Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Smiths Mill Health Campus during CMS and state inspections, most recent first.
Improper medication storage was identified when expired syringes, expired Ensure, and an expired Promethazine suppository were found in both med rooms, and an RN confirmed the items should have been removed from active inventory. Staff also found lidocaine 4.0% patches on a resident’s open bedside shelves instead of in locked storage, and the RN confirmed the patches were a medication that should be secured.
Required care plan conferences were not completed at regular intervals for multiple residents. Records showed residents with dementia, severe cognitive impairment, and significant medical needs had missed admission and quarterly interdisciplinary meetings, and one resident had no care planning meeting since admission. Interviews confirmed the social services vacancy and that several residents on the tracking log still had overdue conferences.
A resident with COPD who was cognitively intact and receiving oxygen therapy had a physician order and facility policy requiring oxygen tubing changes on a monthly basis. Surveyor observation found the resident’s oxygen tubing labeled as last changed in January, well beyond the ordered interval, and an RN confirmed it should have been changed sooner. Review of the oxygen administration policy showed that tubing was to be changed monthly and PRN, but this was not done for the resident, resulting in a cited deficiency related to oxygen services.
Call lights were not kept within reach for three residents with significant cognitive and functional impairment. One resident with dementia and multiple mobility-related diagnoses did not know where the call light was located, while two other residents with dementia or severe cognitive impairment had call lights positioned out of reach during observation. Staff confirmed the call lights were not within reach, despite care plans directing that they be kept accessible.
Failure to Report Injury of Unknown Origin: A resident with severe cognitive impairment and dependence for transfers developed an unwitnessed forehead bruise that was found by staff, but the injury was not reported as a FRI. Hospice was notified, and later notes suggested the bruise may have occurred when the resident bumped her head on grab bars or an enabler bar while turning in bed, but management confirmed the report was not made timely and no formal investigation was known to have been completed.
Failure to Investigate Injury of Unknown Origin: A resident with severe cognitive impairment and extensive assistance needs developed an unwitnessed forehead bruise, but the event was not handled as an FRI because staff suspected the resident may have bumped her head on an enabler bar. Leadership later confirmed there was no thorough investigation, and the file lacked staff witness statements and resident interviews despite policy requiring interviews of all involved persons.
Failure to provide bed hold notice and LTC Ombudsman discharge notification: Two residents were discharged from the facility, one to the hospital and one AMA, but the record lacked proof that a bed hold letter was given to the resident or representative and lacked proof that the LTC Ombudsman was notified of either discharge. One resident had wedge compression fractures, DM2, CKD, and intact cognition; the other had acute respiratory disease, cirrhosis, CHF, and a BIMS of 15.
A resident with TBI, dysphagia, and acute respiratory failure with hypoxia was discharged from the hospital on a soft and bite sized diet with mildly thick liquids, but the facility’s EMR orders listed a consistent carbohydrate diet with pre-cut meats and thin liquids. Nursing notes were silent for physician communication about changing the diet order, and later ST and nutrition documentation reflected the resident on regular textures and thin liquids instead of the hospital discharge diet.
The facility failed to timely review and act on pharmacist drug regimen review recommendations for multiple residents. One resident with anemia had repeated pharmacist recommendations for CBC follow-up that were not completed for weeks, another resident with dementia had morphine orders that were not clarified despite pharmacist warnings about a concentration mismatch and potential med error, and a third resident had lab-monitoring recommendations with no documented response. The DON and DHS confirmed pharmacy recommendations were not being completed within the expected timeframe.
A resident with dementia and an anxiety disorder received PRN morphine for pain, but the MARs and progress notes did not document any non-pharmacological pain interventions being attempted despite a care plan approach to do so. The DHS confirmed that non-pharmacological interventions were not used in managing the resident’s pain.
Improper Disposal Setup for Soiled PPE: A resident with C. difficile carrier status, a colostomy, and contact precautions had no containment system in the room or outside the door for disposing of soiled PPE. An LPN confirmed the absence of a biohazard container, despite facility policy requiring gown and gloves to be discarded in a biohazard container before leaving the room.
A resident with functional quadriplegia, dysphagia, and multiple comorbidities, who was documented as fully dependent on staff for eating, had a lunch tray placed at the bedside and left untouched for an extended period before staff came to assist. The resident reported routinely waiting several minutes to as long as half an hour while the tray sat in front of him, stating he had to sit and look at it. Surveyor observations confirmed the tray remained untouched for a prolonged time with no staff assistance, and the DON acknowledged this constituted an undignified meal experience.
Two residents were affected when staff failed to follow physician orders and recognize a change in condition. One resident with multiple comorbidities and moderate cognitive impairment had two skin tears on the upper arm with an order for scheduled dressing changes; surveyors later observed the dressing still dated from several days earlier, heavily soiled with dried blood, and an LPN confirmed the ordered treatments had not been done. Another resident with severe cognitive impairment and multiple medical issues became drowsy and difficult to arouse; an LPN documented tachycardia but did not record any vital signs or assessment in the record before the resident was sent to the hospital. EMS found the resident hot, pale, tachycardic, with pinpoint non‑reactive pupils and high temperature, administered naloxone and IV fluids, and initiated a sepsis alert, while facility staff interviews revealed gaps in monitoring, documentation, and timely identification of the change in condition.
The facility failed to ensure adequate supervision, appropriate fall‑prevention interventions, and safe assistance with bed mobility and transfers for several residents with cognitive impairment and significant mobility needs. One resident with dementia and a high fall‑risk score had three falls, including a witnessed fall from a wheelchair with head impact, without documented post‑fall assessments such as vital signs. Another cognitively impaired resident, initially assessed as low fall risk despite impaired mobility, experienced multiple falls while attempting to self‑transfer for toileting and bed mobility, with at least one fall lacking an identified root cause or new intervention and no documented post‑fall vital‑sign assessments. A third dependent resident fell from bed and struck the head when a CNA, working alone, turned the resident away from herself during incontinence care, contrary to safe handling practices. Staffing patterns showed only three CNAs and two nurses on night shifts for nearly 50 residents, and a CNA reported that residents needing increased supervision could not be adequately monitored under this staffing.
A high fall-risk resident with dementia, prior fractures, and impaired mobility experienced multiple falls, including one with head impact and another causing painful limited ROM, despite a care plan identifying fall risk and interventions such as transfer assistance, nonskid footwear, and dycem on the wheelchair. The resident was found on the floor in the room and hallway on several occasions, sometimes after becoming anxious when family left, and was not assessed post-fall for further injury or vital signs. Staffing schedules showed only three CNAs and two nurses on night shifts for nearly 50 residents, with each nurse covering two hallways and CNAs covering one hallway plus extra rooms. A CNA reported that residents needing increased supervision could not be adequately monitored under the usual staffing pattern, and the family reported difficulty locating staff responsible for the resident’s care due to staff being assigned across multiple hallways.
A resident with multiple comorbidities, including dementia, peripheral vascular disease, and right lower extremity wounds, returned from a wound-related appointment with an after-visit summary directing initiation of Doxycycline 100 mg PO BID for seven days. The physician’s order, faxed directly to the pharmacy, was later found in the facility copy room and only then transcribed to the MAR, with the first dose administered several days after the appointment. An LPN reported being unsure of the reason for the antibiotic but aware it came from the outside visit, and the DON confirmed the order was not implemented in a timely manner.
Two residents experienced deficiencies in EMR accuracy and completeness when wound care and change-in-condition assessments were not properly documented. For one resident with multiple chronic conditions and moderate cognitive impairment, skin tears on the upper arm were ordered to be treated with scheduled dressing changes, yet the dressing remained unchanged and soiled while LPNs documented on the TAR that treatments had been completed. For another resident with severe cognitive impairment and a recent femur fracture, an LPN documented drowsiness and tachycardia and arranged hospital transfer, but no assessment or vital signs were entered into the EMR, despite another nurse recalling obtaining abnormal vital signs and the LPN later admitting she had failed to chart them.
