Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Wood Glen Alzheimer's Community during CMS and state inspections, most recent first.
Food prep equipment was not kept clean and sanitary, as an unclean can opener and a deli slicer with dried food debris were observed, and frozen ground beef was thawing in a prep sink without running cold water. Multiple resident refrigerators also contained unlabeled food items, lacked thermometers in some compartments, and had incomplete temp logs; an LPN and RN confirmed the labeling and monitoring issues.
Missed Care Conferences and Lack of IDT/Representative Participation: The facility failed to hold care conferences with the IDT and to include resident reps for multiple residents. A resident with dementia, COPD, AFib, and HTN had no care conference since a prior meeting, and the rep said she had only been invited once. Other residents with Alzheimer’s disease, vascular dementia, CKD, DM2, Parkinson’s disease, and behavioral symptoms had either no documented conference or conferences that were not held quarterly, despite calls or messages to spouses/POAs to schedule them.
Two residents with cognitive impairment and significant ADL and nutritional support needs were not treated with dignity during feeding assistance. In both cases, staff members, including a CNA and a Medical Records Coordinator, stood over the residents while assisting with meals instead of sitting with them, despite care plans calling for supervised or assisted eating and a facility policy requiring residents be treated with respect and dignity. An LPN noted that one resident had recently declined and required staff to initiate feeding to stimulate eating.
A resident with Alzheimer’s disease, severely impaired cognition, and documented communication problems was discharged with a remaining balance of $179.33 in a personal funds account. The facility’s own Resident Rights policy required that such funds be returned within 30 days of discharge, but the account was not closed and the refund check was not issued until more than a month after discharge. This delay in returning the resident’s personal funds was confirmed by the Regional Business Office Manager and constituted a failure to ensure timely distribution of personal funds after discharge.
The facility failed to implement care-planned hipster interventions for two residents identified as high fall risk. One resident with Alzheimer’s disease and a history of multiple falls was observed out of bed without hipsters, despite the care plan requiring their use; staff reported the only pair had been soiled and sent to laundry, and an RN confirmed there were no additional hipsters in stock. Another resident with Parkinson’s disease and multiple comorbidities, also with a history of falls and a care plan specifying hipsters after a prior fall, was observed without hipsters, which was confirmed by a CNA and an LPN. These failures occurred despite a facility fall prevention policy requiring appropriate care planning and review for residents at risk for falls.
A resident with severe cognitive impairment, a history of right femur fracture, anemia, and A-fib was care planned as at risk for dehydration and protein-calorie malnutrition, with interventions including regular weight monitoring and nutritional support. Initial weights and a nutrition assessment showed low oral intake and the need for supplements, but after hospitalization and readmission for surgical repair of a femur fracture, staff did not obtain a new admission weight as required by facility policy. Instead, NP progress notes repeatedly relied on an auto-populated weight from a prior month, and no current weight was documented until weeks later, when significant weight loss and temporal wasting were noted and the resident was identified as having ongoing poor intake and cachexia. A corporate RN confirmed that a readmission weight should have been obtained and was not, resulting in failure to adequately monitor the resident’s weight loss.
PPE was not readily accessible for two residents on EBP. One resident had Alzheimer's disease, diabetes, and PTSD, and the other had vascular dementia and ESRD with a dialysis port. Although signs were posted outside both rooms, no PPE was available at the room entrances, and an RN had to search for supplies and later stock a PPE cart with gowns, gloves, and hand sanitizer.
The facility failed to report injuries of unknown origin in a timely manner for two residents. One resident, with cognitive impairment and multiple diagnoses, experienced a fall and later discovered a femoral fracture, which was not investigated or reported. Another resident, also cognitively impaired, had a finger fracture with an incomplete investigation and no self-reported incident. The facility did not follow its policy on timely reporting of such incidents.
The facility failed to investigate injuries of unknown origin for two residents. One resident, with cognitive impairment and multiple diagnoses, experienced a fall and later a femoral fracture, but no investigation was conducted. Another resident, also cognitively impaired, had a finger fracture with an incomplete investigation and no self-reported incident. The facility did not adhere to its policy on timely reporting of such incidents.
