Inspection Reports for Altercare Cuyahoga Falls
2728 Bailey Rd, Cuyahoga Falls, OH 44221, United States, OH, 44221
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
76 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 14
Jun 12, 2025
Visit Reason
The inspection was conducted based on multiple complaints alleging deficiencies in resident care, infection control, medication administration, staffing, and other regulatory compliance issues at the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate environmental cleanliness, failure to provide care and assistance with activities of daily living, incomplete care planning, failure to provide scheduled showers and toileting assistance, medication errors, inadequate infection control practices, incomplete medical records, and failure to offer pneumococcal vaccinations.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Numbers OH00164353, OH00165488, OH00165064, OH00165843, OH00165648, OH00165497, OH00164001, OH00163696, OH00166268, OH00165648, OH00165488, OH00164001, OH00165488.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Resident #9 was not treated with respect and dignity by staff, causing anxiety and fear. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain clean carpeting and bed linens, causing urine odors and sticky carpets affecting multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a member from food and nutrition services participated in care conferences for Resident #284. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary assistance with activities of daily living including showers and incontinence care for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report lab results to physician and ensure comprehensive admission assessments and timely scheduling of appointments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure passive range of motion exercises were provided as ordered for Resident #32. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and accurate post-fall investigations for Resident #3. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled toileting and appropriate catheter care to prevent urinary tract infections for Residents #4 and #20. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess and manage pain appropriately for Residents #20 and #3. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough nursing staff to meet resident needs, resulting in missed showers and inadequate care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents on mechanical soft diets received appropriate diet consistency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain complete and accurate medical records for Residents #12, #142, and #284. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection prevention and control measures consistently for residents on Enhanced Barrier Precautions and Contact Precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to offer, screen, educate, and provide pneumococcal vaccinations to eligible residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 76
Residents affected: 27
Weight loss: 50.8
Medication dosage: 0.7
Medication dosage administered: 0.8
Pain rating: 7
Pain rating: 9
Pain rating: 6
Pain rating: 8
Pain rating: 10
Pain rating: 0
Pain rating: 10
Weight: 226.2
Weight: 226
Weight: 175.2
Weight: 177
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #439 | Certified Nursing Assistant | Named in finding for disrespectful treatment of Resident #9 |
| Nurse #433 | Nurse | Witness and reporter of disrespectful treatment of Resident #9 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including disrespect to Resident #9 and staffing |
| Dietitian #501 | Dietitian | Interviewed regarding failure to assess significant weight loss for Resident #285 |
| CNA #420 | Certified Nursing Assistant | Interviewed regarding failure to provide showers and toileting assistance to Resident #20 |
| Nurse #433 | Nurse | Interviewed regarding pain management for Resident #20 |
| Physician #437 | Physician | Interviewed regarding pain management and lab result reporting for Resident #20 |
| Pharmacist #542 | Pharmacist | Interviewed regarding medication administration for Resident #20 |
| CNA #394 | Certified Nursing Assistant | Interviewed regarding incontinent care and police call for Resident #4 |
| Nurse Practitioner #543 | Nurse Practitioner | Interviewed regarding Resident #4's urinary tract infections and police call |
| Assistant Director of Nursing (ADON) #410 | Assistant Director of Nursing | Interviewed regarding Resident #4's care and police call |
| CNA #420 | Certified Nursing Assistant | Interviewed regarding incontinent care and infection control practices |
| CNA #435 | Certified Nursing Assistant | Interviewed regarding infection control practices for Resident #32 |
| CNA #402 | Certified Nursing Assistant | Observed not wearing PPE for Resident #139 on contact precautions |
| RN #436 | Registered Nurse | Observed administering incorrect enoxaparin dose to Resident #135 |
| RN #417 | Registered Nurse | Witnessed Resident #3 fall |
| LPN #320 | Licensed Practical Nurse | Interviewed regarding Resident #4's care and shower documentation |
| CNA #350 | Certified Nursing Assistant | Interviewed regarding shower documentation for Resident #12 |
| CNA #305 | Certified Nursing Assistant | Interviewed regarding shower documentation for Resident #12 |
| CNA #335 | Certified Nursing Assistant | Interviewed regarding staffing and care for Resident #6 and #32 |
| CNA #544 | Certified Nursing Assistant | Interviewed regarding staffing and Resident #4's care |
| Nurse #387 | Nurse | Interviewed regarding Resident #4's care and police call |
| CNA #394 | Certified Nursing Assistant | Interviewed regarding Resident #241's care and police call |
| Nurse #433 | Nurse | Interviewed regarding pain management for Resident #20 |
| Licensed Practical Nurse (LPN) #349 | Licensed Practical Nurse | Interviewed regarding pain assessment for Resident #3 |
| CNA #316 | Certified Nursing Assistant | Interviewed regarding shower documentation for Resident #142 |
| CNA #412 | Certified Nursing Assistant | Interviewed regarding shower documentation for Resident #142 |
| Dietary Coordinator #378 | Dietary Coordinator | Interviewed regarding mechanical soft diet tray errors |
| Speech Therapist #500 | Speech Therapist | Interviewed regarding mechanical soft diet consistency |
| Regional Nurse Consultant (RNC) #431 | Regional Nurse Consultant | Interviewed regarding pneumococcal vaccination and infection control |
| Assistant Director of Nursing (ADON) #410 | Assistant Director of Nursing | Interviewed regarding Resident #20's care and Resident #4's police call |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 17
Jun 12, 2025
Visit Reason
The inspection was conducted based on multiple complaints alleging mistreatment, inadequate care, infection control issues, medication errors, and other regulatory concerns at the nursing facility.