A resident with multiple chronic pressure ulcers and complex medical conditions received wound care in which an RN failed to separate treatments between five different wounds, repeatedly using the same gloves while removing dressings and cleansing and redressing multiple sites. Although enhanced barrier precautions and specific wound care orders were in place, the RN did not change gloves between wounds and used the same gloves when moving from one wound to another, including from a posterior calf wound to a heel ulcer treated with betadine. This practice conflicted with the facility’s wound care guidelines and created a potential for cross-contamination between chronic wounds.
A resident with dementia and Parkinson's disease was given Seroquel without a documented or appropriate diagnosis to support its use. The medication was ordered and administered for anxiety and hallucinations, despite the absence of documented behaviors or psychiatric disorders and without adherence to FDA-approved indications. Facility staff, including the NP and DON, confirmed the lack of proper documentation and awareness of policy requirements.
A resident with significant medical needs and recent weight loss did not receive prescribed nutritional supplements with meals and was not weighed according to physician orders. Staff interviews and record review confirmed that required supplements were not provided and monthly weight monitoring was not completed as directed.
The facility did not have a registered nurse (RN) on duty for eight hours on a specific day, as required. A review of staffing sheets revealed that no RN was scheduled on one day during the week of February 11 to February 17, 2025. The Administrator confirmed this absence during an interview. The facility had a census of 42 residents at the time.
A resident with multiple medical conditions missed a scheduled wound care appointment due to the facility's failure to provide transportation. The van driver was unavailable, and the facility did not arrange alternative transportation as per their policy. This incident was part of ongoing non-compliance issues.
A resident with multiple health conditions and mobility dependence fell during incontinence care due to inadequate fall risk assessment and care planning. The facility did not complete necessary assessments or update the care plan to reflect the need for increased assistance, leading to the resident sliding out of bed. Staff interviews revealed inconsistent procedures for providing care to residents with mobility issues.
A facility failed to ensure a resident received scheduled baths or showers, as documented records showed inconsistencies and possible alterations. The resident, who required substantial assistance for bathing, was noted to occasionally refuse care. Staff interviews confirmed the use of shower/skin sheets for documentation, but the facility could not provide supporting documents like staff time sheets to verify the care provided.
A facility failed to implement physician orders for lymphedema pumps for a resident with a history of embolism and thrombosis. Despite wound clinic instructions to use the pumps for edema control, no order was found in the resident's records. Interviews confirmed the absence of an order, despite the resident's medical history necessitating the pumps.
A resident with a history of embolism and pressure ulcers was injured during transport to a wound clinic when their foot slipped off a malfunctioning wheelchair pedal, resulting in a bruise. The transportation associate attempted to fix the pedal but was unsuccessful, leading to the injury. The incident was reported, but no documented education or corrective action was noted.
The facility failed to complete MDS assessments within required timeframes for several residents, as identified through medical record reviews and staff interviews. Delays in completing quarterly, admission, and discharge MDS assessments were confirmed by the MDS Coordinator and Regional Nurse, indicating non-compliance with the RAI guidelines.
The facility failed to establish proper parameters for anticoagulant, PRN pain, and blood pressure medications, affecting five residents. Residents received medications without specified parameters, leading to inappropriate administration and lack of physician communication. The facility's policy on medication administration was not followed, resulting in deficiencies in medication management.
The facility failed to ensure timely administration and availability of medications for several residents, including insulin for residents with diabetes. Instances of late administration and unavailability of medications were documented, affecting residents with various medical conditions. The facility's policy on medication administration was not adhered to, leading to deficiencies investigated under a complaint.
A facility failed to notify a resident's representative and CNP of significant changes in the resident's condition, including abnormal vital signs and critical lab results. The resident, with multiple medical diagnoses, experienced a decline in health that was not communicated in a timely manner, leading to a hospital transfer for multiple infections. The facility's policy required immediate notification of such changes, but this protocol was not followed.
A resident with multiple medical conditions was transferred to the hospital in an emergency without a written transfer notice. Despite notifying the resident's representative and CNP, the facility did not complete the required documentation as per their policy.
A facility failed to provide a written discharge notice to a resident or their representative before discharging the resident. The resident, who had multiple medical conditions and required substantial assistance, was found in a critical state and transferred to the hospital. Although the transfer was communicated verbally, no written notice was documented, contrary to facility policy.
A facility failed to accurately complete the MDS assessment for a resident with multiple diagnoses, including dementia and chronic kidney disease, who was receiving hospice care and warfarin. The MDS did not reflect the resident's use of anticoagulant medication during the look-back period, as confirmed by staff interviews, leading to a deficiency.
A facility failed to assess and plan care for a resident with PTSD, who was admitted with PTSD, anxiety disorder, and depression. The resident's care plans did not address the cause of PTSD, potential triggers, or interventions to reduce re-traumatization risk. An interview with the Director of Social Work confirmed the lack of assessment and care plan implementation.
The facility failed to properly inform two residents about their rights regarding a binding arbitration agreement, including the 30-day revocation period. Both residents, who were cognitively intact, were not made aware of their right to rescind the agreement within the specified timeframe. The Director of Sales confirmed the lack of a policy and did not ensure residents understood the agreement before signing.
A resident with a history of hemiplegia, diabetes, and hypertension experienced a delay in treatment for a urinary tract infection. The resident reported discomfort with urination, and a urinalysis was conducted. Although the results were available, there was a delay in ordering antibiotics until several days later, as confirmed by a Regional Support Nurse.
Two residents experienced significant medication errors due to pharmacy and staff issues. One resident received the wrong type of insulin because the pharmacy sent incorrect supplies, and an LPN failed to verify the medication label. Another resident did not receive prescribed insulin due to unavailability, and blood sugar levels were not monitored as required.
A facility failed to adhere to Enhanced Barrier Precautions during medication administration for a resident with a gastric tube. The resident, on hospice care with multiple diagnoses, was observed receiving medication from an LPN who only wore gloves, contrary to the policy requiring both gown and gloves. This deficiency was confirmed by an RN and noted during a complaint investigation.
The facility failed to provide adequate staffing, affecting resident care. Observations showed insufficient staff levels, with only three licensed nurses and four STNAs for 46 residents. Family members and residents reported missed meals, lack of incontinence care, and long call light response times. Staff confirmed inadequate care due to staffing shortages, with residents left soiled and showers not consistently performed.
The facility failed to provide adequate ADL assistance, affecting four residents with varying medical conditions. Observations revealed long, dirty fingernails and inconsistent bathing documentation. A resident was found wearing the same clothes over consecutive days. Interviews confirmed the lack of care, and the DHS verified the poor hygiene. This issue was part of ongoing non-compliance.
A resident with multiple medical conditions, requiring assistance for daily activities, did not receive scheduled showers over a month-long period. Despite being scheduled for showers twice a week, the resident only received one shower and several bed baths. Observations and interviews confirmed the resident's preference for showers and insufficient staff to assist. Documentation of refusals was incomplete, and the facility's policy for bathing frequency was not followed.
Two residents in the facility experienced significant medication errors due to improper identification and administration practices. One resident with Alzheimer's received the wrong medications twice, while another resident with intact cognition was mistakenly given another resident's medications. The facility's policy on medication administration, which includes the five rights and proper identification, was not followed, leading to these errors.
A facility failed to properly disinfect a glucometer after use, affecting a resident with diabetes. An LPN used the glucometer without disinfecting it before or after obtaining a blood glucose reading. The glucometer was placed on surfaces without barriers and stored without cleaning. The LPN confirmed the failure to disinfect and attempted to clean it improperly, not following the manufacturer's guidelines.
Improper Medication Storage and Expired Supplies
Penalty
Summary
Drugs and biologicals were not properly stored in the facility’s medication storage rooms. During observation, both medication storage rooms contained multiple boxes of 100 three milliliter syringes with an expiration date, multiple boxes of tuberculin syringes with an expiration date, a single-serve Vanilla Ensure in the freezer with an expiration date, and a 25 mg Promethazine suppository in the refrigerator with an expiration date. Assistant Director of Health Services #165 confirmed the presence of the expired syringes, Ensure, and Promethazine suppository. The facility policy titled Medication Storage stated that outdated medication must be immediately pulled from active inventory. The facility also failed to ensure a medication was stored in a secured location. Review of Resident #31’s medical record showed the resident was admitted to the facility on [DATE]. During observation, lidocaine 4.0% patches were found on Resident #27’s open bedside shelves. RN #159 confirmed the lidocaine 4.0% patches were a medication and should be kept in locked storage, not at the bedside. The deficiency affected two of two medication rooms reviewed and had the potential to affect all 49 residents in the facility.
