Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sienna Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to consistently monitor and document food and drink serving temperatures for nearly all residents receiving meals from the kitchen. Review of temperature logs showed multiple meals and entire days with missing food and beverage temperature entries, including repeated omissions for dinner meals. The Dietary Manager acknowledged that staff sometimes wrote temperatures on separate sheets of paper instead of the official daily logs and that several of these sheets were incomplete, lacking milk or coffee temperatures. This practice did not comply with the facility’s policy requiring recording of hot and cold temperatures for all menu items at each meal service.
An RN left a medication cart unlocked and unattended while walking down the hall into a resident room and out of sight of the cart, despite facility policy requiring medication storage areas to remain locked when not in use or not attended by authorized staff. At the time, multiple cognitively impaired and independently mobile residents were present on the unit, creating a situation in which unauthorized individuals could have accessed medications.
The facility did not ensure reasonable access to medical records for a resident and family when they requested copies of PT/OT reports after discharge. The resident had multiple chronic conditions, severe cognitive impairment, and used mobility aids. Staff required the resident to appear in person to sign a release, would not accept a verbal request, and the daughter delayed the visit due to the resident’s limited mobility and weather. The daughter was reportedly told therapy records would cost $60–$80, leading the family not to obtain them. The facility’s fee schedule allowed high per-page and search fees, therapy records were controlled by a contracted provider with its own pricing, and facility staff could not provide clear cost information to the family, resulting in a lack of easy access to the requested records.
The facility failed to provide baseline care plan summaries to residents and/or their representatives and did not clearly base initial goals on admission orders. In one case, a resident with dementia had a care conference documented as including medication review and an offer of a care plan copy, but the resident’s POA reported no recall of medication discussion or receiving a copy, and there was no evidence a copy was given to the POA. In another case, a resident with multiple chronic conditions and high ADL dependence reported that medications and treatments were not reviewed, was not asked if she wanted a copy of the care plan, and was not asked about or provided compression hose previously used for edema. Staff confirmed that copies of baseline care plans were not routinely provided unless requested and that documentation did not show review of physician, medication, treatment, or dietary orders, and the facility policy did not address giving residents a copy of the baseline care plan.
A resident with multiple comorbidities, including CHF and diabetes, had documented bilateral lower extremity edema with cracking skin and clear drainage. A physician ordered daily compression stockings for edema management, but observations and interviews showed the resident was never provided compression hose and none were present in the room. The resident reported never being asked to wear them and described prior edema care at another facility. A CNA confirmed the absence of stockings and that the task did not appear in electronic charting, while an RN admitted signing the treatment record indicating stockings were applied when they were not.
A resident with COPD, heart failure, type 2 DM, and significant lower extremity edema had a physician order for daily compression stockings, yet staff repeatedly documented on the Treatment Administration Record that the stockings were on when the resident reported never having worn them and none were observed in the room. Surveyors observed the resident without compression hose, with edematous, reddened legs and scabs, while a CNA stated the task did not appear in electronic charting and an RN admitted signing the treatment sheet indicating the stockings were on when they were not, resulting in an inaccurate medical record.
A resident with multiple chronic conditions was not properly assessed or treated for a pressure ulcer. Staff failed to notify the physician or wound nurse in a timely manner, did not implement ordered pressure-relieving interventions, and did not complete comprehensive wound documentation. Inadequate and inconsistent assessments, along with delayed treatment, were observed, and facility policies for wound care and documentation were not followed.
Improper Food Storage and Kitchen Sanitation: Surveyors found dented tuna cans stored with resident food, opened boxes of beef patties and bacon with the contents exposed to air and cardboard, a container of Icy Hot on the clean plate and cup rack, and an opened, undated, unlabeled container of seafood salad in the food prep refrigerator. An dietary staff member confirmed the findings, and the facility policy stated food must be stored, prepared, handled, and served to minimize the risk of foodborne illness.
A facility failed to maintain resident dignity during lunch service when a CNA did not serve meal trays table by table, leaving one resident without a tray while others at the table began eating and delaying trays for two other residents, including one tray that had to be located on a room cart. The facility also failed to maintain dignity for a female resident who required staff help with shaving, as she was observed with visible facial hair and said staff had not assisted her in several days.
The facility failed to ensure the surety bond covering resident trust funds was greater than the amount of funds it managed. Review showed the bond covered $50,000 and had expired, while the resident funds balance later exceeded that amount at $62,318.40 and $70,729.40. The BOM stated the facility had switched ancillary service providers, which affected billing and caused the account balance to rise because not all provider bills had been paid.
Pharmacy MRRs for several residents with psychotropic and antidepressant orders were not documented as reviewed or addressed by the physician. The record showed blank response areas, missing signatures and dates, and no rationale for continued use or dose reduction decisions for medications such as Prozac, Trazodone, Seroquel, Zoloft, and Paxil. The DON could not verify that the physician had received or acted on the pharmacy recommendations.
The facility failed to maintain infection control during medication administration, incontinence care, and care for a resident on contact isolation. An LPN donned gloves without hand hygiene and later touched a tablet with bare hands before administering it; a CNA changed gloves during incontinence care without hand hygiene; and staff did not follow the posted contact isolation precautions for a resident with VRE, with the wrong sign displayed and PPE not worn on entry. The DON and ADON confirmed the expected hand hygiene and PPE practices.
A resident with COPD, dementia, and heart disease died at the facility, and the business office later verified that $613.71 in personal funds had not been dispersed to the resident's estate within 30 days after death.
