Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Scioto Rehabilitation & Care Center during CMS and state inspections, most recent first.
Unsafe food storage, dishwashing, and food prep practices were observed in the dietary area. A garbage disposal had stagnant gray water, the walk-in freezer was not maintaining proper temps and contained unlabeled opened foods with melted items, and the dish machine repeatedly failed to reach required sanitizing temps while resident dishes were being washed. A staff member also used a wet food processor bowl to puree food without waiting for it to air dry.
Kitchen equipment was not maintained in working order. A garbage disposal near the handwashing sink had stagnant gray water and a dark opaque layer, and staff said it had not worked for about a week. The walk-in freezer had temperature problems with food items found melted, thawed, or semi-frozen, and the compressor was confirmed not working. The walk-in refrigerator had a broken door panel and a damaged shelf, and the dishwasher thermometer gauges were not working while repeated checks showed wash temperatures below the minimum needed for chemical sanitizing.
Pest control in the kitchen was ineffective because the facility’s pest control program did not cover flies, and records showed the kitchen had not been treated for fruit flies. Surveyors repeatedly observed about 15-25 fruit flies on the dishwashing sanitizing bucket and chemical sanitizing bucket, and dietary staff confirmed the presence of fruit flies in the dishwashing area. The Administrator stated he was unaware of any fruit fly problem.
Failure to Notify Physician When IV Access Could Not Be Obtained: A resident with dementia, Parkinson’s disease, diabetes, and other diagnoses had an order for IV NS, but nursing staff could not obtain IV access and there was no documentation that the physician was notified the order was not being carried out. The resident later transferred to the hospital with lethargy, confusion, hypoxia, metabolic encephalopathy, and AKI, and hospital records showed improvement after IV fluids were given.
Protein supplement not administered as ordered for a resident with a pressure ulcer. A resident with acute respiratory failure, anoxic brain damage, enteral nutrition dependence, and hospice services had a stage III pressure ulcer and was ordered ProStat 60 mL via GT daily for protein and skin integrity support. MAR review showed the resident repeatedly received only 30 mL instead of 60 mL, and an LPN and the DON confirmed the supplement was frequently given at the lower amount.
Delayed Nutrition Orders and Missed Enteral Feedings: Two residents who depended on PEG tube feedings were affected. One resident’s tube feeding rate was transcribed at a much lower rate than ordered, with no documented reason or intolerance, and a protein supplement recommendation was also left pending for over a month. Another resident’s enteral feeding pump was observed not delivering ordered Osmolite feedings during repeated checks, and the resident had not been weighed monthly as expected.
Medication administration errors resulted in a 7.4% error rate, above the allowed threshold. An LPN gave one resident acetaminophen regular strength instead of the ordered ER form, and crushed another resident's meclizine for PEG administration even though the order did not authorize crushing and the pharmacist confirmed the tablet should not be crushed.
Care plans for two residents failed to include key diagnoses and medication indications. One resident’s plan did not address neuropathy or migraines despite orders for Gabapentin and Imitrex, while another resident’s plan did not address seizures/convulsions or long-term antibiotic use despite orders for anticonvulsants and daily Cephalexin. The MDS nurse verified the omissions, and the facility policy required care plans to include identified problem areas and related risk factors.
A resident with dementia and hearing loss had a physician order and care plan interventions for hearing aids, but an LPN documented the aids were in place without verifying it. During observation, the aids were not on the resident, and the LPN could not locate them. The UM stated the hearing aids were stored in the med storage room, but new or agency staff would not know where to find them.
Failure to Maintain Resident Nail Hygiene: A resident with aphasia, vascular dementia, COPD, and hemiplegia/hemiparesis was dependent for personal hygiene and had severely impaired decision-making. Staff and family observed that his fingernails were long with a dark substance under both hands, despite his preference for short, clean nails. An RN confirmed the condition of the nails, and the facility policy required assistance with grooming and personal hygiene for residents unable to perform ADLs independently.
A resident with ESRD, CHF, COPD, and intact cognition was identified as needing supervision while smoking, but staff observed her falling asleep holding a cigarette and later found a package of cigarettes on her bedside table and in her room on multiple occasions. The DON confirmed she was not safe to smoke without supervision and that she had cigarettes in her possession, despite the facility policy stating supervised smokers’ smoking materials are to be held by nursing staff or a designee.
A facility failed to follow enteral nutrition recommendations for one resident with dysphagia and protein calorie malnutrition, where the dietitian recommended a cyclic tube-feeding schedule to support hunger cues and weaning but the physician orders were not updated and the resident was observed inconsistently connected to the pump. The facility also failed to flush another resident’s PEG tube before, during, and after administering multiple crushed meds, despite an order for water flushes and a policy requiring flushing between and after medications; the tube showed resistance and appeared clogged during the med pass.
The facility failed to timely provide ordered pain relief for one resident with a right leg fracture and severe reported pain, and it failed to carry out repeated NP recommendations and reschedule a missed pain clinic visit for another resident with chronic pain and cancer-related diagnoses. The second resident had intact cognition, frequent pain ratings of 8/10 or higher, and orders for PRN analgesics, but the recommended Voltaren gel was not ordered until later and the pain specialist appointment was not promptly rescheduled after it was missed.
A resident with ESRD on dialysis, CHF, bipolar disorder, and impaired cognition was maintained on cephalexin daily for dialysis prophylaxis without a documented end date or clear indication. Hospital discharge paperwork did not include antibiotics, the MAR showed ongoing administration for months, and the DON could not identify why the antibiotic was needed prophylactically or what specific risk justified its use.
A resident with documented food allergies to onions and coffee extract was served salsa with a burrito meal even though the meal ticket listed an onion allergy. The resident told staff they could not have it because of the allergy, and a CNA confirmed the salsa contained onions. The resident’s record also documented prior reactions including diarrhea from onions and anaphylaxis from coffee extract.
Inaccurate MAR documentation affected two residents. One resident with depression, anxiety, and agitation had repeated MAR entries for Nuedexta that did not match a note stating the medication was out of stock, and the Unit Manager said later documentation showing administration was incorrect because the drug was not in the building. Another resident with anxiety had PRN diazepam documented in the controlled med log but not on the MAR, and an LPN confirmed the dose had been given earlier that morning.
Urinary Catheter Drainage Bag Left on Floor. A resident with an indwelling urinary catheter and bladder dysfunction was observed with the catheter drainage bag resting on the floor. A CNA confirmed the bag was on the floor before offering to move it. Facility policy states catheter tubing and drainage bags should be kept off the floor.
Antibiotic stewardship was not followed for two residents whose infections did not meet McGeer's or Loeb's criteria. The facility tracked antibiotic use and used an Infection Screening Evaluation, but the DON confirmed the forms were often left incomplete and that she did not discuss the noncompliance with the prescriber. Both residents received Doxycycline Hyclate for a toe infection and sinusitis, respectively, even though the evaluations determined the antibiotics did not meet criteria.
A resident with multiple serious diagnoses, including a tracheostomy and oxygen dependence, experienced a change in condition when the trach was found on the floor and the resident had mild respiratory distress with low O2 saturation. Nursing staff initiated emergency trach protocol and inserted a new size six trach tube, but the record showed no notification to the PCP or family representative, and the DON confirmed they were not informed.
A resident with ESRD, CHF, DM, HTN, HLD, BPH, OSA, MDD, and a femur fracture was dependent on staff for showers and had a care plan noting unsafe and unhygienic behavior during incontinence care. Surveyors observed the resident’s nails were long, jagged, and had a brown substance under them, and the DON verified the condition of the nails; a later observation showed the nails remained unchanged despite the facility’s nail care policy allowing routine fingernail cleaning and trimming by nursing staff or trained nursing assistants.
A resident with multiple chronic conditions, including CHF, AFib, COPD, and respiratory failure, had a care plan calling for monitoring of labs and diagnostics after hospitalization. Physician orders included vitamin B and vitamin D levels, but the record showed no evidence the tests were obtained, and the ADON verified the omission.
A resident with CHF, COPD, AFib, and respiratory failure had a chest x-ray ordered for cough. The x-ray showed findings concerning for bronchitis and pneumonia, but the medical record had no documented evidence that the physician was notified of the results, and the DON verified the lack of documentation.
A resident with cognitive impairment and multiple medical conditions was involved in an incident where another resident became agitated and grabbed her shoulders. Although the resident, her representative, and an LPN confirmed the physical contact, facility documentation and the investigation failed to accurately reflect these accounts or include all relevant witness interviews, resulting in an incomplete abuse investigation.
A resident with an indwelling urinary catheter and multiple medical conditions was identified as being at risk for urinary tract infection, but there were no physician orders in place for catheter care, cleansing, or flushing. Staff interviews confirmed that catheter care is performed according to physician orders, but none had been entered for this resident, resulting in a failure to follow facility policy and established procedures.
A nurse administered Metoprolol to a resident with cardiac conditions without checking blood pressure or heart rate as required by the physician's order, resulting in a failure to ensure the medication was only given when necessary.
