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 Windsor Lane Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse and neglect policy by not reporting to the state agency or documenting an investigation after an Activity Assistant submitted written allegations that two CNAs verbally mistreated and neglected toileting needs of two cognitively impaired residents on a dementia unit. One resident with severe cognitive impairment, incontinence, and dependence for ADLs reportedly requested to use the restroom repeatedly over about an hour while a CNA, occupied with her phone, told her to wait despite her repeated statements that she would soil herself. Another resident with Alzheimer’s disease and severe cognitive impairment was reportedly yelled at on multiple occasions, publicly told it was acceptable to void in a brief instead of being taken to the bathroom, and subjected to a distressing incident in which a CNA threw her stuffed dog and joked that it had grown wings. These events were not documented in the medical records and were not reported or investigated as required.
The facility failed to promptly report, investigate, and document serious allegations that two residents with severe cognitive impairment and total dependence for ADLs were denied timely toileting and subjected to demeaning and bullying behavior by CNAs. An activity assistant reported that one resident was repeatedly refused access to the bathroom and told it was acceptable to use her brief in front of others, and that another resident was made to wait for an hour to toilet while a CNA remained on her phone, despite the resident’s repeated statements that she would soil herself. The assistant also described CNAs yelling at a resident, speaking to her in a demeaning tone, and intentionally distressing her by mishandling a stuffed dog she believed was real. Despite these written allegations, leadership acknowledged that no formal investigation was completed, the state agency was not notified, the accused staff were not removed from duty as required by policy, and there was no related documentation in the residents’ medical records.
A resident who was cognitively intact and dependent on staff for daily care reported experiencing verbal abuse from a CNA during toileting assistance, when the CNA made a comment urging the resident to hurry up because other people needed care. The incident was substantiated by facility investigation and confirmed through interviews and record review, constituting a failure to protect residents from verbal abuse as defined by facility policy.
A resident with multiple skin conditions and at risk for skin breakdown did not receive prescribed skin treatments as ordered. The resident self-administered treatments, kept them at bedside without authorization, and was out of medication for several days despite notifying staff. Staff continued to document treatments as given on the TAR, even though the medications were unavailable and not administered according to physician orders.
A medication was left unsecured on a resident's bedside table without a physician's order for self-administration or bedside storage. The medication was observed accessible while the resident was not present, and an LPN confirmed this practice, which was not authorized by facility policy. The resident also reported that nurses often left medication at the bedside.
A resident with multiple skin conditions was self-administering prescribed topical treatments, which were kept in her room without a physician's order for self-administration or bedside storage. Nursing staff documented these treatments as administered on the TARs without verifying application, contrary to facility policy requiring direct documentation by the person administering the medication.
A resident with severe cognitive impairment and high fall risk was left unattended in a Broda chair with unlocked wheels, leading to a fall and serious injuries. The facility failed to assess the chair for proper use and did not include specific interventions in the care plan, resulting in non-compliance with safety protocols.
A physical altercation occurred between two residents, one of whom was planning a party, leading to a confrontation over party supplies placed on a dining table. The altercation escalated when one resident used derogatory language, prompting the other to grab his arm and run her wheelchair into his leg, causing a skin tear. Staff intervened to separate them, and the incident was later substantiated as abuse.
The facility failed to complete and update comprehensive care plans for three residents, including two registered sex offenders and a resident with dementia. The care plans lacked necessary documentation for addressing the residents' specific needs, as confirmed by the DON, who cited issues with the electronic medical record system.
The facility failed to update care plans for three residents, including one who underwent bariatric surgery and required a high protein diet, another who resumed smoking despite a chronic respiratory condition, and a third receiving hemodialysis. These omissions were confirmed by facility staff.
The facility failed to assess and monitor the skin conditions of two residents, leading to deficiencies in care. One resident had a large red and scabbed area on the shin, which was not documented despite weekly skin assessments being required. Another resident had moisture-associated skin damage on the buttock, inaccurately reported as intact in assessments. Interviews confirmed the lack of proper documentation and monitoring, contrary to facility policy.
A resident with chronic respiratory failure was observed smoking without a required smoking apron, despite a physician's order. The resident had resumed smoking, but the facility did not offer a smoking apron, and the care plan lacked a smoking care area. The DON confirmed the order was still active but should have been discontinued.
