Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 St Clare Commons during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, dementia, CHF, epilepsy, anxiety, and Bell's Palsy had severely impaired cognition and was dependent on staff for transfers. The care plan required a mechanical lift and two staff for transfers, but a CNA confirmed she transferred the resident alone with the lift, and the facility's policy required two nursing assistants for this type of transfer.
A resident with Alzheimer’s disease and other comorbidities, who was cognitively impaired and dependent on staff for care, was not provided a meal consistent with documented food preferences and restrictions. During a breakfast service, the resident received pureed sausage, scrambled eggs, pureed toast, and cranberry juice, despite a meal ticket specifying yogurt, half a banana, tea, and no juice or soda. A CNA confirmed the resident did not receive the ordered items and was served juice contrary to the documented restriction, in violation of facility policy requiring that individualized food preferences and restrictions be reflected in the tray ticket system.
Surveyors found that discontinued narcotic medications for multiple residents, including those who had died or been discharged, remained in locked medication carts instead of being removed and stored or destroyed per policy. Observations of several medication carts revealed leftover Tramadol, oxycodone-acetaminophen, lorazepam, morphine sulfate (including unopened bottles), and Percocet still assigned to residents no longer in the facility. LPNs confirmed the residents were discharged or deceased and that the narcotics had not been removed, and the Interim DON acknowledged awareness that expired narcotics remained in the carts despite a policy requiring discontinued controlled substances to be removed from patient care areas and secured until destruction.
A resident with severe cognitive impairment, dementia, dysphagia, and other comorbidities required maximum assistance with eating, but a CNA failed to provide dignified feeding assistance. The CNA delivered the breakfast tray and left, then later sat at the bedside watching social media on a personal cell phone with an earbud in while nominally assisting with the meal. The CNA offered one food item but fed another, did not consistently alert the resident before offering bites, and at times held food at the resident’s mouth without explanation or was occupied cleaning and reloading the spoon while the resident waited with mouth open. Facility leadership confirmed staff should not use cell phones during resident care, and policy required a relaxing, enjoyable mealtime environment.
Two residents were subjected to verbal abuse by nursing staff. One cognitively impaired, fully dependent resident with dementia and other comorbidities was recorded on video while an LPN loudly scolded her during incontinence care, threw soiled washcloths onto the floor, and shouted about not being an aide, while CNAs later referred to the resident’s daughter as a "spy" and discussed her visitation restrictions within the resident’s hearing during a mechanical lift transfer. Another cognitively intact resident with multiple medical conditions and elected video monitoring was the subject of a personnel report documenting that an LPN was seen on video shouting at him and using foul language, and a family member later submitted a written concern about the LPN’s behavior, which was characterized in the counseling as disrespectful, abusive, and unprofessional.
The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse policy. A resident with multiple chronic conditions and intact cognition had elected video monitoring in the room. Video review showed an LPN shouting at the resident and using foul language, and a family member later submitted a written concern about the LPN’s behavior. The conduct was documented as disrespectful, abusive, and unprofessional, and the IDON confirmed it met criteria for a self-reportable incident. The HR director identified the affected resident, but the Administrator acknowledged that the incident was never reported to the state agency, contrary to the facility’s requirement to report abuse allegations within specified timeframes.
A resident with multiple chronic conditions and intact cognition, who had elected video monitoring in the room, was the subject of a personnel corrective action in which an LPN was documented as having shouted at the resident using foul language and later drew a written concern from the resident’s family member about the LPN’s behavior. The behavior was characterized in the personnel record as disrespectful, abusive, and unprofessional, and leadership acknowledged it met criteria for a self-reportable abuse incident. However, there was no documentation of verbal abuse in the resident’s progress notes and the facility could not produce evidence that any investigation was conducted, despite a policy requiring immediate investigation of suspected or reported abuse.
