Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Walden Park during CMS and state inspections, most recent first.
Surveyors found that two residents with complex medical conditions did not receive weekly comprehensive wound assessments, and appropriate skin interventions were not consistently implemented. One resident's MASD was not assessed weekly as required, while another resident's pressure ulcer was not offloaded and the air mattress was set incorrectly for their weight. Documentation of wound status was inconsistent, and wounds were not always accurately classified, as confirmed by interviews with nursing staff and review of facility policy.
A resident with significant mobility impairments and a history of falls was left sitting unattended on the side of the bed by a CNA, despite care plan interventions requiring supervision and use of a Hoyer lift for transfers. The resident slipped and fell between the bed and dialysis chair, sustaining superficial skin tears. This incident was confirmed by record review, fall investigation, and DON interview, and was not in accordance with the facility's fall management policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective interventions to prevent new ulcers from developing. Observations and record reviews showed lapses in assessment, monitoring, and treatment, with necessary preventive measures not consistently applied.
The facility did not maintain an effective pest control program, resulting in daily sightings of gnats, roaches, and flies in resident rooms and common areas. Multiple residents and staff confirmed the ongoing pest presence, and direct observations documented pests on surfaces and equipment. In one case, a resident with a tracheostomy was found to have fly larvae in the stoma, requiring hospital transfer.
The facility did not ensure that advance directives, such as DNR orders, were readily available to staff and EMS for several residents with significant medical conditions. In one case, a resident with a DNR order experienced a medical emergency, but staff could not provide the required documentation, resulting in unwanted resuscitation efforts. Similar documentation gaps were found for other residents, with missing signed DNR forms in both electronic records and code status binders, as confirmed by staff interviews and record reviews.
Several dependent residents with complex medical needs did not receive adequate personal hygiene care, including shaving and nail care, as required by facility policy. Observations and interviews revealed that staff did not consistently offer or provide these services, and residents or their families reported unmet requests for assistance with grooming.
Failure to Hold Quarterly Care Conferences: The facility did not complete required quarterly care planning conferences for multiple residents with conditions including dementia, schizophrenia, COPD, CHF, malnutrition, and diabetes. Some residents had only two conferences over the review period, while others had none, and SS staff confirmed the conferences were expected on a quarterly basis per policy.
Two residents experienced ongoing issues with a loose, leaking sink faucet and a separated baseboard exposing a dark surface in their shared room. Despite repeated notifications to staff and adherence to facility policy requiring maintenance of a safe and clean environment, the problems were not addressed, resulting in a deficiency.
The facility did not timely report multiple incidents of physical and verbal abuse, as well as injuries of unknown origin, to the State Survey Agency as required by policy. In several cases involving residents with cognitive impairment and complex medical histories, allegations of abuse were either reported late or not reported at all, despite clear documentation of the incidents and facility policy mandating prompt notification.
The facility did not promptly or thoroughly investigate multiple allegations of verbal and physical abuse, as well as injuries of unknown origin, affecting several residents with cognitive impairments and complex medical histories. Required investigations were delayed or not conducted, and there was no evidence of proper follow-up or staff interviews as outlined in facility policy.
Two residents with contractures did not receive their physician-ordered splint devices as required. Despite clear orders and care plan interventions for the use of a palm protector and a c-roll splint, observations over several days showed that neither device was applied. Staff interviews revealed confusion about responsibility for applying the devices, and facility policy regarding splint use was not followed.
The facility failed to prevent accidents and secure hazards for residents, including not thoroughly investigating a fall that resulted in a hip fracture, not ensuring proper footwear to prevent slips, and not securing smoking materials for a resident assessed as unsafe to smoke. These deficiencies involved inadequate supervision, incomplete care plan updates, and failure to follow facility safety policies.
A resident with severe cognitive impairment and total dependence on staff for tracheostomy care was found with fly larvae at the tracheostomy site, requiring hospital evaluation and removal of the infestation. Documentation showed tracheostomy care was signed off as completed, but surveyors observed ongoing fly presence in the unit and noted the facility's policy lacked guidance for such infestations.
A resident with chronic pain conditions received scheduled Tramadol, but staff failed to document pain assessments or evaluate the effectiveness of the medication as required by the care plan and facility policy. Nursing staff confirmed the absence of pain scale documentation and monitoring, despite established procedures for pain management.
The facility did not identify PTSD triggers in the care plan for a resident with a known PTSD diagnosis and failed to assess another resident for PTSD despite recent traumatic experiences. Two residents were affected, and the facility's policy requiring trauma-informed care and identification of triggers was not followed.
A resident with a chronic wound and an active order for Enhanced Barrier Precautions (EBP) received incontinence care from a CNA who wore gloves but failed to wear a gown, despite posted EBP signage and facility policy requiring both for high-contact care activities. The CNA confirmed not following the gown requirement during the care.
Failure to maintain room door privacy. A resident with PTSD, anxiety, and depression had intact cognition, and surveyors observed the room entrance door would not close on multiple occasions. The resident stated she wanted privacy at times, and maintenance records showed no work orders had been made to repair the door despite staff knowing about the issue. The facility policy stated residents have the right to personal privacy.
