Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westmoreland Place during CMS and state inspections, most recent first.
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.
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.
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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.
Illustrative
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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 | ★★★★★ | 19 | 0 |
| Vineyards At Concord, The | 11 mi | ★★★★★ | 33 | 0 |
| Embassy Of Valley View | 13 mi | ★★★★★ | 2 | 0 |
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