Surveyors found that multiple residents receiving PRN Ativan for anxiety had physician orders requiring non-pharmacological interventions such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, toileting, and pain management to be used and documented for monitoring. Review of MARs and nursing progress notes showed that PRN Ativan was administered on several occasions without any documentation that these non-pharmacological measures were attempted beforehand. In an interview, the IDON acknowledged that staff did not complete or document the ordered non-pharmacological interventions prior to giving Ativan and noted there was no specific policy addressing this requirement, despite the need to follow physician orders.
Surveyors found that residents on pureed diets did not receive the same planned menu items as those on regular diets, despite orders for regular diets with pureed texture and, in some cases, nutritional supplements and adaptive equipment. During an evening meal, pureed plates contained generic green, orange, and beige purees and ice cream instead of the scheduled oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake, while other diners received the full regular-texture menu. Dietary staff reported that a broccoli blend was substituted for the listed asparagus and that no pureed cake was prepared, even though asparagus could have been pureed and facility policy required verification that each resident received the correct diet and consistency.
A CNA transferred a resident with cognitive and physical impairments using a mechanical lift without a second staff member present and without having received proper training on the equipment, in violation of facility policy requiring two trained staff for such transfers.
The facility did not ensure that dependent residents received scheduled showers or bed baths, as documented by missed bathing opportunities and confirmed by resident and family interviews. Observations showed poor hygiene, and concerns were repeatedly reported to leadership without resolution, despite facility policy requiring scheduled bathing.
A resident with bowel incontinence and mobility issues did not receive timely incontinence care, resulting in prolonged exposure to body fluids and the development of skin breakdown. The resident waited over an hour for assistance after activating the call light, while a CNA was observed using a cell phone and unaware of the facility's response time policy. The DON confirmed the delay and the presence of skin issues.
A resident dependent on staff for ADLs and using a wheelchair missed multiple PMR appointments for pain management due to the facility's failure to arrange suitable transportation. Interviews and record reviews confirmed that transportation was either unavailable or could not accommodate the resident's wheelchair, resulting in several missed and rescheduled medical appointments.
A resident with severe cognitive impairment and dysphagia was served a pureed meal with portions significantly smaller than required, as staff used incorrect and randomly selected serving utensils and did not follow the dietary spreadsheet. The dietary aide was unaware of the correct portion sizes, and the dietary manager confirmed that proper procedures were not followed.
The facility did not administer medications within the required time frame for several residents with complex medical conditions, resulting in multiple scheduled medications being given hours late. The DON confirmed these late administrations, which were not in accordance with the facility's medication administration policy.
A resident with severe cognitive impairment and multiple medical conditions was found sitting in a wheelchair without the call light within reach, despite being able to use it and requiring staff assistance for toileting. A CNA confirmed the call light was not accessible, which was not in accordance with facility policy requiring call lights to be within reach.
The facility failed to provide timely and accurate care for pressure ulcers in two residents. One resident did not receive treatment for a stage III pressure ulcer until several days after physician orders were given, and a recommended Vitamin C supplement was not implemented. Another resident had a stage III pressure ulcer that was not accurately documented, and a recommended dietician consult was not completed. These deficiencies highlight a lack of adherence to facility policies on pressure injury prevention and wound treatment management.
A facility failed to provide appropriate care for a resident's urinary catheter, lacking physician orders and an updated care plan. Observations showed the catheter was kinked, preventing urine drainage, and the drainage bag was improperly positioned. The facility's policy on catheter care was not followed.
A facility failed to prevent the misappropriation of a resident's funds, resulting in unauthorized charges totaling approximately $5,000.00. The resident, who was moderately cognitively impaired, had her credit card taken and used by an LPN for personal purchases, including lottery tickets. The incident was reported to the bank, local police, and the Ohio Board of Nursing. Surveillance footage confirmed the LPN's involvement, and the LPN resigned shortly after the incident.
The facility failed to thoroughly investigate the misappropriation of a resident's funds, totaling approximately $5,000.00, despite evidence and involvement from local police. The investigation was incomplete, lacking confirmation of the suspect's identity from surveillance footage, staff interviews, in-service training, and audits.
