Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Longmeadow Care Center during CMS and state inspections, most recent first.
A resident with paraplegia and multiple comorbidities developed a new sacral pressure ulcer that rapidly worsened from Stage II to Stage 4 due to delayed and missed wound care treatments as ordered by the wound NP. The treatment administration records showed repeated failures to complete and document prescribed wound care for the sacral and ankle ulcers, despite the resident's dependence on staff for repositioning and care. Staff interviews confirmed these lapses, and the facility's policy requiring timely and documented treatment was not followed.
Surveyors found that the garbage disposal area was not maintained in a clean and sanitary condition, with both dumpster lids and side doors left open and garbage overflowing. This was confirmed by the Dietary Manager and had the potential to affect all residents.
Surveyors found that the facility failed to effectively use its resources to maintain resident well-being, including not reporting or investigating two resident elopements, not updating care plans, missing or delayed treatments for pressure ulcers, not applying splints as ordered, missing recommended weekly weights, and lacking an effective antibiotic stewardship program. Staff were often unaware of orders or requirements, and documentation was incomplete or missing in several areas.
Surveyors found that insulin pens for several residents were not dated when opened, and medications were left unattended at a bedside. Nursing staff did not verify or document insulin opening dates before administration, and a medicine cup with multiple pills was left on a resident's bedside table without supervision, contrary to facility policy requiring medications to be locked or attended by licensed staff.
The facility did not effectively monitor or document antibiotic use, resulting in multiple residents receiving antibiotics that did not meet established criteria for necessity. Staff failed to communicate these findings to prescribing providers or discuss them in QAPI meetings, and required documentation and oversight were not maintained according to facility policy.
A resident with multiple serious health conditions did not have a signed and dated DNR Comfort Care-Arrest form in their medical record, despite a physician's order for DNR status. The signed DNR form was found only in admission paperwork and was not accessible to nursing staff for emergencies or transfers, contrary to facility policy.
The facility did not report two separate incidents of resident elopement to the state agency as required by policy. In both cases, residents with significant cognitive and physical impairments left the facility unsupervised and were found outside by staff or their responsible party. Interviews confirmed that the required self-reported incidents were not completed for either event.
Two residents with significant cognitive and physical impairments exited the facility without staff knowledge, and the facility failed to conduct thorough investigations into how the elopements occurred. In both cases, required interventions such as Wander Guards and activity programs were either not in place or not monitored, and the investigations lacked key details and root cause analysis.
Two residents with complex medical needs did not have comprehensive care plans addressing all aspects of their care. One resident's ongoing pain management was not included in the care plan despite staff awareness and active treatment, while another resident's supervised smoking status was omitted from their care plan. Staff confirmed these omissions during interviews.
Two residents with significant cognitive and physical impairments eloped from the facility due to inadequate supervision and monitoring. One was found several blocks away in a wheelchair, while another was located by a responsible party walking outside in cold weather. The Wander Guard system was not active on all exits, and staff did not promptly notice or respond to the residents' absence.
Surveyors found that several residents' rooms contained oxygen tanks or equipment without the required warning signage on the doors, in violation of facility policy. In some cases, oxygen equipment was stored in rooms of residents who were not prescribed oxygen, and staff confirmed the lack of signage and improper storage practices.
Two residents received PRN opioid and non-opioid pain medications without documented attempts at non-pharmacological interventions and without clear parameters guiding when to use Acetaminophen versus opioids. An LPN confirmed the absence of required documentation and parameters, despite facility policy mandating non-pharmacological approaches prior to medication.
A resident with multiple chronic conditions had a urinalysis showing abnormal findings, but the physician was not notified of the results. An LPN confirmed that there was no documentation of physician notification, despite facility policy requiring such communication when there are changes in treatment or acute conditions.
An LPN failed to follow professional standards by preparing and administering medications for two residents at the same time, instead of handling each resident's medications separately as required. Both residents had complex medical conditions and multiple medications ordered, and the facility's policy and CDC guidelines specify that medications should be prepared and administered for one resident at a time to prevent contamination or infection.
