Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westmoreland Place during CMS and state inspections, most recent first.
RN coverage was not maintained for eight consecutive hours on four days within the review period. Staffing records showed no RN scheduled for either the day or night shift on those dates, and the DON confirmed the missing RN coverage during interview. Although staffing agencies were used for open shifts, they were not used for the affected dates, and the issue had the potential to affect all 84 residents.
Improper food storage and kitchen sanitation were observed when the Dietary Manager found dirty floors throughout the kitchen, an opened and undated half box of cookies and an opened and undated bag of chicken in the freezer, and 13 rotten cucumbers uncovered in the refrigerator. The DM confirmed these conditions, and the facility policy required foods to be covered, labeled, and dated.
Kitchen Infestation With Flies: The facility failed to keep the kitchen free from flies. The DM reported many flies throughout the storage and prep areas, the Dietician observed multiple flies on a prep table during tray prep and described the issue as an infestation, and a staff member swatted away a fly while preparing a tray. The MD stated the opening around the window A/C unit was not known and flies were getting in.
Missing CNA Annual and Dementia Care Training: The facility failed to document required annual training for three CNAs and failed to document training in the care of cognitively impaired residents for three other CNAs. Staff record review showed the affected CNAs had no evidence of the required training, and the Administrator verified the missing documentation during interview.
Resident council minutes showed repeated unresolved concerns about housekeeping, snacks, food quality, staff being on phones, rude staff behavior, vaping in the building, delayed or inaccurate med administration, and poor communication. Residents said they kept raising the same issues and felt brushed off, while the Admin and Activity Director confirmed there was no clear follow-up documentation, audits, or other evidence that concerns were being tracked and resolved.
Homelike Environment Not Maintained: Multiple residents had window AC units secured with duct tape and boards, with unsealed areas visible to the outside, and staff acknowledged this was not homelike. Another resident with severe cognitive impairment and multiple diagnoses had a large area of chipped paint beside the bed, which the resident said looked nasty and bothered her.
Missed Quarterly Care Conferences: A resident with intact cognition and diagnoses including fibromyalgia, chronic respiratory failure, and atherosclerotic heart disease did not have required quarterly care conferences completed, and the same issue affected 32 other residents. The resident’s prior care conferences were held without the resident present, and the LSW confirmed no conference had occurred since the last one because the facility had a temporary gap in social services staffing.
Loose unidentified pills and expired meds were found in multiple med carts, including expired Iron and Guaifenesin, and staff could not identify the loose tablets/capsules. An LPN and RN confirmed the findings, and the DON stated carts were expected to be checked daily. Surveyors also found Bacitracin Zinc ointment and Nystatin powder unsecured on a resident’s nightstand even though the resident had dementia and other neurologic/psychiatric diagnoses and no orders for either medication.
Incomplete DNR Order Form: A resident with intact cognition and diagnoses including fibromyalgia, chronic respiratory failure, and atherosclerotic heart disease had an active DNRCCA order and care plan code status, but the DNR form was incomplete. The form lacked the physician signature date and did not have the DNRCC or DNRCCA box checked, and the Administrator confirmed the omission.
Failure to notify a resident representative after a fall. A resident with altered mental status, repeated falls, COPD, and dementia was found crouched toward the floor and assisted back to bed after showing agitation and confusion. Hospice was notified and safety measures were put in place, but the ADON and DON confirmed there was no notification or documentation that the resident representative was informed.
A resident with Alzheimer’s disease, disorientation, and unspecified dementia was found to have side rails used daily without provider orders or care plan interventions. The MDS coded bed rails and alarms as in use, CNAs confirmed daily side rail use, and the DON confirmed the side rails were not documented in the medical record.
Failure to report alleged resident-to-resident abuse: A resident with spinal stenosis, psychotic disorder with delusions, visual hallucinations, and AFib reported that her roommate tried to kill her and hit and kicked her in the ribs. The resident was checked and had no visible injuries, but the allegation was not investigated or reported to the state agency, and the Administrator confirmed the omission.
A resident with spinal stenosis, psychotic disorder with delusions, visual hallucinations, and paroxysmal atrial fibrillation was documented as short term with plans for discharge to AL, but discharge planning was not followed up after the care conference. The resident said they wanted to discharge and reported the SW was not assisting, and the Interim SSD stated there had been no updates or follow-up since the prior SW left the facility.
Failure to notify the SLTCO of resident discharges. Two residents were discharged, one to another SNF and one home with family, but the facility did not notify the Ombudsman as required. The Administrator confirmed the omission, and facility policy stated that discharge notification must be submitted with a copy of the discharge notice.
PASRR Not Updated for New Mental Health Diagnoses and Psychotropic Medications: The facility failed to ensure the State-designated authority was notified when two residents had newly identified mental health conditions. For one resident, the medical record showed anxiety, depression, and bipolar disorder, along with antidepressant orders, but the PASRR did not reflect the depression, bipolar disorder, or psychotropic medications. An LSW confirmed the PASRR was not accurately completed or updated to match the resident's condition.
A care plan was missing for wandering and exit-seeking behaviors for two residents with dementia-related impairments, despite documented elopement risk, repeated attempts to exit, and staff observations of active wandering. A separate resident had very long toenails and prior podiatry recommendations, but the care plan only addressed fingernail care and did not include toenail or podiatry needs.
A resident with dysphagia and dementia did not receive ordered max-assist feeding; instead, the breakfast tray was left set up while the resident spilled food on the blanket and lap. Another resident with dementia and weakness had toenails extending more than a half inch past the nail bed, despite a NP recommendation for podiatry and facility staff acknowledging the nails were very long and that nail care responsibilities were unclear.
A resident receiving hospice services fell and injured the right elbow and hand, with staff documenting bruising, edema, a skin tear, and pain behaviors in a cognitively impaired resident with a BIMS of 00. The resident's daughter repeatedly asked for an X-ray and splinting, but communication between the facility and hospice was delayed, and the X-ray was not obtained until later, when it showed a fracture of the right fourth digit. Hospice later noted the facility had been educated on hospice and facility responsibilities.
A facility failed to properly assess and document safety needs when three residents with dementia and elopement risk were moved from a secured memory care unit to an unsecured area. Records and staff interviews showed ongoing wandering and exit-seeking behaviors, including attempts to leave through doors and an elevator, while the DON and other staff acknowledged there was no documented updated assessment or care plan information to support the move or show what interventions were in place.
Medication Error Rate Exceeded Allowed Threshold: The facility had a 6.67% medication error rate during observed med passes, with 2 errors in 30 opportunities. An RN allowed a resident with COPD and CHF to take 2 puffs of a fluticasone-salmeterol inhaler when the order was for 1 puff, and an LPN crushed a delayed-release omeprazole capsule and gave it with other meds in applesauce, despite the do-not-crush guidance.
An LPN crushed a delayed-release omeprazole capsule along with other ordered meds and gave the mixture in applesauce to a resident with intact cognition and diagnoses including DM2, respiratory failure, and CKD. The resident’s active order was for omeprazole delayed release, and the pharmacy do-not-crush guide listed omeprazole as a medication that should not be crushed.
Failure to provide routine dental services was identified for a resident with intact cognition and multiple chronic diagnoses, including fibromyalgia, chronic respiratory failure, OSA, and ASHD. The chart showed a PRN dentist consult order and a note that SW was informed the resident needed a dental appt, but there was no documentation that the appt was scheduled or completed, and no dental notes were found in the record.
