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 Willow Woods Rehabilitation And Nursing during CMS and state inspections, most recent first.
Unclean and Poorly Maintained Resident Areas: Multiple resident rooms on a secured unit had scrape damage, missing paint, missing molding, and one broken closet door, while common areas had sticky, scuffed floors with dried spills, dirt, and debris. The MD confirmed the rooms needed maintenance, and the Housekeeper stated the floors had been neglected and lacked deep cleaning.
A resident with intact cognition and diagnoses including fibromyalgia, depression, and anxiety reported that staff would not heat leftover food items for her and that she had to throw food away. She said the DON and Administrator told her this was facility policy and referenced cross-contamination, while staff interviews confirmed the issue had been brought to Administration. The facility had microwaves available in several areas, and the Administrator stated food needed to be heated in the kitchen with a temperature obtained.
A resident with CHF, mood disorder, schizophrenia, pulmonary disease, DM, sleep apnea, and morbid obesity displayed repeated behavioral symptoms including agitation, yelling, accusations that staff were poisoning him or threatening him, distrust of medication administration, verbal abuse, and refusal of care. The care plan listed general behavioral interventions, but staff stated it did not include individualized measures already being used, such as having the resident watch meds being dispensed, using two staff for direct care, and having two housekeeping staff present during room cleaning.
A resident with severe cognitive impairment and постоянly incontinent of bowel and bladder received incontinence care using wipes, but CNAs stated they could not dry the resident because towels and washcloths were unavailable. Observation of unit linen closets showed sheets and blankets but no towels or washcloths, and the DON/Administrator acknowledged the facility was running low on linens.
Medication Administration Errors Exceeded Allowed Rate: During observed med passes, two medication errors were identified among five residents, resulting in a 6% error rate. An RN incorrectly measured polyethylene glycol 3350 for one resident, and another RN failed to administer an ordered zinc supplement to a second resident. The residents had multiple chronic conditions, including dysphagia, cognitive communication deficits, and other significant medical diagnoses.
Surveyors found that dietary staff were inaccurately measuring food portions because they misunderstood scoop sizes and lacked appropriate measuring tools. One staff member consistently used a size 16 scoop, believing it provided three ounces of meat for mechanical soft diets, when it actually provided only two ounces, contrary to the written menu and a posted scoop chart. Additionally, potato portions for both regular and modified diets were served using a spaghetti-style utensil or by hand with gloves, without any measurement to ensure the ordered four-ounce portions. These practices affected multiple residents on mechanical soft and regular diets and showed that prescribed menu portions were not being followed.
Staff failed to follow food safety and sanitation practices during meal preparation and in the storage of perishable food brought by families. During a dinner service, a staff member allowed a thermometer cord that had been on multiple kitchen surfaces to contact ready-to-eat food and used the same contaminated gloves to open a cupboard, handle bowls, and continue serving buns and potatoes without handwashing or changing gloves, contrary to facility policy. On a resident unit, an LPN confirmed that multiple labeled take-out containers in a refrigerator were kept beyond the facility’s three-day limit and that one container’s date was illegible, despite policy requiring clear labeling and timely discarding of perishable items. These failures affected or had the potential to affect numerous residents receiving regular-texture diets.
The facility failed to maintain clean, private, and homelike resident rooms, as multiple cognitively intact residents reported that blinds did not fully cover their windows, leaving gaps that allowed light in and visibility from the parking lot. Observations confirmed short and broken blinds in several rooms facing the parking lot, stained privacy curtains, and dust and debris on windowsills, dressers, and other surfaces. Some residents reported difficulty sleeping due to light entering their rooms and concerns about being seen while using bedside commodes. Staff, including housekeeping, CNAs, an RN, an LPN, laundry, and maintenance, acknowledged that resident rooms were not being dusted regularly, many privacy curtains were dirty, there was no schedule for curtain cleaning, and blinds were too short or broken, contrary to the facility’s homelike environment policy.
A resident with impaired cognition and significant physical limitations was left unattended in a Sara Steady lift by a CNA, contrary to manufacturer guidelines and facility policy. The resident was found unresponsive and required emergency intervention after being left alone in the lift for several minutes, resulting in cardiac arrest and subsequent transfer to the hospital, where the resident later died. The incident was attributed to failure to follow lift protocols and lack of supervision.
A resident with a history of wandering and multiple psychiatric diagnoses exited a locked unit through a fire door after staff failed to respond appropriately to a door alarm. The alarm was silenced without a head count or notification to nursing staff, and the resident was later found at another facility. Required procedures for investigating and reporting missing residents were not followed.
A resident with mental health diagnoses and mild intellectual disabilities was involved in a verbal and physical altercation with a CNA after attempting to move another resident in a wheelchair. The CNA confronted the resident, leading to a fight in which the CNA initiated physical contact, resulting in the resident being pushed to the ground and hitting her head. Witnesses and a police report confirmed the CNA was the aggressor, and the incident was determined to be staff-to-resident physical abuse.
