Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Manor Health & Reha during CMS and state inspections, most recent first.
The facility failed to maintain required ambient temperatures in resident rooms and common areas, affecting residents on the second and third floors. Staff and residents reported cold conditions, with temperatures recorded below the required range due to boiler system issues. Observations showed residents wearing coats indoors, and mobile heaters were used to address the cold.
A resident with a history of psychiatric issues and another resident entered a third resident's room, accusing him of theft, which led to a physical altercation. The accused resident sustained multiple injuries, including scratches and a bloody mouth. The facility's staff intervened, but inconsistencies in reporting and monitoring contributed to the deficiency.
An LPN on the fifth floor of an LTC facility prepared medications for multiple residents at once, contrary to the facility's policy of preparing medications for one resident at a time. This practice was observed as the LPN assembled 13 medication cups labeled with resident names, potentially affecting 35 residents. The LPN cited the busier day shift as the reason for this practice.
The facility failed to provide scheduled activities for residents on the fifth floor, affecting 34 residents. The Activity Director was observed counting money instead of conducting activities, leaving residents with only a television and music for entertainment. The AD was the only staff member working that day, and scheduled activities were not completed due to understaffing following a recent termination.
The facility failed to address pharmacy recommendations timely for four residents, including medication adjustments and monitoring. A resident's antipsychotic GDR and Metformin dosage increase were not acted upon, and another resident's anticoagulant diagnosis was incorrect. A third resident's Seroquel GDR was declined without rationale, and a fourth resident's Meloxicam discontinuation was delayed.
The facility's fourth floor was found to be in disrepair, affecting 42 residents. Observations revealed a caved-in wall in a resident's room, a sink not affixed to the wall in the shower room, and a bathroom with missing tiles. CNAs confirmed these issues, noting some had persisted for months. The DOM was aware of some problems but not others, indicating a lack of consistent maintenance.
A facility failed to timely disburse a deceased resident's funds from the authorized resident fund account (RFA). The resident, diagnosed with schizophrenia and pulmonary heart disease, passed away in the facility. Despite policy requirements for refunding personal funds within 30 days, the RFA dispersal check was delayed. This was confirmed by the Business Office Manager, acknowledging the delay in compliance with the facility's policy and state regulations.
The facility failed to ensure accurate and readily available advanced directives for three residents. One resident lacked a completed DNR form despite having a DNRCC-A order. Another resident's signed DNR paperwork conflicted with electronic records. A third resident's code status was missing from the electronic medical record's main screen. Staff interviews confirmed these discrepancies, which violated the facility's policy requiring coordination to obtain and document legal directives.
The facility failed to provide written bed-hold notices to three residents or their representatives upon hospital transfer, as required by policy. A resident with schizophrenia was transferred due to breathing difficulties, another with bipolar disorder was transferred after a fall, and a third with multiple sclerosis was transferred following an altercation. None received the necessary bed-hold notices, confirmed by a Regional RN.
A facility failed to notify the Ohio Department of Mental Health of a significant change in a resident's mental health condition. The resident, initially diagnosed with dementia, later developed bipolar disorder, schizoaffective disorder, and paranoid schizophrenia. Despite these changes, no new PASARR was conducted after the initial review in 2022, until the day of the survey.
The facility failed to develop individualized care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with PTSD did not have a care plan until it was created with errors, while another resident receiving psychotropic and anticoagulant medications lacked corresponding care plans. Additionally, a resident with a PTSD diagnosis since June did not have a care plan addressing this condition, contrary to the facility's policy.
The facility failed to update a resident's care plans to reflect necessary interventions for behaviors, including sleeping on a yoga mat and removing furniture. Additionally, two residents did not have quarterly care conferences as required, despite severe cognitive impairments and legal guardianship. The facility's policy mandates weekly scheduling of care conferences for certain conditions, which was not followed.
