Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Taylor Springs Health Campus during CMS and state inspections, most recent first.
A resident with significant dependency, limited mobility, an indwelling catheter, and a feeding tube had no Braden Scale completed for several months, and later hospital records documented an unstageable sacral pressure ulcer with bleeding, pain, redness, and additional pressure ulcers and venous ulcers. Facility wound records then listed multiple wounds as unspecified ulcers, diabetic ulcers, MASD, or scabbed areas, while interviews showed an LPN was doing the weekly wound documentation and the RN only viewed the wound monthly, despite policy and OBN guidance indicating RN assessment was required.
Two residents with significant upper extremity limitations and contracture risks did not receive timely, individualized interventions or care planning to address their range of motion (ROM) needs. Despite therapy assessments identifying ROM deficits and dependence on staff for care, neither resident had a care plan or ongoing services to maintain or improve ROM, and staff interviews confirmed a lack of interventions. The facility lacked a policy on ROM or therapy services, leading to actual harm including contracture development and pain.
The facility did not develop or implement comprehensive care plans for several residents with complex medical and psychiatric conditions, including those requiring continuous oxygen therapy, management of constipation and anemia, upper extremity contractures, and insomnia treated with Melatonin. Physician orders and direct observations confirmed the presence of these needs, but care plans were missing, and staff acknowledged the deficiencies.
A resident receiving enteral feedings was found to have dried tube feeding formula splattered across the walls, ceiling, personal items, and equipment in their room. The unsanitary condition resulted from formula spraying out during attempts to flush or unclog the gastrostomy tube, and the mess remained unaddressed for several days despite staff awareness.
A resident with multiple complex medical conditions, including hypoxemia and acute respiratory failure, was documented and observed to be receiving continuous oxygen therapy. However, the MDS assessment did not reflect the resident's oxygen use, and there was no care plan addressing this intervention. This inaccuracy was confirmed by an RN.
A resident admitted with diagnoses of mood disorder and anxiety disorder was not accurately identified on the PASRR screening, as these mental health conditions were omitted from the required section. This led to the resident being incorrectly determined as not needing further evaluation for serious mental illness.
Surveyors found that two residents' care plans were not revised to accurately reflect their current conditions. One resident's care plan included a pressure injury that was not present and lacked individualized non-pharmacological pain interventions, while another resident's care plan did not document the loss and replacement process of lower dentures, despite ongoing dental consults and resident reports.
Three residents who required staff assistance with ADLs did not consistently receive scheduled showers or routine nail care as required by their care plans and facility policy. One resident missed multiple scheduled showers over several months, another was observed with long and dirty nails on consecutive days, and a third received only one bath in a month despite being scheduled for twice-weekly showers. Staff interviews and documentation confirmed these deficiencies.
Two residents with significant mental health and cognitive needs did not receive individualized activities as required by their care plans. One resident missed several weeks of scheduled 1:1 activities, while another with severe cognitive impairment had limited group activity participation and was not accurately assessed for 1:1 attention, despite staff awareness of her needs and interests.
The facility failed to comprehensively assess and document pressure ulcers for two residents on admission and weekly thereafter, and did not implement timely interventions to prevent a new pressure ulcer in another resident. Incomplete wound assessments, delayed or inappropriate treatments, and lack of consistent repositioning contributed to the deficiencies, with staff citing inexperience and discomfort with wound staging as contributing factors.
A resident with multiple complex medical conditions was observed using a Bi-pap device with oxygen without a current physician order or documented monitoring. The care plan and MDS assessment did not address the use of Bi-pap or oxygen, and staff confirmed there was no active order for the device's settings or application.
A resident with multiple cardiac and neurological conditions received Metoprolol outside of physician-ordered parameters, as the medication was administered several times when the resident's pulse was below 60, contrary to the order to hold the medication under these circumstances. This was confirmed by the Regional Nurse.
A resident with a history of dental issues and multiple comorbidities experienced ongoing tooth pain and difficulty chewing, with staff documenting broken and missing teeth. Despite repeated requests and a care plan calling for dental coordination, the resident did not receive a dental exam or timely follow-up, and the facility failed to ensure access to both routine and emergency dental care as required by policy.
A resident with multiple medical conditions and intact cognition was prescribed a short course of cephalexin for cellulitis, but received three additional doses beyond what was ordered. The facility did not identify or address the over-administration during their antibiotic use review, despite having a policy requiring monitoring of antibiotic use.