A CNA provided direct care to a resident with a stage three pressure ulcer and an indwelling urinary catheter without donning a gown, despite physician orders and facility policy requiring enhanced barrier precautions. The CNA was unaware of the need for these precautions, even though a sign was posted outside the room, and assisted the resident without appropriate PPE during wound care.
Two residents did not receive splint application as ordered and recommended by therapy, due to incorrect entry of orders in the electronic medical record and lack of staff awareness. Staff did not document or consistently apply the required splints, and observations confirmed the devices were not in use. Facility policy required systematic prevention of decline in range of motion, but these procedures were not followed.
A resident with significant medical issues and a feeding tube experienced ongoing weight loss, and the dietician repeatedly recommended weekly weights to monitor the situation. Despite these recommendations and facility policy allowing for more frequent weights when ordered, staff failed to consistently obtain and document weekly weights, with several weeks missing. The issue was not addressed in risk meetings, and both the dietician and ADON confirmed the omission without explanation.
The facility failed to maintain safe water temperatures on a specific hall, affecting nine residents. An observation revealed that the shower room's water temperature was 90.4°F after running for seven minutes, and the sink's temperature decreased from 101°F to 99°F after three minutes. The Maintenance Director stated that the water temperature should be between 110 to 120°F and required weekly adjustments based on weather conditions.
The facility failed to deliver unopened mail and packages to residents, affecting two individuals and potentially impacting all residents. One resident reported receiving opened mail and packages, while another found items missing from a delivery. Staff interviews revealed that nurses opened parcels before delivery due to past incidents. The facility's policy stated residents should be free from involuntary searches, indicating a breach of privacy rights.
A resident with cognitive impairment and mobility issues did not receive routine showers as scheduled, despite being dependent on staff for assistance. The facility's policy required regular bathing, but documentation showed multiple periods where the resident was not bathed, and no refusals were recorded. The DON confirmed the lack of compliance with the bathing schedule.
A resident with schizoaffective disorder, HIV, and Alzheimer's disease experienced a change in skin condition that was not timely reported or addressed by the facility. Despite a physician's order for zinc oxide cream application, the resident's peri area was observed to be deep red with crusty particles, and there was no documentation of this condition. Interviews revealed that STNAs did not report the redness to the RN, who later confirmed the condition and initiated treatment for a yeast infection.
A resident with Alzheimer's disease was found with zinc oxide ointment within reach, despite a history of attempting to eat it. Staff interviews revealed a lack of communication and awareness about the resident's behavior. The DON acknowledged the practice of keeping zinc oxide in rooms but noted it was not acceptable if consumed. The facility's dementia care policy was not followed, as the environment was not modified to meet the resident's needs.
A resident with respiratory failure and atrial fibrillation received Midodrine despite physician orders to hold the medication if systolic blood pressure exceeded 120. The MAR showed multiple instances where the medication was administered contrary to these orders, confirmed by interviews with an LPN and the DON. The facility policy required holding medications outside prescribed parameters, which was not followed.