Inaccurate documentation was found in a resident’s medical record involving two fall investigations. The resident had cognitive impairment and required supervision/touching assistance for mobility and transfers. The record showed impossible timelines, including neuro checks and MD notification times documented before the falls occurred. The DON and a visiting DON confirmed the fall investigations contained inaccurate charting, and facility policy required documentation to be objective, complete, and accurate.
The facility did not maintain the substitution log when chilled pears were replaced with pineapple and applesauce for lunch, as confirmed by kitchen staff interviews. The kitchen manager and dietician were unaware of the change, indicating a lapse in communication and documentation, potentially affecting all 94 residents.
The facility failed to maintain safe food storage and handling practices, with expired and undated items found in storage, and food served at unsafe temperatures. The Kitchen Manager lacked knowledge of proper procedures, including the use of the dishwasher and food temperature maintenance.
The facility failed to provide residents with access to their personal funds during evenings and weekends. A resident reported being unable to access funds on weekends, and nursing staff confirmed the unavailability of funds during these times. The facility's policy did not address fund access during these periods, and there was a discrepancy in the reported location of available funds.
The facility failed to maintain comfortable water temperatures, affecting 31 residents. Observations and interviews revealed that residents experienced cold water in their bathrooms, with temperatures significantly below the comfortable range. Staff confirmed that maintenance requests had been made, but the issue persisted for weeks to months. Despite weekly monitoring logs showing adequate temperatures, the problem continued, indicating a discrepancy between recorded data and actual conditions.
A resident with an indwelling urinary catheter was observed multiple times with the collection bag visible from the hallway, lacking a privacy cover, which compromised her dignity. Despite facility policy requiring catheter bags to be covered, this was not adhered to, as confirmed by an RN. The resident's care plan included catheter care and dignity maintenance, but these were not followed, leading to the deficiency.
A facility failed to notify a resident or their responsible party when the resident's account balance reached $200 less than the Medicaid resource limit. The resident's balance exceeded $1800.00 from early October through late January, but no notification was provided, potentially affecting Medicaid eligibility. The Business Office Manager confirmed the oversight.
A facility failed to notify a resident's physician of blood sugar levels outside the ordered parameters, affecting a resident with diabetes. Despite several instances of blood sugar readings below 70 and above 400, there was no documented evidence of physician notification, as confirmed by staff interviews. This oversight violated the facility's policy requiring prompt notification of changes in a resident's condition.
A resident with a complex medical history, including diabetes and chronic respiratory failure, experienced a breach of privacy during a dressing change. The RN did not close the door or draw curtains, and failed to follow proper hand hygiene protocols, violating the facility's dignity policy.
A facility failed to accurately assess a resident's dental health, missing the presence of missing and carious teeth. Despite the resident's complex medical history and need for assistance with personal hygiene, assessments inaccurately reflected her dental condition. Observations and interviews confirmed the inaccuracies, highlighting a deficiency in the assessment process.
The facility failed to ensure accurate assessments for three residents, affecting areas such as smoking compliance, dental status, and mental health diagnoses. A resident was inaccurately assessed as compliant with the smoking policy, another had unrecorded dental issues, and a third had an unrecorded active mental health diagnosis. These inaccuracies were confirmed by staff interviews and observations.
The facility failed to update PASARR assessments for three residents, omitting critical mental health diagnoses such as schizoaffective disorder and anxiety disorder. These inaccuracies were confirmed through staff interviews and record reviews, indicating a lapse in following Medicaid guidelines.
A facility failed to complete a PASARR within 30 days for a resident admitted with multiple diagnoses, including bipolar disorder and major depressive disorder. Despite a preadmission screen at the hospital, the required resident review PASARR was not conducted within the first 30 days, as confirmed by a Licensed Social Worker. The facility's policy, aligned with Ohio Department of Medicaid guidelines, was not followed.
The facility failed to develop comprehensive care plans for three residents, affecting their smoking habits, ADL, and dental care. One resident lacked a plan for dental issues and ADL needs, while two others were non-compliant with smoking policies, smoking in non-designated areas without supervision. Their care plans were not updated to address these issues until recently, leading to deficiencies in meeting their needs.
The facility failed to update care plans for three residents after incidents. Two residents with cognitive impairments were involved in an altercation, and a stop sign intervention was not consistently used. Another resident at risk of falls had a delayed care plan update for non-skid socks after a fall. Facility policies require timely updates, which were not followed.
The facility failed to provide meal assistance to a resident with severe cognitive impairment and physical limitations, leaving her without necessary support during a meal. Additionally, another resident requiring extensive assistance with personal hygiene was observed with long, jagged nails, contrary to the facility's nail care policy.
A facility failed to maintain proper hospice records for a resident receiving hospice services. The resident, with multiple diagnoses and cognitive impairment, had no hospice notes uploaded to their medical record. The hospice binder showed only three visit notes since admission to hospice. Interviews revealed concerns about the provision of hospice services, and the facility's policy required maintaining documentation of hospice communication, which was not followed.
The facility failed to ensure safe smoking practices for two residents and safe hot water temperatures for three residents. Observations revealed water temperatures significantly above the safe limit, confirmed by the Maintenance Director. One resident, a supervised smoker, repeatedly violated the smoking policy by smoking in non-designated areas and keeping cigarettes and a lighter unsupervised. Another resident, an independent smoker, also violated the smoking policy by smoking in non-designated areas and keeping smoking materials against facility rules. The facility did not complete a smoking safety assessment for this resident.
The facility failed to provide adequate hydration to residents, as evidenced by the lack of access to fresh ice water at bedside and failure to provide beverages with meals. A resident with multiple medical conditions reported only receiving fresh ice water upon request, and observations confirmed warm water in her pitcher. Another resident with severe cognitive impairment did not receive a requested beverage with her meal, and a third resident with no cognitive deficit but multiple health issues also lacked access to fresh ice water, with staff confirming water was only provided upon request.
A facility failed to monitor a resident's blood pressure before administering Hydralazine, a medication used to lower blood pressure. The resident, with a complex medical history including hypertension and dementia, had physician orders for Hydralazine to be taken three times daily and as needed for specific blood pressure levels. However, the facility did not monitor the resident's blood pressure prior to administering the medication, as confirmed by a corporate nurse.
The facility failed to obtain physician-ordered lab tests for two residents. One resident with multiple diagnoses did not have a CBC and BMP completed as ordered in August 2024. Another resident with a complex medical history did not have a Hemoglobin A1c test conducted as ordered, which was due in October 2024. These deficiencies were confirmed through interviews with facility staff.
A resident with a complex medical history, including dementia and cerebral infarction, did not receive necessary dental services despite having missing and carious teeth. The facility's policy to assist residents in obtaining dental care was not followed, and the resident had not been seen by a dentist since admission, leading to a deficiency.
A facility failed to maintain proper infection control during a dressing change for a resident with a diabetic foot ulcer. The RN did not wear a gown or sanitize hands between glove changes, violating enhanced barrier precautions. The resident had multiple health issues, including diabetes and chronic respiratory failure, and was on enhanced barrier precautions due to a wound.
The facility failed to maintain an adequate resident call system, affecting two residents who were unable to alert staff for assistance due to a malfunctioning call light system. Despite multiple notifications and a maintenance request dated months prior, no action was taken to repair the system. The facility Administrator was unaware of the issue, and resident council meeting minutes documented a request for repair.