A resident with severe cognitive impairment and physical dependency on staff for eating did not receive timely meal assistance. The resident was observed with an untouched meal for almost thirty minutes while only one CNA was available to assist multiple residents. The CNA confirmed the delay, attributing it to the high number of residents needing assistance.
A resident with severe cognitive impairment reported an unsubstantiated abuse incident to the police, but the LTC facility failed to report the allegation to management and the state agency in a timely manner, as required by their policy. The executive director was informed two days later, leading to a deficiency.
A resident with severe cognitive impairment and multiple diagnoses fell and sustained a wrist fracture. Despite severe pain and visible swelling, the facility failed to provide adequate pain management or timely medical intervention, resulting in over six hours of unmanaged pain.
A resident with severe cognitive impairment and a broken left wrist did not receive the required care as per emergency room instructions. The facility failed to document or implement orders for icing, elevating the wrist, and checking the skin under the splint, as confirmed by the DON.
A resident with severe cognitive impairment did not receive prescribed diazepam as ordered due to medication unavailability and discrepancies between the MAR and controlled drug use record. The DON confirmed the medication was not administered as documented.
The facility failed to maintain an accurate medical record for a controlled drug for a resident with severe cognitive impairment. The MAR indicated that all doses of diazepam were administered, but the controlled drug use record showed missing signatures for several doses. This discrepancy was confirmed by the DON, making the medical record inaccurate.
Weekly Pressure Ulcer Assessments Not Completed by RN
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing occurred for one resident who was admitted with diagnoses including sequelae of cerebral infarction, atherosclerotic heart disease, old MI, type 2 DM, hyperlipidemia, neuromuscular dysfunction of the bladder, anxiety disorder, mild cognitive impairment, major depressive disorder, adult failure to thrive, HTN, and GERD. The resident was dependent on staff for all care, had limited mobility, required assistance to turn and transfer, and had an indwelling catheter and feeding tube. The quarterly MDS documented no pressure ulcers and only MASD, but the medical record showed that a Braden Scale was not completed from 01/01/26 through 04/16/26. After the resident returned from the hospital, outside hospital records documented a chronic sacral wound that was an unstageable pressure ulcer with bleeding, pain, redness, and moderate sanguineous drainage, along with five additional pressure ulcers and two venous ulcers. Facility wound documentation later listed wounds to the buttocks and coccyx as unspecified ulcers, toe and ankle wounds as diabetic ulcers, and other areas as MASD or scabbed. Interviews showed the LPN designated as the wound nurse was completing weekly wound documentation and stated she was not wound certified, while the Regional Nurse said he viewed the resident's wound once a month. The DHS stated the LPN assessed the wounds weekly, but also stated an RN should be assessing wounds every week. Facility policies required weekly wound measurement and condition documentation, and the Ohio Board of Nursing guidance stated LPNs are prohibited from assessing health status for purposes of providing nursing care.
Failure to Implement Individualized ROM Interventions Resulting in Contractures
Penalty
Summary
The facility failed to timely develop and implement comprehensive and individualized interventions to address limitations in range of motion (ROM) and to prevent the onset or worsening of joint contractures for two residents. For one resident with a history of cerebrovascular accident, hemiplegia, and multiple comorbidities, occupational therapy (OT) assessments repeatedly identified limitations in left upper extremity ROM, including the wrist and fingers. Despite these findings and the resident's dependence on staff for activities of daily living, the care plan did not address the identified ROM limitations, risk for contractures, or include an individualized ROM program. After discharge from OT, there was no evidence of ongoing interventions or documentation of ROM services, and observations revealed the resident's arm was fixed in a contracted position, with no staff-provided ROM observed by the resident's spouse. Interviews with therapy and nursing staff confirmed that the resident had not been screened or evaluated by OT since discharge, and functional limitations were not reported by nursing staff. Another resident with a history of cerebellar stroke and contractures was referred to OT for declining upper extremity ROM and contracture prevention. After discharge from OT due to hospitalization, there was no evidence in the medical record of further therapy evaluation, ROM services, or interventions to prevent further decline in contractures for over a year. The resident was dependent on staff for care, had significant upper extremity contractures, and was not receiving any specialized therapies or restorative nursing programs. Interviews with nursing staff confirmed the absence of interventions or splints for the resident's upper extremities, and the resident reported not receiving ROM from staff and being unable to perform basic self-care tasks due to contractures. Both residents' care plans failed to address their upper extremity functional limitations and contracture risks, despite clear documentation of these issues in therapy assessments and resident interviews. The facility did not have a policy regarding ROM or therapy services, and there was no evidence of interdisciplinary planning or implementation of individualized interventions to maintain or improve ROM or prevent further decline. These failures resulted in actual harm, including deterioration in functional ability and pain for at least one resident.
