Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wexner Heritage House during CMS and state inspections, most recent first.
Delayed UTI Testing and Follow-Up: A resident with urinary retention and a Foley catheter history reported burning and had elevated temp, confusion, and an elevated WBC. Staff documented plans for UA/C&S, but the specimen was not sent for several days and no timely lab results were available before the resident became unresponsive, was intubated by EMS, and was hospitalized with septic shock likely due to a urinary source and E. coli bacteremia.
Kitchen sanitation and dishwashing failures were observed, including a broken paper towel dispenser, a leaking dishwasher that did not reach sanitizing temperature, and a 3-compartment sink with sanitizer levels below the required PPM. Food storage issues included expired and improperly labeled items in the walk-in, ice buildup in the freezer, and dirty kitchen surfaces and equipment. A cook also handled food, tray materials, and cleaning rags with the same gloves without hand hygiene or glove changes.
Infection prevention and control failures were identified involving staff TB screening, oxygen equipment handling, and EBP use. Staff records showed delayed or missing annual TB questionnaires and TB test readings that were not completed in a timely manner. For one resident on continuous O2, tubing was dragged across the floor and then reused without cleaning or replacement. For another resident on EBP with a PEG tube, an LPN administered medication and flushed the tube without wearing a gown as required.
The facility failed to follow physician orders for daily weights and timely re-weighs for a resident with tube feeding and significant weight loss, and also failed to complete a timely annual self-medication reassessment. In addition, a resident ordered double portions did not receive them at meals; meal tickets and staff observations confirmed the trays did not reflect the order, and the resident stated he needed more food. The DON acknowledged the missed weight checks and delayed reassessment, and staff confirmed the double-portion order was not followed.
Food was served at improper temperatures. A resident reported meals arrived cold and lacked flavor, and other residents also complained about cold food. During observation, a test tray was left in the kitchen for about 15 minutes before service, and lunch items were only about 60-80 degrees F. At breakfast, plated pancakes and sausage were measured at 107-108 degrees F, and an ADM confirmed they were cold. Facility policy required hot foods to be held and served at least 135 degrees F.
Pureed Diet Food Prepared at Incorrect Consistency: A surveyor observed a fish item prepared for residents on a pureed diet and found it was stringy, not smooth, and had separable strands when processed with broth. An LPN stated the item did not puree correctly and that residents did not like the consistency, but it would continue to be served.
A resident with multiple chronic conditions and a BIMS score of 15 reported that the heater in the room had stopped working and needed extra blankets to stay warm. Staff observed the room at 69 degrees F, and maintenance later measured temperatures between 65 and 67 degrees F despite a high-priority work order being closed as resolved. Facility policy states residents in rooms at 71 degrees F or below are to be moved to another area or room with heat.
Failure to Complete Baseline AIMS for Resident on Antipsychotic Medication: A resident admitted with bipolar disorder, catatonic disorder, dementia with behavioral disturbances, depression, and other chronic conditions was receiving Abilify 10 mg daily along with other psychotropic medications. The record showed no baseline AIMS completed on admission, and the first AIMS was completed later by the contracted psych company. The DON verified that no baseline AIMS had been done on admission, despite facility policy requiring AIMS monitoring for residents on antipsychotic/psychotropic therapy.
Failure to provide routine shaving for a dependent resident. A resident with multiple chronic conditions, including dementia, bipolar disorder, malnutrition, and failure to thrive, was assessed as dependent on staff for bathing and personal hygiene. Observation showed long chin hair during the day, and a CNA confirmed the resident had a scheduled shower but was not shaved because there was not time. Facility policy stated residents are to be shaved on shower days and as needed.
A resident with cerebral palsy, bilateral hand contractures, and muscle weakness had splint-related orders that were not transcribed and implemented correctly. The record showed a right-hand palm protector order written as one time only, while the resident also had a separate hand brace order to be worn during the day and removed at night. An LPN documented a new right-hand brace order, and the DTR later confirmed the palm protector order had been written incorrectly.
Failure to implement fall prevention interventions for two residents at increased fall risk. One resident with osteoarthritis, muscle weakness, and a history of falls was found on the floor with injuries after rolling out of bed while reaching for the call light, and the bed was not in the lowest position when observed. Another resident with traumatic SAH, muscle weakness, depression, and legal blindness fell while trying to get up to use the bathroom; staff had been told he could not see the call light, and the move closer to the nurses' station was not implemented until later.
Unlabeled oxygen tubing and missing change dates were observed for three residents receiving respiratory care. Two residents with COPD and other chronic conditions had unlabeled nasal cannula tubing, and one also had an uncovered nebulizer mask on the nightstand; an LPN confirmed the tubing should be labeled and the mask stored in a bag when not in use. A third resident with respiratory failure and tracheostomy dependence had oxygen tubing without a date showing when it was last changed, and the UM confirmed there were no dates on the tubing and no order for routine tubing changes.
Failure to obtain ordered daily weights for a resident with CHF, AFib, CAD, and other cardiac conditions. The resident had a physician order for daily weights and notification for a 3-lb gain in one day, but weights were only documented on a few occasions and the TAR/MAR showed no daily weights recorded. The DON said the order was entered incorrectly as a no documentation order, the Administrator confirmed the weights were not obtained as ordered, and an LPN Unit Director was unaware of the order.
Failure to follow physician hold parameters affected three residents. One resident with chronic pain had duplicate hydrocodone orders, but nursing staff gave 1 or 2 tabs based on their own assessment without documented pain-scale parameters on the MAR. Another resident with multiple cardiac diagnoses received HCTZ and metoprolol even when BP/HR were outside ordered limits, with no documented MD notification. A third resident with seizures, AFib, and HTN received metoprolol via PEG without required BP/HR checks documented on multiple occasions.
An observation found two open half-used vials of Tubersol in the medication storage refrigerator, including one vial without an open date and another vial with an open date. The facility policy and manufacturer guidance required opened Tubersol to be dated and discarded after 30 days, and an LPN confirmed the vials were present and should have been dated when opened.
Delayed and missing urine specimens affected two residents. One resident with multiple chronic conditions had repeated urine collection orders after leukocytosis was noted, but the specimen was not successfully obtained until several days later. Another resident with an indwelling catheter, fever, confusion, and an elevated WBC had a UA/C&S specimen reportedly collected, but the lab never received it and the specimen was lost, requiring the tests to be reordered. The unit director and CNP confirmed expectations that ordered specimens be completed and sent promptly, and the physician order policy assigned responsibility for carrying out or safely handing off orders.
