Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trotwood Health & Rehab Llc during CMS and state inspections, most recent first.
The facility failed to document Ohio Abuse Registry screening for multiple employees, including the Administrator, former DON, Admissions, HR, two CNAs, and an RN. HR confirmed the files had no evidence of the checks, and the Administrator said the binder with screening documentation could not be located after the former DON left abruptly. The facility policy required screening potential employees for abuse, neglect, exploitation, or misappropriation of resident property.
Failure to Document Abuse Registry Screening: The facility failed to implement its abuse policy by not maintaining evidence that multiple employees, including the Administrator, former DON, HR, Admissions, CNAs, and an RN, were screened through the Ohio Abuse Registry. Personnel files contained no documentation of the required checks, and HR confirmed the absence of this evidence. The Administrator stated the binder with the screening records could not be located after the former DON left abruptly.
The facility failed to ensure the activities program was directed by a qualified activity professional. An SSD was assigned the Activity Director role after hire, but the personnel file had no documentation of qualifications for the position. The SSD confirmed she did not meet the required qualifications and was taking an online course for certification, and HR could not provide documentation for the position change or identify the prior Activity Director.
The facility failed to maintain required RN coverage, with no evidence of RN coverage on two dates identified in PBJ staffing data and timecard review. The Administrator verified the lack of RN coverage, and the facility policy stated an RN would be utilized for at least 8 consecutive hours daily, 7 days per week.
Food was served below the expected hot-holding temperature during breakfast service. A test tray showed scrambled eggs at 107 degrees F and sausage links at 110 degrees F after trays had already been delivered, and the DM confirmed the food was not hot. Two residents stated their breakfast was not hot enough, and the facility policy required hot foods to be held at 135 degrees F.
Food storage and kitchen sanitation were deficient when surveyors found standing water on the kitchen floor, chicken left warm on a counter outside the walk-in cooler, and multiple unlabeled or unsealed food items in the cooler and freezer. Dry storage items were kept on the floor amid dirt and grime, and the kitchen had heavy buildup on vents, pipes, walls, equipment, and floors. During meal service, a CNA placed uncovered cups of fruit punch on a tray cart and pushed them down the hall.
The facility failed to accurately submit PBJ staffing data based on payroll and other verifiable records. The PBJ Staffing Data Report showed a trigger for failure to have licensed nursing coverage for 24 hours a day, even though staffing data showed the nursing coverage requirement was met with agency staff. The Administrator stated agency hours were not submitted for the last quarter, despite the facility policy requiring timely submission of complete and accurate direct care staffing information.
QAA Committee Did Not Meet Quarterly: The facility failed to ensure the QAA Committee met at least quarterly. Review of sign-in sheets for the last four quarters showed no evidence of meetings before 04/29/26, and the DON verified there was no documentation of earlier meetings. The facility QAPI policy stated the QAA Committee would meet quarterly.
The facility failed to maintain infection prevention practices during meal service and med pass when a CNA and an RN did not perform hand hygiene between resident contacts, and an RN handled a tablet with bare hands and administered insulin while the resident was taking oral meds. The facility also failed to ensure EBP supplies were available and used for a resident with a G-tube, did not document Legionella water flushes, and had incomplete TB screening records for several employees.
Medications and biologicals were not stored securely or in a sanitary manner, and expired items were not properly discarded. A resident’s Clozapine tablets were left out in an unlocked area behind the nurse’s station, and multiple medication carts and the med room contained expired B12, throat drops, eye drops, and B-1, along with loose tablets stored outside their packaging. RN staff and the DON verified the items were improperly stored or expired.
Failure to provide coffee consistent with resident preferences: the menu listed coffee at all meals, but staff observed no coffee available during breakfast or lunch tray service. A CNA confirmed residents who requested coffee were told it was not available, and several residents reported missing coffee with meals despite wanting it. The DM stated coffee was served during activities rather than automatically with trays, even though it appeared on the menu.
Failure to maintain resident dignity during feeding assistance. A resident with severe cognitive impairment and multiple diagnoses, including aphasia, depression, schizoaffective disorder, anxiety, and hemiplegia, was observed being fed by a CNA who stood next to the overbed table while providing breakfast. The CNA stated that standing while feeding was common practice, despite the facility policy requiring staff to promote and maintain resident dignity.
Failure to provide access to personal care products: A resident with multiple chronic conditions, including dementia, schizoaffective disorder, and anxiety, was cognitively intact and needed supervision for oral and personal hygiene, but reported difficulty obtaining razors and mouthwash. The resident said the facility had been out of mouthwash for several days and he had not shaved for several days; CNAs stated residents on the locked unit could not keep these items unsupervised and one CNA said the resident drank mouthwash and could cut himself with a razor.
The facility failed to ensure that residents with funds accounts had written authorizations in place. Two residents had active trust accounts, including one with a balance of $4,380.75, but neither had a signed authorization on file. The BOM verified the missing authorizations.
A resident with paranoid schizophrenia was discharged, but the facility did not return the resident trust funds within the required 30-day timeframe. The Business Office Manager verified the account was not refunded until months later, despite the resident's authorization form stating funds would be returned within 30 days of discharge.
A resident admitted with dementia, repeated falls, diabetes, anxiety, and a vertebral compression fracture had MASD to the buttocks documented on the admission nursing assessment, but the baseline care plan did not address the skin issue, pressure injury risk, code status, or advanced directives. The dietary care plan was also incomplete and missing the resident’s specific diet orders. Later, the NP documented IAD treatment for both buttocks, but the EMR had no physician orders for the code status or the treatment. The DON and an LPN both verified the missing and incomplete care planning.
Care Plan Did Not Match Advance Directive Orders: A resident with COPD, CHF, type II DM, major depressive disorder, asthma, and generalized muscle weakness was cognitively intact and had a DNR/DNRCC order in the record, but the care plan listed the resident as Full Code. The DON verified that the EHR care plan did not match the advance directive order, despite the facility policy requiring advance directives to be reviewed and documented during care planning.
Failure to provide adequate ADL grooming assistance for a resident with schizoaffective disorder, bipolar disorder, DM2, PVD, and CHF. The resident required help with bathing and personal hygiene, yet was observed with numerous chin hairs on multiple occasions, and an RN confirmed the hair needed to be shaved. The resident stated she did not prefer to have chin hair, and the facility policy required necessary services to maintain grooming and personal hygiene.
Compression Stockings Not Applied as Ordered: A resident with CHF, PVD, DM2, and psychiatric diagnoses had an order for daily compression stockings for edema, but staff repeatedly signed the TAR as if the stockings had been applied when observations showed the resident was not wearing them. The resident had edema in both legs and feet, with pitting edema visible when non-skid socks were rolled down below the ankle.
Failure to implement ordered wound treatments was identified for a resident with MASD to the buttocks. The resident had diagnoses including dementia, repeated falls, type II DM, and anxiety disorder, and the admission assessment documented MASD on arrival. A wound NP later assessed MASD wounds to both buttocks and ordered wound cleanser, Triad paste, and open-to-air care every shift and PRN, but the DON verified there were no active treatment orders in the record.
Failure to obtain timely reweights for two residents. Both residents had severe cognitive impairment and significant ADL dependence, with multiple chronic diagnoses including DM, CVA-related deficits, COPD, HTN, and respiratory failure. The RD documented a reweight recommendation for each resident, but neither reweight was completed, and the RD and DON stated the facility was not aware of the recommendation documented in the progress notes.
Insulin Dose Administered Below Ordered Amount: An RN administered 12 units of insulin lispro to a resident with DM instead of the ordered 13 units. The RN confirmed the dose error during interview after giving the medication and stated she planned to call the MD to ask about giving the missing unit. Facility policy required meds to be administered as ordered.
