Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shady Lawn Nursing Home during CMS and state inspections, most recent first.
A resident with a history of drug-seeking behavior accessed an unsecured staff purse at the nurses' station, ingested a large quantity of stimulant medication, and experienced a significant decline in condition. Staff failed to promptly recognize and report the change in condition, resulting in delayed transfer to the ER. The resident was later hospitalized, required CPR and intubation, and died after being transitioned to palliative care. The facility's failure to secure staff belongings and timely report condition changes led to neglect and actual harm.
A resident with a history of dysphagia and hypertension experienced multiple episodes of emesis, decreased fluid intake, and respiratory distress. Despite critical changes in vital signs and abnormal chest x-ray findings, staff failed to notify the physician or family or provide additional interventions. The resident was later found without vital signs, and interviews confirmed that required notifications and documentation were not completed.
Three residents experienced harm due to the facility's failure to implement individualized and effective pressure ulcer prevention and treatment, including the use of improperly sized incontinence briefs, delays and omissions in prescribed wound care, and lack of necessary wound care supplies. Staff did not consistently follow physician orders or ensure appropriate interventions, resulting in the development and worsening of pressure ulcers.
Surveyors found multiple expired food items and improperly stored pork in the facility's kitchen and nourishment areas. The Dietary Manager confirmed that expired foods and improperly wrapped meat were present, despite facility policies requiring daily and weekly checks and proper food rotation.
The facility was not administered in a way that ensured effective use of resources or the highest practicable well-being of all residents. Surveyors found neglect resulting in Immediate Jeopardy and actual harm, delays in care due to insufficient staffing, failure to address changes in condition, lack of assistance with outside appointments and alternate placement, poor infection control, unavailable care equipment, and inadequate wound and bariatric care, despite the facility's stated capabilities.
Staff did not follow infection control protocols by using personal equipment for a resident on droplet isolation for strep pharyngitis, failing to clean equipment properly, and neglecting hand hygiene after resident care. Facility policy required dedicated or disposable equipment and proper disinfection, but staff interviews and observations confirmed these practices were not followed.
A facility failed to secure an exit door equipped with a malfunctioning keypad and wanderguard system, allowing residents with severe cognitive impairment and a history of wandering to access an unsecured parking lot and busy highway. Maintenance and nursing staff confirmed the door's inconsistent locking and lack of alarm, and no staff were present to monitor the area, despite facility policy requiring supervision and functioning alarms for residents at risk of elopement.
Two residents discharged from skilled services were not given the required written Notice of Medicare Non-coverage (NOMNC) despite having benefit days remaining. Record review and staff interview confirmed the absence of these notifications for both individuals with complex medical conditions.
Two residents with cognitive capacity and specific activity preferences did not have their activity care plans reviewed or updated to reflect changes in their interests or participation. The Activities Director confirmed that care plans had not been revised for an extended period, and there was no documentation of changes in the residents' medical records, contrary to facility policy requiring ongoing assessment and updates.
The facility did not provide individualized activities to meet the needs and preferences of two residents, both of whom were cognitively intact and dependent on staff for engagement. Activities were often canceled, repetitive, or not tailored to resident interests, and outings were limited due to transportation constraints. The activities director did not document participation or changes in preferences, and one-on-one activities were not offered, resulting in unmet psychosocial needs.
A resident with respiratory failure and pneumonia was observed receiving oxygen at a flow rate higher than the physician-ordered two to three liters per minute. Multiple observations confirmed the oxygen was set at four liters, and an LPN verified this did not match the physician's order. Facility policy required oxygen to be administered as ordered by a physician.
A resident with multiple chronic conditions was prescribed Trazodone for insomnia without a corresponding diagnosis documented in the medical record, as required for psychotropic medications. Although the physician later agreed to add the diagnosis, it was not entered into the record in a timely manner, and staff confirmed the pharmacy's recommendation was not promptly addressed.
A resident with anxiety disorder did not have their psychotropic medication, Vistaril, decreased as ordered by the physician, despite a signed order and facility policy requiring gradual dose reductions. The medication dose remained unchanged for two months before being discontinued, and the DON confirmed the order to decrease the dose was not followed.
Two residents were affected by deficiencies: one experienced unclean conditions around a tube feeding pole, with dried nutritional supplement residue observed and confirmed by staff and family, while another non-smoking resident was exposed to cigarette smoke in her room due to the proximity of the smoking area and the design of the room's ventilation system, despite staff awareness and prior attempts to address the issue.