The facility did not ensure that residents and their legal representatives were properly notified or involved in care conferences, as required by policy. Multiple residents with cognitive impairments and their guardians or POAs were not invited to participate in care planning, and there was no documentation of notification or attendance. Staff interviews confirmed that notifications were not consistently documented, and representatives reported not being informed about care meetings or changes in care.
The facility did not ensure that food and nutrition services staff attended care conferences as required, with the DON instead completing dietary sections of care plans. Multiple residents with complex medical conditions were affected, and interviews confirmed that dietary staff had not participated in these meetings due to staffing challenges.
The facility did not provide the correct dessert to all residents on a Reduced Concentrated Sweets (RCS) diet during lunch, serving brownies or pureed brownies instead of the required fresh fruit, despite physician orders and care plans specifying the need for therapeutic diets due to conditions such as diabetes and dysphagia. Dietary staff confirmed the error, and facility policy required adherence to prescribed diets.
A resident with cognitive impairment and a history of falls was found with a wedge cushion placed between the mattress and bed frame to prevent falling, while the bed was positioned against the wall on the other side. Staff confirmed the wedge was used to restrict movement and prevent the resident from climbing out of bed, but there was no care plan documentation or physician order for this intervention, and facility policy prohibits physical restraints not required for medical treatment.
A resident with multiple medical conditions and frequent incontinence did not have incontinence care addressed in their care plan, despite requiring extensive assistance with activities of daily living. The omission was confirmed by the MDS RN, and the facility's policy requires comprehensive, person-centered care plans with measurable objectives.
A resident with hyponatremia and a physician-ordered 1500 ml fluid restriction did not have their fluid intake properly tracked or coordinated between nursing and dietary staff. Nursing acknowledged the restriction but did not document actual fluid amounts given, while dietary limited only beverages and not other fluid-containing foods. Lack of communication and tracking made it impossible to ensure compliance with the fluid restriction.
A resident with known aggressive behaviors physically assaulted another resident, causing harm. The aggressive resident had a history of psychosis and dementia, and the facility failed to adequately monitor and manage these behaviors, leading to the incident.
A resident with severe cognitive impairment sustained a second-degree burn after accessing a lighter brought into the facility by another resident. The incident occurred due to inadequate supervision and failure to enforce the facility's smoking policy, which prohibited residents from keeping smoking materials. The resident required emergency treatment and follow-up care for the burn.
The facility failed to provide written notice of room changes to residents and their representatives, affecting eight residents with various conditions such as schizophrenia and dementia. The facility's policy required advance notice and documentation, but this was not followed, leading to a deficiency. The administrator was unaware of the requirement, and the absence of a social worker designee contributed to the oversight.
A facility failed to develop a comprehensive care plan for a resident with a history of cognitive impairment and aggressive behaviors. Despite multiple incidents of aggression, the care plan was not updated in a timely manner to address these issues. Interviews confirmed that staff were aware of the resident's behavioral history, but a behavior care plan was only initiated after physical aggression occurred.
The facility failed to maintain a sanitary kitchen, affecting nearly all residents. A drain under the dishwasher flooded the kitchen with foul-smelling liquid, and staff had to walk through the contaminated material while preparing and serving food. Despite directives to use disposable dishware, the issue persisted for over a month, causing health concerns among staff and permeating the Buckeye unit with a strong odor.
The facility failed to maintain a homelike environment on the Buckeye unit due to a malfunctioning drain under the kitchen dishwasher, emitting a strong odor resembling fecal matter and sour milk. This issue persisted for over a month, affecting all 31 residents and was confirmed by multiple staff members and residents.
A resident was not treated in a dignified manner while being assisted with her meal, as an STNA was observed talking on a personal cellphone and standing over the resident. The resident confirmed that this was a recurring issue, and facility policies on cellphone use and meal assistance were violated.
Unclean and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to ensure a clean and sanitary environment in good repair on the Buckeye secured unit and throughout common areas of the building. During a tour of the Buckeye unit, multiple resident rooms had scrape damage and missing paint on the wall surfaces, and one room also had missing molding. One resident room had a broken closet door. The affected rooms included those occupied by residents #75, #1, #20, #40, #45, #7, #38, #33, #9, #16, #76, #35, #65, #57, #56, and #24. A separate tour of the facility revealed the floors in hallways, dining areas, gathering areas, and resident care areas were sticky, scuffed, and had dried liquid spills, ground-in dirt, and debris throughout. The Housekeeper stated the floors had been neglected, were sticky with dried spills and debris, and appeared dull and scratched in need of deep cleaning. The Maintenance Director confirmed the resident rooms on the Buckeye unit required maintenance and stated he was only one person and the facility had taken away his assistant.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to honor Resident #1’s preference to have leftover food items heated up. Resident #1 was admitted with diagnoses including fibromyalgia, depression, and anxiety disorder, and her quarterly MDS assessment indicated intact cognition. She reported that staff refused to heat up leftovers and that she had to throw food away. She stated the DON told her this was facility policy and that the Administrator said the same thing, with the explanation related to cross-contamination. Resident #1 also stated she had asked the kitchen to heat items for her but was told they could not do so, and she said she ordered food from outside vendors because she could not eat the meals brought in. Staff interviews confirmed the resident had raised the issue with Administration. The SSD stated the resident reported to the DON that staff were not heating leftover food, and the DON told her staff were not allowed to heat the food per the Administrator. RN and Maintenance Director interviews confirmed the facility had microwaves in multiple locations, including the nursing office, therapy room, kitchen, and maintenance office. The Administrator stated she had told staff that food needed to be heated in the kitchen with a temperature obtained. The facility policy on foods brought by family/visitors stated liberalized diets would be permitted as much as possible and that staff must be aware of and approve foods brought to a resident by family or visitors.
