Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Roscoe Gardens Skilled Nursing And Rehab during CMS and state inspections, most recent first.
Staff were observed preparing and serving food without wearing facial hair coverings and by handling food with bare hands, including when preparing a mechanically altered diet for a resident with dementia and no teeth. These actions were not in accordance with the facility's food handling policy, and beard covers were available but not used.
A resident with multiple medical conditions did not receive weekly skin inspections as outlined in their care plan. Although initial and one follow-up inspection were documented, subsequent weekly inspections were missed prior to discharge, as confirmed by the DON.
The facility failed to provide alternate menu items, such as cottage cheese, as reported by several residents. Despite being listed on the alternative menu, cottage cheese had not been ordered since mid-September. The dietary department, contracted to an external company, was unaware of this oversight, leading to the deficiency.
The facility failed to maintain the ice machine and clean the cold air vents, potentially affecting all 57 residents. Observations revealed dusty air ducts and a clogged floor drainpipe causing stagnant water to back up into the ice machine drainpipe. These issues were confirmed with the District Manager, despite the contracted company's responsibility for cleaning and sanitizing.
A resident with anoxic brain injury and mental health disorders reported physical abuse by family, but the facility delayed reporting the allegation to the state survey agency by three days, contrary to policy requiring a two-hour reporting window.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in medication and diagnosis documentation. One resident's opioid use was not accurately recorded, and another resident's active diagnosis of anxiety was omitted. These inaccuracies were confirmed by interviews with nursing staff.
The facility failed to ensure accurate PASRR documentation for two residents. One resident's PASRR did not reflect an anxiety diagnosis despite being prescribed medication for it. Another resident's PASRR was outdated and did not include current mental health and intellectual disability diagnoses, which were confirmed by staff interviews.
A facility failed to maintain consistent communication with a dialysis center for a resident receiving hemodialysis. The resident, with end-stage renal disease and other conditions, had missing dialysis communication logs on several dates, which were crucial for managing their care. The facility's administrator confirmed the absence of these logs, highlighting a deficiency in maintaining essential records.
A facility failed to address pharmacy recommendations for a resident's pain management and lab work. The resident, with conditions including diabetes and hip pain, was prescribed acetaminophen and tramadol without proper pain parameters, as recommended by the pharmacy. Additionally, the facility did not conduct a recommended HbA1c test every three months. These deficiencies were confirmed by the Regional Care Consultant and the DON during a survey.
A resident with a spinal surgical wound infection did not receive scheduled doses of vancomycin due to unavailability and communication lapses. The facility's pharmacy adjusted the dosage without proper coordination with the infectious disease pharmacist, leading to further missed doses. The facility's policy on medication administration was not adhered to, resulting in significant medication errors.
The facility failed to ensure proper medication storage and administration. An LPN left a medication cart unlocked and unattended, and the DON found a resident's medications left on a bedside table, contrary to policy. Medications should be secured and administered when prepared.
A resident with hemiplegia and hemiparesis experienced significant dental pain after losing a filling, but the LTC facility failed to provide timely dental services. Despite multiple complaints and requests for pain relief, the resident's care plan lacked a dental plan, and the social worker did not secure an emergency dental appointment, mistakenly believing the resident did not meet emergency criteria. The facility's policy to assist in obtaining dental care was not followed.
A facility failed to provide a resident with the prescribed assistive eating device, a small maroon spoon, as ordered by a physician. The resident, who had hemiplegia and was receiving hospice services, was observed using a regular spoon instead. Interviews with staff confirmed the oversight.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic venous ulcer. The resident was observed without an EBP sign or available PPE, and there was no physician order for EBP, contrary to facility policy. The DON confirmed that EBP should have been in place.
The facility failed to lock three medication carts when unattended, potentially affecting 12 cognitively impaired and independently mobile residents. The carts were found unlocked outside the nurse's station, and a nurse confirmed leaving them unattended while going to the restroom. Facility policy mandates that medication supplies remain locked when not in use or attended by authorized personnel.