The facility failed to maintain complete and accurate medical records for two residents. One resident's fall was not properly documented, with LPNs denying knowledge of the incident or related assessments. Another resident's behavioral incidents and resulting injury were not recorded, with only x-ray results noted. These deficiencies highlight significant gaps in documentation practices.
A resident with dementia and severe cognitive impairment eloped from an LTC facility due to inadequate supervision, despite being assessed as at risk and ordered for 1:1 supervision. The resident was found outside the facility without injuries. Observations later revealed continued lapses in supervision, and staff interviews confirmed the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive enteral feeding as ordered. Despite a physician's order for continuous feeding, the feeding was temporarily stopped due to a residual volume check, which was below the threshold for holding feeding. The resident showed no signs of distress, but the feeding was not resumed as required, leading to a deficiency finding.
A facility failed to follow infection control policies for a resident receiving enteral feedings. The resident, with severe cognitive impairment and multiple medical conditions, required Enhanced Barrier Precautions (EBP) during tube feeding. An RN administered the feeding without donning a gown, despite EBP signage, and confirmed the absence of PPE in the room. The DON acknowledged the need for PPE availability and adherence to EBP during such procedures.
The facility failed to ensure medications were properly labeled with a date after being opened, discarded after their expiration date, and not left unattended at residents' bedside. These deficiencies affected multiple residents and were confirmed by staff during observations.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations included unlabeled and undated food items, dirty kitchen floors, unknown substances on walls and ceilings, rusted equipment, and dead bugs in light fixtures. These deficiencies had the potential to affect 133 residents.
The facility failed to ensure care conferences were completed for three residents, as required by their policy. One resident missed conferences due to scheduling conflicts with dialysis, another had not received any care conferences since July, and a third had no documented care conferences since admission. This was confirmed by both the residents and the Licensed Social Worker.
A facility failed to provide necessary ancillary services for a resident with hearing impairments. Despite being admitted with hearing aids, the resident was observed without them, and no referral services were completed. Interviews revealed a lack of awareness and communication among staff regarding the resident's needs.
The facility failed to ensure adequate indications for antipsychotic medications for three residents, despite severe cognitive impairments and known risks. The care plans did not address contraindications or explore non-pharmacological interventions.
A resident's iPad was confiscated due to the discovery of child pornography, but the facility failed to document the incident in the medical record. The Licensed Social Worker and Administrator confirmed the iPad was taken and the police were called, but no documentation was made, violating facility policy.
A facility failed to ensure a resident's mattress fit properly on the bed frame, resulting in a 12-inch gap between the headboard and the mattress. The resident, who had multiple diagnoses and was dependent on staff for all ADLs, was at risk due to this safety issue. The facility's policy on mattress inspection and bed safety was not followed.
The facility failed to ensure falls were reviewed and discussed by the IDT and a root cause analysis was determined for two residents. Both residents experienced falls, and there was no documented evidence of IDT meetings to review and discuss the incidents, as confirmed by an LPN.
A resident's cell phone was reported missing during a hospital transfer, and despite a VA representative's promise to replace it, the facility failed to follow up. The resident, who was moderately cognitively impaired, did not receive the replacement, and the Licensed Social Worker admitted to not contacting the VA representative.
Unclean Food Equipment and Improper Refrigerator Food Storage
Penalty
Summary
Food preparation equipment was not maintained in a clean and sanitary manner. During observation of the kitchen, the blade of the can opener was unclean, a tube of frozen ground beef was found defrosting in the preparation sink without running cold water, and a deli slicer was observed covered with a plastic bag but still had dried food debris on it after the bag was removed. The Interim Dietary Manager verified the can opener was dirty, confirmed the ground beef should have been thawed with cold water running over it, and acknowledged the deli slicer was unclean. Foods stored in resident refrigerators were also not properly labeled and refrigerator temperatures were not being monitored as required. In multiple unit refrigerators, staff observed unlabeled cups containing unidentified brown or yellow substances, an unlabeled fast food drink container with unknown liquid, and an unlabeled open liquid coffee creamer. One refrigerator had no thermometer in the compartment, another had no thermometer in the freezer compartment, and temperature logs were missing entries for two dates in April 2026. Staff members verified that resident foods should have been labeled with the contents and that refrigerator temperatures should have been monitored and recorded on a log.