Soiled privacy curtains were left hanging in multiple resident rooms, including one room where the stains were visible from the doorway and from the bed while the resident was lying there. A CNA and the HLD confirmed the soiled curtains, and the facility policy states that privacy curtains in resident areas are to be cleaned when visibly soiled.
A resident with CHF, chronic respiratory failure, DM, a fall history, and difficulty walking required ADL assistance and was documented to prefer three morning showers each week. Instead, the shower schedule listed two night-shift showers weekly, and records showed missed scheduled showers. The DON verified the resident was not receiving showers as scheduled or per her preference.
Failure to complete weekly skin assessments for a resident with surgical wounds. A resident admitted with multiple surgical incisions to the foot and ankle, along with DM2, chronic osteomyelitis, CHF, and other conditions, had admission skin findings documented, but the weekly skin assessments did not include the wounds and no wound tracking was completed. The resident was later transferred to the hospital for treatment of the surgical wounds, and the DON confirmed the weekly wound assessments had not been completed before hospitalization.
A resident with bilateral hand contractures and ALS did not receive consistent splint-related treatment and documentation to support ROM care. OT and PT had recommended bilateral hand splints, restorative splint/brace programming, and staff monitoring, but there were no physician orders, no restorative nursing program, and no nursing documentation showing the splints were used after therapy ended. The resident was observed with the splints lying unused nearby and stated they did not fit correctly, while the DON and Therapy Director confirmed the lack of documentation, communication, and physician notification.
A resident with impaired cognition, multiple chronic conditions, and Hoyer lift transfer status was found on the floor next to the bed with right leg deformities after a fall. The LPN assessed the resident, immobilized the leg, and EMS transported the resident to the hospital, but the fall investigation lacked staff witness statements and was confirmed by the DON and ADON to be incomplete.
Failure to provide ordered oxygen therapy. A resident with COPD, emphysema, and acute respiratory failure with hypoxia had an order for 3 L O2 via NC to keep O2 saturation above 90%, but staff and RT found the resident on room air or receiving 2 to 2.5 L instead of the ordered flow rate. Observations also showed the resident without the NC in place, and the facility policy required oxygen to be adjusted to the prescribed flow rate.
Failure to document non-pharmacological pain interventions: A resident with intact cognition and non-ambulatory status, admitted with osteomyelitis of the vertebra, MS, HF, sepsis, and depression, received PRN Tramadol and Tylenol multiple times for pain ratings of 7/10 and 8/10. The MAR and progress notes showed no NPIs attempted or documented before the PRN pain meds were given, and an LPN confirmed no NPIs were offered prior to administration.
Three residents with indwelling catheters did not receive timely and appropriate catheter care, including failure to monitor urinary output, delayed physician notification, and lack of proper catheter changes or irrigation. One resident experienced actual harm, requiring hospital transfer for a blocked catheter and pain management, while another developed a UTI due to delayed intervention. Facility staff did not consistently follow policy for monitoring and reporting catheter-related issues.
Facility staff failed to maintain clean and intact filters and vents on heating and cooling units in multiple resident rooms, with observations revealing dirt, dust, and missing or damaged filters. The Maintenance Director confirmed the lack of proper maintenance and difficulty obtaining parts, while the Housekeeping Supervisor acknowledged the absence of a cleaning schedule for the filters.
Two residents with diabetes and other chronic conditions did not receive podiatry services or appropriate foot care despite having signed consents on file. Family members and photographic evidence confirmed that both residents had long, thick, and untrimmed toenails, with one resident experiencing discomfort. The DON confirmed that the facility was unaware of the need for a physician's signature on podiatry consents, and the issue was compounded by the sudden departure of the social services designee.
A resident with a history of falls and multiple medical conditions did not have required fall prevention interventions in place, including a body pillow, a sign to request help, and a bed in the lowest position, as specified in the care plan. These items were missing following a recent room change, and the DON confirmed the interventions had not been implemented as directed.
A resident with multiple serious health conditions received morphine in a manner not consistent with hospice or physician orders, due to incorrect transcription and administration by nursing staff. Documentation on the MAR and narcotic control sheets showed discrepancies in timing and dosage, with some doses given more frequently than ordered and others not recorded. This resulted in the resident's drug regimen not being free from unnecessary medications.
The facility failed to serve food at safe and appetizing temperatures, affecting all 83 residents. Observations revealed that food was plated and served without maintaining proper temperatures, and residents reported dissatisfaction with the food's quality and temperature. The facility lacked policies on minimum holding temperatures, and the Dietary Manager confirmed the issue.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 83 residents. Observations revealed dirty and greasy surfaces, cracked floors, and improperly stored food. During meal service, food was served at unsafe temperatures, and staff did not recognize the issue. The Dietary Manager confirmed the longstanding issues with cleanliness and equipment maintenance.
Failure to Consistently Monitor and Document Food and Drink Temperatures
Penalty
Summary
The facility failed to consistently monitor and document food and drink serving temperatures for all residents receiving nutrition from the kitchen, affecting all but one resident who did not receive nutrition from that source. During a kitchen tour, review of food temperature logs showed multiple missing entries: no coffee temperatures recorded for one dinner meal; no food or drink temperatures recorded for another dinner; no food or drink temperatures documented for breakfast and lunch on a subsequent day; no food or drink temperatures documented for an entire day; and repeated missing food and drink temperature entries for several dinner meals on additional days. In interview, the Dietary Manager confirmed there were days when food and drink temperatures were not recorded and reported finding seven separate sheets of paper with temperatures written on them that had not been transferred to the official daily logs, five of which were dated and four of which lacked milk or coffee temperatures. The facility’s undated Food Temperature Logs Policy required that temperatures of hot and cold items be recorded for all menu items for meal service, which was not followed, leading to the cited deficiency under the referenced complaint number. No additional resident-specific medical history or clinical condition at the time of the deficiency was provided in the report.
