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 Milcrest Nursing Center during CMS and state inspections, most recent first.
The facility failed to provide and/or document scheduled biweekly showers for two residents who required staff assistance with ADLs, including bathing, per their MDS assessments and care plans. Both residents had multiple chronic conditions such as muscle weakness, COPD, dementia, obesity, diabetes, and bipolar disorder, and were care planned to receive staff assistance with bathing according to their preferences. Review of shower records showed multiple missed or undocumented showers on scheduled days, and both residents reported not receiving showers as scheduled, with one expressing upset about the missed care. The DON confirmed there was no documentation that the scheduled showers occurred, despite a facility ADL policy requiring necessary services to maintain grooming and personal hygiene.
A resident with multiple comorbidities, including a below-knee amputation, bilateral blindness, and amputation of all fingers except the thumbs, required staff assistance with ADLs and daily wound care per the care plan. Surveyors observed the resident with bilateral open hand-stump wounds, without ordered dressings in place, and with numerous red smear marks on the gown and bedding. The resident reported expecting dressings on the stumps, was unaware of the soiling, and expressed being upset about remaining in a soiled gown and bedding. The ADON confirmed the soiled condition, and review of facility ADL policy showed residents dependent in ADLs were to receive services to maintain grooming and personal hygiene, which was not provided in this case.
Surveyors found that staff failed to properly store and date food items in the kitchen, including open and undated bags of frozen foods, uncovered leftovers in the refrigerator, use of dented cans, and outdated shredded cheese. These actions were confirmed by staff and were not in accordance with facility policy, potentially affecting all residents who consumed food from the kitchen.
A resident with anxiety disorder and fibromyalgia, who was cognitively intact and independent with personal hygiene, was unable to open or close the sliding bathroom door in her room because it was stuck on the track. This issue was confirmed through observations and interviews with both the resident and a corporate RN, indicating the facility did not maintain a safe and comfortable environment.
A resident with dementia and other medical conditions was assessed as being at risk for elopement and was observed wearing a Wanderguard device. Despite this, the care plan did not document the elopement risk or the use of the Wanderguard, contrary to facility policy. Staff confirmed the omission during interview.
Two residents did not have quarterly care conferences documented with participation from the interdisciplinary team or the resident/representative, as required. For one resident with cognitive impairment and multiple diagnoses, care conferences lacked evidence of attendance or discussion, and no further conferences were held after the last recorded date. Another resident with dementia and other conditions had only one care conference documented, which was incomplete and lacked participation details.
A resident with multiple chronic conditions receiving hospice care did not have any hospice visit documentation maintained in the required communication binder, electronic, or paper medical records. Staff confirmed the absence of completed hospice communication forms and reported challenges in obtaining the necessary documentation, contrary to facility policy.
A resident with stage three pressure ulcers did not receive a low air loss mattress as recommended by the wound care physician and documented in the care plan. There was no physician order for the mattress, no documentation of its use, and staff confirmed its absence, despite facility policy requiring appropriate interventions for skin integrity.
A resident with multiple medical conditions who required staff assistance for ADLs did not receive necessary toenail care, as neither the care plan nor facility documentation addressed nail care or podiatry services. Observations revealed the resident's toenails were long, thick, and damaged, and staff confirmed the need for podiatry intervention, but there was no evidence that services were offered or provided.
A resident with severe cognitive impairment and multiple medical conditions experienced significant, ongoing weight loss over several months. Despite the care plan identifying nutritional risk and requiring monitoring and interventions, the facility did not complete a re-weight as requested or implement new interventions until several months after the initial weight loss was documented. Staff confirmed that necessary actions were not taken in a timely manner.
A resident with cognitive impairment and multiple diagnoses did not have recommended labs ordered in a timely manner following pharmacy review. Although the pharmacy suggested several lab tests, physician orders for these labs were not placed until months later or in response to new symptoms, as confirmed by a corporate RN.
A resident with multiple medical conditions and moderate cognitive impairment broke a front tooth while at the facility but did not receive dental care or a referral to a dentist. Staff interviews and record reviews confirmed the broken tooth was not previously identified or documented, and the facility did not follow its policy to refer changes in condition to ancillary services.
A registered nurse did not follow infection control protocols during medication administration for a resident with a central venous catheter and other infection risks. The nurse handled oral medications without gloves and administered IV antibiotics without wearing a gown, despite facility policy and physician orders requiring enhanced barrier precautions for residents with indwelling devices and wounds.