Care Plan Not Individualized for Behavioral Symptoms
Penalty
Summary
The facility failed to revise Resident #78’s care plan with individualized interventions to address his behaviors. Resident #78 was admitted with diagnoses including CHF, mood disorder, schizophrenia, pulmonary disease, DM, sleep apnea, and morbid obesity. Clinical notes from 02/14/26 through 05/01/26 documented behaviors including agitation, yelling and screaming at staff, accusations that staff were poisoning him, threats that staff would harm him, distrust of medication administration, accusations that housekeeping moved his belongings, verbal abuse toward staff, and refusal of care. The care plan identified behavioral symptoms such as accusatory statements, verbal aggression, and noncompliance with care and medication administration related to schizophrenia and mood disorder, with goals for the resident not to harm himself or others and for safety to be maintained through 07/28/26. Interventions listed included contracting with the resident as needed, documenting behaviors, attempting to identify patterns, notifying supervising nurses of negative behaviors, and offering foods of choice within dietary orders. Staff interviews stated that the resident needed to watch nurses dispense medications from the original packaging into a medication cup or he would refuse medications, that two housekeeping staff members needed to be present while cleaning his room due to accusations of stealing or looking through belongings, and that two staff members needed to be present during direct care due to accusations of abuse. Staff verified these interventions were not included in the care plan.
Inadequate Incontinence Care Due to Lack of Linens
Penalty
Summary
The facility failed to ensure adequate incontinence care for Resident #20, who was admitted with diagnoses including schizoaffective disorder, muscle wasting, and hypothyroidism and resided on the Buckeye secured unit. The resident’s Quarterly MDS showed severe cognitive impairment and that the resident was always incontinent of bowel and bladder. During observation of morning ADL care, CNA #732 and CNA #769 cleansed the resident’s peri area and coccyx with disposable wipes, but stated they could not dry the resident because no towels or washcloths were available for use. A subsequent observation of the first and second linen closets on the Buckeye secured unit showed several sheets and blankets but no towels or washcloths. CNA #732 stated there were no linens for staff use on a regular basis and confirmed the facility did not have towels to dry Resident #20 following incontinence care. The Administrator stated she was aware the facility was running low on linens and that new linens were ordered. The facility’s Incontinence Care policy stated staff and practitioners will appropriately screen for and manage individuals with urinary incontinence and provide appropriate services and treatment to help residents restore or improve bladder function and prevent UTIs to the extent possible.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents during observed medication passes, resulting in a six percent medication error rate. During observation of four nurses administering 30 medications with 31 opportunities for error, two medication errors were identified. The report states this affected two out of five residents observed during medication administration, and the facility census was 76. For one resident with diagnoses including malnutrition, pleural effusion, cognitive communication deficit, stroke, TIA, spastic hemiplegia, dysphagia, hyperlipidemia, constipation, aortic valve stenosis, mental disorder, and aphasia, an RN administered polyethylene glycol 3350 but measured the powder incorrectly by pouring it only to the first line of the cap instead of the top inner white line indicated on the bottle. For another resident with diagnoses including chronic respiratory failure, malnutrition, COPD, GERD, diabetes mellitus type II, hyperlipidemia, hypertension, obstructive sleep apnea, dysphagia, cognitive communication deficit, and chronic venous hypertension, an RN administered the ordered morning medications but failed to give zinc 50 mg by mouth as prescribed. Both nurses acknowledged the errors during interview.
Inaccurate Portion Control and Lack of Measuring Tools in Dietary Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure menus were followed with accurate portion sizes due to inadequate staff training and lack of proper measuring tools. During an evening meal service, a dietary staff member used a size 16 scoop for mechanical soft meat, repeatedly identifying it as three ounces, while a chart on the wall and the Dietary Manager confirmed that a size 16 scoop equaled only two ounces. The menu required three ounces of meat for residents on mechanical soft diets, but a three-ounce scoop could not be located. The staff member reported she had worked at the facility for 4.5 years and had always believed, based on prior instruction, that the size 16 scoop was three ounces. This error directly conflicted with the posted scoop chart and the written menu requirements. Further observations showed that residents on regular diets were ordered four ounces of red skin potatoes, while residents on mechanical soft and low concentrated sweet diets were to receive four ounces of potato wedges, but no accurate measuring was performed for the potato portions. For the first tray, a utensil shaped like a spaghetti scoop was used to serve potato wedges, and for all other trays (except pureed diets), potato wedges were picked up by hand with a gloved hand without any measurement. The Dietary Manager stated she attempted to locate tongs for serving the wedges but could not find any. These practices affected residents receiving mechanical soft diets and those receiving regular texture food, as identified by the facility, and demonstrated that menus were not being followed with respect to prescribed portion sizes due to staff misunderstanding of scoop sizes and the absence of appropriate measuring tools.