Unlocked and Unattended Medication Cart Accessible to Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure medications were stored to prevent access by unauthorized persons when a medication cart was left unlocked and unattended. During a tour on 02/05/26 at 7:52 A.M., an RN walked away from her medication cart, entered a resident room down the hall, and moved out of sight of the cart, leaving it unlocked. At 7:54 A.M., the RN returned to the cart and confirmed she had left it unlocked and unattended. The facility had identified 23 residents as cognitively impaired and independently mobile, and the unlocked cart was accessible in this environment. Review of the facility’s January 2025 Storage of Medication policy showed that only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications were allowed access to medication carts, and that medication rooms, cabinets, and medication supplies should remain locked when not in use or when not attended by authorized personnel. The observed practice of leaving the medication cart unlocked and unattended was inconsistent with this policy and formed the basis of the cited deficiency, which was investigated under Complaint Number 2734445.
Failure to Ensure Reasonable Access and Fees for Resident Medical Records
Penalty
Summary
The facility failed to ensure ease of access for a resident and the resident’s family to obtain copies of the resident’s medical records, specifically therapy records. The resident, who had diagnoses including peripheral vascular disease, hypertensive heart disease without heart failure, encephalopathy, difficulty walking, dysphagia, atherosclerotic heart disease, kidney disease, alcohol abuse, and chronic peripheral disease, was severely impaired for daily decision making and used a wheelchair and front-wheeled walker for mobility. After discharge, the resident’s daughter requested physical and occupational therapy reports so home health could review what therapy had been provided. She was told the resident would need to come in person to sign a release form because the facility would not accept a verbal request, and the facility required a resident signature unless a power of attorney or other legal representative was in place. Due to the resident’s limited mobility and cold weather, the daughter did not bring him in to sign until a later date. The daughter reported being told by therapy staff that obtaining copies of the therapy records would cost approximately $60 to $80, and due to this reported cost, the family did not obtain the records. The facility’s fee schedule, based on the Ohio Revised Code and Consumer Price Index, allowed charges up to $3.88 per page for requests by a resident or resident representative, and for other requesters included an initial search fee of $23.94 plus up to $1.58 per page. The Administrator stated that therapy was provided by a contracted company using a different computer system and that this company set its own prices for records, which the Administrator did not know or verify for compliance, and that the facility used state fee requirements rather than federal. The Administrator also confirmed that the facility’s fee structure included additional fees for locating records and that verbal requests were not accepted. Medical Records staff indicated that requests required a signed release form, were routed through Quality Assurance and legal, and that the business office had a price sheet, but staff did not inform requesters of the cost. Corporate Business Office staff stated that charges were sometimes waived depending on page count and that the facility business office could not give residents or representatives a price, with therapy records handled separately by the third-party therapy agency.
Failure to Provide and Review Baseline Care Plan Summaries With Residents/Representatives
Penalty
Summary
The facility failed to provide a summary of baseline care plans to residents and/or their representatives and did not ensure that baseline care plans were clearly based on admission orders. For one resident with Alzheimer’s disease and dementia who was confused and oriented only to person, the medical record showed an admission assessment and a multidisciplinary care conference where staff documented that medications were discussed and that a copy of the plan of care was offered. However, the resident’s power of attorney (POA) reported not recalling any discussion of medications as part of the admission care conference and not being offered or given a copy of the baseline care plan. The Social Service Designee confirmed that the form only allowed staff to mark that a copy was offered to or received by the resident, that the resident was very confused with poor vision, and that there was no evidence a copy of the baseline care plan was provided to the POA. For another resident with multiple diagnoses including COPD, ventilator dependence, chronic respiratory failure, morbid obesity, heart failure, diabetes, and significant functional dependence, the multidisciplinary care conference form indicated that admission, goals, therapy, discharge, health, and code status were discussed, that the plan of care was reviewed, and that the resident was offered a copy of the plan of care. The form did not show that initial goals were based on admission orders or that physician orders, including dietary orders, were reviewed. The resident stated that medications and treatments were not reviewed at the conference, that she was not asked if she wanted a copy of the care plan, and that no one asked about or provided compression hose, which she had used at a prior facility for edema. The Social Service Designee verified that the facility did not provide copies of baseline care plans unless requested and that there was no documentation of physician orders, medications, treatments, or dietary orders being reviewed during the meeting. The facility’s care plan policy required resident or sponsor signatures to verify presence and review of the care plan but did not address providing a copy of the baseline care plan as required by regulation.