Unordered laboratory tests were completed for a resident with multiple diagnoses, including bipolar disorder, dementia with behavioral disturbances, anemia, hypothyroidism, and malnutrition. The resident had standing lab orders for periodic CBC, CMP, vitamin D, TSH, Lamictal, and lipid testing, but the facility completed multiple CBC, CMP, vitamin D, TSH, and Lamictal tests without a physician order. The DON confirmed the tests were unnecessary and attributed the issue to an order entry error.
Antibiotic stewardship was not followed when a resident with diabetes, depression, chronic pain, constipation, anxiety, and arthritis was started on ciprofloxacin before full urine C&S results were available. The resident did not meet McGeer UTI criteria, had no documented UTI signs or symptoms, and the culture later showed mixed growth with one organism resistant to ciprofloxacin and nitrofurantoin susceptible to both organisms.
A resident with severe cognitive impairment and total dependence for care did not receive proper incontinence care from a CNA, who failed to dry the vaginal area and did not cleanse or dry the buttocks, rectal, or coccyx area, contrary to facility policy.
Staff failed to perform hand hygiene during meal tray service, as observed with three residents who required assistance with meal setup and feeding. Despite the availability of hand sanitizer and facility policy requiring hand hygiene, a CNA assisted residents without sanitizing hands before or after contact, potentially affecting all residents on the unit. The residents involved had complex medical conditions, including dementia, diabetes, and chronic kidney disease.
A resident with severe cognitive impairment and multiple health conditions was admitted with a skin alteration that was inconsistently assessed and documented by staff. Despite care plans and physician orders for skin care, there was no evidence of consistent repositioning or timely notification of the wound nurse and wound physician. Incomplete assessments and lack of documentation led to the worsening of the wound, resulting in an unstageable pressure ulcer with necrosis requiring debridement.
A resident with severe cognitive impairment alleged sexual assault by a male staff member. The facility's investigation was incomplete, as only night shift staff were interviewed, key staff statements were delayed, and new bruising was not fully documented or investigated. The facility did not follow its own policy for abuse investigations, resulting in an insufficient response to the allegation.
A resident with multiple complex conditions did not receive physician-ordered wound care on several days, and there was no evidence that critical medications for low potassium were administered as ordered. Nursing staff failed to document or recall the administration of these treatments, and required orders were not entered into the medical record, resulting in non-compliance with facility policy.
A resident with multiple serious health conditions experienced a critically low potassium level, prompting a physician to order immediate potassium administration and additional lab tests. Although the RN relayed the orders to an LPN, only a basic metabolic panel was completed, and the required comprehensive metabolic panel and magnesium tests were not performed. The DON confirmed the orders were not entered into the medical record, and staff interviews revealed a breakdown in communication and follow-through.
Two residents experienced harm due to the facility's failure to promptly assess, monitor, and implement individualized interventions for pressure ulcer prevention and care. One resident developed an unstageable heel ulcer that was not identified or treated in a timely manner, while another was admitted with existing unstageable ulcers that were not comprehensively assessed or treated for two days. The facility did not follow its own wound care policies, resulting in delayed interventions and inadequate documentation.
Two residents with indwelling urinary catheters were observed with their catheter collection bags uncovered and visible to others, despite physician orders requiring privacy covers. LPNs confirmed the lack of privacy bags, resulting in urine being visible from the hallway and during resident mobility, which failed to uphold resident dignity.
A resident with multiple medical conditions developed an unstageable deep tissue injury to the left heel, which was identified by staff and reported to management and the resident's power of attorney, but not to the primary care physician as required by facility policy. Medical records showed no evidence of physician notification or immediate intervention for the wound at the time of discovery, despite the resident being at risk for skin breakdown.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital without proper documentation of the transfer or required information being provided to the receiving provider. The DON confirmed that essential details such as responsible physician, representative information, advance directives, and care instructions were missing from the record, contrary to facility policy.
A resident with a gastrostomy tube and multiple complex medical conditions received incontinence care from CNAs who wore gloves but did not don a gown, as required by the facility's enhanced barrier precautions policy for residents with indwelling medical devices. Both staff confirmed that the required precautions were not followed during the observed care.
The facility failed to conduct accurate and timely weekly skin assessments and treatment orders for two residents, leading to deficiencies in care. One resident had a skin alteration under the right breast with no documented weekly assessments, while another had multiple wounds with delayed treatment orders and insufficient documentation. The facility's policies on wound care were not adhered to, resulting in non-compliance.
A facility failed to report an abuse allegation involving a resident with multiple medical conditions to the State agency within the required two-hour timeframe. The incident was reported to an LPN and then to the DON, who informed the Administrator. However, the Administrator delayed reporting to the State agency until the next day, misunderstanding the policy requirements.
A resident with a DNRCC code status was mistakenly given CPR after experiencing cardiac arrest due to a miscommunication about their code status. The error occurred when an LPN provided the wrong room number to the ADON, leading to the incorrect assumption of a full code status. CPR was administered until emergency services arrived, but the resident did not survive.
A facility failed to obtain a urine sample for a resident with end-stage renal disease and urinary tract infections, despite a verbal order due to cloudy urine. The resident experienced no urine output overnight, and it was discovered that the Foley catheter was incorrectly placed. After reinsertion, 350 ml of urine was returned, but no sample was collected. The resident was later hospitalized with an acute complicated UTI. The DON revealed that the nurse involved could not recall if the physician was updated about the situation.
A facility failed to maintain infection control during catheter care for a resident with end-stage renal disease and urinary tract infections. A CNA used alcohol wipes incorrectly and failed to change gloves after care, as confirmed by the ADON. The facility's hand hygiene policy requires hand hygiene before and after resident care and glove removal.
Delayed UTI Testing and Follow-Up
Penalty
Summary
The facility failed to ensure laboratory testing and timely follow-up were completed to diagnose and treat a UTI for a resident with a Foley catheter history, urinary retention, urinary incontinence, legal blindness, traumatic subarachnoid hemorrhage, repeated falls, and muscle weakness. The resident’s care plan identified bladder-function concerns and directed staff to monitor urine characteristics, obtain urine specimens as ordered, and notify the physician/CNP of significant changes. On 12/10/25, the resident complained of burning in the penis area and around the Foley catheter, and the CNP was notified for possible urinalysis and culture and sensitivity. The CNP removed the Foley catheter and ordered Pyridium, but no laboratory testing was ordered at that time because the resident had a recent hospital urinalysis. On 12/11/25, the resident was seen for elevated temperature and burning on urination, and the assessment and plan documented a urinalysis with culture and sensitivity, along with fluids and hygiene. A nursing note also documented low-grade temperature, continued confusion, and that the CNP ordered a urinalysis with culture and sensitivity; however, there was no physician order written that day. Later that day, urine was documented as obtained and awaiting pickup, but there was no evidence the specimen was picked up or sent for testing. The resident’s CBC on 12/11/25 showed an elevated WBC count, and the facility did not recognize until 12/16/25 that the urinalysis had not been completed. A urine specimen was then obtained on 12/16/25 and processed on 12/17/25, with urinalysis results showing turbid urine, blood, leukocytes, nitrates, WBCs, mucous, WBC clumps, and moderate bacteria; the culture later identified E. coli. Before those results were available, the resident became unresponsive on the toilet, was intubated by EMS, and was transferred to the hospital. Hospital records documented acute respiratory failure, shock likely related to UTI, pyuria, painful urination before hospitalization, and septic shock due to E. coli bacteremia with a likely urinary source. The CNP stated she expected laboratory specimens to be obtained within 48 hours and later expressed concern about the delay in diagnosis and treatment of the resident’s UTI.
