Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Stellar Care Center during CMS and state inspections, most recent first.
A resident with a PICC line for IV cefepime therapy and multiple comorbidities received IV medication from an LPN who attached IV tubing directly to the open end of the PICC line without a needleless connector, after cleaning only the open hub. The LPN stated that PICC lines do not have valves, despite reporting prior IV therapy training. Facility leadership and HR reported they did not maintain competency or training records for agency staff, and one agency only verified licensure while another provided a self-assessment showing the LPN rated IV skills as limited and requiring supervision, even though the facility’s contract assigned responsibility for orientation, education, and competency of agency staff to the facility.
A resident with a suprapubic catheter did not receive comprehensive and individualized catheter care as ordered, including missed catheter changes and inadequate documentation. Staff were unaware of or misunderstood physician orders, and catheter care was not consistently performed due to staffing shortages and lack of training. These failures led to the resident developing a severe UTI, sepsis, and acute kidney injury, requiring hospitalization and intensive care.
The facility did not pay multiple vendor and utility bills on time, resulting in overdue accounts, shut-off notices for water and electricity, and delayed payments to the medical director. Staff reported supply delays and concerns about payroll, while the business office manager repeatedly forwarded unpaid bills to corporate accounts payable with limited resolution. All residents, who have complex medical needs, were at risk due to the facility's failure to maintain financial solvency and ensure uninterrupted essential services.
The facility did not adequately assess or provide for the activity needs of all residents, resulting in repetitive and limited programming, lack of specialized activities for memory care residents, and widespread dissatisfaction among both residents and staff. Observations and interviews revealed that scheduled activities were often not meaningful or engaging, and that some residents, including those with mental health conditions, were left without appropriate opportunities for socialization and stimulation.
The facility did not maintain adequate nursing staff, resulting in delayed or missed care such as bathing, feeding, and incontinence care. Staff and residents reported long wait times for assistance, unsafe transfers, and unmet personal care preferences. Facility records and leadership confirmed that current staffing levels were insufficient to meet the needs of residents requiring assistance with ADLs.
The facility did not provide specialized memory care services as advertised, with residents on the memory care unit receiving the same activities as the rest of the facility and lacking individualized programming. Observations and staff interviews revealed minimal engagement, no separate activity calendar, and inadequate staffing, resulting in periods of unsupervised residents and unmet psychosocial needs. Families and staff expressed concerns about the lack of stimulation, safety, and the absence of meaningful activities tailored to residents with dementia.
The facility did not manage its resources effectively, resulting in overdue utility and vendor bills, delayed payments to the Medical Director, and insufficient dietary staffing as outlined in the facility assessment. Administrative staff were often absent or unresponsive, and the dietary department was understaffed, causing delays in meal preparation and requiring CNAs to assist with kitchen duties, impacting all residents.
A facility-wide assessment failed to accurately account for the number of residents dependent on staff for ADLs such as toileting, dressing, bathing, and transferring, resulting in staffing levels that did not meet the actual needs of the resident population. Interviews with the DON, Administrator, and Dietary Director confirmed that both direct care and dietary staffing were insufficient compared to the requirements outlined in the assessment, leading to inadequate care coverage during both routine operations and emergencies.
Multiple residents did not receive prescribed treatments, such as wound care and nutritional supplements, and there were repeated failures to document care or notify providers of significant changes, including missed skin assessments and unreported rapid weight gain in a resident with CHF. Staff interviews confirmed lapses in following care protocols and physician orders, resulting in unaddressed changes in condition and incomplete care documentation.
Two residents did not receive required fall prevention interventions or post-fall assessments, as one lacked a care planned floor mat and another did not have a post-fall assessment documented after an unwitnessed fall. Additionally, hazardous chemicals were left unsecured and accessible to all residents on the memory care unit while staff were not present, as confirmed by an LPN. These deficiencies were identified through observation, interviews, and record reviews.
