Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Welcome Nursing Home during CMS and state inspections, most recent first.
An unlabeled opened Tubersol PPD multi-use vial was found in the med storage room, despite guidance that it be dated when first opened and discarded 30 days after initial entry. In a separate finding, a resident with dementia, DM2, psychosis, seizures, and depression had a cup of multiple meds left at bedside even though an RN confirmed the resident was supposed to be directly observed taking them; the facility policy required direct observation of medication administration.
Surveyors found a partially used tube of 3M Fire Barrier Sealant Caulk in a caulk gun left on a handrail in a common hallway where cognitively impaired, independently mobile residents frequently walked. The product label warned of potential eye, nose, and throat irritation, advised against swallowing, and directed that it be kept out of children’s reach. An LPN confirmed the caulk was unsecured and accessible to residents, and the Maintenance Supervisor verified the same observation and label warnings. This storage practice conflicted with the facility’s policy requiring all chemicals not in use to be kept in a locked location to maintain an environment as free of accident hazards as possible.
Two residents with multiple chronic conditions and intact cognition were found living in rooms where windows were covered with plastic, and in one case secured with duct tape to keep the upper sash from sliding down. Both residents required extensive assistance with ADLs. One resident reported being bothered by the plastic over the window, while the other reported a strong cigarette odor in the room, stating that smoke from outside was entering through the plastic- and tape-covered window. Staff confirmed the use of plastic and duct tape on the windows. These conditions did not align with the facility’s policy that window coverings should support comfort and individual preference and that rooms be kept odor-free.
The facility failed to protect residents from abuse and to conduct a thorough investigation following an incident. In one case, a cognitively intact resident dependent on staff for most ADLs reported that a confused male resident with dementia entered her room, refused to leave, lifted her shirt, grabbed her arm, and slapped her forehead; the facility did not interview or assess other similar residents to determine if they had experienced or feared abuse. In another case, a resident with Alzheimer’s disease, severely impaired cognition, and known aggressive behaviors during care was in the bathroom yelling and combative when a CNA responded by pushing her head back, aggressively grabbing her arms, and grabbing her chin while yelling at her to stop, despite a facility policy prohibiting abuse.
A resident with dementia, neuromuscular bladder dysfunction, and a Foley catheter, who was fully dependent on staff for ADLs and incontinent care, was not checked or changed in accordance with the care plan and facility policy. On two separate mornings, surveyors observed the resident in bed with a strong stool odor. A CNA acknowledged the resident had not been checked for several hours despite a stated expectation of checks every two to three hours and indicated she would delay changing the resident until after breakfast. The facility’s incontinence care policy required proper care to prevent skin breakdown, infection, and to promote dignity, but this was not followed.
Advance directive documentation was missing or incomplete for three residents. Two residents had DNRCC-A status documented in the chart and on physician orders, but their advance directive forms were not signed by a physician, and one resident had DNRCC-A status documented but no advance directive was present in the medical record. An LPN verified the missing and incomplete documentation.
A resident with osteomyelitis and a PICC line had an ordered IV Meropenem dose that was not given when an LPN found the PICC lumen occluded and unable to flush, with no blood return. The eMAR showed the dose as not administered, but there was no progress note documenting the occlusion, the missed dose, or physician notification, and the DON confirmed the physician should have been notified immediately.
Failure to timely report an allegation of abuse involving a resident with severely impaired cognition. During bathroom care, the resident became combative and an aide aggressively grabbed the resident's arms, chin, and head while yelling at her. Another CNA reported the incident, but the facility did not report the allegation to the state agency within the required timeframe; the Administrator and DON verified the delay.
Incomplete Investigations of Abuse and Injury Allegations: The facility failed to fully investigate allegations of abuse and an injury of unknown origin involving multiple residents. One resident with severe cognitive impairment was involved in a bathroom altercation with CNAs, but the investigation did not include other resident interviews or skin sweeps for cognitively impaired residents. A former resident was assaulted by another resident, yet no like-resident interviews or assessments were completed. Another resident with advanced dementia developed bruising and a fractured ulna, but the investigation did not include resident interviews or like-resident assessments as required by policy.