Kitchen sanitation, food storage, and dishwashing failures
Penalty
Summary
The facility failed to ensure the kitchen dishwasher and three-compartment sink were maintained in working order and used in a sanitary manner. During observation, the paper towel dispenser at the handwashing sink was broken and nonfunctional, and the surveyor had to obtain napkins from another area to dry hands. The dishwasher was observed leaking water onto the floor, with a large puddle present in the dishwashing area and broken, missing floor tile nearby. The Regional Dietary Manager confirmed the dishwasher had been having problems since approximately September 2025 and had not yet been replaced. The walk-in refrigerator contained multiple expired, deteriorated, or improperly labeled food items, including produce past use-by dates, items without open or use-by dates, and a degraded box of watermelon with yellow/brown fruit. Two large containers of cereal were also stored under a prep table without open or use-by dates. The freezer had a large amount of ice buildup on the floor, creating a slip hazard and potential for thawing of frozen food items. Later observations showed extensive dirt and grease buildup on exhaust fans, food splatter and residue on walls behind the stove, heavily soiled hood vents, and an ice machine with rust, calcified water dripping into the ice storage area, and a black substance visible inside the ice bin. The dishwasher was observed operating at 170 degrees Fahrenheit, below the expected sanitizing temperature of 180, and continued to leak water, leaving pooled water and white calcified residue on the floor. When the facility switched to the three-compartment sink, sanitizer testing showed 50 PPM and then 100 PPM, both below the required 200 PPM, while dishes used throughout the day had been washed using that sanitizer concentration. Sanitization logs were incomplete, with missing lunch and dinner entries and no sanitizer levels documented for 12/18/25. During service line observation, a cook handled meal tickets, tray racks, food items, cleaning rags, and multiple tray components with the same gloves without hand hygiene or glove changes between tasks.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to ensure Mantoux TB testing and annual TB assessments were completed in a timely manner for staff. Review of personnel files showed that LPN #141 and LPN #350 had TB tests administered on their hire dates, but the first readings were not completed until after those hire dates, and Human Resource Manager #905 confirmed she could not verify that either staff member began providing resident care on or after the documented hire date. The file for LPN #112 showed no evidence that an annual TB questionnaire had been completed at the time of survey. The files for CNA #125, CNA #309, and CNA #315 showed annual TB questionnaires completed on 02/08/24, 01/31/24, and 02/02/24, respectively, with no evidence of more recent questionnaires. The facility TB control plan and TB risk assessment stated that TB testing would be completed on hire and annually. The facility also failed to ensure oxygen tubing was handled appropriately for Resident #105. The resident was admitted with diagnoses including acute posthemorrhagic anemia, gastrointestinal hemorrhage, acute respiratory failure with hypoxia, and acute pulmonary edema, and had an order for continuous oxygen via nasal cannula at 3 liters per minute related to COPD. During observation, a CNA accidentally kicked the resident’s oxygen tubing, causing it to wrap around her leg and be dragged across the floor while the nasal cannula was not on the resident. The CNA handed the tubing to the resident’s daughter, and the nasal cannula was then placed back on the resident without being cleaned or sanitized. The CNA confirmed that the tubing should have been replaced and that she did not explain to the resident or daughter that it should have been changed due to contamination. The facility further failed to follow Enhanced Barrier Precautions for Resident #44 during medication administration via PEG tube. The resident had diagnoses including anoxic brain damage, contractures of the bilateral elbows, wrists, hands, and knees, tracheostomy dependence, and PEG tube dependence. The physician orders indicated the resident was on EBP and that EBP were required with high-contact resident activities. During observation, an EBP sign was posted outside the room, and two LPNs were present while one prepared and administered Baclofen via the PEG tube and the other flushed and checked placement of the tube. The LPN performing the PEG tube flush and medication administration did not don a gown before the procedure, and later confirmed that no PPE gown was worn prior to working with the resident’s PEG tube and administering the medication.
Failure to Follow Weight Orders, Double Portions, and Self-Administration Reassessment
Penalty
Summary
The facility failed to follow physician orders for daily weights and re-weighs for residents with significant weight changes. Resident #01, who had diagnoses including malignant neoplasm of the base of the tongue and was receiving enteral nutrition via gastrostomy tube, had multiple physician orders for weights and re-weighs when a 5-pound or greater change occurred, including orders requiring confirmation within one day. The record showed a significant weight loss from 148.0 pounds to 130.8 pounds, then continued weight loss with discrepant weights documented in December, but no timely re-weigh was completed to confirm the change. The DON confirmed the re-weigh completed on 12/22/25 was not timely and acknowledged that the ordered re-weigh and daily weights after the significant loss were not completed. Resident #01 also had a self-administration medication assessment that was completed on 02/02/24, with no evidence of a subsequent reassessment despite continued self-administration of medications and tube feedings. The care plan indicated the resident was permitted to self-administer bolus feedings and medications through the gastrostomy tube. The DON confirmed that self-administration medication assessments should be completed at least annually and acknowledged the assessment had not been completed timely. The facility also failed to ensure Resident #18 received double portions as ordered. Resident #18 had diagnoses including metabolic encephalopathy, type 1 diabetes mellitus, GERD, and obesity, and the care plan identified a nutritional problem with an intervention to provide and serve the diet as ordered. The physician order required a kosher diet with regular texture, thin liquids, and double portions. Meal tickets and direct observations of breakfast and lunch showed the resident was served regular trays without double portions, and the resident stated he needed additional food. CNA #309, RN #360, and LPN #350 confirmed the meal ticket did not reflect the double portion requirement and that the resident did not receive double portions at lunch.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure food was served at a palatable temperature. During resident interviews, Resident #30 stated that the food was terrible, arrived cold, and lacked flavor, and additional residents interviewed during the survey reported concerns that food was being served cold. The facility census was 85, including two residents receiving an NPO diet. During tray service observation, a test tray was not on the meal cart and staff stated it had been left in the kitchen. Staff later confirmed the test tray had remained in the kitchen for about 15 minutes after preparation and was not placed on the meal cart before service. At that time, lunch items were measured at about 60-80 degrees F and had not been tasted. During a breakfast meal pass observation, plated pancakes were 107 degrees F, sausage was 108 degrees F, and oatmeal was 133 degrees F. The Dietary Assistant Manager confirmed the pancakes and sausage were cold and stated he would not want to eat them cold for breakfast. The facility policy required hot foods to be held and served at least 135 degrees F and cold foods at 41 degrees F or below.