The facility failed to ensure fall interventions were in place for two residents and did not provide adequate assistance during a transfer for another resident. One resident was found in bed without the bed in the lowest position, and another was found without fall mats and the bed not in the lowest position. Additionally, a resident requiring a mechanical hoyer lift for transfers was transferred by a single staff member without assistance, contrary to facility policy.
Mechanical Lift Transfer Performed by One Staff Member
Penalty
Summary
The facility failed to ensure that two staff members were present during resident transfers using a mechanical lift. Resident #16 had diagnoses including Alzheimer's disease, congestive heart failure, epilepsy, anxiety, dementia, and Bell's Palsy, and the comprehensive annual MDS showed severely impaired cognition and dependence on staff for transfers. The care plan identified that the resident required a mechanical lift and two staff for transfers. The facility's Self-Reported Incident #273370 documented a family member's concern that Resident #16 was transferred by one staff person using a mechanical lift. The facility investigation included a written statement from a CNA confirming she transferred the resident by herself with the mechanical lift. The Administrator confirmed the facility's policy required two staff for mechanical lift transfers, and the facility's policy also stated that at least two nursing assistants were needed to safely move a resident with a mechanical lift.
Failure to Follow Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to provide meals according to a resident’s documented food preferences and restrictions. A resident with Alzheimer’s disease, congestive heart failure, anxiety, and seizures, admitted in mid-September 2024, had a comprehensive MDS indicating a cognitive deficit and dependence on staff for all care. The resident’s care plan showed a need for supervision and occasional feeding assistance. On the observed breakfast service, the resident was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice, with appropriate adaptive equipment. However, review of the resident’s meal ticket for that breakfast showed the resident was supposed to receive yogurt, half a banana, and tea daily, with explicit instructions for no juice or soda. Despite these documented preferences and restrictions, the resident was served juice instead of tea and did not receive the ordered yogurt and banana. A CNA confirmed that the resident was not supplied the ordered food and acknowledged that residents’ preferences changed often. Facility policy on accommodation of food preferences required that resident food preferences be listed in the tray ticket system and that alternate menu items be available to meet individualized needs and requests, but this was not followed in this instance.
Failure to Timely Remove and Dispose of Discontinued Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to timely remove and properly dispose of discontinued narcotic medications, including those for residents who had died or been discharged. Surveyors reviewed records and medication carts and found multiple instances where controlled substances remained in the narcotic drawers after the medications had been discontinued or the residents were no longer in the facility. For one resident who had expired, 15 tablets of Tramadol 50 mg remained in the 100-hall medication cart. Another resident with end stage renal disease, congestive heart failure, and multiple malignancies had 22 tablets of discontinued Tramadol HCL 50 mg still stored in the 300-hall medication cart after discharge. Additional observations showed that a resident with anxiety, hemiplegia, hemiparesis, and adjustment disorder had 22 tablets of discontinued oxycodone-acetaminophen 10-325 mg remaining in the narcotic drawer. A resident with dementia, schizophrenia, atrial fibrillation, and congestive heart failure who had been transferred out still had 23 tablets of discontinued Tramadol 50 mg in the cart. Another resident with hip fracture, dementia, anxiety, bipolar disorder, and diabetes mellitus who had expired had 29 tablets of Tramadol 50 mg, 31 tablets of lorazepam 0.5 mg, and a full unopened bottle of liquid morphine sulfate remaining in the locked narcotic drawer. Surveyors also identified that a resident with thoracic vertebra fracture, quadriplegia, contracture, and left shoulder stiffness who had been discharged still had 20 oxycodone-acetaminophen 5-325 mg tablets in the narcotic drawer, and a resident with Alzheimer’s disease, dementia, chronic kidney disease, and peripheral vascular disease who had expired under hospice care had 28 lorazepam 0.5 mg tablets and an unopened bottle of morphine sulfate concentrate remaining in the cart. A resident with migraine, osteoarthritis, heart disease, and Parkinsonism who had discharged to another LTC facility still had 22 Percocet 10-325 mg tablets in the narcotic drawer, despite active orders having been discontinued or the resident no longer being present. LPNs confirmed that these residents were no longer in the facility and that their narcotics remained in the medication carts, and the Interim DON acknowledged awareness that expired narcotics remained in the carts. Facility policy stated that discontinued controlled substances were to be removed from patient care areas and temporarily stored in a securely locked area until destruction, which was not followed in these cases.