Incomplete Care Plan for a Resident at Risk for Fractures A resident with osteoarthritis, protein malnutrition, scoliosis, and kyphosis had intact cognition and was dependent on staff for all ADLs except eating. The care plan lacked documentation for osteoarthritis and fragility of bones, and the DON could not provide documentation that it included caution with repositioning related to osteoarthritis and osteopenia. After two staff members pulled the resident up in bed, the resident reported right leg pain and felt a pop; imaging showed a right hip fracture.
Lack of Hand Hygiene Supplies for a Resident Using a BSC: A resident who required assistance with hygiene and toileting had a BSC in the room but no sink, soap, running water, or ABHS available for hand hygiene after toileting. The resident stated staff did not offer hand hygiene when assisting back to bed, and the DON verified the room lacked hand hygiene supplies.
A resident with quadriplegia, dementia, and contractures did not have ordered lamb's wool hand rolls or rolled washcloths in place to protect skin integrity. Staff observed both hands tightly contracted without the ordered protection while the resident was in a chair and later in bed, and the DON confirmed the ordered interventions were not in place.
Oxygen was not administered per physician order for two residents. One resident with Alzheimer's disease and another resident with COPD, CHF, and other chronic conditions both had orders for oxygen at 2 lpm via NC as needed for SOB or to keep SpO2 above 92%, but observation showed each concentrator running at 3 lpm, which an LPN verified. One resident's care plan did not include oxygen therapies and interventions, despite the resident requiring oxygen therapy.
A resident with multiple complex diagnoses, including osteomyelitis, CHF, diabetes, and a pressure ulcer, did not receive several ordered meds and treatments as scheduled. The record showed missed CHF monitoring, PICC flushes and dressing care, IV Meropenem doses, Nystatin Powder applications, wound dressing treatments, and stump care, with no progress note documentation of the missed care; the DON verified the orders were not consistently followed.
Enhanced Barrier Precautions were not followed for a resident with an indwelling medical device, dementia, and incontinence care needs. Although an EBP sign was posted and the care plan required gowns and gloves for high-contact care, two CNAs provided incontinence care without gowns. A CNA confirmed the resident was on EBP precautions and that gowns were not worn.
Two residents in an LTC facility reported missing money, prompting an investigation that revealed an STNA was responsible for the misappropriation. Both residents were cognitively intact and required assistance with ADLs. A camera captured the STNA searching for money in a resident's room, leading to her confession and termination.
Unlabeled Multi-Use Vial and Unattended Resident Medications
Penalty
Summary
The facility failed to ensure safe medication handling and proper labeling of a multi-use vial. During observation of the medication storage room behind the east nursing station, a 1 mL vial of Tubersol PPD, lot number 4CA12C1 with a manufacturer expiration date of 02/2028, was found opened and not labeled with the date it was first used. An LPN verified that the vial had been opened and was not labeled with the first-use date. The pharmacy refrigerated medication list stated Tubersol PPD must be stored in the refrigerator and discarded 30 days after first use, and the manufacturer insert stated opened vials must be discarded 30 days after initial entry and not used beyond the expiration date or 30 days after opening. The facility also failed to ensure medications were not left unattended for one resident. Resident #71 had diagnoses including dementia, diabetes mellitus type II, peripheral vascular disease, psychosis, seizures, and depression, and the quarterly MDS noted intact cognition and independence with eating. The resident’s care plan addressed behavior problems related to bipolar disorder and dysphagia. During observation, the resident was lying in bed awake with a medication cup on the bedside table containing multiple pills, including aspirin, Colace, Claritin, Depakote, vitamin D, omeprazole, Prozac, gabapentin, Vesicare, and Tylenol. An RN verified the medications were left at bedside and stated the resident was supposed to be observed taking medications and that they should not have been left there. The employee disciplinary form identified an LPN as being disciplined for leaving medications unsupervised, and the facility policy stated medications are to be administered with direct observation of the resident taking them.