A resident with multiple chronic conditions was discharged home without comprehensive discharge instructions or documentation of a discharge note in the medical record. The discharge summary lacked evidence of education on diet or activities, and the DON confirmed the documentation was incomplete.
Two residents admitted with complex medical conditions did not have complete baseline care plans developed within 48 hours of admission. Only partial care plans, such as dietary or nutrition/hydration risk, were initiated, while other required care plans were delayed. Facility leadership confirmed that care plans were not completed in accordance with policy, and care conference documentation was incomplete.
Two residents who were dependent on staff for bathing, due to conditions such as Alzheimer's disease and mobility impairments, did not receive showers according to their preferences and scheduled times. Documentation and staff interviews confirmed that multiple showers were missed, and in some cases, behavioral challenges were cited as reasons for not providing care. The facility's policy allowed residents to choose the frequency and timing of bathing, but this was not followed.
A resident with multiple chronic conditions was admitted and continued to receive oxygen therapy at 2 LPM via nasal cannula, but there was no physician order for this treatment. Both the DON and Administrator confirmed that an order was required, and facility policy mandates physician orders for oxygen administration except in emergencies.
A resident with multiple serious conditions experienced moderate to severe pain over several days due to a delay in receiving ordered Tramadol. During this period, there was no documentation of alternative pain management interventions, despite ongoing pain reports and facility policy requiring appropriate pain assessment and treatment.
A resident with a history of depression, anxiety, and alcohol dependence was unable to attend AA meetings due to a broken facility van, and no alternative support or social services were provided during this period. The resident, who relied on AA for social interaction and emotional support, did not receive follow-up or in-house interventions from the social worker or other staff, despite clear care plan directives and facility policy requirements.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and issues with the facility's medication ordering process. One resident missed several days of an ear wax removal treatment, while another experienced unmanaged pain due to a week-long delay in receiving Tramadol. Staff and nursing interviews confirmed ongoing problems with obtaining both prescription and OTC medications, and the facility did not notify physicians when medications were unavailable.
Two residents with special dietary needs received meals that were unpalatable, lacking flavor, and had poor texture, as confirmed by dietary staff and resident feedback. One resident on a pureed diet received food that was stringy, lumpy, and watery, while another resident reported their meal had no flavor. These deficiencies were observed and verified during meal preparation and service.
Two residents did not receive food prepared in the required texture for their prescribed diets. One was served a whole hot dog instead of a mechanical soft diet, and another received pureed foods that were stringy, lumpy, and lacked flavor, despite orders for a pureed diet. Dietary staff and the dietary director confirmed the food did not meet required consistency standards.
A resident with a suprapubic catheter had monthly catheter changes documented as completed by LPNs, but interviews revealed that the procedure was never actually performed. Staff misunderstood the order, believing it referred to changing the catheter bag, and some lacked training on the procedure. The physician was not notified of the missed catheter changes, and the DON confirmed the inaccurate documentation.
A resident with an indwelling catheter and severe cognitive impairment was observed multiple times with their catheter bag lying on the floor while resting in bed. An LPN confirmed the observation, indicating a failure to follow infection prevention and control practices for catheter care.
A resident with multiple comorbidities and an unstageable pressure ulcer did not receive wound care in accordance with infection control protocols. An LPN and the ADON entered the room without donning gowns as required by enhanced barrier precautions, and the LPN used improper wound cleaning techniques and failed to clean equipment between uses. Staff interviews confirmed that infection control policies were not followed during the procedure.
Medication and treatment carts were left unlocked and unattended at the nurses' station while an LPN was off the unit and a CNA was serving breakfast in the dining room. Several cognitively impaired residents, all able to ambulate independently and known to wander, had access to the area. Facility policy required carts to be locked when unattended, but this was not followed.
A resident with complex medical conditions did not receive all required components of their comprehensive MDS assessments. Specifically, the annual MDS was missing the Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview, and the quarterly MDS lacked the Pain Assessment interview. These assessment omissions were verified by the ADON.