Pureed Diet Food Prepared at Incorrect Consistency
Penalty
Summary
The facility failed to ensure pureed foods were prepared in a form designed to meet individual needs for residents on a pureed diet, affecting Residents #1, #2, #96, #53, and #64. During observation of the pureed food preparation process, the surveyor observed the fish item intended for residents on a pureed diet and noted that it was stringy and not smooth. The fish had separable strands when processed with broth, and the texture was not appropriate for residents prescribed a pureed diet. The staff member preparing the food stated she was trying to remove the fish item from the pureed menu because it did not puree correctly and said residents did not like the consistency, but confirmed the item would continue to be served. The report also states that IDDSI Level 4 pureed foods must be smooth, hold their shape on a spoon, require no chewing, and not be stringy or require tongue manipulation to break apart.
Unsafe Room Temperature for Resident
Penalty
Summary
The facility failed to maintain safe and comfortable temperatures in Resident #36’s room. Resident #36 was admitted on 12/03/24 and had diagnoses including type II diabetes mellitus with other specified complication, morbid obesity, unsteadiness on feet, need for assistance with personal care, lymphedema, essential hypertension, muscle weakness, chronic pain syndrome, bilateral primary osteoarthritis of the hip, low back pain, and left bundle branch block. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. During observation, a CNA was seen wearing a winter coat in the hallway, and maintenance was in the resident’s room regarding the heater. The resident stated the heater had stopped working and that extra blankets were needed to stay warm. The thermostat in the room was observed at 69 degrees Fahrenheit with the heat set at 80 degrees Fahrenheit. The facility work order log showed a high-priority work order for heat not working in the resident’s room, but the issue was documented as checked, verified working, changed, and closed. Despite this, later observations still showed the room at 69 degrees Fahrenheit, and the next morning the thermostat remained at 69 degrees Fahrenheit. Maintenance later measured temperatures in the room ranging from 65 to 67 degrees Fahrenheit and stated the resident should have been temporarily moved to another room if the heater was not working properly overnight. Another maintenance member stated the window was cracked and the thermostat was changed. The facility policy on Extreme Heat/Extreme Cold states that when resident room temperatures are 71 degrees Fahrenheit or below, residents will be moved to another area or room that has heat.
Failure to Complete Baseline AIMS for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete a baseline abnormal involuntary movement scale (AIMS) for one resident who was admitted on psychotic medication. Resident #12 was admitted with diagnoses including bipolar disorder, catatonic disorder, dementia with behavioral disturbances, depression, insomnia, and other chronic conditions. The quarterly MDS indicated the resident had no cognitive deficit, showed indicators of depression, had no behaviors such as rejection of care, and received an antipsychotic, antidepressant, opioid, and anticonvulsant. The care plan identified the resident as using psychotropic medications and included monitoring for side effects, consulting with pharmacy, and considering dosage reduction when clinically appropriate. Review of physician orders showed Abilify 10 mg daily for bipolar disorder, and the medical record did not contain a baseline AIMS on admission. The first AIMS in the record was completed later by the facility contracted psychiatric company. During interview, the DON verified that no baseline AIMS was completed on admission. The facility policy stated that antipsychotic/psychotropic drug therapy shall be used only when necessary to treat a specific condition and that an AIMS test will be completed at minimum every six months.
Failure to Provide Routine Shaving for Dependent Resident
Penalty
Summary
The facility failed to ensure routine shaving was provided for a resident who was dependent on staff for bathing and personal hygiene. The resident was admitted with diagnoses including bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive, and intra-abdominal and pelvic swelling, mass and lump. The quarterly MDS indicated no cognitive deficit, indicators of depression, no behaviors including rejection of care, and dependence on staff for bathing and personal hygiene. The care plan directed staff to assist with daily bathing, hygiene, dressing, grooming, and oral care, and to provide shower bathing per the resident's personal preference. On observation, the resident had long chin hairs in the morning and continued to have long chin hair later that same day while resting quietly in bed. During interview, the CNA confirmed the resident had a scheduled shower that day and the chin hair was not shaved, stating she just did not have time to shave it. Facility policy titled "Shaving a Resident" stated residents are to be shaved on shower days and as needed.
Splint Orders Not Transcribed Correctly
Penalty
Summary
The facility failed to ensure prescribed splint orders were transcribed and implemented correctly for one resident. Resident #75 was admitted on 06/02/2025 with diagnoses including cerebral palsy, contracture of the right and left hand, and muscle weakness. The quarterly MDS 3.0 assessment documented long- and short-term memory problems and severely impaired cognition for daily decision-making. The care plan dated 07/07/25 identified the resident as at risk for or prone to contractures and included interventions for gentle ROM and application of a Royan Hand Brace to the right hand in the morning and removal at night for contracture of the right hand. The medical record also showed a physician order for a right-hand palm protector as tolerated to prevent skin integrity issues one time only for right-hand tightness for 12 months, ordered on 07/08/2025. However, a nursing progress note dated 07/07/2025 documented a new order for a right-hand brace due to contractures, and the Director of Therapy later confirmed the resident had orders for two different splints, including a palm protector and a splint to be worn during the day and removed at night. He also confirmed the palm protector order had been written incorrectly as one time only instead of daily as tolerated for 12 months.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for two residents who were identified as being at increased risk for falls. One resident, admitted with osteoarthritis, muscle weakness, and a history of falls, had a care plan that included keeping the call light within reach. After a fall in which the resident was found face down on the floor in the room between 4:00 A.M. and 5:00 A.M., the nursing assessment documented a laceration to the left lower leg, edema to the head and eye, and pain on touch, and the resident was sent to the emergency room and returned with sutures to the left lower leg. The resident stated she was reaching for the call light on the floor and rolled out of bed. Although the interdisciplinary team later updated the care plan to include keeping the bed in the lowest position, observation showed the bed was not in the lowest position, and the LPN confirmed it and lowered it immediately. Another resident, admitted with traumatic subarachnoid hemorrhage, muscle weakness, depression, and legal blindness, had a care plan identifying increased fall risk related to impaired strength and endurance, visual impairment, cognitive impairment, psychotropic and opioid use, and a history of falls. Interventions included keeping the call light within reach and providing staff assistance with mobility and transfers. The resident was found on the floor after attempting to get up to use the bathroom, and the nursing assessment noted the resident said he hit his head, with no new bruises observed and a pre-existing hematoma on the left side of the head. A family member stated staff had been told at admission and orientation that the resident was blind and could not see the call light, and the unit manager acknowledged that the intervention to move the resident closer to the nurses' station was not implemented until later and that no additional interventions were known to ensure the resident could properly use the call light for assistance.