A resident with Parkinson's disease, dementia, and hearing loss did not receive a timely audiology consult after his hearing aids stopped working. His care plan called for checking hearing aid placement and function and referring him to audiology, but the record did not show when the problem began or any social services follow-up. The resident said he was upset that his hearing aids did not work and wanted to see an audiologist, and he was not wearing his hearing aids during the interview. The SW said the Medicaid authorization form had been received but had not yet been given to the physician for signature.
Improper medication storage and labeling were found on two medication carts. An expired Chlorhexidine bottle was present for one resident, a Novolin 70/30 insulin vial for another resident had been kept past the 30-day discard period after opening, and a Lantus insulin pen for a third resident lacked an open date. An LPN verified the expired and improperly dated medications, and one resident had already been discharged.
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, and a recent femur fracture required substantial to maximal assistance with mobility and self-care, and the care plan directed staff to encourage use of the call light for help. On multiple observations, the call light was found hanging on the wall or lying on the floor out of reach, and an LPN and RN confirmed it was not within the resident’s reach despite the facility policy requiring call lights to be placed within reach.
A resident receiving anticoagulant therapy, with a care plan indicating risk for bleeding and bruising, was found to have multiple bruises that had not been identified or monitored by nursing staff. The RN assigned to the resident was unaware of the bruising, and there was no documentation of monitoring for bruising in the medical record, despite the resident's known risk factors.
A resident with complex medical needs experienced a significant weight gain over a short period, but staff failed to assess, document, or investigate the change as required by facility policy. The dietitian did not notice the weight change when entering data, and the DON indicated that monitoring was the dietitian's responsibility. No reweigh or assessment was completed, and the resident was later hospitalized following a change in condition.
A resident with multiple chronic conditions did not receive prescribed Brimonidine eye drops twice daily as ordered, due to the facility's failure to properly reconcile and verify medication orders upon readmission. Despite clear indications in the hospital discharge summary and prior orders, the medication was administered only once daily, and staff interviews confirmed the error and the resident's awareness of the issue.
A resident with multiple diagnoses, including schizophrenia and dementia, was prescribed Paliperidone, but staff failed to document daily monitoring for antipsychotic side effects as required by the care plan and facility policy. Interviews with the DON and ADON confirmed the lack of required documentation, and this deficiency was identified during a complaint investigation, potentially affecting other residents on antipsychotic medications.
A resident with a history of traumatic brain injury was physically assaulted by a visitor on the smoking patio, resulting in a laceration and swelling. The facility's investigation was incomplete, and neurological checks were not conducted at proper intervals. The incident highlights a failure to ensure a safe environment as per the facility's abuse prohibition policy.
A resident with a history of traumatic brain injury and other conditions was physically assaulted by a visitor in the smoking area, resulting in a fractured nose. The facility's investigation was incomplete as it failed to include a statement from another resident who witnessed the incident. Despite the incident's severity, the facility unsubstantiated the allegation, citing unpredictability of the event.
A resident experienced harm due to the facility's failure to address a low potassium level, resulting in an acute change in condition. The resident's lab results indicating hypokalemia were not reviewed, leading to shortness of breath, bradycardia, and eventual hospitalization for ventricular tachycardia. Interviews revealed a lack of communication and follow-up on lab results, contributing to the deficiency.
A resident with chronic conditions had a BMP ordered post-hospital discharge, revealing low potassium levels. The facility failed to notify the physician or fax results to the cardiologist. Staff interviews confirmed the oversight, and the facility's policy on notifying practitioners of significant changes was not followed.
A resident with severe cognitive impairment and multiple medical conditions left the facility without staff knowledge and was found intoxicated by law enforcement. The facility failed to investigate the incident, as confirmed by interviews with an LPN and the DON, who acknowledged the lack of documentation and investigation into the resident's unauthorized departure.
A resident with multiple medical conditions, including quadriplegia and chronic respiratory failure, missed a scheduled appointment with Ohio Health Neuroscience due to the facility's failure to record the appointment and arrange transport. Despite the resident's full cognitive capacity, the oversight was only discovered when the resident's wife informed the facility, leading to a deficiency finding.
Failure to Complete Weekly Wound Assessments and Ensure Proper Skin Interventions
Penalty
Summary
The facility failed to ensure that weekly comprehensive wound assessments were completed, appropriate skin interventions were in place, and wounds were accurately classified for two residents reviewed for wounds. For one resident with multiple complex diagnoses, including chronic kidney disease, malnutrition, and dependence on dialysis, the initial assessment upon admission identified excoriation and Moisture Associated Skin Damage (MASD) to several areas. Although the care plan included weekly head-to-toe skin assessments and specific interventions, there was no documented weekly comprehensive assessment of the MASD until nearly a month after admission. Interviews with the wound nurse and DON confirmed that weekly assessments should have been performed and documented. Another resident with a history of end-stage renal disease, severe malnutrition, bilateral lower limb amputation, and other comorbidities was admitted with a stage III pressure injury and later developed an unstageable pressure ulcer to the left below-knee amputation site. The care plan required weekly skin assessments, offloading, and use of pressure-relieving devices. However, observations revealed the resident's wound was not offloaded, and the air mattress was set incorrectly for the resident's weight, providing no effective offloading. Documentation inconsistencies were also identified, with the DON confirming that an LPN had been documenting wounds incorrectly or not at all, and the wound was later reclassified as vascular in origin by a wound nurse practitioner. Review of facility policy indicated that residents with wounds or at risk for skin compromise should receive ongoing monitoring, evaluation, and appropriate documentation of skin impairments until resolved. The deficiencies were identified through observation, record review, and staff interviews, and were cited under a complaint investigation and as a recite to the annual survey.