The facility failed to ensure psychotropic medications were necessary before administration, did not monitor their efficacy, and did not comprehensively assess for side effects. Two residents, one with severe cognitive impairment and another with schizoaffective disorder, were affected by lack of documentation regarding medication use, behavioral monitoring, and required assessments, contrary to facility policy.
Two residents dependent on staff for ADLs did not receive adequate assistance with hygiene and grooming. One resident, with significant physical and cognitive needs, did not receive showers as ordered due to equipment and transfer challenges, resulting in incomplete hygiene care. Another resident with cognitive impairment and behavioral issues was repeatedly found in unsanitary conditions, with no individualized care plan to address behaviors affecting cleanliness. Staff confirmed these deficiencies, and facility policy requirements for hygiene and grooming were not met.
Two residents with indwelling urinary catheters did not receive comprehensive and individualized care, as required. For both, there were no physician orders or care plans addressing catheter care, and documentation of catheter care was absent or outdated. Staff confirmed these omissions, and observations revealed issues such as lack of catheter site security and redness. The facility's own policy requiring catheter care every shift was not followed.
A scheduled LPN arrived late, left her assigned unit multiple times, and was eventually sent home, resulting in another LPN taking over and administering medications several hours late to multiple residents. This led to delayed administration of critical medications for residents with complex medical needs, as confirmed by staff and resident interviews and medication records.
A resident with lymphedema, Milroy's disease, and other complex conditions did not receive timely transition of care assistance from social services, resulting in a significant delay in referrals to facilities better equipped to meet their needs. Despite repeated requests from the resident's representative and a physician's order for referrals, the facility did not initiate the process for nearly three months, impacting the resident's access to appropriate care.
A controlled medication, Ativan, prescribed for a resident with neurocognitive disorder, was improperly administered to another resident. The DON confirmed that the medication was signed out for one resident but given to another by an LPN, with no documentation in either medical record. Facility policy required use of the contingency box if medication was unavailable, but this was not followed.
A resident with multiple medical and behavioral diagnoses, who was dependent for ADLs and required bariatric care, was not transported to scheduled medical appointments because local transportation companies could not accommodate bariatric transfers. Despite reminders from the resident's family and documentation in the facility assessment that bariatric care was provided, the facility did not ensure the resident attended necessary outside appointments.
A resident with multiple diagnoses and intact cognition was not offered the influenza vaccine as required, and there was no documentation of consent or refusal in the medical record. Facility policy mandates annual offering and proper documentation, but staff were unable to locate any related information for this resident.
Several residents with intact cognition and multiple medical conditions were not offered the COVID-19 vaccine, and the facility could not provide documentation of vaccine consent or refusal as required by policy. Interviews confirmed the absence of necessary records for these individuals.
A resident with complex medical and mobility needs was unable to be safely transferred or evacuated from his room due to the lack of appropriate bariatric equipment and a bed that was too wide to fit through the doorway. Multiple staff, including the DON, LPN, CNA, and physician, confirmed that the available Hoyer lift and lift pad were inadequate, and the resident could not be moved in the event of an emergency.
The facility failed to ensure that a resident on an anticoagulant was monitored and treated timely for bruising. Despite documented bruises on multiple occasions, there was no evidence that the physician was notified. Interviews with LPNs confirmed lapses in monitoring and reporting, and the DON acknowledged the deficiencies.
The facility failed to document wound care treatments for a resident with multiple severe wounds on two specific dates in March 2024. Despite performing the treatments, the staff did not sign off on the Treatment Administration Records (TAR) as required, leading to non-compliance with the facility's policies.
Failure to Secure Staff Belongings and Timely Report Change in Condition Resulting in Resident Death
Penalty
Summary
The facility failed to ensure that staff belongings, specifically prescription medication, were properly secured and inaccessible to residents. A resident with a history of drug use and drug-seeking behavior, residing on a secured behavior unit, was able to access a CNA's unsecured purse left at the nursing station. The resident obtained and ingested up to 20 tablets of Adipex, a stimulant medication, without staff knowledge. The purse was left in an area that was not secured, and the CNA did not have access to a designated secure area for personal belongings on the unit. Following the ingestion, the resident began to display significant changes in condition, including confusion, inability to stand or walk, rapid pulse, and hypertension. These changes were first noted at 7:40 A.M., but the response from nursing staff was delayed. The resident was not transferred to the emergency room until several hours later, despite ongoing and worsening symptoms such as shortness of breath, decreased oxygen saturation, and further decline in mobility and mental status. Documentation of the resident's condition and the actions taken was also delayed, with several progress notes entered as late entries. The resident was eventually transported to the hospital, where she required CPR and intubation and was found to have amphetamines in her system. She was admitted to the ICU with pneumonia and subsequently died after being transitioned to palliative care. The facility's failure to secure staff belongings and to promptly recognize and report the resident's change in condition resulted in resident neglect and actual harm, including the resident's death.