Missed Care Conferences and Lack of IDT/Representative Participation
Penalty
Summary
The facility failed to ensure care conferences were held with the interdisciplinary team and failed to ensure resident representatives had the opportunity to participate in care conferences for five of seven residents reviewed. Resident #6 had diagnoses including vascular dementia, COPD, adult failure to thrive, alcohol abuse, atrial fibrillation, and hypertension, and was severely cognitively impaired on the quarterly MDS. The last documented care conference for this resident was on 07/08/25, and the resident’s representative stated she had only been invited to one care conference a long time ago and was unsure whether care conferences were still being held. The Social Services Director verified that no care conference had been conducted since 07/08/25, and the Division Director of Risk Management stated the facility did not have a policy regarding care conferences. Resident #105 had diagnoses including Alzheimer’s disease, vascular dementia, major depressive disorder, violent behaviors, Type II diabetes, chronic kidney disease, and restlessness and agitation, and was cognitively impaired on the MDS. Social Services documented a call to the spouse to confirm a care conference, but the record contained no documentation that the conference ever occurred, and the spouse stated she had not been asked to attend and had questions about the resident’s condition. Resident #127, admitted with Alzheimer’s disease, vascular dementia, chronic kidney disease, and Type II diabetes, was cognitively impaired; a 72-hour summary noted a message was left with the POA to schedule a care conference, but no care conference was documented. Resident #69, severely cognitively impaired, had multiple MDS assessments completed over time, but care conferences were only documented on 03/07/25, 06/17/25, and 01/13/26, and the Division Director of Risk Management confirmed they were not held quarterly with the resident’s representative. Resident #83, severely cognitively impaired with diagnoses including Parkinson’s disease, hypertension, peripheral vascular disease, and diabetes mellitus, had no evidence of any care conference since admission, and the Division Director of Risk Management confirmed the facility did not conduct care conferences per the recommendations of the RAI Manual.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity during feeding assistance. For one resident with cerebral ischemia, vascular dementia, and significant cognitive impairment, the MDS showed a need for substantial or maximal assistance with eating, and the care plan included assistance with meals as needed. During a lunch observation, a CNA initially sat at the dining table while assisting this resident, then left to help another resident. When the CNA returned, she remained standing next to the resident while assisting him with the remainder of his meal, rather than being seated. The CNA confirmed in interview that she was standing while assisting and acknowledged she should have been seated with the resident. A second resident, admitted with vascular dementia, Type II diabetes, altered mental status, adjustment disorder with depressed mood, muscle weakness, cognitive communication deficit, and dysphagia, was documented on the MDS as cognitively impaired and requiring supervision while eating. The care plan identified an ADL self-care performance deficit related to cognitive and functional issues, with interventions including eating supervision or touching assist, and helper cues or steadying. Observation showed the Medical Records Coordinator standing next to this resident while feeding him his meal, rather than being seated. In interview, the staff member verified she stood over the resident while assisting with eating. An LPN reported that this resident had a recent decline characterized by sitting and staring instead of eating, and that staff had been feeding him at the start of meals to gain his interest. Facility policy on Resident Rights stated that residents would be treated with respect and dignity.
Failure to Timely Return Discharged Resident’s Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to timely management of personal funds by not returning the resident’s personal funds account balance within 30 days of discharge. The resident, who had Alzheimer’s disease with late onset and severely impaired cognition as evidenced by a BIMS score of three, also had documented communication problems related to Alzheimer’s disease, dementia with behavioral disturbances, and a psychotic disorder with delusions, requiring staff to use simple questions, allow adequate response time, and verify understanding. At the time of discharge, the resident’s fund management services ledger showed an account balance of $179.33. However, the account was not closed and the refund check for the full balance was not issued until 37 days after discharge, contrary to the facility’s Resident Rights policy, which required that resident funds be returned within 30 days. The Regional Business Office Manager confirmed that the account was not closed and the refund was not issued within the required timeframe. This deficiency was identified during a complaint investigation and involved one of three residents reviewed for personal funds accounts, with a facility census of 141.
