Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shepherd Of The Valley-boardman during CMS and state inspections, most recent first.
A resident with cognitive impairment, diabetes, PVD, CHF, contracted hands, and dependence for hygiene developed wounds on the right third and fourth fingers after long nails were found digging into the hand. Staff did not complete timely follow-up assessments after the initial finding, the wounds were later found infected, and the resident was not comprehensively evaluated by the wound NP until the wounds were documented as Stage III pressure ulcers. Ordered treatments and splint use were delayed or missed, and the carrot splint was repeatedly found out of place or not in the resident’s hand.
Expired medications and unsecured storage were observed on multiple medication carts. An opened bottle of acetaminophen, lubricating jelly packets, povidone iodine swab sticks, and heparin flush syringes were found on carts, with several items past expiration. Three medication carts were also left unlocked in the hallway while an LPN was nearby but out of sight of two of the carts, and the LPN confirmed they should have been locked after the med pass.
Late completion of MDS assessments affected four residents. Quarterly assessments for three residents and a discharge return anticipated assessment for one resident were still incomplete when reviewed, with multiple sections left unfinished. The residents included individuals with CVA-related deficits, DM2, depression, dementia, malnutrition, ESRD on dialysis, and CHF, and the MDS nurse stated she was the only MDS nurse and sometimes had to wait on other departments to complete their sections.
Inaccurate and missing charting was found for multiple residents. One resident’s Stage III pressure ulcers were documented on the wrong fingers in the wound record and care plan, another resident’s heel pressure ulcer was incorrectly charted as having been acquired when the resident was not in the facility, a third resident had missing TAR documentation for ordered VS and weights, and a fourth resident had no documentation that activities were offered on several days. Staff interviews verified the documentation gaps and errors.
Failure to Honor a Resident’s Right to Choose When to Get Up: A resident with dementia, repeated falls, weakness, osteoporosis, and impaired cognition repeatedly asked to get out of bed, but staff turned off the call light and left without helping. A housekeeper, an unnamed nurse aide, the Regional DON, and a CNA were all involved in the sequence, and the CNA later said assistance was delayed because the floor had been mopped. Staff and the facility policy indicated residents’ requests were to be answered in a timely manner, but the resident’s request to get up was not honored.
Call lights were not kept within reach for two residents. One resident with stroke-related deficits, cognitive impairment, and dependence for care had the call light placed under a pillow or at head level where it could not be reached, and an LPN confirmed this. Another resident with a history of fractures, repeated falls, dialysis dependence, and weakness had the call light attached to the bed instead of on the resident’s person while seated in a wheelchair eating lunch; the resident could not locate it, and the ADON verified it was not within reach.
Visitation Rights Not Honored: An LPN told a resident’s family member that visiting hours had ended and called police to remove him from the facility, despite the resident’s wishes and a facility visitation policy allowing visitors subject to the resident’s preferences. The resident had serious medical conditions including CKD and prostate cancer, and his son reported he was only there to support his father and denied causing any safety concerns.
Failure to report alleged misappropriation of a controlled medication: A resident with multiple serious diagnoses, including fractures, MS, DM, and dialysis dependence, had Hydrocodone-APAP ordered PRN for pain. After the resident was sent to the hospital and later expired, the controlled drug record showed a nurse signed out one tablet with an illegible signature, and the facility investigated but did not notify the State Agency, believing it was only a documentation error and that no SRI was needed because the resident was no longer there.
Delayed Completion of Significant Change MDS Assessments: Two residents had significant change MDS assessments left incomplete beyond the required timeframe. Both residents were on hospice and had multiple chronic conditions, including COPD/CHF/atrial fibrillation for one resident and CVA, DM2, dementia, and altered mental status for the other. The MDS nurse stated she was the only MDS nurse and sometimes had to wait on other departments to finish their sections.
An inaccurate MDS assessment was completed for a resident with multiple chronic conditions, including chronic pain, CHF, DM, PVD, HTN, and anxiety. The resident had a PRN order for Hydrocodone-Acetaminophen and the MAR showed multiple administrations, but the MDS incorrectly stated no PRN pain medication had been given in the prior five days; the DON confirmed the assessment was inaccurate.
A resident with DM, CHF, PVD, contracted hands, and impaired cognition developed new pressure ulcers on the fingers of one hand, with slough, odor, suspected infection, and edema noted in the wound assessments. Nursing and Wound NP documentation identified the wounds as Stage III pressure ulcers, but the care plan was not updated in a timely manner and was not initiated until later, which an LPN confirmed.