Failure to Hold Required Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences at regular intervals for residents, including conferences due upon admission and quarterly thereafter. Review of the facility policy showed interdisciplinary care conferences were required upon admission, quarterly, with significant changes in condition, and as needed to evaluate and revise the resident’s plan of care with participation from the resident and/or representative. Survey review found that multiple residents listed on the facility’s quarterly Resident First Meeting tracking log had not had the required conferences completed. Resident #50 had diagnoses including unspecified dementia, COPD, hypertension, depression, and dependence on a wheelchair. The resident’s record showed the last documented care conference was 05/08/25, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence for oral hygiene, toileting hygiene, showering or bathing, lower body dressing, footwear, and personal hygiene. The resident’s representative stated the facility had not been conducting care conferences since the previous social worker left about six months earlier. The ED confirmed that required care conferences had not been completed for multiple residents on the quarterly tracking log, including Resident #50. Resident #61 had diagnoses including Alzheimer’s disease, anxiety disorder, and a history of urinary tract infections, and the last documented care conference was 07/31/25. The MDS showed severely impaired cognitive skills for daily decision making and dependence for toileting hygiene, showering or bathing, footwear, and personal hygiene. Resident #62 had diagnoses including dementia, dysphagia, wedge compression fracture, and need for assistance with personal care; the MDS showed severe cognitive impairment and dependence for toileting hygiene with partial to moderate assistance for transfers. The chart showed Resident #62 had not had a care planning meeting since admission. Resident #19 had diagnoses including hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, type 2 diabetes mellitus with peripheral angiopathy, atrial fibrillation, pulmonary hypertension, morbid obesity, and COPD, and the record showed no documented evidence that care conferences were completed. Interviews with RSS #200 and the ED confirmed the social worker position had been vacant since approximately November 2025 and that not all required care conferences had been completed at the time of survey.
Failure to Change Oxygen Tubing per Physician Order and Policy
Penalty
Summary
A deficiency occurred when the facility failed to change oxygen tubing as ordered by the physician and as required by facility policy for a resident receiving oxygen therapy. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, was cognitively intact and had a physician order dated 01/02/26 directing that oxygen tubing be changed monthly. On 04/27/26 at 10:22 A.M., observation showed the resident’s oxygen tubing was labeled as last changed on January 20 (no year), indicating it had not been changed according to the monthly schedule. During an interview at 10:30 A.M. the same day, an RN confirmed that the tubing was dated January 20 (no year) and acknowledged it should have been changed sooner. Review of the facility’s “Administration of Oxygen” policy, effective 05/2018, showed that oxygen tubing was required to be changed monthly and as needed, which was not followed in this case. This deficiency was cited as non-compliance under Complaint Number 2989132 and involved one of two residents reviewed for oxygen services in a facility with a census of 49.
Call lights not kept within reach
Penalty
Summary
The facility failed to ensure call lights were within reach for three residents reviewed for environment. Resident #9 had diagnoses including unspecified dementia, major depressive disorder, anxiety disorder, weakness, history of falling, feeding difficulties, unsteadiness on feet, and muscle weakness. The resident’s MDS showed cognitive impairment and substantial to maximal assistance was needed for rolling and moving from lying to sitting. Although the care plan included keeping the call light within reach, observations on 04/27/26 and 04/29/26 showed the call light hanging below the left bed rail, and the resident stated they did not know where the call light was located. A CRCA confirmed the call light was not within reach. Resident #27 had diagnoses including dementia, anxiety disorder, depression, and cerebral atherosclerosis, and the MDS showed severely impaired cognitive skills for daily decision making and dependence for bed-to-chair transfer. The care plan included keeping the call light in reach, but observation showed the resident up in a specialized wheelchair on the right side of the bed while the call light hung over the arm of a recliner chair on the left side of the bed and was out of reach; an RN confirmed this. Resident #50 had diagnoses including unspecified dementia, COPD, hypertension, depression, and wheelchair dependence, with the MDS showing severely impaired cognitive skills for daily decision making and dependence for multiple ADLs. The care plan also included keeping the call light in reach, but observation showed the call light hanging below the right bed rail, and an RN confirmed it was not within reach. The facility policy stated staff should ensure the call light is plugged in securely and in reach of the resident.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for one resident with severe cognitive impairment. Resident #27 had diagnoses including dementia, anxiety disorder, depression, and cerebral atherosclerosis, and required substantial to maximal assistance with bed mobility and was dependent for transfers. On 11/04/25, staff found a bruise on the resident’s forehead, and the progress note documented that bumper pads and floor mats were already in place before the bruise was discovered. Hospice was notified, but the Ohio Department of Health Application Gateway contained no Facility Reported Incident for the injury. The event was later documented in an event report on 11/05/25, which described an unwitnessed bruise and noted padding on the grab bars as a preventative measure. Subsequent progress notes stated that the resident may have bumped her head on the grab bars or enabler bar while turning in bed, but the Interim DHS confirmed the bruise was not reported timely and that staff did not notify management until the following day. The Executive Director stated only hospice was notified when the bruise was discovered and confirmed the injury was not reported as a FRI because the facility concluded it came from the enabler bar; no formal investigation was known to have been completed.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of injury of unknown origin for one resident with dementia, anxiety disorder, depression, and cerebral atherosclerosis who had severely impaired cognitive skills and required substantial to maximal assistance with bed mobility and was dependent for transfers. The resident had a fall-related plan of care that included an air mattress with bolsters, and progress notes documented that a bruise was found on the resident’s forehead, with bumper pads and floor mats in place before the bruise was discovered. The hospice nurse was notified, and later documentation described the bruise as measuring 4 cm by 4 cm with padding to the grab bars in place. The event was entered as an unwitnessed bruise and linked to the forehead bruise, but the facility did not report it as a Facility Reported Incident because staff suspected the resident may have bumped her head on the enabler bar while turning in bed. The Interim DHS stated she thought staff were interviewed and other residents were looked at, but did not recall whether the event was investigated. The Executive Director was not aware of a formal investigation, and the DHS later confirmed the investigation was not thorough because it did not include witness statements from staff or resident interviews. The facility policy required the investigation to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation.
Failure to Provide Bed Hold Notice and Ombudsman Discharge Notification
Penalty
Summary
The facility failed to issue a bed hold letter when Resident #64 was discharged to the hospital, and failed to notify the LTC Ombudsman of the discharge status of Resident #64 and Resident #66. Resident #64 was admitted with diagnoses including wedge compression fractures, type 2 diabetes mellitus, and chronic kidney disease, and had intact cognition on the MDS with opioid medication use. On 03/16/26, nursing progress notes documented that the resident wanted to leave the facility because pain medications were not being changed, and the resident was offered options including staying for safe discharge planning, leaving against medical advice, or going to the hospital for evaluation of possible altered mental status. The resident chose hospital transfer, and the discharge observation report stated the transfer was necessary to meet the resident’s welfare and that needs could not be met at the facility. The record did not contain proof that a bed hold letter was provided to the resident or representative, and the discharge observation noted the Ombudsman would be notified monthly. Resident #66 was admitted with diagnoses including acute respiratory disease, cirrhosis of the liver, and chronic diastolic heart failure, and had intact cognition on admission with a BIMS score of 15 on the MDS. Nursing progress notes dated 02/19/26 documented that the resident left the facility against medical advice. The medical record did not contain proof that the LTC Ombudsman was notified of the discharge from the facility. Facility policy titled, Guidelines for Transfer and Discharge, stated that before transferring a resident to a hospital, nursing staff should provide written information to the resident and a family member or representative regarding bed hold and admission policies, and the discharge observation report stated that the facility would notify the LTC Ombudsman of discharges monthly.