Failure to Implement Care-Planned Hipster Interventions for Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall interventions, specifically the use of hipsters, for two residents identified as being at risk for falls. Resident #13, admitted with Alzheimer’s disease and assessed as severely cognitively impaired, required maximum assistance for bed mobility and transfers and had a history of two or more falls without serious injury. The resident’s care plan identified multiple fall risk interventions, including the use of hipsters when out of bed. During observation, the resident was noted not to be wearing hipsters. An LPN confirmed the resident should have hipsters on as a fall intervention when out of bed and ambulating. A CNA reported the resident’s hipsters had been soiled earlier and sent to the laundry, and confirmed there were no additional hipsters available to apply. An RN checked the supply room and verified there were no additional hipsters in stock. Resident #83, admitted with Parkinson’s disease, hypertension, peripheral vascular disease, and diabetes mellitus, was also assessed as severely cognitively impaired and required maximum assistance with bed mobility and transfers. The resident’s care plan identified fall risk related to disease process, gait and balance problems, and history of falls, with interventions including hipsters, perimeter mattress, and neuro checks for unwitnessed falls. Following a prior fall of unknown circumstances, hipsters were added as a specific intervention. During observation, the resident did not appear to be wearing hipsters. A CNA verified the resident did not have hipsters on, and an LPN confirmed that hipsters were a fall intervention for this resident and that they were not in use. The facility’s fall prevention and management policy stated that residents at risk for falls should have a care plan initiated and reviewed as needed with each change of condition, but the hipster interventions identified in the care plans were not implemented for these two residents.
Failure to Obtain Readmission Weight and Monitor Nutritional Status
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document required weights to monitor for weight loss in a resident identified as being at risk for dehydration and protein-calorie malnutrition. The resident was admitted with diagnoses including a right femur fracture, acute posthemorrhagic anemia, and atrial fibrillation, and was assessed as severely cognitively impaired with documented issues of coughing and choking during meals and holding food in the mouth. The care plan, initiated shortly after admission, identified risk for dehydration and malnutrition and included interventions such as obtaining weights and nutritional consults. Early weights were documented in late January and February, showing a weight around 100 lbs, and the admission nutrition assessment noted an average intake of 50%, likely inadequate to meet energy needs, with fortified pudding and supplements added. Following a fall and surgical repair of a right femur fracture, the resident was readmitted to the facility, but no admission weight was documented at readmission, contrary to facility policy requiring a weight within 24 hours of admission. Subsequent NP post-hospital visit notes on multiple dates used an auto-populated weight from mid-February (99.8 lbs) rather than a current measured weight, and there was no new documented weight until early April, when the resident’s weight was recorded at approximately 93 lbs. Later NP and dietary notes described ongoing poor oral intake, temporal wasting, and weight loss, and a nutrition-at-risk note confirmed weight loss since late January due to low oral intake. A corporate RN confirmed that a weight should have been obtained upon readmission and verified that this was not done, resulting in inadequate monitoring for weight loss as required by the resident’s care plan and facility policy.
