Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
75% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse involving Resident #59.
Complaint Details
This deficiency represents the noncompliance investigated under Complaint Number OH00161750.
Findings
The facility failed to ensure immediate reporting of an abuse allegation by a nurse practitioner, resulting in late notification to the state agency. The investigation confirmed the delay in reporting and noncompliance with required timeframes.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. This failure affected one resident and resulted in late reporting to the state agency.
Report Facts
Residents present: 65
Residents reviewed for abuse: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #11 | Nurse Practitioner | Named in failure to report abuse allegation finding |
| Registered Nurse #16 | Registered Nurse | Received abuse allegation report from Nurse Practitioner #11 |
| Administrator | Interviewed regarding reporting expectations and awareness of abuse allegation |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 8
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to inform residents about their rights to formulate advance directives, timely reporting of abuse allegations, failure to complete significant change assessments, incomplete care plans, failure to obtain weights for residents at nutritional risk, lack of physician orders for oxygen therapy, improper food safety practices, and inadequate infection control during tracheostomy care.
Complaint Details
The complaint investigation included issues related to advance directives, abuse reporting, significant change assessments, care planning, nutritional monitoring, oxygen therapy orders, food safety, and infection control during tracheostomy care.
Findings
The facility failed to inform residents about advance directives, delayed reporting abuse allegations, did not complete required significant change assessments, had incomplete care plans for multiple residents, failed to obtain timely weights for residents at nutritional risk, lacked physician orders for oxygen therapy, had food safety violations including unlabeled food and uncovered utensils, and failed to maintain proper infection control during tracheostomy care.
Deficiencies (8)
F 0578: The facility failed to inform and provide written information regarding residents' rights to formulate advance directives, affecting three residents reviewed.
F 0609: The facility failed to timely report an allegation of abuse by a nurse, resulting in late reporting to the state agency.
F 0637: The facility failed to identify and complete a Significant Change in Status Assessment when a resident was discharged from hospice care.
F 0656: The facility failed to develop and implement complete care plans addressing residents' needs including language barriers, PTSD, oxygen therapy, and wound care.
F 0692: The facility failed to ensure residents at nutritional risk had weights completed per policy, missing admission and weekly weights for two residents.
F 0695: The facility failed to ensure staff obtained physician's orders for supplemental oxygen therapy for a resident receiving oxygen.
F 0812: The facility failed to ensure food was stored, prepared, and served in accordance with professional food safety standards, including unlabeled food items and uncovered utensils.
F 0880: The facility failed to maintain appropriate infection control practices during tracheostomy care, contaminating sterile fields and not changing gloves or performing hand hygiene between clean and dirty tasks.
Report Facts
Facility census: 65
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 65
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT #19 | Respiratory Therapist | Observed performing tracheostomy care with improper infection control practices |
| LPN #2 | Licensed Practical Nurse | Confirmed resident receiving oxygen therapy without physician order |
| MDS Coordinator #7 | Responsible for care plan development and revision; confirmed care plan deficiencies | |
| Director of Nursing | Director of Nursing | Provided expectations for care plans, oxygen therapy orders, and infection control |
| Administrator | Administrator | Provided expectations for kitchen cleanliness, care plans, and oxygen therapy orders |
| Dietary Manager | Dietary Manager | Managed kitchen staff and food safety practices |
| Registered Dietician | Registered Dietician | Reviewed resident weights and nutritional status; noted facility issues with weight monitoring |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inadequate assistance with eating, insufficient nursing staff to meet resident needs, infection prevention and control deficiencies, and unsafe water temperatures.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Numbers OH00159910, OH00159925, and OH00159811.
Findings
The facility failed to provide timely assistance with eating to dependent residents due to inadequate staffing. Infection control lapses included lack of Legionella filters on handwashing sinks, improper PPE use by staff, and inadequate handwashing stations for residents in Enhanced Barrier Precautions. Water temperatures were below the facility's policy standards.
Deficiencies (4)
F 0677: The facility failed to ensure dependent residents were provided assistance with eating in a timely manner, affecting five of nine residents requiring feeding assistance.
F 0725: The facility failed to maintain adequate nursing staff levels to ensure residents requiring feeding assistance were timely provided meals, affecting five of nine residents.