A resident with multiple health conditions was mistakenly given another resident's medication, including morphine and other drugs, due to a nurse's failure to follow the six rights of medication administration. The resident became lethargic but did not require Narcan. The incident was reported and investigated, revealing the error's root cause.
A nurse failed to perform proper hand hygiene during medication administration, affecting three residents. After administering medication to a resident, the nurse interacted with visitors and family members without washing her hands before preparing medication for another resident. She used her bare hand to handle medication and continued to administer medication to another resident without washing her hands, only doing so after completing the process. This deficiency was identified during a complaint investigation.
A resident was physically assaulted by another resident in the dining room where no staff were present, resulting in multiple injuries and psychosocial harm. The facility failed to provide timely medical care, notify the physician and authorities promptly, and implement appropriate interventions to ensure resident safety.
The facility failed to maintain an effective abuse prohibition program, resulting in an incident of resident-to-resident physical abuse. The investigation by the DON was inadequate, lacking comprehensive documentation and necessary notifications, leading to a delay in treatment for a resident and potential recurrence of such incidents.
The facility failed to ensure a complete and thorough investigation following an allegation of physical abuse involving two residents. The investigation lacked staff interviews, additional resident interviews, and proper documentation of the incident and injuries in the medical record. The facility's abuse policy was not adequately followed, leading to a deficiency in ensuring resident safety and thorough investigation of abuse allegations.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
During meal service, staff failed to maintain sanitary conditions in the kitchen by not wearing facial hair coverings and by handling food with bare hands. Specifically, one staff member was observed preparing a cheeseburger for a resident on a mechanically altered diet by placing bread and cheese on the plate using bare fingers, rather than gloves or utensils. This was confirmed by another staff member who witnessed the incident. Additionally, two staff members were observed behind the steam table preparing trays and serving food without covering their facial hair, despite beard covers being available in the kitchen. The affected resident had diagnoses including dementia, weakness, and indigestion, required assistance with activities of daily living, and was on a mechanically altered, soft-textured diet due to having no teeth. The facility's food handling policy required food to be stored, prepared, handled, and served in a manner that minimized the risk of foodborne illness. All residents in the facility received food prepared in the kitchen, indicating the potential for widespread impact.
Failure to Complete Weekly Skin Inspections as Care Planned
Penalty
Summary
The facility failed to complete weekly skin inspections for a resident as required by the resident's comprehensive care plan. Medical record review showed that the resident, who had a history of fall with nasal fracture, influenza A, cerebrovascular accident, and traumatic brain injury, was admitted and received a skin inspection upon admission and again on 01/15/25. However, no further weekly skin inspections were documented prior to the resident's discharge on 02/01/25. The care plan specifically included an intervention for weekly skin inspections, but these were not performed on 01/22/25 and 01/29/25. The DON confirmed during interview that the required weekly inspections were missed.
Failure to Provide Alternate Menu Items
Penalty
Summary
The facility failed to ensure that alternate menu items were available to residents, as evidenced by multiple interviews and observations. Residents reported that the facility did not honor food alternatives ordered, and specific items such as cottage cheese, lettuce, and orange juice were unavailable. The alternative menu listed items like tossed salad and cottage cheese, but the facility had not ordered cottage cheese since 09/17/24, as confirmed by the review of food invoices and interviews with staff. The dietary department, contracted out to an external company, was unaware that cottage cheese was on the alternative menu, leading to its unavailability. Resident #56, who had diagnoses including endocarditis, diabetes mellitus, and sepsis, also reported that alternate food items were not always available. The resident's medical record indicated an intact and independent cognition level. The facility's certified dietary manager confirmed that the last order of cottage cheese was on 09/17/24, and none was available at the time of the survey. The food service contract stipulated that all food and supplies would be prepared and served by the contracted company, including items on the alternative menu, but this was not adhered to, resulting in the deficiency.