Air Conditioning Unit Dripping Water Into Resident Room. A resident’s room had a large puddle of standing water beneath a wall-mounted AC unit that was actively dripping onto the floor. Housekeepers verified the water and ongoing leak, and a later observation showed the unit was still dripping into a trash can placed below it. The facility policy stated it would provide a safe, clean, and comfortable environment.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
The facility did not maintain comfortable air temperatures in common areas, with multiple locations such as hallways, dining room, and chapel recorded well below policy standards. Residents were observed bundled in coats and blankets, and the main boiler system was found to be permanently shut off. While PTAC units were installed in resident rooms, some were not functioning properly, and common areas remained inadequately heated.
Several residents expressed a desire to eat in the dining room, but the facility failed to provide a comfortable environment due to inadequate heating. Temperatures in the dining room and other common areas were consistently low, as the main boiler was non-functional and auxiliary heaters were insufficient. As a result, all meals were served in residents' rooms, and residents' choices regarding dining location were not supported.
The facility did not ensure its Activities Program was overseen by a qualified Activities Director, as the staff member in the role lacked required certification or training and was originally hired for social services. Resident Council meetings were facilitated by an Activities Aid, and management was not kept informed of resident concerns from these meetings.
The facility did not maintain its boiler in working condition, resulting in low temperatures throughout common areas such as hallways, dining rooms, and lounges. Residents were observed bundled in coats and blankets, and auxiliary heaters were used but were often ineffective. While PTAC units were installed in resident rooms, common areas remained inadequately heated, and staff confirmed ongoing temperature issues and equipment malfunctions.
The facility did not maintain safe and comfortable temperatures, with some rooms exceeding 81°F due to a broken air conditioning system, and failed to provide hot water for bathing and hygiene in several halls. Residents reported significant discomfort, and staff confirmed that both the air conditioning and hot water issues had persisted for weeks without resolution.
The facility did not obtain food from approved sources and failed to follow professional standards for storing, preparing, distributing, and serving food.
Several residents reported that their heating/air conditioning units were not working, and observations confirmed that multiple rooms had non-functioning or inadequate units. The maintenance supervisor initially stated all units were operational, but later confirmed the deficiencies. Facility policy required prompt repairs, but the issue persisted from a previous survey.
A resident with multiple chronic conditions and cognitive intactness was not treated with dignity and respect when a CNA repeatedly yelled at her to take a shower and to get off the phone, disregarding her request to shower later. The incident was reported to the Administrator, who did not follow up with the resident, and the CNA later confirmed her actions.
A resident with multiple chronic conditions and a history of pain reported high pain levels on multiple occasions but did not receive any pain medication or documented non-pharmacological interventions, despite physician orders and a care plan addressing pain management. The DON confirmed the resident had not received pain medication since admission and that pain management interventions were not implemented.
Two residents did not receive medications as ordered: one was given an antihypertensive without required blood pressure monitoring, and another was left without prescribed pain medication for several days due to delays in reordering and delivery. Staff confirmed these lapses, and documentation showed the facility did not follow its own medication administration policy.
Multiple areas of the facility, including a resident's room and common spaces, were found in disrepair, with issues such as a large hole in a resident's wall, damaged cabinetry, broken trim, and chipped paint. Residents and staff confirmed these conditions had persisted for months without repair, and the administrator acknowledged the lack of action and absence of a policy regarding the physical environment.
The facility failed to maintain a clean and homelike environment, with non-functioning and dirty shower rooms and a sticky floor in a resident's room. The 500-hallway shower room, used by all residents, had non-functioning stalls and debris, while the 200-hall shower room had stagnant water and water damage. A resident's room had a sticky floor, possibly due to improper cleaning. These conditions were confirmed by staff.
The facility exceeded the acceptable medication error rate, with errors affecting two residents. An LPN administered Pyridium without an active order to one resident and failed to administer Linagliptin as ordered to another. Both residents were cognitively intact and required assistance with daily activities.
A resident was found with several bottles of medication improperly stored in their room, contrary to the facility's policy requiring safe and secure storage. The resident, who was cognitively intact and dependent on staff for medication administration, had multiple medical conditions. The facility's policy mandates nursing staff to maintain proper medication storage, which was not followed in this case.
A resident with severe cognitive impairment experienced inadequate room temperature due to incomplete installation of new heating units. The room was recorded at 66°F, below the facility's policy threshold, with staff confirming the issue and reliance on hallway heaters. The facility's policy indicated a higher risk for hypothermia at such temperatures.
A resident did not receive prescribed Oxycodone due to a supply issue, as the pharmacy awaited a new prescription. The resident, with chronic pain and other health conditions, was cognitively intact and required assistance with mobility. The facility's policy mandates medications be administered as prescribed, which was not followed in this case.
The facility exceeded the acceptable medication error rate, reaching 6.6%, due to incorrect administration of medications to a resident. An LPN administered Magnesium Oxide 400 mg and Folic Acid 400 mcg instead of the prescribed Magnesium Hydroxide oral suspension and Folic Acid 1 mg. The correct medication was available but not used, violating the facility's medication administration policy.
The facility failed to maintain comfortable air temperatures in the secure behavioral unit, with room temperatures ranging from 43.6 F to 55 F. Despite operational heaters, the temperatures were below the facility's policy range of 71-81 degrees F, potentially affecting 13 residents. A resident noted it was cold, and the issue was confirmed by the Maintenance Director and Administrator.
A facility failed to assist a resident with medical appointments, affecting their follow-up care after an aortic aneurysm repair. The resident, with chronic conditions, had an appointment rescheduled without proper documentation or communication. The cardiologist's office confirmed a no-show, and the facility's administration acknowledged the lack of documentation.
Two residents experienced medication administration and documentation failures. One resident did not receive the correct dosage of Clonazepam due to transcription errors and lack of medication availability. Another resident had inconsistencies in oxycodone documentation and unavailability of methocarbamol due to improper refill requests and documentation. Interviews confirmed these deficiencies, highlighting failures in medication management.
The facility did not ensure RN supervision for eight consecutive hours daily, as required. A review of the nursing schedule showed no RN was scheduled on a specific day, and the DON confirmed this absence. This had the potential to affect all 52 residents in the facility.
The facility failed to provide a clean, safe, and comfortable environment for residents, with issues such as dirty floors, excessively warm rooms, leaking ceilings, and poorly maintained outdoor areas. These conditions were confirmed by staff and residents, highlighting ongoing environmental deficiencies.
The facility failed to prevent residents from accessing hazardous items like knives, razors, and smoking materials, and did not provide adequate supervision for smokers. Several residents, including those with cognitive impairments, were found with smoking materials and other dangerous items, unsupervised, contrary to the facility's policy. This deficiency affected residents who required supervision and secure storage of smoking materials.
The facility failed to maintain proper sanitizer levels in the dishwasher, affecting 51 residents. The Dietary Supervisor confirmed the sanitizer had been at 0 ppm for weeks, despite needing 50 ppm for safe use. The issue was due to an empty sanitizer bucket, with no records of when it was last ordered or opened.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, affecting five residents. A resident with an unstageable vascular ulcer and another with a feeding tube lacked EBP orders and appropriate signage or PPE. Another resident with vascular ulcers and a resident with an indwelling catheter also did not have EBP orders or PPE available. The facility's policy required EBP for such conditions, but it was not followed.
The facility did not ensure that residents were offered pneumococcal and influenza vaccinations, as there was no documentation in the medical records of five residents regarding the receipt or refusal of these vaccines. This issue was confirmed by the Administrator, affecting all residents reviewed for vaccinations.