PPE Not Readily Accessible for Residents on EBP
Penalty
Summary
The facility failed to ensure personal protective equipment (PPE) was readily accessible for residents on enhanced barrier precautions (EBP). Resident #2 was admitted with diagnoses including Alzheimer's disease, Type II diabetes, and post-traumatic stress disorder, and the MDS showed the resident was cognitively impaired. The physician ordered EBP for infection control on 02/23/26, and on 04/20/26 a sign was observed outside the resident's room indicating EBP was in place. However, no PPE was readily accessible near the room entrance, and RN #321 confirmed there was none available at the doorway. Resident #50 was admitted with diagnoses including vascular dementia and end stage renal disease, and the MDS showed the resident was cognitively impaired. The physician ordered EBP on 12/17/24 related to a dialysis port, and on 04/20/26 a sign was observed outside the resident's room indicating EBP. As with Resident #2, no PPE was readily accessible near the room entrance, and RN #321 confirmed there was none available. During observation, RN #321 had to gather PPE supplies, asked staff at the nurses' station where to find them, was told to check central supply, and later stocked a PPE cart outside both residents' rooms with gowns, gloves, and hand sanitizer. The facility policy titled Enhanced Barrier Precautions stated that gowns, gloves, and hand sanitizer should be readily accessible to staff.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin in a timely manner, affecting two residents. Resident #17, who was cognitively impaired and had multiple diagnoses including dementia and violent behavior, experienced a fall on 01/13/25. Initially, no injuries were noted, and the resident refused vital signs. However, on 01/16/25, the resident complained of pain in the right lower extremity, leading to an x-ray that revealed a proximal femoral fracture. Despite the fracture being discovered, no investigation was completed to determine the cause, and the injury was not reported as an injury of unknown origin. Resident #30, also cognitively impaired with diagnoses including Alzheimer's disease and vascular dementia, was found to have a fracture of the distal phalanx of the left fourth digit on 02/27/25. The resident reported an incident involving another resident, but there was no documentation of behavioral outbursts or injuries prior to the x-ray. The investigation into the fracture was incomplete, and the injury was not reported as a self-reported incident. Interviews with facility staff revealed a lack of clarity and communication regarding the investigation and reporting process. The facility's policy on abuse, neglect, and misappropriation requires timely reporting of incidents, bruises, and injuries of unknown origin. However, the facility did not adhere to this policy, as evidenced by the lack of timely reporting and investigation of the injuries sustained by Residents #17 and #30. This deficiency was investigated under Complaint Number OH00162164.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin in a timely manner, affecting two residents. Resident #17, who was cognitively impaired and had multiple diagnoses including dementia and violent behavior, experienced a fall on 01/13/25. Initially, no injuries were noted, and the resident refused vital sign checks. However, on 01/16/25, the resident complained of pain in the right lower extremity, leading to an x-ray that revealed a proximal femoral fracture. Despite this, no investigation was conducted to determine the cause of the fracture, and the Director of Nursing (DON) acknowledged that an investigation should have been completed. Resident #30, also cognitively impaired with diagnoses including vascular dementia and Alzheimer's disease, was found to have a fracture of the distal phalanx of the left fourth digit on 02/27/25. The resident reported an incident involving another resident, but there was no documentation of behavioral outbursts or injuries prior to the x-ray. The investigation into the fracture was incomplete, with the DON and Regional Director of Operations (RDO) unsure of the details and involvement of other residents. The facility failed to report the injury as a self-reported incident, as confirmed by the Regional Risk Manager. The facility's policy on abuse, neglect, and misappropriation requires timely and accurate reporting of incidents, including injuries of unknown origin. However, the facility did not adhere to this policy, as evidenced by the lack of timely investigations and reporting for both residents' injuries. This deficiency was investigated under Complaint Number OH00162164.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for two residents, leading to deficiencies in documentation. For one resident, the medical record indicated a fall occurred, but there was no documentation of neurological checks being completed following the incident. A paper document titled 'Neurological Assessment' was found, but the LPNs whose signatures appeared on it denied completing or even being aware of the document or the fall incident. This discrepancy highlights a significant gap in the facility's documentation practices, as the medical record did not accurately reflect the resident's condition or the care provided. For another resident, the medical record lacked documentation of behavioral incidents and subsequent injuries. Although the resident was found to have a fracture, there was no record of behavioral outbursts or any staff intervention following the incident. The only documentation in the medical record was the x-ray results, with no details about the injury or any change in the resident's condition. This lack of documentation contravenes the facility's policy on maintaining accurate and timely medical records, as it failed to provide a complete representation of the resident's experience and care.