The facility did not maintain a comfortable environment for a resident, as the walls in their room had multiple marks needing repair. The resident, with a history of atrial fibrillation, diabetes, and other conditions, confirmed the walls had been in disrepair since their admission. The Maintenance Director verified the issue.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure RN coverage for eight consecutive hours on four days within the last two months. Review of the daily staffing posted numbers showed that on 05/10/2026, 05/17/2026, 06/27/2026, and 06/28/2026, the facility did not have a Registered Nurse scheduled for either the day shift or the night shift. During an interview on 07/20/2026 at 12:55 P.M., the DON confirmed that the facility did not have the required RN coverage on those dates and stated that although staffing agencies were used to fill open shifts, a staffing agency had not been used for the dates in question. The deficiency had the potential to affect all 84 residents currently residing at the facility.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
Food was not stored appropriately in the kitchen, based on observation, interview, and policy review. During observation with the Dietary Manager, all floors throughout the kitchen area were dirty. In the freezer, there was a half box of cookies that was opened and undated, and one bag of chicken that was opened and undated. In the refrigerator, 13 rotten cucumbers were observed on a tray that was uncovered and ready for use. The Dietary Manager confirmed the condition of the floors, the opened and undated food items in the freezer, and the rotten cucumbers in the refrigerator. Review of the facility policy titled Food Receiving and Storage stated that foods shall be received and stored in a manner that complies with safe food handling practices, and that all foods in the refrigerator or freezer are to be covered, labeled, and dated.
Kitchen Infestation With Flies
Penalty
Summary
The facility failed to ensure the kitchen was free from flies. During observation and interview on 07/13/2026, the Dietary Manager stated there were many flies throughout the kitchen, including the storage and preparation areas, and noted the kitchen air conditioning unit was in a window with a small opening to the outside. On 07/14/2026, the Dietician observed multiple flies on the preparation table during tray preparation and stated the flies were bad; later that day, the Dietician stated the flies in the kitchen were an infestation. A staff member preparing a tray swatted away a fly and stated the flies were a problem in the kitchen. On 07/15/2026, the Maintenance Director stated they were unaware of the opening where the air conditioning unit was in the window and that flies were getting in. Review of the facility's policies showed the kitchen was expected to have an effective pest control program and that cracks, gaps, and penetrations were to be sealed through routine inspection.
Missing CNA Annual and Dementia Care Training
Penalty
Summary
The facility failed to ensure required annual training was completed for three CNAs (#242, #221, and #413) and failed to ensure additional training in the care of cognitively impaired residents was completed for three CNAs (#239, #414, and #277). Review of staff records showed CNA #242, hired 01/30/13, had no documentation of annual training completed; CNA #221, hired 05/24/24, had no documentation of annual training completed; and CNA #413, hired 08/25/23, had no documentation of annual training completed. Staff record review also showed CNA #239, hired 10/31/25, CNA #414, hired 04/24/26, and CNA #277, hired 08/20/25, had no documentation of training for the care of the cognitively impaired. During an interview on 07/20/26 at 2:45 P.M., the Administrator verified there was no documented annual training for CNAs #242, #221, and #413 and no documented training for the care of the cognitively impaired for CNAs #239, #414, and #277.
Resident Concerns Were Not Timely Addressed
Penalty
Summary
The facility failed to ensure resident and family concerns were addressed in a timely manner, affecting 10 residents. Review of resident council meeting minutes across multiple months showed repeated concerns about housekeeping, food service, staffing, medication administration, staff behavior, and smoking/vaping in the building. Residents reported rooms not being cleaned consistently, snacks not being provided evenly, staff being on phones in hallways and dining areas, rude treatment by staff, poor communication at shift changes, delayed showers, and concerns that medications were not being given on time or accurately. Residents also raised concerns about food being overcooked or underfilled, condiments and seasoning not being provided, and requests for menu changes and snack options. The meeting minutes showed that the facility’s responses were largely limited to statements that staff would be educated on customer service, cell phone use, medication administration, ADLs, and food preparation, with some issues repeated month after month. In one instance, residents requested copies of medical records, but the documentation only reflected that one resident was given a release of information form and did not address the second resident’s request. Residents also reported staff vaping inside the building, and concerns about staffing levels and specific staff behavior continued to be raised without documented resolution. The Administrator confirmed there was no additional documentation or evidence of follow-up such as training sign-in sheets or audits and acknowledged the minutes lacked detail showing follow-up to address the concerns. During interviews, residents stated they were bringing up the same issues repeatedly and felt management was not doing enough to fix them, describing that they felt brushed off. The Activity Director confirmed the prior administrator did not encourage documentation and follow-up of resident concerns and did not want concerns documented in the meeting minutes. She also acknowledged the facility had a lack of follow-up and that the same issues kept recurring, including staff being rude, staff vaping, staff using phones, food preparation problems, snacks and condiments not being provided, and peanut butter and jelly sandwiches having minimal filling. Review of the facility policy titled Resident Concerns and Grievance Management Policy showed the facility was required to identify, document, investigate, track, and resolve resident concerns and grievances, including documentation of the concern, assigned follow-up, and resolution.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a homelike environment for four residents. During observation and interview, the Housekeeping Supervisor confirmed that one resident’s window AC unit had holes to the outside around the unit and was not secured except with duct tape, and that a board covering the rest of the window was also duct taped to the window sill. The supervisor stated it was not homelike to have a board and window AC unit duct taped to the wall. Additional observations showed two other residents’ window AC units were secured with boards and duct tape, and another resident’s window AC unit was held in with duct tape. The Maintenance Director confirmed the facility had window AC units that were not fully sealed, with vinyl boards held in place by duct tape or masking tape, and acknowledged that the units were not homelike because they were held by tape with holes to the outside. The report also identified a resident with severely impaired cognition, anxiety, Raynaud’s syndrome, thoracic aortic aneurysm, major depressive disorder, and Alzheimer’s disease whose room had a large area, approximately three feet by three feet, of chipped paint next to the bed extending from the head of the bed to the foot of the bed. The resident stated the chipped paint looked nasty and bothered her. An LPN confirmed the large area of chipped paint, and the Administrator later confirmed the condition of the wall in the resident’s room.
Missed Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were completed for Resident #11 and for 32 other residents identified as missing second-quarter 2026 care conferences. Resident #11 was admitted with intact cognition and diagnoses including fibromyalgia, chronic respiratory failure, and atherosclerotic heart disease. The resident’s most recent care conferences were held on 10/13/25 and 01/16/26, and both notes indicated the resident did not attend. A care conference list provided by the Administrator showed Resident #11’s next conference was scheduled for 07/17/26, and no care conference had been completed since 01/16/26. During interview, the LSW confirmed that no care conference had been completed for Resident #11 since January 2026 and stated the facility had no social worker for a short time, which resulted in many second-quarter care conferences not being scheduled because there was no staff in the social services position. The facility policy stated each long-term resident will have a care conference with the IDT scheduled quarterly, annually, and with any significant changes.
Unsecured and Expired Medications Found on Medication Carts and at Bedside
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional principles. During observation of three medication carts, surveyors found loose unidentified pills in medication drawers on the first-floor cart serving residents in rooms 103 to 112, the first-floor cart serving residents in rooms 113 to 126, and the second-floor cart serving residents in rooms 209A to 226. Surveyors also found expired medications on the carts, including two bottles of Iron 325/65 mg tablets with a best-by date of 06/26 and an opened bottle of Guaifenesin 400 mg immediate release tablets with an expiration date of 12/2024 and an opening date of 06/26/26. The nurses present confirmed they could not identify the loose pills and stated the expired medications had not been administered that day. The DON stated nurses were expected to check medication carts daily for expired medications and loose pills, and the facility was to do weekly audits of the carts. The facility also left prescription medication unsecured at the bedside for Resident #50. Resident #50 had diagnoses including unspecified dementia, anoxic brain injury, ataxia, vascular disease, epilepsy, schizoaffective disorder, Parkinson's disease, unspecified psychosis, and dysphagia, and the MDS showed a BIMS of 11. Surveyors observed a tube of Bacitracin Zinc ointment and a full container of Nystatin powder on the resident's nightstand, with no date on the ointment and a fill date of 06/30/26 on the powder. The resident had no current or past orders for either medication in the medical record, and an LPN confirmed the medications were unsecured at the bedside and not ordered for the resident.