Failure to Timely Implement and Document Pressure Ulcer Treatments Resulting in Harm
Penalty
Summary
A paraplegic resident with a history of diabetes, pressure ulcers, and congestive heart failure developed an in-house acquired Stage II pressure ulcer to the sacrum, which was not treated in a timely manner as ordered by the wound nurse practitioner. The initial treatment order for Medi Honey and silicone bordered foam dressing was not implemented until three days after it was prescribed. During this period, the wound rapidly deteriorated, increasing in size and severity, eventually becoming unstageable with significant slough and discoloration, and later progressing to a Stage 4 ulcer with exposed bone. The treatment administration records (TAR) showed multiple instances where wound care treatments were not completed as ordered, with several days left blank, indicating missed treatments. The resident was dependent on staff for most activities of daily living, including transfers and repositioning, and preferred to lie on his back despite education. The care plan included interventions such as wound treatment, limiting time out of bed, and use of pressure-reducing devices, but these were not consistently implemented or documented. The wound nurse practitioner was not informed that her treatment orders were not being followed promptly, and she confirmed that the wound's rapid decline occurred during the period when treatments were missed or delayed. The facility's own policy required that treatments be provided and documented for all residents with pressure ulcers, but this was not adhered to in this case. In addition to the sacral ulcer, the resident had pressure ulcers on both ankles, with similar failures to complete and document wound care treatments as ordered. The TARs for both the left and right lateral ankle wounds showed multiple missed treatments, though both wounds eventually healed. Interviews with facility staff confirmed the gaps in treatment and documentation. The deficiency affected one of two residents reviewed for pressure ulcers, and the facility census was 73 at the time of the survey.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
Surveyors observed that the facility failed to maintain its garbage disposal area in a clean and sanitary condition. During an inspection of the garbage disposal area with the Dietary Manager, both dumpster lids and side doors were found open, and garbage was overflowing. This situation was confirmed by the Dietary Manager at the time of observation. The deficiency had the potential to affect all 73 residents in the facility. No additional details about individual residents or their medical conditions were provided in the report.
Failure to Administer Facility to Ensure Effective Resource Use and Resident Well-Being
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to maintain the highest practicable well-being of all residents. Surveyors identified multiple deficiencies, including the failure to report and thoroughly investigate two incidents of resident elopement. The Administrator confirmed that no self-reported incident had been completed for these events and was unaware of the reporting requirement. Additionally, the facility did not conduct a root cause analysis to determine how the residents left the facility undetected, nor could staff confirm if care-planned interventions were in place at the time of the incidents. Care planning was also found to be deficient, as not all care plans were updated regularly, with one LPN acknowledging that no one was assigned to oversee care plan accuracy during her absence. The facility failed to implement and document treatment orders for a resident with multiple pressure ulcers, resulting in a significant decline in the resident's condition. Treatment records showed numerous missed or undocumented treatments, and the resident's pressure ulcer progressed from Stage II to Stage IV. Additionally, the facility did not ensure that splints and other therapeutic devices were applied as ordered, with staff unaware of existing orders due to errors in the electronic medical record system, and some devices not being used consistently as required. Further deficiencies included the failure to obtain resident weights according to dietician recommendations, with several weekly weights missing and no clear reason provided by staff. The facility also lacked an effective antibiotic stewardship program, as there was no documentation to confirm that antibiotics met established criteria for use, nor evidence that inappropriate antibiotic use was communicated to medical providers or discussed in quality assurance meetings. The infection control preventionist had not attended QAPI meetings or provided relevant logs for review, and there was no documentation of physician or nurse practitioner awareness regarding antibiotics that did not meet criteria.
Failure to Properly Label Insulin and Secure Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of insulin for three residents with diabetes. Specifically, insulin pen injectors for multiple residents were found opened but not dated, contrary to facility policy which requires dating upon opening to ensure safe administration within usage guidelines. Licensed nursing staff did not verify or document the opening dates prior to administering insulin, and this was confirmed during interviews. The care plans for these residents did not include interventions related to labeling and dating insulin when opened. Additionally, the facility failed to prevent medications from being left unattended at a resident's bedside. During observation, a medicine cup containing approximately 16 pills was found on a bedside table next to a resident who was asleep. The resident confirmed that staff usually supervise medication administration, but on this occasion, the medication was left at the bedside. A CNA confirmed that medications should not be left unattended, and facility policy states that only licensed nurses may access medications, which must be locked or attended by authorized personnel. The deficiencies were observed on the Blue Unit and involved residents with diagnoses including diabetes, hypertension, chronic obstructive pulmonary disease, heart failure, and other chronic conditions. The findings were based on direct observation, interviews with staff and residents, review of medical records, and facility policies regarding medication administration and storage.