A resident requiring total assistance with ADLs, including bathing, did not receive scheduled showers or consistent bed baths over a 90-day period. Despite being scheduled for twice-weekly bathing, documentation showed only four instances of bathing. The DON confirmed the resident should have been bathed twice weekly according to facility policy.
A facility failed to monitor and assess a resident's wound on the left great toe, despite a physician's order for daily care. The resident, with severe cognitive impairment and multiple diagnoses, had no documented wound assessments. An observation revealed no dressing on the wound, and interviews confirmed the lack of monitoring. The wound was first evaluated by a nurse practitioner days after the order was issued, contrary to the facility's wound care policy.
The facility failed to ensure proper dialysis communication for two residents requiring dialysis services. One resident's communication forms were not consistently completed, while another resident's forms were either incomplete or not sent. The facility's policy required pre-assessment documentation to be sent with residents, but this was not adhered to, and there was a lack of communication from the dialysis center.
A facility failed to limit a resident's PRN antipsychotic medication to 14 days and did not attempt non-pharmacological interventions before administration. The resident, with schizoaffective and bipolar disorders, had olanzapine ordered without a stop date, and it was administered without prior non-pharmacological attempts. The facility's policy requires monitoring and documentation of interventions, which was not followed.
The facility failed to provide the correct diets to two residents, as observed during lunch. One resident did not receive the prescribed double protein diet, and another received a meal inconsistent with their dietary needs, including items not ordered. Medical records confirmed these discrepancies, and CNAs verified the observations.
A facility failed to offer and educate a resident with intact cognition on influenza and pneumococcal vaccines, as required by their policies. Despite the resident's medical record showing no evidence of being offered or educated on these vaccines, this was confirmed by interviews with nursing staff. The facility's policies mandated offering vaccines and providing educational information, which was not followed in this instance.
A facility failed to prevent emotional abuse when an STNA posted a video on social media showing a resident with their brief around their ankles without consent. The resident, with severe cognitive impairments, was unaware of the incident. The STNA admitted to posting the video on TikTok, which was deleted after discovery. The facility's policies were reviewed, and the STNA was terminated. No additional violations were found during staff and resident interviews.
The facility did not properly dispose of garbage, as observed with uncovered dumpsters emitting a sour smell and surrounded by debris. The Maintenance Director acknowledged the issue, citing difficulty in cleaning and lack of lids. An exterminator highlighted the importance of sanitation to prevent pests. The facility's policy required secure dumpster lids and routine pest control.
A facility failed to notify a physician or NP of abnormal lab results for a resident with chronic kidney disease, leading to a deficiency. Despite elevated BUN and creatinine levels, there was no documentation of communication with the healthcare provider. An LPN attempted to fax the results, but they were not received, and the NP was unaware of the labs during a follow-up assessment. The DON confirmed it was the nurse supervisor's responsibility to ensure notification, which was not done.
An incident of physical abuse occurred involving two residents, resulting in serious injuries to one resident, including abrasions, swelling, brain bleeding, and a fractured sacrum. The aggressor had a history of paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior, with documented aggressive incidents in multiple facilities. The care plan for the aggressor focused on mood management but lacked specific interventions for violent behavior. The facility's psychiatrist noted challenges in reducing psychiatric medications due to relapse risks. The deficiency was linked to the absence of individualized interventions to prevent resident-to-resident abuse.
The facility failed to ensure adequate behavioral health services and person-centered care planning for a resident with a history of mental disorders and violent behaviors. Despite multiple incidents of aggression and a history of violent behavior, the care plan lacked specific interventions to manage the resident's tendencies, leading to repeated incidents of harm to other residents.
The facility failed to ensure that STNAs were given yearly performance evaluations as required. Two STNAs, employed for more than one year, did not have documented yearly performance evaluations. The HR Director confirmed the absence of these evaluations, potentially affecting all 143 residents.