Unlabeled Oxygen Tubing and Missing Change Dates
Penalty
Summary
The facility failed to label oxygen tubing for three residents who were receiving respiratory care. Resident #09 had diagnoses including COPD, heart failure, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen, and the record showed an oxygen order for 2 liters via nasal cannula. During observation, Resident #09’s nasal cannula tubing was not labeled and was stuck under the bedside table, and an LPN confirmed the tubing was not labeled. Resident #14 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure with hypercapnia, COPD, and dependence on supplemental oxygen, with an oxygen order for 2.5 liters via nasal cannula and an order for tubing to be changed every seven days. Observation showed Resident #14’s nasal cannula tubing was unlabeled, and the resident’s uncovered nebulizer mask was on top of the nightstand; the LPN confirmed the nebulizer mask should be in a bag when not in use and the nasal cannula tubing should be labeled. Resident #44 had diagnoses including anoxic brain damage, respiratory failure, and tracheostomy dependence, with an order for 6 liters of supplemental oxygen via tracheostomy mask with humidified air. Observation showed the oxygen concentrator in the bathroom with tubing attached and running across the room to the humidifier for the tracheostomy mask, and there was no date on the oxygen tubing to show when it had been changed. The Unit Manager confirmed there were no dates on the tubing and also verified that Resident #44 did not have physician orders for the oxygen tubing to be regularly changed. The facility policy titled Oxygen Therapy and Storage was reviewed as part of the investigation.
Failure to Obtain Ordered Daily Weights
Penalty
Summary
The facility failed to ensure a physician-ordered daily weight monitoring order was carried out for one resident. Resident #54 was admitted with diagnoses including hypocalcemia, cognitive communication deficit, atrial fibrillation, muscle weakness, chronic combined systolic and diastolic heart failure, hypertensive heart disease with heart failure, atherosclerotic heart disease with angina, hyperlipidemia, and pulmonary embolism. The resident’s admission assessment showed the resident was cognitively intact and had active heart and circulation diagnoses, and the care plan identified nutritional concerns related to the resident’s cardiac conditions and weight gain prior to admission, with interventions to obtain and monitor weight per policy. A physician order dated 11/21/25 directed daily weights and notification of the physician or nurse practitioner for a gain of three pounds or more in one day for chronic heart failure. Review of weight records showed weights on 11/18/25, 12/08/25, and 12/16/25, but the daily weight task record showed weights were only obtained on 12/16/25 and 12/18/25, and the TAR/MAR contained no recorded daily weights for November or December 2025. The DON confirmed the daily weights had not been obtained as ordered and stated the order was entered incorrectly as a no documentation order, so a prompt was not initiated. The Administrator confirmed the ordered daily weights were not obtained, and the LPN Unit Director stated she was unaware of the order. The dietician reported no concerns regarding weight loss or poor fluid management and attributed the resident’s weight loss to increased activity and improved food intake.
Failure to Follow Physician Hold Parameters for Medications
Penalty
Summary
The facility failed to ensure physician parameters were followed for medication administration for three residents. For one resident with osteomyelitis of the vertebra, discitis, chronic pain, bipolar disorder, PTSD, depression, and gout, there were two active Hydrocodone-acetaminophen orders with different doses, but the MAR did not list parameters for when to give one tablet versus two tablets. Nursing staff reported giving either one or two tablets based on their own assessment of pain, and the unit manager confirmed there was no documentation showing how those assessments were completed or that the resident’s pain scale parameters were consistently followed. For another resident with dementia, schizoaffective disorder, CHF, tachycardia, atrial fibrillation, long QT syndrome, orthostatic hypotension, and other cardiac diagnoses, orders for Hydrochlorothiazide and Metoprolol Succinate ER included hold parameters based on blood pressure and heart rate. Review of the MAR showed multiple administrations when the resident’s heart rate or systolic blood pressure was outside the ordered limits, and the unit manager confirmed the medications should not have been given on those occasions. The unit manager also confirmed there was no documentation that the physician was notified or that any further direction was received when the parameters were not met. For a third resident with seizures, atrial fibrillation, and hypertension, Metoprolol tartrate was ordered twice daily via PEG tube with instructions not to administer if systolic blood pressure was below 110 or heart rate was below 60. The MAR showed multiple occasions in August, September, November, and December 2025 when pulse or blood pressure was not monitored before administration of the medication, and the resident also had another antihypertensive given at 7:00 A.M. while the 8:00 P.M. dose was not being checked for vital signs. The unit director confirmed the MAR lacked pulse and blood pressure documentation on multiple occasions, and the facility policy required staff to document necessary medication administration information and verify the MAR reflected the most recent order.
Expired Tubersol Vials Kept in Medication Refrigerator
Penalty
Summary
The facility failed to remove expired Tubersol tuberculin solution from circulation and failed to ensure opened vials were labeled with an open date. During an observation at the medication storage refrigerator located at the nurses’ desk on the first hallway, an open half-used vial of Tubersol tuberculin solution was found without an open date on either the storage box or the vial. A second open half-used vial of Tubersol tuberculin solution was also observed, and this vial had an open date on it. Both vials had an expiration date of 10/2026. A review of the manufacturer guidelines for Tubersol dated 10/2021 stated that a vial of Tubersol that has been entered and in use for 30 days should be discarded and should not be used after the expiration date. The facility policy on Storage and Expiration Dating of Medications and Biologicals stated that once a medication or biological package is opened, the facility should follow manufacturer or supplier guidelines for expiration dates and record the date opened on the primary medication container when the medication has a shortened expiration date once opened. An interview with an LPN confirmed that the undated vial and the dated vial were in the medication storage refrigerator and stated that the vials should be dated when opened and used for only 30 days before being discarded.