Failure to Provide Timely Medical Intervention After Acute Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to timely identify and obtain medical intervention for a resident following an acute change in condition. The resident, who had diagnoses including dysphagia and hypertension and required assistance with activities of daily living, was admitted with no terminal condition noted. Physician orders included increased fluid intake for dehydration and monitoring of fluid intake, but documentation of actual fluid intake was lacking. The resident experienced multiple episodes of emesis, decreased fluid intake, and adventitious lung sounds, yet there was no evidence that the physician or family were notified or that effective interventions were initiated at that time. On the day prior to the resident's death, staff documented further emesis, possible aspiration, and crackles throughout the lung fields. Orders were received for anti-emetic medication, a clear liquid diet, and intravenous fluids, and a STAT chest x-ray was ordered at the request of the resident's daughter. The x-ray, performed overnight, showed bilateral pulmonary infiltrates and cardiomegaly. At 1:07 A.M., the resident was found to have labored breathing, a respiratory rate of 39, oxygen saturation of 60% on oxygen, no obtainable blood pressure, and a heart rate of 39. Despite these critical findings, there was no documentation that the physician or family were notified, and no additional interventions were provided. There was no further documentation between 1:13 A.M. and 6:02 A.M., when the resident was found without vital signs. Interviews with facility leadership and medical providers confirmed that the nurse did not notify the physician or family of the resident's acute change in condition, as required by facility policy. The lack of timely notification and intervention following the resident's significant change in status resulted in actual harm.
Failure to Provide Comprehensive Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, effective, and individualized pressure ulcer prevention and treatment program for three residents, resulting in the development and worsening of pressure ulcers. One resident, who was morbidly obese, incontinent, and dependent on staff for bed mobility and toileting, developed a dark purple, non-blanchable suspected deep tissue injury to the right posterior thigh. This injury was attributed to the use of incontinence briefs that were too small and fastened tightly, despite physician orders for the brief to remain unfastened while in bed. Staff did not measure residents for appropriate brief sizes, and the largest available size was still inadequate. Documentation indicated that the order to leave the brief unfastened was signed as completed, but observations and interviews revealed that staff routinely fastened the brief, contributing to ongoing skin breakdown and pain for the resident. Another resident, who was cognitively impaired, developed an unstageable pressure ulcer to the right buttock. The initial wound was identified as an abrasion, but it progressed to an unstageable ulcer without evidence of individualized or effective interventions to prevent its development. Although a wound care nurse practitioner recommended a specific treatment regimen, there was a delay in ordering and implementing the treatment, and staff continued to apply the previous, less appropriate treatment. Additionally, there were multiple documented instances where the prescribed wound care was not completed as ordered. A third resident with paraplegia and obesity had multiple pressure ulcers, including a Stage IV ulcer and new suspected deep tissue injuries. The resident's care plan included wound treatments and preventative interventions, but there were issues with the availability of necessary wound care supplies. On at least one occasion, the required Triad cream was not available, and an alternative treatment was used instead, despite documentation indicating the prescribed treatment was completed. Staff interviews confirmed frequent shortages of wound care supplies and inconsistent ordering practices, leading to lapses in appropriate wound care.
Expired and Improperly Stored Food Found in Facility
Penalty
Summary
Surveyors observed that the facility failed to properly store and discard expired food items in accordance with professional standards and facility policy. During a walk-through of the kitchen and nourishment areas, several expired food items were found, including four bags of carrots, a bag of English muffins, a loaf of bread, and a carton of nutritional supplement. Additionally, a sheet pan containing pork was found in the walk-in cooler with foil loosely covering it, exposing the contents to air. The pork was dated several days prior to the observation. Interviews with the Dietary Manager confirmed the presence of expired foods and the improperly wrapped pork. The Dietary Manager acknowledged that all staff were expected to check food stock daily to remove expired items and that unit refrigerators were to be checked weekly. Review of the facility's policy indicated that expired items must be discarded on the expiration date and not used for consumption, and that food should be rotated using the first in, first out (FIFO) method. Despite these policies, expired and improperly stored foods were present in areas accessible for resident consumption.
