Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Continuing Healthcare At Willow Haven during CMS and state inspections, most recent first.
Staff failed to consistently document required meal intake percentages and bowel/bladder continence status in the EMR for multiple residents with dementia, diabetes, malnutrition risk, incontinence, and skin‑integrity concerns. Despite care plans and facility policy requiring that every meal be recorded and continence status be documented on all three shifts daily in PointClickCare, there were numerous days with no entries and many days with only partial documentation for meals and continence. Leadership confirmed that direct care staff were expected to complete these entries on each shift, but the records reviewed showed that this did not occur.
A resident with multiple chronic conditions and moderate cognitive impairment experienced several changes in condition, including pain and drainage at a nephrostomy tube site, a positive MRSA wound culture with initiation of contact isolation, and a catheter change due to abdominal and back pain, which led to new antibiotic therapy and diagnostic testing. Although the resident was informed of new orders, the facility did not document notification of the resident’s POA, despite the POA being actively involved in decision-making and the resident’s expressed wish that his daughter be notified of changes. This pattern of non-notification occurred despite a facility policy requiring that the resident’s legal representative be informed and that such communication be documented for significant status changes and new treatments.
The facility failed to consistently document meal intake percentages for three residents with care plans identifying risk for malnutrition and requiring that every meal be monitored and recorded. One resident with dementia, depression, dysphagia, and a history of TBI had documented poor appetite and significant weight loss, yet over a 30‑day period many meals were not entered in the EMR, with only some days showing all three meals recorded. A second resident with central cord syndrome, COPD, nutrition deficit, and hemiplegia was dependent on staff for eating and had prior SWL, but review of a 30‑day period showed multiple days with no meal documentation and others with only partial meal recording. A third resident with dementia, prior CVA, DM, protein‑calorie malnutrition, and mobility issues had a care plan requiring intake monitoring and recording of every meal, but review of several weeks of records revealed numerous days with no meals documented and only a few days where all three meals were recorded. The Administrator and regional clinical staff acknowledged that meal intakes were not consistently documented and could not provide missing intake records.
A resident with anxiety, cognitive impairment, and other chronic conditions had a PRN order for lorazepam 0.25 mg (½ of a 0.5 mg tablet) every eight hours for target behaviors such as restlessness and yelling out. Review of the MAR and progress notes showed that an RN documented and later recognized administering 0.5 mg instead of the ordered 0.25 mg. The ADON confirmed the wrong dose was given, and this occurred despite a facility policy requiring adherence to the five rights of medication administration, including verification of the correct dose against the MAR and physician order.
A resident with dementia, CKD, dysphagia, a pressure ulcer, and risk for malnutrition had physician orders and a care plan for large protein portions and bite-sized meats/entrées to support wound healing and nutritional status. Despite these orders and clear instructions on the meal ticket, staff served a breakfast tray with a whole piece of ham, uncut bread, and only a small portion of scrambled eggs, not meeting the ordered large protein portion or bite-sized preparation. The resident reported repeated problems with the kitchen not following his diet preferences and needs, and a CNA confirmed the meal did not match the ticket or facility portion-size policy.
A resident with chronic kidney disease, a nephrostomy tube, MRSA at the nephrostomy insertion site, and multiple comorbidities had physician orders and a care plan requiring enhanced barrier precautions for infection prevention. Surveyors observed the resident’s nephrostomy collection bag lying directly on the floor beside the bed, and a CNA confirmed it should have been supported by a basin that was no longer in place. This failure to maintain the nephrostomy bag off the floor was inconsistent with the facility’s infection control policy and resulted in a cited deficiency.
Multiple shower rooms had malfunctioning equipment and inappropriate water temperatures, with some rooms lacking hot water and others having leaking pipes and missing fixtures. A CNA confirmed that residents requested to use other halls due to these issues, and the Maintenance Director acknowledged that repairs were delayed and water temperatures were not routinely checked. These deficiencies had the potential to affect a significant number of residents.
A resident with intact cognition and multiple chronic conditions reported a missing Apple watch, but the facility did not complete a thorough investigation as required by policy. Key investigative steps were missed, including contacting hospital staff, following up with off-site laundry, using the locator app, and interviewing other residents or documenting police involvement.
Two residents experienced discrepancies in the documentation of controlled substance administration, including missing entries on the MAR and incomplete narcotic count sheets. Staff confirmed that records for opioid medications did not consistently reflect administration times, amounts received, or required signatures, resulting in incomplete and inaccurate medical records.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
The facility did not provide eight consecutive hours of RN coverage per day on multiple occasions, as confirmed by payroll records, staffing schedules, and interviews with the DON and ADON. The shortage of RNs, especially on weekends, limited the facility's ability to accept residents with higher acuity needs such as central lines or frequent IV therapy. Staffing decisions were based on budget rather than a formal policy, and recruitment efforts had not filled the necessary RN positions.