Ice Machine and Air Vent Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the ice machine and clean the cold air vents, which had the potential to affect all 57 residents residing in the facility. During an observation of the kitchen, it was noted that three cold air ducts and one unused duct were visibly dusty. Additionally, the bottom drainpipe for the ice machine was improperly installed, running directly into the floor drainpipe without a gap. The floor drainpipe was clogged, causing stagnant water to back up into the ice machine drainpipe. These findings were confirmed during an observation with the District Manager. The review of the food service contract from April 25, 2021, indicated that the contracted company was responsible for various tasks, including cleaning and sanitizing. However, the observed deficiencies in the maintenance of the ice machine and cleanliness of the air vents suggest a lapse in fulfilling these responsibilities.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency in a timely manner, affecting one resident. The resident, who had anoxic brain injury, schizoaffective disorder, and bipolar disorder, was admitted with an independent and intact cognition level. On a specified date, the resident reported an allegation of physical abuse by her family, claiming she was hit in the face. Upon assessment, no injuries or signs of abuse were found. However, the facility did not create a self-reported incident (SRI) until three days after the allegation was made, which was verified by the Director of Nursing and Administrator. This delay was contrary to the facility's policy, which required reporting any abuse allegation to the state survey agency within two hours of receipt.
Inaccurate MDS Assessments for Medications and Diagnoses
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the medication and pertinent diagnoses for two residents. For Resident #6, the medical record indicated that the resident was prescribed Tramadol, an opioid, and received it on specific dates in August and September 2024. However, the quarterly MDS assessment dated September 5, 2024, inaccurately reported that the resident received an opioid for zero days during the seven-day look-back period. This discrepancy was confirmed during an interview with the MDS/Registered Nurse. For Resident #9, the medical records showed that the resident had diagnoses including schizophrenia, bipolar disorder, major depression, and anxiety. A psychiatry progress note instructed staff to monitor anxiety and schizophrenia. Despite this, the MDS assessment dated June 5, 2024, did not reflect an active diagnosis of anxiety. This inaccuracy was also confirmed during an interview with a Registered Nurse. These findings indicate a failure in accurately documenting the residents' medication use and diagnoses in the MDS assessments.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) documents accurately reflected the diagnoses of two residents. Resident #6 was admitted with diagnoses including schizoaffective disorder, dysphagia, chronic kidney disease, low back pain, and muscle wasting and atrophy. Despite having a diagnosis of anxiety disorder and being prescribed Clonazepam for anxiety, the PASRR document did not indicate this diagnosis. This discrepancy was confirmed by the Social Services Director during an interview. Resident #9 was admitted with multiple diagnoses, including schizoaffective disorder, bipolar disorder, major depressive disorder, general anxiety, and intellectual disabilities. However, the PASRR document from 2018 did not reflect any mental illness or intellectual disability, and there was no evidence of a PASRR update since then. The resident's current diagnoses and treatment plan indicated serious mental illness and intellectual disabilities, which were not captured in the PASRR. This was confirmed by a social worker, who acknowledged that the resident would require a Level II PASRR screening based on current diagnoses.
Inconsistent Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. This deficiency affected a resident who was the only individual in the facility receiving dialysis treatments. The resident had been admitted with diagnoses including end-stage renal disease, essential hypertension, and type two diabetes mellitus with diabetic nephropathy. The resident's care plan included interventions for outpatient dialysis three times a week and required communication with the dialysis center regarding medication, diet, and lab results. Upon review, it was found that the dialysis communication logs for the resident were missing on several dates in September 2024. These logs were crucial as they contained vital information such as the resident's code status, transfer time, allergies, mental status, medications, skin issues, and pre and post-dialysis weights. The absence of these logs was confirmed by the facility's administrator, indicating a lapse in maintaining essential communication records necessary for the resident's dialysis care.