Failure to Provide Needed ADL Assistance: A resident with stroke, aphasia, hemiplegia, malnutrition, and dependence for bathing and hygiene was found with brown grime under the fingernails of one hand on repeated observations. Bathing documentation showed the resident was bathed, but an LPN verified the grime and noted it could be fecal matter. The care plan included keeping the resident’s nails short and clean, and the facility ADL policy required assistance with hygiene and grooming.
Two residents had splint-related care failures. One resident with contractures and hand wounds had a carrot splint ordered for the right hand, but observations showed it was not in place and was found on the dresser; staff verified it was not being maintained as ordered. Another resident with stroke-related upper-extremity impairment had a splint observed on the left arm, but the care plan, physician orders, and TAR lacked any splint order or documentation, and staff confirmed no order was present.
A resident with ESRD, weakness, CHF, spinal stenosis, and dysphagia returned from the hospital after a fall with head laceration and sacral fracture, but the full nursing admission assessment was delayed and new fall precautions were not put in place right away. Later, the resident fell from a wheelchair when the wheels were unlocked, and staff also found the call light was not within reach during observation.
The facility failed to follow physician orders for tube feeding for one resident with a gastrostomy tube, as the resident was observed receiving Nutren 2.0 at a rate not supported by active orders and while lying flat in bed. The facility also failed to check gastric residuals before administering multiple meds via feeding tube to another resident who was NPO and receiving continuous tube feeds. Facility policy required residual checks before med administration via feeding tube.
A resident receiving hemodialysis had missing post-dialysis VS and dialysis access site checks after multiple dialysis treatments. The resident had orders for post-dialysis monitoring, and the TAR lacked the required documentation on several occasions. The ADON verified the missing assessments, and facility policy required monitoring of the access site and VS upon return from dialysis.
Controlled medication accounting logs were not consistently reconciled at shift change, and MAR entries did not match controlled drug records for three residents. For one resident with multiple chronic conditions, one with severe cognitive impairment and a stage four sacral ulcer, and one with diabetes, CHF, chronic pain, PVD, HTN, and anxiety, staff documented narcotic use on the controlled drug records without matching MAR documentation, and the DON verified the discrepancies. The Medical Director stated she was unaware staff were signing the controlled drug record but not the MAR, and the facility policy required both the MAR and narcotic book to be signed after administration.
Failure to Administer Ordered Medications: A resident with multiple chronic conditions, including DM, CHF, schizophrenia, PVD, HTN, and anxiety, missed several scheduled doses of ordered medications such as antidepressant, antihypertensive, antianxiety, pancreatic enzyme, antiplatelet, Parkinson’s, and antipsychotic drugs. The MAR documented the doses as unavailable while waiting on pharmacy supply, and the NP and DON confirmed staff were not updating the prescriber when medications were not available.
A resident with an indwelling catheter and diagnoses including vascular dementia and BPH was observed sitting in the hallway with the catheter bag laying on the floor under his wheelchair. An LPN confirmed the bag should not be touching the floor, and the DON stated the facility did not have a policy regarding catheter bag placement or storage during use.
A resident with a sacral wound and multiple comorbidities did not receive daily wound dressing changes as ordered by the physician. Observation revealed the dressing was not changed for two days, despite documentation indicating treatments were completed. An LPN confirmed the dressing should have been changed daily, highlighting a lapse in following prescribed wound care procedures.
The facility did not consistently obtain and document daily weights for residents receiving dialysis, as required by physician orders and facility policy. Several residents with end-stage renal disease and other serious conditions experienced multiple missed weight recordings over several weeks. Staff and resident interviews confirmed that daily weights were not always taken, often due to staffing issues.
An LPN failed to perform hand hygiene during medication administration for two residents, one with respiratory issues and another with incorrect isolation status. The facility's policies on hand hygiene and transmission-based precautions were not followed, leading to deficiencies in infection control practices.