Improper Food Handling and Storage Practices Compromise Sanitation Standards
Penalty
Summary
The deficiency involves failure to prepare and handle food in a sanitary manner and to store resident food brought from outside sources according to facility policy. During dinner meal preparation and service, a staff member monitoring food temperatures allowed the cord of a thermometer, which had been observed resting on multiple kitchen surfaces, to come into direct contact with potato wedges for approximately 30 seconds, while only the probe portion of the thermometer was routinely cleaned. During the same tray line, when a plate required double portions and there was not enough room on the plate, the same staff member used a gloved hand that had been handling hoagie buns and potato wedges to open a cupboard and retrieve bowls. The inner part of the top bowl and the outside of the bottom bowl came into contact with the contaminated gloves, and the staff member then returned to the steam table and continued handling buns and potatoes with the same gloves. The Dietary Manager confirmed the thermometer cord should not have contacted food and that the staff member should have washed hands and changed gloves after touching the cupboard, consistent with the facility’s Food Safety and Sanitation policy requiring handwashing after touching surfaces or items with potential for contamination. A separate deficiency was identified in the storage of perishable food brought in by families or visitors. On a resident unit refrigerator, surveyors observed two large Styrofoam carry-out containers and a Styrofoam bowl labeled with a resident’s name. Two containers were clearly dated with “03/01,” and the third container had only a partially legible date showing the number “3.” An LPN verified the dates and stated that food was only supposed to be kept for three days. The facility’s policy on Food Brought by Family/Visitors required perishable foods to be stored in resealable containers with tightly fitting lids, labeled with the resident’s name, item, and use-by date, and directed nursing staff to discard perishable foods on or before the use-by date. These practices were not followed, affecting or having the potential to affect 53 residents on regular-texture diets out of a census of 73 residents.
Failure to Maintain Clean, Private, and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, specifically related to inadequate window coverings, unclean privacy curtains, and insufficient room cleaning. Multiple cognitively intact residents with various medical and psychiatric diagnoses reported that their room blinds did not extend to the windowsills, leaving gaps that allowed light into the room and permitted visibility from the facility parking lot into their rooms. Observations confirmed that in several rooms facing the parking lot, the blinds were too short, had broken slats, and left gaps of four to twelve inches between the bottom of the blinds and the windowsills. Residents reported difficulty achieving a dark room for sleep and concerns that people in the parking lot could see into their rooms, including when using bedside commodes. In addition to the window blind issues, surveyors observed stained and unclean privacy curtains and dust and debris in resident rooms. In one resident’s room, there were various colored stains on the privacy curtain, a visible layer of white dust on the dresser and TV base, and a windowsill with a buildup of dirt and debris, including dried flower petals. Another resident’s privacy curtain had dark brown stains, and another had multiple orange stains. Several residents stated they had not seen anyone dusting their rooms and believed their privacy curtains had not been cleaned since admission, with one resident reporting that he had to dust his own room and another stating the curtain had never been cleaned during nearly two years at the facility. Staff interviews corroborated these observations and resident reports. A housekeeper stated that on the day of the survey she was the only housekeeper on day shift and would only be able to clean common areas, not resident rooms, and she was unsure who was responsible for cleaning privacy curtains. Nursing staff, including an RN, an LPN, and multiple CNAs, reported seeing accumulations of dust on dressers and windowsills, dead bugs and debris on windowsills, and generally filthy privacy curtains, and several were unsure how often or by whom the curtains were cleaned. Laundry staff and the Maintenance Director confirmed there was no current schedule for cleaning privacy curtains and that they were only cleaned as needed. The Maintenance Director and Administrator acknowledged that many privacy curtains needed cleaning, rooms were not being dusted as often as they should, and many blinds were too short or broken, despite the facility’s policy stating it would provide a safe, clean, comfortable, and homelike environment with comfortable lighting and minimal glare. The combination of these conditions—short and broken blinds that did not fully cover windows facing a public parking lot, stained and unclean privacy curtains, and inadequate dusting and cleaning of resident rooms—resulted in residents experiencing disturbed sleep, using privacy curtains to block sunlight due to inadequate blinds, and expressing concerns about lack of privacy and feeling watched from outside. These findings affected multiple residents whose rooms faced the parking lot and were within view of anyone entering the facility.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure the safe use of a Sara Steady lift for a resident with multiple complex medical conditions, including impaired cognition, hemiplegia, and a history of traumatic brain injury. The resident required dependent assistance for activities of daily living and had no documented intervention or physician's order for the use of a Sara Steady lift for transfers. Despite this, a CNA placed the resident in the Sara Steady lift and left the resident unattended while seeking help, contrary to manufacturer guidelines and facility policy. The manufacturer's guidelines for the Sara Steady lift explicitly state that a resident must never be left unattended in the device, as it is intended only for active, supervised transfers and not for unassisted seating or prolonged periods. Witness statements and facility investigation confirmed that the CNA left the resident alone in the lift for approximately four to five minutes. During this time, the resident was found slumped over the lift's bar, unresponsive, and with a bloody bowel movement. Staff responded, initiated CPR, and emergency services were called. The root cause analysis conducted by facility leadership determined that the incident resulted from the staff member not following protocol for the resident lift and a lack of supervision. The event led to the resident experiencing cardiac arrest and being transferred to the hospital, where the resident later expired. The deficiency was identified as a failure to provide adequate supervision and to ensure the area was free from accident hazards, specifically regarding the use of mechanical lifts.