Failure to Implement Physician-Ordered Compression Stockings for Edema
Penalty
Summary
The facility failed to implement physician-ordered compression stockings for the treatment of edema for one resident. The resident was admitted with multiple diagnoses including COPD, hypertensive heart disease, type 2 diabetes, heart failure, weakness, and arthritis. A quarterly MDS showed the resident was independent in daily decision making but required substantial to maximum assistance with most ADLs. Weekly skin checks in early December documented bilateral leg cracking and clear drainage, and a subsequent health status note described bilateral lower extremities as edematous, hard, and with scant clear drainage. In response, a physician order was written for compression stockings to be applied in the morning and removed at bedtime daily for leg edema starting in December. Despite this order, surveyor observations and staff and resident interviews showed the intervention was not carried out. On observation, the resident’s lower legs were edematous, red, and had thin scabs, and the resident reported itching and scratching. The resident stated she had never worn compression hose at the facility, had not been asked about wearing them, and that at a prior facility her legs had been wrapped for edema. A CNA reported the resident was retaining a lot of fluid in her legs, had never been seen with compression stockings, that there were no stockings in the room, and that application of stockings did not appear in their electronic charting. The treatment record, however, was signed off indicating the stockings had been applied, and an RN acknowledged signing the treatment sheet for compression stockings when they had not actually been in place. This deficiency was cited under a complaint investigation.
Inaccurate Documentation of Compression Stocking Use for Edematous Legs
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with multiple chronic conditions, including COPD, hypertensive heart disease, type 2 diabetes, heart failure, and arthritis. The resident was admitted in late October and had a quarterly MDS showing dependence on staff for several ADLs. In early December, weekly skin checks and a health status note documented bilateral lower extremity edema, hardness, cracking, seeping clear liquid, and scant clear drainage. In response, a physician order dated 12/10/25 directed that compression stockings be applied in the morning and removed at bedtime daily and on night shift for leg edema. However, review of the Treatment Administration Record showed that staff documented the compression hose as being on for multiple days in January and the first days of February, despite the resident not being provided compression stockings during her stay. On the day of surveyor interviews and observations in February, the resident was observed without compression stockings, with edematous, red lower legs and thin scabs on the left lower shin, and reported itching and scratching. The resident stated she had never worn compression hose at the facility, no one had asked her about wearing them, and that at her previous facility her legs had been wrapped for edema. A CNA reported the resident was retaining a lot of fluid in her legs, had never seen the resident with compression stockings, noted there were none in the room, and that application of stockings did not appear in their electronic charting. Despite this, the Treatment Record for that day was signed off indicating the resident had compression stockings on. An RN confirmed she had signed the treatment sheet indicating the resident had compression stockings on when the resident did not, demonstrating inaccurate documentation in the medical record.
Failure to Accurately Assess and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure comprehensive and accurate pressure ulcer assessments, timely implementation of treatments, and adherence to pressure-relieving interventions as outlined in the care plan for a resident with multiple comorbidities, including a right femur fracture, chronic kidney disease, anemia, diabetes, protein-calorie malnutrition, dementia, heart disease, venous insufficiency, and a pressure ulcer. Upon re-admission, the resident was identified as having a suspected deep tissue injury on the sacrum, but there was no documented evidence that the physician was notified or that the wound nurse was consulted until more than a month later. Additionally, a pressure-reducing cushion was ordered, but observations revealed the resident was using an inadequate cushion, and staff confirmed it was not a proper pressure-relieving device. Medical record reviews showed inconsistent and incomplete documentation of the resident's skin condition. Weekly skin observations and skin grid assessments often lacked detailed descriptions of the wounds, including stage, drainage, odor, and other required characteristics. Several weekly pressure ulcer assessment forms were not completed, and the non-pressure forms used did not provide comprehensive information or proper staging. The resident's MDS assessment was also found to be inaccurate, failing to reflect the presence of a pressure ulcer on admission. There was a significant delay in implementing treatment for the sacral area, with no evidence of any treatment from the time the wound was identified until nearly two weeks later. The wound nurse did not assess the pressure ulcer until a telehealth visit was conducted, and the physician's progress notes did not mention or assess the pressure ulcer during the relevant period. Facility policy required prompt notification of the physician and responsible party, comprehensive documentation, and regular assessment, but these procedures were not followed as evidenced by the findings.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
Food was not stored in a sanitary manner in the facility kitchen. During the initial kitchen tour, surveyors observed three 66.5-ounce cans of tuna that were dented along the seal and stored in the main dry food area for resident meal preparation. In the walk-in freezer, an opened box of beef patties had a plastic storage bag opened, exposing approximately 20 frozen patties to the cardboard box and freezer air. In the walk-in cooler, an opened box of bacon had a plastic bag cut open, exposing the bacon to the cooler air and the cardboard box. Additional observations showed a closed container of topical pain ointment medication, Icy Hot, sitting on the plate and cup storage rack. In the food preparation refrigerator near the steam table, surveyors found an opened, undated, unlabeled container of half-eaten seafood salad with a sell-by date of 07/31/25. The dietary staff member confirmed the dented tuna cans, the exposed beef patties and bacon, the Icy Hot container on the clean dish storage area, and the undated, unlabeled seafood salad in the food preparation refrigerator. The facility policy stated that food would be stored, prepared, handled, and served so that the risk of foodborne illness is minimized.