Failure to Document Abuse Registry Screening
Penalty
Summary
The facility failed to ensure employees were screened for a history of abuse on the Ohio Abuse Registry. Review of personnel files showed no evidence of registry screening for the Administrator, the former DON #400, Admissions #76, HR #74, CNA #32, CNA #34, and RN #104. During an interview, HR #74 confirmed the personnel files contained no evidence of abuse registry checks. The Administrator stated the former DON left abruptly and the facility was unable to locate the binder that was supposed to contain evidence that staff had been checked against the Ohio Abuse Registry. Review of the facility policy titled Abuse, Neglect, and Exploitation showed the facility screened potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property and maintained documentation of that screening.
Failure to Document Abuse Registry Screening
Penalty
Summary
The facility failed to implement its abuse policy by not having evidence that employees were screened through the Ohio Abuse Registry. Review of personnel files for the Administrator, former DON #400, Admissions #76, HR #74, CNA #32, CNA #34, and RN #104 showed no documentation of abuse registry checks. During an interview, HR #74 confirmed the personnel files contained no evidence of abuse registry checks. The Administrator stated that the former DON left abruptly and the facility was unable to locate the binder that was supposed to contain evidence that staff had been checked against the Ohio Abuse Registry. Review of the facility’s Abuse, Neglect, and Exploitation policy dated 2025 showed the facility had written policies and procedures to prohibit and prevent abuse and to provide ongoing oversight and supervision to ensure the policies were implemented as written.
Unqualified Activity Director Assignment
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified activity professional. Review of the personnel file showed that Social Services Director #64 was hired on 02/17/25 and was soon assigned the role of Activity Director, but there was no documentation in the file showing qualifications for that position. During interview, SSD #64 stated the Activity Director role was added to her duties after hire and confirmed she did not have the required qualifications, noting she was taking an online course to become certified. Human Resources Director #74 also stated there was no documentation for the change in SSD #64’s position, including the addition of Activity Director duties, and could not provide information about who held the Activity Director position before SSD #64.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to have RN coverage as required, with no evidence of RN coverage on 10/11/25 and 10/12/25. Review of the Payroll Based Journal Staffing Data Report for 10/01/25 to 12/31/25 showed the facility triggered for failure to have RN coverage on those two dates, and review of timecard punches for the same period confirmed no RN coverage. During interview on 06/16/26 at 12:40 P.M., the Administrator verified the facility had no RN coverage on 10/11/25 and 10/12/25. Review of the facility policy titled Nursing Services-Registered Nurse (RN), undated, stated the facility would utilize the services of an RN for at least eight consecutive hours daily, seven days per week.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
Food was not served at the appropriate temperature during breakfast service. During observation of a test tray after all trays had been delivered to residents, the scrambled eggs measured 107 degrees Fahrenheit and the sausage links measured 110 degrees Fahrenheit. The Dietary Manager verified those temperatures and stated the expectation was for food to be at least 130 degrees Fahrenheit when served; the manager also tasted the eggs and confirmed they were not hot. Two residents later stated their breakfast that morning was not hot enough. The facility policy titled, Record of Food Temperatures, dated 2023, stated hot foods would be held at 135 degrees Fahrenheit.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored in a manner to prevent the potential spread of foodborne illness, and the kitchen was not maintained in a clean and sanitary manner. Surveyors observed standing water on the kitchen floor below the ice machine and handwashing sink on two separate observations, with the puddle increasing in size after handwashing. The Dietary Manager verified the standing water and stated it had been that way for a long time because the drain needed to be cleaned out. Surveyors also observed two bags of chicken dated 05/30/26 sitting in a pan on a counter just outside the walk-in cooler, and the chicken was warm to the touch. The Dietary Aide verified the chicken was stored on the counter and warm, and stated it had been on the counter when she arrived that morning. The Dietary Manager later stated the chicken was still on the counter when she arrived and verified meat should not be thawed in that manner. Additional observations in the walk-in cooler and freezer showed 10 pitchers of unidentified liquids with no labels or dates, an unsealed bag of tortillas, an open cup of grapes not labeled, and boxes of hamburgers and ground beef with the plastic bags inside opened and not sealed. In dry storage, a large box of Styrofoam cups was stored directly on the floor, and the area had dirt, grime, and dried brown liquid with debris. The kitchen also had fuzzy gray buildup on vents, pipes, and machine grates, brown splatter on walls and equipment, crumbs and trash on the floor edges, and heavy grime throughout. During meal service, a CNA poured fruit punch into cups and placed them uncovered on a tray cart before pushing it down the hall, and the CNA stated there were no lids available.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to accurately submit staffing data in the Payroll Based Journal (PBJ) system based on payroll and other verifiable and auditable data. Review of the PBJ Staffing Data Report for 10/01/25 to 12/31/25 showed the facility triggered for failure to have licensed nursing coverage for 24 hours a day. However, review of staffing data for the same period showed the facility met the nursing coverage requirement with the use of agency staff. During an interview on 06/15/26 at 5:00 P.M., the Administrator stated that agency hours were not submitted for the last quarter. Review of the undated facility policy titled Payroll Based Journal stated the facility would timely submit complete and accurate direct care staffing information.
QAA Committee Did Not Meet Quarterly
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. Review of the QAA Committee sign-in sheets for the last four quarters showed no evidence of meetings prior to 04/29/26. During interview on 06/16/26 at 11:14 A.M., the DON verified there was no documentation of meetings prior to 04/29/26. Review of the undated facility policy titled Quality Assurance and Performance Improvement (QAPI) showed the QAA Committee would meet quarterly.
Infection Prevention Failures in Hand Hygiene, EBP, Legionella Monitoring, and TB Screening
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during meal tray delivery and medication administration. During observation, a CNA passed meal trays to multiple residents on two halls without sanitizing hands between residents, including after assisting one resident up in bed and setting up the tray. The CNA later confirmed she had not sanitized her hands between tray deliveries. Another CNA was observed pouring drinks into uncovered cups, placing utensils on trays from a plastic bag, and serving trays to residents without sanitizing or washing hands between residents. The facility policy titled Food Safety Requirements stated hands should be washed between contact with residents. The facility also failed to ensure proper hand hygiene and medication handling during medication pass. An RN carried medications, an insulin pen, pen needle, and alcohol swabs to a resident’s room and administered insulin while the resident was swallowing oral medications. During a medication pass observation, the RN prepared and administered medications to three residents without washing hands with soap and water and removed a tablet from the medication card with a bare hand before placing it in a medication cup. The RN later verified she had not washed her hands during the medication pass, and the policy titled Medication Administration stated licensed personnel should not touch medications with bare hands and should perform appropriate hand hygiene. Additional infection prevention deficiencies were identified. A resident with a G-tube had an order for enhanced barrier precautions, and although signage was present, there was no PPE cart outside the room at one observation, and an RN administered medications through the G-tube without wearing a gown. The facility also did not have logs or documentation showing water flushes were completed for Legionella prevention, and the water management plan indicated taps should be run weekly in unoccupied rooms. In personnel records, several employees lacked evidence of two-step Mantoux testing upon hire, and one CNA lacked evidence of annual TB symptom screening. The report stated these issues had the potential to affect all 31 residents in the facility.