Multiple lapses in kitchen sanitation and food safety were observed, including improper use of hairnets by staff, a malfunctioning and leaking refrigerator contaminating beverages, heavy grease and dust buildup on kitchen equipment, and inadequate sanitizer concentration. Exposed electrical wires were also found under the dishwashing station. These deficiencies had the potential to impact all residents receiving food from the kitchen.
The facility did not maintain a clean and homelike environment, with observations of unclean rooms, sticky floors, overflowing trash, and stained curtains. During a meal, a pest control worker sprayed chemicals and handled traps in the dining area while residents ate, and entered the kitchen without a hairnet. Several rooms had maintenance issues such as leaking, moldy air conditioners and broken furniture. Staff and residents reported frequent shortages of essential supplies and linens, with staff confirming that rooms often lacked gloves, towels, and other necessary items, especially after a laundry fire disrupted operations.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Surveyors found that staff failed to consistently implement enhanced barrier precautions and proper infection control practices, including missing PPE signage, lack of EBP orders, and improper use of PPE during care for residents with indwelling devices and wounds. In addition, perineal care was not performed according to best practices due to insufficient policy detail and staff training, and infection control lapses were observed during wound care and handling of soiled linens.
A resident with multiple medical conditions, including dementia and muscle weakness, did not receive required therapy or restorative services for range of motion and ambulation after being discharged from hospice. Despite care plan interventions and the resident's expressed desire to walk, there was no evidence of therapy screening or maintenance programs, and staff confirmed the absence of regular therapy assessments, leading to a decline in the resident's ability to perform ADLs.
Two residents reported their mail was opened by facility staff without consent, violating their right to receive unopened mail. Despite having consent agreements on file, both residents denied giving permission. The facility's corporate office instructed staff to open mail from insurance companies or ODJFS, leading to this breach of privacy.
A resident with Alzheimer's and other conditions had their rollator walker, dentures, and glasses go missing after a hospital transfer. The facility's administrator attempted to contact the hospital but received no response, and no further follow-up was conducted. This failure to resolve the concern violated the facility's policy on resident rights, as noted during a complaint investigation.
A facility failed to provide comprehensive transfer information for a resident who had Alzheimer's, diabetes, and other conditions. The Transfer Form omitted the resident's son as the power-of-attorney, which was confirmed by the Administrator.
A facility failed to coordinate care for a resident by not scheduling a gynecology appointment as ordered for post-menopausal bleeding. Despite having intact cognition and multiple health diagnoses, the resident's referral was not made between the order date and a subsequent review. An interview confirmed the oversight, affecting one of three residents reviewed for appointments.
A resident's grievance about missing upper dentures was not addressed promptly by the facility, leading to a deficiency. The resident, admitted with both upper and lower dentures, reported the upper dentures missing, but the facility delayed scheduling a dental appointment and resolving the issue. The corporate office eventually agreed to cover half the replacement cost, but the resident was not informed, leading to frustration. The facility's policy on handling resident concerns was not effectively followed, resulting in a prolonged resolution process.
A resident with a history of abdominal wall infections experienced complications due to inadequate wound vac management and failure to implement a physician's order for a CT scan and surgical referral. The resident's wound vac leaked, leading to increased drainage and infection signs, resulting in hospitalization and surgical intervention. Staff interviews revealed a lack of training in wound vac management, and the facility's policy to notify physicians of wound changes was not followed.
The facility failed to maintain a safe and comfortable environment during a heat advisory, affecting several residents. The main AC units were non-functional, leading to discomfort in common areas despite the use of portable AC units and fans. Additionally, mold was found in shower rooms on two halls, with inadequate signage and cleaning efforts. Maintenance logs lacked documentation of these issues, indicating a failure in reporting and compliance with facility policies.
The facility failed to maintain a safe environment for 14 cognitively impaired residents who were independently mobile. Large portable air conditioning units and various fans were used in hallways due to non-functional main AC units. The fans posed hazards as their blades were accessible, cords were unsecured, and equipment blocked handrails. The facility lacked a policy on accident hazards.