Diet Order Not Accurately Transcribed for Resident with Dysphagia
Penalty
Summary
The facility failed to accurately transcribe a diet order for Resident #67, who was admitted with traumatic brain injury, dysphagia, and acute respiratory failure with hypoxia. The resident’s hospital records showed hypoxia that was possibly related to bouts of aspiration pneumonitis due to pocketing food. The hospital notes and discharge summary indicated the resident was started on and discharged with a soft and bite sized diet with mildly thickened liquids, but the facility admission assessment documented no swallowing problems and the resident’s electronic physician orders from 04/24/26 through 04/30/26 listed a consistent carbohydrate diet, pre-cut meats, and regular/thin liquids with special instructions for Styrofoam cups. Nursing progress notes from 04/24/26 through 04/27/26 were silent for communication with the physician about changing the diet orders. The resident’s BIMS score was 4, indicating severe cognitive impairment. Speech therapy later assessed the resident as having mild to moderate oropharyngeal dysphagia with prolonged mastication, incomplete bolus formation, pocketing, diffuse oral residue, and incomplete airway protection, though the resident was considered safe for regular textures with thin liquids using compensatory feeding strategies. The nutrition assessment also documented the resident on a consistent carbohydrate diet and thin liquids, and the speech therapist confirmed that the hospital discharge diet order was not implemented into the admission orders.
Delayed Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacist drug regimen review recommendations were reviewed and acted upon in a timely manner for residents #11, #27, and #54. The report states the facility was responsible for having pharmacy recommendations reviewed by the provider, documented in the medical record, and completed within the expected timeframe, but this did not occur for the residents reviewed for unnecessary medications. Resident #54 was admitted with diagnoses including abdominal aortic aneurysm and posthemorrhagic anemia, and had intact cognition on MDS assessment. A CBC on 01/21/26 showed a hemoglobin of 7.8 g/dL and hematocrit of 25%. The pharmacist reviewed the low hemoglobin on 02/12/26 and recommended further follow-up or treatment, with provider acceptance documented on 02/26/26 and a plan to redraw a CBC. However, there was no documentation of a CBC from 02/26/26 to 03/12/26, and a later pharmacist review again recommended rechecking a CBC. The CBC was not redrawn until 03/25/26, when hemoglobin remained low at 8.0 g/dL. Resident #27 had diagnoses including dementia, anxiety disorder, depression, and cerebral atherosclerosis, and had severely impaired cognitive skills for daily decision making. The physician order for morphine solution listed a concentration of 20 mg per 5 mL with directions that did not match the available product, and the pharmacist twice recommended clarification of the product concentration and directions because of potential for medication error. There was no documented physician response to either recommendation. Resident #11 also had a pharmacist drug regimen review with recommendations for laboratory monitoring and no documented response or evidence that the recommendations were reviewed or implemented. The DON and DHS confirmed the recommendations were not being completed within 14 days as expected.
Failure to Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions in the management of one resident’s pain. Resident #27, who was admitted with diagnoses including dementia and an anxiety disorder, had an MDS assessment showing severely impaired cognitive skills for daily decision making and use of scheduled and as-needed pain medications. A physician order dated 06/02/25 included morphine solution as needed for pain, and the resident’s care plan for pain included an intervention to attempt non-pharmacological interventions with a start date of 07/10/25. Review of the MARs from July 2025 through April 2026 showed multiple administrations of PRN morphine solution, but the MARs and progress notes for that period did not document any non-pharmacological interventions attempted for pain management. During interview on 04/29/26 at 4:01 P.M., the Director of Health Services confirmed that non-pharmacological interventions were not attempted in managing the resident’s pain.
Improper Disposal Setup for Soiled PPE
Penalty
Summary
The facility failed to maintain a proper containment system for soiled personal protective equipment for one resident. Resident #26 was admitted with diagnoses including severe sepsis with septic shock, recurrent enterocolitis due to clostridium difficile, and attention to colostomy. The resident’s MDS assessment showed substantial to maximal assistance was needed for toileting hygiene, and the hospital record noted clostridium toxin B was detected with no active infection, identifying the resident as a carrier of clostridium toxin. The resident was receiving oral vancomycin and was on contact precautions during high-contact care because of carrier status and colostomy. During observation of the resident’s room, there was no containment system present in the room or outside the door for disposal of soiled PPE. An LPN confirmed that no containment system was available in the resident’s room. The facility policy for Contact Precautions stated that PPE such as gown and gloves should be disposed of in a biohazard container before leaving the resident’s room.
Undignified Dining Experience for Dependent Resident
Penalty
Summary
A resident who was functionally quadriplegic and dependent on staff for all self-care and mobility, including eating, was not provided a dignified dining experience when staff left his lunch tray at his bedside and did not return to feed him for an extended period. The resident had diagnoses including Guillain-Barre syndrome, dysphagia, urinary retention, diabetes mellitus, hyperlipidemia, and hypertension, and his care plan and functional assessment documented that he was dependent on staff for eating. During an observation at 11:55 A.M., the resident’s lunch tray was seen untouched on his bedside table, and the resident stated that staff come to feed him only after all meal trays have been delivered, reporting that he may wait from eight to 30 minutes while the tray sits in front of him, saying, “I have to sit and look at it.” A follow-up observation at 12:10 P.M. showed the tray remained untouched and no staff had come to feed him. In an interview at 1:00 P.M., the DON confirmed that leaving the meal tray in front of a resident who could not feed himself constituted an undignified meal experience. This deficiency was cited for one resident under Complaint Number 2740077.
Failure to Provide Ordered Skin Treatments and Timely Response to Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered treatment for non‑pressure skin impairments for one resident. A resident with multiple comorbidities, including peripheral vascular disease, dementia, and a left below‑knee amputation, was admitted with moderate cognitive impairment. On admission, two skin tears were identified on the left upper arm, and a physician order was obtained for cleansing with normal saline, patting dry, and applying xeroform, ABD pad, and Kerlix dressings on a Monday/Wednesday/Friday schedule and as needed. The Treatment Administration Record showed treatments were due on two specific dates, but observations later revealed the dressing on the left upper arm was still dated several days earlier and was heavily soiled with a large amount of dark red dried blood. An LPN confirmed the ordered dressing changes had not been performed on the scheduled dates. The deficiency also involves the facility’s failure to timely identify and document a change in condition for another resident. This resident had severe cognitive impairment and multiple diagnoses, including fractures, anemia, dementia, and adult failure to thrive, and was later discharged to an acute care hospital. On the day of transfer, an LPN documented that the resident was drowsy and would not fully wake up, and that the family requested he be sent out; the note stated that vitals were taken and that the resident was tachycardic, but no vital signs were recorded in the medical record. Review of the record showed no documented assessment or vital signs prior to transfer. The ambulance run report documented that upon EMS arrival, the resident was hot, dry, and pale, with coarse lung sounds, a dry cough, rapid pulse, pinpoint non‑reactive pupils, and an elevated temperature, and that naloxone and IV fluids were administered, with a sepsis alert initiated. Further review showed the resident had received two doses of oxycodone earlier that day per PRN orders. In the emergency department, the resident presented with altered mental status, elevated temperature, and tachycardia, and was diagnosed with sepsis present on admission, acute encephalopathy, and an acute left femoral neck fracture, among other findings. A CNA reported that she had delivered the resident’s meal tray and found him sleeping and did not see him again before transfer due to her workload. An RN reported that the resident’s daughter expressed concern, prompting the RN to obtain vital signs and note a pulse in the 120s–130s and irregular, after which the LPN took over. The LPN later stated she had assessed the resident earlier and found no negative findings, did not obtain a temperature, and acknowledged that no assessment or vital signs were charted, stating she must have forgotten. The DON confirmed there was no assessment or vital signs documented and that the change in condition was not identified timely.
