Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Tuscany Gardens during CMS and state inspections, most recent first.
Surveyors found that during medication administration, two RNs repeatedly left an electronic medical record screen open and visible on the med cart while entering resident rooms, exposing protected health information (PHI). For multiple residents with complex conditions such as diabetes, CHF, dementia, cerebral palsy, acute kidney failure, depression, and urinary issues, the EMR displayed names, room numbers, diagnoses, and medications and was not locked or secured. Both RNs confirmed in interviews that they did not lock the computer screens before leaving the cart, resulting in PHI being viewable to anyone passing by.
Surveyors found that RNs repeatedly left medication carts unlocked and unattended in hallways while administering medications to residents in their rooms. The carts, containing drugs and biologicals, were not secured despite being accessible in areas where cognitively impaired and independently mobile residents were present. In interviews immediately following these observations, the RNs acknowledged that they had not locked the carts, resulting in noncompliance with requirements for secure storage of medications.
A resident with multiple chronic conditions and an order for oxycodone/acetaminophen had a discrepancy between the controlled drug record and the actual tablet count, with the record showing more tablets than were present. During a med pass observation, an RN signed out a narcotic dose when the card already showed a lower count than documented, and the record contained entries for future doses that were later errored out. In interviews, the RN first claimed an unwitnessed waste, then admitted to pre-pouring and signing out narcotic and other medications for the entire shift, storing a pre-poured oxycodone/acetaminophen dose in the medication cart drawer and only correcting the records after learning she would be observed.
An LPN failed to follow infection control practices while administering medications via feeding tube to a resident with severe cognitive impairment and multiple chronic conditions, including a gastrostomy. The LPN retrieved a graduate and syringe stored together on a bedside table without a bag or date, took them to the bathroom to fill the graduate, then returned and placed the medication cup and syringe directly on a visibly dirty bedside table without using a barrier before administering the medication. In interviews, the LPN confirmed placing the syringe on the dirty surface, and clinical leadership acknowledged that a barrier should have been used, contrary to facility policy requiring adherence to current clinical standards for enteral medication administration.
Respiratory equipment was not changed, dated, or stored properly for several residents receiving O2 and nebulizer care. Residents with COPD, CHF, asthma, and other chronic conditions were observed with undated O2 tubing, empty humidifier bottles, and nebulizer parts left uncovered or stored in an open box on a paper towel, despite orders for weekly changes and proper storage. Staff confirmed the missing dates and improper storage, and one RN stated there was no policy for nebulizers or for storing and cleaning nebulizer supplies.
A resident with moderate cognitive impairment, total ADL dependence, a Foley catheter, and a fall risk had the call light found on the floor behind the bed on two observations, leaving it out of reach. An RN confirmed the call light was not within reach, and the RN Regional Clinical Nurse Manager stated there was no call light policy.
A resident with cerebral infarction, Parkinson's disease, and moderate cognitive impairment was routinely awakened in the early morning for scheduled meds, including aspirin, amlodipine, magnesium oxide, vitamin D3, and propranolol. The resident stated he preferred to sleep in and receive meds after or around breakfast, but staff continued giving them at 5:00 A.M. to 6:00 A.M. Interviews confirmed early med passes were sometimes driven by staffing and that resident preferences for med timing were not being captured.
A resident with impaired cognition and multiple chronic diagnoses had an advance directive discrepancy between the hard chart and EMR. The signed document in the chart listed DNRCC-A and DNI, while the EMR and physician orders listed DNRCC. An LPN confirmed the mismatch and could not identify the active code; after surveyor intervention, a new advance directive matching the orders was placed in the chart, but it was not dated by the physician.
The facility failed to support antipsychotic use with appropriate diagnoses for one resident and failed to complete ordered or recommended lithium labs for another resident. A third resident continued receiving clonazepam for behaviors after psych review had removed it from the plan, and the DON confirmed the medication’s indication was later changed to epilepsy. The record review and DON interview showed perphenazine, clonazepam, and lithium were used or monitored inconsistently with the documented orders, diagnoses, and pharmacy recommendations.
Inaccurate MDS coding affected two residents. One resident’s MDS incorrectly showed a pressure ulcer as newly identified even though the same unstageable wound had already been documented on the coccyx/left buttocks, and an RN confirmed the coding error. Another resident’s MDS incorrectly stated no wheelchair use despite chart notes, staff confirmation, resident interview, and survey observations showing the resident had and used a wheelchair; the MDS nurse confirmed the entry was in error.
A resident with paraplegia, neuropathy, urethral injury, schizoaffective disorder, and PTSD had a PASARR that required a level II eval, but the chart lacked documented completion or documented attempts to obtain it. The resident’s MDS showed intact cognition, and staff could not provide evidence of the reported follow-up call until surveyor intervention prompted additional email follow-up and receipt of the determination.