Incomplete EMR Documentation of Meal Intake and Continence Status
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, specifically related to documentation of meal intake percentages and bowel/bladder continence status in the EMR. Surveyors found that for multiple residents, required documentation was missing on numerous days and shifts, despite facility policies and care plans that required this information to be recorded. The facility’s own policies on nutritional documentation and records and documentation required timely, accurate, and complete entries by direct care staff in the PointClickCare system. For one resident at risk for malnutrition with a history of unplanned significant weight loss and refusal of supplements, the care plan required monitoring and evaluating meal intake via meal records and observation, with goals for consuming 50–75% of most meals. Review of 30 days of meal intake records showed that all three daily meals were documented on only 14 days, with entire days where no meals were recorded and multiple days where only one or two meals were documented. Another resident with diagnoses including nutrition deficit and a documented significant weight loss had a care plan requiring that every meal be monitored and recorded. Over a 30‑day period, there were multiple days with no meals documented and several days with only partial meal documentation. A third resident at risk for malnutrition had a care plan requiring that every meal be recorded, yet review of the record over several weeks showed multiple days with no meals documented and many days with only one or two meals recorded. The survey also identified widespread failures to document urinary continence status on each of three shifts daily for several residents with bowel and bladder incontinence or at risk for skin impairment. One resident who was always incontinent of bladder and had a care plan for incontinence had no continence documentation on multiple days and only one or two shifts documented on most other days, with only one day in 30 having all three shifts recorded. Another resident, always incontinent of bowel and bladder and care planned for incontinence, had entire days with no continence documentation and no days in a 30‑day period where all three shifts were documented. Additional residents with incontinence or at risk for skin impairment had similar patterns: days with no continence entries, many days with only one or two shifts documented, and very few or no days with all three shifts completed. A short‑stay resident who was always incontinent of bowel and bladder had no days during a 14‑day review period where continence status was documented on all three shifts. During interviews, facility leadership confirmed that meal intakes and continence status were not consistently documented as required and acknowledged that the EMR system was set up to capture this information by shift, even when staff worked 12‑hour shifts.
Failure to Notify Resident Representative of Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal representative of multiple changes in condition and new medical orders, as required by facility policy. The resident, who had diagnoses including epilepsy, dementia, chronic kidney disease, a pressure ulcer, TIA, anxiety, major depressive disorder, hypertension, and dysphagia, was readmitted to the facility and later complained of pain at the right nephrostomy tube insertion site. On one occasion, documentation showed the area was warm, red, and draining, with preliminary lab results leading to new orders for doxycycline 100 mg BID for seven days. The record indicated the resident was informed and agreed to the new orders, but there was no documentation that the resident’s POA was notified of this change in condition or the new medication. Further record review showed that a wound culture from the nephrostomy tube site was positive for MRSA, and the resident was placed on contact isolation precautions for seven days, again with no documentation that the POA was notified of this change in condition. The resident’s MDS showed a BIMS score of 08, indicating moderate cognitive impairment, and dependence for toileting, showering, transfers, and mobility. Later, the resident’s indwelling urinary catheter was changed due to complaints of lower abdominal and back pain, with 550 ml of urine retrieved and a urinalysis sent, but there was still no documentation that the POA was informed of this status change. In interviews, the resident stated he wanted his daughter (POA) notified of changes and believed this was in the record, and a nurse confirmed that the POA was very involved in decision-making and should have been notified of the new medication orders and changes in condition, but was not. Facility policy required notification of the resident, physician, and legal representative or resident representative for significant changes in status and new treatments, with documentation of the exchange of information in the record, which did not occur in this case.
Failure to Consistently Document Meal Intakes for Residents at Risk of Malnutrition
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to monitor and record meal intakes for every meal as required by residents’ care plans and facility policy. The facility’s Nutritional Documentation Guidance policy required daily meal documentation by direct care staff, with CNAs or licensed nurses observing and documenting meal intakes in the EMR (PointClickCare) under point of care. Despite this, record review and staff interviews confirmed that meal intake percentages were not consistently documented for three residents who had active care plans addressing risk for malnutrition and required monitoring and recording of every meal. For one resident with diagnoses including unspecified dementia, epilepsy, hallucinations, delusional disorder, anxiety, major depressive disorder, muscle wasting, dysphagia, and a history of traumatic brain injury, the quarterly MDS showed moderately impaired cognition and poor appetite. The resident had an active care plan for risk of malnutrition, with goals for adequate energy intake and maintaining 50–75% intake of most meals, and interventions requiring monitoring and evaluation of meal percentage intake via meal records and observation. Review of 30 days of meal intake documentation showed multiple days with no meals recorded and several days with only one or two of three meals documented, with only 14 of 30 days having all three meals recorded, despite the resident having experienced significant weight loss over time. Another resident, with central cord syndrome, cervical disc disorder with myelopathy, COPD, anxiety, nutrition deficit, muscle weakness, depression, anemia, and hemiplegia following CVA, had a significant change MDS indicating moderate cognitive impairment, dependence on staff for eating, and a therapeutic diet. This resident’s care plan for risk of malnutrition noted prior significant weight loss and required that intake be monitored and every meal recorded. Review of 30 days of meal intake records showed multiple days with no meals documented and several days with only two of three meals recorded. A third resident, with dementia, history of stroke, diabetes, depression, protein-calorie malnutrition, muscle weakness, and difficulty walking, had an admission MDS showing moderate cognitive impairment and a care plan for risk of malnutrition requiring monitoring and recording of every meal. Review of this resident’s meal intake records over several weeks showed multiple days with no meals recorded, days with only one or two meals documented, and only seven days where all three meals were recorded. The Administrator and Regional Clinical Support confirmed that meal intakes were not consistently recorded for all three residents and could not provide additional documentation to show that care plans were followed.