Failure to Provide Adequate Supervision and Safe Assistance Resulting in Multiple Falls and Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and assistance to prevent falls and injuries, particularly for residents with cognitive deficits and those requiring extensive assistance. One resident with Alzheimer’s disease, dementia, a history of falls with fractures, and a high fall‑risk score experienced three falls within a short period. The care plan identified fall risk and listed general interventions such as keeping the floor free of objects, ensuring call light and personal items were within reach, providing nonskid footwear, and staff assistance with transfers. After the first fall, which occurred when the resident became anxious after family left and attempted to self‑transfer, the facility added dycem to the wheelchair and later an intervention to keep the resident in common areas after family visits. Despite these measures, the resident was next observed falling from his wheelchair in the hallway, striking his head and requiring ER evaluation, and then sustained a third fall in his room with painful and limited lower extremity range of motion. The record showed the resident was not assessed after these falls for further injury, including vital signs. Another resident with dementia, moderate cognitive impairment (BIMS score 8/15), impaired mobility, and multiple medical conditions including peripheral vascular disease, heart failure, and a left below‑knee amputation was initially assessed as low fall risk. The care plan included general fall‑prevention interventions and later added toileting after meals and at bedtime and bilateral floor mats. This resident experienced multiple falls, most associated with attempts to self‑transfer for toileting or getting in and out of bed. The resident was found on the bathroom floor after attempting to go to the bathroom, again on the bathroom floor between the wheelchair and toilet after sliding during a transfer, on the floor in the room after attempting to get out of bed, and under the bed during a meal pass after stating he was trying to fix the bed. Later, the resident was seen sliding out of the wheelchair onto the floor and was found on the floor in front of the bed after attempting to get into bed. For at least one of these falls, the post‑fall investigation documented no root cause and no new intervention. The record also showed the resident was not assessed after falls for further injury, including vital signs. A third resident, who had no cognitive deficit but was dependent on staff for toileting, lower‑body dressing, bed mobility, and required substantial/maximal assistance for showers and sit‑to‑stand, fell from bed during incontinence care. While a CNA was turning the resident away from herself, the resident rolled out of bed, struck her head on the closet, and sustained a bleeding abrasion that required ER evaluation. The facility later documented that the CNA had rolled the resident away from her while working alone, and the DON confirmed that no resident should be rolled away from staff when the staff member is working alone. Across these cases, staffing schedules showed three CNAs and two nurses on night shifts for 47–48 residents, with each CNA responsible for one hallway plus additional rooms and each nurse responsible for two hallways. A CNA interview indicated that with the usual staffing pattern, when staff are in a room or on another hallway, residents who require increased supervision cannot be adequately supervised. The facility’s fall management policy stated that nursing staff would monitor and document resident response and effectiveness of interventions for 72 hours after a fall, but the records for these residents did not show post‑fall assessments including vital signs.
Inadequate Staffing and Supervision Leading to Multiple Falls
Penalty
Summary
The facility failed to provide sufficient staffing and supervision to prevent falls for a high-risk resident. The resident was admitted with multiple diagnoses including a displaced subtrochanteric fracture of the right femur, anemia, cerebral ischemia, urinary retention, Alzheimer's disease, dementia, prior falls with fractures, and adult failure to thrive. A fall risk assessment showed a high fall risk score of 22, and the care plan identified risk for falls related to impaired mobility, medication side effects, and history of falls, with interventions such as keeping the call light and personal items within reach, providing nonskid footwear, assisting with transfers, and therapy evaluation. Additional interventions later included use of dycem on the wheelchair and having the resident in a common area after family left in the evening. Despite these identified risks and interventions, the resident experienced multiple falls within a short period. On three separate occasions, the resident was found on the floor after attempting to self-transfer or falling from the wheelchair, including one fall in the hallway where the resident hit his head and was sent to the ER, and another fall resulting in painful and limited range of motion in the lower extremity. Post-fall investigations documented that the resident became anxious after family left and attempted to self-transfer, and that the resident was to be kept at the nurse’s station or in a common area for supervision. However, the medical record showed the resident was not assessed after the falls for further injury, including vital signs. Staffing schedules for the relevant dates showed three CNAs and two nurses on the night shift for 47–48 residents, with each nurse responsible for two hallways and each CNA for one hallway plus additional rooms. A CNA reported that with the usual staffing pattern, residents requiring increased supervision could not be adequately supervised, and the resident’s family reported difficulty finding CNAs or nurses responsible for the resident’s care due to staff covering multiple hallways. The administrator acknowledged an issue with falls that had been taken to QAPI and a pattern to when falls occurred.
Delayed Implementation of Antibiotic Order Following Wound Care Visit
Penalty
Summary
The deficiency involves the facility’s failure to implement a physician’s order for an antibiotic in a timely manner for one resident. The resident was admitted with multiple diagnoses, including infection and inflammatory reaction due to cardiac and vascular devices, toxic encephalopathy, cellulitis of the right lower limb, myositis of the right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, urinary retention, cardiac arrhythmia, left below-knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia, and hypothyroidism. A Brief Interview for Mental Status (BIMS) completed shortly after admission showed a score of 8/15, indicating a moderate cognitive deficit. An after-visit summary from an appointment related to open wounds on the right lower leg and right great toe directed that the resident was to start Doxycycline 100 mg by mouth twice daily for seven days. Despite this order, the antibiotic was not started until several days later. A progress note documented that an order for Doxycycline 100 mg by mouth twice daily for seven days, faxed directly from the physician to the pharmacy, was observed in the copy room on 02/17/26 at 3:59 A.M., at which time it was then transcribed to the Medication Administration Record (MAR). The monthly physician orders reflected the Doxycycline order dated 02/17/26, and the MAR showed the first dose was administered during the morning medication pass on that same date. During an interview, an LPN stated he was unsure why the resident was on Doxycycline but knew the order originated from the earlier appointment. In a separate interview, the DON confirmed that the Doxycycline order had not been implemented in a timely manner. This deficiency was cited under Complaint Number 2740077.
Incomplete and Inaccurate EMR Documentation for Wound Care and Change in Condition
Penalty
Summary
The deficiency involves failure to maintain complete and accurate electronic medical records and treatment documentation for two residents. One resident with multiple chronic conditions, including dementia, peripheral vascular disease, and a left below-knee amputation, was admitted with moderate cognitive impairment. A progress note documented two skin tears on the left upper arm, and a physician order was obtained for wound care with dressing changes scheduled three times weekly and as needed. The Treatment Administration Record (TAR) showed that LPNs documented that the ordered treatments were provided on specific dates; however, observations on a later date revealed the dressing on the resident’s left upper arm was still dated from the day of injury and was heavily soiled with dried blood. In an interview, one LPN confirmed the dressing had not been changed on the dates documented, verifying that the TAR entries were inaccurate. For the second resident, who had severe cognitive impairment and multiple diagnoses including a right femur fracture, dementia, anemia, and adult failure to thrive, the medical record lacked documentation of an assessment and vital signs at the time of a change in condition. A progress note by an LPN stated the resident was drowsy, would not fully wake up, and was tachycardic, and that the family requested transfer to the hospital, with an order obtained from the CNP to send the resident out. However, the record contained no evidence that the LPN obtained an assessment or vital signs prior to transfer. Another nurse reported that she, not the assigned LPN, initially obtained vital signs showing an irregular pulse in the 120s–130s before the LPN took over. In a subsequent interview, the LPN acknowledged that she had assessed the resident and obtained vital signs earlier but had not documented any assessment or vital signs in the EMR, stating she must have forgotten. The DON confirmed the absence of assessment and vital sign documentation in the medical record and that the change in condition was not identified timely.
Improper Infection Control During Multi-Wound Dressing Change
Penalty
Summary
The deficiency involves a failure to maintain appropriate infection prevention and control practices during a pressure ulcer dressing change for Resident #16. The resident had multiple serious medical conditions, including sepsis, osteomyelitis of the vertebra, a stage IV sacral pressure ulcer, several unstageable pressure ulcers, dementia, and adult failure to thrive, and was dependent on staff for all ADLs. The care plan and physician orders included multiple wound care treatments and the use of enhanced barrier precautions (EBP), requiring staff to wear a gown and gloves during high-contact care. During an observed treatment session, the RN sanitized hands, donned gown and gloves, sanitized the bedside table, and set up supplies. The RN removed the soiled dressing from the right calf, then removed soiled dressings from the sacrum, right upper back, and right scapula using the same gloves. After removing the dressings, the RN washed hands, donned new gloves, and cleansed and dressed the wounds on the right upper back and right scapula with normal saline, calcium alginate, and bordered foam dressings, using the same gloves for both wounds. The RN then cleansed, packed, and dressed the sacral wound with normal saline, calcium alginate, and a bordered foam dressing, again without changing gloves between wounds. The RN left the room for additional supplies, washed hands, then returned and cleansed and dressed the right posterior calf wound and applied betadine to the left heel ulcer, using the same gloves for both sites. In a subsequent interview, the RN confirmed that the treatments to the five pressure ulcers were not separated, introducing the potential to spread infection from wound to wound. Facility policy on general wound and skin care required handwashing before and after resident contact and recognized that all chronic wounds are contaminated, but did not support the practice observed.