Resident Left Unattended Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, impaired mobility, and a history of falls, was left unattended sitting on the side of the bed while preparing for dialysis. The resident required one-person assistance with transfers and ambulation, had a documented fear of falling, and was identified as being at high risk for falls due to factors such as medication effects, impaired vision, unsteady gait, and pain. The care plan specifically included interventions such as not leaving the resident unattended in the bathroom or at the bedside, using a Hoyer lift for transfers, and keeping the call light within reach. Despite these documented interventions, the resident was left alone by a CNA, resulting in the resident slipping off the bed and being found on the floor between the bed and dialysis chair with two superficial skin tears. The incident was confirmed through record review, fall investigation, and interview with the DON, who verified that the resident was left unsupervised, contrary to the care plan and facility policy. The facility's fall management policy required identification of hazards and implementation of interventions to minimize falls, which was not followed in this instance.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, roaches, house flies, and fruit flies throughout the building. Multiple residents reported daily encounters with gnats and roaches in their rooms, with direct observations confirming the presence of these pests on privacy curtains, tray tables, and side tables. Staff interviews corroborated the ongoing issue, with both nursing and housekeeping personnel acknowledging the daily presence of live pests in resident rooms and common areas. Additionally, a roach was observed crawling in a hallway, and a significant number of gnats were seen in a resident's room during maintenance staff observation. In the tracheostomy unit, multiple observations documented house flies and fruit flies flying around and landing on various surfaces. One resident, whose room was adjacent to an exit door leading outside, was found to have a tracheostomy and stoma infested with fly larvae, necessitating hospital transfer. The facility's policy stated an environment free of pests would be provided, but the ongoing pest infestation affected several residents and had the potential to impact all residents in the facility.
Failure to Ensure Advance Directives Are Accessible to Staff and EMS
Penalty
Summary
The facility failed to ensure that residents' advance directives were readily accessible to staff and Emergency Medical Services (EMS) personnel, as evidenced by observations, interviews, and record reviews. In several cases, residents had documented wishes regarding resuscitation and code status, but the necessary paperwork, such as signed Do Not Resuscitate (DNR) forms, was either missing from the electronic health record or not available in the code status binders at the nurses' stations. This deficiency affected four residents who had varying degrees of cognitive impairment and significant medical histories, including dementia, atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. One resident with severe cognitive impairment and a DNR order experienced a critical event where EMS was called due to low oxygen saturation. When EMS arrived, staff were unable to provide a valid, physician-signed DNR form, resulting in the initiation of CPR and transport to the hospital, contrary to the resident's documented wishes. The resident was revived at the hospital, and only after family confirmation was care de-escalated, and the resident passed away. Interviews with nursing staff confirmed the absence of the required DNR documentation at the time of the emergency. For other residents, reviews of their medical records and code status binders revealed similar issues: either the signed DNR paperwork was not present in the electronic health record or not available in the code status book at the nurses' stations. Staff interviews confirmed that the required documentation was missing, and facility policy required that copies of all advance directives be placed in the medical record and, if applicable, a DNR order be obtained from the physician. The lack of accessible advance directive documentation directly impacted the facility's ability to honor residents' wishes regarding life-sustaining treatment.
Failure to Provide Adequate Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and services for personal hygiene to residents who were dependent on staff for activities of daily living (ADLs). Multiple residents with significant medical conditions, including surgical amputation, chronic obstructive pulmonary disease, multiple sclerosis, contractures, dementia, and hemiplegia, were observed to have unmet hygiene needs. These included unshaven facial hair, long and untrimmed fingernails, and dirty contracted hands, despite being fully dependent on staff for these tasks. One resident with intact cognition and dependency for grooming was observed with a long, untrimmed mustache and beard, and reported that staff had not offered to shave or trim his facial hair, though he expressed a desire for this care. Another resident with a contracted hand and multiple sclerosis had long fingernails resting against her palm and reported repeatedly asking staff to trim her nails, but the care was not provided. Staff confirmed that this resident did not refuse grooming or care. A third resident, dependent on staff for personal hygiene due to cognitive impairment, was observed with a long beard and no documentation of refusal of care. The resident’s family member also confirmed the need for daily shaving. Additionally, a resident with diabetes, contractures, and hemiplegia was observed with long, dirty fingernails on a contracted hand. Staff confirmed the presence of debris and a yeast-like odor, and that the hand required cleaning and trimming. Facility policy required daily personal hygiene, including nail care and shaving, but documentation and observations indicated these standards were not met for several dependent residents.