Significant Medication Error in Lorazepam Dosing
Penalty
Summary
A resident with multiple diagnoses including type 2 diabetes, major depressive disorder, anxiety, blindness of one eye, cognitive impairment, and COPD was admitted on 02/26/18 and discharged on 12/24/25. The resident had a care plan, dated 09/20/23 and revised 04/10/25, identifying a behavior problem and use of anti-anxiety medications, with interventions that included administering medications as ordered. A physician’s order dated 12/16/25 directed lorazepam 0.5 mg tablets to be given as 0.25 mg (½ of a 0.5 mg tablet) by mouth every eight hours as needed for anxiety, with target behaviors of restlessness, yelling out, and combativeness. Review of the December 2025 MAR showed that on 12/16/25 at 9:18 p.m., RN #401 documented administration of lorazepam 0.5 mg, rather than the ordered 0.25 mg dose. A progress note entered by nurse #401 on 12/17/25 at 5:26 a.m. documented that the nurse recognized a medication error had occurred with lorazepam. A subsequent progress note at 5:27 a.m. by the ADON recorded that RN #401 notified the ADON that the resident had received 0.5 mg instead of 0.25 mg. During interview, the ADON confirmed that RN #401 administered the wrong dose. Facility policy on medication administration required nurses to observe the five rights of medication administration, including verifying the right dose against the MAR and checking the physician’s original order if there was a concern or question.
Failure to Provide Ordered Bite-Sized, High-Protein Diet
Penalty
Summary
The facility failed to ensure a resident received food prepared and portioned according to physician diet orders and the resident’s identified needs. The resident had diagnoses including epilepsy, dementia, chronic kidney disease, a pressure ulcer, anxiety, major depressive disorder, and dysphagia, and was care planned as at risk for malnutrition and dehydration with a history of unplanned significant weight loss, fluctuating intakes, poor appetite, and multiple episodes of skin breakdown. A physician order dated 02/03/26 required large protein portions at meals and that meats/entrées be cut into bite-sized pieces for wound healing. The care plan interventions included providing meals per physician diet orders, monitoring and evaluating meal intake, and providing feeding and dining assistance as needed. The resident’s MDS showed moderate cognitive impairment and a need for setup/cleanup assistance with eating. During an interview, the resident reported ongoing concerns with the dietary department, stating the kitchen repeatedly “messed up” his food, that it was hard to eat some foods because he did not have teeth, and that despite his stated food preferences being on his meal ticket, he still received the wrong items. Observation of a breakfast meal showed the resident was served a tray with one whole piece of ham, one piece of bread, and a small portion of scrambled eggs. The meal ticket on the tray, highlighted in pink, instructed staff to cut food into bite-sized pieces and provide large protein portions. A CNA confirmed that the ticket specified bite-sized food and large protein portions, but the ham and bread were not cut and the protein portions of ham and eggs were not large. Facility policy defined large portions as one and a half times the standard portion unless otherwise indicated on the meal ticket. This failure to follow the diet order and meal ticket instructions led to the cited deficiency.
Failure to Maintain Nephrostomy Collection Bag per Infection Control Standards
Penalty
Summary
The deficiency involves the facility’s failure to implement infection control interventions for the maintenance of a nephrostomy collection bag under its infection prevention and control program. A resident was re-admitted with multiple diagnoses including epilepsy, dementia, chronic kidney disease, a left buttock pressure ulcer, transient ischemic attack, anxiety, major depressive disorder, hypertension, and dysphagia. Physician orders included enhanced barrier precautions every shift due to an indwelling urinary catheter, nephrostomy tube, and a wound at the right nephrostomy insertion site with MRSA, as well as a recent course of IM ceftriaxone for a UTI. The resident’s quarterly MDS showed moderate cognitive impairment and dependence for toileting, showering, transfers, and mobility, with an indwelling nephrostomy tube and frequent bowel incontinence. The care plan documented a need for enhanced barrier precautions related to the nephrostomy site to reduce the potential spread of multi-drug resistant organisms. During observation, the resident’s nephrostomy collection bag was seen lying directly on the floor beside the bed. A CNA confirmed that the nephrostomy bag was on the floor and reported that there had previously been a basin under the bag to prevent it from touching the floor, but she did not know what had happened to it after being off work for a few days. This situation occurred despite the facility’s written infection control prevention program policy, dated December 2019, which states that residents have the right to reside in a safe environment that promotes health and reduces the risk of acquiring infections. The failure to maintain the nephrostomy bag off the floor constituted a lapse in following the facility’s infection control interventions and policies, leading to the cited deficiency during the complaint investigation.