Delayed assessment and missed wound care for hand pressure ulcers
Penalty
Summary
The facility failed to implement an effective pressure ulcer prevention and treatment program for a cognitively impaired resident with diabetes mellitus, congestive heart failure, peripheral vascular disease, contracted hands, limited upper-extremity range of motion, and dependence on staff for hygiene and transfers. The resident was identified as at risk for pressure ulcers and had care plan interventions for daily skin inspection, monitoring for skin breakdown, and use of a restorative program with a carrot orthotic to the right hand. On 10/08/25, an NP found the resident’s long, dirty nails were digging into her right hand and causing wounds, with the fingers edematous and contracted. The NP ordered rolled washcloths in both hands and nail care, but the documentation did not describe the wounds in detail. On 10/09/25, an LPN attempted to assess and cleanse the resident’s right hand, but the resident refused care and there was no evidence the nurse returned later that day to complete the assessment or treatment. The record then contained no additional nursing progress notes or wound assessments for the hand wounds between 10/10/25 and 10/30/25. When the NP reassessed the resident on 10/31/25, the hand wounds were noted to be infected and an oral antibiotic was ordered. The resident was not comprehensively assessed by the wound NP until 11/10/25, when the wounds to the right third and fourth fingers were documented as Stage III pressure ulcers. The record also showed delays and omissions in ordered wound care and splint use. Physician treatment orders for the right middle and ring fingers were not initiated until 11/05/25, and the carrot splints for both hands were not implemented until 11/07/25. The TAR showed multiple missed treatments in November and December without documentation that the resident refused them. Observations on 12/15/25 and 12/17/25 showed the carrot splint was not in the resident’s right hand and was instead found on the dresser or not replaced after being removed. Staff interviews confirmed the wounds were documented inconsistently, the resident’s right hand wounds were first observed as Stage III pressure ulcers on 11/10/25, and the treatment omissions and delayed implementation occurred as documented in the record.
Expired Medications Found and Medication Carts Left Unlocked
Penalty
Summary
Medications and biologicals were not stored in accordance with facility policy and accepted storage practices. During observation of the 300 Hall medication cart, staff found an opened bottle of Geri-Care acetaminophen 1000 mg tablets and multiple packets and swab sticks of lubricating jelly and povidone iodine with expiration dates ranging from 08/2022 through 11/2025. An LPN verified these findings during interview, and the facility policy stated that medications are to be stored safely and securely, with outdated medications not available for use and destroyed. Medication carts were also observed left unlocked in the hallway near the nurses station. Three carts labeled for resident room ranges 115 to 130, 101 to 111, and 131 to 205 were sitting unlocked while an LPN was seated in a small office area behind the nurses station and out of sight of two of the carts. The LPN confirmed the carts were unlocked and stated there was no reason for them to be unlocked because medication pass had already been completed. In addition, the IV treatment cart contained four Medefil prefilled heparin flush syringes with an expiration date of 11/2025, which the ADON verified during interview. The facility policy again stated medications must be stored in a safe and secure manner and outdated or deteriorated medications are not available for use.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to complete non-comprehensive MDS assessments within the required time frame for four residents. Resident #2 had a quarterly MDS with an ARD of 11/28/25 that was still incomplete on 12/16/25, with sections A, B, C, GG, I, J, L, N, O, and S not completed. Resident #8 had a quarterly MDS with an ARD of 11/21/25 that was also incomplete on 12/16/25, with the same sections not completed. Resident #25 had a quarterly MDS with an ARD of 11/21/25 that remained incomplete on 12/16/25, with sections A, B, C, GG, I, J, L, N, O, and S not completed. Resident #26, who was admitted with diagnoses including type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, and congestive heart failure, was discharged from the facility on 11/30/25. A discharge return anticipated MDS with an ARD of 11/30/25 had not been completed on 12/16/25, with sections A, B, C, GG, I, J, N, O, and S not completed. Interviews with the Regional MDS Nurse and the facility MDS Nurse confirmed the assessments had not yet been completed, and the MDS Nurse stated she was the only MDS nurse for the facility and sometimes had to wait on other departments to complete their sections.
Inaccurate and Missing Clinical Documentation
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for four residents. For one resident with diabetes mellitus, congestive heart failure, peripheral vascular disease, and contracted hands, the wound record, NP wound note, and care plan all documented pressure ulcers on the wrong fingers of the right hand. The skin nurse verified that the resident’s Stage III pressure ulcers were actually on the right third and fourth fingers, and observation confirmed the wounds were on those fingers. The facility policy required all observations, medications administered, and services performed to be documented in the clinical record. For another resident with hypertension, altered mental status, and anxiety, weekly skin assessments for a left heel unstageable pressure ulcer documented that the wound was acquired at the facility on a date when the resident was not in the facility. The LPN verified the resident was not present on that date and stated the documentation on the weekly skin assessments was inaccurate. The same policy required all observations, medications administered, and services performed to be documented in the resident’s clinical record. For a third resident with left arm fracture, history of falling, diabetes mellitus type II, malnutrition, heart failure, and dysphagia, physician orders required daily vital signs and daily weights, and the care plan called for monitoring and reporting changes related to fluid deficit and nutritional problems. Review of the TAR showed missing documentation of vital signs on several dates and missing documentation of weights on multiple dates. The ADON verified the absence of documented vital signs and weights. For a fourth resident, activity participation records showed no documentation of activities offered on several dates, and an Activities Assistant verified the missing documentation and stated it had been forgotten.