F 0880: The facility failed to provide and implement an infection prevention and control program, including lack of Legionella filters on handwashing sinks, inadequate handwashing stations for residents in Enhanced Barrier Precautions, and improper PPE use by a phlebotomist.
F 0921: The facility failed to maintain water temperatures within the appropriate range, with observed temperatures below policy standards in handwashing sinks.
Report Facts
Residents affected: 5
Facility census: 62
Residents in Enhanced Barrier Precautions: 24
Residents positive for C. Auris: 12
Water temperature: 84
Water temperature: 91.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phlebotomist #500 | Phlebotomist | Failed to wear appropriate PPE and perform hand hygiene when caring for residents in Enhanced Barrier Precautions |
| Licensed Practical Nurse #37 | Licensed Practical Nurse | Reported not assisting residents with eating due to other duties |
| Licensed Practical Nurse #501 | Licensed Practical Nurse | Reported not assisting residents with eating due to other duties |
| Certified Nursing Assistant #47 | Certified Nursing Assistant | Reported staffing shortages affecting feeding assistance |
| Certified Nursing Assistant #57 | Certified Nursing Assistant | Assigned to third floor feeding assistance |
| Maintenance Assistant #79 | Maintenance Assistant | Verified lack of Legionella filters and water supply restrictions |
| Regional Director of Operations #800 | Regional Director of Operations | Reported limited number of handwashing sinks with filters available |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about care planning and hygiene for residents, specifically focusing on Resident #15.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00145672 and Complaint Number OH00145287.
Findings
The facility failed to develop and implement a comprehensive care plan for tracheostomy care and failed to provide adequate bathing and hygiene for a resident, resulting in maggots being found on the resident's hairline and mattress. The facility took corrective actions including bathing the resident, cleaning the mattress, and adjusting care plans and orders.
Deficiencies (2)
F 0656: The facility failed to have a comprehensive care plan in place for residents receiving tracheostomy care, affecting one resident. No care plan for tracheostomy care existed prior to 08/24/23.
F 0677: The facility failed to ensure residents dependent on staff for bathing received adequate hygiene, resulting in maggots found on a resident's hairline and mattress. Corrective actions included bathing, mattress cleaning, and new physician orders.
Report Facts
Residents affected: 1
Facility census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinical Director #40 | Verified absence of tracheostomy care plan for Resident #15. | |
| Assistant Director of Nursing (ADON) #30 | Assistant Director of Nursing | Assessed Resident #15 and involved in bathing and care after maggot discovery. |
| Licensed Practical Nurse (LPN) #33 | Licensed Practical Nurse | Reported maggots on mattress and notified Director of Nursing. |
| Director of Nursing (DON) | Director of Nursing | Assessed Resident #15 after maggot report and oversaw care. |
| State Tested Nursing Assistant (STNA) #32 | State Tested Nursing Assistant | Provided care to Resident #15 and reported no bugs on 08/13/23. |
| State Tested Nursing Assistant (STNA) #35 | State Tested Nursing Assistant | Reported maggots on mattress during night shift and assisted in removal. |
| Licensed Practical Nurse (LPN) #31 | Licensed Practical Nurse | Cared for Resident #15 and reported no flies or abnormalities during shift. |
| Maintenance Director #39 | Maintenance Director | Reported pest control procedures and treatment frequency. |
| State Tested Nursing Assistant (STNA) #38 | State Tested Nursing Assistant | Assisted in removing maggots from Resident #15's hairline and commented on pest issues. |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Date: Jul 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding pressure ulcer care, fall prevention, and wound care compliance at Scarlet Oaks Nursing and Rehabilitation Center.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Numbers OH00143918, OH00144181, OH00143880, and OH00143792.
Findings
The facility failed to properly assess and treat pressure ulcers, resulting in actual harm to residents. Additionally, the facility did not follow care plans to prevent falls, leading to injury. Treatment orders were not consistently followed, and staff failed to provide adequate supervision and assistance.
Deficiencies (2)
F 0686: The facility failed to thoroughly assess and timely identify pressure ulcers, resulting in an unstageable pressure ulcer with actual harm to Resident #37 and risk of harm to Resident #04. Pressure ulcer treatments were not consistently administered per physician orders.
F 0689: The facility failed to provide adequate supervision and follow the care plan to prevent falls, resulting in Resident #32 falling from bed and sustaining a laceration requiring hospital treatment.