The facility did not provide ongoing communication about resident rights during Resident Council meetings, as confirmed by a review of meeting minutes and interviews with a resident and the Activity Director. This omission had the potential to affect all residents in the facility.
A resident with a history of serious health conditions was found in respiratory distress and later unresponsive, but the DON and an LPN failed to perform necessary assessments or notify the physician. Despite being a full code, the resident did not receive timely CPR or emergency services, leading to his death. The facility's video surveillance and staff interviews confirmed the neglect.
A resident identified as Full Code was found unresponsive without vital signs, but CPR was not initiated for nine minutes, and EMS was not contacted until ten minutes later. When CPR was performed, it was done inadequately as compressions were given while the resident was in bed without a backboard. The resident, with diagnoses including atrial fibrillation and respiratory failure, was eventually transported to the hospital but pronounced dead shortly after.
A resident with serious medical conditions experienced a change in condition that was not properly documented or communicated to a physician. Despite being a full code, necessary assessments were not conducted, and there was a delay and reluctance to initiate CPR after the resident was found unresponsive. The facility failed to report the neglect to authorities in a timely manner, as required by their policies.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure residents received scheduled showers necessary to maintain activities of daily living (ADLs), resulting in missed showers for two residents who required staff assistance. One resident, admitted with diagnoses including muscle weakness, anxiety, dysarthria and anarthria, severe protein-calorie malnutrition, COPD, tobacco use, and dementia, had an MDS showing a need for partial to moderate assistance with showering and bathing. The resident’s care plan, revised in early February, identified a need for staff assistance with ADLs, including bathing as needed and per preference, and the shower schedule indicated biweekly showers on Wednesdays and Saturdays. Review of shower documentation showed no record of showers on two scheduled dates, and the resident reported not receiving scheduled showers on a regular basis. The DON confirmed there was no documentation that the resident received showers on those dates. Another resident, admitted with muscle weakness, osteoarthritis, polyneuropathy, obesity, bipolar disorder, hypertension, heart failure, COPD, BMI greater than 50 percent, and diabetes mellitus, had an MDS indicating a need for substantial to maximal assistance with showering and bathing. The care plan, updated in early April, documented the need for staff assistance with ADLs related to multiple chronic conditions, with interventions to assist with bathing as needed and per resident preference, and the resident was also scheduled for biweekly showers on Wednesdays and Saturdays. Shower documentation lacked entries for multiple scheduled shower dates, and the resident stated they had missed showers over the previous two weeks and were upset when this occurred. The DON confirmed there was no documentation that the resident received showers on the identified dates. Facility policy on ADLs required that residents unable to carry out ADLs receive necessary services to maintain grooming, personal hygiene, oral hygiene, and good nutrition.
Failure to Maintain Cleanliness and Wound Dressings for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment and to provide necessary ADL support for a resident with extensive physical impairments. The resident was admitted with multiple diagnoses including right below-knee amputation, chronic venous hypertension with ulcer and inflammation of the left lower extremity, cellulitis, obesity, edema, anemia, hypothyroidism, bilateral blindness, hypertension, peripheral vascular disease, gastro-esophageal reflux, absence of right and left fingers, muscle weakness, Type II diabetes, and osteomyelitis. The resident’s care plan, last revised on 01/16/26, documented that the resident required staff assistance with ADLs due to right below-knee amputation, diabetic neuropathy, complete bilateral blindness, and amputation of all fingers except bilateral thumbs. Care plan interventions included assisting with bathing, clothing choices, dressing, and daily wound monitoring and care, including checking for signs of infection, drainage, bleeding, skin breakdown, impaired circulation, documenting drainage, and rewrapping the stump as ordered and as needed. On 02/24/26 at 11:13 A.M., observation revealed the resident had bilateral open wounds on the hand stumps and uncountable red smear marks on the gown and bedding. At 11:14 A.M., the resident stated that the bilateral hand stumps were supposed to be covered with dressings but were not, and the resident was unaware of the red smear marks on the gown and bedding and expressed a desire to be cleaned up, stating they were upset about being in a soiled gown and bedding. At 1:05 P.M., the Assistant Director of Nursing confirmed that the resident’s gown and bedding were soiled with red marks. Review of the facility’s undated ADL policy indicated that residents unable to carry out ADLs would receive necessary services to maintain grooming and personal hygiene, which was not followed in this instance. This failure affected one resident reviewed for ADLs and was investigated under Complaint Number 2645121.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen, including open and undated bags of tater tots, crinkle fries, and hot dogs in the freezer, as well as an uncovered box of garlic bread. The refrigerator contained two undated carry-out boxes with leftovers, one with cake and another with breakfast food. In the dry storage area, two cans with dents near the seals, containing apple pie filling and apple sauce, were found, and staff confirmed that dented cans were used in the facility. Additionally, a container of shredded cheese was found in the service line refrigeration that was outdated and had not been removed as required. Staff interviews confirmed these findings and acknowledged that food should be properly dated, sealed, and covered after opening, and that dented cans should be set aside for vendor return, as per facility policy. All residents in the facility were potentially affected, as they consumed food prepared in the kitchen where these deficiencies were observed.
