Inspection Reports for Altercare Majora Lane
105 Majora Ln, Millersburg, OH 44654, United States, OH, 44654
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
62 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 6
Date: Jul 29, 2025
Visit Reason
The inspection was conducted based on complaints alleging failure to notify physicians of changes in resident conditions, failure to maintain a clean and homelike environment, improper use of physical restraints, inadequate incontinence care, failure to timely assess and notify physicians of blood in urine, and failure to document injuries in medical records.
Complaint Details
The complaint investigation was triggered by allegations of failure to notify physicians of changes in resident conditions, failure to maintain a clean environment, improper use of physical restraints, inadequate incontinence care, failure to timely assess and notify physicians of blood in urine, and failure to document injuries in medical records. The facility census was 62.
Findings
The facility failed to notify physicians and responsible parties of changes in condition for three residents, failed to maintain cleanliness in the secured unit affecting 17 residents, failed to ensure one resident was free from physical restraints, failed to provide timely incontinence care for one resident, failed to timely assess and notify the physician of blood in urine for one resident, and failed to document injuries for two residents in their medical records.
Deficiencies (6)
Failure to notify physician and/or responsible party of change in condition for three residents (#7, #35, #46).
Failure to maintain a clean and homelike environment in the secured unit affecting 17 residents.
Failure to ensure Resident #35 was free from physical restraints.
Failure to provide timely incontinence care for Resident #7.
Failure to timely assess and notify physician when Resident #7 was noted to have blood in urine.
Failure to document injuries for Residents #35 and #46 in medical records.
Report Facts
Facility census: 62
Residents affected: 3
Residents affected: 17
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #210 | CNA | Observed and reported Resident #35's injury and crying after nail trimming incident |
| Certified Nursing Assistant #277 | CNA | Observed Resident #35 crying and reported injury to Program Director |
| Program Director #204 | Program Director | Coordinator for secured unit, interviewed regarding incidents and documentation failures |
| Licensed Practical Nurse #223 | LPN | Involved in trimming Resident #35's nails during incident |
| Certified Nursing Assistant #202 | CNA | Held Resident #35's arm during nail trimming incident |
| Certified Nursing Assistant #239 | CNA | Primary CNA for Resident #7, involved in incontinence care observation |
| Certified Nursing Assistant #281 | CNA | Involved in incontinence care observation for Resident #7 |
| Director of Nursing | DON | Interviewed regarding documentation and notification failures |
| Registered Nurse #316 | RN | Completed progress note for Resident #46's hospital return |
| Assistant Director of Nursing #207 | ADON | Interviewed regarding incontinence care policies |
| Primary Physician/Medical Director #320 | Physician/Medical Director | Interviewed regarding lack of notification about Resident #7's blood in urine |
| Certified Nurse Practitioner #321 | CNP | Interviewed regarding lack of notification about Resident #7's blood in urine |
| Registered Nurse #221 | RN | Charge nurse interviewed regarding lack of CNA communication about Resident #7's condition |
Inspection Report
Routine
Census: 58
Deficiencies: 4
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to accident hazards, food safety, infection control, and overall facility safety.
Findings
The facility was found to have multiple deficiencies including improper storage of oxygen tanks posing accident hazards, expired and moldy food in dry storage, improper cleaning and handling of food preparation equipment, and failure to implement enhanced barrier precautions during wound care.
Deficiencies (4)
Unsecured oxygen tank stored improperly in Resident #34's room after oxygen order was discontinued.
Expired and moldy bread found in kitchen dry storage area affecting potential food safety for residents.
Robo-coupe food processor was not properly cleaned and dried prior to pureeing meals; contaminated spoon used in food mixture.
Failure to apply gowns during wound care for Resident #27 despite signage and PPE availability.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Facility census: 58
Expired bread loaves: 6
Staff signed in-service: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #506 | Interviewed regarding oxygen tank storage practices | |
| Registered Nurse #305 | RN | Confirmed improper oxygen tank storage in Resident #34's room |
| Dietary Coordinator #507 | DC | Confirmed expired bread removal and food preparation deficiencies |
| LPN #205 | Licensed Practical Nurse | Observed and interviewed regarding failure to apply gowns during wound care |
| Assistant Director of Nursing #225 | ADON | Observed and interviewed regarding failure to apply gowns during wound care |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide appropriate treatment and care for residents, specifically related to timely documentation and treatment of skin issues for Resident #31 and pain management for Resident #43.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00154080 and Complaint Number OH00153989.
Findings
The facility failed to ensure timely documentation and treatment of Resident #31's redness and excoriation to the buttocks and failed to provide accurate and timely pain management documentation and treatment for Resident #43. Both deficiencies were found to affect a few residents and represented minimal harm or potential for actual harm.
Deficiencies (2)
Failure to ensure Resident #31's redness and excoriation to the buttocks was documented and treated timely.
Failure to ensure Resident #43's pain was accurately documented and treated timely.