Failure to Administer Facility to Ensure Resident Well-Being and Resource Use
Penalty
Summary
The facility failed to be administered in a manner that enabled effective and efficient use of its resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Survey findings included situations of neglect resulting in Immediate Jeopardy and actual harm to residents. Additional deficiencies were identified, such as failure to address and report changes in resident condition in a timely manner, unmet staffing needs leading to delays in care, lack of assistance for residents to attend outside service appointments, and failure to help residents find alternate placement when the facility could not meet their needs. Infection control practices were not followed, and necessary equipment and supplies for resident care were not available to staff. Further observations revealed that comprehensive wound care was not provided, and appropriate care and services for bariatric residents were lacking, despite the facility's assessment indicating the ability to provide such services. The Administrator, responsible for day-to-day operations, confirmed being notified of all incidents and concerns. Review of the Administrator's job description emphasized responsibilities for ensuring safety regulations, maintaining the facility in good repair, and ensuring residents receive necessary care and services as defined by comprehensive assessments and care plans.
Failure to Provide Dedicated Equipment and Maintain Infection Control for Resident on Isolation
Penalty
Summary
Staff failed to maintain proper infection control practices and did not provide dedicated equipment for a resident on droplet isolation due to streptococcal pharyngitis. The resident, who was cognitively intact but dependent for bed mobility, was placed on droplet precautions per physician orders, with instructions for all care and activities to occur in the resident's room. Facility records indicated that 19 residents were on some form of isolation, and these residents were located throughout the facility. Observations and interviews revealed that staff, including LPNs, used their own personal equipment such as blood pressure cuffs, stethoscopes, thermometers, and pulse oximeters for resident assessments, as the facility did not provide these items. During a vital sign assessment for the resident on isolation, an LPN used personal equipment without cleaning it prior to use, placed the used equipment on top of an isolation cart containing PPE supplies, and performed inadequate cleaning of the equipment after use. The LPN did not allow for the required disinfectant contact time and did not perform hand hygiene after removing PPE or before leaving the resident's room. Interviews with the DON, infection preventionist, and other staff confirmed that the facility did not supply dedicated or disposable equipment for residents on isolation, and that staff routinely used personal equipment. Facility policy required the use of disposable or dedicated equipment for residents on transmission-based precautions and specified proper cleaning and hand hygiene procedures, which were not followed in practice.
Failure to Secure Exit Door for Residents at Risk of Elopement
Penalty
Summary
The facility failed to ensure that exit doors were properly secured to prevent residents at risk for elopement from exiting the building unassisted. Observations revealed that door #5, located in an area not visible from nursing stations or busy areas, was accessible to residents and could be opened to the outside without triggering an alarm. The door was equipped with both a keypad and a wanderguard system, but neither functioned as intended. The keypad had been nonfunctional for over a week, and the wanderguard system did not lock or alarm when tested with a bracelet identical to those worn by at-risk residents. Maintenance staff confirmed the door's inconsistent locking and lack of alarm, and that the door led directly to an unsecured parking lot and a busy highway. No staff were present to monitor the door during these observations. Record review and interviews confirmed that at least ten residents, including one with severe cognitive impairment and a history of wandering and elopement risk, resided outside the secured unit and had access to the unsecured door. The care plan for this resident included the use of a wanderguard device, and staff reported that the resident frequently attempted to open exit doors. The facility's policy required that residents at risk for elopement receive adequate supervision and that door alarms and locks be maintained to prevent accidents. Despite this, the malfunctioning door and lack of staff monitoring created a situation where residents at risk for elopement could have exited the facility undetected.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide required written notification to residents discharged from skilled services regarding the end of their Medicare coverage. Specifically, two residents with multiple diagnoses, including hyperlipidemia, dementia, hypertension, morbid obesity, diabetes, kidney disease, and dysphagia, were discharged from Medicare Part A covered stays while still having benefit days remaining. Record review showed no evidence that a Notice of Medicare Non-coverage (NOMNC) was issued to either resident. The facility's beneficiary notice list confirmed these discharges occurred within the last six months, and an interview with the Social Service Designee verified that there was no documentation of the NOMNC forms being provided.
Failure to Update and Revise Activity Care Plans
Penalty
Summary
The facility failed to ensure that care plans for activities were reviewed and revised as required for two residents. For one resident with an anxiety disorder, the care plan had not been updated since January of the previous year, despite the resident expressing dissatisfaction with the repetitive nature of activities and a desire for more challenging options, such as going for drives and enjoying new scenery. The resident was cognitively intact and had specific interests, but these preferences were not reflected in the most recent care plan. The Activities Director confirmed that there was no documentation of changes in participation or preferences in the resident's medical record. Another resident, with diagnoses including depression, hypertension, diabetes, schizoaffective disorder, insomnia, sleep apnea, and anxiety, also had a care plan that had not been updated since October of the previous year. This resident was cognitively intact and valued going outside and participating in favorite activities, but there was no evidence that the care plan had been revised to reflect any changes in interests or participation. The Activities Director acknowledged that care plans were only updated at scheduled conferences or when changes were noted, and could not provide evidence of recent updates for this resident. Facility policy requires ongoing assessment and updating of activity care plans based on residents' interests and needs.