Unsecured Chemical Caulk Left Accessible in Common Hallway
Penalty
Summary
Surveyors identified a deficiency related to accident hazards when a partially used 10.1-ounce tube of 3M Fire Barrier Sealant Caulk, loaded in a caulk gun, was observed sitting on a handrail in the common area of hall 200. The caulk was within reach in an area where residents frequently mobilize. The product label stated that it may irritate eyes, nose, and throat, advised avoiding eye contact and ingestion, instructed users to wash thoroughly after handling, and directed that it be kept out of reach of children. The facility had previously identified 14 residents as cognitively impaired and independently mobile, and these residents used the area where the caulk was left accessible. An LPN confirmed that the caulk tube was unsecured on the handrail in the 200 hall, verified the warnings on the product label, and acknowledged that cognitively impaired, independently mobile residents could access it. The Maintenance Supervisor also verified that the same tube of caulk had been observed on the handrail and confirmed that the product warning label indicated the chemical may cause irritation or harm if handled or ingested. Review of the facility’s Chemical/Biological Storage policy, dated 08/11/09, showed that all chemicals/biologicals not in use must be stored in a locked location and that the facility will provide residents with an environment as free of accident hazards as possible. The unsecured storage of the caulk was inconsistent with this policy.
Failure to Maintain Homelike, Odor-Free Rooms with Appropriate Window Coverings
Penalty
Summary
The deficiency involves the facility’s failure to ensure a homelike environment for two residents whose room windows were covered in plastic, contrary to the facility’s Homelike Environment Policy. One resident, admitted with multiple conditions including bilateral knee osteoarthritis, generalized muscle weakness, gait abnormalities, cognitive communication deficit, pneumonia, hypertension, and CKD3, had a BIMS score of 15 indicating intact cognition and required assistance or was dependent for most ADLs. During observation, surveyors noted plastic covering the window in this resident’s room. The resident stated they did not like the plastic over the window and found it bothersome. The Director confirmed the presence of plastic covering the window. The second resident, also cognitively intact with a BIMS score of 15 and dependent for most ADLs, had diagnoses including chronic osteomyelitis of the ankle and foot, a pressure ulcer of the left heel, type II diabetes mellitus, CHF, atrial fibrillation, PVD, COPD, obesity, and generalized muscle weakness. Observation of this resident’s room revealed plastic on the window and duct tape across the plastic, with the resident explaining the duct tape was used to keep the upper window from sliding down. A CNA confirmed that the window was covered with plastic and held closed with duct tape. A subsequent observation identified a strong cigarette odor in the room, which the resident verified and attributed to smoke from outside coming through the plastic and taped window. The facility’s policy states that window coverings should support comfort and individual preference and that rooms will be kept odor-free, which was not met in these instances.