Findings
The facility failed to ensure respectful treatment of residents, adequate staffing, proper infection control, timely reporting of lab results, appropriate care planning, medication administration, and provision of services such as showers and toileting. Multiple residents were affected by deficiencies in care, environment, and documentation.
Complaint Details
The complaint investigation included multiple complaint numbers: OH00164353, OH00165488, OH00165064, OH00165843, OH00165648, OH00165497, OH00164001, OH00163696, OH00166268, OH00165648, OH00165488, OH00164001, OH00165488, OH00165648.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (17)
| Description | Severity |
|---|---|
| Resident #9 was subjected to disrespectful treatment by CNA #439 who made inappropriate comments causing anxiety. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain clean carpeting and linens, affecting 27 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Allegation of resident mistreatment by staff was not reported to the State Agency timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure all residents received scheduled showers and personal hygiene care. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #284's care conferences lacked participation from food and nutrition services. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary assistance with activities of daily living for residents #4, #16, #20, and #65. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #20's elevated INR lab result was not reported to the physician timely. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #82's comprehensive admission assessment was incomplete and PEG tube care was delayed. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #234's dermatology appointment was not scheduled timely despite physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #20 was not treated for pain according to physician orders and pain assessments were incomplete. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #3's pain assessments were not completed as ordered by the physician. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #26's dialysis care lacked consistent communication between the facility and dialysis center. | Level of Harm - Minimal harm or potential for actual harm |
| Residents on mechanical soft diets (#14, #286, #292) were served inappropriate diet consistencies. | Level of Harm - Minimal harm or potential for actual harm |
| Resident-identifiable information and medical records for residents #12, #142, and #284 were incomplete or inaccurate. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #20, #235, #241, #32, and #139 were not consistently provided infection control measures per policy. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #135 received an incorrect dose of enoxaparin medication. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #4, #6, #32, #49, and #139 were not offered, screened, educated, or vaccinated for pneumococcal disease as required. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 76
Residents affected by carpet and linen issues: 27
Weight loss: 50.8
INR lab result: 3.9
Enoxaparin dose: 0.7
Enoxaparin dose administered: 0.8
Shower schedule missed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #439 | Certified Nursing Assistant | Named in disrespectful treatment and intimidation of Resident #9 |
| Nurse #433 | Nurse | Witness and reporter of mistreatment incident involving Resident #9 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including mistreatment, pain management, and staffing |
| Dietitian #501 | Dietitian | Interviewed regarding nutrition assessment and weight loss for Resident #285 |
| CNA #420 | Certified Nursing Assistant | Interviewed regarding shower and ADL care deficiencies |
| Nurse #387 | Nurse | Interviewed regarding Resident #4 neglect incident |
| Pharmacist #542 | Pharmacist | Interviewed regarding medication administration for Resident #20 |
| Physician #437 | Physician | Interviewed regarding pain management and lab result reporting for Resident #20 |
| Regional Nurse Consultant #431 | Regional Nurse Consultant | Interviewed regarding dialysis communication and vaccination policies |
| Assistant Director of Nursing #410 | Assistant Director of Nursing | Interviewed regarding Resident #4 neglect incident and vaccination policies |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Jul 23, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate supervision and safety during residents' smoking breaks and failure to provide appropriate incontinence care.
Findings
The facility failed to ensure residents were supervised during smoking breaks or signed out before smoking independently, and smoking materials were not secured. Additionally, the facility failed to provide thorough incontinence care for one resident, neglecting to cleanse the buttocks area and apply moisture barrier cream.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00155906 for smoking supervision and Complaint Number OH00155212 for incontinence care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents were supervised during smoking breaks or signed out before smoking independently; smoking materials not secured. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide thorough incontinence care for Resident #45, including cleansing of buttocks area and application of moisture barrier cream. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents who smoked cigarettes: 16
Residents affected by smoking deficiency: 4
Potentially affected residents by smoking deficiency: 12
Facility census: 68
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 4
Apr 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to non-compliance issues including soiled linens placed on the floor, improper storage of aerosol masks, and medication administration errors.
Findings
The facility failed to ensure soiled linens were not placed on the floor, aerosol masks were not stored in protective barriers, and medication administration errors occurred with a 32.2% error rate affecting one resident. These deficiencies affected multiple residents and were confirmed through observations, medical record reviews, and staff interviews.