Failure to Maintain Resident Dignity During Meal Service and Personal Hygiene
Penalty
Summary
The facility failed to maintain the dignity of residents during lunch service in the dining room. Resident #42, who had diagnoses including heart disease, pulmonary hypertension, COPD, speech and language deficits, stroke, and gastric reflux, was seated at a table with three other residents when CNA #255 began tray pass. Resident #42 was omitted from the initial tray delivery while the other residents at the table began eating, and her tray was not delivered until about 10 minutes later after the CNA had moved on to other tables. Resident #75, who had diagnoses including a broken pelvis, atrial fibrillation, anemia, weakness, diabetes mellitus, and lymphoma, was also affected during the same meal service. CNA #255 could not locate Resident #75's tray and continued serving other residents while Resident #75 remained without a meal tray. Resident #64, who had diagnoses including high blood pressure, heart failure, dysphagia, anemia, and weakness, did not receive his tray in the dining room and left with his spouse to locate it. The spouse asked to help with tray pass because of the delay, but was told she could not. Resident #64 later returned with the Activities Director carrying his tray from the room tray cart, and Resident #75's tray was also later returned from the room tray cart and placed on the table without removing the contents from the tray. The facility also failed to maintain the dignity of Resident #66 by not removing facial hair. Resident #66, a female resident with emphysema and Alzheimer's dementia, required substantial to maximum assistance with personal hygiene, including shaving, and her care plan included staff assistance with shaving as needed. She was observed with dark facial hair covering her upper lip, and she stated that staff usually assisted with shaving but had not done so in several days and that it bothered her when facial hair was not removed. An LPN confirmed the facial hair was present and stated staff should be offering to shave residents during bathing and when needed.
Resident Funds Bond Was Less Than Managed Funds
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was not maintained when the facility failed to ensure its surety bond exceeded the amount of resident funds managed by the facility. Review of the surety bond purchased by the facility showed coverage of $50,000 for resident funds, and the bond had expired on the listed date. Review of the Resident Funds Management Service Trial Balance showed the resident funds balance was greater than $50,000 on two dates, including $62,318.40 and $70,729.40. During interview, the Business Office Manager stated that in June 2025 the facility switched ancillary service providers and billing changed, which caused resident funds to appear higher because not all provider bills had been paid, and she verified the balances were correct on the dates reviewed.
Pharmacy Recommendations Not Addressed for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that monthly pharmacist drug regimen reviews were acted upon and that pharmacy recommendations for gradual dose reduction or discontinuation were addressed by the physician for multiple residents reviewed for unnecessary medications. The report states that the consulting pharmacist was to report irregularities to the physician and that the physician was to document the rationale for continued use or why no action was taken, but the medical records reviewed did not contain signed, dated physician responses or documented rationale for several pharmacy recommendations. For Resident #2, who had diagnoses including diabetes mellitus, heart failure, depression, and a history of falling, the record showed orders for Prozac 20 mg daily and Trazodone 50 mg at bedtime. Pharmacy recommendations on multiple dates asked the physician to consider gradual tapering of Prozac and, later, both Prozac and Trazodone, but the recommendation forms were left blank and were not signed or dated by the physician. The DON stated during interview that the forms had been printed during the survey and could not verify whether the physician had received them when they were issued. For Resident #5, who had chronic respiratory failure with hypoxia, unspecified psychosis, and anxiety disorder, the monthly pharmacy review requested a trial discontinuation of Seroquel 25 mg at bedtime, but the physician response area was blank with no signature, date, or rationale. For Resident #24, who had diagnoses including osteomyelitis of the vertebra, MS, heart failure, sepsis, and depression and was non-ambulatory with intact cognition, pharmacy recommendations were issued on several review dates, but there was no further documentation showing physician review or follow-up. For Resident #54, who had diagnoses including acute respiratory failure, COPD, morbid obesity, prior PE and DVT, insomnia, depressive disorder, substance dependence in remission, bilateral hand contractures, and ALS, pharmacy reviews included recommendations for gradual dose reduction of Paxil 20 mg nightly, yet the record contained no physician documentation of review, rationale, or new orders for the recommendations identified in the report.
Infection Control Lapses During Medication Pass, Incontinence Care, and Contact Isolation
Penalty
Summary
The facility failed to maintain infection control during medication administration, incontinence care, and care for a resident on contact isolation. During medication pass for one resident with moderately impaired cognition and diagnoses including pulmonary hypertension and type 2 diabetes with chronic kidney disease, an LPN brought a medicine cup into the room and donned gloves without performing hand hygiene first. The LPN later confirmed she did not wash her hands before putting on gloves, and the DON and ADON confirmed hand hygiene was to be performed before and after glove use. During medication administration for another resident with intact cognition and an order for pantoprazole 40 mg daily, the same LPN had difficulty removing the tablet from the package and used her bare hand to touch the tablet before placing it in the medicine cup and administering it. The LPN confirmed she used her bare hand to remove the medication and stated she should have used gloves. The DON and ADON confirmed staff were not to use bare hands to touch residents' medication. During incontinence care for a resident who was dependent for toileting assistance and always incontinent of bladder and bowel, a CNA removed her gloves and applied new gloves without performing hand hygiene. In addition, for a resident with VRE in the urine and an order for contact isolation, observations showed the door sign indicated enhanced barrier precautions rather than contact precautions, and staff stated they were not wearing PPE when entering the room. The facility policy for transmission-based precautions stated staff were to wear gloves and gowns at all times and perform hand washing before entering and before leaving the room.
Failure to Forward Deceased Resident's Personal Funds to Estate
Penalty
Summary
The facility failed to ensure Resident #86's personal funds were forwarded to the resident's estate within 30 days after death. Resident #86 was admitted on 01/09/24 with diagnoses including COPD, dementia, and heart disease, and died at the facility on 06/09/25. Review of the Resident Funds Management Service Trial Balance dated 08/06/25 showed a balance of $613.71 remained in the resident's account. During an interview on 08/06/25 at 10:58 A.M., the Business Office Manager verified that Resident #86's personal funds of $613.71 had not been dispersed to the resident's estate within 30 days.
