Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
56 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Feb 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #45, who sustained major injuries after an unwitnessed fall in the facility.
Findings
The facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #45, resulting in a fall with major injury including bilateral tibial fractures. Staff failed to respond timely to the resident's calls for help, and appropriate interventions to prevent additional falls were not consistently implemented.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00161945.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive and individualized fall prevention program to ensure Resident #45's safety and supervisory needs were addressed timely. | Level of Harm - Actual harm |
| Failure to ensure appropriate interventions were implemented to prevent additional falls/injury. | Level of Harm - Actual harm |
Report Facts
Residents affected: 3
Facility census: 56
Date of fall incident: Jan 17, 2025
Date survey completed: Feb 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #104 | Certified Nursing Assistant | Observed Resident #45 yelling for help but walked past without responding |
| CNA #102 | Certified Nursing Assistant | Assigned to Resident #45, involved in fall incident response |
| LPN #103 | Licensed Practical Nurse | Assessed Resident #45 after fall and notified Director of Nursing |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations and fall prevention |
| Executive Director | Executive Director | Interviewed staff and reviewed fall incident investigation |
| CNA #200 | Certified Nursing Assistant | Interviewed during facility investigation about fall incident |
| CNA #202 | Certified Nursing Assistant | Reported pain and swelling in Resident #45's left knee on day shift |
| Nurse Practitioner | Nurse Practitioner | Ordered x-rays and pain medication for Resident #45 |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
May 28, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding improper use of mechanical lifts during resident transfers, which resulted in a resident fall and injury.
Findings
The facility failed to ensure residents were properly transferred by mechanical lift, leading to a resident (#22) falling and sustaining a spiral femur fracture requiring surgery and hospitalization. The investigation included interviews, record reviews, and observations revealing staff errors and equipment handling issues.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00153814.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure residents were properly transferred by mechanical lift, resulting in a resident fall and injury. | Level of Harm - Actual harm |
Report Facts
Residents affected: 2
Facility census: 53
Surgery duration: 2
Non-weight-bearing duration: 8
Bi-monthly inspections: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #201 | Licensed Practical Nurse | Reported incident and provided in-service on hoyer lift safety |
| RN #221 | Registered Nurse | Documented severe pain signs in Resident #22 |
| LPN #215 | Licensed Practical Nurse | Reported Resident #22's condition and coordinated hospital transfer |
| DON | Director of Nursing | Notified resident's representative and confirmed conflicting statements in investigation |
| STNA #230 | State Tested Nurse Aide | Involved in transfer incident and provided statements/interviews |
| STNA #237 | State Tested Nurse Aide | Involved in transfer incident and provided statements/interviews |
| STNA #250 | State Tested Nurse Aide | Observed assisting Resident #44 and interviewed about wheelchair positioning |
| STNA #257 | State Tested Nurse Aide | Observed assisting Resident #44 and interviewed about hoyer lift operation |
| Maintenance Director | Interviewed about hoyer lift operation and remote control |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 6
Mar 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation under Master Complaint Number OH00135930, focusing on allegations of disrespectful treatment of residents, failure to provide immediate care and dietary orders for a newly admitted resident, inadequate fall investigation, and medication management issues.
Findings
The facility failed to ensure residents were treated with respect and dignity, failed to provide timely diet orders and meals to a newly admitted resident, did not complete a thorough fall investigation including root cause analysis, and had discrepancies and delays in psychotropic medication management for a resident.