Undignified Feeding Assistance While CNA Used Personal Cell Phone
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received feeding assistance in a dignified manner consistent with the resident’s rights and facility policy. The resident had diagnoses including Alzheimer’s disease, stroke, anorexia, dysphagia, and dementia with agitation, and a quarterly MDS showed severely impaired cognition with a need for supervision/touching assistance for eating. The care plan documented an ADL self-care performance deficit related to dementia, with interventions indicating the resident required maximum assistance and might need to be fed by staff. On the morning in question, a CNA brought the resident’s breakfast tray into the room and then left to continue passing other trays. Later that morning, the resident was observed sitting up in bed with the CNA seated next to the bed and the overbed table positioned in front of the CNA. The CNA was wearing an earbud and watching a video on her personal cell phone, which she confirmed was social media, while she was supposed to be assisting with feeding. Although the CNA asked the resident if she wanted eggs and the resident nodded and opened her mouth, the CNA instead fed the resident yogurt, which she acknowledged. During the meal, the resident’s eyes were periodically closed, and the CNA would hold a spoonful of food at the resident’s mouth without notifying her that another bite was being offered. At other times, when the resident opened her mouth in apparent anticipation of food, the CNA was occupied with cleaning and reloading the spoon without verbalizing what was occurring. The Interim DON confirmed staff should not watch their cell phones while providing resident care, and facility policy stated that mealtimes should provide a relaxing, enjoyable environment.
Failure to Protect Residents From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse, affecting two residents. One resident with Alzheimer's disease, CHF, anxiety, seizures, cognitive deficit, and total dependence for care had a family-installed camera and a personal care companion. Video from the resident's room showed an LPN assisting a CNA with incontinence care, loudly telling the resident to stop squeezing her buttocks and yelling to the resident's daughter to tell the resident to stop. The LPN threw dirty washcloths over the bed onto the bare floor and loudly stated she was not an aide and was doing the best she could. During this care, the resident, who was non-verbal, was observed grunting, moaning, crying out, and swinging her arms until the family caregiver came to comfort her. In a separate video, two CNAs providing care and transferring the same resident via mechanical lift were heard referring to the resident's daughter as a "spy" and stating they had to do care a certain way because that was how the "spy" wanted it done, and further stating that the daughter was not allowed in the facility and could not visit on the resident's birthday, all while providing care in the resident's presence. Another resident, with diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, had intact cognition and had elected to have video monitoring in his room. Review of the personnel file for an LPN revealed a Corrective Action Report documenting that, on one date, the LPN was observed on video shouting at this resident and using foul and cursing language, and on another date a family member submitted a written concern regarding the LPN's behavior toward them. The written counseling described the LPN's behavior as disrespectful, abusive, and unprofessional. The facility's abuse policy defined verbal abuse as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of age, ability to comprehend, or disability.