Incomplete Care Plan for Bilateral Hand Contractures: A resident with dementia and multiple psychiatric and neurologic diagnoses had bilateral wrist and hand contractures, impaired cognition, and dependence for ADLs, but the care plan only noted noncompliance with orthotic orders. OT had discontinued services after the resident refused hand orthotics, and later notes continued to document contractures and splint use without corresponding care plan interventions for ROM, hand positioning, or hygiene.
Failure to provide appropriate ADL care for two dependent residents. One resident with impaired cognition, contracted wrists, and dependence for personal care had red, odorous palms with residue and long fingernails, while another resident who was dependent for personal hygiene was observed in a food-stained shirt from the prior day with several days of facial hair and no recent shave outside of showers. Staff confirmed the residents’ dependent status and the observed hygiene issues, and the RN stated the facility had no personal care or ADL policies.
A resident receiving hospice services for end stage chronic respiratory failure had an expired hospice certification and plan of care in the facility binder. Although the resident’s chart and care plan reflected hospice involvement, the updated hospice recertification was not available until after the surveyor requested it and the hospice physician signed it.
Incomplete Pressure Ulcer Assessments on Readmission: The facility failed to fully assess pressure injuries for two residents on readmission. One resident with multiple chronic conditions had a stage III coccyx ulcer documented without wound description or exudate status, and staff verified no comprehensive assessment was completed. Another resident with DM, CHF, COPD, and other diagnoses had a left buttocks wound documented without staging, description, or exudate status, and staff also confirmed the lack of a comprehensive readmission assessment.
Failure to monitor and follow up on a resident’s bilateral wrist contractures. A resident with dementia, parkinsonism, and significant dependence for care had no care plan interventions for ROM, hand positioning, or orthotics after OT stopped when the resident refused splints. Progress notes continued to document hand contractures and splints, but staff could not confirm ongoing use, and the chart showed no evidence of active therapy, restorative services, or monitoring for the contracted wrists for an extended period.
Improper catheter maintenance and delayed follow-up of urology recommendations affected two residents. One resident with a Foley/Coude catheter had repeated catheter malfunction, displacement, and ER visits, while urology recommended a suprapubic catheter after noting ureteral erosion; staff were unsure of the plan and the catheter was not secured. Another resident with a suprapubic catheter had discontinued irrigation supplies left in the room and an open syringe package observed, with nursing staff acknowledging the items and the resident reporting he had been told a new syringe should be used for each flush.
A resident with cerebral palsy, dysphagia, protein-calorie malnutrition, and other chronic conditions was not provided ordered adaptive eating equipment during a meal, and a disliked food item was served anyway. The resident’s tray had sausage covered in gravy despite gravy being listed as a dislike, the left-curved utensil was not within reach, only one two-handled cup was present, and water was served in a regular cup instead of the ordered lidded two-handled cup.
A resident with multiple health conditions and fragile skin was subjected to rough handling by a CNA during transfers, resulting in a skin tear and other distressing incidents. Despite reports from staff, the resident, and family members about the CNA's behavior, the facility did not report the incidents as abuse or have a policy for hoyer lift use, leading to a failure to protect the resident from abuse.
A resident with paraplegia and other health conditions missed multiple medical appointments due to the facility's failure to secure necessary bariatric transportation. This resulted in missed Botox treatments and rehabilitation sessions, causing increased pain and being dropped by a rehabilitation facility. The facility lacked a policy for providing transportation to outside appointments.
The facility failed to report an allegation of resident-to-resident sexual abuse involving two cognitively impaired residents. Despite multiple observations of inappropriate touching, the incident was not reported to the state agency as required by the facility's policy.
The facility failed to investigate an allegation of resident-to-resident sexual abuse involving two cognitively impaired residents. Despite the incident being reported and confirmed, no formal investigation was conducted, and the care plan for the resident exhibiting inappropriate behavior was not updated. Additionally, staff did not receive formal training on managing such behaviors, representing non-compliance with the facility's policies.
A resident with hemiplegia was injured when a mechanical lift tipped over during a transfer by a single STNA, contrary to the protocol requiring two staff members. The incident was not properly investigated, and the STNA was not retrained before returning to work.
Failure to Protect Resident PHI During Medication Administration
Penalty
Summary
Surveyors identified a deficiency related to failure to maintain privacy of residents' personal and medical records during medication administration. On multiple occasions on the same day, two RNs prepared medications at a medication cart with an electronic medical record (EMR) screen displaying residents' protected health information and then entered resident rooms without locking the computer screen. For one resident with diabetes, muscle weakness, cognitive communication deficit, need for assistance with personal care, hypertension, constipation, and congestive heart failure, an RN left the EMR open showing the resident's name, room number, diagnoses, and medications visible to anyone passing by. The RN confirmed in interview that she had not locked the computer screen to protect the resident's personal health information. Similar observations were made for five additional residents with various diagnoses including eating disorder, cerebral palsy, acute kidney failure, gastrointestinal hemorrhage, anxiety disorder, constipation, exposure to viral communicable diseases, malignant neoplasms of the pancreatic duct and kidney, depression, dementia, urinary tract infection, urine retention, neuromuscular dysfunction of the bladder, slow transit constipation, altered mental status, and congestive heart failure. In each case, the RN prepared medications at the cart, left the EMR screen active and visible with the resident's name, room number, diagnoses, and medications, and then entered the resident's room to administer medications without securing the screen. Both RNs involved acknowledged during interviews that they had not locked the computer screens to protect the residents' personal health information.
