an elevated WBC count, and the culture later showed 60,000-70,000 cfu/ml E. coli and 60-70,000 cfu/ml Proteus mirabilis with possible ESBL. The resident was started on Tobramycin 100 mg IM every 12 hours for seven days. Further review of the medical record showed the Infection Surveillance Checklist-V 4 dated 07/17/25 indicated the resident did not meet McGeer Criteria for antibiotic use, which require fever or chills, new or worsening urgency, frequency, suprapubic pain, gross hematuria, or dysuria and no more than two species of bacteria in the urine with a cfu/ml of 100,000 or greater. The nurse practitioner was notified that the resident did not meet criteria, but the antibiotic was not discontinued. The ADON confirmed during interview that the resident did not meet criteria for antibiotic usage and continued to receive the ordered antibiotic.
Failure to Maintain Complete Medical Records for Activities and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, specifically regarding documentation of activity participation and medication administration. For four residents with various diagnoses including COPD, dementia, depression, heart failure, and other chronic conditions, there was a lack of documented activity participation in the medical records for multiple months. Although some activity notes existed in separate notebooks or were verbally confirmed by staff, these records were not incorporated into the official medical record as required. The Activity Director confirmed the absence of activity participation documentation in the medical records since March for the affected residents, despite care plans and assessments indicating the importance of social and activity engagement for these individuals. Additionally, the facility failed to ensure accurate medication administration records for a resident prescribed oxycodone for pain management. There were multiple discrepancies between the controlled substance accountability records and the Medication Administration Record (MAR), including instances where doses were signed out from the narcotic supply but not documented as administered on the MAR. In some cases, doses were recorded late or not at all, and the timing of administration did not align with physician orders. The DON acknowledged these discrepancies and attributed them to documentation errors, noting that one nurse involved had worked seven consecutive days. These deficiencies were identified through medical record review and staff interviews, and were verified by the Activity Director and DON. The lack of proper documentation affected all four residents reviewed, and the findings were discovered during a complaint investigation.
Failure to Provide Individualized Activity Program Based on Resident Preferences
Penalty
Summary
The facility failed to ensure that an individualized activity program was developed and implemented based on a resident's preferences. The resident in question had multiple diagnoses, including COPD, anxiety, depression with psychotic symptoms, dementia with mood disturbance, and difficulty walking, and required transfer with a mechanical lift. The care plan indicated the resident should remain active and social, with interventions such as providing an activity calendar, discussing ongoing events, listening to interests, and reminding the resident of activities. The resident's documented interests included group activities, crafts, music, socialization, and community outings, and she was able to communicate her needs and preferences. Despite these documented preferences, activity participation logs showed limited engagement, with most participation being passive or involving solitary activities such as watching television or listening to the radio. There were no activity participation logs available for two consecutive months, and observations revealed the resident spent most of her time in bed with the television on, often sleeping or not actively engaged. Staff interviews indicated that activity staff did not attempt to wake the resident for activities and that there was a lack of re-evaluation of the activity plan despite the resident's limited participation and expressed interest in group activities if reminded. The activity calendars for the reviewed months showed a limited variety of activities, with many days offering only one activity repeated on different units and few individualized or preference-based options. The resident reported she would be interested in group activities, crafts, and socialization if she received reminders, but this was not consistently provided. The lack of individualized activity programming and insufficient documentation of participation led to the deficiency.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident from staff abuse, specifically involving intimidation, verbal, and emotional abuse. On 09/30/24, a State tested Nursing Assistant (STNA) became frustrated while providing care to a resident, yelled, used profanity, and punched the wall above the resident's bed. The resident perceived these actions as directed towards her, resulting in actual psychosocial harm. Despite the incident, the STNA continued to work additional shifts, including caring for the same resident, before being suspended and eventually terminated. The incident was not reported to facility management until 10/06/24, several days after it occurred. During this period, the resident expressed fear of retaliation and reported a lack of appetite and motivation to engage in activities. The facility's investigation revealed that other staff members had witnessed the STNA's aggressive behavior on multiple occasions, and there were concerns about his mental health and frustration levels. However, the incident was not immediately reported by the staff who witnessed it, as they did not initially perceive it as abuse. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury, intimidation, or punishment resulting in harm or mental anguish. The policy emphasizes the need for immediate response to protect residents and maintain the integrity of investigations. Despite this, the facility did not take prompt action to protect the resident or address the STNA's behavior until several days after the incident, highlighting a failure in adhering to their own policies and ensuring resident safety.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to prevent the misappropriation of resident medications, affecting 13 residents. The incident came to light when local law enforcement informed the facility that medication packages with residents' names were found in the vehicle of an LPN. The medications included various prescriptions such as Mirtazapine, Metoprolol, and others, with some packages being unopened and others partially used. The facility's investigation revealed that the medications were dated from the previous year to the current year, and some were discontinued, some were from when residents were out of the facility, and some were marked as administered. Interviews with the facility's Administrator, a police officer, and the Director of Nursing confirmed the discovery of the medications and the ongoing investigation. The Administrator noted that the LPN was acting erratically and was taken to the hospital for evaluation, with her family later discovering the medications in her car. The police officer verified the condition of the medications, and the Director of Nursing confirmed that the medications were checked against the medication administration record, but it was unclear if any residents missed their medications due to the incident. The facility's policy defines misappropriation as the wrongful use of a resident's belongings without consent, which was violated in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse, affecting one resident. Resident #03, who was cognitively intact and had a medical history including acute and chronic respiratory failure, myocardial infarction, anxiety disorder, and major depressive disorder, reported an incident involving a State Tested Nursing Assistant (STNA #174) who became frustrated and punched a wall in the resident's room. The incident occurred on 09/30/24, but the facility's Administrator was not notified until 10/06/24, which was a delay in reporting the incident as per the facility's policy. The facility's policy requires that allegations involving abuse be reported immediately, but not later than two hours after the allegation is made. However, the incident was not reported until several days later. Interviews with staff and residents revealed that the incident was known to some staff members, but it was not escalated to the Administrator in a timely manner. The delay in reporting was partly due to a misunderstanding by STNA #100, who did not report the incident because she did not perceive it as abuse. Additionally, a nurse informed Resident #64 that the incident could not be reported until the Administrator was available, which contributed to the delay.