Antipsychotic Medication Administered Without Appropriate Diagnosis
Penalty
Summary
A deficiency was identified when a resident was administered Seroquel (quetiapine), an antipsychotic medication, without an appropriate or documented diagnosis to support its use. The resident had diagnoses of Parkinson's disease, dementia without behavioral or mood disturbances, altered mental status, and depression. The care plan noted altered behaviors and hallucinations, but the Minimum Data Set assessment indicated severe cognitive impairment with no behaviors or psychiatric/mood disorders. Despite this, Seroquel was prescribed and administered over several months, with dosage adjustments made for reported anxiety and behaviors, but without any formal diagnosis documented in the medical record. Interviews with facility staff revealed that the Nurse Practitioner ordered Seroquel based on a hospice recommendation, acknowledging it was used off-label and not in accordance with FDA-approved indications. The DON was unaware that the medication order lacked an appropriate diagnosis and did not recognize that the documented reasons for use were not FDA-approved indications. Facility policy required psychotropic medications to be prescribed only with appropriate diagnosis or supporting documentation, which was not followed in this case.
Failure to Provide Prescribed Nutritional Supplements and Weight Monitoring
Penalty
Summary
A resident with multiple complex medical conditions, including pneumonia, respiratory failure, sepsis, pressure ulcers, dysphagia, chronic kidney disease, metabolic encephalopathy, and iron deficiency anemia, experienced significant weight loss after re-entry to the facility. The resident was on a physician-ordered weight gain plan, a therapeutic diet, and prescribed several nutritional supplements, including Ensure Clear, Magic Cups, and LiquaCel. Despite these orders, the resident's weight dropped from 132.9 lbs to 123 lbs within 30 days, a 7.4% loss. The facility failed to obtain a valid follow-up weight promptly after an invalid result and did not record the required monthly weight for April as ordered by the physician. Observations and interviews revealed that the resident did not receive the Magic Cup supplement with lunch as ordered, and was unaware of what it was, despite it being listed on her meal ticket. Staff confirmed the supplement was available in the facility but was not provided to the resident. The Registered Dietitian acknowledged that after a slight weight increase, no further monitoring was conducted, and the required monthly weight was not obtained. The facility's policy required daily and monthly weight reviews and referral to a dietitian for significant weight changes, but these procedures were not followed for this resident.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight hours a day, seven days a week, as required. During the review of staffing sheets and the staffing tool for the period from February 11 to February 17, 2025, it was found that there was no RN scheduled on February 16, 2025. This was confirmed during an interview with the Administrator on February 24, 2025, at 10:30 A.M., who acknowledged the absence of an RN on the assignment sheet for that day. The facility had a census of 42 residents at the time of the deficiency.
Failure to Provide Transportation to Medical Appointment
Penalty
Summary
The facility failed to provide transportation for a resident to a scheduled medical appointment, resulting in a missed appointment. The resident, who was cognitively intact and used a walker and wheelchair for mobility, had a history of multiple medical conditions, including acute embolism, thrombosis, respiratory failure, and pressure ulcers. The resident had been attending regular wound care appointments, but missed the appointment on 02/10/25 due to the facility's van driver being unavailable, as they were occupied with another appointment. The facility's transportation policy, last reviewed in 2017, outlines that transportation should be arranged through an outside agency if a Transportation Assistant (TA) is unavailable. However, this policy was not adhered to, leading to the missed appointment. The administrator confirmed the missed appointment and attributed it to the van driver's scheduling conflict. This incident was part of a continued non-compliance issue previously investigated under a complaint survey.
Failure to Prevent Fall During Incontinence Care
Penalty
Summary
The facility failed to prevent a fall for Resident #23, who was at risk due to multiple health conditions including metabolic encephalopathy, dysphagia, and neurocognitive disorder with Lewy bodies. The resident was dependent on staff for all activities of daily living and mobility, using a wheelchair for movement. Despite these needs, the facility did not complete a fall risk assessment prior to the incident on January 31, 2025, when the resident slid out of bed during incontinence care. On the morning of the incident, a CNA reported that Resident #23 slid to the floor while being provided incontinence care, without hitting her head or sustaining visible injuries. The resident was assisted back to bed, and both the responsible party and provider were notified. However, the facility's documentation revealed that no additional fall risk assessments had been conducted prior to this event, and the resident's care plan did not reflect the need for increased assistance during care. Interviews with facility staff indicated a lack of consistent procedures for providing incontinence care to residents with mobility issues. A CNA confirmed that residents should be rolled towards a staff member to prevent falls, while an LPN stated that incontinence care should not be performed without a second staff member present for residents dependent on staff for mobility. The facility's Falls Management Program Guidelines require a fall risk assessment upon admission and quarterly, but these were not completed for Resident #23, contributing to the deficiency.
Failure to Ensure Scheduled Bathing for Resident
Penalty
Summary
The facility failed to ensure that a resident received a bath or shower as scheduled, affecting one of the five residents reviewed for hygiene care. The resident, who had an intact cognition for daily decision-making abilities, was dependent on substantial to maximal assistance for bathing and was scheduled to receive a bath or shower twice a week. However, the review of the electronic medical record indicated that the resident received either a partial or complete bed bath at least twice a week, except for one week in December. The facility's plan of care noted the resident's non-compliance with care, including refusing showers at times. Interviews with staff revealed that the resident occasionally refused care, including showers, but it was not common. The facility used shower/skin sheets to document baths or showers, but these sheets appeared to have been altered, and the facility could not provide supporting documents such as staff time sheets to verify the care provided. The facility's administrator and director of nursing confirmed that they did not chart this information in the electronic ADL task on the residents' medical records, and they were unable to provide documentation to support the staff's completion of the shower sheets.
Failure to Implement Lymphedema Pump Orders
Penalty
Summary
The facility failed to implement physician orders for the use of lymphedema pumps for a resident, which was identified during a review of medical records, wound clinic orders, and staff interviews. The resident, who had a history of acute embolism, thrombosis, pulmonary embolism, and a stage two pressure ulcer, was admitted with intact cognitive abilities and required assistance with various activities of daily living. Despite the wound clinic's instructions on 12/16/2024 to use lymphedema pumps twice daily for edema control, there was no corresponding physician order in the resident's medical records from 10/19/2024 to 01/17/2025. Interviews with the Director of Nursing and Administrator confirmed the absence of an order for the lymphedema pumps, despite the wound clinic's instructions. The wound clinic nurse also confirmed that the resident's daughter had informed them of the resident's medical history, which included cancer treatment that damaged lymph nodes, necessitating the use of lymphedema pumps. The deficiency was investigated under Complaint Number OH00160855, highlighting the facility's non-compliance in ensuring the implementation of necessary medical orders.
Resident Injury Due to Wheelchair Pedal Malfunction During Transport
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation to a wound clinic, resulting in an injury. The resident, who had a history of acute embolism, thrombosis, pulmonary embolism, and a stage two pressure ulcer, required a wheelchair for mobility and substantial assistance for various activities. During transportation, the resident's foot slipped off the wheelchair's foot pedal, causing a small bruise with serosanguineous drainage. The incident occurred as the resident was being transported to a wound clinic appointment, and the wheelchair pedal was identified as the root cause of the injury. The transportation associate reported that the resident had previously mentioned issues with the foot pedal not staying in place. Despite attempts to fix the pedal, the resident's foot was injured when the associate pushed the wheelchair forward. The injury was described as a small scratch with no initial bruising or bleeding, although later photos showed bruising. The incident was reported to the facility, but no physical evidence of education or corrective action was documented, and the transportation associate did not recall receiving any further education or instructions following the incident.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed within the required timeframes, affecting eight residents. The deficiencies were identified through medical record reviews, staff interviews, and a review of the Resident Assessment Instrument (RAI) guidelines. The MDS assessments for these residents were not completed on time, as required by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. For instance, Resident #4's quarterly MDS assessments were consistently completed late, with delays ranging from several days to nearly a month. Similarly, Resident #20's quarterly MDS was completed 21 days after the Assessment Reference Date (ARD), and Resident #30's admission and discharge MDS assessments were also delayed. These delays were confirmed by interviews with the MDS Coordinator, who acknowledged that the assessments were not completed within the required timeframes. The report also highlights that Resident #299's admission assessment was not completed at the time of the review, and Resident #19's quarterly MDS assessments were not completed timely. Additionally, Resident #1's quarterly MDS assessment was signed approximately one month after it was due. Interviews with facility staff, including the MDS Coordinator and Regional Nurse, confirmed these findings and acknowledged that the facility follows the RAI manual guidelines for MDS assessments, yet failed to adhere to the required timelines.