Unattended Unlocked Medication Carts During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked when unattended, as required for the secure storage of drugs and biologicals. Surveyors observed multiple instances on the same day where Registered Nurse (RN) #201 and RN #200 prepared medications at unlocked medication carts positioned in the hallway outside residents’ rooms and then entered the rooms without securing the carts. These observations occurred during medication administration for several residents, including Resident #85 and Resident #77 for RN #201, and Residents #21, #88, #84, and #52 for RN #200. During interviews conducted shortly after each observation, both RN #201 and RN #200 confirmed that they had not locked the medication carts before leaving them unattended. The report notes that this failure had the potential to affect nine cognitively impaired and independently mobile residents on the 200 and 300 halls, identified during the survey as Residents #17, #34, #40, #50, #57, #59, #63, #87, and #93. The cited deficiency is specifically related to the requirement that all drugs and biologicals be stored in locked compartments, with separately locked compartments for controlled drugs.
Failure to Maintain Accurate Narcotic Count and Prohibition on Pre-Pouring Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate controlled drug record and narcotic count for oxycodone/acetaminophen and allowed pre-pouring of narcotic medications. Resident #9, who had diagnoses including mood disorder, bipolar disorder, anemia, diabetes, mild cognitive impairment, chronic pain, dementia, insomnia, cataracts, absence of a spleen, and follicular disorder, had a physician’s order for oxycodone/acetaminophen 10/325 mg, one tablet four times per day for pain. On review of the Controlled Drug Record-Disposition form for this medication, surveyors found that the record indicated there should have been 13 tablets remaining, but only 12 tablets were present in the medication card in the narcotic drawer. During observation of medication administration, a registered nurse retrieved one oxycodone/acetaminophen tablet for Resident #9 when the card showed 12 tablets remaining, while the controlled drug record still reflected 13 tablets. The record also showed doses signed out in advance for future administration times that were later errored out and initialed by the nurse. In interviews, the nurse first stated she had wasted a dose earlier in the day without a witness or signature, but later admitted she had pre-poured the oxycodone/acetaminophen dose for another resident and stored it in the top drawer of the medication cart. She further stated she had pre-poured and signed out medications for the entire shift and then errored them out when she learned she would be observed for medication administration.
Inadequate Infection Control During Enteral Tube Medication Administration
Penalty
Summary
The deficiency involves a failure to maintain proper infection control practices during enteral tube medication administration for one resident. The resident had multiple diagnoses, including Parkinson's disease, COPD, anemia, hypothyroidism, gastrostomy, major depressive disorder, generalized anxiety disorder, hallucinations, schizoaffective disorder, adult failure to thrive, and dementia. An Annual MDS assessment documented that the resident had severely impaired cognition and a feeding tube. During a medication pass, an LPN entered the resident’s room, retrieved a graduated container and syringe from the bedside table, and used them to prepare and administer tube feed medications. Surveyor observation showed that the syringe was stored inside the graduate on the bedside table without a bag or date, and the bedside table surface was visibly dirty. The LPN took the graduate and syringe to the bathroom, filled the graduate with 500 ml, then returned and placed the cup with medication and syringe directly on the visibly dirty bedside table without placing a barrier. She then proceeded to administer the medication using the syringe. In a subsequent interview, the LPN confirmed that she had set the syringe directly on the visibly dirty bedside table without a barrier. The Regional Clinical Nurse later verified that a barrier should have been placed on the bedside table prior to placing the syringe there. Facility policy on enteral tube medication administration stated that medications were to be administered through an enteral feeding tube as prescribed and in accordance with current clinical standards of practice.