Soiled Privacy Curtains Left in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, homelike environment in resident rooms by leaving visibly soiled privacy curtains hanging in multiple rooms. Resident #24’s privacy curtain had several large dark circular stains visible from the doorway and from the bed while the resident was lying there. In addition, privacy curtains in the rooms of Residents #45, #59, #66, and #78 were observed with dark stains visible from the doorway. A CNA confirmed the soiled curtain in Resident #24’s room, and the Housekeeping and Laundry Director confirmed the soiled curtains in the other four rooms, stating that privacy curtains are to be laundered every two weeks and as needed. The facility policy stated that privacy and window curtains in resident areas will be cleaned when visibly soiled.
Failure to Provide Showers per Resident Preference and Schedule
Penalty
Summary
The facility failed to provide showers according to Resident #27’s stated preference and the shower schedule. Resident #27 was admitted with diagnoses including heart failure, chronic respiratory failure, diabetes mellitus, history of falling, and difficulty walking. Her care plan stated she required assistance with ADLs due to shortness of breath, weakness, and a history of falls, and included staff assistance with hygiene and weekly showering. However, the Shower Preference form documented that she preferred three morning showers each week, while the Shower Schedule listed showers on Monday and Thursday on night shift. Review of shower documentation showed Resident #27 did not receive scheduled showers on 07/10/25, 07/14/25, and 07/31/25. A nursing progress note stated she had refused her shower three times on night shift because she had already gotten a shower on dayshift. During interview, Resident #27 stated she had told staff on admission that she wanted morning showers and three showers per week, but the facility had scheduled her for night showers and only two showers weekly. The DON verified that the shower preference sheet stated the resident wanted three showers a week in the morning and confirmed she was not receiving showers as scheduled or per her preference.
Failure to Complete Weekly Skin Assessments for Resident With Surgical Wounds
Penalty
Summary
The facility failed to complete weekly skin assessments for a resident admitted with multiple surgical wounds to the right foot and ankle. The resident was admitted with diagnoses including aftercare for surgical repair of a right ankle fracture, atrial fibrillation, diabetes mellitus type two, chronic osteomyelitis, esophageal varices, liver cirrhosis, and congestive heart failure. The resident was cognitively intact, required partial to moderate assistance with personal care and bathing, used a wheelchair or crutches for mobility, and was non-weight bearing to the right foot. The admission skin assessment documented multiple surgical incisions to the right foot and ankle, callouses to the right heel and under the right great toe, bruising and purple discoloration of the right great toe, and a raised, scaley, cracked area to the left great toe. The weekly skin assessments completed after admission did not include documentation or description of the resident’s specified wounds, and no weekly wound tracking or assessments were created or completed for the surgical wounds to be monitored by the wound nurse. The resident was later transferred to the hospital for treatment of the surgical wounds on the right foot, and hospital documentation showed the resident returned with new wound care treatment orders. The ADON stated that residents are to have a skin assessment within 24 hours of admission and that abnormalities or wounds are to be reported so a more in-depth wound assessment and weekly tracking can be initiated; the DON confirmed that no weekly wound assessments or tracking had been completed before the hospitalization.
Failure to Provide and Document Hand Splint Use for Resident with Bilateral Contractures
Penalty
Summary
The facility did not ensure appropriate treatment and equipment were provided to a resident with bilateral hand contractures and ALS to maintain range of motion. The resident was admitted to the facility on 11/22/23 and reentered on 10/09/24 with diagnoses including bilateral hand contractures and ALS. The record showed OT had treated the resident for bilateral hand contractures and initiated bilateral hand splints for four to six hours per day, along with a hand exercise program and staff education on splint use. PT later recommended a restorative nursing program for a restorative splint and brace program to both hands, including bilateral resting hand splints, ROM before splint use, skin and circulation monitoring, and wearing the splints at night as tolerated. Despite these recommendations, the record contained no physician orders for bilateral hand splints and no nursing documentation showing the splints were being used after therapy services ended. The care plan identified the resident as non-compliant with wearing hand splints and listed nursing interventions, but there was no splint use care plan available for review. On observation, the resident was sitting by the bed with the hand splints lying on a chair and was observed with contractures to four fingers on both hands. The resident stated the splints did not fit correctly and could not be worn. The Therapy Director confirmed there was no nursing documentation reflecting splint use after OT and PT services and no communication between therapy and nursing for placement or education, and the DON confirmed there were no physician orders, no restorative nursing program, no documentation of refusal, and no physician notification that the splints were not being worn.