Failure to Monitor and Document Appropriate Antibiotic Use
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of appropriate monitoring and documentation regarding antibiotic use for 21 residents who were prescribed antibiotics over a two-month period. The facility's own surveillance logs indicated that these antibiotic prescriptions did not meet McGeer's criteria for appropriate use, yet there was no evidence that this information was communicated to the prescribing physicians or nurse practitioners. Additionally, the infection control logs maintained by the Infection Control Preventionist did not include any documentation regarding whether the antibiotics met established criteria for necessity. Interviews with staff revealed further deficiencies in the stewardship process. The Infection Control Preventionist, who was responsible for overseeing the infection control program and maintaining logs, confirmed that she had not documented whether antibiotics met McGeer's criteria and had not informed medical providers when antibiotics were deemed unnecessary. She also stated that she had not participated in Quality Assurance and Performance Improvement (QAPI) meetings or provided relevant data for review, despite the facility's policy requiring such actions. The Director of Nursing, who completed the antibiotic surveillance logs, also verified that there was no documentation of physician or NP awareness regarding antibiotics that did not meet criteria, nor was this issue discussed in QAPI meetings. The facility's policy on antibiotic stewardship required the implementation of protocols, monitoring systems, and documentation of actions related to antibiotic use, including maintaining assessment forms, protocols, data collection, and discussion of findings in QAPI meetings. However, the observed practices did not align with these requirements, as there was a lack of documentation, communication, and oversight regarding inappropriate antibiotic use, affecting all residents who received antibiotics during the specified period.
Failure to Ensure Signed DNR Form in Medical Record
Penalty
Summary
The facility failed to ensure that a signed advance directive/Do Not Resuscitate (DNR) form was present in the medical record for a resident with multiple diagnoses, including paraplegia, diabetes, a sacral pressure ulcer, and congestive heart failure. Although there was a physician's order for DNR Comfort Care-Arrest, the DNR form found in the resident's medical record was undated and lacked the required signature from a physician, Physician Assistant (PA), or Nurse Practitioner (NP). The form indicated that such a signature was necessary, but it was not completed. During a review of the resident's hard and electronic medical records, the Assistant Director of Nursing (ADON)/LPN confirmed the absence of a signed and dated DNR form. It was later discovered that a properly signed DNR form existed in the resident's admission paperwork, but it had not been incorporated into the resident's active medical record. As a result, nursing staff did not have access to the signed DNR form for use during appointments, EMS transfers, or emergencies. The facility's policy required that advance directives be copied and placed in the chart upon admission, but did not specify the need for the DNR form to be signed and dated by the appropriate medical professional.
Failure to Report Resident Elopements to State Agency
Penalty
Summary
The facility failed to report two separate incidents of resident elopement to the state agency, as required by policy. In the first incident, a resident with a history of colon cancer, diabetes, epilepsy, depression, muscle weakness, and macular degeneration, who was care planned as high risk for elopement, was found three blocks from the facility in a wheelchair. The resident was agitated, unable to explain his actions, and required emergency services to return to the facility. The care plan for this resident included interventions such as a Wander Guard and one-to-one supervision, but the incident was not reported to the state agency. In the second incident, another resident with diagnoses including respiratory failure, prostate cancer, and lung cancer, and who was severely cognitively impaired, was found missing from the facility. The resident's responsible party located him walking down the sidewalk and returned him to the facility. The resident was assessed for injuries and a Wander Guard was applied upon return. The investigation did not clarify how the resident exited the building unnoticed, and there was no evidence that the incident was reported to the state agency. Interviews with facility staff, including the Administrator, confirmed that both elopements occurred and that there was no evidence of a self-reported incident being completed for either event. The facility's policy required reporting such incidents to the state survey agency, but this was not done in either case.