Failure to Hold Quarterly Care Conferences
Penalty
Summary
The facility failed to complete quarterly care conferences for multiple residents, including residents with cognitive impairment, dementia, schizophrenia, COPD, CHF, malnutrition, and other chronic conditions. Review of records and interviews confirmed that several residents had only two care conferences over the review period, while others had none at all. The facility policy titled, Care Planning Conference, stated that care planning conferences are to be held on admission, quarterly, annually, with a significant change, and as needed, with participation from the resident, family, or representative. Resident #6, admitted with alcoholic cirrhosis of the liver without ascites, permanent atrial fibrillation, COPD, and schizoaffective disorder, had severe cognitive impairment on the quarterly MDS. Care conferences were documented only on 10/22/24 and 03/06/25, with none after that. Resident #37, admitted with rhabdomyolysis, Alzheimer's disease, generalized muscle weakness, and a history of falling, had moderate cognitive impairment on the significant change MDS and had care conferences only on 08/29/24 and 03/03/25. Resident #82, admitted with dementia with agitation, moderate protein-calorie malnutrition, localized edema of the right lower extremity, and CKD, had severe cognitive impairment and only two care conferences on 08/21/24 and 05/07/25. Resident #170, with dementia without behavioral disturbance, mild protein-calorie malnutrition, COPD, and chronic diastolic CHF, had severe cognitive impairment and only two care conferences on 10/21/24 and 06/24/25. Resident #53, admitted with COPD, asthma, type II diabetes mellitus with circulatory complications, and diabetic neuropathy, had intact cognition on the quarterly MDS but no care conferences were held during the review period. Resident #110, admitted with vascular dementia with other behavioral disturbance, moderate protein-calorie malnutrition, and chronic diastolic CHF, also had no care conferences. Resident #18, who had schizophrenia, polyneuropathy, anxiety disorder, severe cognitive impairment, and a court-appointed guardian, had a last care conference on 02/10/25, and the guardian stated no conference had occurred since then. Resident #198, admitted with CHF and dementia and documented as cognitively intact, had care conferences only on 02/04/25 and 07/30/25. Social Services staff confirmed for these residents that quarterly care conferences were expected and that the documented conferences did not occur at the required frequency.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the rooms of two residents. Record review and interviews revealed that one resident's sink faucet had been loose and leaking since March, and both the resident and their guardian had notified the facility of the issue, but it was never repaired. Observations over several days confirmed the faucet remained loose and dripping. Additionally, the baseboard behind the toilet in the same room was separated from the wall, exposing a dark brown and black surface underneath. Both the resident and their roommate reported the ongoing issues with the sink to the facility, but no repairs had been made. Staff interviews confirmed awareness of the loose and leaking sink faucet, though the RN was not aware of the separated baseboard. Maintenance workers and housekeeping staff acknowledged the problems, with housekeeping stating she had reported the issues to her supervisor. Facility policy requires housekeeping to report repair needs to maintenance and affirms residents' rights to a safe, clean, and comfortable environment. Despite these policies, the facility did not address the reported maintenance issues in a timely manner, resulting in a deficiency affecting the residents' living conditions.
Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report allegations of physical and verbal abuse, as well as injuries of unknown origin, to the State Survey Agency as required. For one resident with severe cognitive impairment and multiple medical conditions, an incident occurred where the resident was found with a bleeding nose and alleged being punched. Although an assessment and room change were completed, no Self-Reported Incident (SRI) was filed for this physical abuse allegation. Additionally, when the same resident was later found with facial bruising, skin tears, and injuries of unknown origin, no SRI was submitted for this event either. The Administrator confirmed that these incidents were not reported until approximately eight months later, following discussion during the survey. Another resident with moderately impaired cognition and multiple diagnoses was subjected to verbal abuse by another resident, which resulted in emotional distress. The SRI for this incident was filed three days after the event, rather than within the required timeframe. A subsequent incident of verbal abuse by the same resident was not reported at all. The facility's policy requires that allegations of abuse or serious injury be reported to state or federal agencies within two hours, and all other allegations within 24 hours, but these requirements were not met in the cases reviewed.
Failure to Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that allegations of verbal and physical abuse, as well as injuries of unknown origin, were thoroughly investigated for three residents. In one instance, a resident with moderately impaired cognition was verbally abused by another resident, resulting in emotional distress. The facility did not initiate an investigation into this incident until three days after it occurred, and failed to investigate a subsequent similar incident involving the same residents. The Administrator confirmed that the required investigations were either delayed or not conducted at all. Another resident with severe cognitive impairment and multiple medical diagnoses experienced physical aggression and later sustained injuries of unknown origin. Although these incidents were documented in nursing notes and discussed in interdisciplinary team meetings, the facility did not initiate any formal investigations to determine the cause or identify responsible parties. There was no evidence of staff interviews, injury assessments of other residents, or follow-up actions consistent with a proper abuse investigation, as required by the facility's own policy.