Failure to Develop Comprehensive Care Plans for Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific needs and conditions of several residents, as required by regulation. For one resident with multiple complex diagnoses, including metabolic encephalopathy, cerebrovascular accident, and acute respiratory failure, there was no care plan addressing the use of continuous oxygen therapy, despite physician orders and direct observation confirming ongoing oxygen use. The resident's Minimum Data Set (MDS) assessment also did not reflect oxygen use, and nursing staff confirmed the absence of a care plan for this intervention. Another resident with diagnoses such as acute respiratory failure, cerebral infarct, and obstructive sleep apnea was observed using a Bi-pap device with oxygen, and physician orders specified continuous oxygen therapy and related care. However, there was no care plan in place to address the resident's oxygen use, and the MDS assessment did not indicate oxygen therapy, despite documentation and observation to the contrary. Nursing staff confirmed the lack of a care plan for this resident's oxygen therapy. A third resident with a history of constipation, anemia, and contractures had active physician orders and was receiving medications for constipation and anemia, but there was no care plan addressing these conditions or the resident's significant upper extremity functional limitations and contractures. Additionally, a fourth resident with multiple psychiatric diagnoses and an order for nightly Melatonin for insomnia did not have a care plan addressing insomnia or the use of Melatonin, despite the order being in place for an extended period. Nursing staff responsible for care planning confirmed the absence of required care plans for these residents.
Failure to Maintain Clean and Sanitary Resident Room and Equipment
Penalty
Summary
A deficiency was identified when a resident's room and equipment were found to be unclean and unsanitary. The resident, who had diagnoses including anxiety disorder, depression, malnutrition, and adult failure to thrive, was receiving daily enteral feedings via a gastrostomy tube. Observations revealed a dried yellow substance, identified as tube feeding formula, splattered across the walls, ceiling, ceiling light, personal items, and television screen in the resident's room. The tube feeding pump pole and its base were also covered with the same dried substance. These findings were confirmed by an LPN, who acknowledged the extent of the splatter but was unaware of its cause at the time. Further interview with the resident indicated that the splattering occurred when nurses attempted to flush or unclog the gastrostomy tube, causing the formula to spray throughout the room. Despite the initial observation and verification by staff, a follow-up observation several days later found that the room and equipment remained in the same unsanitary condition, with the dried formula still present on multiple surfaces. The ongoing presence of the dried tube feeding formula was confirmed by another staff member during the subsequent observation.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was coded accurately regarding oxygen use. The resident, who had multiple complex diagnoses including metabolic encephalopathy, pneumonitis, cerebrovascular accident with right-sided hemiplegia, epilepsy, diabetes, dysphagia, anemia, hypoxemia, sepsis, severe malnutrition, hypertension, and acute respiratory failure with hypoxia, was admitted and readmitted with ongoing medical needs. Physician orders and the Treatment Administration Record (TAR) documented continuous oxygen use at two liters per nasal cannula, and direct observation confirmed the resident was receiving oxygen. However, the quarterly MDS assessment did not indicate the resident's use of oxygen, and there was no care plan addressing oxygen use. This discrepancy was confirmed by a registered nurse during an interview.
Failure to Accurately Complete PASRR for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was completed accurately for a resident admitted with known mental health diagnoses. Upon review, the resident's medical record showed diagnoses of an unspecified (affective) mood disorder and anxiety disorder at the time of admission. However, the PASRR identification screen did not indicate these mental disorders, as required in Section E, despite them being listed among the mental disorders to be reported. As a result, the PASRR result notice concluded that the resident did not have indications of a serious mental illness and did not require a Level II evaluation for specialized services. The current Social Service Director confirmed that the PASRR was not accurate and did not reflect the resident's known mental illness diagnoses.
Care Plans Not Updated to Reflect Residents' Current Status
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised and accurately reflected the current status of two residents. For one resident with a history of constipation, fecal impaction, anemia, contractures, and cerebellar stroke, the care plan listed a pressure injury as a problem area, despite no evidence of a pressure injury in the medical record. Additionally, the care plan for pain management did not include individualized non-pharmacological interventions, and this omission was confirmed by the Regional MDS Coordinator. For another resident with dysphagia, diabetes mellitus, metabolic encephalopathy, and who was edentulous, the care plan only addressed the potential for mouth pain related to the use of top dentures. The care plan was not updated to reflect the loss of the lower denture and the ongoing process of obtaining a replacement, despite documentation in dental consults and resident interviews indicating the resident had been waiting for new lower dentures for approximately six months. The Regional Nurse confirmed that the care plan had not been revised to include these developments.