Failure to Investigate Resident Elopements
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents of resident elopement, affecting two residents who were both at high risk for elopement and had significant cognitive and physical impairments. In the first incident, a resident with diagnoses including colon cancer, diabetes, epilepsy, depression, muscle weakness, and macular degeneration, and who was rarely or never understood, exited the facility in a wheelchair and was found three blocks away. The resident was agitated and unable to explain his actions. The care plan for this resident had previously identified him as high risk for elopement, with interventions such as a Wander Guard and activity programs, but an elopement assessment later indicated he was not at risk. The facility's investigation did not determine how the resident exited the building without staff knowledge and lacked a root cause analysis. In the second incident, another resident with severe cognitive impairment and a history of respiratory failure and cancer was found missing from the facility. The resident's responsible party found him walking outside, about half a mile from the facility, and returned him. The elopement protocol was initiated after the resident was discovered missing, but the facility's investigation did not document what the resident was wearing or how he exited the building unnoticed. The resident's care plan identified him as high risk for elopement, and a Wander Guard was ordered after the incident. Interviews revealed that the Wander Guard system was not active on the front door, and staff were expected to monitor this area when the receptionist was not present. Both incidents revealed that the facility's investigations were incomplete, lacking essential details such as the means of exit and whether care-planned interventions were in place at the time. The facility did not conduct a root cause analysis for either event, and there was no evidence that all required interventions to prevent elopement were being implemented or monitored. The facility policy required thorough documentation and investigation when neglect was suspected, but this was not achieved in these cases.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were comprehensive for two residents, as identified through record review and staff interviews. For one resident with multiple diagnoses including respiratory failure, congestive heart failure, COPD, kidney disease, sleep apnea, glaucoma, and depression, the medical record showed ongoing pain management needs, including scheduled and as-needed analgesic and opioid medications. Despite staff being aware of the resident's chronic pain and the use of both pharmacological and nonpharmacological interventions, there was no evidence that the resident's care plan addressed her pain needs. For another resident with bladder cancer and kidney failure, documentation indicated that the resident was a supervised smoker. However, review of the baseline care plan revealed that smoking was not addressed. Staff confirmed that this aspect of the resident's care was omitted from the care plan. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan addressing all medical, mental, and psychosocial needs, which was not followed in these cases.
Failure to Prevent Resident Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to prevent elopements for two residents who were identified as being at risk for wandering or had significant cognitive impairment. One resident, with diagnoses including colon cancer, diabetes, epilepsy, depression, muscle weakness, and macular degeneration, had a history of elopement and was previously care planned for high elopement risk, including interventions such as a Wander Guard and activity diversion. However, the elopement assessment later indicated the resident was not at risk, and the care plan was resolved and then reimplemented. Despite these measures, the resident was found three blocks from the facility in a wheelchair, agitated and unable to explain his actions, requiring emergency services to return him to the facility. Another resident, with severe cognitive impairment and diagnoses of respiratory failure, prostate cancer, and lung cancer, was also assessed as not at risk for elopement. This resident was later found missing from the facility and was located by his responsible party walking outside, about half a mile from the facility, in cold weather. The responsible party reported that it took approximately 15-20 minutes before staff began searching for the resident. There was no documentation of how the resident exited the building or what he was wearing at the time, and the investigation noted a prior history of attempted elopement at another facility. Interviews with staff revealed that the Wander Guard system was not active on the front door, and staff were expected to monitor this entrance when the receptionist was not present. The administrator confirmed both elopements occurred and was unaware of the requirement to self-report the incidents. Facility policy defined neglect as the failure to provide necessary goods and services to avoid harm, and required the establishment of a safe environment to prevent abuse and neglect.
Failure to Post Oxygen Signage in Resident Rooms
Penalty
Summary
The facility failed to ensure proper signage indicating the presence of oxygen in resident rooms, as required by facility policy. During observations, surveyors found that three residents' rooms contained oxygen equipment or tanks without appropriate warning signs on the doors. In one instance, a resident's room was used to store other residents' wheelchairs and a portable oxygen e-cylinder, despite the resident not being prescribed or using oxygen. The resident confirmed that the oxygen tank and wheelchairs belonged to others and expressed concern about his room being used for storage. Nursing staff verified that oxygen signage was missing and that oxygen equipment should not be stored in rooms of residents who do not use it. Additional observations revealed that another resident's room contained an oxygen tank without signage, even though the resident did not have a physician's order for oxygen and was not care planned for its use. A third resident, who did have an as-needed order for oxygen, also had both an oxygen tank and concentrator in her room without the required signage. The facility's policy mandates that oxygen warning signs must be placed on the door of any room where oxygen is present, but this was not followed in the cases observed.