Respiratory Equipment Not Dated, Changed, or Stored Properly
Penalty
Summary
The facility failed to change and date oxygen tubing and supplies as ordered for residents receiving respiratory care, and failed to store respiratory equipment in a safe and sanitary manner. Resident #44 had diagnoses including COPD, pulmonary embolism, CHF, CKD, and chronic respiratory failure, and the care plan directed oxygen use, aerosol treatments, respiratory assessments, and monitoring. The physician orders required weekly cleaning of the oxygen concentrator filter and weekly changes of the oxygen tubing, cannula, and mask, but the MAR/TAR showed no documented evidence that the nasal cannula or humidifier bottle had been changed weekly. During observation, the resident’s oxygen nasal cannula and humidifier bottle were not dated, and the humidifier bottle was empty; an RN confirmed the tubing had no date and there was no documented evidence it had been changed since admission. Resident #38 had diagnoses including CHF, diabetes mellitus, hypothyroidism, atrial fibrillation, depression, and osteomyelitis of the lumbar vertebrae, and the care plan included oxygen therapy with weekly changes of oxygen tubing, mask, and cannula. The physician orders also required weekly filter changes on the oxygen concentrator and oxygen saturation checks every shift while on oxygen. On observation, the resident’s oxygen nasal cannula and humidifier bottle were not dated, and the humidifier bottle was empty; an RN verified the items were undated and empty. Resident #71 had diagnoses including paralytic syndrome, COPD, asthma, GERD, osteoporosis, pulmonary heart disease, diaphragmatic hernia, allergic rhinitis, dysphagia, and peripheral vascular disease, and received budesonide via nebulizer. The physician order required nebulizer tubing, cannula, and mask to be changed weekly. The nebulizer tubing and mask were observed lying in an open plastic box on a brown paper towel with no visible date, and an RN confirmed the supplies were undated. Resident #82 had COPD, type II diabetes mellitus, CHF, and obstructive sleep apnea, with orders for continuous oxygen and weekly changes of oxygen and nebulizer tubing/mask/cannula. The TAR did not document an oxygen tubing change on one scheduled date, and the resident was observed with an undated empty humidifier bottle, no date on the oxygen tubing, and an uncovered nebulizer mask lying on the bed with tubing labeled with a prior date; an LPN confirmed the humidifier bottle was empty, the oxygen tubing was not dated, and the nebulizer mask was uncovered on the bed.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach of one resident. Resident #60 was admitted with diagnoses including sepsis, atrial fibrillation, paranoid schizophrenia, muscle weakness, dysphagia, mild cognitive impairment, depression, hypothyroidism, hyperlipidemia, acute respiratory failure, urinary retention, neuromuscular dysfunction of the bladder, primary hypertension, and abnormalities of gait and mobility. The most recent MDS showed moderate cognitive impairment, dependence on staff for all ADLs, a Foley catheter, and occasional bowel incontinence. The care plan identified a fall risk and included an intervention to ensure the call light was within reach. On two separate observations, the resident was found in bed with the call light lying on the floor behind the bed and not within easy reach. An RN confirmed the call light was on the floor behind the bed, and the RN Regional Clinical Nurse Manager stated there was no call light policy.
Resident Preferences Not Followed for Early Morning Medication Administration
Penalty
Summary
The facility failed to ensure resident preferences were followed for medication administration for one resident. The resident was admitted with diagnoses including cerebral infarction, Parkinson's disease, progressive supranuclear ophthalmoplegia, vitamin D deficiency, falls, and hypertension, and was assessed as moderately cognitively impaired. Physician orders included aspirin, amlodipine, magnesium oxide, vitamin D3, and propranolol. The MAR showed these medications were routinely administered in the early morning, with several given at 5:00 A.M. and propranolol at 6:00 A.M. over multiple days. Interview findings showed the resident complained that he was being awakened daily between 5:00 A.M. and 6:00 A.M. for medications and stated he preferred to sleep in and receive medications after or around breakfast. He also stated he had asked night shift staff why the medications were given so early, but they continued to hand them to him without explanation. The DON and Regional Clinical Nurse confirmed that early medication times were used on some units for medications that needed to be given before meals or if it was the resident's choice, and otherwise residents were not supposed to be woken that early. RN and LPN interviews confirmed that some residents were given morning medications early due to staffing and that resident preferences for medication timing were not being captured in assessment.
Incorrect Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the signed advance directive for Resident #4 was correct. Resident #4 was admitted with diagnoses including unspecified diastolic congestive heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, and unspecified sequelae of cerebral infarction. The significant change MDS showed a BIMS score of 06 out of 15, indicating impaired cognition. The advance directive in the hard chart was dated 12/18/23 for DNRCC-A and DNI, while the electronic medical record listed the advance directive as DNRCC and the physician orders were for DNRCC. During interview, an LPN confirmed that Resident #4 had transitioned to hospice and acknowledged that the signed document in the hard chart was for DNRCC-A while the order stated DNRCC. The LPN could not identify which code was active and stated she assumed it would be updated but did not know where to find the correct code. After surveyor intervention, a newly signed advance directive was placed in the hard chart for DNRCC, matching the physician orders, but it was not dated by the physician.