Two residents with complex medical needs did not have comprehensive care plans or discharge plans developed, despite being cognitively intact and expressing goals to return to the community. Both lacked documented referrals and active discharge planning, and one resident did not have a pain management care plan, even though pain was regularly assessed and treated.
A resident with significant medical needs developed new pressure ulcers and did not receive the prescribed silver alginate wound treatment, instead receiving calcium alginate for an extended period. During a dressing change, an LPN and the ADON failed to follow infection control protocols, including not using required PPE and reusing contaminated instruments, contrary to facility policy.
Two residents with colostomies did not consistently receive ostomy care as ordered by their physicians, as documented in the TAR and confirmed by the ADON. Both residents were cognitively intact and had care plans specifying the need for regular ostomy care, but records showed multiple missed care opportunities.
Two residents experienced medication administration errors, including late administration, incorrect dosages, and wrong medication forms, resulting in a medication error rate of 26.9%. Nursing staff acknowledged the errors, which occurred despite facility policy requiring timely and accurate medication administration.
The facility failed to implement a comprehensive pressure ulcer prevention program for two residents, resulting in the development of Stage II pressure ulcers. Both residents were at risk due to impaired mobility and incontinence, but care plans were not adequately followed. Incontinence care was not provided every two hours, and required pressure-relieving devices were not in place. Staff shortages contributed to the inability to provide necessary care, as confirmed by staff interviews and observations.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents receiving food. Expired and undated food items were found, and a staff member did not follow proper hand hygiene when changing gloves during food preparation. The dishwasher also failed to reach the required rinse temperature.
The facility failed to maintain a clean and safe environment, with issues such as discolored tile and grout, rusty air vents, torn walls, and sticky floors. A resident's room was particularly unkempt, with soiled bedding, cluttered window sills, and flies present. Staff confirmed the lack of maintenance and cleaning, noting the absence of a maintenance person for over a month and the facility's quarterly exterminator contract not addressing flies.
The facility failed to ensure proper documentation of advanced directives for two residents. One resident lacked an order for code status upon admission, while another had conflicting code status orders in electronic and paper records. The DON confirmed these discrepancies, which violate the facility's policy requiring clear display of advanced directives in medical records.
A facility failed to accurately document a resident's psychiatric diagnoses in the PASRR, despite the resident having major depressive disorder and unspecified psychosis. The PASRR did not reflect these conditions, although the resident's care plan and MDS indicated active diagnoses and antidepressant use. The DON confirmed the oversight, and the facility's policy required a review for unrecognized serious mental illness, which was not conducted.
The facility failed to develop comprehensive care plans for three residents, affecting their diagnoses, medications, and ADLs. A resident with dementia, depression, hallucinations, insomnia, and diabetes lacked care plans for these conditions and medications. Another resident with cerebral infarction and heart disease had no care plans for anticoagulation and bleeding risks. A third resident with dementia and other conditions lacked an ADL care plan. The facility's policy required care plans within seven days of the MDS assessment, which was not followed.
A resident with dementia and Alzheimer's disease did not receive consistent assistance with bathing, shaving, and oral care, despite requiring substantial help. The resident experienced gaps of up to ten days between showers, was often unshaven, and lacked access to oral care supplies. Staff interviews revealed that personal hygiene supplies were out of reach, and there was no follow-up after shower refusals. The facility's policy did not address handling refusals, leading to inadequate care.
A resident with a history of malnutrition and anxiety did not receive the required level of activity engagement as per her care plan, due to staffing challenges and inadequate scheduling. The resident's participation in activities was minimal, and she was often observed in her room without engagement. Interviews revealed that the Activity Director was the sole staff member for activities and was sometimes reassigned to other duties, leading to incomplete activity schedules.
A facility failed to implement pressure ulcer prevention interventions for a resident with known pressure ulcers. Despite physician's orders to use Prevalon boots to alleviate pressure, observations revealed the boots were not in place, and the resident's heels were not offloaded. An LPN confirmed the resident did not have the boots on and acknowledged signing off the treatment record inaccurately. The boots were later retrieved and applied after obtaining the resident's consent.