Facility Fails to Maintain Required Ambient Temperatures
Penalty
Summary
The facility failed to maintain an appropriate ambient temperature in resident rooms and common areas, affecting residents on the second and third floors. Interviews with staff and residents confirmed that the facility had been cold for several days, with temperatures recorded below the required range of 71 to 81 degrees Fahrenheit. The issue was linked to problems with the boiler system in the basement, which had been previously serviced due to a sewage flood. Observations and temperature readings taken by the Mobile Administrator and recorded on the Floor Plan Master Audit Sheet revealed that temperatures in various resident rooms ranged from 60 to 69 degrees Fahrenheit, consistently below the required minimum. Residents were observed wearing coats and hats indoors, and mobile air and power rental units were deployed in an attempt to mitigate the cold temperatures. The facility's Extreme Weather Heat or Cold policy was reviewed, which outlined procedures for monitoring weather conditions, contacting utility companies, and ensuring resident care during extreme temperatures. However, the policy's implementation appeared inadequate, as the facility did not maintain the required ambient temperatures, potentially affecting the health and comfort of the residents.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident, identified as Resident #74, from physical abuse by other residents. The incident involved Resident #701 and Resident #141, who entered Resident #74's room and accused him of theft, leading to a physical altercation. Resident #701 and Resident #141 struck Resident #74, resulting in multiple scratches, red eyes, and a bloody mouth. The facility's staff intervened and separated the residents, but the incident highlighted a lapse in monitoring and preventing resident-to-resident abuse. Resident #701 had a history of psychiatric issues, including delusions and paranoia, which contributed to the altercation. Despite being monitored closely by staff, Resident #701 accused Resident #74 of stealing her belongings and, along with Resident #141, confronted him in his room. This confrontation escalated into physical violence, with Resident #701 later stabbing Resident #74 with a pen, causing injuries that required medical attention. The facility's records indicate that Resident #701 had a pattern of making false allegations and targeting male residents, which was not adequately addressed to prevent the incident. The facility's documentation and interviews with staff revealed inconsistencies in the reporting of the events, with some staff members providing conflicting accounts of the altercation. The facility's investigation into the incident initially deemed the allegations unsubstantiated, but subsequent events confirmed the abuse. The failure to prevent the altercation and the inadequate response to Resident #701's behavioral issues contributed to the deficiency, as the facility did not ensure a safe environment free from abuse for Resident #74.
Medication Preparation Deficiency
Penalty
Summary
The facility failed to ensure that medications were prepared and administered for one resident at a time, as observed on the fifth floor. An LPN was found to have assembled 13 medication cups, each labeled with a resident's name, containing varying amounts of pills. These cups were placed on the medication carts for later administration. The LPN confirmed that this practice was done to manage the workload after switching to a busier day shift. This practice was contrary to the facility's medication administration policy, which mandates that medications be prepared for one resident at a time. This deficiency had the potential to affect 35 residents on the fifth floor, with a total facility census of 144.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide scheduled activities for residents on the fifth floor, affecting 34 residents. On the observed date, the Activity Director (AD) was seen counting money for residents instead of conducting scheduled activities. The residents were left in their rooms or in the common area with only a television and music for entertainment, and no formal activities were conducted in the afternoon. The AD revealed that she was the only activity staff member working that day, and the scheduled activities, including Hydration Hour, Griddle Goodies, and Table Games, were not completed. The facility's activity staff was understaffed due to a recent termination, leaving only the AD and two other staff members to cover activities during the week and weekends. The facility's Life Enrichment Programming Policy requires a resident-centered program based on comprehensive assessments and care plans, which was not adhered to in this instance.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician in a timely manner, affecting four residents. For Resident #10, multiple pharmacy consultation reports indicated recommendations for medication adjustments and monitoring, such as a gradual dose reduction (GDR) for antipsychotics, increasing Metformin dosage, and monitoring valproic acid trough concentrations. However, there was no evidence of physician responses or actions taken on these recommendations within the required 30-day period. Additionally, there were no documented diagnoses for several medications prescribed to Resident #10. Resident #75's records showed that the pharmacy had repeatedly recommended correcting the diagnosis associated with the anticoagulant Eliquis, which was incorrectly listed for hypertension. Despite multiple recommendations, there was no physician response or correction made. Similarly, for Resident #92, a recommendation for a GDR of Seroquel was declined by the physician without providing a rationale, and there was no documentation in the medical record to support the decision. Resident #19's records revealed that pharmacy recommendations to discontinue Meloxicam and consider an alternative analgesic were not acted upon in a timely manner. The recommendations were made multiple times, yet the physician's response was delayed, and the medication was not discontinued until several months later. The facility's Medication Regimen Review policy requires that the consultant pharmacist's recommendations be documented and addressed, but this was not adhered to in these cases.