A CNA entered the room of a resident on contact precautions for an infection without wearing the required PPE, such as a gown and gloves, despite clear signage and available supplies. An LPN confirmed the resident's precaution status and the CNA's failure to comply with infection control protocols.
Multiple infection control lapses were observed, including dirty linen left on hallway floors, an LPN failing to clean a glucometer between resident uses, improper sterile technique during trach care by a respiratory therapist, and delayed or missing Enhanced Barrier Precautions for residents with wounds or tracheostomies. These deficiencies were confirmed through staff interviews, record reviews, and direct observation.
A resident with multiple chronic conditions was transferred to the hospital, but the facility did not notify the resident's POA as required by policy. The DON confirmed that the emergency contact was not informed of the transfer, despite the facility's procedures mandating such notification.
Surveyors found that a resident with CHF experienced significant weight gain without physician notification, despite clear orders and facility policy. Two other residents did not receive proper treatment for non-pressure skin alterations as ordered, including missed wound care and dressing changes. Nursing leadership confirmed these deficiencies.
The facility did not properly document or treat pressure ulcers for three residents, including failing to measure and stage wounds on admission, not updating wound care orders per wound nurse recommendations, delaying initiation of treatment, and not clarifying conflicting orders. Multiple wounds were not captured in admission assessments, and appropriate treatment orders were not established, as confirmed by the DON.
Two residents did not receive required fall prevention interventions, including proper placement of fall mats and use of two staff for Hoyer lift transfers. One resident's fall mats were not in place as ordered, and another resident experienced a fall when a CNA performed a mechanical lift transfer alone, contrary to policy. Additionally, a resident's bed was repeatedly observed not in the lowest position as required by the care plan.
A resident with multiple medical conditions and cognitive impairment did not receive Acetaminophen, Gabapentin, and Oxycodone as prescribed, due to discrepancies between hospital discharge orders and facility medication administration. The resident was given Acetaminophen more frequently than ordered and had conflicting Gabapentin orders, leading to confusion and improper dosing. The resident experienced a decline in condition, requiring transfer to the hospital, and staff interviews confirmed the medications were not administered per physician orders.
The facility did not ensure medical records were accurate and up-to-date for three residents, including failure to update code status after a resident transitioned to hospice, documenting care for a resident after discharge, and missing wound care notes from an outside consultant. The DON and Assistant DON confirmed these discrepancies during interviews.
The facility failed to provide meals as ordered and maintain proper food temperatures, affecting most residents. Observations revealed that cold foods were served above the acceptable temperature, and several residents did not receive the meals indicated on their meal tickets. A delay in food delivery led to inappropriate meal substitutions, which were not properly documented as per facility policy.
A resident with an NG tube for nutritional support did not receive proper care due to the facility's failure to reorder and document the verification of tube placement upon readmission. This oversight led to inadequate care, including an incident where the resident was found unresponsive and required emergency medical intervention. The Director of Nursing confirmed the absence of the necessary order in the resident's records.
The facility failed to implement a comprehensive pressure ulcer prevention program, resulting in harm to three residents. One resident developed a Stage III ulcer due to inadequate interventions, another developed an unstageable ulcer without an individualized prevention plan, and a third developed a Stage III ulcer due to malfunctioning equipment. Prescribed treatments were not consistently administered, contributing to skin breakdown.
The facility failed to maintain sanitary conditions in food storage and preparation areas, affecting 108 residents. Observations revealed sour-smelling liquid pools and dirty walls in the dietary department. Interviews confirmed a punctured hose in the three-compartment sink caused the leak, violating the facility's sanitation policy.
The facility failed to employ a qualified social worker despite having over 120 certified beds. SSD #320, introduced as the new social worker, had a Master's degree but had not passed the State licensing exam and was not licensed. The Administrator was aware of this at the time of hiring. The job description required a Bachelor's Degree, supervisory experience, and ACSW registration, which SSD #320 did not meet. This deficiency potentially affected all 109 residents.
The facility failed to maintain effective pest control in the kitchen, affecting 108 residents. Observations revealed standing pools of sour-smelling liquid and fruit flies in the dietary department. The Dietary Director confirmed the presence of fruit flies, and the facility's Sanitation policy requires areas to be clean and pest-free.
The facility failed to provide adequate supervision and ensure the functionality of safety devices for residents, leading to incidents such as unsupervised smoking and malfunctioning wanderguard alarms. A resident with hemiplegia was found smoking unsupervised, resulting in a burn, while another resident with dementia had smoking materials in his room and was not supervised. Additionally, wanderguard alarms for two residents at risk of elopement were not properly checked for functionality, highlighting deficiencies in the facility's safety protocols.
The facility failed to manage medications and medical supplies properly, with expired items found in the medication room and an unattended, unlocked medication cart on the 400 unit. An LPN confirmed the expired items and the unlocked cart, which was against the facility's policy.
The facility failed to maintain the dignity of two residents. One resident reported witnessing inappropriate behavior from another resident, and management's response was inadequate. Another resident was observed without clothing, with a soiled brief visible from the hallway, which was confirmed by an LPN. These incidents violated the facility's policy on resident rights, which emphasizes treating residents with dignity and respect.
The facility failed to provide timely access to social security benefits for a resident with intact cognition, who had been requesting access since March 2024. Additionally, another resident with cognitive impairment did not have a Power of Attorney or guardianship in place, and the facility was unaware of the guardianship process, lacking a Licensed Social Worker.
A facility failed to update a resident's code status from full code to DNR after admission to hospice services. Despite the resident's DPOA agreeing to the change and a DNR order being completed, the facility did not update the medical records to reflect this change, as confirmed by the ADON.
The facility failed to provide required written transfer notices and inform residents or their families of their rights regarding hospitalization for three residents. One resident was hospitalized multiple times with only one incomplete transfer notice documented. Another resident's transfer notices lacked essential information, and the resident's family confirmed not receiving any documentation. A third resident was transferred due to altered mental status without the necessary appeal information. The Administrator admitted to not completing transfer notices for all facility-initiated transfers.
The facility failed to provide bed hold notices to residents and their families during hospitalizations, affecting two residents with complex medical conditions. Despite the facility's policy, no written notices were given, depriving residents of the opportunity to make informed decisions about bed retention. Interviews confirmed the lack of communication, and the facility's Administrator admitted that bed hold notices were not completed or provided.
The facility failed to conduct accurate and timely assessments for residents, affecting their care. A resident with a wanderguard was incorrectly marked as not using alarms in the MDS, while another resident's significant weight change was inaccurately documented due to flawed calculation methods. Additionally, a resident's admission MDS was not completed within the required timeframe, indicating a lapse in adherence to assessment protocols.
The facility failed to complete accurate significant change MDS 3.0 assessments for two residents, affecting their care documentation. One resident admitted to hospice services had an MDS assessment that did not reflect their hospice status, confirmed by an MDS Nurse. Another resident with multiple diagnoses and hospice admission also lacked a significant change MDS assessment, verified by the IDON.
A resident with multiple medical conditions, including a cerebrovascular accident, did not receive timely assistance with meals due to staffing issues. The resident's breakfast tray remained untouched for over 30 minutes, contrary to the facility's policy on providing necessary ADL support.
The facility failed to monitor and address conditions for two residents. One resident experienced significant weight gain and edema without appropriate treatment or documentation, while another resident on anticoagulants had a bruise that was not documented or monitored. Interviews confirmed lapses in following facility policies for notifying changes in condition and documenting skin issues.
Unsafe food storage, dishwashing, and food preparation practices
Penalty
Summary
Food was not stored and prepared in a clean and sanitary manner in the kitchen and dietary areas. During observation, there was approximately six inches of stagnant gray water with a dark gray opaque substance on top near the handwashing sink and garbage disposal. A staff member stated the garbage disposal had not been working for about one week and that kitchen staff were periodically removing the water buildup with a plastic mug. In the walk-in freezer, the external thermometer showed temperatures of 45 degrees Fahrenheit, 28 degrees Fahrenheit, 23 degrees Fahrenheit, and later 10 degrees Fahrenheit and 20 degrees Fahrenheit on the internal thermometer. The freezer compressor was confirmed not to be working, and the freezer logs showed repeated temperatures above freezing, including 35 degrees Fahrenheit on one evening entry. Inside the freezer, melted popsicles had dripped over boxes, and opened bags of raw chicken, cooked cubed chicken, and cooked breaded chicken were not labeled or dated. The facility policy required freezer foods to be covered, labeled, dated, and kept frozen solid. The dishwashing process also did not reach required sanitizing temperatures. The dishwasher thermometer gauges were not working, and repeated observations with a temperature disc showed wash cycle temperatures of 105.6 degrees Fahrenheit, 106.8 degrees Fahrenheit, 107 degrees Fahrenheit, 102.3 degrees Fahrenheit, and 110.3 degrees Fahrenheit while resident dishes were being washed. In addition, during pureed food preparation, a staff member used a food processor bowl to puree hamburger patties, washed the bowl in the dishwasher, and then used the wet bowl without waiting for it to air dry to puree mixed vegetables.