Deficient Shower Room Maintenance and Inadequate Water Temperatures
Penalty
Summary
The facility failed to maintain safe and functional shower room environments, resulting in inappropriate water temperatures and malfunctioning equipment across multiple units. Observations and interviews revealed that the 200-hall shower room had a faulty valve and leaking pipes, with water dripping into a glove placed over the pipes. The shower room was not operational, leading residents to request showers in other halls. The 400-hall shower room had no hot water at the sink, and the water temperature in both the 400 and 500-hall shower rooms was consistently cold, measured at 101°F and 102°F, which was verified as not appropriate for resident bathing. Additionally, the 200-hall shower room had a missing exhaust fan cover and water-stained ceiling light cover. Maintenance records showed that parts had been ordered to address the issues, but repairs had not been completed due to competing maintenance demands. The Maintenance Director confirmed that water temperatures were not being routinely checked in the shower rooms. These deficiencies had the potential to affect 56 residents residing on Units 200, 300, 400, and 500, out of a total facility census of 76.
Failure to Thoroughly Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation involving a resident who reported a missing Apple watch. The resident, who had intact cognition and multiple medical diagnoses including COPD, anxiety disorder, and chronic respiratory failure, reported the watch missing after returning from a hospital stay. The resident's personal inventory at admission did not list the Apple watch, and staff acknowledged that inventories were not always updated when residents received new items. Multiple employees confirmed seeing the watch in the resident's room prior to the report, and the resident had a locator app on her phone to track the device. However, there was no documentation that the locator app was effectively used, and the missing item was not recorded in the facility's missing items log. The facility's investigation lacked several critical steps as outlined in their abuse policy. There was no evidence of communication with hospital staff to determine if the watch was left there, nor was there documentation of contact with the off-site laundry service beyond an initial message, with no follow-up recorded. Additionally, there was no documentation of interviews with other residents on the same unit to determine if they had knowledge of the missing watch or had experienced similar issues. The facility also did not document any police involvement or statements from other potentially affected residents, as required by their own investigative protocols.
Incomplete and Inaccurate Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete regarding the administration of controlled substances for two residents. For one resident with multiple diagnoses including diabetes, COPD, and chronic kidney disease, there was a discrepancy between the Individual Patient Controlled Substance Administration Record and the Medication Administration Record (MAR) for Hydrocodone-Acetaminophen. The controlled drug record indicated the medication was administered at a specific time, but the MAR did not reflect this administration. This discrepancy was confirmed during an observation of the medication cart and through interviews with facility staff. For another resident with a history of hemiplegia, diabetes, and chronic pain, the MAR showed that Oxycodone was administered at bedtime, but the narcotic count sheet marked this dose as an error, suggesting it was not given. Additionally, two narcotic sheets for this resident lacked critical information such as the date and amount of narcotic received, amount sent, and the signature of the person receiving the medication. These omissions were verified by staff interviews and were not in accordance with the facility's policy for controlled medication storage and accountability.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of registered nurse (RN) coverage per day, as required, which had the potential to affect all 68 residents. Payroll-Based Journal records for the second quarter of 2025, along with staffing schedules from January through July 2025, showed multiple dates where there was no RN coverage for the required consecutive hours. The facility assessment tool indicated an average daily census of 69 to 78 residents, and the staffing plan was based on resident needs, but the facility did not meet the RN coverage requirement on numerous specific dates. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the lack of RN coverage on these dates and verified ongoing shortages, particularly on weekends. The DON stated that the facility had only one RN on nights, two PRN RNs, and a wound nurse who was on medical leave. The facility was unable to accept residents with central lines, TPN, or orders for IV therapy more than twice a day due to the lack of available RNs or IV-trained LPNs. The DON and Administrator confirmed that there was no staffing policy in place and that staffing decisions were based on the facility's budget. Efforts to recruit RNs included job postings and participation in job fairs, but these had not resulted in sufficient hires to meet the required RN coverage.