Failure to Maintain Functional Bathroom Door for Resident
Penalty
Summary
The facility failed to ensure that a resident's bathroom door opened and closed properly, resulting in a deficiency related to maintaining a safe, clean, and comfortable environment. The resident, who was cognitively intact and independent with personal hygiene but required supervision for toilet transfers and walking, was unable to open or close the sliding bathroom door because it was stuck on the track. This issue was observed on two separate occasions, and both the resident and a corporate registered nurse confirmed the difficulty with the door. The deficiency affected one resident out of sixteen reviewed for environmental concerns, with a facility census of 44. The resident's medical record indicated diagnoses of anxiety disorder and fibromyalgia. Despite being able to manage personal hygiene independently, the resident reported being unable to use the bathroom door due to it being stuck, which was verified through staff and direct observation.
Failure to Care Plan for Elopement Risk and Wanderguard Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing elopement risk and the use of a Wanderguard device for a resident with dementia, high blood pressure, diabetes, and depression. The resident was identified as being at risk for elopement through an assessment, which included the intervention of a Wanderguard. However, the resident's care plan did not document this risk or the use of the Wanderguard, despite facility policy requiring such interventions to be included in the care plan. Observation confirmed the resident was wearing a Wanderguard, and staff interview verified the absence of a corresponding care plan entry.
Failure to Complete and Document Quarterly Care Conferences with Interdisciplinary and Resident Participation
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly and that participation from the interdisciplinary team and the resident or their representative was documented, as required by facility policy. For one resident with vascular dementia, anxiety disorder, major depressive disorder, and chronic kidney disease, care conferences were documented on three occasions within a year, but there was no evidence of meeting documentation, participation by the resident or representative, or involvement of the interdisciplinary team. Additionally, there were no records of any quarterly care conferences after the last documented date. For another resident with diagnoses including dysphasia, dementia, Alzheimer's, insomnia, cognitive communication deficit, and Crohn's disease, the only care conference on record was completed by the admissions director, with no documentation of staff or resident/family attendance or discussion details. No further quarterly care conferences were documented for this resident. Staff interviews confirmed the lack of required documentation and participation, and the absence of recent quarterly care conferences for both residents.
Failure to Maintain Hospice Documentation
Penalty
Summary
The facility failed to maintain required hospice documentation for one resident who was receiving hospice care. Record review showed that the resident had multiple diagnoses, including adult failure to thrive, malnutrition, muscle weakness, Parkinson's disease, atrial fibrillation, and chronic kidney disease, and had been admitted to hospice care. Despite this, there was no documentation from hospice visits in the hospice communication binder, electronic medical record, or paper medical record for this resident. Staff interviews confirmed the absence of completed hospice communication forms and noted difficulties in obtaining the necessary binder from hospice. The facility's policy required maintaining hospice communication, but this was not followed for the resident in question.
Failure to Provide Physician-Recommended Pressure-Reducing Mattress
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including stage three pressure ulcers, was not provided with the pressure-reducing intervention recommended by the wound care physician. The resident's care plan and wound evaluations documented the need for a low air loss mattress to aid in the healing of a stage three pressure ulcer. Despite these recommendations, there was no physician order for a low air loss mattress, and progress notes did not indicate that such a mattress was in use. Direct observations confirmed that the resident was lying in bed on the affected hip without a low air loss mattress in place. Interviews with staff verified the absence of the recommended mattress. The facility's own policy required that appropriate interventions be initiated for residents at risk of skin breakdown, and that wound treatments be supported by physician orders, but these steps were not followed in this case.