A resident with type II diabetes, morbid obesity, and irritable bowel syndrome did not receive the recommended high protein nutritional supplementation. Despite a dietary manager's recommendation for a high protein shake, the resident only received a yogurt and occasionally an orange, lacking sufficient protein intake. The ADON confirmed the absence of an order for the supplement in the resident's medical record.
A facility failed to assess and monitor the nutritional and hydration needs of a resident who began hemodialysis. The resident, with moderately impaired cognition, was readmitted after hospitalization for dialysis. The RD recommended a specific diet but did not reassess nutritional needs or document the continuation of double protein portions. The RD also failed to coordinate care with the HD clinic, as no lab tests were received since the resident started HD. The facility's policy for nutritional service coordination was not adequately followed.
A resident with a history of prostate cancer experienced a delay in receiving his prescribed anti-cancer medication upon readmission to the facility. Although the resident brought the medication with him, the facility took it and delayed obtaining a physician's order for 10 days, resulting in the resident not receiving his medication until 12 days after readmission. The delay was confirmed by the ADON, and the resident expressed dissatisfaction with the situation.
A resident with intact cognition and multiple health issues required dental extractions by an oral surgeon. Despite a care plan to coordinate dental care, the facility failed to arrange an appointment. Interviews revealed attempts to contact dentists who could not accommodate the resident's size, and no general surgeon was contacted. The facility's policy stated it would assist in obtaining dental care.
The facility failed to provide residents with diets as ordered and recommended by the dietitian, affecting three residents. A resident with kidney failure did not receive the double protein portion ordered, while another with diabetes and dementia received a standard portion instead of the required double protein. Additionally, a resident with morbid obesity and diabetes did not receive the recommended weekly protein intake. The facility's policy required the Nutritional Service Coordinator to prepare and discuss clinical recommendations, but these were not adequately implemented.
A resident with kidney failure and moderately impaired cognition was not provided with nectar thickened liquids as ordered by the physician. Observations revealed the resident received unthickened milk and water, confirmed by a speech therapist familiar with the resident's risk for choking. The resident admitted to consuming the unthickened water.
The facility failed to complete employee reference checks and verify staff in the Ohio Abuse Registry, affecting multiple staff members including an Activity Aide, STNAs, Housekeepers, Dietary Staff, Maintenance Staff, Admissions Staff, and an RN. The facility's policy lacked guidelines for reference checks, and Human Resource Staff confirmed these deficiencies.
The facility did not follow its procedure to maintain an adequate emergency water supply on site, potentially affecting all 61 residents. The emergency water supply was kept off site, contrary to the facility's policy, which required storing three days' worth of water in the old assembly hall supply closet.
The facility did not ensure that STNAs received the required twelve hours of annual training, potentially affecting all 61 residents. Personnel files for four STNAs showed no documented education hours in the past year. Interviews with HR staff and the DON confirmed the lack of documentation for training hours, despite the job description requiring 12 hours of continuing education.
Failure to Report and Investigate Allegations of Neglect and Verbal Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of resident neglect to the state agency and to document an investigation, as required by its abuse and neglect policy. The facility’s policy dated 2016 states that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source must be immediately reported to the administrator or designee, and that the administrator or designee will notify the state survey agency of all such alleged violations within 24 hours of the allegation being made known to staff. Despite this policy, the Human Resources Director acknowledged that written allegations submitted by an Activity Assistant regarding staff treatment of residents on the dementia unit were not reported to the state agency and that no written investigation was completed. Resident #2, admitted on 10/28/25, had diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, parosmia, and hypertension. The most recent MDS showed severe cognitive impairment, no behaviors, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcer without current skin breakdown. Progress notes from October 2025 through February 2026 contained no documentation of alleged incidents. In the Activity Assistant’s written statement, she reported that Resident #2, while seated at a table with other residents, repeatedly stated she needed to use the restroom over the course of about an hour. CNA #401 was assisting another resident, and CNA #400, who was on her phone, repeatedly told Resident #2 she had to wait, while Resident #2 repeatedly said she was going to soil herself and needed the bathroom immediately. Resident #3, admitted on 09/01/25, had diagnoses including Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder. The MDS indicated severe cognitive impairment, behaviors directed at others, dependence on staff for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development with no current skin breakdown. The Activity Assistant’s statement described multiple occasions where CNA #400 raised her voice at Resident #3, including telling her she was not allowed to speak to people a certain way and that she needed to apologize, and later yelling at her to be quiet from down the hall. On another occasion, when Resident #3 requested to use the restroom about 45 minutes after a prior toileting, CNA #400 questioned her in a demeaning tone, delayed responding for 5–10 minutes, then refused to take her when the lunch cart arrived, telling her in front of others that it was acceptable because she was wearing a brief. The statement also described CNA #400 and CNA #401 recounting as a joke an incident where CNA #401 threw Resident #3’s stuffed dog in front of her, telling her the dog grew wings, which caused the resident distress. These allegations were not documented in the residents’ progress notes, not reported to the state agency, and not formally investigated by the facility.