Failure to Prevent and Thoroughly Investigate Abuse Incidents
Penalty
Summary
The facility failed to protect residents from abuse and to thoroughly investigate an allegation of resident-to-resident abuse. A former resident with intact cognition, dependent on staff for most ADLs, reported that a confused male resident with dementia entered her room, refused to leave when asked, lifted her shirt, grabbed her arm, and slapped her on the forehead. A CNA heard the resident yelling "get out," found the male resident standing over her, removed him from the room, and then returned to check on the former resident, who described the unwanted contact. The Administrator and Charge Nurse later interviewed the former resident, who stated she was unsure what the male resident was doing and was fearful at the time of the incident. Although the incident was reported and the former resident was assessed with no apparent injury, the investigation did not include interviews or assessments of other similarly situated residents to determine whether they had experienced or were fearful of abuse. The facility also failed to protect another resident from staff-to-resident abuse during personal care. This resident had Alzheimer’s disease, severely impaired cognition with a BIMS score of 03, and required dependence or substantial/maximal assistance for bathing and toilet hygiene. Her care plan identified behavior problems and physical aggression during care, with interventions to anticipate and meet her needs and provide positive interaction. During an episode of bathroom assistance, the resident began yelling and became combative, prompting a second CNA to enter and assist. According to the self-reported incident and witness statement, when the resident attempted to bite the assisting CNA, that CNA responded by pushing the resident’s head back while yelling at her to stop, aggressively grabbing her arms, and then grabbing her chin and yelling into her face to stop. The witness CNA reported that the assisting CNA later remarked that adrenaline made her want to do something before leaving the room. These actions occurred despite a facility policy stating that abuse, defined as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, would not be tolerated.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to a resident who was always incontinent of bowel and had a Foley catheter in place. The resident had diagnoses including unspecified dementia with psychotic disturbance, neuromuscular dysfunction of the bladder, and pneumonitis due to inhalation of food and vomit, and was documented as having impaired cognition and being dependent on staff for ADLs and incontinence care. The care plan directed staff to monitor and document for signs and symptoms of UTI, provide staff intervention for incontinent episodes, and reposition the resident every two hours and as needed due to risk for skin breakdown. On one observed date at 9:59 A.M., the resident was found lying in bed with a strong odor of stool. At 10:30 A.M., a CNA reported that the resident had not been checked since 6:00 A.M., acknowledged that the resident should have been checked every two to three hours, and confirmed the resident had an odor of stool. On another observed date at 8:42 A.M., the resident was again observed lying in bed with a strong odor of stool, and the same CNA confirmed the odor and stated she would change the resident after feeding her breakfast. The facility’s incontinence care policy required proper incontinence care for all incontinent residents to help prevent skin breakdown, the spread of infection, and to promote dignity, but the observed care did not align with these expectations.
Advance Directive Documentation Missing or Incomplete
Penalty
Summary
The facility failed to ensure that advance directives were present in the medical record for one resident and failed to ensure that the advance directive forms for two other residents were signed by a physician. Resident #28 had diagnoses including unspecified dementia, unspecified atrial fibrillation, and sleep apnea, and the quarterly MDS showed impaired cognition. The care plan and physician order documented a DNRCC-A status, but the advance directive form in the record was not signed and completed by a physician. Resident #97 had diagnoses including chronic kidney disease, atrial fibrillation, and intestinal obstruction, and the entry MDS showed the resident was cognitively intact but dependent on staff for toileting and ADLs. The care plan and physician order documented DNRCC-A status, but the advance directive form was not signed and completed by a physician. Resident #80 had diagnoses including acute respiratory failure with hypoxia, essential hypertension, and chronic kidney disease, and the quarterly MDS showed moderately impaired cognition with dependence for ADLs and supervision for toileting. The care plan and physician order documented DNRCC-A status, but the resident did not have an advance directive in the medical record. An LPN verified that Residents #28 and #97's advance directives were not signed by a physician and that Resident #80 did not have an advance directive present in the medical record or paper chart.