Failure to Respond to Door Alarm Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and did not respond appropriately to a door alarm on a locked unit, resulting in a resident leaving the facility unsupervised. The resident involved had a complex medical history, including paranoid schizophrenia, bipolar disorder with psychotic features, dementia, and other mental health diagnoses. The resident was known to wander, had a history of pushing code pads at doors, and was identified as an elopement risk due to impaired cognition and competence. The care plan included interventions such as distraction, structured activities, and supervision, but the resident did not exhibit exit-seeking behavior prior to the incident. On the day of the incident, the resident exited the facility through a fire door at the end of a hallway that was not visible from the nurse station or dining room. The door could be opened by pressing on the handle for 15 seconds, which triggered a loud alarm. A certified nurse assistant heard the alarm, checked the door, did not see anyone outside, and turned off the alarm, assuming it was set off by the wind. The staff member did not notify the nurse or conduct a head count, and the resident was not signed out for a leave of absence. The resident was later found at another facility after walking approximately 75 feet outside, and staff only became aware of the elopement when contacted by the other facility. Interviews with staff and the resident confirmed that the alarm sounded when the resident exited, but no staff were present in the area at the time. The resident stated she left to inquire about moving to another facility and was not supervised during her time outside. The facility's policies required staff to investigate and report missing residents and to notify supervisors if a resident left without being properly signed out, but these procedures were not followed during the incident.
Failure to Protect Resident from Staff-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, borderline personality disorder, and mild intellectual disabilities was not protected from staff-to-resident physical abuse. The resident, who was cognitively intact and required supervision for personal care, became involved in an altercation with a certified nurse aide (CNA) after attempting to move another resident in a wheelchair. The CNA shouted at the resident, leading to a verbal argument that escalated into a physical confrontation in the hallway. Multiple witness statements and a police report indicated that the CNA approached the resident, engaged in a face-to-face confrontation, and initiated physical contact by belly bumping the resident, which led to a fight and the resident being pushed to the ground and hitting her head. The incident was witnessed by another CNA and an LPN, who confirmed that the CNA and the resident exchanged insults and that the CNA was the aggressor in the situation. The police were called, and the CNA was arrested for assault. The resident was assessed for injuries and transported to the hospital, where a CT scan revealed no abnormal findings, and she was discharged back to the facility. The facility's investigation included reviewing statements from involved staff and the resident, as well as the police report, which corroborated that the CNA initiated the physical altercation. The facility's policy defined abuse as willful injury or intimidation resulting in physical harm, pain, or mental anguish, and the actions of the CNA were found to be in violation of this policy. The root cause was identified as a failure to appropriately deescalate and manage resident behaviors, leading to the escalation and subsequent physical abuse of the resident by staff.
Failure to Notify and Involve Residents and Representatives in Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in care conferences as required by policy. In multiple cases, there was no documented evidence that residents or their legal representatives were notified of or attended care plan meetings. This deficiency was identified through record reviews, interviews, and examination of care conference attendance records and facility policies. For example, one resident with multiple diagnoses including COPD, dementia, and chronic respiratory failure, had a legal guardian who reported never being invited to or attending a care conference. The resident herself also stated she did not attend care plan meetings, and documentation confirmed the absence of invitations or attendance records for both the resident and her guardian. Another resident, who was cognitively intact but had a legal guardian, similarly had no documentation of being invited to care conferences, and the guardian stated he was not notified of meetings unless he initiated contact with the facility. Additional cases included residents with moderate to mild cognitive impairment and their representatives, who reported never being invited to care conferences or informed of changes in care. Facility staff interviews revealed that notifications were often made verbally and not documented, with staff relying on memory rather than maintaining records as required by facility policy. The policy specified that a seven-day notice should be provided and documented, including the method of contact and any input or refusal, but this was not followed in the reviewed cases.