Environmental Disrepair on Fourth Floor
Penalty
Summary
The facility failed to maintain the resident environment on the fourth floor in good repair, affecting all 42 residents residing there. Observations revealed several areas of disrepair, including a caved-in wall in a resident's room, a sink in the shower room that was not affixed to the wall, and a bathroom with missing ceiling and floor tiles. Interviews with Certified Nurse Aides (CNAs) confirmed these observations, with one resident stating that the wall damage had been present since they moved into the room four months prior. The CNAs also noted that the bathroom had been in disrepair for over five months. During a follow-up observation with the Director of Maintenance (DOM), it was confirmed that the sink in the shower room was not properly affixed, and the DOM was unaware of the missing tiles in the bathroom. The DOM acknowledged awareness of the patched wall but was uncertain about the timeline of the repairs due to the frequency of such issues. Additionally, a baseball-sized hole was discovered in another wall, which the DOM was not previously aware of. The facility census report confirmed that 42 residents were affected by these environmental deficiencies.
Delayed Disbursement of Deceased Resident's Funds
Penalty
Summary
The facility failed to ensure the timely disbursement of a deceased resident's funds from the authorized resident fund account (RFA). The deficiency was identified during a review of the medical records and an interview with the Business Office Manager (BOM). The resident, who had been diagnosed with other specified schizophrenia and pulmonary heart disease, passed away in the facility. Despite the policy requiring that personal funds be refunded within 30 days of a resident's death, the RFA dispersal check was not issued in a timely manner. This was confirmed by the BOM, who acknowledged the delay in disbursing the funds as required by the facility's policy and state regulations.
Failure to Ensure Accurate and Available Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurate and readily available for three residents. Resident #87 had an active physician order for a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) status, but there was no completed and signed DNR form in the medical record. Interviews with an LPN confirmed the absence of the DNR form, despite the resident's confirmation of their advance directive preferences. The facility's policy required coordination among the patient, family, and staff to obtain and place legal documents in the clinical record, which was not adhered to in this case. Resident #99's records showed a discrepancy between the signed DNR paperwork and the electronic medical records. The signed paperwork indicated a DNR-CC (comfort care only) status, while the electronic records showed a DNR-CCA status. An LPN confirmed this inconsistency. For Resident #143, there was a lack of documentation of the code status on the main screen of the electronic medical record, despite a full code status being indicated in the care plan and physician orders. Interviews with staff confirmed that the code status should be displayed on the main screen, but it was missing. The facility's policy required coordination to ensure legal documents were obtained and placed in the clinical record, which was not followed in these instances.
Failure to Provide Bed-Hold Notices to Residents
Penalty
Summary
The facility failed to provide written bed-hold notices to three residents or their representatives upon transfer to a hospital, as required by their policy. Resident #29, who was admitted with schizophrenia, anxiety disorder, and violent behavior, was transferred to the hospital due to difficulty breathing. Despite having intact cognition, there was no evidence that Resident #29 or their representative received a bed-hold notice upon transfer. Similarly, Resident #43, with diagnoses including bipolar disorder and epilepsy, was transferred to the hospital after reporting hand pain and was later diagnosed with fractures. The medical record did not show that Resident #43 or their representative received a bed-hold notice. Resident #47, diagnosed with multiple sclerosis and vascular dementia, was transferred to the emergency room following a fall during an altercation with another resident. The medical record did not indicate that Resident #47 or their representative received a bed-hold notice upon transfer. Interviews with the Regional Registered Nurse confirmed that none of the residents were provided with the necessary bed-hold notices, which should have included information on bed-hold days and the policy for returning to the facility. The facility's policy, revised in 2020, mandates tracking Medicaid bed hold days and notifying the appropriate parties via a Medicaid Bed Hold Letter.