Failure to Maintain Safe and Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, as evidenced by multiple observations during meal preparation and service. Staff were observed not following proper food safety and hygiene protocols, including a dietary staff member whose hairnet did not fully cover her hair while serving food, and a pest control employee entering the kitchen without a hat or hairnet. The reach-in refrigerator was found to be malfunctioning, with water leaking onto beverages prepared for meal service, and the thermometer inside was not working. Staff confirmed that the refrigerator had been leaking for several weeks and that the thermometer was not functional. Additionally, the stove and kitchen hood had heavy grease and dust buildup, with food debris present along gas pipes, outlets, and serving carts, all of which were verified by staff at the time of observation. Further deficiencies included improper sanitizer concentration in a red bucket used for cleaning, which tested below the required level according to posted guidelines. Exposed electrical wires with only wire nuts for protection were found under the dishwashing station, though staff stated these wires were not in use. Facility policies required food contact and non-food contact surfaces, equipment, and utensils to be kept clean and sanitized, and for thermometers to be maintained in working order, but these standards were not met. These failures had the potential to affect all 68 residents who received food from the kitchen.
Failure to Maintain Clean, Homelike Environment and Adequate Supplies
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several resident rooms were found to be unclean, with sticky floors, overflowing trash, stained privacy curtains, and bathrooms with stained caulking. Housekeeping logs indicated that some rooms had not been cleaned or had their floors mopped or trash emptied for several days, particularly over weekends when only one housekeeper was on duty. The Housekeeping Manager confirmed that staffing shortages on weekends prevented all rooms from being cleaned as required. During a lunch meal in the main dining room, a pest control employee was observed spraying chemicals and handling glue traps in the presence of residents eating their meals. The pest control employee also entered the kitchen without a hairnet during meal service. The chemical used, PT Fendona Pressurized Insecticide, has aspiration hazards and should be kept away from food and drink, according to its safety data sheet. The Regional Culinary Manager verified that it was inappropriate to spray pest chemicals during meal service and that the pest control employee was not following proper hygiene protocols. Multiple resident rooms had maintenance issues, such as leaking and moldy air conditioning units, broken headboards, scraped and dirty walls, and floors that were dull, dirty, or covered in debris. Residents and family members reported that maintenance requests, such as mounting a television or fixing air conditioning units, were not addressed in a timely manner. Additionally, the facility consistently lacked adequate supplies and linens, including gloves in appropriate sizes, wet wipes, tissues, towels, and washcloths. Staff interviews confirmed that they frequently ran out of these essential items, impacting their ability to provide proper care. The facility's laundry operations were disrupted due to a fire, resulting in further shortages of clean linens, and the par level for washcloths was insufficient to meet the needs of incontinent residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) and proper infection control practices during resident care, as evidenced by multiple observations and interviews. For several residents with indwelling medical devices such as gastrostomy tubes and urinary catheters, there was a lack of EBP signage, absence of personal protective equipment (PPE) outside rooms, and missing physician orders for EBP. Staff were observed providing care without appropriate PPE, and some were unaware of the requirements for EBP during high-contact activities, such as dressing changes and hygiene care. In one instance, a sign was incorrectly placed above the wrong bed, and a PPE basket was missing due to being broken and not replaced. During incontinence care, staff did not follow proper perineal cleansing techniques. One CNA was observed not cleansing the inner labia as required, and both the skills checklist and facility policy lacked specific instructions on how to perform perineal care. The Director of Nursing confirmed that the policy and competency documents did not provide detailed guidance, and staff training was insufficient in this area. This resulted in incomplete hygiene practices for residents requiring incontinence care. Additionally, improper infection control practices were observed during wound care for a resident with multiple wounds, including a Stage III pressure ulcer. Staff used the same gloves for different tasks, such as cleansing the perineal area and then handling the wound and clean supplies, which could lead to cross-contamination. Dirty linens were also left on the floor instead of being properly bagged. These lapses in infection prevention and control affected multiple residents and were confirmed through interviews, observations, and policy reviews.
Failure to Maintain Resident's ADL Abilities Due to Lack of Therapy and Restorative Services
Penalty
Summary
The facility failed to ensure that a resident maintained the ability to perform activities of daily living (ADLs), including range of motion (ROM) and ambulation, without a documented medical reason for decline. The resident, who had diagnoses including heart failure, unspecified dementia, muscle weakness, and cognitive communication deficit, was discharged from hospice but did not receive therapy or restorative services for ROM or ambulation in the months following discharge. Medical record review showed no evidence of therapy screens or restorative programs in 2024 or 2025, except for a single therapy screen after the resident slid out of her wheelchair. The resident's care plan noted impaired mobility and encouraged participation in ADLs, but there was no documentation of ongoing therapy or maintenance programs to support ambulation or ROM. Observations and interviews revealed that the resident expressed a desire to walk again and reported not receiving recent therapy or ROM services. Staff interviews confirmed that the resident had not been screened by therapy since hospice discharge, and that quarterly therapy screens, which were standard practice, had not been completed. The Rehab Manager acknowledged the lack of recent ROM assessment and services, and certified nurse aides reported only seeing the resident self-transfer or take steps during toileting, with no independent ambulation observed in the room or hallway. The lack of regular therapy screening and absence of restorative or maintenance programs contributed to the resident's decline in ADL performance.