Unnecessary Psychotropic Use and Missed Lithium Monitoring
Penalty
Summary
The facility failed to have appropriate diagnoses to support the use of antipsychotic medication for Resident #11 and failed to complete ordered or recommended lithium monitoring for Resident #14. The report also identified concerns with Resident #13’s clonazepam use, including that the medication continued to be given for involuntary movements and dementia with behaviors even after psychiatric review noted the medication had been removed from the resident’s plan. These findings were based on interview, record review, and facility policy review. For Resident #11, the record showed perphenazine was ordered over multiple periods for diagnoses including unspecified psychosis not due to a substance or known physiological condition and major depressive disorder. The resident’s MDS described the resident as cognitively intact with anxiety and depression and taking antipsychotics. The DON confirmed that major depressive disorder with auditory hallucinations and unspecified psychosis were not appropriate diagnoses for perphenazine use, and confirmed the resident did not have schizophrenia. The only appropriate administration identified in the record was the short course ordered for severe nausea and vomiting. For Resident #13, clonazepam was ordered for involuntary movements and dementia with behaviors, while the resident also had diagnoses including epilepsy, schizoaffective disorder bipolar type, dementia, anxiety, and insomnia. The MDS showed severe cognitive impairment, delusions, hallucinations, and behaviors, and psychiatric notes documented ongoing medication management. The DON confirmed clonazepam had been removed from the psychiatric plan but continued to be administered under the earlier indications until the diagnosis was changed to epilepsy. For Resident #14, lithium was ordered for bipolar disorder, but the record showed a lithium level ordered for one-time testing and later every six months was not found as completed in the medical record; the DON confirmed the ordered level could not be located and that a pharmacy recommendation and physician order for lithium monitoring were not carried out until the level was obtained during hospital pre-operative testing.
Inaccurate MDS Coding for Pressure Ulcer Status and Wheelchair Use
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents. For Resident #4, the record showed a readmission with a pressure wound to the left buttocks, and the resident had a history that included diabetes mellitus, neuromuscular dysfunction of the bladder, hypertension, hyperlipidemia, hypothyroidism, depression, anxiety, congestive heart failure, cerebral infarct, pressure ulcer, and COPD. The care plan and skin documentation reflected an unstageable pressure ulcer to the coccyx/left buttocks area, with the wound described as 50% dry brown crust and 50% purple, and the resident’s Braden score indicated risk for skin breakdown. The resident’s readmission skin assessment documented the wound size but did not include staging, wound description, or whether exudate was present. The significant change MDS identified one unstable pressure ulcer that was present on admission, but RN #700 confirmed the resident was readmitted with the same unstageable pressure ulcer previously identified and that the MDS was coded inaccurately as a newly identified wound. The record also showed physician orders for ongoing wound care to the left buttocks. For Resident #99, the admission MDS documented severe cognitive impairment, one-sided upper and lower extremity impairment, dependence for ADLs, setup required for eating, and that no medical equipment was used. However, the progress note stated the resident had a wheelchair and walker and was observed using the wheelchair, and the resident confirmed having a wheelchair since admission. RN #524 also confirmed the resident initially had a wheelchair, and surveyors observed the resident multiple times in the wheelchair, including independently eating in the dining room. MDS Nurse #515 confirmed the MDS entry stating the resident did not use a wheelchair was entered in error and was based on verbal report rather than chart documentation.
Delayed PASARR Level II Follow-Up
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not timely followed up for one resident. The resident was admitted with diagnoses including paraplegia, hereditary and idiopathic neuropathy, injury of the urethra, schizoaffective disorder, and PTSD. The annual MDS showed a BIMS score of 15, indicating intact cognition. Review of the chart showed the PASARR required a level II evaluation, but there was no documented evaluation or documented attempt in the medical record to obtain it. A social worker stated that another staff member had initially submitted the level II PASARR evaluation to the Department of Developmental Disabilities, and later reported that a call had been made previously for the evaluation but no documentation of that call was available. After surveyor intervention, an email was sent to follow up, and the level II determination was then received and scanned into the chart.
Incomplete Care Plan for Bilateral Hand Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #8’s bilateral wrist and hand contractures. The resident was admitted with diagnoses including type II diabetes, dementia, psychotic disturbance, mood disturbance, anxiety, secondary parkinsonism, stiffness of unspecified joint, and schizoaffective disorder. The 5-day MDS documented impaired cognition with a BIMS score of 09 out of 15, impairments in both upper extremities, maximal dependence for upper-extremity dressing, dependence for rolling in bed, and need for assistance with transfers. On observation, the resident’s wrists were contracted with her fingers folded into her palm. Review of the care plan showed only a reference to noncompliance with orthotic orders and did not address the contractures themselves, range-of-motion maintenance, hand positioning, or hygiene. The care plan had not been updated after OT discontinued services when the resident refused bilateral hand orthotics, despite later progress notes repeatedly documenting bilateral upper-extremity hand contractures, tremors, and splint use. Staff interviews confirmed that splints had been attempted and that the resident removed them, and an RN stated there was no information in the care plan regarding the resident’s contractures.