Failure to Honor Resident’s Choice to Get Out of Bed
Penalty
Summary
The facility failed to honor Resident #13’s right to choose when to get out of bed. Resident #13 was admitted on 12/26/24 with diagnoses including dementia, repeated falls, muscle weakness, hypertension, glaucoma, age-related osteoporosis, and a personal history of transient ischemic attack. The care plan identified impaired self-performance for ADLs related to repeated falls, weakness, and osteoporosis, and the quarterly MDS showed moderately impaired cognition with substantial to maximal assistance needed for bed mobility and transfers. The physician’s orders included transfer assistance with one staff and rails, effective 07/02/25. On 12/15/25 at 3:00 P.M., Resident #13 was observed calling out for assistance and stating a desire to get out of bed. A housekeeper assisted by turning on the call light, but within less than one minute an unnamed nurse aide entered the room, turned the call light off, and left without providing assistance. At 3:03 P.M., the housekeeper stated someone had turned the call light off without getting Resident #13 out of bed and turned it back on. At 3:08 P.M., the Regional DON entered, answered the call light, and Resident #13 again asked to get up; the Regional DON turned the light off and exited, then informed a nurse aide of the request. At 3:11 P.M., CNA #113 brought a mechanical lift device but told Resident #13 assistance could not be provided until the floors were dry after housekeeping mopped. The housekeeper later verified that staff turned the call light off without providing assistance, and said nursing aides frequently went into rooms and turned call lights off without helping residents. A Regional Staff Educator stated staff could turn the call light off if in the middle of something, but were expected to return and address the resident’s needs. The facility policy required staff to respond to resident requests in a timely manner and to turn the call light off before asking what assistance was needed.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. Resident #44 was admitted with diagnoses including stroke, respiratory failure, dysphagia, aphasia, hemiplegia, hemiparesis, and malnutrition. The care plan identified the resident as at risk for falls and included an intervention to keep the call light within reach. The MDS showed the resident was moderately cognitively impaired, had upper limb impairment on one side, required maximal assistance or was completely dependent for care needs, and was always incontinent of bowel and bladder. During observation, the call light was found under the resident’s pillow at head height on the right-hand side, and later it was again observed at head level on the right-hand side when the resident was unable to reach it. An LPN verified the resident could not reach the call light. Resident #30 was admitted with diagnoses including sacral fracture, repeated falls, dependence on renal dialysis, heart failure, spinal stenosis, and weakness. The care plan identified the resident as at risk for falls and included interventions to keep needed items in reach, remind the resident to ask for assistance before standing or walking, provide visual reminders to use the call light, and keep the call light within reach. The MDS showed the resident had fractures and other trauma, was cognitively intact, was dependent on staff for toileting, required moderate assistance for transfers, was frequently incontinent of bowel and bladder, and required hemodialysis. During observation, the resident was in a wheelchair with a tray table positioned over her and a lunch tray ready to eat, while the call light was attached to the bed and not on her person. When asked, the resident was unable to find the call light, and the ADON verified it was not within reach.
Visitation Rights Not Honored
Penalty
Summary
The facility failed to honor a resident’s right to receive visitors of his choosing at the time of his choosing. Resident #63 was admitted with diagnoses including sepsis, chronic kidney disease, and prostate cancer. A care plan meeting was held with the resident and his son, and the facility discussed hospice care and the resident’s decline in status. The resident’s son stayed overnight in the facility with the resident, and later the son returned to the bedside after visiting hours had ended. On the night of the incident, an LPN informed the family that visiting hours were over and they needed to return in the morning. The family member stated he was not leaving, and the LPN called police to have him removed; police told him he would be charged with trespassing if he did not leave. The facility handbook encouraged family and friends to visit and stated visitors could enter after the doors were locked by ringing the doorbell, and the facility visitation policy stated residents were permitted to receive visitors subject to the resident’s wishes and the rights of other residents. The Administrator later verified there were no specific visiting hours listed in the resident handbook or facility policy, and the resident’s son denied being argumentative or causing safety concerns.