Failure to Notify Physician When PICC Line Occlusion Prevented IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure physician notification when Resident #66 experienced a significant change in condition involving an occluded lumen of a PICC line that prevented administration of a physician-ordered IV antibiotic. Resident #66 was admitted with diagnoses including chronic osteomyelitis of the ankle and foot, a pressure ulcer of the left heel, type 2 diabetes mellitus, congestive heart failure, atrial fibrillation, peripheral vascular disease, COPD, obesity, generalized muscle weakness, and wheelchair dependence. The resident’s most recent quarterly MDS showed a BIMS score of 15 and dependence for all functional abilities except eating assistance. A physician order dated 12/11/25 directed Meropenem 1 gram IV three times daily for osteomyelitis. During observation, a one-gram bag of Meropenem was hanging in the resident’s room but had not been administered, and the PICC-line dressing was loose and partially detached. The LPN attempted to flush the purple lumen of the PICC line and was unable to flush it, with no blood return. The eMAR showed the 6:00 A.M. Meropenem dose was not administered and was documented as Other/See Progress Notes, but the progress notes contained no documentation of the occluded PICC lumen, the inability to administer the medication, or physician notification. The RN and DON both confirmed there were no progress notes documenting the occlusion, the missed dose, or physician notification, and the DON stated the physician should have been notified immediately when the PICC lumen was found to be occluded and the antibiotic could not be administered.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse to the state agency involving one resident with severely impaired cognition. Resident #41 had diagnoses including Alzheimer's disease, cognitive communication deficit, major depressive disorder, and hyperlipidemia, and was dependent for showers/bathing and required substantial to maximal assistance for toilet hygiene. The resident's care plan noted a behavior problem and that she could become physically aggressive during care. On 11/04/25, while being assisted in the bathroom by CNA #304, the resident was yelling and CNA #426 entered to help. The resident became combative, attempted to bite CNA #426, and CNA #426 pushed the resident's head back, aggressively grabbed her arms, grabbed her chin, and yelled into her face to stop. CNA #304 reported the incident at approximately 7:45 P.M. on 11/04/25. The facility's self-reported incident stated the allegation of abuse was submitted to the state agency on 11/05/25 at 2:34 P.M., after staff interviewed multiple employees regarding the situation. The Administrator and DON verified that the facility failed to report the allegation to the state agency in a timely manner. The facility policy stated that if abuse is alleged, it should be reported to the Ohio Department of Health immediately, but not later than two hours after the allegation is made.
Incomplete Investigations of Abuse and Injury Allegations
Penalty
Summary
The facility failed to ensure thorough investigations were completed for allegations of abuse and injuries of unknown origin involving three residents. The report states that the facility did not complete all required investigative steps to determine the cause of the incidents and whether abuse, neglect, or mistreatment occurred. The deficiency was identified through record review, staff interviews, review of self-reported incidents (SRIs), and review of the facility policy on abuse, neglect, exploitation, and misappropriation of resident property. For one resident with Alzheimer's disease, severely impaired cognition, and dependence for bathing and toilet hygiene, an SRI described a bathroom incident in which two CNAs were involved in a physical altercation with the resident during care. One CNA reportedly pushed the resident's head back, aggressively grabbed her arms, and grabbed her chin while yelling at her. The investigation did not include interviews of other residents, and no skin sweeps were completed for cognitively impaired residents related to the abuse allegation. The facility also did not complete nursing assessments on the day of the incident, and a later skin assessment identified a right lower leg skin tear. For a former resident with intact cognition who was dependent for most ADLs, an SRI described a confused male resident entering the room, lifting the resident's shirt, grabbing her arm, and slapping her forehead. Although staff statements and an interview with the resident were obtained, the investigation did not include interviews or assessments of like residents to determine whether others had experienced abuse or feared abuse. For another resident with advanced dementia, dependence for all ADLs, and impaired cognition, the facility investigated bruising and a left ulna fracture but did not complete resident interviews or assessments of like residents for an injury of unknown origin. The facility policy required identifying suspicious bruising and other injuries, evaluating occurrences, patterns, and trends that may constitute abuse, and determining the direction of the investigation.
Incomplete Care Plan for Resident at Risk for Fractures
Penalty
Summary
The facility failed to have a complete care plan developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals for Former Resident #100, who was identified at risk for fractures. Review of the resident’s record showed an admission date of 03/20/21 and a discharge date of 09/04/25, with diagnoses including osteoarthritis, protein malnutrition, scoliosis, and kyphosis. The resident’s quarterly MDS assessment showed intact cognition and dependence on staff for all ADLs except eating. The most recent care plan was absent documentation regarding osteoarthritis and fragility of bones. An intradisciplinary team note dated 9/11/25 documented that on 09/03/25 the resident complained of right leg pain after two staff members pulled her up in bed and she felt a pop; radiological examination revealed a right hip fracture. The DON stated on 03/05/25 at 12:10 P.M. that she was unable to provide documentation that the care plan included caution with repositioning related to osteoarthritis and osteopenia. The facility policy stated that care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment.