Complaint Details
This inspection was conducted under Complaint Numbers OH00153037, OH00152758, and Master Complaint Number OH00153037. The deficiencies represent non-compliance investigated under these complaints.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Soiled linens were placed directly on the floor in the rooms of Resident #25 and #50. | Level of Harm - Minimal harm or potential for actual harm |
| Aerosol masks for Resident #25 and #50 were not stored in sanitary protective barriers and lacked date markings. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 32.2% with ten errors in 31 opportunities affecting Resident #5, including incorrect route of administration and failure to administer some medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer medication as ordered for Resident #5, including oral administration instead of gastric tube and omission of inhalers and nasal spray. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 32.2
Residents affected: 2
Residents affected: 1
Facility census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Agency Registered Nurse #102 | Verified soiled linens were on the floor and aerosol masks should be stored in protective barriers. | |
| State Tested Nursing Assistant #104 | Confirmed linen on the floor was from the midnight shift. | |
| Director of Nursing | Verified linen should not be placed on the floor and confirmed medication administration concerns. | |
| Agency Registered Nurse #100 | Observed medication errors including incorrect route and failure to administer some medications to Resident #5. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 28, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure correct medications were provided upon discharge to residents.
Findings
The facility failed to ensure that Resident #272 received only her prescribed medications upon discharge, as medications belonging to other residents were sent home with her. This was confirmed through record reviews, interviews, photographic evidence, and policy review.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00148961.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure correct medications were provided upon discharge, resulting in Resident #272 receiving medications belonging to other residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for discharge planning: 6
Residents affected: 1
Medication punch cards observed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #508 | Completed discharge assessment and discharge instructions with Resident #272 | |
| Director of Nursing (DON) | Interviewed regarding facility policy and medication storage | |
| Regional Nurse Consultant #502 | Interviewed regarding facility policy |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 4
Dec 2, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly care conferences for two residents, inadequate assistance with activities of daily living such as nail care and shaving, failure to provide appropriate wound care for two residents, and failure to provide physician-ordered adaptive eating devices for two residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide quarterly care conferences for two residents (Resident #14 and #158). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide nail care for two dependent residents (Resident #32 and #158) and failure to provide shaving for one resident (Resident #158). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide wound care for two residents (Resident #158 and #5) for non-pressure wounds. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents #27 and #44 had their physician's ordered adaptive devices for eating. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 52
Untreated wounds: 6
Wound measurements: 6
Wound measurements: 7
Wound measurements: 5
Deficiency count: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #21 | Registered Nurse | Primary charge nurse for Resident #158; confirmed wound condition and care deficiencies |
| STNA #34 | Social Services | Confirmed care plan conference scheduling and lack of conferences for Resident #14 and #158 |
| Hospice Nurse #58 | Hospice Nurse | Confirmed not being invited to care plan conferences for Resident #14 |
| STNA #28 | State Tested Nursing Assistant | Interviewed regarding nail care for Resident #32 |
| LPN #6 | Licensed Practical Nurse | Verified condition of Resident #32's fingernails |
| STNA #17 | State Tested Nursing Assistant | Interviewed regarding nail care for Resident #32 |
| Assistant Director of Nursing/Wound Care Nurse #42 | Assistant Director of Nursing/Wound Care Nurse | Provided wound care assessment and confirmed treatment needs for Resident #158 |
| CNP #53 | Certified Nurse Practitioner | Responded to concerns about Resident #5's chole tubing and potential complications |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 3
Oct 10, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, medication administration, and food safety.
Findings
The facility failed to provide dignified care for a resident with an indwelling urinary catheter by not covering the catheter drainage bag and exposing the resident's incontinence brief. Medications were left unsecured during preparation, potentially affecting multiple residents. Additionally, resident foods were not properly labeled or stored, posing a risk to food safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide dignified care by not covering urinary catheter drainage bag and exposing resident's incontinence brief. | Level of Harm - Minimal harm or potential for actual harm |
| Medications were left unsecured on the medication cart during preparation, accessible to multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Resident foods were stored in an unsafe and unsanitary manner, including unlabeled and undated food items in refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 58
Census: 61
Medications dispensed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #500 | Licensed Practical Nurse | Named in medication administration and dignity findings |
| STNA #112 | State Tested Nursing Assistant | Verified urinary catheter drainage bag was not covered |
| STNA #125 | State Tested Nursing Assistant | Verified resident's back and incontinence brief were exposed |
| STNA #104 | State Tested Nursing Assistant | Verified urinary catheter bag was not covered |
| Activity Director #126 | Activity Director | Verified resident's dignity was not maintained during breakfast meal |
| Director of Nursing | Director of Nursing | Confirmed dignity care standards and medication administration findings |
| Dietary Manager #100 | Dietary Manager | Verified unsafe food storage and labeling findings |
| Registered Nurse #101 | Registered Nurse | Reported nursing staff responsibility for cleaning nourishment refrigerators |
| Corporate Food Service Director #103 | Corporate Food Service Director | Verified concerns with nourishment refrigerators and food safety |
| Administrator | Administrator | Interviewed regarding medication administration findings |
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