Failure to Develop Discharge Plan of Care
Penalty
Summary
The facility failed to develop a discharge plan of care for a resident, which was identified during a review of medical records, policy, and interviews. The resident, who was admitted with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy, and anoxic brain injury, was discharged without a documented discharge plan. Despite the resident's power of attorney and the Social Service Designee (SSD) communicating about the need for home care products and services, no active discharge planning or referrals were made as per the Minimum Data Set (MDS) assessment. The SSD admitted to not developing a discharge plan of care due to concerns about forgetting to update it. Although the SSD had been working on discharge arrangements for about a month before the resident's discharge, there was no evidence of a formal discharge plan. The facility's policy required an effective discharge planning process involving the interdisciplinary team and the resident or their representative, which was not followed in this case.
Failure to Revise Care Plan with Resident Preferences
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to reflect the preferences of a resident, which led to a deficiency. The resident, who was admitted with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy, and anoxic brain injury, was cognitively intact and had specific preferences documented in their care plan. These preferences included being addressed with they/them pronouns, appearing more masculine, and not wanting male caregivers. However, the care plan was not updated to reflect the resident's preference against male caregivers, which was only communicated to the facility by the resident's power of attorney after a male caregiver had already provided care. The Director of Nursing confirmed that the care plan had not been revised to include the resident's preference against male caregivers. This oversight occurred despite the facility being informed of the resident's preferences, and it was only after the notification from the power of attorney that male staff were removed from providing care to the resident. This deficiency was identified during an investigation under Complaint Number OH00156997.
Failure to Provide Ordered Tracheostomy Care
Penalty
Summary
The facility failed to ensure tracheotomy care was completed as ordered for two residents who were reviewed for tracheostomy care. Resident #64, who had diagnoses including cerebral infarction, epilepsy, and acute tracheitis, was admitted with orders for tracheostomy care every shift, along with weekly changes of aerosol, cool mist, and oxygen tubing. However, the treatment records indicated that tracheostomy care was not completed on several occasions, and equipment changes were missed. The care plan for Resident #64 did not include interventions for changing or cleaning equipment, despite the resident's partial ability to perform self-care. Similarly, Resident #75, with diagnoses including cerebral infarction, diabetes mellitus type-1, and anoxic brain injury, also had orders for tracheostomy care every shift and weekly equipment changes. The treatment records showed that these orders were not consistently followed, with missed tracheostomy care and equipment changes. The care plan for Resident #75 lacked interventions for cleaning equipment or daily care. The facility's policy required tracheostomy care to be provided according to physician's orders and professional standards, but this was not adhered to, as confirmed by the Director of Nursing.
Improper Gloving and Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure proper gloving and hand washing during incontinence care for a resident diagnosed with dementia, obstructive and reflux uropathy, and functional incontinence. During an observation, a State tested Nurse Aide (STNA) and a Housekeeping Aide gathered supplies, washed their hands, and applied gloves before removing the resident's urine-soaked incontinence product. The STNA cleansed and rinsed the perineal area and buttocks but did not change gloves before adjusting the resident's gown, call light, and bed linens. The STNA then gathered soiled supplies, removed her gloves, and walked down the hallway to dispose of them without washing her hands before leaving the resident's room. During an interview, the STNA confirmed she had not changed her gloves or washed her hands, stating she hadn't given it a thought. The facility's policies on hand hygiene and perineal care require changing gloves if soiled and performing hand hygiene immediately after removing gloves, which were not followed in this instance.
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What surveyors actually found near you
We read the 207 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Village Hc Np Llc | 2.5 mi | ★★★★★ | 0 | 0 |
| Amberwood Manor | 3 mi | ★★★★★ | 0 | 0 |
| Country Club Center I | 4.7 mi | ★★★★★ | 43 | 1 |
| New Dawn Rehabilitation And Healthcare Center | 4.7 mi | ★★★★★ | 7 | 0 |
| Claymont Health And Rehabilitation | 4.7 mi | ★★★★★ | 6 | 0 |
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