Incomplete DNR Order Form
Penalty
Summary
The facility failed to complete an advance directive form in a timely manner for Resident #11, who was admitted with intact cognition and had diagnoses including fibromyalgia, chronic respiratory failure, and atherosclerotic heart disease. The resident had an active physician order revised on 01/12/26 for DNRCCA, and the care plan identified the resident's code status as DNRCCA initiated 10/16/25. However, review of the DNR order form showed that the resident information, required physician/APRN/PA signature, and supervising or collaborating physician name were completed, but the form did not include a date of physician signature and did not have a box checked for the ordered DNR type. The Administrator confirmed during interview that the DNR order form was incomplete and should have been dated with either the DNRCC or DNRCCA box checked.
Failure to Notify Resident Representative After a Fall
Penalty
Summary
The facility failed to ensure the resident representative was notified after a resident’s fall. Resident #93 was admitted with diagnoses including altered mental status, repeated falls, COPD, and dementia, and the most recent MDS showed moderately impaired cognition with substantial assistance needed for toileting and bathing. A progress note documented that on 01/23/2026 at 2:10 P.M., the nurse found the resident crouched toward the floor in the hallway, assisted the resident to one knee, and then back into bed after the resident showed agitation and confusion. Hospice was notified, fall mats were placed on both sides of the bed, the bed was lowered, and more frequent checks were initiated. The ADON confirmed the resident representative was not notified of the fall, and the DON confirmed there was no documentation that the resident representative had been notified.
Unordered Side Rail Use
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints when Resident #94, who was admitted with diagnoses including Alzheimer’s disease with late onset, mood disorder, disorientation, and unspecified dementia, was found to have side rails used without any provider orders or care plan interventions for side rails. The most recent MDS assessment coded bed rails and alarms as being utilized, and the resident had severely impaired cognition and required substantial assistance with bathing and toileting. During interviews, two CNAs stated that side rails were used for the resident on a daily basis, while the ADON was unsure but believed side rails would be used. The DON later confirmed that side rails were not documented as utilized in the resident’s medical record. The facility policy stated that residents have the right to be free from physical restraints.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state agency. Resident #56, who was admitted with diagnoses including spinal stenosis, psychotic disorder with delusions, visual hallucinations, and paroxysmal atrial fibrillation, had a most recent MDS assessment indicating she was cognitively intact and required partial assistance with toileting and bathing. A progress note documented that she was in her room, moved her bedside commode next to the closet door, and stated that her roommate had tried to kill her all day and had hit and kicked her in the ribs. The resident was checked for injuries and had no red marks or bruises, and she was redirected and reoriented. During an interview, Resident #56 stated she was beat up by her roommate and that the roommate was moved out the next day. The Administrator later confirmed that an investigation was not completed and the allegation was not reported to the state agency. The facility policy titled Abuse stated that possible indicators of abuse include resident reports of abuse, that an immediate investigation is warranted when abuse is suspected or reported, and that all alleged violations are to be reported to the Administrator, state agency, and other required agencies within specific timeframes.
Discharge Planning Not Followed Through
Penalty
Summary
The facility failed to ensure discharge planning was in place for Resident #56, who was admitted with diagnoses including spinal stenosis, psychotic disorder with delusions, visual hallucinations, and paroxysmal atrial fibrillation. The most recent MDS showed the resident was cognitively intact and required partial assistance with toileting and bathing. A care conference documented that the resident was short term with plans for discharge to an Assisted Living, but the resident later stated they wanted to discharge and that the social worker was not assisting with discharge plans. The Interim Social Service Director stated there had been no updates or follow-up to the resident’s discharge plan since the care conference because the previous social worker stopped working at the facility.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of resident discharge for two residents reviewed in the discharge process. Resident #2 was admitted with diagnoses including generalized anxiety, a T11-T12 wedge compression fracture, and major depressive disorder, and nursing progress notes showed the resident was admitted to a local hospital and planned to discharge to another skilled nursing facility to be closer to family; the Administrator confirmed the Ombudsman had not been notified of the discharge. Resident #92 was admitted with diagnoses including dementia, emphysema, and atrial fibrillation, and a nursing progress note documented discharge home with family; the Administrator also confirmed the Ombudsman had not been notified of this discharge. Facility policy titled Notification to Ombudsman of Resident Discharge stated that nursing facilities are required to notify the SLTCO of resident discharge and submit the completed form with a copy of the discharge notice.
PASRR Not Updated for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the appropriate State-designated authority was notified when a resident had newly identified or diagnosed intellectual disability or mental disorder. This deficiency affected two of three residents reviewed for PASARR assessments in a facility with a census of 84. Review of the medical record for one resident showed diagnoses of generalized anxiety disorder, depression, and bipolar disorder, along with active orders for Mirtazapine and Duloxetine HCL. However, the resident's PASRR identification screen did not reflect the depression or bipolar disorder diagnoses, and it also indicated that no psychotropic medications had been prescribed in the past six months. The PASRR result notice for that resident stated there were no indications of serious mental illness and/or developmental disability. During interview, the LSW confirmed that when a new mental health diagnosis is added to the medical record and is not reflected on the current PASRR, a new PASRR should be completed, and that a new PASRR should also be completed when a resident has a new antidepressant prescription not reflected on the current PASRR. The LSW confirmed the resident's PASRR was not completed accurately or updated with changes to the resident's condition. Facility policy stated that PASRR guidelines are used for all new admissions and continued stays.
Missing Care Plans for Wandering and Toenail Care
Penalty
Summary
A care plan was not in place for wandering and exit-seeking behaviors for two residents, and a care plan was not in place for toenail care for one resident. Resident #47 had diagnoses including unspecified dementia with severe behaviors, diabetes, failure to thrive, and kidney disease, was cognitively impaired with a BIMS of 4, and was documented as disoriented, unable to recall most events, and resistant to care. The resident had been on a secure unit, had an elopement assessment showing risk, and later had documented exit-seeking behaviors, including attempting to exit through a secured door, pressing on doors until alarms sounded, attempting to go down the elevator, and being monitored on 15-minute checks. Despite these behaviors and observations, the care plan contained no mention of wandering or exit seeking. Resident #35 had diagnoses including polyneuropathy, respiratory failure, hypoxia, Alzheimer's disease, dementia with behaviors, atrial fibrillation, and heart disease. The resident was cognitively impaired with a BIMS of 00, had documented wandering and exit-seeking behavior in prior assessments and provider notes, and was described as having poor safety awareness and purposeful wandering. Staff interviews and observations confirmed the resident was actively wandering, pressing on exit doors, and scooting back and forth in the hall in a wheelchair. The care plan, however, did not include any entry related to wandering, exit seeking, or the resident's history of residing on a secured locked unit. Resident #81 had diagnoses including unspecified dementia without behaviors, heart disease, kidney disease, and weakness. A podiatry note documented nail trimming and recommended professional treatment and follow-up, and a nurse practitioner later recommended podiatry for toenail trimming. The resident was dependent with hygiene care, and observation showed toenails over a half-inch past the nail bed. The existing care plan addressed fingernail care but did not mention toenails or podiatry services, and the MDS coordinator confirmed the care plan did not include toenail care.