Failure to Provide Physician-Ordered Splint Devices for Residents with Contractures
Penalty
Summary
The facility failed to provide physician-ordered splint devices to residents with contractures, as evidenced by the care of two residents reviewed for range of motion. One resident, with diagnoses including paralytic syndrome, polyneuropathy, and contracture of the right hand and wrist, had a physician order and care plan intervention for a right palm protector to be applied daily for up to eight hours. Despite this, multiple observations over several days showed the resident was not wearing the palm protector. Interviews with nursing staff and CNAs revealed confusion and lack of clarity regarding responsibility for applying the device, with none of the interviewed staff having applied the palm protector as ordered. Another resident, diagnosed with contracture of the left hand and elbow as well as hemiplegia and hemiparalysis, had an active physician order and care plan for a left c-roll splint to be applied for six hours daily. Observations on multiple occasions found the resident in bed with contracted extremities and no splint or device in place. Staff interviews confirmed the resident had not had the splint applied during the observed period. Facility policy indicated that splints and braces are to be used to enhance mobility and maintain alignment, but these were not provided as ordered for the residents in question.
Failure to Prevent Accidents and Secure Hazards for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. In one instance, a resident with Alzheimer's disease, dementia, and osteopenia, who was at high risk for falls, experienced a fall in her room after turning off the lights. The fall resulted in a right hip fracture. The facility's fall investigation did not include staff interviews to determine the root cause or other contributing factors, and the care plan was not updated to reflect the use of a walker and wheelchair as interventions after the resident returned from the hospital. The intervention to maintain adequate lighting was not new and had been in place prior to the fall, but the investigation did not address why the resident was able to turn off the lights or if additional measures were needed. Another resident with dementia, unsteadiness, and muscle weakness experienced a fall attributed to worn non-skid socks that lacked sufficient grip. The facility provided these socks, which were shared and cleaned between residents, but staff did not routinely check their condition before use. The only immediate intervention after the fall was replacing the socks with a new pair. The care plan did not address the need for routine inspection or replacement of facility-provided footwear, and the fall investigation did not identify or implement additional preventive measures. A third resident, who was cognitively intact but had bilateral above-knee amputations and muscle wasting, was assessed as unsafe to smoke and required supervision. Despite this, the resident was observed with two lighters within reach at the bedside, contrary to the facility's smoking policy, which required all smoking paraphernalia to be maintained by staff and locked away. Staff interviews confirmed that even safe smokers were not permitted to keep lighters or smoking materials on their person, and the policy required staff to secure all such items. The presence of lighters at the bedside represented a failure to follow the facility's own safety protocols.
Failure to Provide Adequate Respiratory Care Resulting in Tracheostomy Site Infestation
Penalty
Summary
A resident with acute and chronic respiratory failure, hemiplegia, hemiparesis, and who was ventilator dependent with a tracheostomy, was found to have multiple fly larvae (maggots) in and on the tracheostomy site. The resident was totally dependent on staff for all care, including tracheostomy care, which was ordered to be performed every 12 hours with skin checks under the tracheostomy ties on each shift. Documentation in the Treatment Administration Record indicated that tracheostomy care was completed and signed off by various respiratory therapists. However, a nursing note documented the discovery of the larvae, and the resident was subsequently sent to the emergency room, where the infestation was removed. Hospital records confirmed the presence and removal of three larvae, with no further intervention required. Observations during the survey revealed multiple house flies and fruit flies present in the tracheostomy unit, landing on various surfaces. The resident's room was located next to an exit door leading outside, which staff had frequently used prior to the incident. The facility's policy on tracheostomy suctioning did not contain information on care required for fly larvae infestation. Interviews confirmed the infestation and the presence of flies in the unit, but attempts to interview the staff directly involved at the time of the incident were unsuccessful.
Failure to Monitor Effectiveness of Scheduled Opioid Pain Medication
Penalty
Summary
The facility failed to consistently evaluate the effectiveness of regularly scheduled opioid pain medication for a resident with chronic pain conditions, including fibromyalgia and polyarthritis. The resident had a physician's order for Tramadol 50 mg twice daily for pain management, and the care plan required evaluation of the medication's effectiveness, review of compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on functional ability and cognition. However, review of the medication administration record, treatment administration record, and progress notes revealed no documentation of pain scale assessments or evaluation of the medication's effectiveness during the specified period. Interviews with nursing staff confirmed that there was no pain scale or documentation of pain assessment or medication effectiveness for this resident, despite facility policy requiring such monitoring for residents identified with pain. The facility's pain management policy specified the use of a consistent pain scale, regular re-evaluation, and documentation of pain monitoring, but these procedures were not followed for the resident receiving scheduled Tramadol.