Report Facts
Facility census: 64
Residents reviewed for incontinence care: 3
Residents reviewed for pain: 3
Pain rating: 8
Pain rating: 8.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #262 | Registered Nurse | Helped Resident #31 use the restroom and applied barrier cream; confirmed no documentation of reddened buttocks |
| STNA #253 | State Tested Nursing Assistant | Documented skin assessments for Resident #31; reported no redness on 06/03/24 and 06/06/24 |
| STNA #230 | State Tested Nursing Assistant | Documented redness and pain on Resident #31's buttocks on 06/10/24 |
| LPN #237 | Licensed Practical Nurse | Documented no new skin issues on Resident #31 on 06/11/24; stated no STNA reported redness |
| STNA #238 | State Tested Nursing Assistant | Observed and assisted with incontinence care for Resident #31; applied extra protection cream; noted redness and excoriation |
| STNA #274 | State Tested Nursing Assistant | Assisted with incontinence care for Resident #31; noticed redness days prior and reported to nurse |
| Director of Nursing | Director of Nursing | Interviewed regarding skin assessment documentation and pain management policies |
| LPN #221 | Licensed Practical Nurse | Evaluated Resident #43's pain; administered acetaminophen; did not contact physician about pain level |
| LPN #270 | Licensed Practical Nurse | Observed Resident #43 in pain; asked pain rating; communicated with physician about pain medication |
| STNA #250 | State Tested Nursing Assistant | Offered to assist Resident #43 out of bed; resident refused |
Inspection Report
Census: 59
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
The inspection was conducted to assess compliance with safety measures to prevent accidents, specifically focusing on fall interventions and physician orders for residents at risk of falls.
Findings
The facility failed to ensure that fall interventions and physician orders were implemented for one resident (Resident #33) reviewed for falls. Specifically, a required floor mat was not placed beside the resident's bed as ordered by the physician.
Deficiencies (1)
Failure to ensure fall interventions/physician orders were implemented for Resident #33, specifically the absence of a floor mat beside the bed as ordered.
Report Facts
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #110 | Interviewed regarding the absence of the floor mat and verified the physician order |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to safely transport Resident #57 in a wheelchair, resulting in a fall and injury.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00147522 and OH00148041.
Findings
The facility failed to prevent Resident #57 from falling out of her wheelchair while being transported by a hospitality aide who was not qualified to perform this task. The aide was terminated, and a new safety intervention was implemented. The deficiency was found to be non-compliant under two complaint numbers.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in Resident #57 falling out of her wheelchair and sustaining a head injury.
Report Facts
Facility census: 60
Residents reviewed for accidents/hazards: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HA #221 | Hospitality Aide | Named in the finding for transporting Resident #57 unsafely and causing a fall; terminated on 10/10/23 |
| Regional Staff Coordinator #300 | Provided interview details regarding HA #221's qualifications and role in the incident |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Date: Feb 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse involving residents #67 and #74 at the facility.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00139625. The allegations involved Resident #74 grabbing Resident #67 and inappropriate sexual behavior. The facility did not report the incidents timely and did not investigate thoroughly. The allegation from 09/24/22 was unsubstantiated after investigation.
Findings
The facility failed to timely report allegations of abuse to the state agency and did not thoroughly investigate the abuse allegations involving Resident #67. The incidents involved Resident #74 grabbing Resident #67 forcefully and inappropriate sexual behavior. The facility census was 70 at the time.
Deficiencies (2)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Report Facts
Residents affected: 1
Facility census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #102 | Registered Nurse | Provided signed witness statement confirming abuse incident on 08/13/22 |
| Wellness Director #113 | Wellness Director | Received report from nursing assistant about abuse incident on 09/24/22 |
| Director of Nursing | Director of Nursing | Verified she was on vacation during incident and confirmed lack of reporting and investigation |
| Administrator | Administrator | Verified not employed at time of incident and confirmed delayed reporting to state agency |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Majora Lane Center for Rehab & Nursing Care Inc, summarizing the findings from the survey completed on 07/21/2022.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 61
Deficiencies: 5
Date: Sep 5, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including activities, skin care, pressure ulcer prevention, smoking safety, and fall prevention.
Findings
The facility failed to provide activities that met the interests of Resident #42, failed to accurately assess and address a bruise on Resident #6, failed to follow physician-ordered pressure ulcer interventions for Resident #4, failed to provide a safe smoking environment for three residents, and failed to ensure appropriate fall interventions for Resident #15.
Deficiencies (5)
Failed to provide activities that met the interest of Resident #42.
Failed to accurately assess and address Resident #6's left wrist/hand bruise.
Failed to follow physician ordered pressure ulcer interventions for Resident #4's bilateral heel pressure wounds.
Failed to provide a safe smoking environment for three residents and failed to ensure Resident #14 used adaptive smoking equipment (clothespin).
Failed to ensure appropriate fall interventions were in place for Resident #15.
Report Facts
Facility census: 61
Resident #4 right heel wound size: 3
Resident #4 left heel wound size: 3
Resident #6 bruise size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Assistant #124 | Verified activity participation records and confirmed Resident #42 did not use a clothes pin while smoking. | |
| Registered Nurse #104 | RN | Interviewed regarding Resident #6's bruise and confirmed it was old and not reported. |
| State Tested Nurse Assistant #153 | STNA | Interviewed about Resident #6's bruise and care observations. |
| Licensed Practical Nurse #100 | LPN | Observed Resident #6's bruise and discussed pressure ulcer care and Heelex boots with staff. |
| Maintenance Coordinator #106 | Verified no ashtrays were available in the resident smoking area. | |
| Director of Nursing | DON | Confirmed fall intervention issues related to Resident #15. |
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