Kitchen Equipment Not Maintained Safely
Penalty
Summary
The facility failed to keep kitchen equipment working safely, including the garbage disposal, walk-in freezer, walk-in refrigerator, and dishwasher. During observation, there was approximately six inches of stagnant gray water with a dark gray opaque substance on top in the garbage disposal near the handwashing sink. A staff member confirmed the water buildup and stated the garbage disposal had not been working for about one week, and kitchen staff were periodically removing the water with a plastic mug. The walk-in freezer was observed with an external thermometer reading 45 degrees F, and no internal thermometer could be located at that time. Food items inside the freezer were found in compromised conditions, including melted popsicles in liquid form, an opened bag of raw chicken that was semi-frozen, an opened bag of cubed cooked chicken that was thawed and spongy to the touch, and an opened bag of cooked breaded chicken that was semi-frozen. Later observations showed continued temperature problems in the freezer, and the Maintenance Director confirmed the freezer compressor was not working. Review of temperature logs showed repeated low and fluctuating freezer temperatures over May and June, and a work order noted the compressor was acting up. Additional observations showed the walk-in refrigerator door had a broken and peeling panel and a broken wall shelf hanging off the wall with popped screws. The dishwasher thermometer gauges were not working, and repeated temperature checks with a temperature disc showed wash temperatures of 105.6 degrees F, 106.8 degrees F, 107 degrees F, 102.3 degrees F, and 110.3 degrees F. The Dietary Manager confirmed the dishwasher did not reach the minimum wash temperature of 120 degrees for chemical sanitizing.
Pest Control Program Did Not Address Fruit Flies in Kitchen
Penalty
Summary
The facility failed to ensure effective pest control in the kitchen because its pest control program did not cover flies, and six months of pest control records showed the kitchen had not been treated for fruit flies. The pest control agreement dated 01/29/24 stated that flies were not included in the regular program and would be treated as needed for an additional discounted charge. During observations in the dishwashing area on 06/08/26, approximately 15-20 fruit flies were seen on the dishwashing sanitizing bucket, and a staff member confirmed their presence. Similar observations on 06/09/26 found approximately 20 fruit flies on the dishwashing sanitizing solution bucket, which the Dietary Manager confirmed. On 06/11/26, approximately 20-25 fruit flies were again observed on the chemical sanitizing bucket at the dish machine, and a Dietary Aide stated the kitchen had had fruit flies for a while. The Administrator stated he was unaware of any fruit fly problems in the kitchen.
Failure to Notify Physician When IV Access Could Not Be Obtained
Penalty
Summary
The facility failed to ensure the physician was notified when IV access could not be obtained for a resident during a change in condition. Resident #130 was admitted with diagnoses including bipolar disorder, dementia, psychotic disturbance, mood disturbance, anxiety, diabetes, Parkinson’s disease, and muscle weakness. The resident’s MDS showed intact cognition with a BIMS score of 15 and need for staff assistance with self-care and mobility. The care plan identified the resident as at risk for a nutritional problem and directed staff to monitor the resident and lab work and report signs of malnutrition to the physician. A physician order was entered for normal saline to infuse at 75 mL per hour for one liter, but the record contained no documented reason for the IV fluid order. On the night shift, nursing staff were unable to insert an IV catheter to start the ordered saline infusion and obtained permission from the DON to contact an outside provider to attempt IV insertion. The progress notes did not show that the physician was notified that the order was not being carried out, and there was no documentation that an outside provider was contacted, that IV access was obtained, or that the infusion was started in the facility. The resident was later transferred to the hospital, where documentation showed lethargy, confusion, hypoxia, metabolic encephalopathy, and acute kidney injury, and the resident received IV fluids and improved. Interviews with staff and the physician confirmed the physician team was not notified timely that the IV could not be started.
Protein supplement not administered as ordered for resident with pressure ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure that Resident #12’s protein supplement was administered as ordered to support wound healing. Resident #12 was admitted with diagnoses including acute respiratory failure with hypoxia and anoxic brain damage, was reliant on enteral nutrition as a sole source of nutrition support, and was enrolled in hospice services. The care plan identified nutritional risk related to skin impairment and listed an intervention to provide supplements as ordered. A nutrition assessment recommended ProStat 30 mL twice daily for additional protein and skin integrity support, and a pressure ulcer assessment later documented a stage III pressure ulcer on the right buttock. Physician orders dated 10/29/25 prescribed ProStat 60 mL via gastrostomy tube once daily at 6:00 P.M. Review of the MAR showed the resident repeatedly received only 30 mL instead of 60 mL: 18 of 30 administrations in April, 25 of 31 in May, and 9 of 10 in June. An LPN confirmed administering ProStat in a total daily amount of 30 mL and stated the usual orders were for 30 mL via gastrostomy tube. The DON also confirmed that ProStat was frequently administered at 30 mL instead of 60 mL. A diet technician stated that not receiving a liquid protein supplement as ordered could affect the wound healing process. The facility policy stated nurses will ensure that orders, interventions, and treatments for skin and wounds are implemented as ordered.
Delayed Nutrition Orders and Missed Enteral Feedings
Penalty
Summary
The facility failed to meet nutritional recommendations and delayed implementation of nutrition orders for one resident with tracheostomy and gastrostomy status and protein calorie malnutrition, and it failed to provide ordered enteral feedings for another resident with cerebral infarction, hemiplegia, and gastrostomy status. Both residents relied on PEG tube feedings as their sole source of nutritional support. For the first resident, the record showed that the resident had been receiving Jevity 1.5 at 55 ml/hr continuous feeding, which the nutrition assessment documented as meeting 100% of caloric needs. On 01/07/26, the physician order was transcribed by an LPN unit manager as Jevity 1.5 at 25 ml/hr continuous, and the chart contained no documentation explaining why the rate was changed or any indication of feeding intolerance. The resident remained on the lower rate until 01/30/26, when the dietitian clarified the order back to 55 ml/hr. During that period, the diet technician stated the lower rate provided about 898 calories per day, approximately 50% of estimated daily needs, and could have led to significant weight loss. The resident’s weight later dropped from 144.3 lbs to 135.2 lbs, and the nutrition note documented a significant loss of 5.7% in less than one month. The same resident also had delayed implementation of a protein supplement recommendation. Nutrition notes dated 04/10/26 and 04/28/26 recommended increasing the protein supplement to 30 ml twice daily, and a note on 05/01/26 stated the recommendation was still pending. The physician order for the protein supplement was not written until 05/15/26, more than a month after the initial recommendation. The LPN unit manager confirmed the supplement was started untimely. For the second resident, the nutrition assessment documented NPO status and continuous Osmolite 1.5 at 60 ml/hr via PEG tube to meet full caloric needs, and the physician order matched that regimen. On 06/10/26, surveyors observed the enteral feeding pump not administering feedings during multiple observations, with the monitor showing system error and feed error messages. An LPN confirmed the pump was not delivering the ordered feeding and stated it had been malfunctioning all day. The resident’s record also showed a weight of 107.9 lbs on admission, with no monthly weights documented through 06/09/26, and staff confirmed the resident had not been weighed since admission.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. During observation, interview, medical record review, facility policy review, and review of medication labels, surveyors found 2 medication errors out of 27 opportunities, resulting in a 7.4% medication error rate. This involved two residents observed during medication administration, with the census at 102. One resident had orders for acetaminophen ER 650 mg every six hours as needed, but an LPN administered acetaminophen regular strength 650 mg from the facility's over-the-counter supply instead of the ordered ER formulation. The LPN later confirmed the wrong formulation was given. Another resident had a PEG tube and an order for meclizine 25 mg twice daily for dizziness; the order did not state to crush the tablet. The LPN crushed the meclizine along with other medications and administered it through the PEG tube. The pharmacist confirmed the meclizine sent for the resident should not be crushed, and the facility policy stated medications were not to be crushed for enteral tube administration unless verified with the pharmacy and supported by a specific crushing order.
Care plans did not address key medications and diagnoses
Penalty
Summary
The facility failed to ensure that the care plans for Resident #15 and Resident #2 comprehensively addressed their medications and medical conditions. Resident #15 was admitted with diagnoses including anxiety disorder, protein-calorie malnutrition, cirrhosis of the liver, alcohol dependence, depression, and COPD. The resident’s quarterly MDS showed intact cognition, and the medication regimen included antianxiety, antidepressant, hypnotic, diuretic, and anticonvulsant medications. Physician orders included Imitrex as needed for migraines and Gabapentin for neuropathy, but the care plan did not address the resident’s neuropathy or migraines. Resident #2 was admitted with diagnoses including convulsions, CHF, ESRD with dependence on renal dialysis, bipolar disease, adult failure to thrive, generalized anxiety disorder, and muscle weakness. The quarterly MDS showed moderately impaired cognition. Physician orders included Cephalexin daily for dialysis prophylaxis, levetiracetam for seizures, and divalproex for seizures, but the care plan did not address the resident’s long-term antibiotic use or convulsions/seizures. The MDS nurse verified that the care plan did not address these medication indications or diagnoses, and the facility policy stated that comprehensive person-centered care plans were to include identified problem areas and risk factors associated with identified problems.