Failure to Identify and Address PTSD Triggers and Assess for Trauma
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with significant histories of trauma and mental health concerns. For one resident with diagnoses including PTSD, anxiety disorder, and depression, the care plan did not include specific PTSD triggers, despite documentation in the social services evaluation that identified triggers such as people, thoughts, and feelings. The care plan only addressed general interventions for mood and anxiety but omitted the individualized triggers that could help staff avoid re-traumatization. This omission was confirmed by the social worker during an interview. For another resident with a history of recent traumatic events, including the loss of a child to suicide and a recent bilateral leg amputation, there was no assessment for PTSD upon admission or during the resident's stay. The resident expressed feelings of sadness and depression and requested to speak with someone, but the social service designee was unaware of the resident's traumatic loss and confirmed that no PTSD assessment had been completed. The facility's policy requires trauma to be identified and addressed in the care plan, including triggers and interventions, but this was not done for these residents.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) as required for a resident with a chronic wound. The resident, who had a diagnosis of chronic obstructive pulmonary disease and an active physician order for EBP due to a chronic wound, was observed receiving incontinence care from a Certified Nursing Assistant (CNA) who wore gloves but did not don a gown, despite clear signage outside the resident's room indicating the need for both gloves and a gown during high-contact care activities. The CNA confirmed during interview that he did not wear a gown while providing care, contrary to the posted EBP requirements. Facility policy and CDC guidance both specify that gloves and gowns must be worn during high-contact care for residents on EBP, particularly those with chronic wounds. Observations confirmed that the required EBP signage was present and visible outside the resident's room, outlining the need for gloves and gowns during specific care activities. Despite these clear instructions and policies, the staff member did not adhere to the EBP protocol during care provision.
Failure to Maintain Room Door Privacy
Penalty
Summary
The facility failed to provide personal privacy to Resident #48 when the door to the resident’s room would not close. Resident #48 was admitted on 06/17/25 and had diagnoses of post traumatic stress disorder, anxiety disorder, and depression; the MDS 3.0 assessment dated [DATE] showed intact cognition. On 08/04/25 at 10:32 A.M. and again on 08/06/25 at 1:45 P.M., observation revealed the room entrance door would not close. Resident #48 stated on 08/04/25 at 10:45 A.M. that she was upset because she wanted privacy at times. Review of the prior ninety days of maintenance work orders showed no work orders had been made to repair the door, and Maintenance #811 confirmed on 08/06/25 at 1:50 P.M. that he knew about the door not closing prior to the survey. The facility policy titled Federal and State- Resident Rights and Facility Responsibilities dated 05/14/24 stated the resident has the right to personal privacy.
Delayed Audiology Consult for Resident With Hearing Loss
Penalty
Summary
The facility failed to obtain an audiology consult in a timely manner for Resident #46, who had diagnoses including Parkinson's disease, dementia, and hearing loss. The resident's care plan identified impaired communication related to mixed conductive and sensorineural bilateral hearing loss, noted that he wore hearing aids, and included interventions to check hearing aid placement and functioning and to refer to audiology for a hearing consult. A prior audiology visit recommended that he wear hearing aids daily, and a later MDS assessment documented moderate cognitive impairment, moderate difficulty hearing, and no hearing aid use. The resident's record from 01/01/25 through 08/04/25 did not show when his hearing aids stopped working, when he requested to see an audiologist, or any follow-up by social services to arrange the visit. During interview and observation, the resident stated he was upset that his hearing aids did not work and that he wanted to see an audiologist, and he was not wearing his hearing aids at that time. The social worker stated the facility obtained audiology consultations as needed and said she had received the Medicaid authorization form in the summer but had not yet given it to the physician for signature, even though audiology and physician visits had occurred at the facility during that period. The facility policy stated that social services/designee would make referrals to outside services and provide demographics and signed consent as needed.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were properly stored and labeled in accordance with accepted professional principles. On the 500-hall medication cart, an unopened bottle of Chlorhexidine labeled for Resident #33 was found with an expiration date of February 2025, and the Unit Manager verified that it was expired. On the 400-hall medication cart, a vial of Novolin 70/30 insulin for Resident #237 had an open date of 06/27/25, and an LPN verified it should have been discarded after 30 days; the LPN also stated that Resident #237 had been discharged from the facility. The same cart also contained a Lantus insulin pen for Resident #53 without an open date, and the LPN verified that an open date should have been present. The facility identified 11 medication carts in the building, and these findings affected two of the six carts observed and three residents.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure that a call light was positioned within reach of Resident #15. Resident #15 was admitted with diagnoses including fracture of the neck of the left femur, dementia, psychotic disturbance, mood disturbance, and anxiety. The MDS assessment showed impaired cognitive function and the need for substantial to maximal assistance with mobility, and the care plan directed staff to encourage use of the bell/call light for assistance. Observations on multiple occasions showed Resident #15 in bed with the call light either hanging on the wall out of reach or lying on the floor at the foot of the bed. Staff interviews confirmed these conditions, including an LPN and an RN who observed the call light out of the resident’s reach. The facility policy stated that call lights would be placed within the resident’s reach and answered in a timely manner.