Failure to Provide Ordered Feeding Assistance and Toenail Care
Penalty
Summary
The facility failed to ensure Resident #3, who had diagnoses including cerebral infarction, dysphagia, dementia, chronic obstructive pulmonary disease, and cognitive communication deficit, received the ordered assistance with eating. The medical record showed orders for max assist feeding with each meal and for staff to ensure the resident was fed for all meals. During observation, the resident was found in bed with the breakfast tray placed across the bed, holding the plate in his lap and spilling food on his blanket and lap. CNA #407 stated the tray had been set up so the resident could start eating while trays were passed to other residents, and the DON later confirmed the resident needed max assist with meals and staff needed to be with him to provide that assistance. The facility also failed to provide toenail care for Resident #81, who had unspecified dementia without behaviors, heart disease, kidney disease, and weakness, and was dependent with hygiene care. The care plan addressed fingernail care but did not mention toenails or podiatry services, despite a nurse practitioner note recommending podiatry for toenail trimming. On observation, the resident’s toenails were more than a half inch past the nail bed. CNA #290 confirmed the toenails were very long, and the MDS coordinator stated aides were not trained to complete nail care and nursing should be trimming toenails and monitoring for podiatry needs. The Administrator confirmed the last podiatry visit was in 06/2025 and staff could not locate notes from the past year.
Delayed Communication and X-Ray for Hospice Resident After Fall
Penalty
Summary
Facility failed to ensure timely communication and care for a resident receiving hospice services after the resident fell and sustained injuries to the right elbow and right hand. The resident had diagnoses including polyneuropathy, respiratory failure, hypoxia, Alzheimer's disease, dementia with behaviors, atrial fibrillation, and heart disease, and was cognitively impaired with a BIMS of 00 and substantial maximum assistance needed for mobility. After the fall, staff documented bruising, hematoma, edema, and a skin tear, and the resident's daughter repeatedly voiced concern about the right hand, requested an X-ray, and asked about splinting. Notes also documented that the resident was unable to follow commands for assessment and was expressing pain by withdrawing from touch, facial grimacing, and groaning. The record showed that hospice was notified of the fall and later of the family's concerns, but there was a delay in obtaining an X-ray for the injured hand. Staff contacted hospice multiple times regarding the X-ray, and one note indicated the family was told to contact hospice directly because hospice was the primary provider. The X-ray was ultimately obtained and showed a complete fracture through the base of the proximal phalanx of the fourth digit on the right hand. Hospice documentation stated the nurse educated facility staff about hospice and facility responsibilities after the delay in getting the X-ray, and the hospice executive director confirmed the facility could have ordered the X-ray and that the facility was responsible for communicating concerns to hospice.
Failure to assess and document safety needs after moving residents from secured to unsecured units
Penalty
Summary
The facility failed to ensure residents were properly assessed and that interventions were in place when three residents were moved from a secured memory care unit to an unsecured unit. The report states that Residents #35, #47, and #81 were all identified in the record as having dementia-related impairments and elopement risk concerns, yet the medical record did not document updated assessments or decision-making to support the move or to show what safety interventions were needed after the transfer. For Resident #47, the record showed diagnoses including unspecified dementia with severe behaviors, diabetes, failure to thrive, and kidney disease. The resident had been ordered to reside on the secure unit and was documented as disoriented, unable to recall most events, and resistant to care. After the room move, staff documented exit-seeking behavior, attempts to leave through a secured door, attempts to get on the elevator, and the resident being found on the floor next to her wheelchair by the doorway. Staff and the DON acknowledged concerns that the resident wandered and had been moved to a non-locked area without new interventions, while the record lacked documentation of updated elopement assessments after the move and lacked care plan entries for wandering or exit-seeking. For Resident #35, the record showed diagnoses including polyneuropathy, respiratory failure, hypoxia, Alzheimer's disease, dementia with behaviors, atrial fibrillation, and heart disease. The resident had prior elopement risk documentation, wandering and exit-seeking behaviors, poor safety awareness, and severe cognitive impairment. Despite this, the record later reflected no current or history of wandering or exit-seeking, and the care plan did not address the move from the secured unit or related behaviors. Staff reported the resident wandered and pressed on doors until they alarmed, and observations showed the resident actively wandering and pressing on exit doors while seated in a wheelchair. For Resident #81, the record showed diagnoses including unspecified dementia without behaviors, heart disease, kidney disease, and weakness. The resident had been ordered to reside on the secure unit and was documented as an elopement risk with wandering behavior, purposeless wandering, and severe cognitive decline. After the room move, the DON stated she was unaware the resident remained at risk and there was no documentation of updated assessments or decision-making for the transfer to the unsecured area. Although the resident was not observed outside the room during survey observations, the record still reflected wandering-related concerns and the facility acknowledged the lack of documentation supporting the move and related interventions.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. During observation of medication administration, 30 opportunities were observed and 2 errors were made by facility staff, resulting in a 6.67% medication error rate. This affected two of six residents observed for medication administration, including Resident #62 and Resident #72, at a facility census of 84. Resident #62 had diagnoses including COPD, chronic diastolic heart failure, and acute kidney failure, and was documented as having intact cognition. During medication administration, RN #408 prepared Fluticasone-Salmeterol inhalation aerosol for one puff, but the resident inhaled two puffs before returning the inhaler. RN #408 confirmed the order was for one puff and stated she did not notice the resident took two puffs. Resident #72 had diagnoses including Type II DM, respiratory failure, and CKD, and was documented as having intact cognition. During medication administration, LPN #203 crushed omeprazole delayed-release capsules with other medications and mixed them into applesauce, and confirmed the delayed-release omeprazole was crushed and given to the resident. The resident's order was for omeprazole delayed-release 20 mg, and the drug guide listed omeprazole as a do-not-crush medication.
Crushed delayed-release omeprazole during medication pass
Penalty
Summary
Resident #72, who had diagnoses including Type II Diabetes Mellitus, respiratory failure, and chronic kidney disease and was documented as having intact cognition, was found to have a significant medication error during medication administration. During observation, an LPN placed a 20 mg Omeprazole delayed-release capsule in a medicine cup with other prescribed pills, crushed all of the medications together, mixed them with applesauce, and administered the crushed mixture to the resident. The LPN confirmed at the time of administration that the delayed-release omeprazole had been crushed and stated that the resident took medications crushed every day and tolerated them well. The resident’s active physician order included Omeprazole Oral Capsule Delayed Release 20 mg, and the pharmacy’s Do Not Crush Drug Guide listed omeprazole as a medication that should not be crushed. The facility policy on crushing medications stated that nursing staff and/or the consultant pharmacist shall notify the attending physician when an order is given to crush a drug that the manufacturer states should not be crushed.
Failure to Provide Routine Dental Services
Penalty
Summary
Provide or obtain dental services for each resident was not ensured for Resident #11. The resident was admitted with intact cognition and diagnoses including fibromyalgia, chronic respiratory failure, obstructive sleep apnea, and atherosclerotic heart disease. The physician’s orders included a PRN consult/treat order for a dentist, and a progress note dated 12/10/25 documented that the social worker was made aware the resident needed a dentist appointment. However, review of progress notes from 12/10/25 through 07/16/26 showed no documentation that a dental appointment was scheduled or attended, and review of facility dental notes for the last six months found no dentist appointment notes for Resident #11. A Licensed Social Worker confirmed on 07/16/26 that the resident had not been seen by a dentist since the need for an appointment was identified.