Failure to Include Food and Nutrition Services Staff in Care Conferences
Penalty
Summary
The facility failed to ensure that a member of the food and nutrition services staff, as required by policy, attended care conferences for residents. Record reviews for four residents revealed that there was no documented evidence of food and nutrition services staff participation in care conferences, despite the facility's policy stating that the interdisciplinary team (IDT) must include such a member. Instead, the Director of Nursing (DON) was completing the dietary section of the care conference forms. Interviews with the Dietary Manager and Dietitian confirmed that dietary staff had not been attending care conferences due to staffing challenges. The Dietary Manager acknowledged past attendance but stated she had not been able to participate recently. The Dietitian also confirmed non-attendance and indicated that dietary staff should be present at these meetings. The Social Service Designee corroborated that no dietary staff had attended, and the DON was filling out the relevant sections instead. The affected residents had complex medical histories, including conditions such as COPD, dementia, schizophrenia, diabetes, and various cognitive impairments. Documentation for each resident showed that care conferences were held with other disciplines present, but not with food and nutrition services staff, as required. In some cases, there was also no evidence that the resident or their representative was invited to or participated in the care planning process.
Failure to Provide Appropriate RCS Diet Desserts
Penalty
Summary
On 04/08/25, the facility failed to provide the appropriate dessert to all residents identified as being on a Reduced Concentrated Sweets (RCS) diet during lunch. According to the facility's menu for that day, residents on an RCS diet were to receive four ounces of fresh fruit in place of a brownie. However, observations of the tray line revealed that all residents, regardless of their dietary orders, received either a brownie or a pureed brownie as dessert. There was no evidence of fresh fruit being provided to any resident on the RCS diet. Record reviews for eleven residents with orders for an RCS diet showed that each had physician orders, care plans, and Minimum Data Set (MDS) assessments specifying the need for a therapeutic diet due to diagnoses such as type two diabetes mellitus, schizoaffective disorder, schizophrenia, dysphagia, and other chronic conditions. The care plans for these residents included interventions to provide diets as ordered, specifically to address their nutritional and medical needs. Despite these documented requirements, the dietary staff did not follow the prescribed menu substitutions for the RCS diet on the date in question. Interviews with dietary staff confirmed the failure to provide the correct dessert. The dietary aide responsible for placing desserts on trays acknowledged that only brownies or pureed brownies were served, and the assistant regional dietary staff member confirmed that residents on an RCS diet should have received fresh fruit instead. Review of the facility's policy on therapeutic diets further indicated that the facility was responsible for ensuring residents received diets as ordered, which did not occur in this instance.
Unapproved Use of Physical Restraint for Fall Prevention
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including schizoaffective disorder, intellectual disabilities, a wedge compression fracture, and a history of falls, was found to have a blue wedge cushion placed between the mattress and bed frame on one side of the bed, while the other side of the bed was against the wall. The wedge cushion was used to prevent the resident from falling out of bed, as confirmed by interviews with nursing staff. The resident's care plan addressed fall risk and included interventions such as ensuring a safe environment and keeping the call light within reach, but did not mention the use of a wedge cushion. There was also no physician order or care plan documentation for the wedge cushion. Observations over two days confirmed the continued use of the wedge cushion in this manner. Staff interviews revealed the wedge was intended to keep the resident from falling or climbing out of bed, and the DON acknowledged that this setup could restrict the resident's movement. Facility policy states that residents have the right to be free from physical restraints not required for medical treatment, and the facility had identified no residents as having a physical restraint. The use of the wedge cushion in this way constituted a physical restraint that was not care planned or ordered.
Failure to Include Incontinence Care in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement an accurate and comprehensive care plan for a resident with multiple diagnoses, including schizophrenia, type two diabetes mellitus, and cerebral infarction. The resident required extensive assistance with all activities of daily living and was frequently incontinent of urine and bowel, as documented in the medical record and quarterly MDS assessment. Despite these needs, the care plan did not include a focus area or interventions for incontinence care. This omission was confirmed during an interview with the MDS RN, who acknowledged the lack of incontinence-related interventions in the resident's care plan. The facility's policy requires that care plans be comprehensive and person-centered, with measurable objectives and timetables to meet each resident's needs, but this was not followed in this case.