Failure to Provide Nail Care for Resident Requiring ADL Assistance
Penalty
Summary
A deficiency was identified when a resident with vascular dementia, stage three kidney disease, anxiety, and a cognitive communication deficit did not receive appropriate nail care. The resident was cognitively intact and required staff assistance for activities of daily living (ADLs), as documented in the Minimum Data Set (MDS) and care plan. However, the care plan only specified assistance with bathing and did not address nail care. Medical records, progress notes, and skin and shower sheets over a two-month period contained no documentation of toenail care being provided, offered, or refused, nor any record of podiatry services. During observations and interviews, the resident was found to have long, thick toenails, with the left big toenail torn and jagged, and smaller toenails wrapping around the tips of the toes. The resident expressed interest in podiatry services and agreed to see a podiatrist. Staff confirmed the need for podiatry intervention and acknowledged that the resident was on a list for podiatry services, but there was no evidence that consents had been obtained or that services had been scheduled or provided. The facility's policy required assistance with ADLs for residents unable to perform them, but this was not followed in the case of nail care for this resident.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
A resident with diagnoses including a right pubic fracture, major depressive disorder, anxiety disorder, and Alzheimer's disease experienced significant weight loss over several months. The resident was assessed as having severe cognitive impairment but was independent with eating. The care plan identified the resident as being at risk for altered nutrition and included interventions such as monitoring weights, encouraging intake, and providing supplements as ordered. Despite these interventions being listed, the facility failed to implement them in a timely manner after a documented significant weight loss. The resident's weight dropped by 8.6 pounds (an 8% loss) within 30 days, but no re-weight was completed as requested, and no new interventions were implemented for several months. Weights continued to decline, with no action taken from August through January, despite ongoing losses. Interventions such as nutritional supplements and increased monitoring were not ordered until several months after the initial significant weight loss. Staff interviews confirmed that the re-weight was not completed as requested and that interventions were delayed.
Failure to Timely Implement Pharmacy Lab Recommendations
Penalty
Summary
The facility failed to timely implement pharmacy recommendations for one resident reviewed for medications. The resident, who had diagnoses including fracture of the superior rim of the right pubis, major depressive disorder, anxiety disorder, and Alzheimer's disease, was noted to have cognitive impairment. The monthly medication review recommended laboratory tests including magnesium, complete metabolic panel (CMP), thyroid stimulation hormone (TSH), and complete blood count (CBC). However, there was no evidence in the physician orders that these labs were ordered following the pharmacy's recommendations. Orders for some labs were only placed later in response to new symptoms, and the TSH was not ordered until several months after the initial recommendation. This was confirmed by a corporate RN who verified that the labs were not completed as recommended.
Failure to Provide Dental Care After Resident Broke Tooth
Penalty
Summary
A resident with multiple diagnoses, including muscle weakness, protein calorie malnutrition, iron deficiency anemia, constipation, anxiety disorder, and dysphagia, was admitted to the facility and was moderately cognitively impaired. The resident was independent with eating and required set up assistance with oral hygiene. Medical record review and observation revealed that the resident had her own teeth and was noted to have cavities, but no broken teeth were documented during the oral cavity assessment. However, during an observation, it was found that the resident had a front left tooth that appeared to be broken in half, with the bottom half missing. The resident reported breaking her tooth while residing at the facility and stated she had not seen a dentist since the incident. Interviews with facility staff confirmed that the broken tooth was not previously identified or documented, and the resident had not been referred to or seen by a dentist after the tooth was broken. The facility's policy required nurses to contact the physician immediately upon any perceived change in condition and to refer to ancillary services as needed. Despite this, there was no evidence in the medical record or dental visit history that the resident received dental care or was referred for dental services following the incident.
Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow infection control measures during medication administration for a resident with multiple risk factors for infection, including bacteremia, end stage renal disease, and a central venous catheter (CVC). The resident's care plan and physician orders required the use of enhanced barrier precautions (EBP), specifically gown and glove use, during high-contact care activities due to the presence of indwelling medical devices and an open wound. Despite these documented requirements, the nurse administered oral medications by popping them into her bare hands and then into a medication cup, and subsequently administered intravenous antibiotics through the resident's CVC without wearing a gown as required by EBP protocols. The nurse confirmed during an interview that she did not use gloves when handling the medications and did not wear a gown while administering the IV antibiotics. Review of the facility's policy on enhanced barrier precautions indicated that gown and glove use is mandatory during high-contact care activities for residents at increased risk of multidrug-resistant organism (MDRO) acquisition, including those with wounds or indwelling devices. The failure to adhere to these infection control measures was observed and verified through staff interview and policy review.