Inaccurate Documentation in Fall Investigations
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident, identified in the report as Resident #69, out of 24 records reviewed. The resident had an admission date of 05/11/26 and diagnoses that included cervical disc disorder, diabetes, kidney disease, spinal stenosis, and heart failure. The MDS assessment dated [DATE] showed the resident was cognitively impaired with a BIMS of 00 and required supervision/touching assistance for mobility and transfers. The deficiency involved inaccurate documentation in two fall investigations. One fall was documented as occurring at 3:45 A.M. in the bathroom, with a scalp bruise, but the neurological checks were recorded as beginning at 3:40 A.M. and the physician notification was documented at 4:32 A.M. Another fall was documented as occurring at 6:45 A.M. in the resident's room, with a nosebleed, but the neurological checks were recorded as beginning at 6:00 A.M. and the physician notification was documented at 6:32 A.M. During interviews on 07/16/26, the DON and a visiting DON confirmed the fall investigations contained inaccurate documentation and acknowledged the timeline of events was not possible as written. The facility policy stated documentation in the medical record shall be objective, complete, and accurate.
Failure to Maintain Substitution Log for Menu Changes
Penalty
Summary
The facility failed to maintain the substitution log for the menu, which is a requirement to ensure that the nutritional needs of residents are met. On the specified date, chilled pears were scheduled to be served for lunch, but due to a shortage, kitchen staff substituted them with pineapple for regular texture and applesauce for puree texture. This substitution was not recorded in the substitution log, as confirmed by interviews with kitchen staff and the kitchen manager. The kitchen manager and the dietician were unaware of the substitution, indicating a lapse in communication and documentation. The failure to document the substitution had the potential to affect all 94 residents in the facility.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to maintain safe and sanitary food storage conditions, as observed during a survey. In the freezers, several food items, including pie crumbles and black olives, were found with expired or smudged dates, and some appeared frostbitten. The refrigerator contained undated or expired items such as ham, fruit cups, milk, blueberries, salad dressing, and various leftovers. The dry storage area had open and undated brownie mix and noodles, and uncovered sweet potato pies. The Kitchen Manager acknowledged the issues but was unsure of the requirements for dating and covering food items. The facility's policy mandates that all refrigerated and frozen foods be covered, labeled, and dated, which was not adhered to. Additionally, the facility failed to ensure food was held at safe temperatures. A hamburger ordered by a resident was found to be at 110 degrees, below the required 135 degrees, indicating a failure to maintain proper food holding temperatures. The Kitchen Manager was unable to explain why the warming box was not keeping food hot enough. Furthermore, the Kitchen Manager demonstrated a lack of knowledge regarding the dishwasher's operation, incorrectly using chlorine strips instead of sanitation strips and misunderstanding the required chemical concentration. The facility's policy requires kitchen equipment to be cleaned and sanitized after each use, which was not properly executed.
Deficiency in Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents had ready and reasonable access to their personal funds during evenings and weekends. This deficiency was identified through interviews with residents and staff, as well as a review of the facility's policy on managing residents' personal funds. A resident reported that he could not access his money on weekends, which was corroborated by interviews with nursing staff who confirmed that funds were not available during these times. The Business Office Manager stated that funds were available at a specific location on weekends, but this was contradicted by the nursing staff's statements. The facility's policy on the management of residents' personal funds, last revised in March 2021, did not address the availability of funds to residents during evenings or weekends. The Administrator confirmed that the policy lacked guidance on this issue and that there was a discrepancy in the reported location of available funds. The Business Office Manager mentioned that funds were placed in a locked box at the receptionist desk, but this could not be confirmed at the time of the survey. This lack of access to personal funds could potentially affect all 50 residents whose funds were managed by the facility.
Facility Fails to Maintain Comfortable Water Temperatures
Penalty
Summary
The facility failed to ensure comfortable water temperatures for its residents, affecting 31 individuals. Observations and interviews revealed that residents, including one with dementia and other medical conditions, experienced cold water in their private bathrooms. A resident reported that the water had been cold since moving into the room several months ago, and a CNA confirmed that the water temperature reached only 52 degrees Fahrenheit after running for over three minutes. Staff interviews indicated that maintenance requests had been made multiple times, but the issue persisted, with the most recent work order response suggesting waiting for the tank to warm up. During a tour of a secured dementia unit, hot water temperatures in several rooms were found to be significantly below the comfortable range of 100-110 degrees Fahrenheit, with readings between 50 and 60 degrees Fahrenheit. Staff interviews confirmed that the problem had been ongoing for weeks to months, with maintenance requests made but not effectively resolved. The maintenance director acknowledged the recurring issue and the lack of documentation for repairs. Despite weekly monitoring logs showing adequate temperatures, the problem persisted, indicating a discrepancy between recorded data and actual conditions.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner concerning the management of an indwelling urinary catheter collection bag. The resident, who had a complex medical history including cerebral infarction, dementia, and obstructive uropathy, was observed on multiple occasions with her urinary catheter collection bag visible without a privacy cover. This lack of privacy was noted during observations on different days, where the urine in the collection bag was visible from the hallway, compromising the resident's dignity. The facility's policy on dignity, which mandates that residents be treated with respect and that urinary catheter bags be covered, was not adhered to. A registered nurse confirmed the absence of a privacy cover on the resident's catheter bag, acknowledging the visibility of the urine from the hallway. The resident's care plan included interventions for catheter care and maintaining dignity, but these were not followed, leading to the deficiency noted in the report.
Failure to Notify Resident of Account Balance Nearing Medicaid Limit
Penalty
Summary
The facility failed to notify a resident or their responsible party when the resident's account balance reached $200 less than the resource limit for Medicaid eligibility. This oversight affected one resident whose personal funds were managed by the facility. The resident's account balance was $1778.78 on September 30, 2024, and had not exceeded $1800.00 between July 1, 2024, and September 30, 2024. The Business Office Manager confirmed that a notification letter was sent to the resident's responsible party on September 30, 2024, indicating the balance was $1778.78. However, the resident's account balance increased to $1828.78 on October 1, 2024, and remained above $1800.00 through January 30, 2025, with a current balance of $1889.13. There was no evidence that the resident or their responsible party was notified between October 1, 2024, and January 30, 2025, that the account balance had reached $200 less than the resource limit, which could potentially affect the resident's Medicaid or Social Security eligibility. The Business Office Manager confirmed the lack of notification during this period.
Failure to Notify Physician of Critical Blood Sugar Levels
Penalty
Summary
The facility failed to notify a resident's physician of blood sugar levels that were outside the parameters set by the physician's orders. This deficiency affected a resident who was admitted with multiple diagnoses, including diabetes mellitus, and was receiving hypoglycemic medications. The resident's medical record indicated several instances where blood sugar levels were either not obtained or were outside the specified range, including levels below 70 and above 400. Despite these occurrences, there was no documented evidence that the physician was informed as required by the facility's policy. The facility's policy mandates prompt notification of the resident's physician and representative in the event of changes in the resident's medical condition. However, interviews with facility staff confirmed that the physician was not notified of the critical blood sugar readings or the failure to obtain the readings. This oversight was identified during a review of the resident's medical records and interviews with facility staff, highlighting a lapse in adherence to the established protocol for managing changes in a resident's condition.