Failure to Address Pharmacy Recommendations for Pain Management and Lab Work
Penalty
Summary
The facility failed to address pharmacy recommendations regarding a resident's pain medication and lab work in a timely manner. The resident, who was admitted with diagnoses including type two diabetes mellitus, pain in the left hip, and a non-pressure chronic ulcer of the left foot, was prescribed acetaminophen and tramadol for pain management. However, the pharmacy recommended evaluating these medications and establishing proper pain parameters, which the facility did not implement. Additionally, the resident's October 2024 physician orders did not include pain parameters for the prescribed medications. Furthermore, the facility did not obtain a Hemoglobin A1C (HbA1c) test every three months as recommended by the pharmacy. This oversight was confirmed during interviews with the Regional Care Consultant and the facility's Director of Nursing (DON), who acknowledged that the lab work was not completed as required. These deficiencies affected the resident's care and were identified during a survey of the facility.
Failure to Administer Vancomycin as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of vancomycin for a spinal surgical wound infection. The resident, who was admitted with diagnoses including infection and inflammatory reaction due to orthopedic prosthetic devices, did not receive scheduled doses of vancomycin on multiple occasions. On the day of admission, the resident missed the second dose of vancomycin, and the first dose the following day, due to the medication not being available in the emergency medication kit. Additionally, the resident missed another dose later in the month for the same reason. There was no documented evidence that the infectious disease physician or the facility's physician was notified of these missed doses. Further issues arose when the facility's pharmacy adjusted the vancomycin dosage without proper communication with the infectious disease pharmacist. The infectious disease pharmacist had recommended holding certain doses and re-drawing trough levels, but these instructions were not followed, and no orders were written to hold the medication. The Director of Nursing confirmed these lapses in medication administration and communication. The facility's policy on medication administration, which requires adherence to prescriber's written orders, was not followed in these instances.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as observed on two separate occasions. On the first occasion, a medication cart in the Sycamore Valley area was left unlocked and unattended while the LPN responsible was in a resident's room at the other end of the hall. This was confirmed by a State tested Nurse's Aide who noted the cart was not secured as per the facility's policy, which mandates that medication carts must be closed and locked when out of the nurse's sight. On the second occasion, the Director of Nursing observed a pill cup with several pills on a resident's bedside table. The resident explained that the nurse had left the medications there earlier because she preferred to take them with her breakfast. The DON confirmed that medications should not be left unattended and should be administered at the time they are prepared, as per the facility's policy. The medications involved included a range of prescriptions such as aspirin, budesonide, and metoprolol succinate, among others.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for a resident who was admitted with hemiplegia and hemiparesis following a cerebral infarction, among other conditions. The resident, whose primary insurance was Medicaid, lost a filling in a bottom right tooth and began experiencing significant pain. Despite multiple complaints of pain documented in progress notes from early September, the resident did not receive a dental appointment. The resident's care plan lacked any evidence of a dental plan, and the facility's social worker did not complete an emergency referral form, believing the resident did not meet the criteria for an emergency visit. The resident continued to experience pain, requiring Tylenol for relief, and expressed frustration over the delay in receiving dental care. The social worker was aware of the dental issues but did not attempt to secure an appointment with an outside dentist, mistakenly believing that the resident would have to wait for the facility dentist's next visit. It was only after further inquiry that the social worker discovered a local dental office would see Medicaid patients promptly. The facility's policy stated that they would assist residents in obtaining both routine and emergency dental care, which was not adhered to in this case.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide an appropriate assistive device for a resident, leading to a deficiency in care. Resident #5, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, muscle wasting, lack of coordination, and cognitive communication deficit, was affected by this oversight. The resident was cognitively intact and receiving hospice services, with a care plan indicating limited ability to eat and drink due to weakness and dysphagia. A physician's order specified the use of a small maroon spoon as an assistive device during meals. However, during an observation, the resident was seen using a regular spoon instead of the prescribed assistive device. Interviews with the Regional RN Consultant and the Dietary Manager confirmed the absence of the small maroon spoon, as ordered by the physician.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident admitted with a chronic venous ulcer. The resident, who had diagnoses including unspecified venous ulcer, cellulitis, morbid obesity, and peripheral vascular disease, was observed without an EBP sign on the door or available Personal Protective Equipment (PPE) near the resident's door. The medical record review revealed that there was no physician order for EBP, despite the facility's policy indicating that EBP should be in place for residents with chronic wounds. The Director of Nursing confirmed that EBP should have been implemented for the resident.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that three medication carts were locked when unattended, which had the potential to affect 12 cognitively impaired and independently mobile residents. During an observation on the Buckeye Unit, three medication carts were found outside the nurse's station, unlocked and unattended. An interview with a nurse confirmed that she had left the medication carts unlocked while she went to the restroom. The facility's policy on medication storage requires that medications and biologicals be stored properly and accessible only to authorized personnel, with medication supplies remaining locked when not in use or attended by authorized individuals. This deficiency was identified during a complaint investigation.