Failure to Provide Appropriate ADL Care
Penalty
Summary
The facility failed to provide appropriate ADL care for two dependent residents. Resident #8 was admitted with diagnoses including UTI, COPD, type 2 diabetes mellitus, and morbid obesity, and the MDS documented impaired cognition, upper extremity impairments, and dependence on staff for eating, oral hygiene, toileting, bathing, dressing, rolling, and transfers. The care plan noted noncompliance with orthotic orders and personal care, but did not address the resident’s contracted wrists or hygiene needs. During observation, the resident’s wrists were contracted with fingers folded into the palms, the right palm had redness, foul odor, white residue, and hair removed from the palm, and the resident’s right fingernails were approximately one-half inch long. The resident stated she preferred short fingernails and wanted them trimmed, and staff observations confirmed the hand findings. Resident #70, who had diagnoses including epilepsy, morbid obesity, mild intellectual disabilities, shortness of breath, pulmonary embolism, hypertension, vitamin D deficiency, traumatic brain injury, dyspnea, and chronic pain syndrome, was assessed as dependent on staff for personal hygiene and requiring maximum assistance with bathing. Observation showed the resident lying in bed wearing a t-shirt with crusted food near the neckline and the same shirt from the prior day. The resident also had several days of black and white bristly facial hair on the chin and upper lip and stated she did not like the hair and was only shaved when she got showers. A CNA confirmed the shirt had dried food from the previous day, the facial hair appeared three to four days old, and the resident was totally dependent on staff for personal hygiene. Shower records showed the resident’s last shower occurred two days earlier, and the RN stated there were no facility policies for personal care or ADLs.
Expired Hospice Certification and Plan of Care Not Available
Penalty
Summary
The facility failed to ensure hospice information, including the hospice certification and plan of care for certification, was current and available in the facility for Resident #44. The resident was admitted with diagnoses including COPD, pulmonary embolism, CHF, HTN, CKD, hyperlipidemia, GERD, osteoarthritis, constipation, hypothyroidism, anxiety disorder, and chronic respiratory failure. The resident’s care plan identified hospice services for end stage chronic respiratory failure with hypoxia and included interventions such as following physician orders and advanced directives, hospice collaboration with facility staff, contacting hospice for changes in condition, pain assessment, oral hygiene, skin inspection, and medication administration as ordered. Record review showed the resident received hospice services, and monthly physician orders included admission to hospice. However, the hospice plan of care in the binder was expired, and the hospice certification and plan of care were not up to date at the facility. Further review showed the certification period had been renewed only after the surveyor requested it, and the hospice physician signed the recertification after that request. An RN confirmed the hospice company sent the certification and plan of care after the surveyor requested it and after the physician signature was obtained.
Incomplete Pressure Ulcer Assessments on Readmission
Penalty
Summary
The facility failed to comprehensively assess pressure ulcers/injuries upon admission or readmission for two residents. Resident #2 had a history that included acute myocardial infarction, acute respiratory failure with hypoxia, diabetes mellitus, dysphagia, atrial fibrillation, congestive heart failure, anxiety, depression, sleep apnea, pressure ulcer, sick sinus syndrome, obstructive and reflux uropathy, and gastrostomy status. On readmission, the resident was documented as having a stage III pressure ulcer to the coccyx measuring 4.5 cm by 1.5 cm by 0.3 cm, but the assessment did not include a description of the wound or whether exudate was present. A later readmission skin assessment again identified a stage III coccyx pressure ulcer measuring 8.1 cm by 2.4 cm by 0.3 cm, and that assessment also lacked wound description and exudate information. Resident #2’s record showed weekly pressure skin grids completed over multiple weeks, and the quarterly MDS indicated moderate cognitive impairment, risk for skin breakdown, one stage III pressure ulcer present on admission, and MASD. During interview, the RN stated the wound was staged the same as prior to hospitalization as a stage III pressure ulcer and verified that no comprehensive assessment had been completed upon readmission for the pressure ulcer. The facility policy stated that staging of a pressure injury is performed to indicate the characteristics and extent of tissue injury and that licensed nurses may document observation, measurements, and comparative analysis. Resident #4 had diagnoses including diabetes mellitus, neuromuscular dysfunction of bladder, hypertension, hyperlipidemia, hypothyroidism, depression, anxiety, congestive heart failure, cerebral infarct, pressure ulcer, and COPD. The record showed MASD that resolved, but a progress note documented an unstageable pressure ulcer to the coccyx described as 50% purple and 50% dry brown crust. The weekly skin grid identified an unstageable pressure ulcer to the left buttocks measuring 4.0 cm by 4.0 cm, and the readmission skin assessment documented a pressure wound to the left buttocks measuring 4.0 cm by 3.5 cm by 0.2 cm without staging, wound description, or exudate status. Later weekly grids classified the wound as stage III and then again as unstageable, and the RN and Regional Nurse both verified that no comprehensive assessment had been completed upon readmission.