Complaint Details
The complaint investigation was triggered by allegations of disrespectful treatment of Resident #7, failure to provide immediate care and dietary orders for Resident #203, inadequate fall investigation for Resident #50, and medication management issues for Resident #11. The investigation confirmed non-compliance in all these areas under Master Complaint Number OH00135930 and Complaint Number OH00131654.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to treat Resident #7 with respect and dignity by staff member STNA #359. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide doctor's orders for immediate care and dietary orders for Resident #203 upon admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure newly admitted Resident #203 received quality standard care including timely meals and nursing assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete a comprehensive fall investigation including root cause for Resident #50 after a fall with injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to act timely on pharmacy recommendations and discrepancies in psychotropic medication orders for Resident #11. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #203 had diet orders and received breakfast tray timely. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 53
Resident #7 residents reviewed: 3
Resident #203 closed records reviewed: 3
Resident #50 residents reviewed for falls: 2
Resident #11 residents reviewed for medications: 5
Remeron dose: 7.5
Ativan dose discrepancy: 0.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| STNA #359 | State Tested Nurse Aide | Named in disrespectful treatment of Resident #7 |
| LPN #300 | Licensed Practical Nurse | Involved in care and observations related to Resident #203's admission and meal issues |
| LPN #334 | Licensed Practical Nurse | Assessed Resident #50 after fall and involved in fall investigation |
| RN #305 | Registered Nurse, Director of Nursing | Director of Nursing during Resident #203 incident and involved in investigation |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including Resident #7, #50, #203, and #11 |
| RN #307 | Registered Nurse | Observed Resident #11 and reported on resident's condition |
| Hospice RN #416 | Hospice Registered Nurse | Interviewed regarding medication discrepancies for Resident #11 |
| Hospice Clinical Director #417 | Hospice Clinical Director | Interviewed regarding medication discrepancies for Resident #11 |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 16
Mar 23, 2023
Visit Reason
The inspection was conducted due to complaints regarding resident dignity, abuse investigations, transfer and discharge procedures, medication management, restorative therapy, fall investigations, dental services, and COVID-19 notification practices.
Findings
The facility was found non-compliant in multiple areas including failure to treat residents with dignity, incomplete and untimely abuse investigations, inadequate transfer and discharge documentation and notification, lack of timely medication and dietary orders for new admissions, insufficient restorative therapy services, incomplete fall investigations, failure to provide timely dental services, improper antibiotic use monitoring, and delayed COVID-19 notifications to residents and families.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00135930 and Complaint Number OH00131654.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure residents were treated with respect and dignity by staff members. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the results of all abuse allegation investigations were reported in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct a thorough investigation for an allegation of abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all required information was sent to the receiving provider upon resident transfer to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify resident's representative in writing of transfer and discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure newly admitted resident had routine care and dietary orders to provide immediate care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure newly admitted resident received quality standard care including nursing assessment and diet orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents with pressure ulcer wounds had wound assessments completed at least every seven days. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents received restorative therapy per plan of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a comprehensive fall investigation including root cause and ensure resident safety after fall with injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pharmacy review was acted upon timely, psychotropic medication had stop dates, and resident received appropriate dose of anti-anxiety medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident received laboratory testing per orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure newly admitted resident had diet orders and received breakfast tray timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents with Medicaid received timely dental services per therapy/physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure antibiotic assessments were completed to determine appropriate use and indication for antibiotic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents, their representatives, and families were notified timely after confirmation of staff testing positive for COVID-19. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 53
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| STNA #359 | State Tested Nurse Aide | Named in dignity violation for disrespectful behavior to Resident #7 |
| Director of Nursing | Director of Nursing | Verified multiple deficiencies including dignity violation, abuse investigations, transfer/discharge issues, medication and restorative therapy problems, fall investigation, and COVID-19 notification |
| LPN #334 | Licensed Practical Nurse | Involved in fall incident and investigation for Resident #50 |
| RN #305 | Registered Nurse | Director of Nursing during Resident #203 admission incident |
| LPN #300 | Licensed Practical Nurse | Involved in Resident #203 admission and care issues |
| RN #307 | Registered Nurse | Verified wound care deficiency for Resident #204 and observed Resident #11 |
| RN/Restorative Nurse #309 | Registered Nurse/Restorative Nurse | Reported restorative therapy staffing and service deficiencies |
| Restorative Aide (RA)/STNA #322 | Restorative Aide/State Tested Nurse Aide | Reported restorative therapy staffing shortages and service gaps |
| Therapy Manager #410 | Therapy Manager | Confirmed restorative therapy continuation for Resident #12 |
| Hospice RN #416 | Hospice Registered Nurse | Discussed medication discrepancies for Resident #11 |
| Hospice Clinical Director #417 | Hospice Clinical Director | Discussed medication discrepancies for Resident #11 |
| LPN #310 | Licensed Practical Nurse/Infection Preventionist | Verified no antibiotic assessments and COVID-19 notification delays |
| Licensed Social Worker #412 | Licensed Social Worker | Confirmed no written transfer/discharge notice sent to Resident #50 representative |
| Facility Advisor #414 | Facility Advisor | Verified untimely abuse investigation conclusion reporting |
| RN/Consultant/Advisor #414 | Registered Nurse/Consultant/Advisor | Verified dignity violation by STNA #359 |
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 1
Feb 20, 2020
Visit Reason
The inspection was conducted to evaluate the facility's antibiotic use program and ensure antibiotics were used with appropriate indications according to facility policy and criteria.