Failure to Provide Individualized and Documented Activities for Residents
Penalty
Summary
The facility failed to provide individualized activities to meet the needs and preferences of its residents, as required by policy. For one resident with anxiety disorder and cognitive intactness, the care plan indicated a need for encouragement to participate in activities of interest, with a wide range of preferred activities such as crafts, music, outings, and computer-related tasks. However, observations revealed that scheduled activities were canceled or not conducted as planned, and the activities that did occur were repetitive and not challenging, leading to resident dissatisfaction. The resident expressed that activities were monotonous and that outings, which she enjoyed, were not made available to her, especially due to limitations with wheelchair accessibility on the facility van. Another resident with depression, schizoaffective disorder, and other chronic conditions was also dependent on staff for activities and social interaction. His care plan included encouragement for group activities, pet visits, and outings, with a particular interest in going outside and fishing. Despite these documented preferences, the activities director confirmed that one-on-one activities were not provided, outings were infrequent, and there was no evidence of the resident's participation in activities for several months. The director also stated that most activities for residents requiring one-on-one attention were limited to watching TV or coloring. Documentation practices were also deficient, as the activities director admitted to not recording activity participation or changes in resident preferences in the medical records for years. Attendance was tracked informally, and there was no documentation of individualized activity engagement or adjustments based on resident feedback. These failures affected at least two residents reviewed and were observed during a census of 77 residents.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident with acute and chronic respiratory failure, hypoxia, anxiety, congestive heart failure, and pneumonia. The physician had ordered oxygen via nasal cannula at two to three liters per minute every shift, and the resident's care plan included interventions to provide oxygen as ordered and to monitor oxygen saturation. However, during multiple observations, the resident's oxygen was found to be set at four liters per minute, exceeding the prescribed amount. This was confirmed by an LPN, who acknowledged that the oxygen flow rate did not match the physician's order. The facility's policy required oxygen to be administered only as ordered by a physician, except in emergencies.
Failure to Timely Address Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were addressed in a timely manner. A resident with multiple diagnoses, including major depressive disorder, dementia, hypertension, hypothyroidism, type 2 diabetes, malignant neoplasm of the pituitary gland, dysphagia, anxiety, and vitamin D deficiency, was prescribed Trazodone 25 mg at bedtime. The pharmacy identified that Trazodone was ordered for insomnia, but the resident did not have a documented diagnosis of insomnia, which is required for the use of psychotropic medications. Although the physician later agreed to add the diagnosis of insomnia, the medical record did not reflect this addition as of the review date. Facility staff, including a registered nurse, confirmed that the pharmacy's recommendation was not addressed promptly and the necessary diagnosis was not documented in the resident's medical record, contrary to facility policy.
Failure to Decrease Psychotropic Medication as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's psychotropic medication, Vistaril (hydroxyzine pamoate), was decreased as ordered by the physician. The resident, who had a diagnosis of anxiety disorder and was cognitively intact, had been receiving Vistaril 25 mg at bedtime. A consultant pharmacy recommendation was made to attempt a gradual dose reduction, and the physician accepted this recommendation, modifying the order to decrease the dose to 12.5 mg at bedtime for anxiety. This order was signed and dated by the physician. Despite the physician's order to decrease the medication, review of the Medication Administration Record (MAR) for the following two months showed that the Vistaril dose was not reduced as directed. The medication was only discontinued later, rather than being tapered as ordered. The Director of Nursing confirmed that the dose reduction order was not implemented and acknowledged that the medication should have been decreased according to the physician's instructions. Facility policy required the use of the lowest possible dose of psychotropic medications and gradual dose reductions unless clinically contraindicated, but this was not followed in this instance.