Failure to Investigate and Report Allegations of Neglect and Disrespectful Care
Penalty
Summary
The deficiency involves the facility’s failure to promptly act on and thoroughly investigate allegations of neglect and disrespectful treatment toward two cognitively impaired residents on the dementia unit. Resident #2, admitted with multiple diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, and hypertension, had a recent MDS showing severe cognitive impairment, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcers without current skin breakdown. Resident #3, admitted with Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder, had an MDS indicating severe cognitive impairment, behaviors directed at others, dependence for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development without current skin breakdown. Progress notes for both residents from October 2025 through February 2026 contained no documentation of any alleged incidents related to neglect or mistreatment. According to a written statement dated 12/03/25 from Activity Assistant #300, CNA #400 repeatedly raised her voice at Resident #3, including telling the resident she was not allowed to speak to people a certain way and that she needed to apologize, and later yelling at her to be quiet while the resident was in her room. On another occasion, Resident #3 requested to use the restroom about 45 minutes after a prior toileting; CNA #400 responded in a demeaning tone, questioned whether the resident would actually go, and repeatedly told her to “hold on.” After five to ten minutes of continued requests, when the lunch cart arrived, CNA #400 told Resident #3 she could not be taken to the bathroom because it was lunch time and stated in front of others that it was okay because the resident was wearing a brief, leaving the resident clearly upset. AA #300 also reported that CNA #400 and CNA #401 recounted, as if humorous, an incident where CNA #401 took Resident #3’s stuffed dog (which the resident considers real), threw it in front of her, and told her the dog grew wings, causing the resident distress. AA #300 stated Resident #3 was regularly targeted and subjected to bullying and neglectful treatment. AA #300 further reported that a few weeks prior, Resident #2, who was seated at a table with other residents, announced she needed to use the restroom. CNA #401 was assisting another resident, and CNA #400 told Resident #2 they would help her soon. Over the next hour, Resident #2 repeatedly asked to use the restroom while CNA #400, who was on her phone, continued to tell her she had to wait; Resident #2 repeatedly stated she was going to defecate in her pants and needed to go to the bathroom immediately. Despite these allegations, the Human Resources Director confirmed that when AA #300 submitted the written allegations on 12/03/25, no investigation was documented, the state survey agency was not notified, and the accused CNAs were not removed from the facility but instead reassigned to a different unit. This response was inconsistent with the facility’s Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, which requires immediate reporting to the administrator, notification of the state agency within 24 hours, removal of accused staff from the facility pending investigation, completion of an investigation within five working days, and documentation of resident assessment and notifications in the medical record.
Verbal Abuse by CNA During Toileting Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was verbally abusive to a resident during toileting assistance. The resident, who was cognitively intact and dependent on staff for several activities of daily living, reported that the CNA told her to hurry up and finish on the bedpan because the CNA had other people to take care of. This comment was perceived by the resident as verbally abusive and caused her mental anguish. The incident was substantiated by the facility after investigation, and the CNA was identified as the perpetrator of the verbal abuse. The facility's policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including verbal abuse. The incident was reported through the facility's self-reported incident process, and interviews with the resident and facility leadership confirmed the occurrence of verbal abuse. The deficiency was identified during a review of records, interviews, and facility policy, affecting one resident among those reviewed for abuse.