Failure to Report Alleged Misappropriation of a Controlled Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation to the State Agency for Resident #17. Resident #17 was admitted with diagnoses including fractures of the left tibia and fibula, multiple sclerosis, diabetes, and dependence on renal dialysis, and later expired at the hospital. Review of the physician’s orders and MAR showed an order for Hydrocodone-Acetaminophen 5-325 mg as needed for pain, with the last documented dose given at 3:56 A.M. on the day the resident was sent to the hospital for difficulty breathing. The Controlled Drug Record showed a nurse signed out one tablet of Hydrocodone-APAP 5/325 mg at 11:19 P.M., but the signature was illegible. The facility investigation found a concern that a medication entry had been signed out after the resident had passed away, and the Administrator stated the pharmacy was updated and an internal investigation was started. The two nurses who worked the shift were suspended, interviewed, and drug tested, and the facility concluded there was no evidence of narcotic misappropriation or diversion and considered it a documentation error. The DON and Administrator confirmed the State Agency was not notified, and the Administrator stated she believed no self-reported incident was needed because the resident was no longer at the facility.
Delayed Completion of Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete significant change MDS assessments in a timely manner for two residents. Resident #11 had an admission date of 03/08/20 and diagnoses including COPD, bladder cancer, major depressive disorder, CHF, and atrial fibrillation. The resident was admitted to hospice services on 11/06/25, and a significant change MDS with an ARD of 11/14/25 had not been completed when reviewed on 12/16/25; sections A, B, C, GG, I, J, L, N, O, S, and V were still incomplete. The Regional MDS Nurse verified the assessment had not been completed, and the MDS Nurse stated she was the only MDS nurse for the facility and sometimes had to wait on other departments to complete their sections. Resident #15 had an admission date of 09/11/25 and diagnoses including cerebral infarction, type 2 diabetes mellitus, major depressive disorder, atrial fibrillation, dementia, hypertension, and altered mental status. The resident was admitted to hospice services on 11/12/25, and a significant change MDS with an ARD of 11/19/25 had not been completed when reviewed on 12/16/25; sections A, B, C, GG, I, J, L, N, O, S, and V were still incomplete. The Regional MDS Nurse verified the assessment had not been completed, and the MDS Nurse again stated she was the only MDS nurse for the facility and sometimes had to wait on other departments to complete their sections. The LTC RAI 3.0 User's Manual stated significant change assessments' ARD dates and completion dates were no later than the 14th calendar day after the significant change was determined to have occurred.
Inaccurate Pain Medication Assessment
Penalty
Summary
Resident #51, who was admitted with diagnoses including diabetes mellitus, congestive heart failure, chronic pain, peripheral vascular disease, hypertension, and anxiety, had an order for Hydrocodone-Acetaminophen 5-325 mg every six hours as needed for pain. Review of the October 2025 MAR showed the resident received this PRN pain medication multiple times on 10/01/25, 10/03/25, 10/04/25, and 10/05/25. However, the quarterly MDS 3.0 assessment dated [DATE] stated the resident received scheduled pain medication but had not received as needed pain medication in the five days prior to 10/05/25. The DON verified during interview that the MDS was inaccurate because the resident had received PRN Hydrocodone-Acetaminophen during that period.
Delayed Care Plan Update for New Finger Pressure Ulcers
Penalty
Summary
The facility failed to timely update Resident #51’s care plan after changes in her condition were identified. Resident #51 was admitted with diagnoses including diabetes mellitus, congestive heart failure, peripheral vascular disease, and contracted hands, and her quarterly MDS showed impaired cognition. A wound assessment documented new unstageable pressure ulcers on the resident’s right second and third fingers, with documentation noting slough, inability to determine depth, a missing fingernail, foul odor, suspected infection, and a red, warm, edematous hand. The assessment also noted that the wounds were first observed during the NP’s visit and that the resident had contractures. Subsequent nursing documentation described new areas on the resident’s right hand involving the middle and fourth fingers, and the Wound NP documented the wounds as Stage III pressure ulcers. The resident was ordered to receive Betadine, alginate silver, and a carrot splint in the hand, but the care plan addressing the Stage III pressure ulcers was not initiated until 12/15/25. During interview, the LPN verified that the resident’s Stage III pressure ulcers were not care planned timely.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to ensure Resident #44 received needed assistance with activities of daily living, specifically grooming and hygiene. Resident #44 was admitted with diagnoses including stroke, respiratory failure, dysphagia, aphasia, hemiplegia, hemiparesis, and malnutrition. The care plan identified fragile skin and included an intervention to keep the resident’s nails short and clean. The MDS showed the resident was moderately cognitively impaired, had upper limb impairment on one side, was dependent on staff for toileting, bathing, and hygiene, did not reject care, and was always incontinent of bowel and bladder. Review of bathing documentation showed the resident was bathed on 12/12/25 and 12/16/25. However, observations on 12/15/25 and 12/17/25 revealed brown grime underneath the fingernails of the resident’s right hand. An LPN verified the grime and stated it could be fecal matter. The facility policy on ADL stated that residents were to receive assistance with hygiene, including bathing and grooming, and that interventions were to be monitored and evaluated.