Failure to Monitor and Follow Up on Bilateral Wrist Contractures
Penalty
Summary
The facility failed to monitor and provide timely follow-up for a resident’s bilateral wrist contractures. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, dementia, psychotic disturbance, mood disturbance, anxiety, secondary parkinsonism, stiffness of joint, and schizoaffective disorder. The 5-day MDS showed a BIMS score of 09 out of 15 and documented that the resident was dependent on staff for personal care and fully or partially dependent for transfers, rolling, and mobility. The care plan did not address management of the bilateral wrist contractures or the use of hand orthotics, and it contained no measurable goals, specific interventions, or monitoring instructions for ROM exercises, hand positioning, or hygiene. OT services were discontinued after the resident refused to wear bilateral hand orthotics, and the chart showed no updated care plan after that time despite ongoing documentation of contractures in progress notes. Provider notes continued to document upper-extremity hand contractures and bilateral hand splints, but the record contained no evidence of active therapy or follow-up from April 2024 through June 2025, including no restorative aide intervention. Interviews showed the resident did not have splints in place at the time of observation, staff could not confirm when splints were last used, and rehab staff reported later referrals for contractures with wrist measurements showing flexion contractures. The chart also lacked evidence of monitoring or additional interventions for the resident’s contracted wrists during that period.
Improper Catheter Maintenance and Delayed Follow-Up of Urology Recommendations
Penalty
Summary
The facility failed to properly and safely maintain urinary catheters and to timely address urology recommendations for one resident’s suprapubic catheter, affecting two residents reviewed for catheter care. Resident #60 had diagnoses including urinary retention, neuromuscular dysfunction of the bladder, and cognitive impairment, and was dependent on staff for all ADLs. The record showed a long history of catheter problems, including failed voiding trials, repeated catheter replacements, and hospital visits for catheter displacement and malfunction. The care plan identified a Foley catheter, but also described the catheter as a Coude catheter without a corresponding order or size documented in the care plan. For Resident #60, hospital and urology records documented repeated catheter-related events. The resident was sent to the emergency room when the catheter was not flushing, when the Foley was displaced, and when the catheter was malfunctioning and not in the appropriate place. Urology documented a 16 FR two-way Coude catheter placed with immediate urine return and noted significant ureteral erosion, recommending transition to a suprapubic catheter and placing a referral for interventional radiology. The urology record later showed unsuccessful attempts to contact the facility, then contact with nursing staff and the POA, who agreed the procedure was reasonable. Facility staff interviews showed uncertainty about the plan, with staff stating they were not sure whether the resident was supposed to get a suprapubic catheter, that the catheter was not secured because the snap secure was broken, and that the resident would need to go to the hospital if the catheter became dislodged. Resident #81 had a suprapubic catheter and was cognitively intact, with diagnoses including diabetes with neuropathy and neuromuscular dysfunction of the bladder. The care plan included catheter irrigation and infection monitoring, and physician orders included daily flushing with normal saline. During observation, the resident’s room contained an open syringe, an open bottle of acetic acid, and a small unopened bottle of normal saline, even though the acetic acid order had been discontinued months earlier. A later observation again found an open syringe package in the room. Nursing staff verified that the discontinued acetic acid bottle should have been discarded and acknowledged the open syringe package, stating it would be used later and then backtracked when questioned about sterility. The resident stated he had repeatedly told nurses that a new syringe should be used for each flush, as instructed by urology.
Failure to Provide Ordered Adaptive Eating Equipment and Honor Food Preferences
Penalty
Summary
The facility failed to ensure a resident was provided adaptive equipment to promote independence with eating and failed to ensure foods the resident disliked were not served. Resident #79 had diagnoses including cerebral palsy, chronic respiratory failure, chronic pain syndrome, protein calorie malnutrition, anemia, anxiety disorder, gastro-esophageal reflux disease, and neuropathy. The resident’s care plan identified a risk for altered nutrition and hydration related to malnutrition, dysphagia, cerebral palsy, a history of gastrointestinal bleed, and anxiety, with interventions including adaptive equipment as ordered, honoring food preferences as able, monitoring consistency of diet served, obtaining food preferences, providing assistance with meals/snacks as necessary, extensive assistance, and providing the ordered diet. The resident’s meal ticket listed dislikes including oatmeal, biscuit and gravy, chocolate, cereal, gravy, and watermelon. The resident’s physician orders included a regular mechanical soft diet, double handled cups with spout lid, divided plate, and left-hand curve utensils. During observation, the resident’s ground sausage was covered in brown gravy even though gravy was listed as disliked, the left curved utensil was not within reach, only one two-handled cup was on the tray, and water was in a regular cup instead of a two-handled cup. A CNA confirmed the water was typically poured into the two-handled cup after cranberry juice was finished and verified the sausage was covered in gravy despite the resident’s dislike. The Dietary Supervisor stated the sausage should not have had gravy and verified each fluid should have a lidded two-handled cup and the resident should be handed the left curved utensil with set-up.