Failure to Maintain Cleanliness of Medical Equipment and Provide Smoke-Free Environment
Penalty
Summary
Surveyors identified that a resident with severe cognitive impairment, quadriplegia, and multiple complex medical conditions, including a feeding tube, was living in an environment that was not maintained in a clean and sanitary manner. Observations on multiple occasions revealed that the resident's tube feeding pole had a dried brown substance, consistent with dried Nutren, on the feet of the pole. The family reported scraping dried substances off the floor near the pole, and an LPN confirmed the presence of the dried substance. These findings indicate that the equipment and surrounding area used for enteral feeding were not kept clean as required. Additionally, another resident with paraplegia, who was cognitively intact and dependent on a wheelchair, reported that the designated smoking area for residents was located outside her window. She stated that cigarette smoke entered her room through the heating/air conditioning unit, causing the smell to permeate her clothing and leaving black spots. Despite the administrator's request for residents to smoke further away, observations confirmed that multiple residents continued to smoke near her window, and staff verified that the room's ventilation system drew in outside air, including cigarette smoke, when in use.
Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were necessary prior to administration, did not monitor the efficacy of these medications, and did not comprehensively assess residents for side effects. For one resident with severe cognitive impairment and multiple diagnoses including major depressive disorder and dementia, there was a lack of documentation regarding behaviors that would warrant the use of Ativan, as well as no record of the medication being administered or its effects, despite staff statements indicating it was given. The facility's policy required adequate indication for use and documentation of medication effects, which was not followed in this case. Another resident with diagnoses including depression, schizoaffective disorder, and anxiety had not received a quarterly Abnormal Involuntary Movement Scale (AIMS) assessment since the previous year, despite being on antipsychotic medication known to cause tardive dyskinesia. The resident exhibited behavioral issues, but there was inconsistent documentation of these behaviors to monitor the efficacy of the prescribed psychotropic medications. The Director of Nursing confirmed these lapses in monitoring and documentation, which were contrary to facility policy.
Failure to Provide Adequate ADL Assistance and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) and maintain proper hygiene and grooming for two residents who required such care. One resident with lymphedema, autism, ADHD, and expressive language disorder was dependent for ADLs and weighed 544 pounds. Despite physician orders for regular showers to prevent skin breakdown, documentation showed the resident received showers less frequently than ordered. Staff interviews confirmed that multiple staff were needed for transfers, the shower bed did not fit properly in the shower room, and the resident could not be fully cleaned during showers. The resident experienced pain and shearing injuries during transfers, and the physician's orders were changed due to these difficulties, but the resident still did not receive showers as ordered. Another resident with a history of intracranial injury, psychosis, Alzheimer's disease, and impaired cognitive processes was observed in unsanitary conditions on multiple occasions. The resident's room and bathroom had visible smears of stool and blood, soiled linens, and personal hygiene was neglected, as evidenced by impacted fingernails and open sores from skin picking. Staff confirmed the resident was a 'picker' and often smeared stool and blood throughout the room. The care plan did not address these behaviors, and staff interviews revealed that while the resident received some hygiene care on scheduled days, there was no individualized plan to manage the behaviors affecting cleanliness and hygiene. Facility policy required that residents unable to perform ADLs receive necessary services to maintain hygiene and grooming, but observations, record reviews, and staff interviews demonstrated that these standards were not met for the two residents. The lack of individualized care planning and failure to follow physician orders for hygiene contributed to the deficiencies observed.
Failure to Provide Comprehensive Catheter Care and Documentation
Penalty
Summary
The facility failed to provide comprehensive and individualized treatment and maintenance plans for residents with indwelling urinary catheters, as evidenced by the care of two residents. For one resident, medical records showed an indwelling catheter was reinserted following a urology appointment, but there were no corresponding physician orders for catheter care or documentation of catheter care in the Treatment Administration Record (TAR) for several months. Observations revealed the resident had a catheter in place with visible urine and sediment, and the insertion site was slightly red. Staff interviews confirmed the absence of catheter care orders, lack of daily documentation of urine output, and that the catheter was not properly secured. Nursing staff acknowledged that catheter care orders and documentation should have been present and that the catheter should not have been clamped after placement. For the second resident, medical records indicated the presence of a suprapubic catheter and multiple diagnoses related to urinary retention and bladder disorders. However, there were no physician orders for catheter care, and the resident's care plan did not address catheter care. The last documented catheter care was over two months prior to the survey, and the TAR for the relevant period did not include any catheter care treatments. Staff interviews confirmed the absence of catheter care orders, care plan interventions, and recent documentation of catheter care. A review of the facility's catheter care policy revealed that catheter care should be performed every shift and as needed, with specific instructions for maintaining privacy, changing bags, and ensuring proper drainage. The facility did not follow its own policy, as evidenced by the lack of orders, documentation, and care planning for residents with indwelling catheters.