Failure to Attempt Non-Pharmacological Pain Interventions and Lack of PRN Pain Medication Parameters
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering as needed (PRN) pain medications and did not establish clear parameters for when to administer Acetaminophen versus opioid pain medications. This deficiency was identified through interviews, record reviews, and policy review, affecting two residents out of five reviewed for unnecessary medications. One resident with multiple chronic conditions, including respiratory failure, heart failure, COPD, kidney disease, and depression, had physician orders for both scheduled and PRN Acetaminophen, as well as PRN Oxycodone. Medication administration records showed frequent administration of Oxycodone for varying pain levels, but there was no documentation that non-pharmacological interventions were attempted before giving these medications. Additionally, there were no documented parameters guiding staff on when to use Acetaminophen versus Oxycodone for pain management. Another resident with diagnoses such as schizophrenia, emphysema, heart disease, and a history of stroke also had orders for PRN Acetaminophen and Dilaudid. The records indicated that both medications were administered for different pain levels, but again, there was no evidence that non-pharmacological interventions were tried first, nor were there parameters for selecting which pain medication to administer. An LPN confirmed the lack of documentation and absence of medication administration parameters. Facility policy required non-pharmacological approaches to be attempted before medication, but this was not followed in these cases.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of laboratory results for one resident. Record review showed that a resident with multiple diagnoses, including respiratory failure, congestive heart failure, COPD, kidney disease, sleep apnea, glaucoma, and depression, had a urinalysis performed that revealed abnormal findings such as nitrites, epithelial cells, bacteria, hyaline casts, mucous, and white blood cell clumps. There was no evidence in the medical record that the physician was informed of these results. An interview with an LPN confirmed that the laboratory results were not reported to the physician. Facility policy required physician consultation when there was a change in treatment, including new or acute conditions, but this was not followed in this instance.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered to two residents according to professional standards of practice. During an observation, an LPN dispensed medications for two residents into two medication cups at the same time and proceeded to administer the medications, rather than preparing and administering medications for one resident at a time as required by accepted standards. The LPN confirmed during interview that medications should have been dispensed and administered separately for each resident. Both residents involved had complex medical histories, including conditions such as atrial fibrillation, hypertension, heart disease, and Alzheimer's disease, and had physician orders specifying multiple medications to be administered upon rising. Review of CDC nursing standards and facility policy confirmed that medications should be prepared for one resident at a time and administered in accordance with professional standards to prevent contamination or infection.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to don appropriate personal protective equipment (PPE) while providing direct care to a resident with a stage three pressure ulcer and an indwelling urinary catheter. The resident's care plan, revised on 12/13/24, indicated a need for enhanced barrier precautions due to the presence of wounds and medical devices. Physician orders specified that gloves and a gown were to be worn during high-contact care activities, including dressing changes, bathing, transferring, and wound care. Despite these orders and a sign posted outside the resident's room, the CNA assisted the resident without wearing a gown. The CNA confirmed during an interview that she was unaware of the requirement for enhanced barrier precautions for this resident, even though a sign was present outside the room. Facility policy required the use of gown and gloves for residents with wounds or indwelling devices to prevent the transmission of multidrug-resistant organisms. The failure to follow these precautions was observed during care of the resident's sacral pressure ulcer, which was uncovered and treated with a moisture barrier cream at the time of the incident.