Report Facts
Facility census: 67
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 2.4
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 1
Fall date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #125 | Assistant Director of Nursing (ADON) / Licensed Practical Nurse | Authored nurse progress note assessing Resident #37's pressure ulcer and involved in fall investigation |
| NP #575 | Nurse Practitioner | Provided wound treatment orders and assessments for Residents #37 and #04 |
| RN #415 | Registered Nurse | Observed and confirmed treatment issues with Resident #04's pressure ulcer dressing |
| STNA #455 | State Tested Nursing Assistant | Provided peri-care alone to Resident #32 leading to fall; received education on two-person assist requirement |
Inspection Report
Routine
Census: 62
Deficiencies: 5
Date: May 20, 2022
Visit Reason
Routine inspection of Scarlet Oaks Nursing and Rehabilitation Center to assess compliance with care standards, medication storage, food safety, respiratory care, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to provide nail care, improper oxygen humidifier maintenance, unlocked medication carts with expired and improperly stored medications, poor food storage and sanitation practices, improper food portioning and hygiene, and failure to offer or administer influenza and pneumonia vaccinations as required.
Deficiencies (5)
F 0677: The facility failed to ensure a resident was assisted with nail care, resulting in extremely long, dirty, and jagged nails for Resident #35.
F 0695: The facility failed to ensure Resident #25's oxygen humidifier bottle contained water and was dated as required.
F 0761: Medication carts were left unlocked and unattended, expired medications were not disposed of, and controlled medications were not stored in separately locked compartments.
F 0812: The facility failed to maintain food service areas in a sanitary manner, including mold in refrigerators, backed-up drains, ineffective dishwasher sanitization, and improper food handling and portioning.
F 0883: The facility failed to ensure residents were offered influenza vaccinations and failed to administer pneumonia vaccinations despite having signed consents.
Report Facts
Facility census: 62
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 55
Residents affected: 2
Expired medications: 8
Dishwasher sanitizer level: 0
Dishwasher sanitizer level: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #460 | State Tested Nurse Aide | Named in nail care deficiency for Resident #35 |
| RN #330 | Registered Nurse | Verified oxygen humidifier expectations and deficiency for Resident #25 |
| LPN #225 | Licensed Practical Nurse | Verified medication carts were unlocked and unattended |
| LPN #270 | Licensed Practical Nurse | Verified expired medications and improper storage of controlled medications |
| DM #500 | Dietary Manager | Verified multiple food safety and sanitation deficiencies |
| Maintenance Director #23 | Maintenance Director | Verified kitchen drain issues and maintenance awareness |
| Technician #300 | Outside Contractor | Evaluated dishwasher and sanitizer issues |
| DA #514 | Dietary Aide | Observed improper food handling and plating practices |
| DON | Director of Nursing | Verified immunization deficiencies for Residents #5 and #19 |
| RD #605 | Registered Dietitian | Reported unawareness of kitchen portioning and food weighing issues |
Inspection Report
Routine
Census: 62
Deficiencies: 6
Date: Mar 28, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of Medicare/Medicaid coverage, safe medication administration, staff training, psychotropic medication use, medication error rates, and infection prevention and control practices.
Findings
The facility was found deficient in providing Skilled Nursing Facility Advanced Beneficiary Notice letters to discharged residents, ensuring licensed practical nurses were IV certified for PICC line medication administration, providing required annual in-services and performance evaluations for nursing assistants, limiting psychotropic medication PRN orders to 14 days, preventing medication errors, and implementing proper infection control procedures during blood sugar testing and catheter care.
Deficiencies (6)
F 0582: The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice letters to two residents discharged from Medicare Part A services.
F 0694: Licensed practical nurses administered medications via PICC line without IV certification, affecting one resident.
F 0730: One state tested nursing assistant did not receive 12 hours of annual in-services or an annual performance evaluation.
F 0758: The facility failed to limit PRN psychotropic medication orders to 14 days and did not ensure gradual dose reductions prior to continuing such medications for three residents.
F 0759: Medication error rate was 22.58%, with one resident affected due to improper administration technique through a gastrostomy tube.
F 0880: The facility failed to use appropriate infection control techniques during blood sugar testing and allowed urinary catheter bags to lie on the floor, affecting multiple residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medication error rate: 22.58
Medication errors: 7
Facility census: 62
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