Failure to Monitor and Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician-ordered fluid restriction was properly monitored and followed for a resident diagnosed with hyponatremia and hypo-osmolality, among other conditions. The resident had a physician's order for a 1500 ml fluid restriction, which was documented in the care plan and dietary assessments. However, there was no clear system in place to track or allocate the total allowed fluids between nursing and dietary services, nor was there documentation of how much fluid was actually provided by each department. Review of the resident's medical record and medication administration record showed that while nursing staff acknowledged the fluid restriction order, they did not record the amount of fluids given during each shift. Dietary staff reported that only the beverages on the meal tray were limited, but other fluid-containing foods such as soups, gelatin, pudding, and ice cream were still provided without being counted toward the restriction. There was no coordination or communication between nursing and dietary regarding the total fluid intake, and the dietitian was unsure of the process or whether nursing was aware of the fluids provided by dietary. Interviews with nursing, dietary, and the dietitian confirmed the lack of tracking and communication regarding the resident's fluid intake. The facility's policy required that fluids be shared between nursing and dietary using a fluid restriction breakdown and that input/output records be maintained for residents on fluid restriction. Despite this, the required monitoring and documentation were not implemented, making it impossible to determine if the resident's fluid restriction was being adhered to as ordered.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. Resident #2, who was alert and oriented, was punched in the face by Resident #44, who had known aggressive behaviors. This incident occurred while Resident #2 was lying in bed, leading to a hematoma to the right eye area and bruising to the right upper arm. Resident #2 was taken to the hospital for evaluation and diagnosed with a facial hematoma. The incident was a stressor for Resident #2, who expressed feeling shaken up by the unprovoked attack. Resident #44 had a documented history of aggressive behaviors and cognitive impairment, including psychosis and dementia. Prior to the incident, Resident #44 had exhibited aggressive behaviors towards staff and other residents, including throwing objects and making threats. Despite these behaviors, there was no behavior care plan developed for Resident #44 until after a previous incident of aggression. Behavior tracking for Resident #44 was discontinued shortly after admission, and there was no documentation of behavior monitoring leading up to the incident with Resident #2. The facility's failure to adequately monitor and manage Resident #44's behaviors contributed to the incident. Interviews with staff revealed that Resident #44 was known to be aggressive and had issues with sharing a bathroom with Resident #2. The facility's policy on abuse prevention emphasized the need for assessment, care planning, and monitoring of residents with behaviors that might lead to conflict. However, the lack of behavior tracking and an updated care plan for Resident #44 indicated a lapse in following these procedures, ultimately resulting in harm to Resident #2.
Resident Burn Incident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and intervention to prevent a resident with severe cognitive impairment from sustaining a burn injury. The incident occurred when the resident was found in his room with a cigarette lighter, which belonged to another resident, and his clothing was smoldering. This resulted in a second-degree burn to his abdomen, requiring emergency room treatment and follow-up care at a wound clinic. The resident had a history of severe cognitive impairment and required substantial assistance with daily activities, including dressing and toileting. Despite these needs, the facility did not prevent the resident from accessing a lighter, which was brought into the facility by another resident after a leave of absence. The facility's incident documentation and investigation revealed that the resident was unable to explain how he obtained the lighter, and there was no initial assessment or measurement of the burn in the incident report. The facility's policies on safety and supervision, as well as smoking, were not effectively implemented, as evidenced by the resident's access to smoking materials. The incident highlighted a lapse in the facility's procedures for monitoring and controlling potentially hazardous items brought into the facility by residents or their families.
Removal Plan
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Assistant DON, the Medical Director, Social Services, the Dietary Manager, Business Office Manager, Activity Director, Maintenance, Central Supply/Scheduler and Admissions. The root cause of the incident was identified as a family member allowed Resident #85 to retain smoking materials when they returned from leave of absence.
- Resident #64 was sent to the emergency room.
- Room sweeps on all rooms were completed to check for smoking materials.
- Room sweeps of five rooms per week for four weeks was started.
- The smoking policy was reviewed and updated to include that any smoking materials obtained on LOA must be returned to staff upon return to the facility.
- Smoking assessments for all residents who smoke (#6, #7, #8, #11, #13, #18, #25, #30, #32, #38, #40, #46, #47, #50, #53, #57, #61, #66, #71, and #85) were updated.
- Education was completed by Admissions #220 to all residents who smoke.
- All care plans of residents who smoke were reviewed and updated for all residents who smoke.
- A handout was created for Leave of Absence binders and the front desk reminding family and friends that smoking materials must be returned to staff.
- Education was provided to Resident #85's family to turn in smoking materials to staff after leave of absence.
- All staff were in-serviced on resident supervision, smoking policy, leave of absence process and ensuring residents who return from leave of absence do not retain smoking materials.
- Five resident and or family interview upon return from leave of absence was started and continued for four weeks.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to ensure that residents and their representatives received written notice of room changes, affecting eight residents. These residents included individuals with schizophrenia, alcohol dependence, and dementia, among other conditions. The facility's policy required advance notice and documentation of room changes in the residents' medical records, but this was not adhered to. For instance, Resident #2, who had a court-appointed guardian, experienced a room change without the guardian being notified. Similarly, Resident #3's mother, who was the resident representative, was not informed of a room change. The deficiency was further highlighted by the lack of documentation for other residents, such as Resident #6, who had multiple room changes without notification to their legal guardian, and Resident #57, who filed a grievance after not being informed of a room change. The facility's administrator admitted to handling room changes without being aware of the requirement for written notification. The absence of a social worker designee since early November contributed to this oversight. The facility's policy, dated May 2017, clearly outlined the need for advance notice and documentation, which was not followed, leading to the deficiency.