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and interventions for a resident assessed as being at risk for elopement. The resident, who had a history of dementia and other medical conditions, was admitted to the facility and identified as having a severe cognitive impairment. Despite being assessed as at risk for elopement, the resident was not provided with the required 1:1 supervision, which was ordered to prevent elopement. On the morning of the incident, the resident was last seen by staff at 7:20 A.M. and was discovered missing at 8:00 A.M. An elopement code was called, and the resident was found near a local park at 8:19 A.M. The resident was returned to the facility without injuries. Observations made on a subsequent date revealed that the resident was again left unsupervised in their room, contrary to the 1:1 supervision order. Interviews with staff, including the Administrator, Director of Nursing, and other personnel, confirmed the lapse in supervision and the resident's elopement. The facility conducted an investigation but was unable to determine how the resident managed to leave the premises. The facility's policy on elopement prevention and management was reviewed, highlighting the need for proper supervision and intervention to prevent such incidents.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to administer enteral feeding as ordered for Resident #137, who was admitted with medical diagnoses including dementia, chronic kidney disease stage III, hypertensive heart disease, and dysphagia. The resident had severe cognitive impairment and required substantial staff assistance for daily activities. The medical record indicated that the resident received more than 51% of total calories through tube feeding. A physician's order specified the administration of Jevity 1.5 at 55 ml per hour for 22 hours via pump, with specific instructions to check for residuals and hold feeding if residuals were 100 cc or more. On the day of the incident, the tube feeding was placed on temporary hold at 10:15 A.M. due to a residual volume of approximately 50 ml, which was below the threshold to hold feeding. Despite the resident showing no signs of distress, the feeding was not resumed as per the physician's order. Observations later in the day confirmed that the tube feeding pump was turned off, and the resident was not receiving any feeding. The facility's policy on enteral feeding emphasized continuous delivery using a programmable pump, with interruptions only as ordered by a physician. This deficiency was identified during a complaint investigation.
Infection Control Deficiency in Enteral Feeding
Penalty
Summary
The facility failed to adhere to its infection control policies, specifically regarding Enhanced Barrier Precautions (EBP) for a resident receiving enteral feedings. Resident #30, who was severely cognitively impaired and dependent on staff for various activities, had medical diagnoses including right-sided hemiplegia, Alzheimer's disease, and dysphagia. The resident was on a nothing by mouth (NPO) status and received nutrition through a gastrointestinal tube (g-tube) with specific orders for Nepro 1.8 and water flushes. The facility's policy required the use of personal protective equipment (PPE) such as gowns and gloves during high-contact activities, including tube feeding administration, to prevent the transmission of multi-drug resistant organisms. During an observation, Registered Nurse (RN) #275 administered a bolus tube feeding to Resident #30 without donning a gown, despite the presence of an EBP sign on the resident's door. The RN confirmed the absence of PPE in the resident's room and acknowledged not wearing a gown during the procedure. The Director of Nursing (DON) also confirmed that staff should follow EBP during tube feeding administration and that PPE should be available in rooms of residents with EBP orders. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's infection control practices.
Medication Labeling, Expiration, and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled with a date after being opened, affecting one resident observed for medication administration. Specifically, Resident #58's Humalog KwikPen and Insulin Glargine pen were found opened but not labeled with an open date. This was confirmed by RN #54 during an observation of the Heatherwood medication cart. Additionally, the facility failed to discard medications after their expiration date, affecting six residents who received medication from the Magnolia medication cart. A bottle of Geri-knot 8.6 mg with an expiration date of March 2024 was found, and RN #45 confirmed it was expired. The affected residents had orders to receive this medication, which was not properly managed according to the facility's policy on medication storage and expiration checks. Furthermore, the facility failed to ensure medications were not left unattended at residents' bedside, affecting one resident observed. Resident #01, who was cognitively intact, was found with two white pills inside a clear plastic container on their bedside table. LPN #23 confirmed she left the medication cup with two potassium pills at the resident's bedside and acknowledged that she was supposed to watch the resident take the medication. This incident highlights a lapse in following the facility's policy on the safe and secure storage of medications, which mandates that medications should be administered directly and not left unattended.