Delayed and Missing Urine Specimens
Penalty
Summary
The facility failed to ensure physician-ordered urine screenings were collected in a timely manner for two residents. For one resident, who had diagnoses including type 2 diabetes mellitus, depression, chronic pain syndrome, constipation, anxiety, and arthritis, the record showed a physician visit summary noting leukocytosis and an order for urinalysis and culture and sensitivity. Orders for straight catheter urine collection were entered on multiple days, and progress notes documented that urine could not initially be obtained because there was insufficient urine. Staff later spoke with the nurse practitioner about the inability to obtain the specimen and received an order to place a catheter until enough urine was available. The record further showed that urine was eventually collected several days after the initial order, with the specimen collected on 11/19/25 after earlier attempts and repeated orders on 11/14/25, 11/17/25, and 11/18/25. The unit director confirmed that staff were expected to obtain urine specimens the day the order was received and have them ready for laboratory pickup the next morning, but also confirmed that the initial request was not successfully completed until day four. The physician later reviewed the pending lab results and the urine culture was positive for Klebsiella pneumoniae, with an order for Cipro. For the second resident, who had legal blindness, traumatic subarachnoid hemorrhage, repeated falls, muscle weakness, and an indwelling urinary catheter for urinary retention, the record showed a low-grade fever, confusion, and an elevated WBC count, followed by a CNP order for urinalysis and culture and sensitivity. The unit director stated the specimen was obtained, but the laboratory never received it and the specimen was never recovered at the facility. When the CNP later asked about the urinalysis results, the missing specimen was discovered and the tests had to be reordered. The physician order policy stated that the nurse taking the order is responsible for executing it or providing a safe hand-off, including notifying internal staff of changes or updates.
Unordered laboratory tests were completed for one resident
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained only when ordered by a practitioner for one resident. Resident #12 was admitted on 08/22/25 with diagnoses including bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive, and intra-abdominal and pelvic swelling, mass and lump. The resident’s quarterly MDS assessment indicated no cognitive deficit. Current physician orders included a lipid panel every 12 months and CBC, CMP, vitamin D level, TSH, and Lamictal level every six months. Review of the laboratory results showed the facility completed CBC, CMP, vitamin D level, TSH, and Lamictal testing on 09/05/25, 09/22/25, 09/23/25, 10/09/25, 10/31/25, 11/11/25, and 11/19/25 without a physician’s order. During interview on 12/18/2025, the DON verified that these laboratory tests were unnecessary and stated there was an order entry error with how the once-every-12-month and once-every-6-month lab orders were entered. The facility policy titled, Laboratory Services and Reporting, stated the community must provide or obtain laboratory services when ordered by a practitioner in accordance with state law.
Antibiotic Stewardship Not Followed for Resident With UTI Workup
Penalty
Summary
The facility failed to ensure antibiotic stewardship was followed for one resident reviewed for antibiotic use. The resident was cognitively intact and dependent on staff for personal hygiene and toilet transfers, with substantial to maximal assistance needed for bed mobility. The care plan identified the resident as prone to bowel and bladder alterations and included monitoring urine and obtaining urine specimens as ordered. After a physician visit summary noted leukocytosis with a white blood cell count of 13.3 and ordered a urinalysis and culture and sensitivity, straight catheter orders were entered and urine was collected and stored in the unit refrigerator. The physician later documented follow-up on labs in the context of UTI and ordered ciprofloxacin for seven days before the full culture and sensitivity results were available. The resident received two doses of ciprofloxacin, and later laboratory results showed growth of Klebsiella pneumoniae and Escherichia coli, with E. coli resistant to ciprofloxacin and nitrofurantoin susceptible to both organisms. The resident was then ordered Macrobid. The infection preventionist confirmed ciprofloxacin was started before the full culture and sensitivity returned, acknowledged the E. coli resistance to ciprofloxacin, and confirmed the culture results were below the threshold for antibiotic initiation. The McGeer criteria checklist dated 11/21/25 indicated the resident did not meet criteria for UTI and had no required clinical signs, symptoms, or qualifying microbiological criteria.
Inadequate Incontinence Care Provided by CNA
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate incontinence care to a resident who was always incontinent of bowel and bladder. The resident had severe cognitive impairment and required total assistance with activities of daily living, including toileting and personal hygiene. During observed incontinence care, the CNA washed and rinsed the vaginal area and creases, then applied a clean adult brief, but did not dry the vaginal area as required by facility policy. Additionally, the CNA did not cleanse or dry the resident's buttocks, rectal, or coccyx area during the care process. The CNA confirmed in an interview that these steps were omitted. Facility policy specifies that after washing and rinsing, the genital area should be dried, and the rectal area should be washed, rinsed, and dried using a clean area of the washcloth for each stroke. The failure to follow these procedures resulted in non-compliance with the facility's incontinence care policy.
Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
The facility failed to maintain infection control practices during meal tray service, as observed with three residents. Certified nursing assistant (CNA) #100 was seen assisting residents with meal tray setup and other tasks, such as raising the head of the bed and removing linens, without performing hand hygiene before or after these activities. This occurred despite the presence of hand sanitizer on the meal delivery cart and the facility's policy requiring hand hygiene by all employees. CNA #100 confirmed during interviews that hand hygiene was not performed during the lunch tray pass. The residents involved had significant medical histories, including dementia, diabetes mellitus with chronic kidney disease, Crohn's disease, heart failure, arthritis, peripheral vascular disease, and cognitive impairment. Observations were made both in resident rooms and the dining area, affecting all three residents observed during the meal service. The failure to perform hand hygiene had the potential to impact all thirteen residents on the unit, with a total facility census of seventy-six.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Care
Penalty
Summary
A cognitively impaired resident with multiple comorbidities, including diabetes, peripheral vascular disease, and a recent surgical amputation, was admitted to the facility with a documented skin alteration to the coccyx. Upon admission, there were inconsistencies in the assessment and documentation of the resident's skin condition, with records alternately describing the area as moisture-associated skin damage (MASD), an open area, and an unstageable pressure ulcer. The initial assessments failed to provide a comprehensive description, staging, or measurements of the wound, and there was no clear photographic evidence to support the presence or stage of a pressure ulcer. Despite care plans and physician orders for skin care interventions, such as the application of Triad paste and HydraGuard, there was no documented evidence that staff consistently provided or encouraged turning and repositioning every two hours as required. Additionally, the facility failed to ensure timely notification and involvement of the wound nurse and wound physician when the skin alteration was first identified. The wound physician was not made aware of the resident's condition until several days after admission, and the wound nurse was not notified at all during the initial period. Weekly skin assessments and wound documentation were either incomplete or missing, with staff failing to document wound descriptions, measurements, or photographs as required by facility policy. The lack of comprehensive assessment, documentation, and timely intervention led to the deterioration of the resident's skin condition, resulting in the development of an unstageable pressure ulcer with necrosis that required debridement. The facility's failure to implement a resident-centered plan for the prevention and treatment of pressure ulcers, including appropriate assessment, documentation, and communication among staff and consulting clinicians, directly contributed to actual harm to the resident.