Medication Error Involving a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, resulting in a medication error involving Resident #58. The resident, who had multiple diagnoses including cellulitis, urinary tract infection, cognitive communication deficit, dysphagia, hypertension, dementia, atherosclerotic heart disease, chronic kidney disease, and atrial fibrillation with a pacemaker, was given another resident's medication. This error occurred on the morning of 06/13/24 when Nurse #100 administered the wrong medication to Resident #58, which included a combination of drugs such as mycophenolate, cyclosporine, famotidine, Ativan, magnesium oxide, morphine, nystatin, and prednisone. Following the medication error, the nurse reported the incident, and the Nurse Practitioner was contacted. Orders were given to administer Narcan if the resident's respirations fell below 10 per minute and did not improve with arousal, and to send the resident to the emergency room if Narcan was administered. The resident's vital signs were closely monitored, and additional tests were ordered to assess hepatic and kidney function. The resident was noted to be lethargic and drowsy but did not require Narcan administration as her condition did not deteriorate to that extent. The facility's investigation determined that the root cause of the medication error was the failure of Nurse #100 to adhere to the six rights of medication administration. The Director of Nursing confirmed the error and noted that the resident's only change in condition was a slight drop in oxygen levels. The facility's policy on medication discrepancies required documentation and reporting of such incidents, which was followed in this case. This deficiency was investigated under Complaint Number OH00154888.
Failure to Perform Proper Hand Hygiene During Medication Administration
Penalty
Summary
During a medication administration observation, Nurse #101 failed to perform proper hand hygiene, affecting three residents. After administering medication to Resident #51, the nurse hugged a visitor and shook hands with a family member without washing her hands before preparing medication for Resident #54. She used her bare hand to remove a gabapentin capsule from the medication card and placed it into a medication cup. The surveyor intervened, and a new capsule was administered. The nurse continued to set up medication for Resident #25 without washing her hands, only washing them after completing the administration. An interview with Nurse #101 confirmed the lack of hand hygiene during the medication administration process for Residents #25, #51, and #54. This deficiency was identified during a complaint investigation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure Resident #2 was free from an incident of resident-to-resident abuse. On 04/21/24, Resident #2 was physically assaulted by Resident #3 in the dining room where no staff were present. Resident #3 struck Resident #2 multiple times, resulting in two facial lacerations, a laceration to the lower lip, and multiple hematomas on the arms, upper breasts, and chest wall. Resident #2 also experienced psychosocial harm, expressing fear of reoccurrence and isolating herself from activities and meals. The facility did not provide timely medical evaluation, failed to notify the physician and authorities promptly, and did not implement appropriate interventions to ensure resident safety. Resident #2 had a history of schizoaffective disorder, bipolar type, anxiety, major depressive disorder, personality disorder, cognitive communication disorder, dysphagia, heart failure, muscle weakness, and seizure disorder. The care plan for Resident #2 included interventions for verbal behaviors and supervision during meals due to poor self-monitoring and impulsivity with eating. Despite these interventions, the incident occurred, and the facility's response was inadequate. The facility did not conduct a thorough investigation, failed to provide timely medical care, and did not offer psychosocial support to Resident #2 following the incident. Resident #3 had a history of diffuse traumatic brain injury, major depressive disorder, mood disorder, anxiety disorder, and muscle weakness. The care plan for Resident #3 included monitoring for anxiety, restlessness, poor impulse control, and fear/apprehension. Despite these interventions, Resident #3 exhibited aggressive behavior towards Resident #2. The facility did not provide adequate supervision in the dining room, failed to implement appropriate interventions to prevent further incidents, and did not conduct a comprehensive investigation following the altercation. The facility's failure to ensure resident safety and provide appropriate care resulted in Immediate Jeopardy and physical and psychosocial harm to Resident #2.