Failure to Monitor Bruising in Resident on Anticoagulant
Penalty
Summary
A resident with diagnoses including end stage renal disease, anemia, and heart failure was admitted to the facility and was receiving Apixaban, an anticoagulant, as ordered by her physician. The resident's care plan identified her as being at risk for hematological alterations due to anemia and anticoagulant side effects, with interventions to administer medications as ordered and observe for side effects such as bruising. Despite these interventions, observations revealed maroon, gray-brown, and yellow bruising on the resident's bilateral forearms and lower right extremity. The assigned RN was unaware of the bruising until it was pointed out during the survey, despite the resident being on anticoagulant therapy. Further review and interviews with the DON and wound nurse confirmed there was no documented evidence of monitoring the resident's bruising in the medical record. This lack of monitoring and documentation for bruising in a resident on anticoagulant medication constituted the deficiency identified during the survey.
Failure to Assess and Investigate Significant Weight Gain
Penalty
Summary
A resident with multiple complex medical conditions, including chronic respiratory failure, end stage renal disease, and dysphagia, was identified as being at risk for nutritional decline according to their care plan. The care plan required observation and evaluation of weight and weight changes. The resident experienced a significant weight gain of 7.6% in less than 30 days, increasing from 169.1 lbs to 181.9 lbs. Despite this notable change, there was no documentation in the progress notes acknowledging, identifying, or assessing the weight gain during the period reviewed. Interviews revealed that the dietitian entered the resident's weight into the system but did not notice the significant change at the time, and confirmed that no assessment or documentation of the weight gain occurred. The DON stated that the dietitian was responsible for monitoring weekly weights, not the nursing staff. Facility policy required reweighs within 48 to 72 hours for significant weight changes, but this was not done. The resident was later sent to the hospital due to a change in condition, but there was no evidence that the significant weight gain was investigated or addressed prior to this event.
Failure to Reconcile Medication Orders Leads to Incorrect Eye Drop Administration
Penalty
Summary
The facility failed to properly reconcile a resident's medication orders upon readmission, resulting in the resident not receiving prescribed eye drops as ordered by the physician. Specifically, the resident, who had a complex medical history including end stage renal disease, kidney transplant, congestive heart failure, and glaucoma, was supposed to receive Brimonidine Tartrate Ophthalmic Solution 0.2% one drop in each eye twice daily. Prior to hospitalization, this was the established order, and the hospital after visit summary (AVS) also indicated continuation of this regimen. However, upon readmission, the facility entered an order for the medication to be administered only once daily, and this was how it was given from 04/01/25 to 04/09/25. Interviews with the resident and an LPN confirmed the discrepancy between the intended twice-daily dosing and the once-daily administration. The resident reported awareness of the change and expressed concern that the facility was not following the correct regimen. The LPN acknowledged that the AVS contained conflicting instructions but that the check marks for morning and evening administration indicated the medication should have continued twice daily. Facility policy and the nurse admission checklist required verification and reconciliation of orders with the physician and pharmacy, but this process was not properly followed, resulting in the medication error.
Failure to Monitor and Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to monitor and document the side effects of antipsychotic medication for a resident diagnosed with conditions including cerebrovascular disease, schizophrenia, hypothyroidism, dementia, and drug-induced dyskinesia. The resident was prescribed Paliperidone, an antipsychotic, and her care plan included interventions to observe and report side effects such as sedation, headaches, dizziness, and other symptoms. However, a review of the resident’s medical record, including medication and treatment administration records from January through April 2025, revealed no documented evidence of daily monitoring for antipsychotic side effects as required by the care plan and facility policy. Interviews with the DON and ADON confirmed that daily documentation of side effect monitoring for antipsychotic medications was expected and should be present in the medical record, but was missing for this resident. The facility’s policy on behavior management also emphasized the importance of describing behaviors that could indicate medication side effects. This deficiency was identified during a complaint investigation and had the potential to affect other residents receiving antipsychotic medications.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a deficiency. Resident #145, who had a history of traumatic brain injury and other medical conditions, was involved in an altercation with a visitor on the smoking patio. The resident, who had intact cognition and required minimal assistance with activities of daily living, was struck twice on the right upper eye by the visitor, leading to a laceration and swelling. Despite the resident's refusal to file a police report, the facility proceeded with reporting the incident to the authorities. The facility's investigation into the incident revealed that the altercation occurred over a lighter, and the visitor was identified as the aggressor. The Smoking Aide, who was present at the time, confirmed that the visitor continued to assault the resident even after he fell from his wheelchair. The facility's response included escorting the visitor out and notifying the police. However, the facility's investigation was incomplete as it did not include an interview with another resident who was present during the incident. Additionally, the facility failed to conduct neurological checks on Resident #145 at the proper intervals following the incident. The resident was later seen in the emergency department, where a CT scan revealed an age-indeterminate nasal fracture, and the resident was treated for pain and swelling. The facility's policy on abuse prohibition emphasizes the responsibility of staff to ensure a safe environment, which was not upheld in this case.