Failure to Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse, neglect and exploitation policy. Resident #65, who had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, was admitted on 07/23/25 and discharged on 03/02/26, with a quarterly MDS dated 01/28/26 indicating intact cognition. The resident’s care plan, initiated 07/29/25 and revised 08/12/25, documented that the resident elected to have video monitoring in his room. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. Review of LPN #221’s personnel file on 03/26/26 revealed a Corrective Action Report (CAR) signed 01/01/26 for incidents on 12/01/25 and 12/22/25, citing violations of rules of conduct and behavior. The CAR documented that on 12/01/25, LPN #221 was observed on video shouting at the resident and using foul or cursing language, and that on 12/22/25 a family member submitted a written concern regarding the LPN’s behavior toward them. The CAR described this behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the described behavior met criteria for a self-reportable incident. The Human Resources Director confirmed that Resident #65 was the resident involved. The Administrator later confirmed that the incident was not reported to the state agency, despite the facility’s policy requiring immediate reporting, but no later than two hours after an allegation of abuse is made. This deficiency was identified incidentally during a complaint survey completed on 03/26/26.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving one resident. The resident had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, and had intact cognition per a quarterly MDS assessment. The resident’s care plan documented that he had elected to have video monitoring in his room. A Corrective Action Report (CAR) in an LPN’s personnel file, signed on 01/01/26, stated that on 12/01/25 the LPN was observed on video shouting at the resident and using foul or cursing language, and that on 12/22/25 a family member submitted a written concern regarding the LPN’s behavior toward them. The CAR described the LPN’s behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the behavior described in the CAR met criteria for a self-reportable incident due to abusive behavior. The Administrator initially stated she could not determine which resident was involved in the incident, while the Human Resources Director confirmed that the resident with video monitoring was the resident affected by the LPN’s behavior. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. The Administrator later confirmed that the facility could not provide evidence of any investigation into the incidents involving the resident and the resident’s family member, despite the facility’s abuse policy requiring an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. This lack of investigation was identified as an incidental finding during a complaint survey.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
Surveyors identified a deficiency related to the requirement that each resident’s drug regimen be free from unnecessary drugs, specifically regarding the use of PRN psychotropic medications without prior non-pharmacological interventions. For one resident with hip fracture, dementia, anxiety, and bipolar disorder, the record showed a physician’s order for non-pharmacological interventions (such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, pain medication, and other measures documented in progress notes) to be used for monitoring, and a separate order for PRN Ativan 0.5 mg for anxiety. The MAR documented multiple administrations of PRN Ativan over several days, but review of the MAR and nursing progress notes showed no documentation that non-pharmacological interventions were attempted prior to giving the medication on any of those occasions. Another resident with Alzheimer’s disease and anxiety had physician orders for non-pharmacological interventions similar to those above, as well as an order for PRN Ativan 0.25 mg for anxiety. The MAR showed several PRN Ativan administrations over a three-day period, but the MAR and nursing progress notes lacked documentation of non-pharmacological interventions before the medication was given. A third resident with dementia, hypertension, and incontinence had an order for non-pharmacological interventions and subsequent orders for scheduled and PRN Ativan for anxiety. Review of this resident’s MAR and nursing notes showed PRN Ativan was administered without any documented alternate non-pharmacological interventions beforehand. In an interview, the Interim DON confirmed staff failed to complete or document non-pharmacological interventions prior to administering Ativan and stated there was no specific facility policy requiring such interventions before psychotropic medications, though physician orders were to be followed.
Failure to Provide Pureed-Diet Residents with Menu-Consistent Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that residents on pureed diets received the planned menu items in the prescribed texture, as required by facility policy and diet orders. Three residents with severe cognitive impairment and significant dependence for eating and ADLs were affected. One resident with Alzheimer’s disease, COPD, anxiety, dementia, and dysphagia had orders for a regular diet with pureed texture and nectar-thick liquids, plus a nutritional supplement before lunch and dinner. Another resident with Alzheimer’s disease, CAD, CHF, ESRD, type II diabetes, and anxiety had orders for a regular diet with pureed texture, use of a divided plate and sippy cup, and to be fed for all meals. A third resident with hypertension, insomnia, nontraumatic subarachnoid hemorrhage, and a history of repeated falls had orders for a regular diet with pureed texture and a magic cup with meals for weight loss. The daily menu for the observed evening meal listed oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake. Observation of a pureed meal showed mounds of green, orange, and beige purees and a nutrition supplement ice cream, while a regular-texture meal contained fried chicken, mashed sweet potatoes, and asparagus spears. Staff interviews revealed that the morning cook prepared a broccoli blend as the vegetable for the three residents on pureed diets instead of pureed asparagus, and that no pureed chocolate banana marble cake was prepared; ice cream was used as the pureed dessert instead. Dietary staff and another interviewee confirmed that residents on pureed diets were supposed to receive the same menu items as those on regular diets, except for preferences or allergies, and that asparagus could be pureed to an appropriate texture. The facility’s policy required staff to check trays before serving to ensure the correct diet and ordered consistency, but this was not followed for the affected residents on pureed diets.