Failure to Develop Comprehensive Behavior Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the behavioral needs of a resident, identified as Resident #44, who had a history of cognitive impairment and aggressive behaviors. The resident was admitted with multiple diagnoses, including encephalopathy, unspecified psychosis, dementia, and a history of homelessness. Despite these conditions and a documented history of aggression during a hospital stay, the facility did not create a behavior care plan upon admission. The resident exhibited aggressive behaviors on multiple occasions, including becoming belligerent with staff, throwing a lunch tray, and physically assaulting staff members. These incidents led to the resident being sent to the emergency room for psychiatric evaluation and readmission to the facility. Despite these repeated episodes, the care plan was not updated to reflect the resident's behavioral issues until several weeks after admission, and even then, it was not revised following further incidents of aggression. Interviews with facility staff, including the Director of Nursing, confirmed that the facility was aware of the resident's behavioral issues prior to admission. However, a behavior care plan was not initiated until after the resident had already exhibited physical aggression. The facility's policy required care plans to be comprehensive and person-centered, with measurable objectives and timetables, but this was not adhered to in the case of Resident #44.
Unsanitary Kitchen Conditions Due to Drain Issue
Penalty
Summary
The facility did not maintain the kitchen in a sanitary manner, which had the potential to affect all residents except two who did not receive food from the kitchen. Observations revealed a strong offensive odor in the kitchen and dining room, resembling fecal matter and sour milk. The source of the odor was traced to a drain under the dishwasher, which was flooding the kitchen with greenish-brown liquid material. Staff were observed walking through the contaminated material while preparing and serving food. Interviews with dietary aides and cooks confirmed that the drain had been an issue for over a month, with the flooding occurring daily and the smell causing headaches and stomachaches among staff. The Administrator was aware of the issue and had scheduled a plumbing contractor to address it, but the problem persisted in the meantime. Further interviews revealed that the dietary staff had been instructed to use disposable dishes and utensils and to avoid using the dishwasher, but this directive was not consistently followed. The kitchen continued to flood, and the smell permeated the Buckeye unit, where residents resided. The Maintenance Director confirmed that the drain was connected to a sewer sanitation pipe, and the issue was exacerbated when showers were being provided on the unit. The Dietary Manager expressed concerns about the unsanitary conditions and the safety risks posed by standing in contaminated water while preparing and serving food. Despite sending pictures to corporate and discussing the issue with the Regional Dietary Manager, the problem remained unresolved. The Regional Dietary Manager confirmed that he had given the directive to use disposable dishware and to stop using the dishwasher, but he was unaware that this directive had not been consistently followed. Upon learning of the ongoing issue, he ordered the kitchen to be shut down and arranged for a mobile kitchen to be brought in until the drain was fixed. The facility's policy on preventing foodborne illness emphasized the importance of serving, preparing, handling, and servicing food in a manner that minimizes the risk of foodborne illness, which was not adhered to in this case.
Pervasive Offensive Odor on Buckeye Unit
Penalty
Summary
The facility did not ensure a homelike environment was maintained on the Buckeye unit, as there was a pervasive offensive odor affecting all 31 residents on the unit. The issue was primarily due to a malfunctioning drain under the dishwasher in the kitchen, which emitted a strong odor resembling fecal matter and sour milk. This problem had persisted for over a month, as confirmed by multiple staff members and residents. Observations revealed greenish-brown liquid material pouring out of the drain, covering the kitchen floor and emitting a foul smell that spread to the dining room and surrounding areas. Staff were observed walking through the contaminated area while attempting to complete their tasks, further exacerbating the issue. Interviews with residents revealed that the smell was particularly bothersome during meal times, with one resident describing it as smelling like vomit. Staff members, including dietary aides and cooks, confirmed the severity of the odor and the ongoing nature of the problem. The facility's administrator acknowledged the issue but had not personally inspected the drain. The maintenance director suggested that the drain might be connected to the main sewer line, which could explain the persistent odor. Despite the acknowledgment of the problem, the facility did not have a policy in place to ensure a homelike environment or to prevent pervasive offensive odors.
Staff Use of Personal Cellphones During Meal Assistance
Penalty
Summary
The facility did not ensure Resident #29 was treated in a dignified manner while being assisted with her meal. An STNA was observed standing over Resident #29, who was in her wheelchair, and talking on a personal cellphone while assisting her with breakfast. The STNA continued the phone conversation without interacting with the resident, and the conversation was loud enough to be heard from the hallway. Resident #29 confirmed that this was not the first time staff talked on their personal phones during her care, and it bothered her, especially when she had to wait for her next bite of food because the staff were distracted by their phone conversations. The facility's policies on employee cellphone use and assistance with meals were reviewed and found to be in violation. The policy stated that cellular phones may only be used during authorized breaks and must remain off or silent during work hours. Additionally, the policy on meal assistance emphasized that residents should be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals. The Regional Director of Clinical Services confirmed that staff were not to be on their personal phones or standing while feeding residents.
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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 North Lima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aventura At Assumption Village | 0.2 mi | ★★★★★ | 19 | 1 |
| Caprice Health Care Center | 0.4 mi | ★★★★★ | 5 | 0 |
| Shepherd Of The Valley Poland | 0.7 mi | ★★★★★ | 9 | 0 |
| Briarfield Place | 1.1 mi | ★★★★★ | 3 | 0 |
| Hampton Woods Nursing Center, Inc | 2.1 mi | ★★★★★ | 3 | 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.