Failure to Maintain Resident Privacy During Dressing Change
Penalty
Summary
The facility failed to maintain personal privacy for a resident during a dressing change, which was observed by surveyors. Resident #74, who has a complex medical history including sepsis, type two diabetes mellitus, and chronic respiratory failure, was affected by this deficiency. The resident, who is moderately cognitively impaired and uses mobility aids, was undergoing a dressing change for a diabetic ulcer on the right heel. During the procedure, the Registered Nurse (RN) #257 did not close the door or draw the curtains to ensure the resident's privacy. Additionally, the RN did not follow proper hand hygiene protocols during the dressing change. After removing the soiled dressing, the RN changed gloves without sanitizing or washing hands. This was repeated when the RN removed gloves again and put on a new pair without washing hands. The facility's dignity policy, which emphasizes the importance of maintaining resident privacy and dignity during personal care and treatment procedures, was not adhered to in this instance.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for a resident, specifically regarding dental health. The resident, who had a complex medical history including cerebral infarction, dementia, and other conditions, was admitted with her own teeth. However, the admission review did not address whether she had broken or carious teeth. Subsequent assessments also failed to accurately reflect the resident's dental condition, as they did not note her missing and carious teeth. Observations later confirmed that the resident had missing natural teeth and obvious carious teeth. Interviews with the MDS Coordinator confirmed that the assessments were inaccurate in reflecting the resident's dental status. The resident's comprehensive Minimum Data Set (MDS) assessment inaccurately indicated no cognitive deficit and no obvious dental issues, despite the resident requiring reminders for oral hygiene and having impaired hand dexterity and decreased mobility. This inaccuracy in the resident's assessment highlights a deficiency in the facility's assessment process.
Inaccurate Resident Assessments in Smoking, Dental, and Mental Health
Penalty
Summary
The facility failed to ensure accurate assessments in several areas, affecting three residents. For Resident #6, the facility did not accurately assess his compliance with the smoking policy. Despite being listed as a supervised smoker, he was observed smoking independently in a non-designated area with a lighter and cigarettes in his possession. The MDS Nurse confirmed that the smoking assessment was inaccurately completed, as it stated the resident followed the smoking policy when he did not. Resident #89's assessments were also inaccurate, particularly regarding her dental status. The admission review failed to address the condition of her teeth, and subsequent assessments did not reflect her missing and carious teeth. An observation confirmed the presence of missing and carious teeth, which was not accurately coded in the MDS. The MDS Coordinator verified the inaccuracies in the coding of the resident's dental status. For Resident #70, the facility did not accurately document his mental health diagnoses. The MDS assessment failed to reflect his active diagnosis of schizoaffective disorder, despite a psychiatry progress note indicating an exacerbation of this condition. The Corporate Nurse confirmed that the MDS was not coded to reflect the resident's schizoaffective disorder, highlighting a discrepancy between the resident's documented condition and the assessment records.
Inaccurate PASARR Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Pre-Admission Screening and Resident Review (PASARR) assessments for three residents, affecting their mental health diagnosis records. Resident #7, who was admitted with multiple diagnoses including schizoaffective disorder bipolar type, did not have an updated PASARR reflecting this diagnosis until nearly a year after it was given. Similarly, Resident #81, who was diagnosed with anxiety disorder and psychotic disorder with delusions, had no mental disorders listed in their PASARR until several months after the diagnoses were made. These oversights were confirmed during an interview with Social Services. Additionally, Resident #32's PASARR, dated from several years prior, failed to include a diagnosis of schizophrenia, despite the resident having multiple mental health diagnoses including schizoaffective disorder bipolar type and schizophrenia. The facility's policy on PASARR, dated April 2023, mandates adherence to Medicaid guidelines, which was not followed in these cases. This deficiency was identified through staff interviews and record reviews, highlighting a lapse in updating critical mental health information in the PASARR assessments.
Failure to Complete PASARR Within 30 Days of Admission
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) within 30 days following admission for one resident. This deficiency was identified during a review of the medical record, interviews, and facility policy review. The resident in question was admitted with multiple diagnoses, including bipolar disorder, major depressive disorder, and anxiety disorder, among others. Despite the completion of a preadmission screen at the acute care hospital, the facility did not conduct the required resident review PASARR within the first 30 days of the resident's admission. The facility's policy, which follows the Ohio Department of Medicaid guidelines for PASARR, was not adhered to in this instance. An interview with a Licensed Social Worker confirmed the oversight. The resident's plan of care indicated undetermined discharge plans and possible long-term care placement, with interventions to support the resident's adjustment and transition. However, the lack of a timely PASARR review represents a failure to comply with regulatory requirements for new admissions and continued stays.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for three residents, affecting their smoking habits, activities of daily living (ADL), and dental care. Resident #89, who had multiple diagnoses including cerebral infarction and dementia, was admitted without a complete assessment of her dental status or ADL needs. Her care plan lacked specific interventions for her dental issues, such as missing and carious teeth, and did not address her need for assistance with daily activities, despite her impairments in hand dexterity and mobility. Resident #6, diagnosed with chronic obstructive pulmonary disease and bilateral above-knee amputations, was identified as a supervised smoker. Despite this, he was observed smoking in non-designated areas without supervision, contrary to the facility's smoking policy. His care plan, dated only recently, did not reflect previous non-compliance with smoking regulations, and there was no evidence of a comprehensive plan addressing his smoking behavior prior to the recent updates. Resident #75, with a history of diabetes and a below-knee amputation, was also found to be non-compliant with the smoking policy. He smoked in non-designated areas and even in his room, despite being educated on the policy. His care plan, like Resident #6's, was only recently updated to address smoking, with no prior comprehensive plan in place. The facility's failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for these residents led to deficiencies in meeting their physical, psychosocial, and functional needs.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to ensure care plan interventions were updated for three residents involved in separate incidents. Resident #13, who has schizophrenia and cognitive impairment, was involved in a resident-to-resident altercation with Resident #67, who also has schizophrenia and cognitive impairment. The altercation occurred when Resident #67 wandered into Resident #13's room, resulting in Resident #13 striking Resident #67, causing bruising and a laceration. Although a stop sign was ordered to be placed on Resident #13's door as an intervention, it was not consistently used, and the facility staff were unaware of its absence during the survey. Additionally, Resident #17, who has dementia and is at risk of falls, experienced a fall on 11/07/24. The intervention of non-skid socks was planned but not added to the care plan until 12 days after the fall. The Director of Nursing confirmed the delay in updating the care plan. The facility's policies on falls and comprehensive person-centered care plans require timely updates and interventions, which were not adhered to in these cases.
Failure to Provide Meal and Nail Care Assistance
Penalty
Summary
The facility failed to provide adequate meal assistance to a resident with severe cognitive impairment and physical limitations. The resident, who had a history of cerebrovascular accident with right-sided hemiplegia and other significant health issues, was observed during a meal without receiving necessary assistance or cues from staff. Despite the resident's care plan indicating a need for setup to limited assistance with eating, the staff did not provide the required support, leaving the resident's bedside table pushed away and the head of the bed laid down, which hindered the resident's ability to eat independently. Additionally, the facility did not provide necessary nail care for another resident who required extensive assistance with personal hygiene. This resident, who had multiple health conditions including dementia and visual loss, was observed with long and jagged nails, which she expressed a preference against. The facility's policy on nail care, which includes regular trimming to prevent infection, was not followed, as confirmed by a CNA who acknowledged the resident's need for nail care.
Failure to Maintain Hospice Records
Penalty
Summary
The facility failed to maintain proper hospice records for a resident receiving hospice services. The resident, who was admitted with multiple diagnoses including encephalopathy, COPD, respiratory failure, dementia, epilepsy, schizophrenia, muscle weakness, and cognitive communication deficit, was cognitively impaired and receiving hospice care. However, upon review of the medical record, there was no evidence of hospice notes being uploaded directly to the resident's medical record. The hospice binder maintained by the facility showed that the resident was admitted to hospice in June 2024, but only three visit notes were documented. Interviews with the resident's family and facility staff revealed concerns about whether hospice services were being provided as promised. The facility's policy required maintaining documentation of hospice communication, which was not adhered to in this case.