Lack of Hand Hygiene Supplies for Resident Using Bedside Commode
Penalty
Summary
The facility failed to ensure access to hand hygiene supplies for a resident using a bedside commode. Resident #64 was admitted with diagnoses including bilateral osteoarthritis of the knees, weakness, generalized muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, pneumonia, hypertension, bilateral knee pain, shortness of breath, hyperlipidemia, hypothyroidism, history of thyroid cancer, lymphedema, neuralgia and neuritis, alcohol dependence, and stage 3 chronic kidney disease. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and that the resident required assistance or was dependent for multiple ADLs including hygiene and toileting. Observation of the resident’s room revealed a bedside commode with no sink, soap, running water, or alcohol-based hand sanitizer available for hand hygiene. During interview, the resident stated concern that after using the bedside commode there was no access to soap, running water, or ABHS in the room and verified that staff did not offer hand hygiene when assisting the resident back to bed after toileting. The DON verified there was no sink with soap and running water or ABHS available in the room. The facility policy stated hand hygiene is the single most important means of preventing the spread of infection and that handwashing with soap and water is required when hands are visibly soiled.
Failure to Provide Ordered Hand Protection for Contractured Hands
Penalty
Summary
The facility failed to ensure a resident had skin breakdown protection in place as ordered. Resident #72 was admitted with diagnoses including quadriplegia, neurocognitive disorder, and dementia, and the quarterly MDS indicated low cognitive function. The care plan identified the resident as at risk for skin breakdown and impaired functional range of motion related to decreased mobility, weakness, pain, and contractures, with interventions to keep lamb's wool hand rolls in both hands and to keep washcloths in both hands to protect the skin. A physician order dated 08/27/25 directed staff to ensure lamb's wool hand rolls were in both hands. Observations showed the resident sitting in a geriatric chair with both hands contracted and tightly folded, with neither lamb's wool hand rolls nor rolled washcloths in place. A later observation showed the resident lying in bed with both hands still tightly contracted and again without the ordered hand rolls or rolled washcloths. The DON verified that the resident failed to have the physician-ordered interventions in place to protect the contracted hands. The facility policy stated that residents are to be provided the appropriate splint/appliance to protect skin integrity and that the splint is to be worn per physician order and documented in the medical record.
Oxygen Not Administered Per Physician Order
Penalty
Summary
The facility failed to ensure oxygen was administered per physician order for two residents receiving oxygen therapy. Resident #86 had diagnoses including Alzheimer's disease with early onset, type 2 diabetes mellitus, muscle weakness, and hypertensive chronic kidney disease, and the quarterly MDS indicated moderately impaired cognition and the need for oxygen therapy. The physician ordered oxygen at 2 lpm via nasal cannula as needed for shortness of breath or to keep pulse oximetry above 92%, but the care plan did not include oxygen therapies and interventions. During interview, Resident #86 stated he wore oxygen all the time because he felt he needed it, and observation showed the oxygen concentrator running at 3 lpm; the LPN verified the setting. Resident #17 had diagnoses including COPD, CHF, chronic atrial fibrillation, chronic bronchitis, type 2 diabetes mellitus, and dependence on supplemental oxygen. The quarterly MDS showed intact cognition with a BIMS score of 14, and the care plan identified risk for respiratory distress with interventions to administer oxygen and monitor pulse oximetry per physician orders. The physician ordered oxygen at 2 lpm via nasal cannula as needed for shortness of breath or to keep pulse oximetry above 92%, but observation showed the oxygen concentrator running at 3 lpm, which the LPN also verified. The facility policy stated oxygen would be used according to physician orders and monitored by nursing.