Failure to Train Staff on Mechanical Lift Use and Adherence to Transfer Protocols
Penalty
Summary
The facility failed to ensure that staff were properly trained and demonstrated competency in the use of mechanical lifts, as required by facility policy. Observation revealed that a Certified Nursing Assistant (CNA) attempted to transfer a resident with dementia, muscle weakness, and impaired balance from bed to wheelchair by pulling the resident to a standing position multiple times before resorting to a mechanical lift. The CNA then used the mechanical lift to transfer the resident without the assistance of a second staff member, contrary to the facility's policy that mandates at least two staff for such transfers. Interviews with the CNA and the Administrator confirmed that the CNA had not received training on the use of mechanical lifts upon hire and that two staff should be present during mechanical lift transfers. The facility's policy also requires staff to be trained and demonstrate competency with the specific equipment used. The deficiency was identified during a review of residents dependent on mechanical lifts, affecting one resident directly observed and potentially impacting others.
Failure to Provide Scheduled Showers and Bed Baths to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for care received showers or bed baths as scheduled. Three residents with significant physical and/or cognitive impairments were affected. Documentation showed that scheduled bathing opportunities were frequently missed, with one resident receiving only two of eight scheduled bed baths in a month, another missing multiple scheduled showers, and a third receiving only three of eight scheduled showers. Observations revealed poor hygiene, such as long fingernails with dirt, dry skin, unkempt hair, and visible food on clothing and face. Interviews with residents and their family members confirmed that scheduled showers and bed baths were not consistently provided, with some residents going weeks without proper bathing. Family members reported having to provide care themselves during visits due to staff not fulfilling these duties. These concerns were repeatedly brought to the attention of facility leadership, including the Administrator and DON, but no resolution was achieved. Review of Resident Council meeting minutes indicated that concerns about missed showers were voiced by residents. The facility's own policy required that residents be provided showers as per request or facility schedule, but this was not followed. The DON confirmed the missed showers and acknowledged that the issue had been reported to leadership, but no evidence of staff education or corrective action was provided.
Failure to Provide Timely Incontinence Care Resulting in Skin Breakdown
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, weakness, and parkinsonism, who was cognitively intact and required maximal assistance with activities of daily living, did not receive timely incontinence care. The resident's care plan indicated the need for assistance with toileting as needed due to bowel incontinence related to mobility. Despite this, the resident reported sitting in his own bowel movement for hours, resulting in two areas of skin breakdown on his buttocks, later diagnosed as irritant dermatitis due to body fluid. Direct observation confirmed that the resident activated his call light after a bowel movement and waited over an hour for assistance, during which time a CNA was observed using a cell phone and wearing an ear bud. The CNA stated she was delayed due to caring for other residents and was unaware of the expected response time. The DON later confirmed that the acceptable response time was 10 minutes and acknowledged the delay and the presence of scabbed areas on the resident's buttocks. Facility policy required all staff to respond promptly to call lights, but this was not followed in this instance.
Failure to Provide Appropriate Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure appropriate transportation for a resident requiring outside medical appointments, specifically for follow-up care related to diabetes with neuropathy, hemiparesis, and pain management. The resident, who was dependent on staff for activities of daily living and used a wheelchair, missed multiple appointments with Physical Medicine and Rehabilitation (PMR) for evaluation and possible Botox injections due to pain and contractions. Documentation showed that transportation arranged by the facility was either not suitable for the resident's wheelchair or did not arrive as scheduled, resulting in several missed and rescheduled appointments. Interviews with the resident's family, PMR staff, and the Director of Nursing confirmed that the resident missed at least three appointments because transportation was either unavailable or inadequate. The facility's own policy required working with residents and families to secure appropriate transportation for off-site appointments, but there was no documentation explaining why some appointments were missed. The deficiency was identified through review of medical records, staff and family interviews, and policy review, affecting one resident out of three reviewed for outside medical appointments.