Findings
The facility failed to ensure antibiotics were used appropriately based on McGeer's Surveillance Criteria, affecting two of six residents reviewed. The facility's Antibiotic Stewardship Policy did not specify criteria for appropriate antibiotic use.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure antibiotics were used with appropriate indications for use and facility policy did not indicate criteria used to determine appropriate antibiotic use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for antibiotic use: 6
Facility census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #10 | Interviewed regarding antibiotic use and policy |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 7
Dec 19, 2018
Visit Reason
The inspection was conducted as an annual and extended survey to assess compliance with regulatory requirements, including investigation of allegations of sexual abuse, care plan reviews, medication management, accident prevention, and food safety.
Findings
The facility was found to have multiple deficiencies including failure to prevent sexual abuse by Resident #13 against other cognitively impaired residents, inadequate investigation and reporting of abuse incidents, failure to update care plans timely, improper medication administration, inadequate supervision leading to resident injury, and unsanitary food service conditions. Immediate Jeopardy was identified related to sexual abuse incidents but was later removed after corrective actions were implemented.
Severity Breakdown
Immediate jeopardy: 1
Minimal harm or potential for actual harm: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to prevent sexual abuse by Resident #13 against other residents and failure to thoroughly investigate and report incidents of sexual abuse. | Immediate jeopardy |
| Failure to update care plans timely for Residents #6, #12, and #39 related to psychoactive medication use, safe wandering behavior, and pain management. | Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and assistance to prevent injury from mechanical lift and prevent Resident #39 from sliding out of wheelchair. | Minimal harm or potential for actual harm |
| Failure to ensure documentation of dialysis access site monitoring every shift for Resident #55. | Minimal harm or potential for actual harm |
| Failure to ensure Resident #62 was free from unnecessary insulin medication use. | Minimal harm or potential for actual harm |
| Failure to store, prepare and serve food in a sanitary manner to prevent contamination and potential food borne illness. | Minimal harm or potential for actual harm |
| Failure to implement an effective Quality Assurance program to ensure allegations of sexual abuse were comprehensively reviewed and corrective actions initiated. | Minimal harm or potential for actual harm |
Report Facts
Facility census: 70
Staff in-serviced on sexual abuse training: 174
Staff not yet in-serviced on sexual abuse training: 5
Residents at risk for sexual abuse: 21
Residents reviewed for care plan revision: 19
Residents reviewed for unnecessary medication use: 5
Residents receiving dialysis: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| STNA #601 | State Tested Nursing Assistant | Named in failure to provide dignified dining experience and meal service |
| Resident Assistant (RA) #520 | Resident Assistant | Named in supervision failure of Resident #13 during dining |
| LS #500 | Laundry Supervisor | Witnessed sexual abuse incident involving Resident #13 and Resident #123 |
| STNA #501 | State Tested Nursing Assistant | Witnessed sexual abuse incident involving Resident #13 and Resident #123 |
| STNA #504 | State Tested Nursing Assistant | Witnessed sexual abuse incident involving Resident #13 and Resident #12 |
| STNA #510 | State Tested Nursing Assistant | Named in lack of training on sexually inappropriate behaviors of Resident #13 |
| STNA #512 | State Tested Nursing Assistant | Named in failure to properly assist Resident #39 in wheelchair |
| LPN #505 | Licensed Practical Nurse | Named in failure to update care plan and medication administration |
| RN #519 | Registered Nurse | Named in failure to update care plan and medication administration |
| CNP #506 | Certified Nurse Practitioner | Named in lack of notification of sexual abuse incidents |
| CNP #611 | Certified Nurse Practitioner | Named in management of Resident #13's sexually inappropriate behaviors |
| MD #535 | Medical Director | Named in lack of notification of sexual abuse incidents |
| DON | Director of Nursing | Named in multiple findings including failure to investigate abuse, failure to update care plans, and failure to supervise |
| Administrator | Administrator | Named in oversight and failure to disclose sexual abuse incidents |
| CDM #509 | Certified Dietary Manager | Named in dietary sanitation deficiencies |
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