Violation of Residents' Mail Privacy
Penalty
Summary
The facility failed to ensure residents had their mail delivered unopened, affecting two residents. Resident #19, who was cognitively intact and had no communication issues, reported that his mail from the Ohio Department of Jobs and Family Service (ODJFS) was opened by facility staff without his consent. Although the facility claimed he had signed a Mail and Package Consent Agreement, Resident #19 denied ever giving such consent and revoked any perceived consent after the incident. The facility's process for obtaining consent was unclear, and the resident was not aware of signing any electronic form. Resident #69, who was also cognitively intact, experienced similar issues with her mail being opened. She reported that her insurance card and another letter, mistaken for junk mail, were opened by the facility. Despite having a Mail and Package Consent Agreement on file, she denied giving consent for her mail to be opened and expressed dissatisfaction with the situation. The receptionist acknowledged the mistake and apologized, indicating the mail was opened accidentally. Interviews with facility staff revealed that the corporate office instructed them to open mail from insurance companies or ODJFS for Medicaid recipients. The facility's Administrator confirmed this practice and acknowledged the violation of residents' rights to receive unopened mail. The facility's Welcome Packet included a copy of the Resident's Rights, which stated that residents have the right to receive unopened mail, yet the facility's actions contradicted this policy.
Failure to Resolve Missing Resident Property
Penalty
Summary
The facility failed to ensure the timely resolution of a concern regarding missing resident property, specifically affecting a resident with moderately impaired cognition due to Alzheimer's disease and other medical conditions. The resident, who had been admitted with a rollator walker, dentures, and glasses, was transferred to a hospital and upon return, these items were missing. The resident's power-of-attorney filed a concern about the missing items, but the facility's efforts to resolve the issue were inadequate. The facility's administrator made an attempt to contact the inpatient psychiatric hospital where the resident had been transferred, but no response was received. Interviews with the Social Services Designee and the Administrator confirmed that the last attempt to resolve the concern was made shortly after the resident's return, with no further follow-up. The facility's policy on resident rights emphasizes the right to retain personal possessions, but this was not upheld in this instance, leading to the deficiency being noted during a complaint investigation.
Failure to Provide Accurate Transfer Information
Penalty
Summary
The facility failed to ensure comprehensive resident information was provided to the receiving facility during a transfer, affecting one resident reviewed for death. The resident, who had diagnoses including Alzheimer's disease, diabetes mellitus, anxiety disorder, depression, and a personal history of malignant neoplasm, was admitted to the facility and later expired there. A review of the resident's Transfer Form revealed that the facility did not include accurate information regarding the resident's representative, specifically omitting the resident's son, who was the power-of-attorney (POA)/resident representative. This omission was confirmed during an interview with the Administrator.
Failure to Schedule Gynecology Appointment for Resident
Penalty
Summary
The facility failed to ensure coordination of care for a resident related to a gynecology appointment to address medical symptoms in a timely manner. The resident, who had diagnoses including multiple sclerosis, anxiety disorder, chronic kidney disease stage four, and chronic diastolic heart failure, was noted to have intact cognition. A progress note dated 10/23/24 indicated a new order for a referral to gynecology for post-menopausal bleeding, and a physician order dated 10/24/24 confirmed the referral. However, a review of the resident's medical record from 10/23/24 to 11/11/24 revealed no evidence that the referral had been made. An interview with the Administrator on 12/17/24 confirmed that an appointment with gynecology had not been scheduled as ordered by the physician. This deficiency affected one resident out of three reviewed for appointments, with the facility census being 76 at the time. The incident was identified during a closed record review, facility investigation, and staff interview, highlighting a lapse in the coordination of care for the resident.
Delayed Resolution of Missing Dentures Grievance
Penalty
Summary
The facility failed to address a resident's grievance regarding missing upper dentures in a timely manner, leading to a deficiency. The resident, who was admitted with both upper and lower dentures, reported the upper dentures missing on October 1, 2024. Despite the resident being cognitively intact and able to communicate effectively, the facility did not resolve the issue promptly. The dentures were reportedly missing since the resident's move from the 400 hall to the 100 hall in August 2024, and the resident had repeatedly informed staff about the missing dentures. The facility's investigation into the missing dentures was delayed, with a dental appointment scheduled over a month after the initial report. The cost of replacement dentures was not covered by the resident's insurance, and the facility's corporate office was involved in discussions about covering the cost. The corporate office eventually agreed to pay half the cost, but this decision was not communicated to the resident, who was frustrated with the delay and lack of resolution. The resident's son, who was not initially aware of the missing dentures, believed the facility should cover the full cost of replacement since the dentures were lost while under the facility's care. Interviews with staff revealed that the resident's dentures were initially stored in an emesis basin rather than a denture cup, which may have contributed to their loss. The facility's policy on handling resident concerns was not followed effectively, as the investigation and resolution process took several months without a satisfactory outcome for the resident. The deficiency was identified during a complaint investigation, highlighting the facility's failure to ensure the resident's grievance was addressed promptly and appropriately.