Incomplete fall investigation after resident found on floor
Penalty
Summary
The facility failed to complete a thorough investigation after a resident fall. Resident #5 had chronic respiratory failure with hypoxia, COPD, morbid obesity, asthma with exacerbation, moderately impaired cognition, substantial assistance needs for several ADLs, and was a Hoyer lift transfer resident with multiple fall-risk interventions in place, including a mat beside the bed, a perimeter mattress, and the bed kept in the lowest position. On 03/22/25 at about 3:30 A.M., an LPN was called to the resident’s room by a CNA and found the resident lying supine on the floor next to the bed with deformities to the right lower leg. The LPN assessed the resident, immobilized the leg with pillows, and EMS was called for hospital transfer. The resident was unable to describe what happened. The fall investigation report documented the event, the assessment, and notifications to the physician, family, and DON, but it did not include witness statements from staff. During interview, the DON confirmed the investigation was missing staff statements and stated she could not find them. The ADON also confirmed the investigation was not thorough because no staff statements had been completed, and later contacted staff by phone for statements. The facility policy for Fall Management stated that when a fall occurs, the licensed nurse will assess the resident for injury and initiate an investigation of the reason for the fall.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care per physician order for Resident #77. The resident was admitted with diagnoses including atherosclerotic heart disease, COPD, emphysema, acute respiratory failure with hypoxia, protein-calorie malnutrition, dysphagia, and weakness. Her care plan identified shortness of breath and included administering oxygen as ordered and as needed to relieve shortness of breath. A physician order dated 11/18/24 directed that she receive 3 liters of oxygen by nasal cannula to keep oxygen saturation above 90%. Record review and observations showed the resident was not consistently receiving oxygen at the ordered flow rate. On 07/29/25, the respiratory therapist found her on room air with an oxygen saturation of 88% and replaced her oxygen at 2 liters instead of the ordered 3 liters. On 08/04/25 and 08/05/25, observations showed her oxygen concentrator set at 2 liters, and at one point she did not have her cannula in her nose. An LPN confirmed the ordered oxygen was 3 liters, then adjusted the concentrator and applied the cannula. Later that day, the concentrator was again noted at 2.5 liters and was adjusted to 3 liters. The facility policy stated oxygen was to be adjusted to the prescribed flow rate.
Failure to Document Non-Pharmacological Pain Interventions
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #24, who was admitted with diagnoses including osteomyelitis of the vertebra, MS, heart failure, sepsis, and depression. The resident had intact cognition and was non-ambulatory. Physician orders dated 07/18/25 included PRN Tramadol 50 mg every 8 hours for pain and PRN Tylenol 650 mg every 6 hours for pain, but there were no non-pharmacological interventions (NPIs) included in the orders to be attempted before administering pain medication. Review of the MAR for 07/01/25 to 07/31/25 showed Tylenol was administered 8 times for pain rated 7/10 and Tramadol was administered 10 times for pain rated 8/10, with no NPIs documented as attempted before either medication was given. Progress notes for the same period contained no entries related to attempted NPIs prior to PRN pain medication administration. The Medicare 5-day MDS indicated the resident received PRN pain medications and did not use and/or receive any NPIs. An LPN confirmed that no NPIs were offered and/or attempted before PRN pain medication was administered, and the facility's Pain Management policy stated the nurse will explore pharmacological and non-pharmacological interventions as appropriate.
Failure to Provide Timely and Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and timely assessment for three residents with indwelling catheters, resulting in actual harm to one resident. One resident with multiple comorbidities, including chronic kidney disease and neuromuscular bladder dysfunction, experienced no urinary output for two days and minimal output on the third day. Despite documentation of blood in the Foley catheter and the resident's increasing pain, staff did not properly irrigate or change the catheter, nor did they notify the physician in a timely manner. The resident's wife repeatedly requested intervention, and the resident was eventually transferred to the hospital, where a blocked catheter was found, requiring replacement, continuous bladder irrigation, and pain management. Another resident with a history of neuromuscular bladder dysfunction and chronic kidney disease had a Foley catheter with milky, foul-smelling urine that was not promptly reported to the physician. The catheter bag was tinted, making urine assessment difficult, and the last documented assessment was nearly a month prior. The physician was not notified until after the urine was observed to be abnormal, and a urinalysis and culture were delayed. The resident was later found to have a urinary tract infection with specific bacteria identified, and antibiotic treatment was started only after the delay. A third resident with a suprapubic catheter and neuromuscular bladder dysfunction did not have current orders for regular catheter changes, irrigation, or equipment changes following a recent hospitalization. The resident's care plan and urology recommendations for monthly catheter changes were not reflected in current orders, and staff were unable to change the catheter as required, resulting in the resident being sent to the hospital. Facility policy required monitoring and reporting of catheter-related issues, but these were not consistently followed for the residents involved.
Failure to Maintain Clean and Functional Heating and Cooling Units
Penalty
Summary
The facility failed to maintain the heating and cooling units (PTACs) in a safe and clean condition in four out of five resident rooms observed. During an observation with the Maintenance Director, it was found that the PTAC filters and vents in rooms 101, 215, 303, and 412 were covered with dirt and dust, with some filters ripped or missing entirely. The Maintenance Director confirmed that each PTAC should have two filters to prevent the coils from becoming dirty and dusty, and acknowledged the difficulty in finding replacement parts due to the age of the units. The Housekeeping Supervisor stated there was no established cleaning schedule for the PTAC filters, although they should be cleaned weekly. An email from the Executive Director of Facilities Management clarified the function of the vent screens but did not address the lack of filter maintenance. These findings were confirmed during the survey and represent a failure to ensure a clean and safe environment for residents, staff, and the public.