Improper Medication Storage and Expired Drugs Found
Penalty
Summary
Medications and biologicals were not stored in a sanitary and secure manner, and expired medications were not properly disposed of. During observation at the Team One nurse’s station, two medication cards containing a total of 60 Clozapine 50 mg tablets for one resident were found sitting out in an unlocked room on top of a wire rack holding hard charts. The DON confirmed the medication cards were improperly stored and should have been locked in the medication room. Additional observations of medication carts and the front medication room found expired and improperly stored medications, including expired vitamin B12 tablets, expired Vapor action throat drops, expired Refresh Plus eye drops, and expired Thiamine B-1 100 mg tablets. Loose tablets were also found out of their packages in the bottoms of medication cart drawers, including empagliflozin, L-methylfolate calcium, and two other tablets. RN staff verified the expired items and loose tablets were improperly stored or should have been discarded, and the DON confirmed there were no active orders for B12 100 mcg in the facility while some expired B12 remained stored.
Failure to Provide Coffee Consistent With Resident Preferences
Penalty
Summary
Drinks were not provided consistent with resident preferences when the facility failed to make coffee available for residents whose menus listed coffee at all three meals. Review of the weekly menu and diet spreadsheets showed coffee was listed for breakfast and lunch, and the weekly menu listed coffee at all three meals every day. However, observations during breakfast meal service in the kitchen and during lunch tray delivery showed there was no coffee available to serve residents. CNA #44 confirmed there was no coffee available at breakfast or lunch and stated residents who asked for coffee were told it was not available. Resident interviews showed the impact of this failure on multiple residents. Resident #10 stated she liked coffee with breakfast and did not receive it that morning. Resident #09 stated she did not receive coffee with breakfast or lunch and wanted coffee with every meal but often did not receive it as requested. Resident #4 stated she preferred coffee with breakfast but had been told for two weeks that there was no coffee. Resident #35 stated no coffee had been provided since admission. The Dietary Manager stated coffee was normally sent with breakfast trays but not with lunch and dinner, and that coffee was served during activities rather than automatically with trays, even though the menus listed coffee as a menu item at all meals. Facility policy stated menu items should be prepared following written menus and staff should accommodate resident preferences.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect. Resident #02, who was admitted on 09/04/18 and had diagnoses including type two diabetes mellitus with diabetic polyneuropathy, aphasia following cerebral infarction, pseudobulbar affect, major depressive disorder, schizoaffective disorder, generalized anxiety disorder, and flaccid hemiplegia affecting the right dominant side, was assessed on the quarterly MDS as severely cognitively impaired and dependent or requiring substantial to maximal assistance with multiple activities of daily living, including eating. During observation on 06/14/26 at 9:59 A.M., the resident was sitting in bed with the breakfast tray on the overbed table while CNA #14 stood next to the table and fed the resident. When interviewed immediately afterward, CNA #14 stated it was common practice to stand while providing feeding assistance. The facility policy titled Promoting/Maintaining Resident Dignity stated that all staff were involved in providing care to residents to promote and maintain resident dignity.
Failure to Provide Access to Personal Care Products
Penalty
Summary
The facility failed to ensure residents had access to personal care products, affecting one resident sampled for dignified care. Resident #22 was admitted with diagnoses including type II diabetes, COPD, schizoaffective disorder-bipolar type, unspecified dementia, recurrent major depressive disorder, unspecified intellectual disabilities, HIV, unspecified protein-calorie malnutrition, unspecified epilepsy, and unspecified anxiety disorder. The most recent MDS showed the resident was cognitively intact, had no behaviors, did not wander, did not reject care, and required supervision for oral and personal hygiene. During interview, Resident #22 stated he had problems getting razors and mouthwash, reporting the facility had been out of mouthwash for four days and that he had not shaved in four or five days. A CNA stated residents on the locked unit were not allowed to keep mouthwash or razors in their rooms unsupervised and said staff had to supervise residents on the men's unit while they used them. Another CNA stated Resident #22 asked for razors and mouthwash frequently and told him the facility did not have any because the resident drank the mouthwash, and the CNA did not want the resident cutting himself with a razor. The facility policy on Accommodation of Needs stated residents were to be treated with dignity and respect and given reasonable accommodations for individual needs and preferences.
Missing Written Authorizations for Resident Funds Accounts
Penalty
Summary
The facility failed to ensure that residents with funds accounts had written authorizations in place. Review of records and the Trust Account Balance list showed that Resident #17, admitted with type II diabetes mellitus, had an active facility funds account with a balance of $4,380.75, but no signed authorization for the account was present. Resident #04, admitted with chronic obstructive pulmonary disease, also had an active facility funds account with a balance of $0.10, and no signed authorization for that account was found. The Business Office Manager verified that both residents did not have signed authorizations for their funds accounts.
Delayed Refund of Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to timely refund a resident's personal funds after discharge. Resident #37, who had diagnoses including paranoid schizophrenia, was discharged from the facility, but the final resident trust fund check for $1,770.86 was not issued until several months later. The Business Office Manager verified that the resident's account had not been refunded until the check was issued and stated that refunds should be issued within 30 days of discharge. The resident's Management of Personal Funds authorization form also stated that personal funds would be returned to the appropriate source within 30 days of discharge.
Baseline Care Plan Missing Admission Needs
Penalty
Summary
The facility failed to ensure Resident #32’s baseline care plan addressed needs identified upon admission within 48 hours. Resident #32 was admitted with diagnoses including wedge compression fracture of an unspecified vertebra, unspecified dementia, repeated falls, type II diabetes, and unspecified anxiety disorder. The minimum data set assessment in progress showed moderately impaired cognition, no behaviors, no wandering, and no rejection of care. The admission nursing assessment documented Moisture Associated Skin Damage (MASD) to the buttocks, but the baseline care plan dated 06/08/26 did not include a care plan for the current MASD or pressure injury risk, did not include a care plan for code status or advanced directives, and the dietary care plan was incomplete and missing the resident’s specific diet orders. A progress note dated 06/11/26 documented that the nurse practitioner assessed the resident’s skin and recommended treatment for Incontinence Associated Dermatitis (IAD) to both buttocks, including cleansing with wound cleanser or normal saline, applying Triad paste, leaving open to air, and changing every shift and as needed. The electronic medical record did not contain physician orders for the code status or the IAD treatment. During interviews, the DON verified the baseline care plan was missing MASD/pressure injury risk, the dietary care plan was incomplete, and there was no care plan for code status or advanced directives. An LPN stated the admission assessment should populate the baseline care plan and verified the resident had no care plan for MASD with treatment or monitoring, and that the dietary care plan did not accurately reflect the current diet orders.
Care Plan Did Not Match Advance Directive Orders
Penalty
Summary
The facility failed to ensure Resident #4’s care plan was revised to reflect advance directives. Resident #4 was admitted with diagnoses including COPD, chronic diastolic heart failure, type II diabetes mellitus, major depressive disorder, unspecified asthma, and generalized muscle weakness. The MDS assessment identified the resident as cognitively intact with a Brief Interview for Mental Status score of 15 and documented functional needs including assistance with oral hygiene, eating, toileting, bathing, dressing, grooming, bed mobility, transfers, and wheelchair mobility. The medical record showed a physician’s order dated 05/18/26 for DNR, and the DON presented a hard copy advance directive order form from the same date indicating DNRCC. However, the care plan completed on 05/20/26 listed the resident as Full Code. During interview on 06/15/26 at 9:13 A.M., the DON verified that the current care plan in the electronic health record did not match the resident’s advance directive order. The facility policy stated that advance directives are to be identified, clarified, reviewed, and documented during the care planning process and communicated to the interdisciplinary team and staff.