Failure to Administer Skin Treatments per Physician Orders
Penalty
Summary
The facility failed to ensure that skin treatments for a resident were completed according to physician orders. The resident, who had diagnoses including morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus, was at risk for chronic cellulitis and skin breakdown. Physician orders required the application of ketoconazole cream, miconazole powder, and triamcinolone cream at specific intervals. Review of the Treatment Administration Record (TAR) indicated these treatments were documented as administered as ordered. However, interviews revealed that the resident was self-administering her skin treatments and had been out of the prescribed treatments for three days, despite informing nursing staff. The treatments were kept at the resident's bedside without an order permitting self-administration or bedside storage. The LPN/Unit Manager confirmed that the treatments were not available in the medication cart and had not been available for some time, yet staff continued to sign off on the TAR as if the treatments had been given. Facility policy required medications to be administered in accordance with physician orders, which was not followed in this case.
Medication Storage Deficiency: Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a medication, specifically fluticasone propionate nasal suspension, was left unsecured on a resident's bedside table without a physician's order for self-administration or for medications to be left at bedside. The resident, who had diagnoses including morbid obesity, chronic respiratory failure with hypoxia, Type I diabetes mellitus, COPD, and CHF, was not present in the room at the time the medication was observed. The medication was found with the prescription box, clearly labeled with the resident's name, and accessible in the resident's absence. Interviews confirmed that nursing staff, including an LPN, left the medication at the bedside after morning administration, despite facility policy requiring a physician's order for self-administration or bedside storage. The resident reported that nurses often left her medication on the bedside table. Review of the medical record and facility policy further substantiated that there was no authorization for this practice, resulting in non-compliance with requirements for proper medication storage.
Inaccurate Documentation of Treatment Administration Records
Penalty
Summary
The facility failed to ensure the accuracy of Treatment Administration Records (TARs) for one resident. A review of the medical record for a resident with multiple diagnoses, including morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus, showed that the resident was at risk for chronic cellulitis and skin breakdown. Physician orders were in place for several topical treatments, including ketoconazole cream, miconazole powder, and triamcinolone cream, to be administered at specific intervals. The TARs indicated that these treatments were documented as administered according to the orders. However, interviews with the resident and the LPN/Unit Manager revealed that the resident was self-administering her skin treatments, and the medications were kept in her room. Nursing staff did not have an order for the resident to self-administer these treatments or to keep them at bedside. Despite this, nursing staff continued to sign off on the TARs as if they had administered the treatments themselves, without verifying whether the treatments were actually applied. The facility's policy required that the individual who administered the medication record the administration immediately after giving the medication, which was not followed in this case.
Failure to Ensure Safe Use of Specialized Chair Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safe and proper use of specialized chairs, resulting in actual harm to a resident. Resident #01, who had severe cognitive impairment and was at high risk for falls, was placed in a Broda chair with caster wheels that were not locked. The resident was left unattended in the chair, which had not been assessed for proper use. As a result, the resident leaned forward, causing the chair to tip over, leading to serious injuries including a skin tear and fractures that required surgical repair. The resident's medical history included dementia, muscular dystrophy, and rheumatoid arthritis, among other conditions. The resident was dependent on staff for daily activities and used a wheelchair for mobility. Despite being at high risk for falls, the care plan did not include specific interventions for the use of a Broda chair. On the day of the incident, the resident was left alone in the memory care unit dining room, and the chair tipped forward when the resident leaned over, resulting in a fall. Interviews and observations revealed that the staff did not lock the wheels of the Broda chair due to concerns about it being a restraint. The facility's Director of Nursing confirmed that there was no documentation of the chair being assessed for proper use. The Broda chair's operating manual emphasized the importance of locking the wheels and supervising the resident to prevent tipping. The facility's fall management policy required staff to assess residents for fall risk and implement appropriate interventions, which were not adequately followed in this case.
Physical Altercation Between Residents
Penalty
Summary
The deficiency involved an incident of physical abuse between two residents at the facility. Resident #2, who had diagnoses including morbid obesity, lymphedema, and chronic pain, was involved in an altercation with Resident #3, who had diagnoses including morbid obesity, congestive heart failure, and pulmonary edema. Both residents had intact cognition and no negative behaviors noted in their assessments. The incident occurred when Resident #2 was planning a birthday party, and Resident #3 became annoyed because the party supplies were placed on a dining room table he normally used for lunch. This led to a verbal confrontation outside the building. During the altercation, Resident #2 confronted Resident #3 about taking photos of the party decorations. Resident #3 responded with derogatory remarks, which escalated the situation. Resident #2 admitted to grabbing Resident #3's arm and running her wheelchair into his leg, causing a skin tear. Resident #3 threatened to hit Resident #2 if she did not let go. The altercation was witnessed by other residents and staff, who intervened to separate the two residents. Resident #3 later reported an open area on his leg, which was treated by the nursing staff. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property defines abuse as the willful infliction of injury or intimidation resulting in physical harm or mental anguish. The incident was unwitnessed by the nurse initially, but staff and other residents provided accounts of the event. The facility substantiated the abuse, and Resident #3 expressed a desire to press charges against Resident #2. The deficiency was identified as past non-compliance that was subsequently corrected prior to the survey.