Failure to Maintain Adequate Nursing Staff Resulting in Delayed Medication Administration
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the needs of residents, specifically regarding timely medication administration. On the night in question, an LPN who was scheduled to work from 6:00 P.M. to 6:00 A.M. arrived late, left the unit multiple times, and was absent from her assigned area for extended periods. Statements from staff indicated that the LPN spent significant time in her vehicle and was eventually sent home around 1:00 A.M. by another LPN, who then assumed responsibility for the unit. As a result, several residents did not receive their scheduled evening medications on time. Three residents were directly affected by the delayed medication administration. One resident with multiple chronic conditions, including multiple sclerosis, diabetes, and hypertension, did not receive several scheduled medications until after midnight, despite them being ordered for the evening. Another resident with chronic kidney disease and diabetes received insulin several hours late, and a third resident with dementia, psychosis, and anxiety received both an antihistamine and acetaminophen later than scheduled. Interviews with these residents confirmed that their medications were administered much later than expected, with some residents remaining awake until the medications were provided. The deficiency was substantiated through review of facility records, time punches, staff and resident interviews, and medication administration records. The documentation confirmed that the absence and inaction of the scheduled LPN led to a delay in medication administration for multiple residents, and that the facility did not have adequate licensed nursing staff present and available on the unit throughout the shift to meet resident needs.
Delay in Transition of Care Assistance for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide timely and appropriate transition of care assistance for a resident with complex medical needs, specifically related to lymphedema and Milroy's disease. The resident was admitted with multiple diagnoses, including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. A physician requested referrals to other facilities better equipped to address the resident's needs, but there was a significant delay of almost three months before any referrals were made. During this period, the resident's representative repeatedly requested updates on placement options but was informed that no progress had been made in locating a suitable facility, particularly one capable of providing necessary transportation and specialized care. Interviews with facility staff confirmed that the resident required a higher level of care than the facility could provide, and documentation showed that referrals were not initiated in a timely manner. The facility's assessment indicated that it provided care for residents with morbid obesity and bariatric needs, but did not address the specific requirements for lymphedema specialty care. The deficiency was identified during a review of records, interviews, and the facility assessment, affecting one resident out of two reviewed for discharge planning.
Misappropriation of Controlled Medication Due to Improper Administration
Penalty
Summary
The facility failed to prevent the misappropriation of a controlled medication when Ativan, prescribed for one resident, was administered to another resident. The affected resident had a history of neurocognitive disorder with Lewy Bodies, anxiety, and depression, and was cognitively intact at the time of the incident. Physician orders specified that Ativan was to be administered intramuscularly as needed for seizures, and the medication was discontinued after a set period. Review of the controlled drug records showed that a dose of Ativan was signed out for administration, but it was not given to the intended resident. An interview with the Director of Nursing (DON) confirmed that the Ativan intended for one resident was instead administered to another resident, and there was no documentation in either resident's medical record regarding this transfer. The DON acknowledged signing out the medication but stated that an LPN actually administered it. The facility's medication administration policy required verification of the resident's name and medication details before administration, and specified that if a medication was unavailable, the contingency box should be used. However, the LPN failed to follow this policy and took the medication from another resident's supply instead.
Failure to Provide Transportation for Bariatric Resident to Medical Appointments
Penalty
Summary
The facility failed to provide required transportation services for a resident with multiple complex medical conditions, including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. The resident was cognitively intact but dependent for activities of daily living. Medical records indicated that the resident had scheduled appointments with a cardiologist and a plastic surgeon, but was not transported to these appointments as ordered. The resident's mother repeatedly reminded staff about the need for a signed referral and the upcoming appointments. Interviews with the DON and the resident's physician confirmed that the resident had not attended any outside medical appointments due to the inability of local transportation companies to transfer bariatric residents. The facility assessment documented that the facility provided care for residents requiring bariatric care, yet no arrangements were made to ensure transportation for this resident. The resident's mother expressed concern about the lack of transportation and the need for transfer to a facility that could meet this requirement.
Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to ensure that Resident #64 was offered the influenza vaccine during the period from 02/27/25 to 03/31/25. Record review showed that Resident #64, who was admitted with diagnoses including altered mental status, muscle weakness, cognitive communication deficit, and major depressive disorder, had intact cognition according to the Minimum Data Set assessment. Despite facility policy requiring annual offering of the flu vaccine and documentation of consent or refusal in the medical record, there was no evidence in the resident's medical record that the vaccine was offered, nor was there documentation of consent or refusal. During an interview, the Regional Director of Clinical Services confirmed that no information regarding the resident's consent or refusal for the influenza immunization could be located.