Failure to Provide Scheduled Showers and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide routine nail care and scheduled showers for three residents who required staff assistance with activities of daily living (ADLs). For one resident with multiple diagnoses including dysphagia, aphasia, heart failure, and obesity, the care plan required staff assistance for ADLs and scheduled showers twice weekly. Documentation revealed that this resident missed several scheduled showers over a three-month period, with confirmation from the Regional MDS Coordinator that showers were not provided as scheduled. Another resident, with severe cognitive impairment and multiple complex medical conditions such as metabolic encephalopathy, sepsis, and Alzheimer's disease, required extensive staff assistance for self-care and mobility. The care plan specified nail care on shower days and as needed. Observations on two consecutive days found the resident's nails to be long and dirty with a brown substance underneath, and both an LPN and an RN confirmed the need for nail care at the time of observation. A third resident, who was cognitively intact but dependent on staff for functional abilities including bathing, received only one bath during a one-month period despite being scheduled for showers twice weekly. Review of documentation and interviews with the DON confirmed that there was no additional bath or refusal documentation for this resident. Facility policy required bathing at least twice a week unless otherwise specified by resident preference, but this was not adhered to for the residents involved.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide appropriate activity programming to meet the individualized needs of two residents. One resident with major depressive disorder, anxiety, contractures, and a history of stroke was assessed to require weekly 1:1 meaningful activities, such as board games, music, and animal-related activities. However, documentation showed that this resident did not receive the required weekly 1:1 activity for a period of over three weeks. The Area Life Enrichment Director confirmed the absence of documentation and that the resident did not receive the scheduled activities during that time frame. Another resident with severe cognitive impairment, toxic encephalopathy, anxiety, and repeated falls was identified as being at risk for limited activity engagement. The care plan noted interests in sports and social interaction, and the resident expressed a desire for more social and sports-related activities. Despite this, activity logs indicated minimal participation in group activities, and the assessment inaccurately reflected the resident's engagement level. Staff interviews confirmed that the resident often required 1:1 attention, which was not properly documented or provided according to the assessment, and that family presence was incorrectly considered as a substitute for activity participation.
Failure to Assess, Document, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure comprehensive assessment and documentation of pressure ulcers for two residents upon admission and on a weekly basis, as well as failed to implement interventions to prevent the development of a pressure ulcer for another resident. For one resident with multiple comorbidities including spinal stenosis, diabetes, and recent surgery, the initial wound assessments were incomplete, lacking proper staging, detailed descriptions, and consistent measurements. The wound nurse was reportedly inexperienced and uncomfortable with staging, resulting in delayed and inadequate documentation. Physician-ordered treatments were not implemented promptly, and wound care was not always appropriate for the stage of the ulcer. Another resident with a history of severe medical conditions and high risk for skin breakdown was admitted and readmitted with skin impairments, including abrasions and moisture-associated skin damage (MASD). The facility did not provide comprehensive assessments of these wounds, often omitting location, measurements, staging, and descriptions. Weekly wound observations were incomplete, and there was a consistent failure to determine whether wounds had improved, deteriorated, or remained unchanged. Documentation was insufficient, and the care plan interventions were not always based on thorough wound assessments. A third resident, who was at risk for pressure ulcers and required significant assistance with mobility and hygiene, developed a new pressure ulcer after admission. The facility did not implement timely interventions such as regular turning and repositioning, despite recommendations from a prior wound care consult. Documentation of the new ulcer lacked staging and pain assessment, and the care plan was not updated with new interventions until after the ulcer developed. Observations showed the resident frequently left in bed with the head elevated and expressing discomfort, with staff interviews confirming that repositioning was not consistently performed or documented.
Failure to Obtain Physician Order and Monitor Bi-pap Use
Penalty
Summary
The facility failed to obtain a current physician order and provide appropriate monitoring for a resident using a Bi-pap non-invasive ventilation device. The resident, who had multiple complex diagnoses including acute respiratory failure with hypoxia, obstructive sleep apnea, and other chronic conditions, was observed on two occasions using the Bi-pap machine with oxygen. However, review of the medical record showed that the only physician order for Bi-pap had been discontinued, and there was no active order specifying the settings, application, or monitoring requirements for the device. Additionally, the resident's care plan did not address the use of oxygen or Bi-pap, and the comprehensive MDS assessment did not indicate the use of these respiratory therapies. Further review of the resident's records revealed ongoing orders for oxygen therapy but none for Bi-pap after the previous order was discontinued. Interdisciplinary team notes indicated the resident was non-compliant with Bi-pap but would use nasal cannula oxygen. Despite this, direct observation confirmed the resident was using the Bi-pap device without a current physician order or documented monitoring. Interview with the regional nurse confirmed the absence of an order for the Bi-pap machine's use and monitoring.