Failure to Provide Adequate ADL Grooming Assistance
Penalty
Summary
The facility failed to ensure adequate ADL care was provided for one resident reviewed for ADL care. Resident #10 was admitted with diagnoses including schizoaffective disorder, bipolar disorder, type 2 diabetes mellitus, peripheral vascular disease, and congestive heart failure. The quarterly MDS indicated the resident had intact cognition and required supervision with eating, bed mobility, and transfers, along with partial/moderate assistance with bathing and personal hygiene. The care plan identified an ADL self-care performance deficit related to CHF and PVD and included assistance with bathing/showering. During observation, Resident #10 was noted to have numerous hairs on her chin, approximately one-half inch long, and stated she did not prefer to have chin hair. An RN verified the chin hair needed to be shaved. A later observation still showed numerous chin hairs present. The facility policy stated that a resident unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal hygiene.
Compression Stockings Not Applied as Ordered
Penalty
Summary
The facility failed to provide care and services according to orders for edema for one resident. The resident had diagnoses including schizoaffective disorder, bipolar disorder, type 2 diabetes mellitus, peripheral vascular disease, and congestive heart failure. The resident’s record showed an order dated 02/06/26 to apply compression stockings every day shift, and the resident stated on 06/14/26 that nobody was applying the stockings. During observation on 06/14/26, the resident had edema in both legs and feet, was wearing non-skid socks rolled down below the ankle, and pitting edema was visible. The resident was not wearing compression stockings at that time. The June 2026 TAR showed RN #15 signed off that the compression stockings had been applied, but observation later that day showed the resident still was not wearing them. RN #15 verified the resident was not wearing compression stockings and confirmed she had signed the TAR to indicate they had been applied. The same pattern occurred on 06/15/26, when RN #11 signed off the compression stockings on the TAR, but observation later showed the resident was not wearing them. RN #11 verified the resident was not wearing compression stockings and stated that signing the TAR should indicate the stockings had been applied.
Failure to Implement Ordered Wound Treatments
Penalty
Summary
Failure to implement ordered wound treatments was identified for one resident with Moisture Associated Skin Damage (MASD) to the buttocks. The resident was admitted with diagnoses including wedge compression fracture of an unspecified vertebra, unspecified dementia, repeated falls, type II diabetes, and unspecified anxiety disorder. The admission nursing assessment documented MASD to the buttocks on admission, and the care plan dated 06/08/26 did not include a care plan related to the current MASD or risk for pressure injury. A wound assessment by the Wound NP on 06/11/26 documented MASD wounds to the right and left buttocks and included treatment orders to clean with wound cleanser, apply Triad paste, and leave open to air every shift and as needed. During interview, the DON verified there were no active treatment orders for the resident’s MASD to the bilateral buttocks. The Wound NP stated she gave verbal treatment orders to the nurse during wound rounds and also documented the orders in her written wound assessment note, with the expectation that facility staff would enter the orders into the electronic record.
Failure to Obtain Timely Reweights for Two Residents
Penalty
Summary
The facility failed to obtain timely reweights for two residents reviewed for nutrition. Resident #02 had diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, aphasia following cerebral infarction, pseudobulbar affect, major depressive disorder, schizoaffective disorder, generalized anxiety disorder, and flaccid hemiplegia affecting the right dominant side. The quarterly MDS showed severe cognitive impairment and dependence or substantial/maximal assistance with multiple activities of daily living, including eating, oral hygiene, toileting, bathing, dressing, personal hygiene, transfer, and bed mobility. The medical record showed the last documented weight on 06/01/26, and a progress note on 06/07/26 documented that RD #412 recommended a reweight. Resident #17 had diagnoses including type 2 diabetes mellitus without complications, COPD, hypertension, chronic respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, hyperlipidemia, dysthymic disorder, encephalopathy, hypo-osmolality and hyponatremia, syncope and collapse, and pure hypercholesterolemia. The quarterly MDS showed severe cognitive impairment and need for supervision, partial/moderate assistance, and substantial/maximal assistance with several ADLs. The last documented weight was on 06/01/26, and a progress note on 06/07/26 documented that RD #412 recommended a reweight. RD #412 stated she had no documentation related to a reweight for either resident, and the DON stated no reweight had been completed because the facility was not aware of the recommendation documented in the progress notes. The facility policy stated it would ensure all residents maintained acceptable parameters of nutritional status.
Insulin Dose Administered Below Ordered Amount
Penalty
Summary
Resident #3, who was admitted with diagnoses including non-pressure chronic ulcer of the left foot, acute osteomyelitis of the right ankle and foot, type II diabetes, and acquired absence of the left leg below the knee, had a physician order dated 04/24/26 for Insulin Lispro 13 units subcutaneously four times daily for diabetes mellitus. During observation on 06/14/26 at 8:55 A.M., RN #9 brought the resident’s medications, insulin pen, pen needle, and alcohol swabs to the room, administered the oral medications, and then dialed the insulin pen to 12 units instead of the ordered 13 units before injecting the insulin into the resident’s left upper arm. During interview at 9:01 A.M., RN #9 confirmed that only 12 units had been given and stated she was going to call the doctor to see if it was okay to give another unit of insulin. RN #9 also verified that the order was for 13 units. The facility policy stated medications are to be administered by licensed personnel as ordered.
Air Conditioning Unit Dripping Water Into Resident Room
Penalty
Summary
The facility failed to ensure a comfortable environment with properly functioning equipment for Resident #12. During observation, a large puddle of standing water, measuring approximately two by three feet, was found in the corner of the resident’s room below the wall-mounted air conditioning unit. The air conditioning unit was actively dripping onto the floor, and housekeepers later verified the standing water and ongoing dripping. A later observation showed the unit was still dripping, with a trash can placed beneath it to catch the water. The facility policy titled Safe and Homelike Environment stated the facility would provide a safe, clean, and comfortable environment.
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Maintain Safe and Comfortable Air Temperatures in Common Areas
Penalty
Summary
The facility failed to maintain air temperatures within comfortable ranges in multiple common areas, affecting all 33 residents. Observations revealed that temperatures in the main entrance, administration offices, dining room, hallways, chapel, and common gathering rooms were consistently below the facility's policy range of 71-81 degrees Fahrenheit, with some areas as low as 48.5 degrees Fahrenheit. Residents were observed wearing winter coats, sweatshirts, hats, and blankets in an attempt to stay warm. The Secured Behavioral Unit and other common areas also had low temperatures, and portable heaters were either insufficient or malfunctioning. The main boiler system, which provided heat to these areas, was found to be permanently shut off and non-functional, with exposed wires in the boiler room. Interviews with the Maintenance Director and Administrator confirmed the ongoing low temperatures and the non-functioning boiler. The facility had installed PTAC units in resident rooms, allowing residents to control their own room temperatures, but these units were not always working correctly, as evidenced by discrepancies between thermometer readings and PTAC displays. The Administrator acknowledged that common areas were not prioritized for heating, and the dining room had been closed for at least two years due to the boiler issue. Facility policy required maintaining safe and comfortable temperatures in all resident rooms and areas, but this was not achieved in the common spaces.
Failure to Accommodate Resident Dining Preferences Due to Inadequate Heating
Penalty
Summary
The facility failed to accommodate residents' preferences to eat in the dining room due to inadequate heating in common areas, including the dining room itself. Observations revealed that the temperatures in these areas, measured by the Maintenance Director using a hand-held infrared thermometer, ranged from 51.2 to 56.5 degrees Fahrenheit. The boiler responsible for heating these spaces was found to be non-functional and had been permanently shut off, with exposed wires visible in the boiler room. Auxiliary heaters were present but insufficient to make the dining room comfortable for regular use. Staff interviews confirmed that the dining room had not been used for meals or activities for two years, except for a single event where additional heaters were used. Resident interviews indicated a clear desire to eat in the dining room if the temperature were comfortable. One resident, who was cognitively intact and independent with eating, specifically expressed enjoyment in dining in the communal space but cited the cold as a deterrent. Other residents echoed this sentiment. The Administrator acknowledged that the dining room and other common areas had not been prioritized for heating due to cost concerns and stated that the focus was on maintaining resident room temperatures. As a result, all meals were served in residents' rooms, and the facility did not support or facilitate resident choice regarding dining location.