Incomplete Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to ensure that comprehensive care plans were completed and updated for three residents, affecting their ability to receive appropriate care. Resident #12, who was cognitively intact and required a wheelchair for mobility, was identified as a registered sex offender. However, his care plan lacked documentation regarding care and interventions related to his status as a sex offender. Similarly, Resident #25, also cognitively intact and using a wheelchair, was a registered sex offender with no corresponding care plan documentation addressing this aspect of his care needs. The Director of Nursing (DON) confirmed the absence of these critical care plan components during an interview. Additionally, Resident #2, diagnosed with dementia and dependent on staff for personal hygiene, had an incomplete care plan that did not address activities of daily living. The DON acknowledged the care plan's deficiencies and attributed the issue to difficulties with the electronic medical record system, which resulted in care plans not being consistently updated in resident records. These oversights in care planning highlight significant gaps in the facility's ability to meet the comprehensive needs of its residents.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure timely updates to resident care plans, affecting three residents. Resident #46, who had undergone bariatric surgery and was prescribed high protein nutrition shakes, did not have these changes reflected in their care plan. Despite receiving high protein shakes post-surgery, the care plan lacked documentation of the surgery and the dietary requirements. This oversight was confirmed by the Assistant Director of Nursing and the Dietary Manager. Resident #5, diagnosed with chronic respiratory failure, had a care plan that did not address their smoking habits. Although the resident had quit smoking, they resumed the habit, which was not updated in the care plan. The Director of Nursing confirmed that the smoking assessment was outdated and did not reflect the resident's current status. Additionally, Resident #10, who was undergoing hemodialysis, did not have this treatment documented in their care plan. The Director of Nursing confirmed that Resident #10 was the only resident receiving hemodialysis, yet this critical information was missing from the care plan.
Failure to Monitor and Document Skin Conditions
Penalty
Summary
The facility failed to adequately assess and monitor the skin conditions of two residents, leading to deficiencies in care. Resident #15, who has diagnoses including muscular dystrophies, congestive heart failure, morbid obesity, and cerebral vascular accident, was found to have a large red and scabbed area on the left lower shin during an observation. Despite the resident's care plan indicating a need for weekly skin assessments due to risks associated with anticoagulant therapy and morbid obesity, the medical record lacked documentation of this skin condition. Interviews with the Assistant Director of Nursing and the resident confirmed the absence of documentation and the long-standing nature of the skin issue. Similarly, Resident #50, with diagnoses including chronic respiratory failure and anxiety, had a new wound identified as moisture-associated skin damage (MASD) on the right buttock. Despite this, weekly skin observation assessments inaccurately reported the resident's skin as clean, dry, and intact. Interviews with the resident, the Director of Nursing, and a Wound Care Nurse Practitioner confirmed the ongoing presence of MASD and the lack of proper skin assessments since the wound was first noted. The facility's policy required weekly skin assessments, which were not adhered to, resulting in a failure to monitor and document the resident's skin condition accurately.
Failure to Ensure Resident Wore Smoking Apron
Penalty
Summary
The facility failed to ensure that a resident wore a smoking apron as ordered by the physician, which was necessary to prevent accidents related to smoking. The resident, who had a diagnosis of chronic respiratory failure and intact cognition, was required to wear a smoking apron while smoking, as per a physician's order initiated in March 2023. However, the most recent smoking assessment indicated that the resident no longer smoked, and there was no clarification on whether the resident could smoke independently. Despite this, the resident was observed smoking without a smoking apron on multiple occasions, and the facility's list of residents who smoked confirmed that the resident was still smoking. Interviews with the resident and staff, including the Director of Nursing (DON), revealed that the resident had resumed smoking after previously quitting and was not offered a smoking apron by the facility. The DON confirmed that the order for the smoking apron was still active but should have been discontinued. The facility's smoking policy required smoking evaluations upon admission, change of condition, and annually, but the resident's care plan did not include a care area for smoking, indicating a lapse in adherence to the policy and physician's orders.