Failure to Notify State Agency of Resident's Mental Health Changes
Penalty
Summary
The facility failed to notify the Ohio Department of Mental Health of a significant change in a resident's mental health condition as required by regulations. This deficiency affected a resident who was admitted with a diagnosis of dementia and later developed additional mental health diagnoses, including bipolar disorder, schizoaffective disorder, and paranoid schizophrenia. Despite these changes, the facility did not conduct a new Preadmission Screening and Resident Review (PASARR) after the initial review in 2022, which had ruled out further PASARR related to dementia or other neurocognitive disorders. Interviews with the Administrator confirmed that no additional PASARRs were conducted until the day of the survey, despite the resident's evolving mental health conditions.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to ensure individualized care plans were developed and accurate for three residents. Resident #133, who was admitted with diagnoses including PTSD, end-stage renal disease, and schizophrenia, did not have a care plan addressing PTSD until it was created on 12/04/24. The care plan was erroneously copied from another resident's plan, leading to incorrect information being included. MDSRN #356 acknowledged the error, stating that she had created a template from another resident's care plan and copied it to Resident #133's care plan. Resident #92, admitted with diagnoses such as schizoaffective disorder and bipolar disorder, was receiving psychotropic and anticoagulant medications without corresponding care plans. Regional Nurse #467 confirmed the absence of care plans for these medications. Additionally, Resident #40, with a diagnosis of PTSD since 06/29/23, did not have a care plan addressing PTSD. Social Services #317 and Regional Nurse #467 confirmed the lack of a PTSD care plan for Resident #40. The facility's Comprehensive Care Planning Policy requires a comprehensive Person-Centered Care Plan for each resident, which was not adhered to in these cases.
Failure to Update Care Plans and Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to update Resident #44's care plans to reflect the resident's behaviors and necessary interventions. Despite the resident's preference to sleep on a yoga mat on the floor and the removal of furniture to prevent it from being thrown out of windows, these interventions were not documented in the care plans. The resident was admitted with diagnoses including schizoaffective disorder, bipolar disorder, antisocial disorder, and generalized anxiety, and exhibited moderate cognitive impairment. The care plans included interventions for violent behavior and other behaviors such as pacing and hallucinations, but did not include the specific interventions related to the resident's sleeping arrangements and room setup. Additionally, the facility did not conduct care conferences quarterly for Residents #13 and #29. Resident #29, who has severe cognitive impairment and a legal guardian, had not had a care conference in over three months, despite the guardian not being present after three notifications. Resident #13, with diagnoses including epileptic seizures and dementia, had no documentation of a care conference in the past twelve months. The facility's policy required care conferences to be scheduled at least weekly for various resident conditions, but this was not adhered to, as confirmed by interviews with facility staff.
Failure to Provide Scheduled Bathing for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who required total assistance with activities of daily living, including bathing, received the necessary care. The resident, who had intact cognition and was dependent on staff for all ADLs, reported not being offered a shower in two months and only sometimes receiving a bed bath. The resident's care plan, last reviewed on 11/18/24, indicated a self-care deficit but did not specify bathing preferences or frequency. The facility's shower rotation sheet indicated that the resident was scheduled for bathing twice weekly, on Wednesdays and Saturdays. However, a review of the resident's shower sheets for the past 90 days showed only four documented instances of bathing, with one sheet undated. The Director of Nursing confirmed the lack of documentation for the required bathing schedule and acknowledged that the resident should have been bathed twice weekly, as per the facility's policy revised on 09/09/22.