Splints Not Implemented or Ordered for Two Residents
Penalty
Summary
The facility failed to ensure Resident #51’s splint was implemented and used as ordered. Resident #51 had diagnoses including diabetes mellitus, congestive heart failure, peripheral vascular disease, and contracted hands, and her care plan documented limited physical mobility related to contractures and weakness. Occupational therapy recommended a restorative nursing program to both upper extremities with stretching and a carrot orthotic for the right hand, and later physician and wound-related notes documented worsening hand contractures, wounds, and orders for rolled washcloths and then a carrot splint to the right hand to remain in place except for hygiene and skin inspection. Despite these orders, observations showed the carrot splint was not in Resident #51’s right hand on multiple occasions. On one observation, she had a palm splint in the left hand but no carrot splint or treatment in the right hand. On later observations, the carrot splint was again not in place and was found on the dresser beside the bed. An LPN verified the splint was not in place and stated staff had difficulty putting it back when it came out. The therapy manager confirmed therapy had provided the splint order and nursing was to enter and carry out the restorative intervention. The NP stated the resident’s wounds worsened because the nails were not trimmed and treatments were not put into place, and that the Stage III pressure ulcers to the right hand third and fourth fingers could have been prevented if the splint had been in place. The facility also failed to ensure Resident #44 had a physician’s order for the left arm splint that was observed in use. Resident #44 had diagnoses including stroke, respiratory failure, dysphagia, aphasia, hemiplegia, hemiparesis, and malnutrition, and the MDS showed moderate cognitive impairment and upper limb impairment on one side. The care plan lacked interventions related to left arm splint application, the December 2025 physician orders did not include a left arm splint order, and the TAR had no splint documentation. Yet observation showed a splint applied to the left arm, and an LPN verified it was present. Therapy and nursing staff confirmed there was no physician order for the left arm splint.
Delayed re-admission assessment and missing fall safety measures
Penalty
Summary
The facility failed to ensure a timely re-admission assessment and new fall prevention interventions after Resident #30 returned from a four-day hospitalization following a fall with injury. Resident #30 had diagnoses including dependence on renal dialysis, weakness, end stage renal disease, spinal stenosis, congestive heart failure, and dysphagia, and the care plan identified her as being at risk for falls and injury related to gait and balance problems and psychoactive drug use. After the resident returned from the hospital with nine staples to the head and a large bruise to the coccyx due to fracture, the full nursing admission assessment was not completed until three days later. The record also showed that new fall prevention interventions were not implemented until two days after the resident returned from the hospital. Those interventions included placing a falling star magnet on the doorway and keeping needed items in reach. The progress notes documented that the resident was sent to the emergency room after a fall, admitted to the hospital the next day, and returned to the facility on 10/06/25. The physician was notified of the return and medication changes, and the resident was placed into bed with vital signs recorded. A later fall investigation showed that on 12/21/25 the resident fell from her wheelchair to the floor because the wheelchair wheels were not locked, and it was not documented whether the call light was within reach. During an observation the next day, the resident was in her wheelchair with the tray table over her and the lunch tray ready to eat, the wheelchair wheels were observed unlocked, and the call light was attached to the bed rather than on the resident's person. The resident was unable to locate the call light when asked, and the ADON verified that the wheelchair wheels were unlocked and the call light was not within reach.
Feeding Tube Orders Not Followed and Residuals Not Checked
Penalty
Summary
The facility failed to establish and implement physician’s orders for tube feed administration for one resident with a gastrostomy tube. The resident had diagnoses including gastrointestinal hemorrhage, angiodysplasia of the colon, dementia, dysphagia, gastrostomy status, and adult failure to thrive. The care plan and nutrition documentation indicated the resident required nocturnal tube feedings and water flushes, but the physician’s orders in the record did not include an active order for the tube feeding formula or infusion rate. During observation, the resident was receiving Nutren 2.0 at 80 ml per hour while lying flat in bed, and the LPN confirmed the resident was not properly positioned for tube feeding administration and that the formula was infusing at that rate. The RD also verified there were no active physician’s orders for the tube feeding formula or rate of infusion. The facility also failed to check tube feed residuals prior to medication administration for another resident receiving enteral nutrition. That resident had diagnoses including stroke, respiratory failure, dysphagia, aphasia, hemiplegia, hemiparesis, and malnutrition. Physician orders included NPO status, continuous tube feeding at 45 cc per hour, flushing the gastrostomy tube with water before and after medication administration, and giving oral medications via gastrostomy tube. During observed medication administration, residual gastric contents were not checked before famotidine, tamsulosin, clopidogrel, and polyethylene glycol were administered through the feeding tube. The facility policy for medication administration via feeding tube stated residual gastric contents were to be checked before medication administration to ensure less than 150 cc remained in the stomach. The policy for appropriate use of feeding tubes stated residents fed by enteral means would receive appropriate treatment and services to prevent complications of enteral feeding, including aspiration pneumonia and dehydration. The findings involved two residents out of two reviewed for enteral feedings.