Failure to Provide Recommended High Protein Supplementation
Penalty
Summary
The facility failed to ensure that a resident received high protein nutritional supplementation as recommended by the dietary manager. The resident, who had diagnoses of type II diabetes mellitus, morbid obesity, and irritable bowel syndrome, was on a 1,200 kilocalorie partial liquid diet. Despite the dietary manager's recommendation to include a high protein shake with breakfast and lunch, the resident did not receive the Ensure High Protein shake she requested, as she did not like the facility's in-house shake. The dietary manager stated that the resident did not request an alternative, and the kitchen continued to send the in-house shake. Observations and interviews revealed that the resident's meal trays only contained a yogurt and occasionally an orange, with the yogurt providing only 60 kilocalories and four grams of protein. The Assistant Director of Nursing confirmed that there was no order for a nutrition supplement in the resident's medical record, despite the dietary manager's progress note indicating the need for a high-protein shake. This oversight affected the resident's nutritional intake, as she did not receive the recommended high protein supplementation.
Failure to Monitor Nutritional Needs for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper nutritional and hydration assessment and monitoring for a resident who began hemodialysis (HD). The resident, who had moderately impaired cognition, was readmitted to the facility after hospitalization to establish dialysis. The Registered Dietitian (RD) recommended a no concentrated sweets, no added salt diet with thickened liquids but did not reassess the resident's nutritional needs or document whether double protein portions should continue. The RD did not conduct further assessments or document any progress notes regarding the resident's condition after starting HD. The Director of Nursing (DON) confirmed that the resident was the only one receiving HD in the facility and that the resident began HD treatments on a specific date. The RD admitted to not reassessing the resident's nutritional needs after the initiation of HD, relying instead on the initial dietary recommendations. The RD also failed to coordinate care with the HD clinic, as no laboratory tests had been received from the clinic since the resident began HD. The facility's policy required the Nutritional Service Coordinator or Consult Dietician to prepare a list of clinical recommendations and discuss them with the Nutrition Service Director and/or Nursing, which was not adequately followed in this case.
Delay in Cancer Medication Administration
Penalty
Summary
The facility failed to timely provide a cancer medication to a resident with a history of prostate cancer. The resident was readmitted to the facility with a past medical history of prostate cancer, type II diabetes mellitus, and obesity. Upon readmission, the resident brought his prescribed long-term anti-cancer medication to the facility. However, the medication was taken from him with the assurance that the facility would obtain an order from the physician for its administration. Despite this, the request for the medication order was not addressed until 10 days later, resulting in the resident not receiving his medication from the time of his readmission. The delay in obtaining the medication order was confirmed by the Assistant Director of Nursing, who acknowledged that the request made on 07/12/24 was not addressed until 07/22/24, and the order was only initiated on 07/23/24. The resident expressed dissatisfaction with the delay, as he had not received his medication since his readmission on 07/11/24 until 07/23/24. This deficiency affected the resident's continuity of care and timely access to necessary medication.
Failure to Arrange Timely Dental Services for Resident
Penalty
Summary
The facility failed to timely arrange dental services for a resident, affecting one of three residents reviewed for dental services. The resident, who had intact cognition, was admitted with diagnoses including morbid obesity with alveolar hypoventilation, atrial fibrillation, and chronic respiratory failure with hypoxia. The care plan initiated in April indicated dental problems related to poor oral hygiene, with interventions to coordinate dental care and provide mouth care. A dental note from June indicated the need for extraction of two teeth by an oral surgeon, but no appointment was documented as set up with an oral surgeon by late July. Interviews revealed that the resident was informed by the dentist about the need for an oral surgeon, but the facility had not made the appointment. The Director of Nursing confirmed the lack of an appointment, citing attempts to contact three dentists who could not accommodate the resident's size. The facility considered contacting a general surgeon instead. Transportation staff confirmed contacting three oral surgeons who could not perform the extraction and had not attempted to call a general surgeon. The facility's undated policy stated it would assist residents in obtaining routine and emergency dental care.