Unqualified Activities Director Oversight
Penalty
Summary
The facility failed to ensure that its Activities Program was directed by a qualified Activities Director (AD). Record review showed that the AD did not sign attendance forms for several Resident Council meetings, and these meetings were instead facilitated and signed by an Activities Aid (AA). Interviews revealed that the DON was unaware of any concerns from these meetings and did not know if the AD met the required qualifications. The AA stated she had only recently been informed of her responsibility to share meeting minutes with management. Personnel file review indicated that the individual serving as AD was originally hired as social services staff and lacked documentation of certification or appropriate training for the AD role. The AD confirmed in an interview that she did not meet the qualifications for the position and had not enrolled in the necessary program due to a change in facility ownership. This deficiency had the potential to affect 32 residents interested in or participating in activities.
Failure to Maintain Safe and Functional Heating in Common Areas
Penalty
Summary
The facility failed to maintain essential mechanical equipment, specifically the boiler, in a functional and safe operating condition, which resulted in inadequate heating throughout multiple common areas and resident-accessible spaces. Observations revealed that temperatures in the main entrance, administration offices, dining room, hallways, chapel, and common gathering rooms were significantly below the facility's policy requirement of 71-81 degrees Fahrenheit, with recorded temperatures ranging from 48.5 to 61.6 degrees Fahrenheit. Residents were observed wearing winter coats, sweatshirts, hats, and blankets to keep warm while ambulating or self-propelling in these areas. The boiler was found to be permanently shut off with exposed wires, and auxiliary heaters were being used as supplemental heat sources, some of which were not functioning properly. Interviews with the Maintenance Director and Administrator confirmed the non-functional status of the boiler and the ongoing low temperatures in the affected areas. The facility had installed PTAC units in resident rooms, allowing residents to control their room temperatures, but did not address heating in the common areas linked to the non-functional boiler. Discrepancies were noted between actual room temperatures and those displayed on PTAC units, with some units requiring frequent resets. The dining room had been closed for at least two years due to the lack of heat, and the Administrator stated that heating common areas was not a priority as they believed it did not affect resident care.
Failure to Maintain Safe and Comfortable Environmental Conditions
Penalty
Summary
The facility failed to maintain comfortable and safe environmental conditions for its residents, specifically regarding air temperature and access to hot water. On the 400 and 500 halls, the air conditioning system was inoperable, resulting in room temperatures exceeding 81 degrees Fahrenheit, with specific readings as high as 83.3 degrees. Residents reported discomfort due to the heat, with some removing clothing or opening windows to cope. Staff interviews confirmed the air conditioning had been nonfunctional for several weeks, and the facility's own policy required immediate action to maintain temperatures within the 71 to 81 degrees Fahrenheit range, which was not followed. Additionally, residents on the 100, 200, and 300 halls did not have access to hot water in their rooms or shower areas. Water temperatures in resident sinks and shower rooms were measured between 65.0 and 73.5 degrees Fahrenheit, which was insufficient for bathing and personal hygiene. Residents reported being unable to wash up or take bed baths, and the issue had persisted for several weeks. Despite obtaining an estimate for hot water heater replacement, there was no evidence that the facility had taken action to repair the hot water system.
Non-Compliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.
Failure to Maintain Properly Functioning Heating and Air Conditioning Units
Penalty
Summary
The facility failed to maintain a comfortable and home-like environment by not ensuring that heating and air conditioning units in several resident rooms were properly functioning. Multiple residents reported that the heating/air conditioning units in their rooms were not working. Specifically, five residents voiced complaints about non-functioning units. During interviews, the maintenance supervisor initially stated that all units were working and that residents could control them in their rooms. However, subsequent observations and interviews with the maintenance supervisor confirmed that the units in four residents' rooms were not functioning properly, and the unit in another resident's room was working but not blowing strong enough and required repair. A review of the facility's Room Temperatures policy indicated that air conditioning repairs or modifications should be completed as soon as possible. The deficiency was identified through resident and staff interviews, direct observation, and policy review. This issue was found to be ongoing from a previous survey, indicating that the problem had not been resolved since it was first identified.
Resident Not Treated with Dignity and Respect During Shower Assistance
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, edema, post-traumatic stress disorder, and hypertension, who was cognitively intact and required supervision for all activities of daily living, reported being treated without dignity and respect by a Certified Nursing Assistant (CNA). The resident stated that while on the phone, the CNA repeatedly insisted that she take a shower immediately, disregarding the resident's request to shower later. The CNA returned and began yelling at the resident to take a shower and to get off the phone, stating that the phone call was not important. The resident reported this incident to the Administrator, who told her he would speak with her later but did not follow up. Further interviews confirmed the CNA's actions, as the CNA admitted to yelling at the resident from a distance and telling her to hang up the phone, expressing disbelief in the importance of the call. The Administrator stated he was unaware of the specific accusations and did not address the resident's concerns at the time. The care plan for the resident included interventions to approach and speak to her in a calm voice due to her anxiety and depression, which were not followed during the incident.
Failure to Provide Adequate Pain Management
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, polyneuropathy, a history of a displaced bimalleolar fracture, hypertension, type 2 diabetes, and COPD, was admitted to the facility and identified as being at risk for pain. The resident's care plan included interventions such as administering medication as ordered, monitoring for pain every shift, and notifying the physician as needed. Physician orders were in place for acetaminophen as needed for pain and a daily aspirin, though the DON later clarified that the aspirin was not intended for pain management. Despite these orders, documentation showed that the resident reported significant pain levels of 7 and 8 out of 10 on two consecutive days, but did not receive any pain medication on those occasions. Further review of the medical record and interviews confirmed that the resident had not received any pain medication since admission, and there was no documentation of non-pharmacological pain interventions being offered or implemented. The DON acknowledged these findings and confirmed the lack of pain management provided, despite the resident's ongoing pain and an upcoming appointment at a pain clinic. The facility's pain assessment and management policy required staff to identify pain and develop interventions to meet the resident's goals, but these steps were not followed in this case.
Failure to Administer and Reorder Medications as Prescribed
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for two residents. For one resident with a history of chronic obstructive pulmonary disease, hypertension, and other conditions, there was a physician's order to administer Olmesartan Medoxomil 20 mg daily, with instructions to hold the medication if the systolic blood pressure was 100 or less. Despite this, the medication was administered on multiple occasions without documentation of the resident's blood pressure at the time of administration. The Director of Nursing confirmed that blood pressures were not monitored when the medication was given, contrary to the physician's order and care plan interventions. Another resident, with diagnoses including right lower quadrant pain and schizoaffective disorder, had a physician's order for Norco 5-325 mg every six hours for pain. The resident's medical record and progress notes indicated that the Norco was not available for administration for several days, resulting in the resident receiving Tylenol instead, which was documented as ineffective for pain relief on at least one occasion. Staff notes repeatedly indicated that the Norco was on order or awaiting delivery, and the controlled drug record showed the last dose was administered several days prior. Nursing staff confirmed the resident had been without the prescribed pain medication for a week, and the nurse practitioner was unaware of the medication's unavailability. Facility policy required medications to be administered in a safe and timely manner as prescribed. The failure to monitor blood pressure prior to administering antihypertensive medication and the lack of timely reordering and availability of prescribed pain medication for the residents constituted non-compliance with pharmaceutical service requirements. These deficiencies were identified through medical record review, staff interviews, and policy review.