Hearing Aids Not Ensured for Resident With Communication Impairment
Penalty
Summary
The facility failed to ensure appropriate treatment and services were in place to maintain or improve a resident’s ability to communicate and hear. The resident was admitted with diagnoses including adult failure to thrive, dementia, osteoarthritis, and protein calorie malnutrition. The physician order dated 03/28/24 directed staff to put in the resident’s hearing aid every day shift, and the care plan identified impaired communication related to hearing loss with interventions including adjusting voice tone, allowing time to express self, hearing aids, and assisting with placement and maintenance of hearing aids as needed. The quarterly MDS assessment documented that the resident was rarely or never understood. On 06/10/26, the MAR indicated an LPN documented that he had put in the resident’s hearing aids. However, during interview and observation later that day, the LPN was unsure where the hearing aids were and the resident’s hearing aids were not in place. The LPN verified they were not in place and stated he had documented that they were in place without ensuring they were. The Unit Manager later stated the hearing aids were stored in the medication storage room and that new nurses or agency staff would not know their location.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to ensure that Resident #5’s nails were filed and maintained in a clean and sanitary manner according to his preferences. Resident #5 was admitted with diagnoses including aphasia, vascular dementia, COPD, and hemiplegia and hemiparesis following cerebral infarction. His care plan identified ADL self-care performance deficits and included assistance with ADLs such as grooming and personal hygiene. Assessments showed impaired range of motion in both upper extremities, dependence for personal hygiene, and severely impaired cognitive skills for daily decision making. During the review period, personal hygiene care was documented on four days, and the resident was documented as dependent for personal hygiene. A family member stated that Resident #5 preferred his nails short and clean and expressed concern about his nail care. Observations on multiple occasions showed the resident’s fingernails were approximately a half centimeter long with a dark substance under the nails of both hands. An RN confirmed that the nails were long and had a dark substance under them, and stated she would file and clean the resident’s nails. The facility policy stated that residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Supervised smoker kept cigarettes in room
Penalty
Summary
The facility failed to ensure a supervised smoker did not have smoking materials on her person. Resident #40 was admitted with diagnoses including end stage renal disease, congestive heart failure, chronic obstructive pulmonary disease, and muscle weakness, and her MDS assessment showed intact cognition with a BIMS score of 15. Her smoking evaluation identified her as requiring supervision while smoking, and her care plan stated she could only smoke with family or staff supervision because of a potential safety hazard or injury related to smoking. A staff member observed the resident falling asleep while holding a cigarette, and the nurse manager was notified. Subsequent observations showed a package of cigarettes on the resident’s bedside table and later in her room on multiple occasions. The DON confirmed the resident was not safe to smoke without supervision and acknowledged that she had cigarettes in her possession. The facility smoking policy stated that for residents deemed supervised smokers, smoking materials are to be labeled and held by nursing staff or a designee.
Failure to Follow Enteral Feeding and PEG Tube Care Orders
Penalty
Summary
The facility failed to implement nutritional recommendations intended to promote weaning off enteral feedings for a resident with dysphagia and protein calorie malnutrition. Resident #66 was admitted with diagnoses including dysphagia and protein calorie malnutrition, had a care plan addressing nutritional risk, and was receiving Osmolite 1.5 at 30 ml/hr continuous feeding along with a regular diet and double protein portions. A nutrition progress note documented that the resident had gained 16.1% of body weight in one month and requested real food, and the dietitian recommended changing the tube feeding to a cyclic schedule of Osmolite 1.5 at 40 ml/hr for 18 hours daily with a daily off period from 12:00 P.M. to 6:00 P.M. However, physician orders did not reflect that recommendation, and observations showed the resident was not connected to the feeding pump at times while also being connected at other times on the original continuous order. Staff interviews confirmed the feeding was not being administered as ordered, and the DON stated there were no known barriers to weaning the resident from continuous enteral feedings. The facility also failed to provide appropriate care for a feeding tube during medication administration for another resident with a PEG tube. Resident #89 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, heart failure, tracheostomy status, and gastrostomy status, and had an order for the PEG tube to be flushed with 10 cc of water before and after medication administration every shift. During observation of the 9:00 A.M. medication pass, an LPN checked blood pressure, combined multiple crushed medications, and administered them through the PEG tube while adding 30 cc of sterile water to the medication mixture. The PEG tube was not flushed before, during, or after medication administration, and the tube appeared clogged with resistance noted after the second syringe of medication. The LPN later confirmed that the tube had not been flushed as ordered. Facility policy stated that the dietitian determines whether intake is adequate and makes recommendations for enteral nutrition, with physician orders based on those recommendations. The medication administration policy for enteral tubes required flushing the tubing with prescribed water before and after medications and between medications when more than one medication is given. The findings involved two of three residents reviewed for enteral nutrition in a facility census of 102 residents.
Delayed Pain Medication and Unimplemented Pain Management Recommendations
Penalty
Summary
The facility failed to timely administer ordered pain medication for a resident with diagnoses including pain in the right leg, a displaced right tibia fracture, mood disorder, bipolar disorder, anxiety disorder, gastroparesis, and muscle weakness. The resident’s care plan identified her as being at risk for pain related to osteoarthritis and the right tibial and fibula fracture and directed staff to administer medications per physician orders. A physician order dated 06/05/26 prescribed buprenorphine HCl 2 mg sublingually, with instructions to place 6 tablets under the tongue daily for 10 days. The resident reported pain levels of 7/10 on 06/04/26, 10/10 on 06/05/26 in the morning, and 7/10 later that day, but the MAR showed the medication was not given on 06/05/26 and the first dose was not administered until 06/06/26. The DON confirmed the delay occurred because the pharmacy required a prescription from the facility provider and staff were unable to reach the doctor until the end of the day on 06/05/26, so the medication was not delivered until the next morning. The facility policy, Pain-Clinical Protocol, stated the physician will order appropriate medication interventions to address the resident’s pain. The facility also failed to implement pain management recommendations and to timely reschedule a pain clinic appointment for another resident with arthritis in multiple sites and malignant neoplasm of the kidney with secondary malignant neoplasm of the lung. This resident had a BIMS score of 15 and reported significant pain, with the MDS noting pain that occasionally limited daily activities and a pain rating of 9/10. Orders included acetaminophen PRN, lidocaine patches, and later oxycodone PRN, while the MAR documented pain levels of 8 or higher on numerous occasions. The nurse practitioner recommended Voltaren gel on multiple occasions, but no order was present until 06/09/26, and the resident’s pain clinic appointment scheduled for 05/28/26 was missed because the clinic could not see him due to lack of photo identification; the appointment was not rescheduled until after surveyor intervention.
Unnecessary Long-Term Antibiotic Use Without Documented Indication
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary drugs when Resident #2 was maintained on cephalexin without an appropriate documented indication for long-term use. The resident was admitted with diagnoses including convulsions, chronic heart failure, end stage renal disease with dependence on renal dialysis, bipolar disease, adult failure to thrive, generalized anxiety disorder, and muscle weakness, and had moderately impaired cognition on the quarterly MDS assessment. Hospital discharge paperwork showed no antibiotic prescription, yet physician orders beginning shortly after admission included cephalexin 250 mg by mouth daily for dialysis prophylaxis with no end date documented. Review of the resident’s record from admission through the survey date found no documentation explaining why cephalexin was started or why it was needed for dialysis. The MAR showed the resident received the antibiotic regularly over several months, and a NP progress note stated the resident was on cephalexin prophylactically. The plan of care did not address the antibiotic use, and the DON stated antibiotic use for dialysis was not typical and that she could not identify why the resident needed prophylactic antibiotic therapy or what specific risk justified it. The facility’s Antibiotic Stewardship policy required antibiotic orders to include the indication for use, along with the drug name, dose, frequency, route, and start and stop date or duration.
Food Allergy Not Honored During Meal Service
Penalty
Summary
The facility failed to ensure Resident #54 was not provided food they were allergic to. Resident #54 was admitted on 10/05/25 and had diagnoses including unspecified protein-calorie malnutrition, type II diabetes with diabetic neuropathy, hyperlipidemia, depression, and essential hypertension. The resident’s MDS showed a BIMS score of 15. The medical record listed food allergies to arabica coffee extract and onions, and a drug allergy to codeine with no reaction manifestations listed. A progress note dated 05/22/26 documented that the facility confirmed the resident experienced itching from codeine, anaphylaxis from coffee extract, and diarrhea from onions. On 06/09/26, the resident’s meal ticket listed an allergy to onions. During lunch observation at 12:02 P.M., the resident was served two containers of salsa with a burrito meal and stated to staff, “I cannot have them, I am allergic.” A CNA confirmed the resident received two containers of salsa that contained onions, which the resident was allergic to, with the lunch tray. Review of the Heinz salsa sauce and dip ingredients list showed onions were an ingredient of the salsa sauce and dip. The facility policy titled, Food Preferences and Special Diets dated 12/2023 stated residents have the right to refuse foods offered and should be given substitutions for disliked or restricted foods.