Failure in Wound Vac Management and Physician Order Implementation
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and knowledgeable in the use of Negative-Pressure Wound Therapy (NPWT) and did not implement a physician's order for a CT scan and surgical referral for a resident showing signs of an infected abdominal wound. This deficiency affected a resident with a history of abdominal wall infections, who displayed possible signs of infection in an abdominal wound. The wound physician ordered a CT scan and a referral to a surgeon, but the facility did not make these referrals as ordered. The resident experienced complications related to the use of a wound vac, and a nurse failed to adequately intervene or notify the wound physician of these complications. The resident's wound vac began to leak, and the drainage increased throughout the night, saturating the area around the abdominal wound. By morning, the wound area became red, hard, and warm to the touch, with the resident experiencing mild to severe abdominal pain. The resident was transferred to the hospital, where he was hospitalized and required two separate incisions and drainage procedures to debride the abdominal abscess and remove a foreign body. The hospital's CT scan revealed a retained foreign body, identified as a large white vac sponge, which was likely left from a previous wound vac dressing. Interviews with staff revealed that the facility's nurses were not adequately trained in wound vac management prior to the incident. The facility's policy required notifying the physician when a change in wound condition was noted, but this was not done. The resident's medical record lacked evidence of the CT scan being ordered or the surgeon being contacted for a re-consult. The facility's failure to act on the physician's orders and the lack of proper wound vac management led to the resident's hospitalization and the need for surgical intervention.
Facility Fails to Maintain Safe Environment During Heat Advisory and Mold Issues
Penalty
Summary
The facility failed to maintain a comfortable and safe living environment during an excessive heat advisory, affecting five residents. The main air conditioning units were not functioning properly, leading to the use of portable AC units and fans to cool the common areas. Despite these measures, residents reported discomfort due to high temperatures in the hallways and common areas. Maintenance staff confirmed that the AC units on certain halls had been non-functional for an extended period, and there was a lack of documented temperature monitoring during the heat advisory. Additionally, the facility had issues with mold in the shower rooms on the 100 and 200 halls. The 100 hall shower room had exposed water pipes and mold on broken drywall and tiles, which had not been addressed or tested for black mold. The shower room was supposed to be out of use, but there was no signage indicating this. The 200 hall shower room also had mold, and staff were instructed to clean it with bleach, but the mold persisted. The presence of mold was verified by multiple staff members, and it was noted that residents used the 200 hall shower room. The facility's maintenance logs did not document the AC unit failures or the mold issues in the shower rooms, indicating a lack of proper reporting and documentation. The facility's policy on temperature extremes required specific monitoring and safety measures in case of AC system failure, which were not adequately implemented. This deficiency was investigated under specific complaint numbers, highlighting the facility's non-compliance with maintaining a safe and comfortable environment for residents.
Facility Fails to Maintain Safe Environment Due to Improper Use of Fans
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment, affecting 14 residents identified as cognitively impaired and independent with mobility. During an observation, large portable air conditioning units with dual vent coils were noted in each hallway, along with various types of fans placed on the floor. These fans included three freestanding metal fans, a high-velocity fan, a box fan, and two stand-up cylinder fans. The Environmental Services Director confirmed that the main air conditioning units were not operational, and the fans were used to circulate air. However, the fan blades were accessible through the slats, posing a risk to residents. Further observations revealed that the fans' cords were unsecured, and the placement of air conditioning units and fans, along with other equipment, obstructed access to handrails. Additionally, some fan plugs were not securely inserted into outlets. The Administrator acknowledged these hazards, particularly for cognitively impaired residents who were independently mobile. The facility did not have a policy regarding accident hazards, contributing to the deficiency identified under Complaint Number OH00155031.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 152 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Zanesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adams Lane Healthcare And Rehabilitation Center | 0.6 mi | — | 0 | 0 |
| Oaks At Bethesda The | 0.7 mi | — | 0 | 0 |
| Continuing Healthcare At Cedar Hill | 0.9 mi | — | 4 | 0 |
| The Oaks Rehabilitation And Healthcare Center | 1.7 mi | — | 3 | 0 |
| Altercare Zanesville Inc. | 2.7 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Continuing Healthcare At Willow Haven.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.