Failure to Communicate Resident Rights During Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents regarding their rights, as evidenced by a review of Resident Council meeting minutes over a period of several months, which showed no documentation of resident rights being discussed. An interview with a resident confirmed that staff did not review resident rights during Resident Council meetings. Additionally, the Activity Director, who had been conducting the meetings since September 2024, acknowledged that she was not discussing resident rights with residents and only became aware of the requirement to do so in March 2025. This lack of communication regarding resident rights had the potential to affect all residents in the facility, which had a census of 44 at the time of the survey.
Neglect Leads to Resident's Death Due to Inadequate Response
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in serious life-threatening harm and eventual death. The deficiency occurred when the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) did not adequately assess, monitor, or notify the physician of the resident's change in condition. On the evening of the incident, the resident was found by State Tested Nursing Aides (STNAs) in respiratory distress, unresponsive, and grabbing at his chest. Despite these signs, there were no ongoing assessments or notifications to the physician, and the resident was not sent out for evaluation or treatment. The resident, who had a history of atrial fibrillation, mesothelioma, and respiratory failure, was admitted to the facility with a full code status. On the day of the incident, the resident experienced a change in condition, but the DON failed to perform necessary assessments or notify the physician. The resident's condition was not properly documented, and vital signs were not recorded. The LPN, who took over the shift, also failed to assess the resident or notify the physician, despite being aware of the resident's distress. The situation escalated when the resident was found unresponsive later that night. The LPN did not initiate CPR immediately or contact emergency services, resulting in a delay in CPR and notification to EMS. The resident was eventually transported to the emergency room, where he was pronounced dead. The facility's video surveillance and staff interviews confirmed the lack of appropriate response and documentation, substantiating the allegation of neglect.
Removal Plan
- Staffing Agency #500 was made aware of the neglect allegations involving LPN #21. LPN #21 was placed on the Do Not Return list.
- The Administrator and President of Operations #140 suspended the DON. The DON was terminated as an employee from the facility.
- All 56 employees at the facility were educated on the facility's abuse policy including identification of neglect and reporting an allegation of neglect.
- The facility initiated an investigation.
- An Ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to determine the root cause of the Immediate Jeopardy.
- LPN #93 and Registered Nurse (RN) #177 educated all 16 licensed nursing staff regarding identification of change in condition, the components of a comprehensive assessment, monitoring of the change in condition as well as timely notification of the physician according to professional standards of practice. In addition, all staff were educated regarding the prevention, identification and reporting of abuse to include neglect according to facility policy.
- 50 residents were interviewed regarding abuse. There were no concerns about any allegations of abuse/neglect made known as a result of the interviews.
- The facility submitted the initial SRI.
- The Local Police and the Ohio Board of Nursing were made aware of the neglect allegation involving the DON.
- Quality Assurance Director (QAD) #180 completed an audit of nurse's progress notes to identify any resident that experienced a change in condition without being appropriately assessed, monitored and reported timely to the physician. A comprehensive assessment was performed for any resident identified as experiencing a change in condition not appropriately assessed, monitored and timely report made to the physician. The audit was conducted for the timeframe.
- QAD #180 completed an audit on 50 residents' progress notes to identify any documentation indicating an incident of abuse including neglect, as well as any other category of reportable incident according to the Centers for Medicare and Medicaid Services (CMS) regulation, had occurred. No documentation was identified indicating a reportable incident occurred.
- Clinical Director #143 educated the facility's 13 Directors and Supervisors regarding the investigation and reporting requirements according to CMS regulation for all reportable events including neglect.
- The facility will complete questionnaires to evaluate licensed nursing staffs' understanding of the components of a comprehensive assessment, monitoring of the change in condition, and timely notification of the physician according to professional standards of practice as well as audits also in the form of questionnaires consisting of staff understanding of abuse identification and reporting specifically neglect. This will be conducted six times per week each for four weeks to include all shifts.
- The facility will complete audits in the form of questionnaires which will be conducted by the facility Directors and Supervisors to evaluate understanding of incident investigation and reporting requirements. The audits will be conducted six times per week for four weeks.
- The facility will complete audits consisting of review of nurse's progress notes to determine completion of a comprehensive assessment, monitoring of a change in condition and timely notification of the physician according to professional standards of practice. The audits will be performed three times a week for four weeks.
- The facility will submit their audit findings to the QAPI Committee weekly for recommendations.