Inaccurate MAR Documentation for Scheduled and PRN Medications
Penalty
Summary
The facility failed to ensure Medication Administration Records (MARs) were accurate for two residents. One resident had diagnoses including depression, mood disorder due to a known physiological condition with depressive features, anxiety disorder, type 2 diabetes mellitus, and restlessness and agitation, and was rarely or never understood on the quarterly MDS. The resident had a physician order for Nuedexta 10 mg every 12 hours for suspected pseudobulbar effect, but the MAR showed multiple inconsistencies, including doses documented as not given, given once, or given twice on several dates in May and June 2026. A progress note dated 05/21/26 stated the medication was not in stock because the pharmacy needed prior authorization, and the Unit Manager later stated that any documentation showing the medication was administered after that note was incorrect because it was not in the building. A second resident with an admission diagnosis of anxiety had an order for diazepam 10 mg every 6 hours as needed for anxiety for 14 days. The controlled medication log documented diazepam as administered at 5:30 A.M. on 06/10/26, but the June 2026 MAR did not show that administration. When the resident requested PRN diazepam later that morning, an LPN told the resident a dose had already been given at 5:30 A.M. The LPN Unit Manager confirmed the dose was logged in the controlled medication log but not documented in the MAR, and stated it should have been documented in both records.
Urinary Catheter Drainage Bag Left on Floor
Penalty
Summary
The facility failed to maintain infection control when Resident #42's urinary catheter bag was observed resting on the floor. Resident #42 was admitted on 12/25/22 with a diagnosis of neuromuscular dysfunction of the bladder. The resident's MDS dated [DATE] showed a BIMS score of 15, and section H indicated the resident had an indwelling catheter and was always incontinent of bladder and bowel. The care plan stated the resident had a urinary catheter due to bladder dysfunction and would have reduced risk of complications of catheter use. During observation on 06/08/26 at 4:40 P.M., the catheter bag was on the floor, and a CNA later confirmed the bag was resting on the floor before offering to move it to hang off a trash can. Facility policy titled Urinary Catheter Care dated 02/2024 states staff should ensure the catheter tubing and drainage bag are kept off the floor.
Antibiotic Stewardship Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure antibiotic stewardship was followed for 2 of 4 residents reviewed on the infection control log for the months of December 2025 through May 2026. Review of the infection control log showed the facility tracked residents who received antibiotics and used an Infection Screening Evaluation to determine whether the clinical findings met McGeer's or Loeb's criteria for antibiotic use. For Resident #6, who was prescribed and administered Doxycycline Hyclate for a toe infection, the Infection Screening Evaluation determined the antibiotic did not meet either McGeer's or Loeb's criteria. Resident #6 completed treatment with fourteen doses. Resident #28 was also prescribed and administered Doxycycline Hyclate for sinusitis, and the Infection Screening Evaluation likewise determined the antibiotic did not meet either McGeer's or Loeb's criteria. Resident #28 completed treatment with ten doses. During interview, the DON, who served as the facility's infection control designee, stated that when a resident infection was reported or discovered she entered the information on the Infection Screening Form, which was often left incomplete, meaning the antibiotic did not meet McGeer's or Loeb's infection criteria. She confirmed that Resident #6 and Resident #28's infections did not meet criteria for antibiotic use and stated she did not have further conversations with the prescriber about the residents not meeting criteria.
Failure to Notify Physician and Resident Representative of Change in Condition
Penalty
Summary
The facility failed to ensure the physician and the resident representative were notified of a change in condition for Resident #30. The resident was admitted with diagnoses including protein calorie malnutrition, depression, congestive heart failure, obstructive sleep apnea, metabolic encephalopathy, anemia, atrial fibrillation, pleural effusion, acute respiratory failure with hypoxia, hypertension, hyperlipidemia, myotonic muscular dystrophy, and rheumatoid arthritis. The resident had orders for tracheostomy suctioning, tracheostomy care, tracheostomy inner cannula changes, tracheostomy tie changes, and oxygen via tracheostomy mask at 4 liters continuously. The resident’s MDS assessment indicated a persistent vegetative state/no discernible consciousness, with bowel and bladder incontinence, oxygen therapy, suctioning, and tracheostomy care. The progress note documented that the resident’s tracheostomy was found laying on the floor beside the bed, with mild respiratory distress and an oxygen saturation of 78%. The nurse initiated emergency tracheostomy protocol, inserted a new size six tracheostomy tube without complications, and the resident’s oxygen saturation improved to 96%; the resident was then placed on close supervision. The medical record contained no documented evidence that the PCP or family representative was notified of the tracheostomy being on the floor, the resident’s respiratory distress, or the insertion of a new tracheostomy tube. The DON verified in interview that the PCP and family representative were not notified. The facility policy stated that the licensed nurse will ensure timely notification of the physician and resident representative for a significant change in condition.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for showers received routine nail care. Resident #100 was admitted with diagnoses including end stage renal failure, CHF, diabetes mellitus, hypertension, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea, major depressive disorder, and a fracture of the lower end of the right femur. The resident’s care plan dated 11/03/25 documented unsafe and unhygienic behavior during incontinence care, including smearing fecal matter and placing soiled fingers in the mouth, and the resident’s five-day MDS assessment indicated no cognitive deficit and dependence on staff for showers. During observation on 03/09/26, the resident’s nails were noted to be long, jagged, and with a brown substance under them, and the resident stated, “they will not cut my nails.” Later that day, the DON verified the nails were long, jagged, and had a brown substance under them and stated she would cut the resident’s nails. A follow-up observation on 03/10/26 showed the resident’s nails remained long, jagged, and with a brown substance under them. The facility policy titled Nail Care stated that nursing staff or trained nursing assistants may provide routine fingernail care, including cleaning and trimming.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain physician-ordered diagnostic laboratory tests for Resident #40, who had a closed record showing an initial admission and latest readmission with diagnoses including acute and chronic respiratory failure, congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, anxiety disorder, nicotine dependence, hyperlipidemia, and benign prostatic hyperplasia. The resident’s plan of care identified a risk for rehospitalization and included interventions to monitor weights, edema, oxygen saturations, shortness of breath, follow-up appointments, labs and diagnostics, medication reconciliation, fever, confusion, appetite decline, high-risk medications, and therapy consults as needed. Review of the discharged physician orders showed an order for a vitamin B level and a vitamin D level, but the medical record contained no evidence that either test was obtained. During interview, the ADON verified that the facility failed to obtain the ordered vitamin B and vitamin D levels. The facility policy stated that the physician identifies and orders diagnostic laboratory testing based on diagnostic and monitoring needs, and staff are to process test requisitions and arrange for the tests.
Failure to Notify Physician of Chest X-Ray Results
Penalty
Summary
The facility failed to notify the physician of diagnostic radiology results for one resident reviewed for diagnostic laboratory tests and x-rays. The resident had diagnoses including acute and chronic respiratory failure, congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, anxiety disorder, nicotine dependence, hyperlipidemia, and benign prostatic hyperplasia, and the care plan identified the resident as at risk for rehospitalization and requiring individualized interventions to detect early changes in condition and avoid unnecessary transfers. A CNP evaluated the resident for cough and ordered a two-view chest x-ray; the resident’s lungs were documented as clear on auscultation, and the x-ray was obtained with results pending later that day. The chest x-ray report showed post-sternotomy status, bilateral hilar prominence, generalized prominence of bronchovascular markings concerning for bronchitis, and ill-defined patchy radiopacities in the right middle and lower zones concerning for pneumonia, with follow-up imaging recommended. The medical record contained no documented evidence that the physician was notified of these diagnostic radiology results. The DON verified on interview that there was no documented evidence the physician had been notified, and the facility policy stated that nursing staff will review resident results and notify the physician via preferred method.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple diagnoses, including dementia, Parkinson's disease, and mild cognitive impairment. The incident involved another resident who became agitated and grabbed the resident's shoulders, as confirmed by interviews with the resident, her representative, and an LPN who intervened. The resident reported a stress-induced headache following the incident, which was treated with a pain reliever. Documentation in the medical record and investigative documents did not accurately reflect the physical interaction, instead stating there was no evidence of physical contact. The investigation conducted by the facility was incomplete, as it did not include interviews with all relevant witnesses, specifically the resident's representative who was present during the incident. The DON stated she was unaware of any reports or documentation indicating physical contact and did not document her interview with the resident. The facility's policy requires a thorough investigation of all abuse allegations, including interviews and documentation, but these steps were not fully carried out in this case.