Failure to Offer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 immunization was offered to residents, as required by policy. Record reviews for four residents with various medical conditions, including cerebral palsy, COPD, heart failure, diabetes, demyelinating disease, paraplegia, asthma, cellulitis, MRSA infection, and altered mental status, revealed no evidence that these residents were offered the COVID-19 vaccine. All four residents had intact cognition according to their Minimum Data Set assessments. Interviews with the Regional Director of Clinical Services confirmed that the facility was unable to locate documentation of COVID-19 vaccine consent or refusal for these residents. The facility's policy required that residents be offered the vaccine, sign consent prior to administration, and that documentation of consent or refusal be retained in the medical record. However, for these residents, there was no such documentation present.
Failure to Ensure Safe Emergency Evacuation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with significant mobility and medical needs could be safely transferred and evacuated from his room in the event of an emergency. The resident was admitted with diagnoses including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder, and was primarily nonverbal and totally dependent on staff for all activities of daily living. Documentation and staff interviews revealed that the resident's weight exceeded the capacity of the available bariatric Hoyer lift, and the facility did not have a lift pad that would properly fit him. As a result, the resident could not be moved out of bed except when transferred to a shower bed, and attempts to reposition him caused elevated heart rate and shortness of breath. Further investigation showed that the resident's bariatric bed was too wide to fit through the doorway of his room, as confirmed by direct measurement and staff interviews. The resident's mother and the Assistant Fire Chief both verified that the bed could not be used for evacuation, and the facility lacked an alternative plan or equipment to evacuate the resident in an emergency. Multiple staff, including the DON, LPN, CNA, and physician, confirmed the inability to use the Hoyer lift or evacuate the resident from his room, demonstrating a failure to provide a safe and accessible environment for the resident.
Failure to Monitor and Report Bruising in Resident on Anticoagulant
Penalty
Summary
The facility failed to ensure that Resident #72, who was on an anticoagulant, was monitored and treated timely for bruising. Resident #72 had diagnoses including cerebral infarction, unspecified dementia, polyp of colon, and age-related osteoporosis, and had severely impaired cognition. The care plan included monitoring for signs of bleeding or bruising due to anticoagulant use. However, the Treatment Administration Record (TAR) for March and April 2024 revealed that the order to monitor for signs and symptoms of bleeding or bruising was not signed off as completed on multiple occasions. Additionally, shower sheets documented bruises on Resident #72's legs and thighs on several dates, but there was no documented evidence that the physician was notified of these findings. Interviews with Licensed Practical Nurses (LPNs) confirmed that they did not observe or report the bruising as required by the facility's policy on anticoagulant therapy. The Director of Nursing (DON) confirmed the lapses in monitoring and documentation. The facility was notified of the issue via email from the ombudsman after Resident #72 was transferred to a new facility, which noted bruises on admission. An investigation was initiated, but it failed to include the bruising noted on the shower sheets from March and April 2024. The allegation was unsubstantiated, stating that no bruises were noted while Resident #72 was a resident in the facility. However, interviews and documentation revealed that the required monitoring and reporting were not consistently performed, leading to a deficiency in the care provided to Resident #72.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure documentation was completed on the Treatment Administration Records (TAR) as required after treatment was provided for Resident #73. This affected one resident out of three reviewed for wounds. Resident #73 had multiple severe wounds, including stage IV pressure ulcers and suspected deep tissue injuries, which required specific treatments and regular documentation. However, the treatments for Resident #73's wounds were not signed off as completed on the TAR for two specific dates in March 2024. The resident was admitted with multiple wounds, including a stage IV pressure ulcer on the sacrum and other severe wounds on the legs and foot. The wound care physician provided detailed treatment plans, including the use of wound vacs, silver alginate, and other dressings. Despite these detailed plans, the facility's staff failed to document the completion of these treatments on the specified dates. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) confirmed that the treatments were performed but not documented as required. The facility's policy required that wound care and treatments be documented at the time of service or no later than the shift in which the care occurred. The failure to document these treatments as completed was confirmed through interviews and a review of the facility's policies. This deficiency represents non-compliance with the facility's own policies and accepted professional standards for maintaining medical records and safeguarding resident-identifiable information.
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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 Dalton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orrville Pointe | 5.8 mi | ★★★★★ | 5 | 0 |
| Accord Care Community Orrville Llc | 6.5 mi | ★★★★★ | 3 | 0 |
| Brewster Convalescent Center | 7.3 mi | ★★★★★ | 0 | 0 |
| Country Lawn Ctr For Rehab | 9 mi | ★★★★★ | 0 | 0 |
| Amherst Meadows Skilled Nursing And Rehab | 9.3 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.