The facility failed to implement fall prevention interventions for three residents at risk for falls. A resident with dementia was found without non-skid socks, another with a femur fracture lacked fall mats and reminders, and a third with a history of falls did not have Dycem under her wheelchair cushion as ordered. Staff were unaware of these deficiencies, leading to inadequate supervision and increased fall risk.
A resident with dementia and anxiety disorder experienced inadequate pain management following a fall. Despite complaints of hip pain and signs of distress, the facility failed to implement a comprehensive care plan or document pain assessments and medication effectiveness. The resident was eventually sent to the hospital, where fractures were discovered, highlighting the facility's failure to manage the resident's pain appropriately.
A facility failed to perform AIMS assessments for a resident on antipsychotic medication, Seroquel, to monitor for side effects like extrapyramidal symptoms or tardive dyskinesia. The resident's medical record showed no evidence of these assessments since the medication's initiation, which the DON confirmed should occur at specific intervals. This oversight affected the monitoring of the resident's condition.
The facility failed to maintain adequate staffing levels in the Memory Lane secure unit, leaving one STNA to care for ten residents while the nurse administered medication in the assisted living area. This resulted in insufficient support for residents, some of whom were fall risks and required two-person assistance. The lack of communication and coordination among staff further exacerbated the issue, leading to non-compliance with staffing standards.
The facility failed to ensure a clean, safe, and homelike environment for 25 residents. Observations revealed missing toilet paper holders, paint and drywall damage, and a mouse trap in the Memory Care Unit. On the first floor, there were coffee spills, cracked linoleum, clogged sinks, and a urine odor. Maintenance and nursing staff confirmed these issues, with maintenance identifying a plumbing problem causing the sink clog.
The facility failed to ensure proper discharge procedures for two residents, leading to deficiencies in the discharge process. One resident was discharged against medical advice due to communication issues, and the other was transferred without complete documentation. The facility did not provide necessary discharge plans or transfer level of care documentation, and staff interviews revealed a lack of understanding and communication regarding the discharge process.
The facility failed to complete discharge summaries for three residents, each with complex medical histories, who were transferred to other nursing facilities. The records lacked necessary discharge documentation, including recapitulations of their stays and discharge plans of care. Interviews with staff confirmed these deficiencies.
The facility failed to administer prescribed medications and monitor two residents with edema and congestive heart failure. One resident did not receive Lasix and had no documentation of Neosporin application, while another lacked daily weight and intake/output records. The DON confirmed these lapses, which were noted as continued non-compliance.
The facility failed to provide timely and ordered pressure ulcer care for two residents. One resident with a Stage 1 pressure ulcer on the coccyx did not receive the prescribed daily treatment, as confirmed by the TAR and staff interviews. Another resident with an unstageable pressure ulcer on the right heel also did not receive the ordered treatment, as verified by the DON. This issue was part of ongoing non-compliance.
The facility failed to provide physician-ordered nutritional supplements to two residents with identified nutritional needs. One resident with severe protein-calorie malnutrition did not receive Healthshakes as recommended, and the DON had not communicated the dietician's recommendations to the physician. Another resident with a history of severe sepsis and malnutrition did not receive a Health Shake as ordered. This issue was part of a continued non-compliance from a previous survey.
A facility failed to maintain respiratory equipment in a sanitary manner for a resident with COPD. The nebulizer machine and mask were improperly stored in the dining room, and the mask was not changed as ordered. Staff interviews confirmed the oversight, and the treatment sheet showed missed changes. Facility policy on nebulizer care was not followed.
A facility failed to maintain a medication error rate of five percent or less, resulting in a 7.69 percent error rate. An LPN administered respiratory medications to a resident with COPD without adhering to the required one-minute interval between puffs, as per manufacturer guidelines and facility policy. The LPN was unaware of this requirement, contributing to the non-compliance.