Removal Plan
- 1:1 supervision was initiated for Resident #3 with one staff member assigned for supervision of the resident. Additional staff were added to the shifts (as needed) to ensure monitoring occurred until the resident's discharge. The following staff provided 1:1 supervision through discharge: State tested Nursing Assistant (STNA) #130, #148, #160, and Activities Staff #160.
- An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. Regional DON #702 and VPCO #703 educated the Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, Activities Director #91 on the facility abuse policy, Centers for Medicare and Medicaid abuse reporting guidelines, future expectations with reporting abuse and completing investigations. Topics also discussed during the meeting were resident behaviors and care planned interventions as well as the facility removal plan. QAPI committee meetings would be held weekly for weeks, then monthly for recommendations and further follow-up regarding the removal plan based upon evaluation of audits and observations. Audits would continue to be submitted to the QAPI committee for review and to ensure compliance goals. QAPI committee reserved the right to modify or extend monitoring times according to outcomes. The Administrator was responsible for the oversight of this plan to ensure ongoing compliance. Any issues identified thru the audits would be reviewed and revised thru the facility QAPI process.
- The DON and Licensed Practical Nurse (LPN) #132 completed a record review for all 57 residents (the current census) for behavioral diagnosis including but not limited to traumatic brain injury (TBI), dementia and schizophrenia with no newly identified residents at risk for resident-to-resident abuse through diagnoses.
- LPN #132 reviewed residents (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) determined to be at risk for potential aggressive behaviors to ensure care planned interventions were appropriate.
- Resident #3 was placed in a private room by Plant Director #158 and Medical Records #126.
- The Director of Nursing spoke with Resident #6 (the resident who witnessed the incident between Resident #3 and Resident #2) to offer emotional/psychosocial support, but the resident declined.
- Facility resident profiles for residents at risk for potential aggressive behaviors (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) were updated to reflect care planned interventions to be followed when caring for a resident with a behavioral care plan by SSD #100, LPN #132 and/or the ADON.
- Resident #2 was evaluated by Physician #810 regarding the incident with Resident #3 via telehealth. The provider's progress note indicated there were no lasting effects from the incident. There were no current updates made to the resident's care plan and no new orders were received.
- All 82 staff (17 nurses, 23 STNA, two Activity Aides, 14 Department Managers, two Agency Nurses, 12 therapy, seven dietary and five housekeeping/laundry) were educated by the Administrator, DON or ADON either in-person or by phone regarding the facility abuse policy and reporting abuse to the Administrator (the facility abuse coordinator).
- All nursing staff (17 nurses, 23 STNA and two agency nurses) were educated either in person or via phone on access to resident care plans by SSD #100, LPN #132, the DON, or the Assistant Director of Nursing (ADON). A hand-out was also provided regarding how to access the information and the staff who received education via phone will receive the hand-out on their next scheduled shift. Staff will also be required to show a return demonstration or recite the process on their next scheduled shift. The resident profiles are in the electronic medical record (EMR).
- The facility implemented a plan that any facility initiated Self Reportable Incident(s) and facility investigation(s) would be escalated to regional support, Regional DON #702, and [NAME] President of Clinical Operations (VPCO) #703 for review to ensure the facility policy was followed.
- A plan for Social Services Designee (SSD) #100 to conduct weekly psychosocial follow-up with Resident #2 was implemented to ensure no lingering effects from the incident had occurred. Follow up would be completed for four weeks.
- The DON, ADON, and/or LPN #132 would review all new admissions for behavior risks.