Failure to Ensure Proper Medication Parameters
Penalty
Summary
The facility failed to ensure proper parameters were identified for the administration of anticoagulant, PRN pain, and blood pressure medications, affecting five residents. Resident #96 had orders for Tramadol and Tylenol PRN for pain without specified parameters, leading to both medications being administered for the same pain levels. The LPN confirmed the lack of parameters and stated that the resident was asked which medication they preferred when multiple PRN pain medications were ordered. Resident #98 had orders for Oxycodone and Ibuprofen PRN for pain, but only Oxycodone was administered, with no parameters noted for either medication. The LPN confirmed the absence of parameters and stated that typically Ibuprofen would be administered for mild pain and Oxycodone for moderate to severe pain. Resident #12 had orders for Metoprolol without blood pressure parameters, leading to the medication being held without physician communication. The Assistant Director of Nursing verified the lack of parameters and confirmed that blood pressure parameters should be part of the physician order. Resident #146 had orders for Warfarin without INR parameters, resulting in the medication being administered despite elevated INR levels. The Regional Nurse confirmed the lack of parameters and stated that the INR should be between 2 and 3. Resident #28 had orders for Losartan without parameters, and the LPN held the medication due to low blood pressure, confirming the absence of parameters. The facility's policy on medication administration requires that medications be administered as prescribed, with supplemental information to ensure accurate dosing, which was not adhered to in these cases.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure the timely administration and availability of medications for several residents, as identified through medical record reviews, staff interviews, and policy reviews. Resident #20 experienced multiple instances of late administration of Soliqua insulin, with specific dates noted in August and September. Additionally, there were occasions when the medication was unavailable, and the pharmacy and Certified Nurse Practitioner were notified, but the issue persisted, as verified by Regional Clinical Support. Resident #12 also faced issues with the timely administration of insulin lispro, with several instances of late administration documented in September. The Assistant Director of Nursing confirmed these late doses during an interview. Similarly, Resident #30 experienced delays in medication administration due to waiting for pharmacy delivery, as verified by Regional Clinical Support. Resident #22, who is severely cognitively impaired and receiving hospice care, had instances of late administration of Novolog insulin in September. The Assistant Director of Nursing confirmed these late administrations. The facility's policy on medication administration, last revised in 2018, states that medications should be administered within 50 minutes of the scheduled time, which was not adhered to in these cases. This deficiency was investigated under Complaint Number OH00157913.
Failure to Notify Resident's Representative and CNP of Condition Changes
Penalty
Summary
The facility failed to timely notify a resident's representative and certified nurse practitioner (CNP) of changes in the resident's condition, which is a deficiency in the facility's communication protocol. The resident, who had multiple medical diagnoses including abdominal aortic aneurysm, urinary tract infection, and pressure ulcers, experienced a decline in health that was not promptly communicated to the necessary parties. Despite having intact cognition upon admission, the resident required substantial assistance with activities of daily living and had a named Power of Attorney (POA) who was not informed of significant changes in the resident's condition. On several occasions, the resident exhibited abnormal vital signs and symptoms such as lethargy, cough, and low blood pressure, which were not communicated to the resident's representative or the CNP in a timely manner. Critical lab results indicating high white blood cell counts and low red blood cell counts were also not promptly reported. The CNP was not notified of these critical values or the resident's deteriorating condition between on-site visits, leading to a delay in necessary medical interventions. The facility's policy required immediate notification of significant changes in a resident's condition to the resident, their physician, and their legal representative. However, this protocol was not followed, as evidenced by the lack of documentation of communication attempts with the resident's representative. The failure to notify the resident's representative and CNP of critical changes in the resident's condition and treatment plan resulted in the resident being transferred to the hospital with multiple infections, including sepsis, without prior notification to the POA.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was sent to the hospital. Resident #34, who had multiple medical diagnoses including abdominal aortic aneurysm, severe protein-calorie malnutrition, and pressure ulcers, was found in a critical condition during a nighttime medication administration. The resident was grey, going in and out of consciousness, hypotensive, and tachycardic, prompting the nurse to call 911 for an emergency transfer to the hospital. Although the resident's representative and the Certified Nurse Practitioner were notified of the transfer, there was no evidence of a written transfer notice in the resident's medical record. The facility's policy on transfer and discharge, dated 2017, requires that emergency transfer procedures include sending the resident's Continuum of Care Document (CCD) with pertinent medical information. However, during an interview, the Administrator confirmed that no written transfer notice had been completed for this emergency transfer. This deficiency affected one resident out of three reviewed for transfer and discharge, in a facility with a census of 41.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident or the resident's representative prior to discharging the resident from the facility. This deficiency was identified during a review of the medical record for a resident who was admitted on June 13, 2024, and discharged on September 27, 2024, with an expected return to the facility. The resident had multiple medical diagnoses, including abdominal aortic aneurysm, urinary tract infection, severe protein-calorie malnutrition, and pressure ulcers, among others. The resident required substantial assistance to total dependence from staff for activities of daily living and had intact cognition, scoring 15 out of 15 on the Brief Interview for Mental Status assessment. On the night of September 27, 2024, the resident was found to be grey and going in and out of consciousness during nighttime medication administration, with hypotension and tachycardia. The nurse called 911, and the resident was transferred to the hospital. Although the resident's representative and a certified nurse practitioner were notified of the transfer, there was no evidence of a written discharge notice in the resident's medical record. An interview with the Administrator confirmed that no written discharge notice had been completed for the resident's discharge while the resident remained hospitalized. The facility's policy required that a discharge summary be completed, signed, and scanned into the medical record, with a copy provided to the resident or representative, which was not done in this case.
Inaccurate MDS Assessment for Resident on Anticoagulant
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed accurately for a resident, affecting one out of nine residents reviewed. The resident, who was admitted with multiple diagnoses including dementia, atrial fibrillation, and chronic kidney disease, was receiving hospice care and was on warfarin medication. During the review of the quarterly MDS, it was found that the resident was severely cognitively impaired and was receiving various medications, including warfarin. However, the MDS did not accurately reflect the resident's use of anticoagulant medication during the look-back period, as confirmed by interviews with the MDS Registered Nurse and MDS Regional Support. This oversight in the MDS assessment process led to the deficiency noted in the report.
Failure to Assess and Plan Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and minimize triggers and/or re-traumatization. This deficiency affected one resident, who was admitted with diagnoses including PTSD, anxiety disorder, and depression. The admission Minimum Data Set (MDS) assessment was ongoing and not completed. A Brief Interview for Mental Status (BIMS) assessment showed a score of 15 out of 15, indicating full cognitive function. However, the active care plans for the resident did not address the cause of PTSD, potential triggers, or interventions to reduce the risk of re-traumatization. An interview with the Director of Social Work confirmed that no assessment had been completed to identify the cause of PTSD or potential triggers, and no care plan was implemented to minimize re-traumatization risk.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to fully explain the binding arbitration agreement and the right to rescind it within 30 days to two residents, affecting their understanding and decision-making. Resident #297, who was cognitively intact with a BIMS score of 13, signed the arbitration agreement but later expressed regret and stated that she was not informed about the 30-day revocation period. Similarly, Resident #150, also cognitively intact with a BIMS score of 15, did not recall the details of the agreement and confirmed that she was not informed about the option to revoke it within 30 days. The Director of Sales confirmed that the arbitration agreement is voluntary and reviewed upon admission, but residents are only informed they can change their minds within 24-48 hours, not the full 30 days as stated in the agreement. The facility does not have a policy related to arbitration agreements, and the Director of Sales does not ensure residents demonstrate understanding before signing. This lack of proper explanation and policy led to the deficiency in informing residents of their rights regarding the arbitration agreement.