Failure to Implement Physician Orders for Catheter Care
Penalty
Summary
The facility failed to implement physician orders for the care of an indwelling urinary catheter for one resident. Record review showed that the resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disorder, tracheostomy, obstructive sleep apnea, and muscle wasting. The resident was cognitively intact and required assistance with self-care activities. The care plan identified the resident as being at risk for urinary tract infection, but there were no physician orders in place for catheter care, cleansing, or flushing as of the date reviewed. Interviews with facility staff confirmed that catheter care is conducted according to physician orders in the system of record. However, both an LPN and the DON acknowledged that no such orders had been entered for this resident, despite the presence of an indwelling urinary catheter. The facility's policy on urinary catheter care emphasizes the importance of routine hygiene and regular emptying of the drainage bag to prevent catheter-associated urinary tract infections. The lack of physician orders for catheter care represented a failure to follow established procedures and contributed to the cited deficiency.
Failure to Monitor Vitals Before Administering Cardiovascular Medication
Penalty
Summary
A deficiency occurred when a registered nurse administered Metoprolol Tartrate 25 mg to a resident diagnosed with atherosclerotic heart disease, hypertension, and atrial fibrillation without first checking the resident's systolic blood pressure or heart rate as required by the physician's order. The order specifically directed that the medication should be held if the systolic blood pressure was less than 100 or the heart rate was less than 60. During observation of the medication administration, it was confirmed that the nurse did not perform these checks prior to giving the medication. The facility's policy on administering medications requires verification of the right resident, medication, dosage, time, and method, but does not specifically address the monitoring required by the physician's order in this case.
Failure to Follow Contact Precautions for Resident with Infection
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) entered the room of a resident who was on contact precautions for an infection without donning the required personal protective equipment (PPE), specifically a gown and gloves. The resident, admitted with a diagnosis of osteomyelitis, had a sign posted outside the room indicating contact precautions and a PPE cart was available at the door. Despite these measures, the CNA failed to follow proper transmission-based precautions as outlined in the facility's infection control policy, which adheres to CDC guidelines. This lapse was confirmed by a licensed practical nurse (LPN) who verified the resident's precaution status and the CNA's failure to use appropriate PPE.
Infection Control Deficiencies: Improper Linen Handling, Equipment Cleaning, and Precaution Implementation
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control measures, as evidenced by multiple observed deficiencies. Dirty bed linen was found piled on the hallway floor outside a resident's room, rather than being bagged and removed from the resident's room as required by infection control protocols. A CNA confirmed that this practice was not in accordance with facility policy, which mandates that soiled linen should not be placed on the floor to prevent the spread of infection. Additionally, an LPN was observed using a glucometer on multiple residents without cleaning it between uses. The LPN admitted to not disinfecting the device after each use, despite having access to approved disinfectant wipes in the medication cart. This failure to clean shared medical equipment between residents increases the risk of cross-contamination and infection transmission. Further deficiencies were noted in the performance of sterile procedures and the implementation of Enhanced Barrier Precautions (EBP). A respiratory therapist did not maintain sterile technique during trach care, including failing to perform hand hygiene, improperly donning sterile gloves, and contaminating sterile supplies. Several residents with wounds, tracheostomies, or other conditions requiring EBP did not have appropriate precautions or care plans in place upon admission, as confirmed by the DON. These lapses in infection control practices were identified through medical record review, staff interviews, and direct observation, affecting multiple residents and potentially placing all residents at risk.
Failure to Notify POA of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) for a resident who was transferred to the hospital. The resident, who had diagnoses including chronic kidney disease stage 4, chronic obstructive pulmonary disease, chronic diastolic heart failure, and iron deficiency anemia, was admitted to the facility and later transferred to the hospital. The medical record indicated that the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and required varying levels of assistance with activities of daily living. A review of the resident's closed record showed that the POA was listed as the emergency contact. However, documentation revealed that when the resident was transferred to the hospital, the POA was not notified as required by facility policy. This was confirmed during an interview with the Director of Nursing, who acknowledged that the notification should have occurred. The facility's policy, revised in May 2017, states that a nurse will notify the resident's representative when a transfer to the hospital is necessary.
Failure to Notify Physician of Weight Gain and Inadequate Treatment of Non-Pressure Skin Alterations
Penalty
Summary
The facility failed to notify the physician of significant weight gain in a resident with congestive heart failure, despite clear discharge instructions from the hospital and facility policy requiring such notification. The resident experienced a weight increase of over 10 pounds within a week, as documented in the weight log, but there was no evidence that the physician was informed at any point. The Director of Nursing confirmed that the required notification did not occur. Additionally, the facility did not ensure that non-pressure skin alterations were treated according to physician orders for two residents. One resident with bilateral lower leg stasis dermatitis did not receive the recommended ammonia lactate application and daily ace wrap, as suggested by the wound consultant, due to the absence of corresponding physician orders. The Assistant Director of Nursing verified that the correct treatment was not provided as recommended. Another resident with multiple surgical incisions did not have dressings changed daily as ordered by the physician. Observations revealed that dressings had not been changed for three days, and the resident confirmed that only one dressing change was refused, with no staff offering to change the dressings on other days. Facility policy required that wound treatments be implemented as ordered, but this was not followed.
Failure to Accurately Document and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately document and treat pressure ulcers for three residents, resulting in deficiencies in pressure ulcer care. For one resident with multiple diagnoses including heart failure and pneumonia, the admission skin assessment did not include measurements or staging of a sacral pressure ulcer, and physician orders for wound care were not updated to reflect the wound nurse practitioner's recommendations. The Director of Nursing confirmed that the correct orders were not entered or administered, and that the admitting nurse did not properly assess the wound upon admission. Another resident was admitted with chronic ulcers and peripheral vascular disease, but no treatment orders were initiated until several days after admission. Additionally, there were conflicting physician orders for wound care on the left foot, which were not clarified. The Director of Nursing acknowledged the delay in initiating treatment and the presence of inconsistent orders for wound care. A third resident was admitted with a history of heart disease and a recent hip fracture. The admission assessment failed to capture multiple wounds, including a skin tear, surgical incision, and pressure injuries, and treatment orders were not put in place for these wounds. The Director of Nursing confirmed that the wounds were not documented on the admission assessment and that appropriate treatment orders were not established.
Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident with orthopedic aftercare needs and a recent fracture, the care plan required fall mats to be placed on both sides of the bed while the resident was in bed. However, during observation, the fall mats were found against the wall and not in position as required, despite a physician order and care plan specifying their use. A registered nurse confirmed that the mats should have been in place while the resident was in bed. Another resident, who had diagnoses including acute respiratory failure and required a wheelchair for mobility, was dependent on staff for transfers and had a care plan specifying the use of a bed enabler, floor mat, and perimeter air mattress for fall prevention. The resident experienced a fall when a CNA attempted a Hoyer lift transfer alone, contrary to facility policy and the resident's care plan, which required two staff members for such transfers. The CNA reported that the resident became agitated while waiting for assistance, leading her to proceed alone, and the resident slipped out of the Hoyer lift pad and fell to the floor. The incident was witnessed and documented, and the resident later reported pain, prompting further medical evaluation. Additionally, repeated observations showed that the resident's bed was not kept in the lowest position as required by the care plan, and this was confirmed by a licensed nurse. Review of facility policies indicated that two staff members are required for mechanical lift transfers and that fall prevention interventions should be implemented based on assessment results. These failures affected two of three residents reviewed for accidents or falls.
Failure to Administer Medications as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for a resident with multiple complex medical conditions, including chronic non-pressure ulcer, peripheral vascular disease, and cerebral infarction. Upon admission from the hospital, the resident had specific orders for Acetaminophen, Gabapentin, and Oxycodone, with detailed dosing schedules and indications for use. However, review of the medication administration records revealed discrepancies between the hospital discharge orders and the facility's transcription and administration of these medications. For example, Acetaminophen was administered more frequently than every 8 hours as ordered, and there were multiple, conflicting Gabapentin orders active at the same time, leading to confusion about the correct dosage and schedule. The resident, who had significant cognitive impairment and required daily administration of opioids, antiplatelets, and anticonvulsants, experienced a decline in condition during their stay. On one occasion, the resident was found to be non-responsive to commands, prompting assessment by a CNP and subsequent transfer to the emergency room. Hospital documentation indicated the resident was drowsy and had received pain medication earlier in the day, with Narcan administered for improvement. Interviews with facility staff, including the DON, confirmed that the medications were not transcribed or administered according to the hospital's orders, particularly regarding the timing and dosage of Acetaminophen and Gabapentin. Facility policy required medications to be administered in accordance with physician orders, including specified time frames, and for staff to consult with a physician if a dosage appeared inappropriate. Despite this, the facility did not ensure accurate transcription or administration of the resident's medications, resulting in significant medication errors. The deficiency was identified during a review of medical records, staff interviews, and hospital paperwork, and was confirmed by the DON.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records for multiple residents, resulting in discrepancies regarding code status, wound care documentation, and charting after discharge. For one resident with diagnoses including acute respiratory failure and COPD, the medical record contained conflicting information about code status. While the physician order and care plan indicated full code status, the resident had transitioned to hospice care with a DNRCC order, which was not promptly or clearly reflected in the records. The Director of Nursing was unable to confirm the resident's current code status during the interview, and the updated DNRCC documentation was only later found uploaded in the record. Another resident, who had been admitted with chronic conditions and later discharged after a hospital transfer, had progress notes entered by nursing staff documenting vital signs and health status on days after the resident had already left the facility. The DON confirmed that these entries were inaccurate, as the resident was not present in the facility at the time the notes were made. A third resident with multiple chronic conditions and pressure ulcers was seen by an outside wound nurse practitioner, but the assessment and treatment recommendations from that visit were never received or uploaded into the resident's medical record. The Assistant DON verified that the documentation should have been included to ensure the record was complete and accurate. These failures affected three of the ten residents reviewed for accurate medical record information.