Failure to Provide Podiatry Services and Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care and ensure podiatry services for two residents with significant medical histories, including diabetes and end stage renal disease. In both cases, signed consents for podiatry services were present in the residents' records, but there was no evidence that either resident had been seen by a podiatrist during their stay. For one resident, family-provided photos and interviews confirmed that the resident's toenails were long, thick, brittle, and had buildup underneath, with dry, scaly skin present on both feet. The family reported that no foot or nail care had been performed since admission, despite the resident's enjoyment of such care prior to entering the facility. The Director of Nursing confirmed the lack of podiatry visits and noted that the facility was unaware that a physician's signature was required on the consent forms, partly due to the abrupt departure of the social services designee. In the second case, the resident's husband had requested podiatry services due to complaints of discomfort from long toenails, and was told the resident was on the list to be seen. However, the resident was not seen by the podiatrist, and subsequent review revealed that the necessary physician order had not been signed. The Director of Nursing again confirmed the absence of podiatry care and attributed the oversight to a lack of awareness regarding the need for a physician's signature and the recent loss of the social worker designee. Both cases were substantiated by medical record reviews, family interviews, and photographic evidence.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls, cerebrovascular disease, diabetes, seizures, and an absent right great toe did not have fall prevention interventions in place as outlined in their care plan. The resident had experienced three falls over several months, each resulting in new interventions being added to the care plan, such as hanging a sign to ask for help, moving personal items within reach, and using a low bed. The care plan also specified that the bed should be in the lowest position when occupied, a body pillow should be placed on the right side of the bed, personal items should be within reach, and a visual reminder should be present to use the call light for assistance. During an observation of the resident's room with the DON, it was found that the required body pillow and sign were missing, and the bed was not in the low position as specified in the care plan. The DON acknowledged that the resident had recently changed rooms and that the body pillow and sign had not been transferred to the new room. Additionally, the DON stated that she did not believe the resident wanted the bed in the lowest position and intended to update the care plan, but at the time of observation, the interventions were not in place as required.
Failure to Ensure Drug Regimen Free from Unnecessary Medications Due to Improper Morphine Administration
Penalty
Summary
A deficiency occurred when a resident's drug regimen was not kept free from unnecessary medications, specifically regarding the administration of morphine that was not in accordance with hospice orders. The resident, who had multiple complex diagnoses including tracheostomy, respiratory failure, COPD, diabetes, and several cancers, was under hospice care and had orders for several medications, including morphine for pain and dyspnea. The original morphine order was for 5 mg every four hours as needed, which was later increased to 10 mg every two hours as needed, and then clarified to every four hours as needed. However, the medication administration records (MAR) and narcotic control sheets showed multiple discrepancies in the timing, dosage, and documentation of morphine administration. The review of records revealed that morphine was administered at intervals not consistent with either the original or clarified orders, with doses given as frequently as 20 to 40 minutes apart, and some doses not documented on the MAR or narcotic control sheets. There were also inconsistencies in the administration and documentation of other medications, such as lorazepam. The DON confirmed that the nurse had transcribed the hospice order incorrectly, entering every two hours as needed instead of every four hours as needed, and that morphine was not administered per either order. Additionally, a dose of morphine given shortly before the resident's death was not documented on the control sheet. Throughout the resident's final hours, progress notes indicated ongoing administration of morphine and lorazepam, with varying documentation of effectiveness and resident response. The resident was described as minimally responsive, with signs of pain and terminal restlessness, and ultimately expired with chronic hypoxic respiratory failure and malignancies listed as causes of death. The failure to ensure accurate transcription, administration, and documentation of medication orders, particularly for morphine, resulted in the resident receiving unnecessary drugs and doses not in accordance with hospice or physician orders.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that food was prepared and served at an appetizing and safe temperature, affecting all 83 residents. During the lunch tray line observation, it was noted that the lids were off the chafing dishes, and the food was plated and sent to the dining room in an open-air cart. The dietary staff did not retake food temperatures halfway through the tray line, and the fish and tater tots were served at temperatures significantly below the industry standard of 135 degrees Fahrenheit. The dietary staff seemed unaware of the inadequate temperatures and continued to serve the food without reheating it. Interviews with residents revealed dissatisfaction with the food, citing it as cold, repetitive, and difficult to cut. Residents also expressed concerns about the quality and safety of the food, with some fearing it was undercooked. The facility's policies did not include minimum holding temperatures for food on the tray line, and the Dietary Manager confirmed the food holding temperatures did not meet industry standards. Resident Council minutes from January to March 2025 documented ongoing complaints about the food, including issues with temperature, repetition, and quality.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting all 83 residents. Observations revealed that the kitchen was in a state of disrepair and uncleanliness. The shelf above the cooktop and the top of the steamer were dirty with brown debris and a greasy, sticky film. The fronts of the refrigerators, freezers, and ovens were sticky and smeared with dried food. The Ansel system was dusty, and the floor was soiled and cracked with food debris around the appliances. The steam table had a thick lime buildup, and the knife block was dusty. Additionally, the reach-in refrigerator had rusting shelves, and there was an open, undated container of applesauce. The freezer contained unsealed hamburger patties, and the exit door wall was crumbling and rusty. The ceiling air vent was discolored, and the dumpster lid was broken. During the trayline observation, the fish and tater tots were served at temperatures below the safe threshold, with the fish at 128 degrees Fahrenheit and the tater tots at 122 degrees Fahrenheit. The staff member responsible for checking temperatures did not recognize these as too low and continued to serve the food. The Dietary Manager confirmed the findings, noting that the kitchen staff struggled to clean the old floors and that the damaged wall had been an issue for years. The manager also mentioned that the ovens and deep fryer were not used, and the steamer had issues with holding compression. The lime buildup on the steam table was attributed to water leakage.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 220 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wintersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dixon Healthcare Center | 0.9 mi | ★★★★★ | 18 | 0 |
| Steubenville Country Club Manor | 1.9 mi | ★★★★★ | 0 | 0 |
| Villa Vista Royale Llc | 2.1 mi | ★★★★★ | 3 | 0 |
| Carriage Inn Of Steubenville | 2.5 mi | ★★★★★ | 18 | 0 |
| Laurels Of Steubenville The | 3.6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.