Failure to Provide Diets as Ordered and Recommended
Penalty
Summary
The facility failed to provide residents with diets as ordered and as recommended by the registered dietitian, affecting three residents. Resident #10, who had moderately impaired cognition and a diagnosis of kidney failure, was ordered a no-added salt, no concentrated sweets diet with double protein. However, during meal service, the dietary staff failed to provide the double protein portion, instead offering a standard portion of spaghetti and compensating with cheese after the error was identified. Resident #26, diagnosed with type II diabetes mellitus and dementia, was also ordered a no-added salt, no concentrated sweets diet with high protein. During meal service, the resident received a standard portion of ham and potato casserole, contrary to the double protein portion indicated on the tray ticket. Additionally, Resident #17, with multiple diagnoses including morbid obesity and diabetes, required a therapeutic diet with 100 to 110 grams of protein per day. However, the facility's menu provided only 588.7 grams of protein per week, falling short of the 700 to 770 grams recommended by the dietitian. The facility's policy required the Nutritional Service Coordinator to prepare and discuss clinical recommendations, but these were not adequately implemented for Resident #17.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to ensure that a resident received thickened fluids as ordered by the physician. The resident, who was admitted with a diagnosis of kidney failure and had moderately impaired cognition, was prescribed a diet that included nectar thickened liquids. However, during observations, it was noted that the resident was provided with unthickened milk and water during meals. This was contrary to the physician's order for nectar thickened liquids. During an observation and interview with a speech therapist, it was confirmed that the resident was at risk for choking with unthickened liquids. The speech therapist verified that the water provided to the resident was not thickened to the required consistency. The resident also confirmed having consumed some of the unthickened water, indicating a lapse in adherence to the prescribed dietary requirements.
Failure to Complete Employee Reference Checks and Abuse Registry Verification
Penalty
Summary
The facility failed to ensure proper employee reference checks and verification in the Ohio Abuse Registry for several staff members, which had the potential to affect all 61 residents residing in the facility. Personnel records revealed that an Activity Aide, two State Tested Nursing Assistants, a Housekeeper, Dietary Staff, Maintenance Staff, Admissions Staff, and a Registered Nurse were either not checked in the Ohio Abuse Registry or did not have completed reference checks. Specifically, the Activity Aide, Housekeeper, Dietary Staff, Maintenance Staff, Admissions Staff, and Registered Nurse were not verified in the Ohio Abuse Registry, while the State Tested Nursing Assistants and Maintenance Staff lacked completed reference checks. The facility's policy titled "Abuse, Neglect, Exploitation & Misappropriation of Resident Property," dated 2016, did not include guidelines for completing employee reference checks. The policy stated that the facility would check with all applicable licensing and certification authorities to ensure employees hold the requisite license and/or certification status and do not have disciplinary actions against their professional license due to findings of abuse, neglect, exploitation, or misappropriation of resident property. However, the lack of adherence to these procedures was confirmed by Human Resource Staff, who verified the deficiencies in the employee verification process.
Failure to Maintain On-Site Emergency Water Supply
Penalty
Summary
The facility failed to adhere to its procedure for maintaining an adequate emergency water supply, which had the potential to affect all 61 residents. During an interview with the Director of Nursing and the Director of Maintenance, it was confirmed that the facility did not have an emergency water supply on site, as it was kept off site. A review of the facility's undated policy titled 'Emergency Water Supply' indicated that the facility was supposed to provide three days of food and water for staff or other persons who would stay at the facility during an emergency. Additionally, the policy stated that the water should be stored in the old assembly hall supply closet.
Failure to Provide Required Annual Training for STNAs
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) received the required twelve hours of annual training, which had the potential to affect all 61 residents in the facility. Personnel files for four STNAs revealed no documented hours of education completed in the past year. Interviews with Human Resources Staff and the Director of Nursing confirmed the absence of documentation for the annual inservice training hours. The job description for STNAs, dated 06/01/05, required a minimum of 12 hours of continuing education programs to maintain certification.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 586 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Gibsonburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Otterbein Portage Valley | 8.4 mi | ★★★★★ | 2 | 0 |
| Bethesda Care Center | 9.1 mi | ★★★★★ | 17 | 0 |
| Genoa Retirement Village | 9.5 mi | ★★★★★ | 14 | 0 |
| Parkview Care Center | 9.5 mi | ★★★★★ | 13 | 0 |
| Elmwood Assisted Living & Skilled Nursing Of Fremo | 10.3 mi | — | 0 | 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.