Missed Medications and Treatments for a Resident with Multiple Orders
Penalty
Summary
The facility failed to ensure medications and treatments were administered as ordered for one resident reviewed for medication and treatment administration. The resident was admitted with diagnoses including chronic osteomyelitis of the ankle and foot, a pressure ulcer of the left heel, type II diabetes mellitus, CHF, atrial fibrillation, PVD, COPD, obesity, generalized muscle weakness, and dependence on a wheelchair. The resident’s most recent quarterly MDS indicated a BIMS score of 15 and that the resident required assistance with eating and was dependent for all other functional abilities, including hygiene, bathing, dressing, rolling, turning, repositioning, transferring, and wheelchair propulsion. Review of the record showed multiple missed or incomplete ordered interventions. The CHF protocol requiring monitoring of lung sounds, edema, and weight changes was not followed on two dates. The PICC line was not flushed as ordered on two dates, Meropenem IV doses were missed on three occasions, Nystatin Powder treatments were not completed on numerous bedtime entries in January and February 2026, Triad Hydrophilic Wound Dressing was not completed on multiple evening and night shifts across January and February 2026, PICC dressing and cap changes were missed on two dates, and the right stump wash with stump shrinker application was not completed on four scheduled times. The progress notes contained no documentation of missed medications or treatments, and the DON verified that the physician orders were not consistently followed and that the resident did not receive multiple scheduled medications and treatments as ordered.
Enhanced Barrier Precautions Not Followed During Incontinence Care
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when Enhanced Barrier Precautions were not followed for Resident #11. Resident #11 was admitted with diagnoses including unspecified dementia with psychotic disturbance, neuromuscular dysfunction of the bladder, and pneumonitis due to inhalation of food and vomit. The quarterly MDS showed impaired cognition, dependence on staff for ADLs, and incontinence care. The care plan required Enhanced Barrier Precautions related to an indwelling medical device, including a yellow sign on the door frame and staff wearing gowns and gloves during high-contact care activities. Observation of the resident’s room showed an EBP sign posted, but during incontinence care two CNAs provided care without gowns. One CNA later confirmed that Resident #11 was on EBP precautions and that the CNAs were not wearing gowns. The facility policy stated EBP should be used for residents with chronic wounds or indwelling medical devices and during changing briefs or assisting with toileting.
Misappropriation of Resident Funds by STNA
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money, resulting in an incident of misappropriation affecting two residents. Resident #1, who was cognitively intact and required extensive assistance for activities of daily living, reported missing money from her cell phone/wallet. The incident occurred after 10:00 A.M. on 10/23/24, and the resident discovered the money was gone by 2:30 P.M. on 10/24/24. An investigation was initiated immediately, involving staff and resident interviews, and a camera was placed in Resident #1's room. During this process, Resident #2 also reported missing money, stating that he had $200.00 in his possession, which was reduced to $2.00 after he left his room for a period. The facility's investigation revealed that STNA #100 was involved in the misappropriation of funds from both residents. A camera placed in Resident #2's room recorded STNA #100 rummaging through the resident's belongings and searching for money. Upon questioning, STNA #100 initially denied involvement but later confessed to taking money from both residents. The facility confirmed the misappropriation through interviews and a review of the evidence, leading to the termination of STNA #100's employment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oberlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kendal At Oberlin | 1.5 mi | ★★★★★ | 3 | 0 |
| Keystone Pointe Health And Rehabilitation | 6.6 mi | ★★★★★ | 0 | 0 |
| Wesleyan Village | 7.8 mi | ★★★★★ | 0 | 0 |
| Elms Retirement Village Inc | 7.8 mi | ★★★★★ | 0 | 0 |
| Amherst Manor Nursing Home | 8.3 mi | ★★★★★ | 0 | 0 |
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