Failure to Apply and Document Splint Use as Ordered
Penalty
Summary
The facility failed to ensure that splints were applied as ordered and per therapy recommendations for two residents who required them to maintain or improve range of motion. For one resident with a history of cerebral infarction, hemiplegia, and cognitive impairment, there was a physician order and occupational therapy recommendation for a left-hand splint to be applied in the morning and removed in the evening. However, there was no documentation of splint application on the Treatment Administration Record (TAR) or task bar, and multiple staff interviews revealed a lack of awareness of the order. The splint was consistently observed unused on the resident's dresser, and it was later determined that the order had been entered incorrectly into the electronic medical record, preventing it from appearing on staff task lists and the TAR. Another resident with a history of stroke, diabetes, muscle weakness, and heart failure had a physician order for a right-hand thumb spica to be applied in the morning and removed in the evening. Review of the TAR showed multiple dates where the spica was not applied as ordered. Observations confirmed the resident was not wearing the device, and staff interviews revealed the device could not be located and was not consistently used. The rehabilitation director confirmed the resident had used the spica for an extended period and was unaware of the inconsistent application. The facility's policy required systematic prevention of decline in range of motion, including assessment, care planning, and provision of appropriate equipment such as splints. Despite these policies, the lack of proper documentation, communication, and staff awareness led to the failure to provide care as ordered for residents requiring splints, as evidenced by the absence of documentation and direct observations of non-use.
Failure to Obtain Weekly Weights per Dietician Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to obtain weights for a resident according to the recommendations of the dietician. The resident in question had multiple medical diagnoses, including cerebral infarction, diabetes, hypertension, and was dependent on a gastrostomy tube for nutrition. The care plan recognized the resident's risk for malnutrition and significant weight changes, but only included monthly weight monitoring, not the weekly weights recommended by the dietician. The dietician had documented significant and undesired weight loss for the resident over several months and repeatedly recommended weekly weights to monitor the situation. Despite these recommendations, the facility's records showed that weekly weights were not consistently obtained, with several weeks missing data. The dietician and ADON both confirmed in interviews that the recommended weekly weights were not completed and could not provide a reason for the omission. Additionally, the issue of missing weights was not discussed in the facility's regular risk meetings, even though residents at nutritional risk were routinely reviewed. Facility policy required that residents be weighed weekly on admission for three weeks and then monthly unless otherwise ordered by a physician or dietician. The policy also stated that the dietician would track weights and collaborate with the facility to review trends and determine if further interventions were needed. In this case, the facility did not follow the dietician's order for weekly weights, resulting in a failure to adequately monitor the resident's nutritional status as recommended.
Facility Fails to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable water temperatures for residents on [NAME] Hall, affecting nine residents. During an observation, the shower room's water temperature was recorded at 90.4 degrees Fahrenheit after running for seven minutes, while the sink's water temperature started at 101 degrees Fahrenheit but decreased to 99 degrees Fahrenheit after three minutes. The Maintenance Director acknowledged that the water temperature should be between 110 to 120 degrees Fahrenheit and mentioned that adjustments were made weekly based on weather conditions. This deficiency was identified during an investigation under Complaint Number OH00160559.
Facility Fails to Deliver Unopened Mail and Packages
Penalty
Summary
The facility failed to ensure that residents' mail and personal packages were delivered unopened, affecting two residents and potentially impacting all residents. Resident #1, who was cognitively intact and used a wheelchair for mobility, reported receiving mail and packages that were opened without her permission. Interviews with staff revealed that the Activity Director delivered mail, but nurses opened parcels before delivery due to past incidents of residents receiving prohibited items. The Activity Director found opened mail and packages belonging to Resident #1 in her mailbox and reported the issue to the previous Administrator without resolution. Resident #24, also cognitively intact and using a walker and wheelchair, reported that his packages were opened before delivery, with items such as hot dogs being removed and returned later. The facility's policy on resident rights stated that residents should be free from involuntary searches of their personal possessions. This deficiency was investigated under Complaint Number OH00155925, highlighting a breach of residents' rights to privacy in their communication and personal belongings.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #5, received routine showers or baths according to their preference and the facility's schedule. Resident #5, who was moderately cognitively impaired and required assistance for activities of daily living due to conditions such as autistic disorder, morbid obesity, and malignant neuroleptic syndrome, was dependent on staff for showering. The care plan indicated that Resident #5 needed weight-bearing assistance for showering and was scheduled to receive showers twice a week on Mondays and Thursdays. Interviews and record reviews revealed that Resident #5 did not consistently receive the scheduled showers. The Director of Nursing (DON) confirmed that there were multiple periods, spanning from June to August 2024, where there was no documentation or evidence that Resident #5 received or was offered a shower or bath. The facility's policy required residents to be bathed or assisted to shower routinely and as needed per their preference. However, the lack of completed shower sheets and documentation of refusals indicated non-compliance with this policy, as confirmed by the DON.