Failure to Provide Meals as Ordered and Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure that residents received meals as ordered and needed, affecting 105 out of 110 residents. During an observation of the kitchen, it was noted that meal temperatures were not within the required range, with cold foods such as mechanical texture ham sandwiches and regular texture ham sandwiches being served above the acceptable temperature of 41 degrees Fahrenheit. Additionally, several residents did not receive the meals as indicated on their meal tickets. For instance, residents who were supposed to receive tomato soup and crackers did not receive them, nor did they receive an appropriate substitution. Interviews with residents revealed dissatisfaction with meal substitutions and inaccuracies, such as receiving chocolate ice cream instead of sherbet or not receiving the coleslaw they were expecting. The kitchen manager confirmed that there was a delay in the food truck delivery, which led to the substitution of macaroni salad for tomato soup, a substitution deemed inappropriate. The facility's policy requires consultation with the director of food and nutrition services for menu substitutions and mandates that substitutions be recorded, which was not adhered to in this instance.
Failure to Ensure Proper NG Tube Care for Resident
Penalty
Summary
The facility failed to ensure proper care for a resident receiving nutritional support through a nasogastric (NG) tube. The resident, who had a history of heart failure, hemiplegia, hemiparesis, dysphasia, and gastrostomy status, was readmitted to the facility with an NG tube after a hospital stay. Despite the physician's order to check the NG tube placement before administering formula, medication, or flushing the tube, this order was not re-entered into the resident's medication administration record (MAR) or treatment administration records (TAR) upon readmission. This oversight led to the resident not receiving the necessary verification of tube placement before medication administration, as confirmed by the Director of Nursing (DON). The deficiency was further highlighted by an incident where the resident was found unresponsive in a wheelchair, leading to emergency medical intervention and hospitalization. Additionally, the resident experienced a clogged NG tube and an elevated blood glucose reading, which required physician intervention due to the absence of current orders for hyperglycemia management. The facility's failure to ensure the reordering and documentation of the NG tube placement verification order contributed to the inadequate care provided to the resident.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in actual harm to three residents. Resident #54, with moderate cognitive impairment and high risk for pressure ulcer development, developed a Stage II pressure ulcer on the right buttock that progressed to a Stage III ulcer due to inadequate interventions. The facility did not provide timely and individualized care, such as applying prescribed treatments after incontinence episodes, which contributed to the deterioration of the resident's condition. Resident #163, with severe cognitive impairment and dependent on staff for care, developed an unstageable pressure ulcer on the sacrum. Despite being at high risk for pressure ulcers, the facility failed to create and implement an individualized prevention plan. The resident's condition was not adequately monitored, and the pressure ulcer was not identified until it became unstageable, indicating a lack of proactive skin assessment and intervention. Resident #89, who had a history of pressure ulcers and was at high risk, developed a new Stage III pressure ulcer on the right ischium due to malfunctioning pressure-relieving equipment. The facility failed to ensure timely replacement and proper functioning of the air mattress, leading to the resident's skin coming into contact with the metal bed frame. Additionally, there were multiple instances where prescribed wound care treatments were not administered as ordered, further contributing to the resident's skin breakdown.
Unsanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions, affecting 108 of 109 residents, as one resident was not eating by mouth. Observations revealed two large pools of sour-smelling liquid on the dietary department floor, one near the skilled dining room door and another in the dish room area. Fruit flies were seen flying over these puddles. Additionally, the walls behind the three-compartment sink and the beverage dispenser were dirty with dried food and beverage stains. Interviews with the Dietary Director and Maintenance Director confirmed the unsanitary conditions. The Dietary Director acknowledged the presence of the pools of liquid and the dirty walls, while the Maintenance Director identified a punctured hose in the three-compartment sink as the source of the leak leading to the standing water. The facility's sanitation policy, last revised in 2008, mandates that all kitchen and dining areas be kept clean and free from insects, with regular cleaning schedules to prevent grime accumulation.
Facility Lacks Qualified Social Worker for Over 120 Beds
Penalty
Summary
The facility failed to ensure a qualified social worker was on staff, despite having over 120 certified beds, which is a requirement. The deficiency was identified through a review of Resident Council meeting minutes, staff interviews, and examination of the Social Services Designee (SSD) #320's credentials and work history. SSD #320, who was introduced as the facility's new social worker, had a Master's degree in Social Work but had not passed the State licensing board exam and was not a licensed social worker at the time of the survey. SSD #320 confirmed she would not retake the exam until January 2025 and had not been supervised by a licensed social worker in her previous roles. The facility's job description for the Director of Social Services required a minimum of a Bachelor's Degree in Social Work, two years of supervisory experience in a medical facility, and registration as an Academy of Certified Social Workers (ACSW) member in good standing with the National Association of Social Workers (NASW). However, SSD #320's resume did not indicate she met these requirements. The Administrator acknowledged hiring SSD #320 with the knowledge that she had not yet obtained a social work license, expecting her to pass the exam in the summer of 2024, which she did not. This oversight had the potential to affect all 109 residents in the facility.
Ineffective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen, which had the potential to affect 108 of 109 residents, as one resident was not eating by mouth. Observations made on December 16, 2024, between 8:22 A.M. and 8:40 A.M. revealed standing pools of liquid, approximately three feet by three feet, on the dietary department floor next to the skilled dining room door and in the dish room area. These pools of liquid emitted a sour smell, and several fruit flies were observed flying over them. Additionally, fruit flies were seen on the clean silverware and dishes rack. An interview with the Dietary Director confirmed the presence of fruit flies in the dietary department. A review of the facility's Sanitation policy, dated 2001 and revised in October 2008, indicated that all kitchen and dining areas should be kept clean and free from pests such as rodents, roaches, flies, and other insects.
Inadequate Supervision and Safety Device Failures in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, as evidenced by inadequate supervision and malfunctioning safety devices. Resident #17, who had multiple medical conditions including hemiplegia and dependence on a wheelchair, was observed smoking unsupervised, resulting in a cigarette burn on his clothing. Despite the facility's smoking policy requiring assessments and supervision for residents who smoke, there were no documented smoking assessments for Resident #17, and the care plan inaccurately stated that he did not require supervision. Resident #56, with a history of multiple health issues including dementia and schizophrenia, was also found to be smoking unsupervised, with burn holes observed on his clothing and personal items. The facility's policy required that smoking materials be kept by staff and that residents be supervised while smoking, yet Resident #56 had smoking materials in his room and was not being supervised. No smoking assessments were documented for Resident #56, contrary to the facility's policy. Additionally, the facility failed to ensure the proper functioning of wanderguard alarms for Residents #27 and #87, both of whom were at risk for elopement. The wanderguard for Resident #27 was not checked for functionality as required, and staff were unable to locate the device needed to test it. Similarly, Resident #87, who had previously eloped, had a wanderguard that was not consistently verified for functionality. These lapses in safety measures and supervision highlight significant deficiencies in the facility's adherence to its own policies and procedures designed to prevent accidents and ensure resident safety.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medical supplies were properly managed, leading to potential risks for residents. During an observation in the medication room on the 100 unit, it was found that a box of vacutainers with 22-gauge needles was expired, and the reference number on the needles did not match the box. Additionally, prefilled sodium chloride syringes were also expired. A Licensed Practical Nurse (LPN) confirmed the presence of these expired items during a review of the medication storage room. On the 400 unit, an unlocked medication cart was observed unattended in the hallway, with no staff visible nearby. The LPN assigned to the cart was found at the nurse's station and later entered the medication storage room, leaving the cart unlocked and out of sight. The LPN confirmed that the cart was supposed to be locked when not in use or in direct sight. The Unit Manager confirmed the incident and provided education to the LPN regarding the facility's policy on medication storage.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide dignified living conditions for two residents, as observed in separate incidents. Resident #49, who has intact cognitive status, reported witnessing another resident exposing himself and engaging in inappropriate behavior from his room across the hallway. Despite reporting these incidents to management, Resident #49 was told to 'deal with it' and close her door, which she found undignified. The facility's policy on resident rights emphasizes the need for residents to be treated with courtesy, respect, and dignity, which was not upheld in this situation. In another incident, Resident #81, who has a severe cognitive deficit and is dependent on staff for activities of daily living, was observed lying in bed without clothing, with a soiled incontinence brief visible from the hallway. This was confirmed by a Licensed Practical Nurse. The facility's policy on resident rights was again not adhered to, as the resident was not treated with the dignity and respect outlined in the policy. These observations highlight a failure to maintain the dignity of residents as required by the facility's own policies.