Failure to Timely Initiate CPR and Contact EMS
Penalty
Summary
The facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) or contact Emergency Medical Services (EMS) for a resident who was found unresponsive, without a pulse or respirations, and identified as Full Code status. The resident did not receive CPR for nine minutes after being discovered with no vital signs, and EMS was not contacted until ten minutes after the resident was found. When CPR was initiated, it was performed inadequately as chest compressions were done while the resident remained in bed without a backboard, reducing the effectiveness of the compressions. The incident involved a resident with diagnoses including atrial fibrillation, mesothelioma, and respiratory failure with hypoxia. The resident was admitted to the facility with intact cognition and had a physician order to be a full code. On the night of the incident, a State Tested Nursing Aide (STNA) found the resident unresponsive and cold, and alerted a Licensed Practical Nurse (LPN). Despite recognizing the resident's full code status, the LPN delayed initiating CPR and contacting EMS, instead making a phone call to the Director of Nursing (DON) and expressing reluctance to perform CPR. Video surveillance and staff interviews revealed that the LPN did not act promptly, and another LPN eventually initiated CPR without a backboard. The facility's policy and American Heart Association guidelines were not followed, as CPR was not started immediately, and the correct technique was not used. The resident was eventually transported to the hospital by EMS but was pronounced dead shortly after arrival.
Removal Plan
- Clinical Director #143 submitted their initial SRI.
- The facility held an ad-hoc Quality Assurance and Performance Improvement (QAPI) committee meeting to discuss and identify the problem and complete a root cause analysis.
- The DON and LPN #93 educated all 16 licensed nurses regarding verification of the resident's code status and when the nurse should complete CPR. Education will be provided to all agency licensed nurses upon their next scheduled shift by the DON/designee. The education included advance directive specifics (Full Code, Do Not Resuscitate Comfort Care Arrest (DNRCCA), and Do Not Resuscitate Comfort Care (DNRCC)), physician required pronouncement of death and steps to performing a code/providing CPR according to AHA guidelines as well as location of crash carts and the supplies/equipment necessary to perform resuscitative measures.
- The DON and LPN #93 verified all 16 licensed nurses had active CPR certification.
- The DON, LPN #93 and Clinical Director #143 conducted an audit on all 46 residents' advance directive. The Advance Directive state forms, physician orders, and care plans were audited to ensure all were consistent throughout the medical record.
- The DON and LPN #93 completed an audit of the facilities crash carts. The equipment and supplies were present on the two crash carts in the facility.
- Mock codes will be conducted to ensure staff proficiency as well as CPR is performed according to AHA guidelines. Mock codes will be conducted three times weekly to include both licensed nurse shifts as well as nine staff questionnaires weekly regarding understanding of the Advanced Directive policy. Mock codes and questionnaires will be coordinated to include licensed nurses provided by the staffing agency. Both mock codes and questionnaires will be performed at minimum for four weeks by the DON and/or designee. Audit findings will be presented to the QAPI Committee weekly for recommendations.
- Clinical Director #143 educated all 14 therapists (physical, occupational, and speech) regarding advance directive specifics (Full Code, DNRCCA, and DNRCC) as well as the required response to identifying a resident experiencing a potential life-threatening event. Education was also provided regarding potential for participation in code events whether CPR certified or not.
- The facility reported LPN #21 to the Ohio Board of Nursing and to the local police for failure to initiate CPR on a resident whose code status was Full Code.
Failure to Timely Report and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to timely report allegations of neglect to the State Survey Agency and Local Law Enforcement, affecting one resident. The resident, who had a history of atrial fibrillation, mesothelioma, and respiratory failure, experienced a change in condition that was not properly documented or communicated to a physician. Despite being a full code, there was no documentation of vital signs or assessments after the change in condition was noted by nursing aides. The DON was informed of the resident's condition but did not see the need to send the resident to the hospital, and there was no documentation of necessary assessments by the LPN on duty. The facility's investigation revealed a delay and reluctance to initiate CPR on the resident after they were found unresponsive, which was substantiated as neglect. The DON instructed an LPN to start CPR, but the LPN refused, leading the DON to call another LPN to initiate CPR. The facility did not report the neglect to the State Survey Agency and Local Law Enforcement in a timely manner, as required by their policies. The facility's review of video evidence confirmed the DON's failure to assess, monitor, and notify the physician of the resident's change in condition, contributing to the resident's death.
What surveyors are citing around you — mapped
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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 336 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prestige Gardens Rehabilitation And Nursing Center | 0.4 mi | — | 2 | 0 |
| The Gables Of Marysville Health And Rehabilitation | 1.2 mi | — | 21 | 0 |
| Als Woodstock Inc | 10.5 mi | — | 1 | 0 |
| The Convalarium Of Dublin | 13.8 mi | — | 21 | 0 |
| Arbors At Delaware | 14.8 mi | — | 35 | 0 |
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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.