- Auditing would be completed by the Director of Nursing/Assistant Director of Nursing and/or LPN #132 five days a week for the next eight weeks then three times a week for four weeks for all residents, which includes all new admissions.
- The Director of Nursing, ADON and/or LPN #132 would review/audit all nursing staff documentation including progress notes, events, observations, and Care Assist documentation to ensure all residents with behaviors have care planned interventions to ensure safety. Auditing would be completed on all current residents five days a week for eight weeks, then three times a week for four weeks.
- Resident #3 was discharged to a sister facility related to the resident's behavioral health needs.
- The Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, and Activities Director #91 conducted an audit (questionnaire) of current interviewable residents, whose Brief Interview for Mental Status (BIMS) score was eight and higher with no reported incidents of abuse and the residents interviewed indicated they felt safe within the facility.
- Non-interviewable residents (#27, #71, #47, #9 and #58), received a skin assessment.
Failure to Maintain Effective Abuse Prohibition Program
Penalty
Summary
The facility failed to maintain effective administrative services to provide a comprehensive abuse prohibition program, resulting in an incident of resident-to-resident physical abuse. The incident involved Resident #2 and Resident #3, where Resident #2 alleged that Resident #3 attacked her in the dining room. The initial investigation by the Director of Nursing (DON) was inadequate, as it did not include obtaining witness statements from all involved staff, conducting thorough resident interviews, or completing necessary skin assessments for non-interviewable residents. Additionally, the DON did not notify the psychiatric providers or the attending physician of the incident, resulting in a delay of treatment for Resident #2. The DON was administering medications at the time of the incident and was working as a floor nurse due to staffing needs. The DON's investigation concluded that the incident did not constitute abuse, as she believed Resident #3 did not act willfully to harm Resident #2. However, the investigation lacked comprehensive documentation, including staff statements and interviews, and failed to implement preventative interventions following the altercation. The facility's self-reported incident (SRI) indicated that Resident #2 had scratches on her face and later developed bruises on her chest and forearms, but the DON did not document these injuries in the resident's medical record or notify the physician. The Administrator, who was also the facility Abuse Coordinator, confirmed that the investigation should have included staff interviews and resident assessments. The facility's policy on abuse, neglect, and misappropriation of property required a thorough investigation and documentation of all allegations, which was not followed in this case. The failure to conduct a comprehensive investigation and implement corrective actions resulted in the potential for recurrence and compromised the safety and well-being of the residents in the facility.
Incomplete Investigation of Physical Abuse Allegation
Penalty
Summary
The facility failed to ensure a complete and thorough investigation following an allegation of physical abuse involving two residents. Resident #2 alleged that Resident #3 attacked her in the dining room, resulting in scratches and bruises. The only witness, Resident #6, corroborated Resident #3's account that Resident #2 had instigated the altercation by attempting to remove Resident #3's oxygen tubing. The facility's investigation, led by the Director of Nursing (DON), concluded that the allegation was unsubstantiated and did not suspect abuse. However, the investigation was incomplete, lacking staff interviews, additional resident interviews, and proper documentation of the incident and injuries in the medical record. The DON did not notify the psychiatric providers of the involved residents, and there was no follow-up from psychiatry for either resident following the incident. Additionally, the facility failed to provide evidence of a 72-hour psychosocial evaluation for Resident #2, who expressed fear and tearfulness when reminded of the incident. The facility's abuse policy was not adequately followed, leading to a deficiency in ensuring resident safety and thorough investigation of abuse allegations.
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Illustrative
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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.
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Nursing homes near Coshocton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Coshocton Inc. | 2.1 mi | — | 20 | 0 |
| Lafayette Pointe Nursing & Rehab Ctr | 7.1 mi | — | 1 | 0 |
| Riverside Manor Nrsg & Rehab Ctr | 15.2 mi | — | 4 | 0 |
| Oak Pointe Nursing & Rehabilitation | 15.2 mi | — | 0 | 0 |
| Majora Lane Ctr For Rehab & Nsg Care Inc | 18.8 mi | — | 12 | 0 |
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