Deficiencies in Resident Financial Access and Guardianship
Penalty
Summary
The facility failed to provide timely access to social security benefits for a resident with intact cognition, who had been requesting access since March 2024. The resident needed the funds to purchase preferred toiletry items. The facility lacked a Business Office Manager, and the Administrator was unsure how to assist the resident in obtaining a state identification card due to her transient status. The resident's social security benefits had stopped because the Social Security office was unaware of her location. Eventually, the Admissions Director assisted the resident in contacting Social Security to reroute her benefits to the facility. Another resident, with multiple diagnoses including cognitive impairment, did not have a Power of Attorney or guardianship in place. A volunteer guardian evaluated the resident but deemed guardianship unnecessary. The resident's Payee, who managed financial matters and appointments, informed the facility of the need for guardianship, but the facility lacked a Licensed Social Worker and was unaware of the guardianship process. The resident's primary care physician had not been involved in determining the need for guardianship.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to ensure an accurate code status for a resident, leading to a deficiency in honoring the resident's right to request, refuse, and/or discontinue treatment. The resident, who had intact cognition at the time of admission, was initially documented as full code. However, upon admission to hospice services, a Do Not Resuscitate (DNR) order was completed, indicating a change in the resident's code status. Despite this, the facility did not update the resident's code status in the medical records, both in the hard chart and the electronic medical record, to reflect the DNR status. The Assistant Director of Nursing (ADON) confirmed that the resident's Durable Power of Attorney (DPOA) had agreed to the change in code status, and the hospice nurse had provided the DNR order to the physician for signing. However, the facility staff failed to review the admission paperwork and follow up to confirm the resident's code status change. The facility's policy required that a DNR form be completed and signed by the attending physician and placed in the front of the resident's medical record, which was not done in this case.
Failure to Provide Required Transfer Notices and Appeal Information
Penalty
Summary
The facility failed to provide written transfer notices and inform residents or their families of their rights regarding hospitalization for three residents. Resident #41, who had multiple chronic conditions, was hospitalized several times, but only one transfer notice was documented, which lacked essential information such as appeal rights and contact details. The Administrator confirmed that no other transfer notices were completed for Resident #41's hospitalizations, and the resident confirmed not receiving any transfer notice. Resident #76, diagnosed with various conditions including hemiplegia and diabetes, was hospitalized multiple times. Although some transfer notices were completed, they did not include required information like appeal rights or contact information. The Administrator admitted that the facility only submits transfer notices when a resident is discharged from the facility, and the resident's daughter confirmed the lack of written transfer documentation. Resident #106, with a history of osteomyelitis and diabetes, was transferred to a hospital due to altered mental status. The transfer report did not include necessary information about the right to appeal the transfer or contact details for the State entity and Ombudsman. The Administrator acknowledged that the facility did not complete transfer notices for all facility-initiated transfers, including emergency transfers, as required by federal regulation.
Failure to Provide Bed Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide bed hold notices to inform residents or their families of their rights regarding the retention of their room and bed during hospitalizations. This deficiency was identified for two residents out of three reviewed for hospitalizations. Resident #41, who had multiple complex medical conditions including chronic respiratory failure and diabetes, was hospitalized several times throughout the year. Despite the facility's policy requiring written notice of bed hold rights at the time of transfer, the medical record for Resident #41 contained an undated and unsigned notice lacking essential information. Interviews with the interim Director of Nursing revealed that the notices were incomplete and could not be located, and Resident #41 expressed frustration over the lack of communication regarding her room reassignment during hospitalization. Similarly, Resident #76, who also had multiple health issues such as hemiplegia and chronic kidney disease, experienced several hospital stays without receiving any bed hold notices. An interview with Resident #76's daughter confirmed that the family did not receive any written documentation regarding bed hold rights. The facility's Administrator acknowledged that bed hold notices were not completed or provided to residents or families, which violated the terms of the Admissions Agreement and regulatory requirements. This omission deprived residents and their representatives of the opportunity to make informed decisions regarding care and bed retention during hospitalizations.
Inaccurate and Untimely Resident Assessments
Penalty
Summary
The facility failed to conduct accurate and timely assessments of residents' functional capacities, affecting multiple residents. Resident #27, who had a wanderguard in place due to elopement risk, was inaccurately assessed in the quarterly MDS as not using physical restraints or wander alarms, despite having an order and care plan for the wanderguard. MDS nurse #356 confirmed that the wanderguard was not considered a restraint, leading to the incorrect assessment marking. Resident #87 experienced a significant weight change that was not accurately documented in the MDS. The facility's process for calculating weight gain was flawed, as it used the lowest and highest weights within a month rather than following the RAI manual's instructions. Additionally, Resident #220's admission MDS was not completed within the required timeframe, as it was still in progress beyond the 14-day submission deadline. These deficiencies highlight the facility's failure to adhere to assessment protocols, potentially impacting resident care.
Failure to Complete Accurate Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete accurate significant change Minimum Data Set (MDS) 3.0 assessments for two residents, affecting their care documentation. Resident #97, who was admitted to hospice services with a diagnosis of cerebral atherosclerosis, had an MDS assessment that did not reflect their hospice status. This oversight was confirmed by MDS Nurse #356, who acknowledged the inaccuracy of the assessment. Additionally, the facility lacked a specific MDS policy, relying instead on the Resident Assessment Instrument (RAI) guidelines, as confirmed by Regional Nurse #504. Similarly, Resident #163, who had multiple medical diagnoses and was admitted to hospice services, did not have a significant change MDS assessment completed to reflect this change. Despite a progress note indicating a hospice referral and subsequent admission, the MDS assessment failed to document the resident's hospice status. This deficiency was verified by the Interim Director of Nursing (IDON), who confirmed that the required significant change MDS assessment was not completed.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals to a resident, identified as Resident #163, who was unable to perform activities of daily living independently. The resident had a complex medical history, including conditions such as gastrostomy malfunction, asthma, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, syncope, repeated falls, cerebrovascular accident with left-sided hemiplegia, anxiety disorder, dysphagia, aphasia, hypertension, and hypothyroidism. The resident's care plan indicated a need for extensive to dependent assistance with various activities, including eating, due to a self-care performance deficit related to a cerebrovascular accident. Despite these needs, the resident's breakfast tray was observed untouched for over 30 minutes, indicating a lack of timely assistance. The deficiency was further highlighted during an interview with a Certified Nursing Assistant (CNA), who confirmed that due to staffing cuts, there was insufficient time to assist the resident with meal setup promptly. The facility's policy on ADL support, which mandates providing necessary services to maintain or improve residents' ability to carry out daily activities, was not adhered to in this instance. This lapse in care resulted in the resident not receiving the required assistance with meals, as evidenced by the untouched breakfast tray and the resident's acknowledgment of hunger.
Failure to Monitor and Address Resident Conditions
Penalty
Summary
The facility failed to treat and monitor conditions for two residents according to professional standards of practice. Resident #85, who was admitted with diagnoses including chronic heart failure and chronic kidney disease, experienced a significant weight gain of 24.6 pounds over thirty days, indicative of edema. Despite the resident's complaints about discomfort from edema in his lower extremities, there were no physician orders for diuretics or treatments for edema. Interviews with the resident, an LPN, and a dietitian revealed that the weight gain and edema were not addressed with the physician or documented in the medical chart, contrary to the facility's policy requiring notification of significant changes in a resident's condition. Resident #87, admitted with conditions such as end-stage renal disease and atrial fibrillation, was on anticoagulant therapy. The care plan included monitoring for signs of abnormal bleeding, but there was no specific order for monitoring skin for bruising or bleeding. Observations revealed a bruise on the resident's forearm, which was not documented in the medical record or incident log. Interviews with nursing staff confirmed that there was no documentation of the bruise, and the facility lacked a comprehensive policy for monitoring non-pressure skin issues, focusing only on pressure ulcers.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Grove Transitional Care | 4.1 mi | ★★★★★ | 0 | 0 |
| Monterey Care Center | 4.2 mi | ★★★★★ | 13 | 0 |
| Scioto Pointe | 4.7 mi | ★★★★★ | 22 | 0 |
| West Park Care Center Llc | 5 mi | ★★★★★ | 11 | 0 |
| Embassy Of Woodview | 5 mi | ★★★★★ | 32 | 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.