Failure to Conduct Thorough Investigation of Alleged Sexual Assault
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual assault involving a resident with severely impaired cognitive skills, who was admitted with multiple diagnoses including a urinary tract infection, Parkinson's disease, fibromyalgia, and dystonia. The resident, who was incontinent of bowel and bladder, reported to her daughter that she had been raped by a male staff member. The allegation was reported to the facility, and a self-reported incident was created. The resident described the alleged perpetrator as a short man with short black hair, but the only male CNA on duty did not match this description, and no other males were present according to the staff schedule and employee list. The resident was assessed, and no immediate signs of abuse were found, though a full body assessment later revealed multiple bruises and a hematoma. The facility's investigation was limited in scope. Only staff working the night shift on the date of the alleged incident were interviewed, and staff who provided care during the following day were not questioned about the resident's condition or demeanor. Statements from key staff, including the accused CNA, were not obtained until several days after the incident, and the investigation did not address new findings of bruising to the back of the resident's knees. Documentation of the bruising was incomplete, lacking photographs, measurements, or detailed descriptions. The facility's policy required interviews with all relevant witnesses and thorough documentation, but these steps were not fully followed. The resident was ultimately sent to the hospital for examination, where a rape kit was performed, and a police report was filed by the family. The family also requested additional safety measures for the resident. Despite these actions, the facility's internal investigation did not meet its own policy standards for thoroughness, as it failed to interview all potentially relevant staff, did not fully document physical findings, and delayed obtaining statements from involved personnel. The deficiency centers on the incomplete and insufficient investigation of the abuse allegation.
Failure to Complete Physician-Ordered Treatments, Medications, and Lab Testing
Penalty
Summary
The facility failed to provide treatments, administer medications, and obtain laboratory testing as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open surgical wound. The resident was at risk for skin breakdown and had a physician order for daily wound care, but the treatment administration record showed no evidence that the wound care was completed on several specified days. The Director of Nursing confirmed there was no documentation of the required treatments on those dates, despite facility policy requiring immediate documentation after treatment. Additionally, the resident experienced critically low potassium levels as revealed by laboratory results. Although the physician provided orders for immediate administration of potassium and anti-nausea medication, there was no evidence in the medical record that these medications were administered or that the orders were entered as required. Interviews with nursing staff confirmed a lack of recall or documentation regarding the administration of these medications, and the DON verified the absence of evidence for the ordered interventions. Facility policy required that verbal orders be transcribed and executed or safely handed off, but this process was not followed in this case.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, and an open wound. The resident had a critically low potassium level identified through laboratory testing, which prompted the physician to order immediate administration of potassium chloride and additional laboratory tests, specifically a comprehensive metabolic panel (CMP) and magnesium level. The orders were communicated by an RN to an LPN, who acknowledged understanding of the instructions. Despite these orders, only a basic metabolic panel (BMP) was completed, and the required CMP and magnesium tests were not performed. The failure was confirmed through closed record review and interviews, with the DON verifying that the orders for the additional blood work were not entered into the medical record. The LPN involved could not recall details about the potassium or the ordered blood work, and the RN confirmed that the orders were relayed but not executed. Facility policies required nurses to transcribe and execute physician orders or ensure a safe hand-off, and to contact laboratory services as needed, but these procedures were not followed in this instance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to assess, monitor, and implement a comprehensive and individualized pressure ulcer prevention program for two residents, resulting in the development and inadequate management of pressure ulcers. One resident, who was dependent on staff for bed mobility and used a wheelchair, was admitted without skin issues but was identified as at risk for skin breakdown. Despite care plans and physician orders for preventive measures such as floating heels and regular repositioning, the resident developed an unstageable pressure ulcer on the left heel. The ulcer was not discovered until it had progressed significantly, and there was no evidence of timely intervention, assessment, or notification to the physician at the time of discovery. The facility did not implement appropriate offloading interventions or wound care until several days after the ulcer was identified. Another resident was admitted with multiple complex medical conditions, including end-stage renal disease and an unstageable pressure ulcer to the sacrum and right heel, as documented in the hospital discharge summary. However, the facility's admission assessment failed to identify these skin issues, and the resident was not comprehensively assessed for pressure ulcers upon admission. There was a delay of two days before any wound treatment was initiated, and the required comprehensive wound assessment and documentation were not completed as per facility policy. Both cases demonstrate a lack of timely and thorough skin assessments, failure to implement and document individualized interventions, and delays in initiating appropriate wound care. The facility's actions did not align with its own wound care policy, which requires prompt assessment, documentation, and intervention for residents at risk of or presenting with pressure ulcers. These deficiencies resulted in actual harm to at least one resident and affected two out of three residents reviewed for pressure ulcers.
Failure to Ensure Privacy for Residents with Indwelling Catheters
Penalty
Summary
Surveyors identified that two residents were not treated in a dignified manner due to the facility's failure to ensure privacy for residents with indwelling urinary catheters. One resident, admitted with multiple diagnoses including surgical aftercare, chronic kidney disease, and lymphoma, was observed with a visible urinary catheter collection bag containing clear yellow urine that could be seen from the hallway. The resident's medical orders specified that the urinary drainage bag should have a cover over it every shift, but no privacy bag was present in the room at the time of observation. An LPN confirmed that the catheter bag was not contained in a privacy bag and was visible from the hallway. Another resident, with a history of acute transverse myelitis, quadriplegia, and other chronic conditions, was observed mobilizing in a power wheelchair with the indwelling urinary catheter collection bag resting on the footrest, uncovered and visible while moving down the hallway. This resident's physician orders also required a privacy cover for the urinary drainage bag every shift. An LPN verified that the catheter bag was not contained in a privacy bag and urine was visible as the resident moved through the hallway. These observations demonstrated the facility's failure to maintain resident dignity as required by their care plans and physician orders.
Failure to Notify Physician of Unstageable Deep Tissue Injury
Penalty
Summary
The facility failed to notify a resident's primary care physician of an unstageable deep tissue injury (DTI) to the resident's left heel at the time of discovery. The resident, who had multiple diagnoses including COPD, pressure-induced deep tissue damage, and a history of traumatic brain injury, was found by a CNA to have a dark, painful mark on the left heel. The nurse observed an 8.0 cm unstageable pressure area with intact skin and notified management and the resident's power of attorney, but did not notify the physician. The weekly skin and wound evaluation confirmed the presence of an unstageable pressure ulcer with slough and/or eschar, but lacked a detailed wound description. Medical record review showed no evidence of treatment or intervention for the unstageable DTI at the time of discovery, nor documentation that the physician was informed. The resident's quarterly MDS assessment indicated risk for skin breakdown and the presence of an unstageable pressure ulcer not present on admission, with interventions such as pressure-reducing devices and skin care in place. The Director of Nursing later verified that the physician had not been notified when the wound was first identified. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in a resident's condition, which was not followed in this instance.