Failure to Provide Correct Meal Portion Sizes for Resident on Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure correct portion sizes for meals as required by dietary guidelines. During observation of a lunch meal service, a resident with Alzheimer's disease, chronic kidney disease, epilepsy, and severe cognitive impairment, who was on a mechanically altered diet due to dysphagia, was served a pureed meal with portions significantly smaller than those specified on the dietary spreadsheet. The meal included less than two ounces each of pureed pasta and vegetables, despite the dietary spreadsheet indicating larger portions were required. Serving utensils used did not match the required portion sizes, and a spoon with no measured serving size was used for one of the items. Staff interviews revealed that the dietary aide responsible for serving the meal was unaware of the correct portion sizes and used randomly selected utensils, relying on estimation rather than following the dietary spreadsheet. The dietary manager confirmed that staff should have used color-coded serving utensils with specific serving sizes and followed the dietary spreadsheet, but this was not done during the observed meal service.
Failure to Administer Medications Timely for Multiple Residents
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner for four residents, as required by their policy to administer medications within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. Record reviews showed that residents with complex medical conditions, including heart failure, diabetes, chronic kidney disease, respiratory disorders, and depression, received their scheduled medications several hours late. For example, one resident with hypertensive heart disease, heart failure, and atrial fibrillation received multiple morning medications, including furosemide, Jardiance, metoprolol, amiodarone, and apixaban, at 11:38 A.M. instead of the scheduled times between 7:00 A.M. and 9:00 A.M. Another resident with acute respiratory failure, asthma, and major depressive disorder received several medications, such as metoprolol, Trelegy Ellipta, Jardiance, and others, at 11:31 A.M. instead of the scheduled morning times, and on another day, medications were also administered late in the morning and afternoon. Additional residents with diabetes, heart failure, and malnutrition also experienced late administration of critical medications, including insulin and antidepressants. The DON confirmed the late administration of medications for all affected residents, and the facility's policy on medication administration was not followed.
Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including dementia, psychosis, and depression, was observed sitting in a wheelchair in their room without the call light within reach. The call light was found lying on the bed, out of the resident's reach, despite the resident being capable of using it and dependent on staff for toileting. This was confirmed by a Certified Nursing Assistant, who acknowledged the call light was not accessible to the resident. Facility policy requires staff to ensure call lights are within reach and secured as needed, but this was not followed in this instance. The incident affected one of nine residents reviewed for call light accessibility, with the facility census at 56. The deficiency was established through record review, observation, staff interview, and policy review.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to implement timely orders for the care of a stage III pressure ulcer for Resident #5. Despite receiving physician orders on 06/28/24 to treat the pressure ulcer on the sacrum, these orders were not entered into the medical record until 07/01/24, and the first treatment was not administered until 07/04/24. Additionally, a recommendation for Vitamin C supplementation by the wound care provider was not documented or implemented. This delay in treatment and failure to follow wound care recommendations contributed to inadequate care for Resident #5's pressure ulcer. Resident #39 also experienced deficiencies in pressure ulcer care. The resident, who was at risk for skin breakdown, had a stage III pressure ulcer identified by a wound care provider on 06/24/24. However, the skin assessment completed on the same day did not reflect this finding, and subsequent documentation, including a shower sheet dated 06/30/24, inaccurately reported no skin issues. Furthermore, a dietician consult recommended by the wound care provider to address nutritional needs for wound healing was not completed, indicating a lack of comprehensive care and monitoring for Resident #39. The facility's policies on pressure injury prevention and wound treatment management were not adhered to, as evidenced by the lack of timely and accurate documentation, implementation of physician orders, and interdisciplinary care planning. The Unit Manager's responsibility to review documentation and ensure compliance was not fulfilled, contributing to the deficiencies observed in the care of Residents #5 and #39. These failures were identified during an investigation under Master Complaint Number OH00154788 and Complaint Number OH00154178.