Failure to Monitor and Assess Resident's Wound
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a wound on a resident's left great toe. The resident, who was admitted with diagnoses including Huntington's disease, acute respiratory failure with hypoxia, and muscle weakness, exhibited severe cognitive impairment according to their annual MDS assessment. A physician's order dated 10/22/24 required daily cleansing and dressing of the wound on the night shift. However, there was no evidence in the medical record of any monitoring or assessment of the wound. An observation on 12/02/24 revealed the absence of a dressing on the resident's toe. Interviews with the interim LPN wound nurse and the wound nurse practitioner confirmed that the wound was not assessed or monitored, and the wound nurse practitioner only evaluated the wound for the first time on 12/04/24. The facility's Skin and Wound Care Best Practices policy, revised on 11/05/24, stated that evidence-based preventative skin care and wound treatment should be provided to prevent unavoidable skin complications.
Failure in Dialysis Communication for Two Residents
Penalty
Summary
The facility failed to ensure proper pre and post dialysis communication for two residents requiring dialysis services. Resident #100, diagnosed with end-stage renal disease and acute kidney failure, had an order for dialysis observation tools to be completed and sent with the resident to dialysis. However, interviews and record reviews revealed that these communication forms were not consistently completed as required. The facility's policy mandated documentation of pre-assessments, including vital signs and pre-treatment weight, to be sent with the resident, but this was not adhered to. Similarly, Resident #133, who had diagnoses including end-stage renal disease and schizophrenia, also experienced lapses in dialysis communication. The resident's records showed that communication tools were either incomplete or not sent on several occasions, and there was no documentation from the dialysis center on the forms that were sent. Additionally, there were days when the resident refused dialysis, but on other days, the communication tools were not utilized as per the facility's policy. Interviews confirmed the lack of communication from the dialysis center and the failure to send the necessary documentation.
Failure to Limit PRN Antipsychotic Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that a resident's as-needed antipsychotic medications were limited to fourteen days until the physician evaluated the resident, and non-pharmacological interventions were attempted prior to administering as-needed antipsychotic medications. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and generalized anxiety, had a physician order for olanzapine without a stop date. The pharmacy consultation report later indicated a stop date, but the medication administration records showed no evidence of the medication being administered during that time frame. A regional RN confirmed the lack of an appropriate stop date. Additionally, the resident's medical record showed that olanzapine was administered on three occasions without evidence of non-pharmacological interventions being attempted first. The facility's psychoactive medication policy requires that all residents receiving such medications have their behaviors and the effectiveness of interventions monitored and documented, but this was not done in this case. The regional RN confirmed the absence of documentation for non-pharmacological interventions prior to administering the medication.
Failure to Provide Correct Diets to Residents
Penalty
Summary
The facility failed to ensure the coordination of dietary services, resulting in two residents not receiving the correct diets as prescribed. During an observation of lunch, it was noted that one resident's meal ticket indicated a regular double protein diet, but the meal provided did not include the double protein. A review of the medical record confirmed that this resident was supposed to receive double protein with meals, and a CNA verified the absence of double protein in the meal. Another resident's meal ticket indicated a regular, renal diet, but the meal served included items not consistent with the prescribed diet, such as noodles and a plain hamburger instead of fortified potatoes. The medical record review revealed that this resident was not ordered a renal diet, and a CNA confirmed the discrepancy in the meal provided.
Failure to Offer and Educate on Vaccines
Penalty
Summary
The facility failed to ensure that a resident was provided education and offered the influenza and pneumococcal vaccines. The resident, who was admitted with diagnoses including essential hypertension, other chronic pain, and a history of falling, exhibited intact cognition according to their Minimum Data Set (MDS) 3.0 assessment. However, a review of the resident's medical record did not reveal any evidence that the resident was offered or educated on the influenza and pneumococcal vaccines. This was confirmed during an interview with the Registered Nurse Infection Preventionist and a Regional Registered Nurse. The facility's policies, revised in August 2020, stated that all residents should be offered these vaccines and provided with educational information, but this was not adhered to in the case of this resident.