The facility failed to obtain ordered lab tests for three residents, affecting their medical management. A resident with Alzheimer's and COPD did not receive scheduled lab tests, confirmed by the DON. Another resident with dementia and kidney failure also missed regular lab tests. Additionally, a resident with hemophilia and diabetes lacked Lipid testing since admission, as verified by the DON.
Failure to Ensure Competent IV Therapy Administration by Agency LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an IV medication was administered by a competent licensed nurse and to verify and document IV therapy competencies for an agency LPN. A resident was admitted with a postoperative wound infection, a PICC line placed in the right upper arm for long-term IV antibiotic therapy, and multiple comorbidities including diabetes, liver disease, hypertension, anemia, depression, and a history of stroke. The resident had an order for IV cefepime 2 g in 100 ml normal saline to be given three times daily via the PICC line. On observation, the PICC line had a flesh-colored bandage wrapped around the base, obscuring the insertion site, and the external catheter had a purple open-ended hub labeled “5 ml” with no needleless connector/valve attached. During administration of IV cefepime, the LPN cleaned the open end of the external PICC with an alcohol swab, flushed with normal saline, and then attached the IV tubing directly to the open end of the PICC line without a needleless connector device. When questioned, the LPN stated that PICC lines she worked with never had valves and that this was how PICC lines are, despite reporting that she had IV therapy training and certification. Licensure review showed the LPN had been licensed less than a year and, per the Ohio Board of Nursing, IV certification is no longer listed on LPN licenses for those licensed after a certain date, making IV training and competency verification the employer’s responsibility. The Human Resource Director reported she did not maintain personnel files, licensure checks, or competency records for agency staff, and the interim DON reported having no education or competency documentation for the LPN other than IV training provided after the issue was identified, stating that the agency would have competency records. The Administrator reported that one staffing agency only verified licensure and did not check competencies, and that another agency provided only a self-assessment skills checklist on which the LPN rated her IV therapy skills as limited and requiring supervision. The facility’s contract with that agency specified that the facility was responsible for orientation, education, training, and competency of agency staff.
Failure to Provide Comprehensive Suprapubic Catheter Care Resulting in Sepsis and Hospitalization
Penalty
Summary
A deficiency occurred when facility staff failed to develop and implement comprehensive and individualized care and interventions for a resident with a suprapubic catheter. The resident, who had a history of neurogenic bladder, diabetes, hypertension, and other chronic conditions, had a physician order for suprapubic catheter care every shift and monthly catheter changes. Despite these orders, there was no evidence that a care plan was developed at the time of catheter placement, and documentation showed repeated missed catheter care and tubing checks across several months. Staff interviews revealed that catheter care was not consistently performed due to staffing shortages, and some staff were unaware of or misunderstood the physician's orders regarding catheter changes, with some believing the order referred only to the catheter bag rather than the catheter itself. The resident's medical records indicated that catheter care and monthly changes were not documented as completed on multiple occasions, and there was no documentation of the resident refusing care or of the physician being notified about missed catheter changes. Additionally, there was no monitoring or documentation of urinary output or urine appearance prior to the resident's acute change in condition. Staff interviews confirmed that the suprapubic catheter had not been changed as ordered, and some staff admitted to not having received training on how to perform the procedure. The resident's care plan addressing the suprapubic catheter was not initiated until several months after placement, and interventions to monitor for complications were not implemented in a timely manner. As a result of these failures, the resident developed a severe urinary tract infection that progressed to sepsis and acute kidney injury, requiring hospitalization and intensive care. Hospital records documented grossly purulent urine, obstructive kidney stones, and the need for surgical intervention, including catheter exchange and stent placement. The lack of adherence to physician orders, inadequate documentation, and insufficient staff knowledge and training directly contributed to the resident's acute medical deterioration.
Removal Plan
- Resident #05 was transferred to the hospital and remained in the hospital.