Failure to Document and Communicate Required Transfer Information
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including dementia with behavioral disturbances, diabetes, hypertension, and a history of repeated falls, was transferred from the facility to an acute care hospital. The resident, who had a severe cognitive deficit, was assessed by a nurse after becoming unresponsive to commands, and the transfer to the emergency room was initiated at the request of the resident's son. However, the medical record review revealed that there was no documentation of the disposition of the resident's transfer or the required information provided to the receiving provider. Specifically, the facility failed to document essential transfer information such as the physician responsible for the resident's care, resident representative information, advance directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary details to ensure a safe and effective transition. The Director of Nursing confirmed that there was no evidence in the medical record that the receiving facility received the required information, and the transfer itself was not properly documented, which was not in accordance with the facility's own policy.
Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for a resident with an indwelling medical device. During an observation of incontinence care provided to a resident with multiple diagnoses, including dementia, chronic pulmonary edema, hepatic failure, and a stage IV sacral pressure ulcer, staff were seen performing incontinence care without donning a disposable gown, despite the presence of a gastrostomy tube. The care plan for the resident indicated a high risk for infection due to incontinence and the use of an indwelling device. Certified Nursing Assistants (CNAs) washed their hands and wore gloves but did not use a gown during high-contact care activities, such as changing briefs and cleansing the resident. Both CNAs confirmed in an interview that EBP, specifically the use of a disposable gown, was not maintained during the procedure. Facility policy required the use of gowns and gloves during high-contact care for residents with indwelling medical devices, but this protocol was not followed during the observed care event.
Deficiencies in Skin Assessment and Treatment Orders
Penalty
Summary
The facility failed to ensure accurate and timely weekly skin assessments and treatment orders for two residents, leading to deficiencies in care. Resident #21, who was admitted with conditions including unspecified dementia and a need for assistance with personal care, had a treatment order for a skin alteration under the right breast. However, there were no weekly skin assessments documented to monitor the wound, as confirmed by the Director of Nursing (DON). Resident #41, admitted with conditions such as acute kidney failure and type 2 diabetes, had multiple wounds upon admission, including arterial wounds on the right leg and a surgical wound on the right knee. The plan of care did not include these wounds, and there were no documented skin assessments or treatments for these wounds from admission through mid-November. The DON confirmed that the orders for wound care were placed late, and there was a lack of documentation regarding the wounds' types, locations, and descriptions. The facility's policies required specific documentation and weekly assessments for wounds, which were not followed in these cases. The deficiencies were identified during an investigation under several complaint numbers, highlighting the facility's non-compliance with its wound and skin care program guidelines.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident abuse to the State agency within the required timeframe. Resident #46, who was cognitively intact and had multiple medical conditions including chronic respiratory failure, cirrhosis, and dementia, was involved in the incident. An allegation of abuse was reported to an LPN on the evening of 12/16/24, who then informed the DON. The DON subsequently notified the Administrator. However, the Administrator did not report the allegation to the State agency until the following day, exceeding the two-hour reporting requirement for abuse allegations. The facility's policy mandates that allegations of abuse or serious bodily injury be reported to the State Department of Health immediately, but no later than two hours after the allegation is made. The Administrator misunderstood the policy, believing he had 24 hours to report the incident due to the absence of significant injury to the resident. This misunderstanding led to the delay in reporting the abuse allegation, resulting in a deficiency finding during the survey related to Complaint Number OH00160901.
Failure to Honor DNRCC Code Status
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate Comfort Care (DNRCC) code status, resulting in the administration of life-saving measures and cardiopulmonary resuscitation (CPR) after the resident experienced cardiac arrest. The resident, who had diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, and viral hepatitis B, was found by a State tested Nursing Assistant (STNA) to be having difficulty breathing. A Licensed Practical Nurse (LPN) was informed and, upon assessing the situation, called for assistance from the Assistant Director of Nursing (ADON). Despite the resident's DNRCC status, CPR was initiated due to a miscommunication regarding the resident's code status. The incident occurred when the LPN, after being alerted to the resident's distress, mistakenly provided the wrong room number to the ADON, leading to the incorrect assumption that the resident had a full code status. As a result, CPR was administered until emergency medical services arrived. It was only after the resident was transported to the hospital that the error was discovered, revealing that the resident had a DNRCC code status. Unfortunately, the resident did not survive the incident.
Failure to Obtain Urine Sample and Incorrect Catheter Placement
Penalty
Summary
The facility failed to obtain ordered urine samples for testing due to cloudy urine for Resident #196, who was admitted with diagnoses including end-stage renal disease and urinary tract infections. The resident required an indwelling catheter for urine elimination and was dependent on staff for personal care. On a specific date, a nurse received a verbal order to change the Foley catheter and perform a urine dip test due to the cloudy appearance of the urine. However, the urine sample was not obtained, and the order was not documented as completed. Subsequently, the resident experienced no urine output overnight, and it was discovered that the Foley catheter was incorrectly placed in the vagina instead of the bladder. After reinsertion, 350 ml of urine was returned, but there was no documentation indicating that a urine sample was collected. The resident later presented with symptoms of nausea, labored breathing, and confusion, leading to hospitalization where she was diagnosed with an acute complicated urinary tract infection due to the chronic indwelling Foley catheter. The Director of Nursing (DON) revealed that the nurse involved could not recall if the physician was updated about the inability to obtain the urine sample. The facility's policy on catheter care emphasizes meeting the psychosocial, physical, and emotional needs of residents, yet the failure to complete the urine test and the incorrect catheter placement contributed to the resident's hospitalization. This deficiency was investigated under a specific complaint number.
Infection Control Deficiency During Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control measures during catheter care for a resident. The resident, who had end-stage renal disease, urinary tract infections, and required assistance with personal care, was observed to have intact cognition and was dependent on staff for toileting and personal hygiene. During an observation, a CNA was seen wearing a gown and gloves while performing catheter care but used alcohol wipes incorrectly by wiping towards the body instead of away. Additionally, the CNA used the same gloves to adjust the bed and cover the resident after completing the care, which violated infection control protocols. The Assistant Director of Nursing (ADON) was present during the procedure and confirmed that infection control measures were not maintained. The facility's policy on hand hygiene, dated March 31, 2022, requires hand hygiene before and after caring for a resident and after glove removal. This incident was identified during an investigation for a specific complaint, indicating a deficiency in the facility's infection control practices.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terrace Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 4 | 1 |
| Mohun Health Care Center | 3 mi | ★★★★★ | 8 | 0 |
| Eastland Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Majestic Care Of Whitehall | 3.7 mi | ★★★★★ | 9 | 0 |
| Ohio Living Westminster-thurber | 4.4 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.