Failure to Follow Physician Parameters for Antihypertensive Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's antihypertensive medication, Metoprolol, was administered according to the physician's ordered parameters. The physician's order specified that Metoprolol 25 mg should be held if the resident's systolic blood pressure was less than 110 or if the heart rate was less than 60. Despite these instructions, the medication was administered on multiple occasions when the resident's pulse was below 60, including documented instances where the pulse was 58, 57, 52, 55, and 59. The resident had a medical history that included dysphagia, aphasia, dysarthria, atrial septal defect, asthma, atrial fibrillation, hypertensive urgency, hypertensive heart disease with heart failure, obesity, heart failure, and hyperlipidemia. The Regional Nurse confirmed that the medication was given outside the prescribed parameters.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident received both emergent and routine dental care as required. The resident, who had a history of multiple medical conditions including dysphagia, aphasia, heart disease, and obesity, was identified in the care plan as having two broken teeth and difficulty chewing. Interventions in the care plan included coordinating dental care and monitoring for oral health issues. Despite these interventions, documentation showed that the resident continued to report tooth pain and difficulty chewing over several months. Nursing staff observed missing and broken teeth and offered pain medication, which the resident declined, and initiated a referral to a dentist. However, there was no documented evidence that the resident was actually seen by a dentist or that the facility followed up to secure a dental appointment. Further review revealed that the resident had not received a dental exam since early in the previous year, despite ongoing complaints of dental pain and visible oral health issues such as broken and missing teeth with obvious caries. Interviews confirmed that the resident had repeatedly requested to see a dentist and continued to experience pain when eating. The facility's policy required assistance in obtaining both routine and emergency dental care, including making appointments and arranging transportation, but these actions were not completed for this resident.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to administer antibiotics as ordered for one resident. Medical record review showed that the resident was admitted with multiple diagnoses, including anxiety disorder, depression, psychotic disorder with delusions, contractures, and cerebellar stroke. The resident was cognitively intact according to the quarterly MDS assessment. A nurse practitioner evaluated the resident for right lower extremity edema and mild pain, diagnosed very mild cellulitis, and ordered a short course of cephalexin 500 mg three times a day. The electronic physician orders reflected this prescription. However, review of the medication administration record revealed that the resident received 18 doses of cephalexin instead of the 15 doses ordered, resulting in three additional doses being administered. The infection control log confirmed the resident met criteria for antibiotic treatment, but there was no evidence that the facility identified or addressed the administration of extra doses during their antibiotic use review. An interview with the regional nurse confirmed the over-administration. The facility's antibiotic stewardship policy required monitoring of antibiotic use to prevent unnecessary or inappropriate administration, but this was not followed in this instance.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to provide timely meal assistance to a resident who was dependent on staff for eating. Resident #44, who had diagnoses including dementia, osteoporosis, contracture of the left hand, and muscle weakness, was observed sitting in the dining room with a plate in front of her, untouched, for almost thirty minutes. The resident's comprehensive Minimum Data Set (MDS) assessment indicated severely impaired cognition and a dependency on staff for eating, with a diet order for a puree diet. During the observation, only one Certified Nursing Assistant (CNA) was present in the dining room, assisting three other residents who also required feeding assistance. Additional staff entered the dining room later, but no one assisted Resident #44 with her meal during the observation period. CNA #185 confirmed that Resident #44 was dependent on staff for eating and acknowledged the delay in assistance, citing the high number of residents needing help at meals. This deficiency was investigated under Complaint Numbers OH00162840 and OH00161491.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident with severe cognitive impairment. The resident, who had diagnoses including gastro-esophageal reflux disease, hypertension, osteoporosis, and diverticulosis, reported to the police that a man had entered her room and had his way with her. The police found the complaint unsubstantiated and left. Despite the serious nature of the allegation, the incident was not reported to the executive director or the state agency until two days later. Interviews with facility staff revealed that the resident's confusion and agitation were noted on the night of the incident, and the resident's daughter was contacted. However, the staff did not notify management immediately, as required by the facility's policy. The executive director was only informed of the allegation two days later, at which point an SRI was initiated. The facility's policy mandates immediate reporting of such allegations, but this protocol was not followed, resulting in a deficiency.