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that the reach-in refrigerator contained multiple food items, including bowls of salads, cups of pears, and pureed fruit, all without labels or dates. Additionally, a large fast-food container was found with no label or date. The kitchen floor under the dishwasher was dirty with dried food particles, and there was an unknown black substance on the walls and under the appliances. The ceiling had an unknown brown substance splattered on it, and a long metal table in front of the dishwasher had a rusted bottom shelf with chunks of metal missing. The trash receptacles had dried food debris and a dried, splattered substance running down the sides, and the light fixtures above the dishwasher contained dead bugs. The Registered Dietician confirmed these findings during the tour. The facility's policies, dated 09/2017, stated that all food preparation, service, and dining areas should be maintained in a clean and sanitary condition, and that all foods should be stored wrapped or in covered containers, labeled and dated to prevent cross-contamination. The facility's failure to adhere to these policies had the potential to affect 133 residents who received meals from the facility kitchen, with one resident identified as not receiving food from the kitchen.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were completed for three residents, as required by their policy. Resident #01, who was cognitively intact and had multiple diagnoses including heart failure and dementia, did not have care conferences every three months. The facility scheduled care conferences on days when Resident #01 was out for dialysis, resulting in missed conferences. This was confirmed by both the resident and the Licensed Social Worker (LSW) #123. Resident #15, who was moderately cognitively impaired and had diagnoses including coronary artery disease and Alzheimer's disease, had not received any care conferences since their last one dated 07/17/23. This was confirmed by both the resident and LSW #123. Additionally, Resident #91, who had impaired cognition and multiple diagnoses including dementia and PTSD, had no documented care conferences since admission. LSW #123 confirmed that a care conference should have been scheduled in December 2023 but was not. The facility's policy required care conferences to be scheduled and documented, which was not adhered to in these cases.
Failure to Provide Ancillary Services for Hearing Impairment
Penalty
Summary
The facility failed to ensure ancillary services were provided to residents with hearing and visual impairments, specifically affecting Resident #116. The resident, who had diagnoses including parkinsonism, dementia, generalized anxiety disorder, and hypertension, was admitted with hearing aids and batteries. Despite this, observations during the annual survey revealed that the resident was not wearing hearing aids and did not have them present in his room. The care plan for the resident included interventions for sensorineural bilateral hearing loss, but these were not followed through as no ancillary referral services had been completed for the resident. Interviews with the Administrator and Social Services Director (SSD) revealed a lack of awareness regarding the resident's hearing aids. The Administrator was initially unaware that the resident had hearing aids, and the SSD confirmed that no ancillary referral services had been completed. This indicates a communication breakdown and failure to implement the care plan effectively, leading to the resident not receiving the necessary hearing services.
Inadequate Indications for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure residents' antipsychotic medications were given with adequate indications for use, affecting three residents. Resident #104 was prescribed Seroquel for agitation and Alzheimer's Disease despite severe cognitive impairment and the medication's black box warning against use in elderly patients with dementia-related psychosis. The Director of Nursing (DON) confirmed the prescription and the associated risks, but the care plan only indicated the provision of the medication per physician's orders without addressing the contraindications or exploring non-pharmacological interventions. Similarly, Resident #61, who had severe cognitive impairment and multiple diagnoses including dementia and depression, was prescribed Trazodone for mood and mental health. The care plan for this resident also failed to address the necessity of the medication or consider alternative interventions. Resident #71, with diagnoses including Alzheimer's disease and dementia, was prescribed Seroquel for dementia behaviors, despite the known risks. The DON confirmed awareness of the black box warning but did not ensure the medication was used appropriately. The facility's failure to implement gradual dose reductions and non-pharmacological interventions before continuing psychotropic medications was evident in these cases.
Failure to Document Confiscation of Resident's iPad
Penalty
Summary
The facility failed to ensure proper documentation in the medical record for a resident who had their personal iPad confiscated. The resident, who was admitted with multiple medical diagnoses including Alzheimer's disease and dementia, reported that his iPad was taken away three days after admission without any explanation. The Licensed Social Worker (LSW) confirmed that the iPad was removed because it contained passwords for different accounts and, upon attempting to shut it off, discovered a gallery of child pornography. The LSW reported this to the Administrator, who then called the police. However, there was no documentation in the resident's medical record regarding the confiscation of the iPad or the subsequent police involvement. The Administrator confirmed that no documentation was entered into the resident's electronic record because the matter was handed over to the police. This lack of documentation is a violation of the facility's policy, which requires social service workers to document progress notes and pertinent information affecting the resident's health and well-being. The failure to document the incident in the medical record was identified during a review of the resident's progress notes and interviews with the staff and the resident.