Delayed Treatment for UTI
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection for Resident #299. The resident, who has a medical history of hemiplegia and hemiparesis following cerebrovascular disease, diabetes mellitus, and hypertension, complained of discomfort with urination on September 21, 2024. A urinalysis was ordered, and a urine sample was collected on September 23, 2024, with a urinalysis and culture and sensitivity to be completed. The results were available on September 26, 2024. However, there was no physician's order for an antibiotic to treat the urinary tract infection until October 2, 2024, at 4:20 PM. This delay in treatment was confirmed during an interview with Regional Support Nurse #601 on October 2, 2024, at 4:28 PM.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident #98, who had medical diagnoses including cirrhosis of the liver and chronic kidney disease, was administered the wrong type of insulin due to a pharmacy error. The resident was supposed to receive Humulin R, a short-acting insulin, but was given Humulin N, a long-acting insulin, by an LPN. This error occurred because the pharmacy sent the incorrect insulin type, and the LPN did not verify the medication label against the physician's order before administration. Resident #20, with diagnoses including diabetes and chronic kidney disease, experienced a medication error due to the unavailability of the prescribed insulin, Soliqua 100/33. The medication was documented as unavailable on multiple occasions, and the pharmacy was notified, but the issue persisted. As a result, the resident did not receive the necessary insulin, and blood sugar levels were not monitored on specific dates. This deficiency was confirmed during an interview with Regional Clinical Support.
Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during the administration of medication via a gastric tube for a resident. The resident, who was on hospice care, had multiple diagnoses including Parkinson's disease, dementia, and acute respiratory disease, and was under isolation precautions. During an observation, it was noted that the Licensed Practical Nurse (LPN) administering the medication only wore gloves, despite the requirement to wear both a gown and gloves as per the facility's Enhanced Barrier Precautions policy. The policy, dated April 1, 2024, mandates the use of enhanced barrier precautions to reduce the risk of infections with multidrug-resistant organisms, especially for residents with chronic wounds and indwelling devices. The Registered Nurse (RN) confirmed that the LPN should have adhered to the policy by wearing a gown in addition to gloves. This oversight was identified during a complaint investigation, highlighting a lapse in adherence to infection control protocols for residents with indwelling devices.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, affecting four out of seven residents reviewed for activities of daily living (ADL) care, with the potential to impact all 46 residents. Observations revealed insufficient staffing levels, with only three licensed nurses and four State Tested Nursing Assistants (STNAs) on duty to care for 46 residents, many of whom required assistance with feeding, toileting, and transfers. Family members and residents reported concerns about inadequate care, including missed meals, lack of incontinence care, and long response times to call lights. Family members of several residents expressed concerns about the lack of staff, which led to residents not receiving necessary care. One family member reported that their relative was not fed properly and was left in bed without being repositioned or provided incontinence care for extended periods. Another family member noted that their relative had aspirated on medication due to a lack of supervision. Residents also reported not receiving regular showers and being left unattended for long periods, with some requiring family members to assist with feeding. Staff interviews corroborated these concerns, with several staff members indicating that there were not enough personnel to provide adequate care. They reported that residents were often left soiled for long periods and that showers and daily weights were not consistently performed. The facility's staffing plan indicated a need for more staff than were present, and efforts to hire additional staff were ongoing. However, the current staffing levels were insufficient to meet the needs of the residents, leading to significant deficiencies in care.
Deficiency in ADL Assistance and Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for residents requiring staff support, specifically in the areas of nail hygiene and dressing. This deficiency affected four residents, each with varying medical conditions that necessitated staff assistance. Resident #5, who was cognitively intact and dependent on staff for bathing, had long, dirty fingernails despite care plans indicating nail care should be provided on shower days. Documentation revealed inconsistencies in bathing and nail care, with significant gaps between recorded care events. Resident #12, with severe cognitive impairment and requiring extensive assistance, also exhibited long, jagged fingernails with a dark substance underneath. The care plan specified nail care during showers, yet documentation failed to consistently record the type of bathing or nail care provided. Observations confirmed the lack of proper nail hygiene, verified by the Director of Health Services (DHS). Resident #19, with severe cognitive impairment, was observed wearing the same clothes over consecutive days, contrary to care expectations. Interviews with staff confirmed no care was provided on the morning of the observation. Similarly, Resident #39, with cognitive impairment, had long, dirty fingernails and reported infrequent showers. Documentation showed irregularities in recorded bathing and nail care, with the DHS verifying the resident's poor nail hygiene. This deficiency was part of a continued non-compliance issue from a previous complaint survey.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for Resident #29, who was admitted with multiple medical conditions including hemiplegia, chronic kidney disease, and legal blindness. The resident required substantial assistance for daily activities and was scheduled for showers twice a week. However, documentation revealed that the resident only received one shower and several bed baths over a month-long period. The shower sheets indicated refusals, but they were not signed by the resident, aide, or nurse, and there was no evidence in the medical records of the resident refusing showers or requesting bed baths instead. Observations and interviews with Resident #29 confirmed that the resident had not received a shower in approximately two weeks and preferred showers over bed baths. The resident expressed that there was insufficient staff to assist with showers. An interview with the LPN and the Director of Health Services confirmed that the resident's requests for showers were not followed up on, and the required documentation of refusals was incomplete. The facility's policy stated that bathing should occur at least twice a week unless otherwise preferred by the resident, which was not adhered to in this case.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents. Resident #8, who had Alzheimer's Disease and was receiving hospice care, was administered the wrong medications on two separate occasions. On the first occasion, Resident #8 received the roommate's medications, including Tylenol, Depakote, Morphine, and Trazodone. The error was identified, and the resident was assessed with stable vitals and no adverse effects. The same error occurred again, with the same medications being administered to Resident #8, and the root cause was identified as a failure to correctly identify the resident before medication administration. Another incident involved Resident #19, who had intact cognition and required assistance with ADLs. Resident #19 was mistakenly given another resident's medications, including Tylenol and Propafenone, by LPN #202. The error was immediately recognized, and the resident was informed. The nurse notified the CNP and DHS, and the resident was assessed with stable vitals and no new symptoms. The facility's policy on medication administration emphasizes the five rights of medication administration and proper resident identification, which were not adhered to in these cases. The facility's failure to follow its medication administration policy resulted in these medication errors. The policy requires personnel to administer medications only after proper orientation and to ensure safe administration without unnecessary interruptions. The errors occurred due to a lack of adherence to the policy's guidelines, including the triple check of the five rights of medication administration and proper resident identification methods.
Failure to Properly Disinfect Glucometer
Penalty
Summary
The facility failed to ensure proper disinfection of a glucometer after use, affecting one resident out of five observed for medication administration. The incident involved a resident with type two diabetes mellitus, unspecified dementia, and anxiety, who required assistance with activities of daily living, including obtaining blood glucose readings. The resident's physician had ordered blood glucose readings to be taken before meals and at bedtime. During an observation, an LPN was seen using the glucometer to obtain a blood glucose reading for the resident without disinfecting it before or after use. The glucometer was placed directly on the resident's bedside table and the medication cart without any barrier, and it was stored back in the medication cart drawer without cleaning. Upon interview, the LPN confirmed the failure to disinfect the glucometer and attempted to clean it with an alcohol pad without wearing gloves, which was not in accordance with the manufacturer's guidelines. The guidelines specified the use of disinfectant wipes and wearing gloves during the cleaning process. The LPN acknowledged the partial cleaning with an alcohol pad instead of the approved disinfecting wipes. This deficiency was identified during a complaint investigation under Complaint Number OH00154383.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Woods At New Albany | 1.1 mi | ★★★★★ | 1 | 0 |
| Otterbein New Albany | 2.6 mi | ★★★★★ | 13 | 0 |
| New Albany Care Center | 3.1 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Gahanna | 4.3 mi | ★★★★★ | 27 | 0 |
| Otterbein Gahanna | 4.6 mi | ★★★★★ | 9 | 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.