Failure to Maintain Safe and Homelike Physical Environment
Penalty
Summary
The facility failed to maintain the building and furnishings in good repair, affecting multiple residents, including one with chronic obstructive pulmonary disease and bipolar disorder who required assistance with activities of daily living. Observations revealed a large hole in the wall of this resident's room, which had been present since admission and had not been repaired despite requests. The resident and staff confirmed the ongoing disrepair, and the administrator acknowledged the damage was caused by a power wheelchair. Additional observations identified significant deterioration in common areas, including a built-in buffet cabinet in the resident lounge with missing baseboards, chipped wood, scuff marks, and cracked drawers. Staff noted the cabinets appeared moldy and had been in poor condition for several months. The walls and doors in the 300 and 400 halls also showed broken trim, chipped paint, and scuffing. Residents and staff confirmed the poor state of repair, and the administrator admitted repairs were not prioritized, stating that damage would likely recur. The facility did not have a policy regarding the physical environment.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by the condition of the shower rooms and the floor in a resident's room. Observations revealed that the 500-hallway shower room, the only one used by all residents, had non-functioning stalls, dirt, debris, and trash scattered on the floor, and lights containing what appeared to be bugs. Additionally, the 200-hall shower room was found to be in disrepair, with a foot of stagnant water covering the floor, water pouring from the ceiling, and brown stains and black dotted substances on the walls and ceiling. The Maintenance Supervisor confirmed these conditions and noted that the bathroom was filled with various chairs and debris, with the water turned off. Resident #36, who was cognitively impaired and required assistance with daily activities, was affected by the facility's failure to maintain cleanliness. During a medication pass, an LPN observed that her shoes were sticking to the floor in the resident's room, making a loud noise. This was confirmed by a Regional Nurse, who suggested that the stickiness might be due to the chemical cleaner used. The facility's cleaning checklist required proper cleaning and disinfection of floors, which was not adhered to in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to physician orders, resulting in a medication error rate of 6.45%, which exceeds the acceptable threshold of 5%. This deficiency affected two residents. Resident #40, who was cognitively intact and required assistance with various activities of daily living, was administered Pyridium 100 mg by an LPN despite having no active order for this medication. The LPN confirmed the absence of an active order, and the Regional Nurse verified that the medication should not have been administered. Resident #47, also cognitively intact and requiring assistance with daily activities, had a physician's order for Linagliptin 5 mg to be administered for diabetes management at 8:00 A.M. However, the LPN failed to administer this medication during the scheduled time. The LPN later confirmed the omission. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not followed in these instances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in a safe manner, affecting one resident. During an observation and interview, it was found that the resident had several bottles of medication in his room, including milk thistle, St. John's Wort, zinc, B vitamins, and soy lecithin. These medications were not stored in accordance with the facility's policy, which requires all drugs and biologicals to be stored in a safe, secure, and orderly manner. The resident, who was cognitively intact and dependent on staff for medication administration, had a range of medical conditions including alcohol dependence withdrawal, emphysema, anxiety disorder, major depressive disorder, and others. The facility's policy, dated 2001, mandates that nursing staff are responsible for maintaining medication storage, but this was not adhered to in this instance, leading to the deficiency.
Inadequate Room Temperature for Resident
Penalty
Summary
The facility failed to ensure a comfortable environment for a resident, identified as Resident #46, who was affected by inadequate room temperature. The resident, who was severely cognitively impaired with a BIMS score of three, required supervision and assistance with daily activities. During an observation, the temperature in the resident's room was recorded at 66 degrees Fahrenheit, which was below the facility's policy threshold of 71 degrees for implementing procedures to prevent hypothermia. The facility's heating system was not fully operational due to incomplete installation of new heating and air conditioning units, which were not yet connected to the outdoor condenser. Interviews with facility staff, including a Housekeeping Technician and a Certified Nurse Aide, confirmed the issue with the room temperature and the reliance on hallway heaters to warm resident rooms. The Administrator verified the room temperature with a laser thermometer and acknowledged the deficiency. The facility's policy on extreme cold indicated a higher risk for hypothermia when temperatures dropped below 65 degrees for four consecutive hours, highlighting the potential risk to the resident's safety and comfort.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident #44, who was affected by this deficiency. Resident #44, admitted on 08/24/21, had diagnoses including chronic obstructive pulmonary disease, heart disease, delusional disorder, and chronic pain. The resident was cognitively intact with a BIMS score of 15 and required extensive assistance for bed mobility and toileting hygiene. The plan of care indicated a risk for pain related to muscle spasm, post-procedural pain, and chronic pain, with interventions to administer medication as ordered. However, on 02/19/25, Resident #44 did not receive the prescribed Oxycodone Hcl 5 mg at 9:00 A.M. and 9:00 P.M. The deficiency occurred because the facility ran out of the Oxycodone supply, and the pharmacy was awaiting a new prescription script. The LPN documented the situation in a progress note, and the provider was made aware. The Director of Nursing confirmed that the new prescription was ordered timely, but the emergency drug kit supply could not be used to administer the pain medication on that day. The facility's policy on medication administration, dated 01/2018, states that medications should be administered as prescribed, which was not adhered to in this instance.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.6% error rate during the survey. This deficiency was identified through record reviews, observations, and staff interviews. Specifically, the error involved Resident #44, who was prescribed Magnesium Hydroxide oral suspension and Folic Acid 1 mg tablet. However, the resident was administered Magnesium Oxide 400 mg in tablet form and Folic Acid 400 mcg in pill form, which did not align with the physician's orders. The incident was observed when LPN #288 administered the incorrect medications to Resident #44. Upon interview, LPN #288 confirmed the administration of the wrong form and dosage of medications. Further observation with the Director of Nursing revealed that the correct Magnesium Hydroxide oral suspension was available in the medication cart but was not used. The facility's policy on medication administration, which requires medications to be administered as prescribed, was not followed, leading to this deficiency.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain air temperatures within comfortable ranges for residents residing on the secure behavioral unit (100 hall). During an observation conducted on January 21, 2025, from 4:16 P.M. to 4:30 P.M., it was noted that the air temperatures in the unit were below 71 degrees Fahrenheit. Specific room temperatures were recorded, with one room at 43.6 degrees F, another at 55 degrees F, and a third at 51.1 degrees F. The temperatures in all 12 rooms on the unit ranged from 43.6 F to 55 F. Two portable heating units were present in the hallway, but residents were observed in the unit without any visible signs of distress. Interviews with the Maintenance Director (MD) and the Administrator confirmed that the air temperatures were not at comfortable levels. The MD stated that the resident room heaters were operational but unable to keep up with the current low outside temperatures. A resident expressed that it was cold in the unit. The facility's policy, revised in July 2020, mandates maintaining room temperatures between 71-81 degrees F. This deficiency was investigated under Complaint Number OH00161777 and had the potential to affect 13 residents residing on the secure behavioral unit.