Failure to Report and Address Change in Skin Condition
Penalty
Summary
The facility failed to timely report and address a change in skin condition for Resident #21, who was diagnosed with schizoaffective disorder, HIV, and Alzheimer's disease. The resident was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A physician's order dated 10/17/22 required the application of zinc oxide cream to the resident's bilateral buttocks every shift and as needed for skin integrity. However, during an observation on 08/19/24, the resident's entire peri area, including the penis, scrotum, under the scrotal area, upper thighs, and the fold between the buttocks, was found to be deep red with multiple small white crusty particles under the scrotum. Despite this, there was no documentation in the resident's medical record of the peri/rectal area being red. Interviews revealed that the State Tested Nursing Assistants (STNAs) responsible for the resident's care did not report the change in skin condition to the Registered Nurse (RN) on duty. The RN confirmed that the STNAs routinely applied zinc oxide as a moisture barrier but did not report the redness, which would have required different treatment. A progress note later documented by the RN confirmed the presence of reddened and excoriated areas, and a physician ordered treatment for a yeast infection. An STNA mentioned that the resident had been red for about a month, and despite informing the nurses, they were instructed to continue using the zinc barrier cream.
Failure to Prevent Resident from Accessing Poisonous Substance
Penalty
Summary
The facility failed to ensure proper interventions were in place to prevent a resident with Alzheimer's disease from consuming poisonous substances. The resident, who was rarely or never understood and required assistance with activities of daily living, was observed with a 16-ounce jar of zinc oxide ointment within reach on their bedside stand. Despite the resident's history of attempting to eat the ointment, as noted by a State Tested Nursing Assistant (STNA), the ointment was left accessible, posing a risk of ingestion. Interviews with staff revealed a lack of awareness and communication regarding the resident's behavior of eating the zinc oxide cream. One STNA, who frequently worked with the resident, was aware of the behavior and had previously informed a nurse, but could not recall who. Another STNA, who was less familiar with the resident, was unaware of the risk and left the ointment on the nightstand. The Director of Nursing acknowledged that while it was common practice to keep zinc oxide in residents' rooms, it was not acceptable if residents were consuming it. The facility's dementia care policy indicated that the environment should be modified to meet individual care needs, which was not adhered to in this case.
Failure to Hold Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Midodrine, a medication used to increase blood pressure. The resident, who was cognitively intact and had diagnoses including respiratory failure with hypoxia and atrial fibrillation, had a physician's order to hold Midodrine if the systolic blood pressure (SBP) was above 120. However, the Medication Administration Record (MAR) indicated that the medication was administered multiple times despite the resident's SBP being above the prescribed threshold on several occasions. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the MAR showed the medication was given when it should have been held according to the physician's orders. The facility's policy on medication administration required that vital signs be recorded and medications held if they were outside the prescribed parameters. The failure to adhere to these orders and policies resulted in the resident receiving Midodrine when it was contraindicated by their blood pressure readings.
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Nursing homes near Ravenna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlands Health And Rehab Center | 1.5 mi | — | 5 | 0 |
| Tamarack Ridge Health And Rehabilitation | 7.1 mi | — | 2 | 0 |
| Altercare Post-acute Rehab Center | 7.6 mi | — | 4 | 0 |
| Arbors At Streetsboro | 7.7 mi | — | 17 | 0 |
| Majestic Care Of Kent | 8.5 mi | — | 23 | 0 |
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