Emotional Abuse Incident Due to Social Media Post
Penalty
Summary
The facility failed to prevent an incident of staff-to-resident emotional abuse when a State Tested Nurse Aide (STNA) posted a video on social media showing a resident with their brief around their ankles. The video, which was captioned inappropriately, was posted without the resident's consent. The resident involved had severe intellectual disabilities, seizures, schizophrenia, and dementia, and was noted to have severely impaired cognition with various behavioral symptoms. The incident was discovered when the Director of Nursing (DON) was notified of the video, which had been posted a few days prior. The STNA involved admitted to posting the video on TikTok, claiming it was meant to showcase her work life and not to cause harm. The video was deleted after the facility became aware of it, and the STNA was suspended pending investigation. The facility's investigation revealed that the resident had no awareness of the incident due to their cognitive condition and showed no signs of distress or harm. The facility's policies on abuse and social media were reviewed, and it was found that the STNA did not adhere to these policies. The facility's personnel records indicated that the STNA was terminated following the incident. Interviews with staff and residents revealed no additional violations of the social media policy. The facility's abuse policy was found to be adequate, and the incident was reported to the state agency as required. The facility took immediate steps to address the situation, including notifying the resident's legal guardian and conducting staff education on relevant policies.
Improper Garbage Disposal and Pest Control
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which could potentially affect all 144 residents. During an observation, it was noted that three outside dumpsters near the kitchen doors were not covered with lids, and a sour smell was present. Additionally, wet boxes and debris were piled around the dumpsters. The Maintenance Director confirmed these findings and mentioned the difficulty in cleaning the area behind the dumpsters and the absence of lids to cover the trash. An exterminator emphasized the importance of garbage containment and sanitation to prevent and control pests. The facility's pest control policy required routine pest control measures and maintenance of the garbage storage area to prevent pest harborage, including keeping dumpster lids shut and secure.
Failure to Notify Practitioner of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of abnormal laboratory results for a resident, which was identified as a deficiency. The resident, who had a history of intracranial hemorrhage, hyperparathyroidism, cocaine abuse, hypertension, chronic kidney disease stage four, and hemiplegia, was admitted to the facility. A physician ordered a complete blood count with differential, a comprehensive metabolic panel, and magnesium to be drawn, with specific instructions to monitor for chronic kidney disease. The lab results showed elevated levels of blood urea nitrogen and creatinine, indicating a potential change in the resident's condition. Despite the abnormal lab results, there was no documentation that the ordering physician or nurse practitioner was notified. A progress note indicated that the resident's family was informed about the lab results, but it did not mention any communication with the healthcare provider. The nurse practitioner, during a follow-up assessment, noted the absence of recent labs to review, which suggests a lack of communication regarding the abnormal findings. An interview with the LPN revealed that the labs were faxed to the nurse practitioner, but the fax did not reach the intended recipient, and there was no documentation to confirm that the nurse practitioner received or reviewed the labs. The Director of Nursing confirmed that it was the responsibility of the nurse supervisor to ensure the practitioner was notified of lab results at the end of each shift. An audit revealed that the nurse supervisor failed to notify the nurse practitioner about the high blood urea nitrogen level from the lab draw, which was a significant oversight in the resident's care management.
Removal Plan
- The facility identified that the lab work completed for Resident #113 was not reported to the Nurse Practitioner.
- The NP evaluated Resident #113 and ordered a STAT lab to be obtained and a STAT dose of Lokelma was administered and IV fluid was ordered after review of STAT labs.
- The Director of Nursing completed audits of all current resident's medical records for validation of laboratory testing and results reported to the practitioner from the past thirty days. All labs were found to have been reported to the practitioner.
- The DON educated all nursing staff in person or by phone related to immediate reporting of resident change in condition pertaining to laboratory results and timely follow up for physician orders. All education was completed.
- The specified nurse was placed on a Performance Improvement Plan regarding follow through with reporting of labs.