- An audit of all current residents was completed by the DON for any residents with a suprapubic catheter. No other residents noted with a suprapubic catheter. Resident #09 was identified to have an order for an indwelling urinary catheter (Foley). Resident #09 was seen by the Nurse Practitioner.
- An investigation was completed by the DON of why this error occurred in order to implement corrective actions.
- RDCO #1022 reviewed facility policies including the Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures to ensure they were comprehensive, and no changes were needed prior to staff education.
- RDCO #1022 provided education to the DON on Physician Orders policy, Suprapubic Cath Care and Suprapubic Cath Replacement procedures.
- Education was provided in person or via phone to all current licensed nurses by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The education included following physician orders regarding catheters including catheter care (video was given on steps for suprapubic catheter replacement), along with the suprapubic catheter care and replacement procedure. In addition, staff were educated if they were unable to complete this task for the day as ordered, they were to report to the DON/ADON and they would assist on how to get the task completed. The DON followed up with the nurses after the education to ensure there were no unanswered questions related to the education.
- All current Certified Nurses Assistants (CNAs) were educated by the DON on catheter care for Foley catheters using the facility Catheter Care policy. A video was provided on how to do catheter care. The CNA staff were educated if they were unable to complete this task as ordered for the day they were to report to the DON/ADON and they would assist in how to get the task completed. The DON followed up with CNAs after the education to ensure there were no unanswered questions related to the education.
- The Medical Director was notified by the DON of the Immediate Jeopardy (IJ) concern involving Resident #05. An Ad-hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with Medical Director, DON, Administrator, and RDCO #1022. The IJ was reviewed, the reason for the IJ, and the facility abatement plan.
- The Administrator provided contracted staffing agencies education related to catheter care. Education would be added for the staff to review prior to picking up a shift. The DON/designee would ensure agency staff reviewed education by contacting them once they had arrived at the facility and getting a verbal acknowledgement they have reviewed.
- The facility implemented a plan for all new staff to be verbally educated on Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures, what to do if you do not know how to change a catheter, following physician orders by the DON/designee during new hire orientation.
- The DON/ADON would review physician orders daily and would ensure if there were any new suprapubic catheter orders that the care and changing orders were in place and being followed. The DON/ADON would review residents with suprapubic catheters and would review catheter orders to ensure they were accurately documented when completed by going in and checking if the care and or catheter had been changed per order.
Failure to Ensure Timely Payment of Essential Services and Vendor Bills
Penalty
Summary
The facility failed to ensure timely payment of bills and invoices, resulting in multiple overdue accounts and shut-off notices for essential services such as water and electricity. Review of financial records and interviews revealed that invoices from the State Fire Marshal, local hardware store, and utility companies were not paid on time, with some accounts receiving final collection notices and threats of service interruption. The business office manager consistently forwarded overdue bills and shut-off notices to corporate accounts payable, but payments were often delayed or only partially made, leaving outstanding balances. Staff interviews confirmed that the facility was experiencing financial difficulties, with some supplies delayed and concerns expressed about payroll and the overall financial health of the facility. The medical director reported not being paid for several months, and the State Fire Marshal's office confirmed outstanding survey fees dating back to the previous year. The corporate representative acknowledged that some utility accounts exceeded autopay limits and that bills were sometimes only paid after shut-off notices were received, citing cash flow issues and the need to avoid bounced checks. The facility assessment indicated that all 35 residents were clinically complex, with multiple chronic or comorbid conditions, making uninterrupted services critical to their care. Despite the absence of actual service shut-offs at the time of the investigation, the ongoing risk of interruption due to unpaid bills was evident. The administrator's job description included responsibilities for financial oversight, but the system in place failed to ensure timely payment of essential services, potentially affecting all residents.