Inadequate Pain Management for Resident Following Fall
Penalty
Summary
The facility failed to develop and implement an individualized, effective, and comprehensive pain management program for a resident who experienced pain following a fall. The resident, who had severe cognitive impairment and multiple diagnoses including a displaced bicondylar fracture of the right tibia and unspecified dementia, fell and sustained a closed fracture of the distal ends of the left radius and ulna. Despite the resident's complaints of severe pain and visible swelling, the facility did not provide adequate pain management or timely medical intervention. On the day of the fall, the resident was found on the floor with a swollen left wrist and reported pain rated at eight out of ten. The resident was given one dose of Hydrocodone-Acetaminophen, which was noted to be ineffective. However, no further pain medication or non-pharmacological interventions were provided, and the resident was not transferred to the emergency room until over six hours later. During this time, the resident continued to exhibit signs of pain, such as grimacing and guarding the injured wrist, but no additional assessments or follow-ups were conducted. Interviews with facility staff revealed a lack of communication and proper pain management protocols. The LPN caring for the resident did not document the pain scale, failed to administer additional pain medication, and did not contact the Certified Nurse Practitioner for further instructions. The Director of Nursing acknowledged the need for reeducation on pain management and proper assessment for residents with severe cognitive impairments. The facility's policy on pain observation and management was not followed, leading to inadequate care for the resident.
Failure to Provide Care for Broken Wrist
Penalty
Summary
The facility failed to provide appropriate care for a resident with a broken left wrist. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, experienced an unwitnessed fall resulting in pain and swelling to the left wrist. An X-ray confirmed a closed fracture of the distal ends of the left radius and ulna. The emergency room discharge instructions included applying ice to the wrist, elevating it, and checking the skin under the splint daily. However, there was no documentation in the resident's chart indicating that these instructions were followed, nor were there any orders placed to ensure these care measures were implemented. The Director of Nursing confirmed that no orders were placed for the resident's wrist care as instructed by the emergency room. The progress notes from the date of the fall to the resident's discharge showed no evidence that the wrist was iced, elevated, or that the skin under the splint was checked. This deficiency was identified during a complaint investigation and represents non-compliance with the required standards of care.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was prescribed diazepam to be administered three times a day for anxiety. However, the medication was unavailable for administration on multiple occasions, and there were discrepancies between the Medication Administration Record (MAR) and the controlled drug use record. Specifically, doses were signed off as administered on the MAR, but the controlled drug use record did not reflect these administrations, indicating that the medication was not given as prescribed. Interviews with the Director of Nursing (DON) confirmed that the diazepam tablets were not administered when documented as unavailable and that doses were not signed out on the controlled drug record form despite being marked as given on the MAR. This discrepancy led to the conclusion that the medication was not administered to the resident as ordered by the physician. The deficiency was identified during a complaint investigation and was verified through closed medical record review and staff interviews.
Failure to Maintain Accurate Medical Record for Controlled Drug
Penalty
Summary
The facility failed to maintain an accurate medical record for a controlled drug for one resident. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was prescribed diazepam for anxiety. The Medication Administration Record (MAR) indicated that all doses of diazepam were administered as prescribed. However, the controlled drug use record showed missing signatures for several doses, indicating that the medication may not have been administered as recorded in the MAR. This discrepancy was confirmed by the Director of Nursing during an interview, who verified that the doses were not signed out on the controlled drug record form, making the medical record inaccurate. The resident's medical history included a displaced bicondylar fracture of the right tibia, age-related osteoporosis, and unspecified dementia with behavioral disturbances. The resident was also taking antipsychotic, antianxiety, and opioid medications. The failure to accurately document the administration of diazepam raises concerns about the accuracy and reliability of the resident's medical records. This deficiency was identified during a review of the closed medical record and was part of an investigation under Complaint Number OH00152040.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 906 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gahanna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allbridge Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 2 | 0 |
| Mother Angeline Mccrory Manor | 1.8 mi | ★★★★★ | 1 | 0 |
| Continuing Healthcare Of Gahanna | 2.2 mi | — | 29 | 0 |
| Otterbein Gahanna | 2.9 mi | ★★★★★ | 9 | 0 |
| Majestic Care Of Whitehall | 3 mi | ★★★★★ | 9 | 0 |
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