Failure to Assist Resident with Medical Appointments
Penalty
Summary
The facility failed to provide medically-related social services by not assisting a resident with their medical appointments. Resident #21, who has diagnoses including chronic obstructive pulmonary disease, chronic pain, hypertension, and depression, was affected by this deficiency. The resident had intact cognition and required assistance with daily activities. The facility did not document the resident's medical appointments on 10/17/24 and 10/28/24 in the progress notes, which were crucial for the resident's follow-up care after an aortic aneurysm repair. Interviews revealed that the resident attended the appointment on 10/17/24, but the appointment on 10/28/24 was rescheduled to 11/04/24 without proper documentation or communication. The transportation staff confirmed the appointment was scheduled but canceled without a documented reason. The cardiologist's office confirmed the resident was a no-show for the 10/28/24 appointment, and the facility's administration acknowledged the lack of documentation and could not explain the cancellation. This deficiency was investigated under Complaint Number OH00159497.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, accurately documented, and reordered as necessary, affecting two residents. Resident #52, who was admitted with multiple diagnoses including anxiety and schizophrenia, had an order for Clonazepam that was not transcribed correctly. The facility's medication administration record showed discrepancies in the dosage and frequency of administration, with the resident not receiving the prescribed doses. Interviews with the Director of Nursing (DON) and the pharmacist confirmed these errors, and the facility did not utilize the emergency box to provide the medication when it was unavailable. Resident #21, admitted with conditions such as chronic pain and depression, had orders for oxycodone and methocarbamol. The facility's records showed inconsistencies in the documentation of oxycodone administration, with more tablets signed out than documented as given. Additionally, methocarbamol was not available, and there was a lack of documentation for its administration. Interviews revealed that the facility did not request refills or document insurance issues properly, leading to the unavailability of the medication. The facility's policy on medication errors defines such errors as deviations from physician orders and documentation standards. The deficiencies were identified during a complaint investigation, highlighting failures in medication management and documentation processes. The facility's staff, including the DON and corporate RN, verified the discrepancies and acknowledged the lack of proper documentation and medication availability.
Failure to Ensure RN Supervision for Required Hours
Penalty
Summary
The facility failed to ensure the supervision by a Registered Nurse (RN) for eight consecutive hours daily, which is a requirement. This deficiency was identified through a review of the nursing schedule dated June 16, 2024, which revealed that no RN was scheduled for that day. An interview with the Director of Nursing (DON) on July 17, 2024, confirmed that the facility did not have an RN on duty on June 16, 2024. This failure had the potential to affect all 52 residents residing in the facility.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by several observations and interviews. In the secured Memory Care Unit, the floors were found to be dirty, with 80% of the laminate wood stained black and littered with food crumbs, soda cans, and other debris. This was confirmed by a State Tested Nursing Assistant (STNA) who verified the poor environmental conditions. In another instance, a resident's room was observed to be excessively warm, with temperatures reaching 85 degrees Fahrenheit despite attempts to adjust the thermostat. The resident reported discomfort due to the heat, and a Housekeeping Assistant confirmed the room's temperature was above the recommended range. Additionally, the common area between two halls had multiple buckets and trash cans collecting water from leaking ceilings, which had been an ongoing issue for several months, as confirmed by a Licensed Practical Nurse (LPN) and the Maintenance Supervisor. The outdoor environment of the facility was also found to be poorly maintained, with overgrown landscaping, decaying tree branches, and debris such as empty plastic bottles and fabric pieces scattered across the patio area. This made it difficult for residents to navigate the pathways, as confirmed by a resident and an STNA. The facility's administrator acknowledged the poor conditions and the need for a safe and homelike environment. The facility's housekeeping policy indicated that residents should receive regular housekeeping services, which were evidently not being provided. This deficiency was a repeat issue from previous complaint surveys.
Failure to Supervise Smoking and Control Hazardous Items
Penalty
Summary
The facility failed to ensure that residents did not have access to potentially dangerous items such as knives, razors, and smoking materials, and did not provide adequate supervision for residents who smoked. This deficiency affected several residents, including those with cognitive impairments and those who required supervision while smoking. For instance, Resident #50, who had intact cognition and was independently mobile, was observed lighting a cigarette for Resident #29, who had moderately impaired cognition and required supervision. Both residents were unsupervised on the smoking patio, contrary to the facility's policy. Resident #48, who had severely impaired cognition and was independently mobile, was found with cigarettes in his walker basket, despite the care plan indicating that smoking items should be stored at the nurse's station and that the resident required supervision while smoking. Similarly, Resident #107, who had a history of suicidal ideation and required partial assistance for transfers, was found with a large pocketknife, razors, and a carton of cigarettes in his drawer, which he was not supposed to have access to. This resident also expressed feelings of depression and had been consulted for psychiatric services. Additionally, Resident #21, who was cognitively intact, was observed smoking outside the designated area with a lighter, despite being a supervised smoker. The resident claimed to have had the lighter since admission, and the Director of Nursing confirmed that the resident was not supposed to have a lighter without supervision. These incidents highlight the facility's failure to adhere to its smoking policy, which mandates supervision for residents with supervised smoking privileges and secure storage of smoking materials.
Dishwasher Sanitization Failure
Penalty
Summary
The facility failed to ensure the dishwasher was functioning properly to clean and sanitize dishes, which had the potential to affect 51 of the 52 residents. The Dietary Supervisor (DS) confirmed that the sanitizer concentration levels in the dishwasher had been reading 0 parts per million (ppm) for a few weeks, despite the requirement for a safe level of 50 ppm. The dishwasher continued to be used during this period, and the issue was not addressed until a service technician was called. The technician confirmed that the sanitizer bucket was empty, which was the cause of the 0 ppm reading. The sanitizer bucket had a delivery date of several months prior, and there was no record of when it was opened or when the sanitizer was last ordered. The DS was unable to provide invoices or documentation regarding the ordering of sanitizer, and the staff member responsible for managing kitchen chemicals was unavailable. This lack of oversight and documentation contributed to the deficiency, as the facility did not maintain the necessary supplies to ensure proper sanitation of dishes.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, affecting five residents. Resident #14, with an unstageable vascular ulcer, had no physician orders for EBP, and there was no signage or personal protective equipment (PPE) outside the resident's room. Similarly, Resident #15, who had a feeding tube, also lacked EBP orders and appropriate signage or PPE outside the room. Registered Nurse #368 confirmed the absence of necessary precautions for both residents. Resident #28, with vascular ulcers on both lower extremities, also did not have physician orders for EBP, and there was no notification or PPE outside the room. The same issue was observed for Resident #33, who had an indwelling catheter and was a carrier of methicillin-resistant Staphylococcus aureus. Despite the care plan indicating the need for EBP, there were no orders or PPE available. The Director of Nursing confirmed that both Residents #16 and #33 should have been placed in EBP due to their conditions. The facility's policy on Enhanced Barrier Precautions, dated April 1, 2024, stated that EBP should be used to prevent the transmission of multidrug-resistant organisms and protect patients with chronic wounds and indwelling devices. The policy required physician orders for EBP to be reflected in the resident's medical record. However, the facility did not adhere to this policy, resulting in the deficiency noted during the survey.
Failure to Document Vaccination Offers
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal and influenza vaccinations, as evidenced by the lack of documentation in the medical records of five residents. The medical records for these residents did not include any information regarding the receipt or refusal of the vaccines. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of documentation for the vaccinations in question. The facility's census at the time was 52 residents, and the deficiency affected all five residents reviewed for vaccinations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 540 citations issued within 25 miles in the last 12 months — including the 2 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 Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maria Joseph Living Care Center | 0.5 mi | ★★★★★ | 15 | 0 |
| Arc At Trotwood Llc | 1.1 mi | ★★★★★ | 12 | 0 |
| Aventura At Shiloh Springs | 1.3 mi | ★★★★★ | 26 | 1 |
| Siena Woods Care Center | 2.3 mi | ★★★★★ | 14 | 0 |
| Aventura At Carriage Inn | 2.3 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Trotwood Health & Rehab Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.