Failure in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident's urinary catheter, affecting one resident out of three reviewed for urinary catheters. The resident, who was cognitively intact and required maximal assistance for toilet hygiene, was admitted with diagnoses including acute cystitis with hematuria, neuromuscular dysfunction of the bladder, and paraplegia. Upon returning from the hospital with an indwelling urinary catheter, there were no physician orders for catheter care and maintenance from the time of return until a later date. Additionally, the resident's care plan was not updated to reflect the presence of the indwelling urinary catheter. Observations revealed that the resident's urinary drainage bag was uncovered and hanging with a dependent loop, and the catheter was kinked, preventing proper urine drainage. A State tested Nursing Assistant confirmed the kink and adjusted the catheter to ensure proper urine flow. The Assistant Director of Nursing verified the lack of physician orders and the absence of an updated care plan for the catheter. The facility's policy required catheter care every shift, covered drainage bags, and proper positioning to prevent backflow, which was not adhered to in this case.
Failure to Prevent Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent the misappropriation of resident funds, specifically affecting one resident who was moderately cognitively impaired. The resident's credit card was taken and used to make unauthorized purchases totaling approximately $5,000.00, including 31 charges for the state lottery. The incident was reported to the bank fraud department, the local police, and the Ohio Board of Nursing. Surveillance footage confirmed that the alleged perpetrator was an LPN employed by the facility since 2019, who resigned shortly after the incident was reported. The facility's policy on abuse, neglect, and exploitation was not effectively implemented to protect the resident's property. The resident expressed feeling hurt upon learning that a staff member had used her credit card without authorization. The facility's administrator acknowledged that the misappropriation occurred over a two-month period and confirmed the identity of the suspect through surveillance footage provided by the detective. Despite the facility's policy to prevent such incidents, the misappropriation was not detected or prevented in a timely manner, leading to significant unauthorized charges on the resident's credit card.
Failure to Investigate Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate the misappropriation of a resident's funds, specifically affecting a resident who was moderately cognitively impaired. The resident's financial administrator reported unauthorized use of the resident's credit card, totaling approximately $5,000.00, for purchases including lottery tickets. The facility's self-reported incident revealed that the local police were involved, and a detective requested the facility not to share information with the suspect or staff until further investigation. Despite this, the facility did not confirm the suspect's identity from surveillance footage, only conducted five resident interviews, and did not perform any in-service training or audits. The facility's policy on abuse, neglect, and exploitation requires thorough investigation, including identifying and interviewing all involved persons and documenting the investigation comprehensively. However, the facility's investigation was incomplete as it did not include confirmation of the suspect's identity from surveillance footage and lacked staff interviews, in-service training, and audits. The administrator acknowledged that the facility did not have all the information at the time of the self-reported incident submission, which led to the misappropriation being unsubstantiated despite evidence suggesting otherwise.
Failure to Implement Fall Interventions and Proper Transfer Assistance
Penalty
Summary
The facility failed to ensure fall interventions were in place for two residents and did not provide adequate assistance during a transfer for another resident. Resident #21, who was at risk for falls and had a history of falls, was observed in bed with the bed not in the lowest position, contrary to the care plan. Similarly, Resident #47, who was also at risk for falls, was found in bed without the required fall mats and with the bed not in the lowest position. Both instances were verified by staff members who were unaware of the required interventions. Additionally, Resident #28, who required a mechanical hoyer lift for transfers with the assistance of two staff members, was transferred by a single staff member without assistance. This was observed and confirmed by the staff member, who stated that she sometimes performed the transfer alone if the resident was small enough. The facility's policy mandates that at least two nursing assistants are needed to safely move a resident with a mechanical lift. These deficiencies were identified during a survey and represent non-compliance with the facility's policies and procedures for preventing accidents and ensuring resident safety.
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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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Nursing homes near Perrysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Three Meadows Post Acute | 3.2 mi | ★★★★★ | 13 | 1 |
| Avalon By Otterbein At Perrysburg | 3.2 mi | ★★★★★ | 23 | 0 |
| Manor At Perrysburg | 3.7 mi | ★★★★★ | 29 | 0 |
| Kingston Health Center Of Perrysburg | 3.9 mi | ★★★★★ | 0 | 0 |
| Astoria Place Of Waterville | 4.9 mi | ★★★★★ | 31 | 1 |
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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.