- The facility conducted an Ad-Hoc Quality Assurance and Performance Improvement Action Plan to review during the meeting. The Medical Director was in attendance by phone.
- The facility implemented a plan for twice a week audits of laboratory testing documentation and reporting results to the physician. The audits will continue for four weeks then monthly times two months. Results of the audits would be submitted to the QAPI Committee for further review and recommendation.
Incident of Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
The deficiency reported in the survey pertains to an incident of physical abuse involving Resident #1 and Resident #2 at the facility. Resident #1 was found on the floor with injuries including abrasions, swelling, bleeding on the brain, and a fractured sacrum, following an assault by Resident #2. Resident #1 had a history of seizures, depression, and post-traumatic stress disorder, while Resident #2 had diagnoses of paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior. Resident #2 had a documented history of aggressive behaviors, including incidents of physical altercations with other residents in the facility. The report highlighted that Resident #2's care plan focused on managing mood problems related to paranoid schizophrenia but lacked specific interventions to address his violent and aggressive behaviors. Resident #2 had been involved in multiple incidents of physical altercations with other residents in various nursing facilities, indicating a pattern of behavior. The facility's psychiatrist noted Resident #2's ongoing behaviors and the challenges in reducing his psychiatric medications due to the risk of relapse if lowered. The deficiency was exacerbated by the lack of individualized interventions to prevent Resident #2 from physically abusing other residents, including Resident #1. The investigation revealed that Resident #1 reported being assaulted by Resident #2, leading to serious injuries requiring hospitalization. Law enforcement confirmed the incident as a case of felonious assault, with charges being pursued against Resident #2. The facility's failure to develop specific interventions to address Resident #2's violent tendencies and protect other residents, such as Resident #1, contributed to the deficiency. The lack of tailored interventions and oversight to prevent resident-to-resident abuse, particularly in cases involving residents with a history of violent behaviors, underscored the critical need for enhanced monitoring and individualized care planning to ensure resident safety and well-being.
Failure to Provide Adequate Behavioral Health Services
Penalty
Summary
The facility failed to ensure adequate behavioral health services and person-centered care planning for a resident with a history of mental disorders and violent behaviors. Resident #2, who was admitted with diagnoses including paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior, had a history of physically assaulting other residents and staff. Despite this history, the facility did not have specific care plan interventions to address Resident #2's violent behaviors, which resulted in multiple incidents of aggression towards other residents, including physical altercations and assaults causing injuries. The medical record review revealed that Resident #2 had been involved in 16 separate incidents resulting in facility self-reported incidents (SRIs) across four different nursing facilities since 2014. Notable incidents in the current facility included Resident #2 placing another resident in a chokehold and punching a roommate for no reason. Despite these behaviors, the care plan for Resident #2 lacked specific interventions to manage his violent tendencies, focusing instead on general mood management and medication administration. Interviews with the facility's Administrator, Director of Nursing (DON), and various staff members confirmed that there were no specific behavioral health interventions in place for Resident #2. The facility's assessment and policy on behavior management did not adequately address the individualized needs of residents with violent behaviors, leading to repeated incidents of aggression and harm to other residents. This deficiency represents non-compliance with the requirement to provide necessary behavioral health care and services to residents.
Failure to Conduct Yearly Performance Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) were given yearly performance evaluations as required. This deficiency was identified during a review of personnel files and staff interviews. Specifically, two STNAs, who had been employed for more than one year, did not have documented yearly performance evaluations in their personnel records. The Human Resources Director confirmed that no yearly performance reviews were completed for these STNAs. This deficiency had the potential to affect all 143 residents residing in the facility.
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We read the 1,152 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 Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Judson Park | 0 mi | ★★★★★ | 0 | 0 |
| Cedarwood Plaza | 0.8 mi | ★★★★★ | 8 | 0 |
| The Gardens Of Fairfax Health Care Center | 0.9 mi | ★★★★★ | 14 | 0 |
| Crawford Manor Healthcare Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Singleton Health Care Center | 1.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.