Missing Post-Dialysis Monitoring
Penalty
Summary
Failure to provide safe, appropriate dialysis care/services occurred for a resident who required hemodialysis. Resident #30 was admitted with diagnoses including dependence on renal dialysis, heart failure, and weakness. The resident’s MDS showed fractures and other trauma, cognitive intactness, dependence on staff for toileting, moderate assistance needed for transfers, frequent bowel and bladder incontinence, and that the resident received hemodialysis. Physician orders dated 10/09/25 directed staff to check vital signs and the dialysis access site upon completion of dialysis, including every day shift Monday through Friday. Record review showed the resident received dialysis on 11/14/25, 12/02/25, 12/04/25, and 12/08/25, but the TAR did not contain the required post-dialysis vital signs or dialysis access site checks for those dates. During an interview on 12/22/25 at 12:35 P.M., the Assistant Director of Nursing verified the missing post-dialysis vital signs and access site checks. Facility documents titled Long-Term Care Facility Renal Dialysis Coordination Agreement and Care of Residents Receiving Renal Dialysis stated the facility would help monitor the resident’s access site and that residents receiving dialysis were to be monitored, including access site assessment and vital signs upon return from dialysis.
Controlled medication counts and MAR documentation were not reconciled
Penalty
Summary
The facility failed to ensure controlled medication accounting logs were reconciled before and after each shift and failed to ensure medications were accurately reflected on the MAR and controlled medication records for three residents. Surveyors found missing shift-change documentation on narcotic count sheets, including instances where the nurse going off shift did not sign, the incoming nurse did not reconcile medication cards or count sheets, and required count documentation was incomplete. The facility policy required controlled medications to be counted at the end of each shift by both the incoming and outgoing nurses. For one resident with diagnoses including fractures of the left tibia and fibula, multiple sclerosis, diabetes, and dependence on renal dialysis, the MAR showed 27 doses of Hydrocodone-Acetaminophen were administered during the month reviewed, while the controlled drug records reflected 48 doses documented as given. The DON verified the MAR and controlled drug records did not match and stated staff were probably signing the controlled drug record only and forgetting to sign the MAR. The Medical Director stated she was unaware staff were documenting on the controlled drug record and not in the MAR, and she did not review the controlled drug record when reviewing the resident’s medical record. For another resident with severe intellectual disabilities, a stage four sacral pressure ulcer, and prostate cancer, the MAR showed only three Percocet administrations, while the controlled drug record showed 26 tablets signed out as administered and 28 tablets documented as administered in total. The DON verified the discrepancy and stated staff were not documenting the medication administration in the electronic medical record, making it impossible for her to state how effectiveness of pain medication was being determined. For a third resident with diabetes, CHF, chronic pain, PVD, hypertension, and anxiety, the MAR showed 29 doses of Hydrocodone-Acetaminophen during one month and 14 doses during another, while the controlled drug records reflected 43 doses documented during one month and additional discrepancies including documentation of doses before the medication card had arrived at the facility. The DON verified the mismatches and stated the documentation errors appeared to involve staff signing the controlled drug record without completing the MAR.
Failure to Administer Ordered Medications
Penalty
Summary
Resident #51 was admitted with diagnoses including diabetes mellitus, congestive heart failure, schizophrenia, peripheral vascular disease, hypertension, and anxiety. Review of the physician orders showed multiple scheduled medications, including Dextromethorphan-Bupropion ER, Hydralazine HCL, Hydroxyzine HCL, Pancrelipase, Ticagrelor, Buspirone HCL, Carbidopa-Levodopa, and Aripiprazole. Review of the November 2025 MAR showed that several ordered doses were not administered, including Bupropion ER, Hydroxyzine HCL, Hydralazine HCL, Pancrelipase, Ticagrelor, Buspirone HCL, Carbidopa-Levodopa, and Aripiprazole. The missed doses were documented as unavailable because the facility was waiting on the medication from the pharmacy. During interview, the NP stated medications were frequently unavailable and staff were not updating her when medications were not available to be administered. The DON verified that the listed medications were not administered as ordered and that the physician or NP were not updated when medications were unavailable. Facility policy stated medications were to be administered as ordered.