Failure to Ensure Safe Smoking Practices and Water Temperatures
Penalty
Summary
The facility failed to ensure safe smoking practices for two residents and safe hot water temperatures for three residents. Observations revealed that the water temperatures in the rooms of three residents were significantly above the maximum limit of 120 degrees, with temperatures recorded at 131.2, 125.7, and 138.8 degrees. The Maintenance Director confirmed these temperatures were above the safe limit, posing a potential risk to the residents. Regarding smoking safety, Resident #6, who has chronic obstructive pulmonary disease and bilateral above-knee amputations, was observed smoking in a non-designated area despite being a supervised smoker. The resident's care plan indicated non-compliance with the smoking policy, and multiple staff members confirmed the resident's repeated violations. The facility's policy required supervision during smoking, but the resident was found with cigarettes and a lighter unsupervised, indicating a failure to enforce the policy effectively. Similarly, Resident #75, who is cognitively intact and uses a wheelchair, was identified as an independent smoker but was found smoking in non-designated areas and even in his room. Despite being educated on the smoking policy, the resident continued to violate it, keeping cigarettes and a lighter against the facility's rules. The facility failed to complete a smoking safety assessment for this resident, and there was no evidence of a care plan addressing smoking safety prior to the surveyor's observations.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure adequate hydration for residents, as evidenced by the lack of access to fresh ice water at bedside and failure to provide beverages with meals. Resident #8, who has multiple complex medical conditions including fibromyalgia, COPD, and chronic kidney disease, reported only receiving fresh ice water upon request. Observations confirmed that the resident's water pitcher contained warm water on multiple occasions, and staff interviews revealed that fresh ice water was not routinely passed. Resident #9, with severe cognitive impairment and a history of anorexia and cerebrovascular accident, was observed to have only unsweetened tea with her meal, which she refused to drink. Despite requesting another beverage, she did not receive one, and there was no fresh ice water at her bedside. Staff interviews confirmed the lack of beverage provision as requested. Resident #89, who has no cognitive deficit but suffers from conditions such as cerebral infarction and acute kidney failure, also did not have access to fresh ice water at her bedside. Observations noted her lips and mouth were dry, indicating potential dehydration. Staff confirmed that ice water was only provided upon request, contrary to the facility's hydration policy, which mandates routine provision of water with meals and at each shift.
Failure to Monitor Blood Pressure Before Administering Hydralazine
Penalty
Summary
The facility failed to monitor a resident's blood pressure prior to administering the medication Hydralazine, which is used to lower blood pressure. This deficiency affected one resident out of five reviewed for unnecessary medications. The resident, who had a complex medical history including conditions such as hypertension, diabetes mellitus, COPD, and dementia, was admitted with the latest readmission on 08/28/24. The resident's physician orders included Hydralazine 10 mg to be taken three times daily and as needed for specific blood pressure thresholds. However, the medical record review revealed that the resident's blood pressure was not being monitored before administering the scheduled doses of Hydralazine. This was confirmed during an interview with a corporate nurse, who verified the lack of blood pressure monitoring prior to medication administration.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for two residents, which was identified during a survey. Resident #81, who has multiple diagnoses including dementia with psychotic disturbance and malignant neoplasm of the prostate, had physician orders for a complete blood count (CBC) and basic metabolic panel (BMP) on two separate occasions in August 2024. However, a review of the medical records on January 30, 2025, revealed that these laboratory tests were not documented as completed. This was confirmed by the Regional Director of Clinical Operations during an interview. Similarly, Resident #70, who has a complex medical history including rhabdomyolysis, diabetes mellitus, and chronic obstructive pulmonary disease, had a physician order for a Hemoglobin A1c test to be conducted three months after July 23, 2024. The medical record review showed no results for this test, which was due on October 23, 2024. This oversight was verified by a Corporate Nurse during an interview. The facility's policy on lab and diagnostic test results, last revised in November 2018, outlines the process for ordering and obtaining lab tests, which was not followed in these instances.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, affecting one of the two residents reviewed for dental care. The resident, who had a complex medical history including cerebral infarction, dementia, and other conditions, was admitted with her own teeth, but the admission review did not address the condition of her teeth. The resident's plan of care did not include any information on her dental status, despite observations of missing and carious teeth. Additionally, the resident's oral assessment indicated a need for daily reminders to clean her teeth due to intermittent confusion and impaired hand dexterity. Despite having orders for dental consultation, the resident had not been seen by a dentist since her admission. The Licensed Social Worker confirmed that there was no documented evidence of the resident refusing the new facility-contracted dental service. The facility's policy on dental services, which was last revised in September 2024, states that the facility is responsible for assisting residents in obtaining routine and emergency dental care. However, this policy was not followed in the case of the resident, leading to the deficiency noted in the report.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and failure to follow enhanced barrier precautions during a dressing change for a resident with a diabetic foot ulcer. The resident, who was admitted with multiple diagnoses including sepsis, type two diabetes mellitus, and chronic respiratory failure, was on enhanced barrier precautions due to a wound. During the dressing change, the registered nurse did not wear a gown as required by the facility's enhanced barrier precautions policy and failed to sanitize or wash hands after removing soiled gloves and before putting on new gloves. The resident's medical records indicated a physician's order for daily wound care, which included cleansing the wound and applying specific dressings. Despite the presence of a sign indicating enhanced barrier precautions and available personal protective equipment, the nurse did not adhere to the facility's policies. The nurse acknowledged these lapses during an interview, confirming the failure to follow proper infection control procedures, which are critical in preventing the transmission of infections in the facility.
Inadequate Resident Call System Maintenance
Penalty
Summary
The facility failed to maintain an adequate resident call system, affecting two residents out of the 30 reviewed for call light function. Resident #48, who has diagnoses including inflammatory neuropathy, heart failure, paraplegia, and chronic obstructive pulmonary disease, and Resident #20, with diagnoses of radiculopathy, polyneuropathy, type II diabetes mellitus, and chronic obstructive pulmonary disease, were unable to alert staff for assistance due to a malfunctioning call light system. Observations confirmed that when Resident #48 activated the call light, the hallway notification light did not illuminate, leaving staff unaware of the resident's need for assistance. Interviews with the residents and a Certified Nursing Assistant (CNA) revealed that the call light system had been non-functional for at least four months, despite multiple notifications to staff. A maintenance request dated 10/27/24 for the repair of the call light system was found in the Maintenance Request Log, but no action had been taken as the work completion section was left blank. The facility Administrator was unaware of the issue, and resident council meeting minutes from 01/23/25 also documented a request for the repair of the call light system.
Facility Failed to Maintain Wall Condition in Resident's Room
Penalty
Summary
The facility failed to maintain a functional and comfortable environment for its residents, as evidenced by the condition of the walls in a resident's room. Specifically, the walls in the room of Resident #65 were observed to have multiple marks that required sanding and painting. This issue was confirmed during an observation and interview with the resident, who indicated that the walls had been in this state since their admission. The Maintenance Director also verified the condition of the walls during a subsequent observation. Resident #65 has a medical history that includes atrial fibrillation, type two diabetes mellitus, peripheral vascular disease, congestive heart failure, and insomnia.
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 141 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chillicothe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| National Church Residences Chillicothe | 0.7 mi | ★★★★★ | 11 | 0 |
| Hopewell Grove Rehabilitation And Healthcare | 1.5 mi | ★★★★★ | 10 | 1 |
| Chillicothe Post Acute | 2.4 mi | ★★★★★ | 18 | 0 |
| Vineyards At Concord, The | 11 mi | ★★★★★ | 33 | 0 |
| Embassy Of Valley View | 13 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.