Incomplete Investigation of Physical Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of physical abuse involving a resident, identified as Resident #145. The incident occurred when Resident #145 was struck twice on the right upper eye by a family member of another resident while outside in the smoking area. The resident sustained an injury to the right upper eye, which was treated on-site, and later complained of nose pain, leading to a hospital visit where a fractured nose was diagnosed. Despite the severity of the incident, the facility's investigation was incomplete as it did not include an interview or written statement from another resident, Resident #69, who was present during the incident. Resident #145 had a medical history that included a fracture of nasal bones, hemiplegia, a history of traumatic brain injury, difficulty in walking, seizures, and a mental disorder. The resident was noted to have intact cognition and required minimal assistance for activities of daily living. The incident was reported to the police, and the alleged perpetrator was escorted out of the building and not allowed to return. However, the facility unsubstantiated the allegation, claiming they could not have predicted the event. The facility's policy on abuse prohibition requires interviews with any witnesses to incidents, but this was not fully adhered to in this case. The Smoking Aide, who witnessed the incident, confirmed that the alleged perpetrator was the aggressor and that Resident #145 was injured during the altercation. The Administrator acknowledged the oversight in not obtaining a statement from Resident #69, who was also a witness. This deficiency was investigated under Complaint Number OH00161880.
Failure to Address Hypokalemia Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate, timely, and necessary care to a resident, leading to an acute change in condition due to hypokalemia. The resident's laboratory results on 10/25/24 indicated a low potassium level of 3.0 mmol/L, which was not reviewed or addressed by the facility staff. This oversight resulted in the resident experiencing shortness of breath and requiring supplemental oxygen by 10/28/24. By 10/30/24, the resident's heart rate was significantly low, and the resident reported that his automated implanted cardioverter defibrillator (AICD) had alarmed. On 10/31/24, the resident exhibited a change in condition, including an irregular pulse, generalized weakness, and signs of delirium. The resident was transferred to a local emergency department, where he was diagnosed with chest pain and ventricular tachycardia (VT), requiring multiple defibrillations. The hospital records indicated that the VT was likely precipitated by significant hypokalemia, with a potassium level of 2.6 mmol/ml upon arrival at the emergency department. The resident was admitted to the hospital and did not return to the facility. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's laboratory results. The registered nurse and unit manager were unaware of the need to notify the physician or fax the results to the cardiologist. The director of nursing confirmed that the BMP results were not reviewed, and the facility's policy on notification of change was not followed. This deficiency was investigated under Complaint Number OH00159685.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure timely notification to the physician or Certified Nurse Practitioner (CNP) of abnormal laboratory values for a resident. The resident, who had multiple chronic conditions including heart failure, diabetes, and kidney disease, was discharged from the hospital with instructions for outpatient testing, including a Basic Metabolic Panel (BMP). The BMP was ordered and collected as scheduled, revealing a low potassium level. However, there was no evidence that the physician was notified of these results, nor were they faxed to the resident's cardiologist as instructed. Interviews with facility staff, including a Registered Nurse, Unit Manager, and the Director of Nursing, confirmed that the abnormal lab results were not communicated to the appropriate medical personnel. The Unit Manager indicated that the order for the BMP likely originated from the hospital, and the in-house provider was not aware to check for the results. The facility's policy on 'Notification of change' requires informing the resident and consulting with the resident's practitioner when there is a significant change in status, which was not adhered to in this case.
Failure to Investigate Resident's Unauthorized Departure and Intoxication
Penalty
Summary
The facility failed to appropriately investigate an incident involving a resident with severe cognitive impairment who had an unwitnessed fall and later left the facility without staff knowledge. The resident, who had multiple complex medical conditions including vascular dementia and depression, was found by local law enforcement near a liquor store, appearing intoxicated, and was subsequently taken to a hospital for treatment. Despite the resident's absence being noted during a neurological check, there was no documentation indicating that the facility was aware of his departure or had conducted an investigation into the incident. Interviews with staff revealed that the LPN on duty did not know the resident was out of the facility until notified by the hospital. The Director of Nursing confirmed that no investigation was conducted to determine when or how the resident left, nor were any staff or the resident interviewed to gather information about the incident. This lack of investigation and documentation represents a deficiency in the facility's responsibility to ensure resident safety and supervision.
Missed Medical Appointment for Resident
Penalty
Summary
The facility failed to ensure that Resident #11 attended a scheduled medical appointment, resulting in a deficiency. Resident #11, who was admitted with diagnoses including demyelinating disease of the central nervous system, chronic respiratory failure with hypoxia, tracheostomy status, and quadriplegia, was assessed to require total dependence on all aspects of care. Despite having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment, the resident missed an appointment with Ohio Health Neuroscience. The appointment was scheduled for 08/21/24 at 10:00 A.M., but there was no record of it being entered into the medical record, nor was transport arranged by the facility. The resident's wife informed the facility of the missed appointment, which she rescheduled, and the Director of Nursing confirmed the oversight.
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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 Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Hills Center | 1.8 mi | ★★★★★ | 6 | 0 |
| Westerwood Rehabilitation | 2.1 mi | ★★★★★ | 10 | 0 |
| Laurels Of Worthington, The | 2.4 mi | ★★★★★ | 0 | 0 |
| Wesley Glen Health Services Corp | 2.5 mi | ★★★★★ | 1 | 0 |
| Laurels Of Norworth The | 2.6 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.