Catheter Bag Placed on Floor Under Wheelchair
Penalty
Summary
The facility failed to ensure urinary catheter bags were placed in a manner to prevent contamination and risk of infection for Resident #43. Resident #43 was admitted on 01/15/25 with diagnoses including vascular dementia, benign prostatic hyperplasia with lower urinary tract symptoms, hematuria, and neuromuscular dysfunction of the bladder. The care plan identified the resident as at risk for urinary retention, painful urination, and frequent urination due to benign prostatic hyperplasia, and noted that the resident had an indwelling catheter due to urinary retention. Physician orders included irrigation of the catheter as needed for occlusion, monthly catheter changes, and monthly drainage bag changes with catheter change. The quarterly MDS indicated the resident had moderately impaired cognition and required an indwelling catheter. On 12/17/25 at 8:17 A.M., observation showed the resident's catheter bag laying on the floor under his wheelchair while he sat in the hallway by the nurses station. An LPN verified at the time of observation that the catheter bag was on the floor under the wheelchair and stated it should not be touching the floor. Later that day, the DON stated the facility did not have a policy regarding catheter bag placement or storage during use.
Failure to Provide Wound Care per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including a sacral wound, was not provided wound care in accordance with physician orders. The resident's care plan and physician orders specified that the dressing to the sacral wound should be changed daily and as needed, with specific wound care procedures to be followed. However, during an observation, it was noted that the dressing on the resident's buttocks was dated two days prior, indicating that the dressing had not been changed daily as ordered. The Treatment Administration Record for the month showed all treatments as completed, but direct observation and staff interview confirmed that the dressing had not been changed according to the prescribed schedule. The resident was highly dependent on staff for all activities of daily living and had severely impaired cognition, requiring substantial assistance for mobility and hygiene. The failure to change the dressing daily as ordered was confirmed by both observation and interview with the LPN who performed the wound care. This lapse in following physician orders for wound care constituted a deficiency in the facility's pressure ulcer care practices for this resident.
Failure to Obtain and Document Daily Weights for Dialysis Residents
Penalty
Summary
The facility failed to obtain and document daily weights as ordered by physicians for residents receiving dialysis treatment. Specifically, three residents with end-stage renal disease and dependence on dialysis were identified as not having their weights recorded on multiple days, despite physician orders and care plans requiring daily weight monitoring. Medical record reviews showed several missed weight entries for each resident over a period of weeks, and interviews with staff and residents confirmed that weights were not consistently obtained as required. Residents affected had significant medical histories, including end-stage renal disease, pleural effusion, congestive heart failure, and other comorbidities, and required close monitoring due to their dialysis needs. The facility's own policy mandated daily weights for these residents, yet documentation revealed repeated lapses. Staff interviews indicated that weights were sometimes missed due to workload and staffing assignments, and residents themselves reported not being weighed daily before or after dialysis sessions.
Infection Control Deficiencies in Medication Administration
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during medication administration for two residents, which was observed during a survey. Resident #21, who had a history of acute and chronic respiratory failure, COPD, and an active COVID-19 infection upon initial admission, was administered medication by an LPN who did not perform hand hygiene between administering medications to different residents. The LPN was observed exiting another resident's room and proceeding to administer medication to Resident #21 without washing hands, despite the facility's policy requiring hand hygiene before and after medication administration. Additionally, the facility failed to correctly identify the transmission-based precautions status for Resident #44, who had a history of congestive heart failure, diabetes, and cellulitis, among other conditions. The resident was incorrectly placed under droplet isolation, as indicated by a sign on the door, despite having no active orders for such precautions. The LPN administered medications to Resident #44 without performing hand hygiene between glove changes and without wearing a mask, which was required for droplet precautions. The LPN confirmed the incorrect isolation status during an interview, acknowledging the error in precautionary measures. The facility's policies on medication administration and hand hygiene were not adhered to, as staff were required to perform hand hygiene between resident contacts and before and after handling medications. The failure to follow these protocols was identified during a complaint investigation, highlighting deficiencies in infection prevention and control practices within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Youngstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Center Of Boardman | 0.2 mi | ★★★★★ | 14 | 0 |
| Beeghly Oaks Center For Rehabilitation & Healing | 1.1 mi | ★★★★★ | 0 | 0 |
| Briarfield Place | 2.3 mi | ★★★★★ | 3 | 0 |
| Oasis Center For Rehabilitation And Healing | 2.7 mi | ★★★★★ | 16 | 0 |
| Shepherd Of The Valley Poland | 2.7 mi | ★★★★★ | 9 | 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.