Failure to Protect Resident from Staff Abuse During Transfers
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, morbid obesity, major depression, and reduced mobility, was not protected from abuse by staff. The resident, who was dependent on staff for most activities of daily living and had fragile skin, experienced several incidents involving a CNA. During one transfer, the CNA caused a skin tear on the resident's arm while assisting her into a sitting position. The injury was documented, and the resident denied pain at the time, but the incident was not reported as abuse. Further review and interviews revealed additional concerning events. Another CNA reported that the same CNA dropped the resident from a hoyer lift into a shower chair from a significant height and later violently yanked the hoyer pad, causing the resident's head to snap back. The resident expressed fear of this CNA and reported that her hair had been pulled during care, though she was unsure if it was intentional. The resident and her family requested that this CNA no longer provide care due to perceived roughness and an uncaring attitude. Another family made a similar request for a different resident. Despite these reports and concerns, the facility did not have a policy or procedure for hoyer lift use, and the Director of Nursing and Administrator did not report the incidents as abuse. The lack of reporting and absence of a clear policy contributed to the failure to protect the resident from potential abuse and neglect by staff.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to provide necessary transportation for a resident to attend outside medical appointments, resulting in missed treatments and therapies. The resident, who has diagnoses including paraplegia, morbid obesity, and various mood disorders, required transportation for Botox injections to manage leg spasms and outpatient neurological rehabilitation. Despite having intact cognition and requiring assistance with activities of daily living, the resident missed several appointments due to the facility's inability to secure bariatric transportation. Interviews with the resident, a scheduler, and the administrator confirmed the missed appointments were due to transportation issues. The resident reported missing Botox injections, neurological rehabilitation, and gynecologist appointments, leading to increased pain and being dropped by the rehabilitation facility. The facility lacked a policy addressing transportation for outside appointments, contributing to the deficiency identified during the survey.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse involving Resident #12 and Resident #16. Resident #12, who has severe cognitive impairment and dementia, was fondled by Resident #16, who also has dementia and moderate cognitive impairment. The incident was witnessed by a State Tested Nurses Aide (STNA) and reported to the unit manager. However, the facility did not report the incident to the state agency as required by their policy, which mandates immediate reporting of all allegations of abuse, neglect, exploitation, and misappropriation of resident property to the administrator and the state survey agency. Interviews with STNAs revealed that Resident #16 frequently wanders and has been observed inappropriately touching Resident #12 on multiple occasions. Despite these observations, the STNAs were not required to provide statements or receive formal training on how to manage such behaviors. The Director of Nursing (DON) confirmed that the incident was reported internally but not to the state agency, as the facility's practice is to report only incidents that cause physical harm or changes in psychosocial status. This practice is in direct violation of the facility's own policy, which defines sexual abuse as nonconsensual sexual contact of any type with a resident.
Failure to Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse involving Resident #12 and Resident #16. Resident #12, who has severe cognitive impairment and dementia, was allegedly fondled by Resident #16, who also has dementia and moderate cognitive impairment. Despite the incident being reported by a State Tested Nurses Aide (STNA) and confirmed by the Director of Nursing (DON), no formal investigation was conducted. The facility did not interview staff or other residents, nor did they update Resident #16's care plan to address his new sexual behaviors. Additionally, the facility did not provide formal training to staff on how to appropriately manage such behaviors. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property mandates that all alleged violations be investigated and reported immediately to the administrator and the Ohio Department of Health. However, this policy was not followed in this case. The DON confirmed that no formal investigation was completed, and the care plan for Resident #16 was not updated. The failure to investigate and address the incident represents non-compliance with the facility's own policies and state regulations.
Failure to Investigate and Correct Improper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure an investigation and appropriate corrective action was implemented after a staff member used a mechanical lift incorrectly, affecting one resident. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was being transferred by a State Tested Nurses Aide (STNA) using a Hoyer lift. The lift tipped and fell on the resident, hitting her in the head. The resident reported that two staff members are supposed to use the lift, but sometimes only one does. Despite the incident, no injury was noted, and the resident only experienced a temporary headache. The incident was reported to the Registered Nurse (RN) and the Director of Nursing (DON), but no incident report or investigation was completed. The STNA involved was suspended for one day but was not retrained on the proper use of the Hoyer lift before returning to work. The facility's Director of Nursing confirmed that Hoyer transfers always require two staff members to ensure safety, but this protocol was not followed, and no further action was taken to address the deficiency in training or procedure adherence.
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 895 citations issued within 25 miles in the last 12 months — including the 9 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 Pataskala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pataskala Oaks Care Center | 1.3 mi | ★★★★★ | 20 | 0 |
| Robert A Barnes Center | 6.7 mi | ★★★★★ | 0 | 0 |
| Violet Springs Health Campus | 7.6 mi | ★★★★★ | 19 | 0 |
| Pickerington Care And Rehabilitation | 8.9 mi | ★★★★★ | 28 | 0 |
| Mcnaughten Pointe Nursing And Rehab | 9 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Tuscany Gardens.
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 July 2026) and official state health department websites.