Improper Mattress Fit on Bed Frame
Penalty
Summary
The facility failed to ensure a resident's mattress fit properly on the bed frame, affecting one resident out of the 134 residents in the facility. The resident, who had multiple diagnoses including dementia, epilepsy, and congestive heart failure, was dependent on staff for all activities of daily living and had impaired cognition. A bed safety evaluation revealed the resident had poor bed mobility and difficulty sitting on the side of the bed, and was unable to transfer independently or use a call light for help. An observation of the resident's bed showed a gap of approximately 12 inches between the headboard and the mattress, which was confirmed by a staff member as a safety risk. The facility's policy on the use of support surfaces indicated that mattresses should be inspected regularly to identify areas of possible entrapment and ensure they fit the bed frame properly. However, the policy was not followed in this case, as evidenced by the large gap observed. The Regional Clinical Nurse confirmed that such a gap could pose a safety risk and potentially harm the resident. The facility's failure to adhere to its own policy on mattress inspection and bed safety led to this deficiency.
Failure to Conduct IDT Meetings for Fall Incidents
Penalty
Summary
The facility failed to ensure falls were reviewed and discussed by the Interdisciplinary Team (IDT) and a root cause analysis was determined for two residents. Resident #20, who had diagnoses including non-traumatic brain disorder, renal insufficiency, diabetes, dementia, and psychotic disorder, experienced falls on two separate occasions. On 12/12/23, Resident #20 was found on the floor next to his bed with minor injuries, and on 02/19/24, the resident fell again and was sent to the hospital. In both instances, there was no documented evidence of an IDT meeting to review and discuss the falls or to determine a root cause analysis. This was confirmed by an interview with an LPN on 04/11/23. Similarly, Resident #01, who had medical diagnoses including cardiorespiratory conditions, heart failure, peripheral vascular disease, renal insufficiency, and non-Alzheimer's dementia, fell while ambulating in the hall using her walker on 01/20/24. The resident hit her head on the floor, and although neuro checks were initiated and were negative, there was no documented evidence of an IDT meeting to review and discuss the fall or to determine a root cause analysis. This was also confirmed by the same LPN during the interview. The facility's policy on Fall Prevention and Management mandates that the IDT should review all falls at the next daily clinical meeting, discuss potential causes, and document the discussion, which was not followed in these cases.
Failure to Follow Up on Missing Cell Phone
Penalty
Summary
The facility failed to follow up on a missing cell phone reported by Resident #15, who was moderately cognitively impaired and had multiple diagnoses including coronary artery disease, heart failure, peripheral vascular disease, renal insufficiency, diabetes, Alzheimer's disease, and dementia. The resident's cell phone was lost during a transition to the hospital from another facility, and a VA representative had indicated that the phone would be replaced. However, there was no documentation in the progress notes from 07/17/23 through 04/11/24 regarding the lost cell phone or any follow-up communication with the VA representative. An interview with the resident on 04/09/24 revealed that the cell phone had not been replaced as promised. The Licensed Social Worker (LSW) acknowledged knowing about the missing cell phone but admitted to not following up with the VA representative. The facility's policy on Social Services emphasizes the importance of meeting the social and psychological needs of residents, including communication with outside agencies. This deficiency was investigated under Complaint Number OH00152479.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vienna Springs Health Campus | 0.7 mi | ★★★★★ | 1 | 0 |
| Laurels Of West Carrollton The | 0.8 mi | ★★★★★ | 18 | 0 |
| Sycamorespring Of Miamisburg | 1 mi | ★★★★★ | 3 | 0 |
| Sycamore Trails Post Acute | 1.3 mi | ★★★★★ | 0 | 0 |
| Centerville Health And Rehab | 2.3 mi | ★★★★★ | 5 | 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.