Failure to Assess and Meet Resident Activity Needs
Penalty
Summary
The facility failed to assess and meet the activity needs of all 35 residents, as evidenced by record review, observation, interviews, and review of the activity calendar and job descriptions. The activity calendar showed repetitive and limited activities, such as beverage cart and sit and chat, with only one main activity per day, and little to no evening programming. Observations and staff interviews confirmed that beverage cart and sit and chat were not considered meaningful activities by staff or residents, and that activities were often not conducted as scheduled. Residents and staff reported dissatisfaction with the lack of variety, frequency, and engagement in the activities provided, with some residents expressing boredom and a desire for more options. The memory care unit was particularly affected, with no specialized programming or activities provided for its residents. Observations revealed long periods with no activities, and staff confirmed that activity assessments had not been completed for memory care residents. Residents in this unit were often left without stimulation or opportunities to participate in group activities, and staff noted that when memory care residents were able to leave the unit for activities such as church, their mood improved significantly. However, such opportunities were rare, and the activity staff did not regularly provide or invite memory care residents to participate in activities. One resident with a history of major depression, anxiety disorder, and alcohol dependence in remission was specifically noted to have a care plan that included goals and interventions for activity participation, but reported that there were not enough activities to meet his needs. The activity director confirmed that she was the only member of the activity department, with limited time and resources to provide a variety of activities, and that the activity room was not accessible to residents outside of her working hours. The job description for the activity director outlined responsibilities for providing a comprehensive activity program, but these were not being met, as evidenced by the lack of assessments, limited programming, and resident and staff dissatisfaction.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple staff and resident interviews, observations, and review of facility records. Staff reported frequent instances where Certified Nursing Assistants (CNAs) were left alone on the floor, especially during weekends and night shifts, resulting in delayed or missed care such as bathing, oral care, feeding assistance, and incontinence care. Staff also described situations where tasks requiring two staff members, such as Hoyer lift transfers, were performed by a single staff member due to inadequate staffing. Observations confirmed that call lights often went unanswered for extended periods, and residents expressed frustration with long wait times for assistance, sometimes exceeding an hour. Residents reported feeling unsafe, particularly during night shifts, and described incidents where they were not assisted with mobility aids, leading to fear of falls and actual accidents. Several residents stated that their personal care preferences, such as timely showers and the ability to choose their clothing, were not being met due to staff rushing through care. Staff interviews further revealed that the lack of adequate staffing led to poor quality and untimely care, with some residents not receiving regular incontinence care, turning, or repositioning as required. Staff also reported that nurses were often pulled away from medication passes to assist with resident care, causing further delays. A review of the facility's assessment tool indicated that the number of full-time and part-time nursing staff employed was insufficient to meet the needs of the current resident population, particularly those who were fully dependent on staff for activities of daily living (ADLs) such as dressing, bathing, transferring, and toileting. The Director of Nursing and Facility Administrator confirmed that, based on the facility assessment, the current staffing levels were not adequate to provide timely and quality care to residents. The deficiency was substantiated through direct observation, staff and resident interviews, and review of facility documentation.
Failure to Provide Specialized Memory Care Services and Activities
Penalty
Summary
The facility failed to provide specialized memory care services as advertised for all residents residing on the memory care unit. Record review showed that multiple residents with diagnoses such as dementia, Alzheimer's disease, depression, and other cognitive impairments were admitted to the unit. Despite facility brochures and fliers promoting a specialized memory care program, interviews with staff and observations revealed that no specific memory care program or specialized activities were implemented. The activities provided to memory care residents were the same as those offered to the rest of the facility, and there was no separate activity calendar or tailored programming for the memory care unit. Observations on the memory care unit showed a lack of engagement and stimulation for residents, with minimal activities occurring and residents often left sitting in common areas or in their rooms without interaction. Staff interviews confirmed that the activity director was unable to provide activities for the memory care unit due to other responsibilities, and activity assessments for these residents were not completed until after they were requested by surveyors. The only activities listed, such as beverage cart and sit and chat, were not consistently provided, and staff did not consider them meaningful activities. Residents were not routinely invited to participate in facility-wide activities, and the activity room was locked when the activity director was not present. Staffing on the memory care unit was consistently reported as inadequate, with only one aide assigned per shift, leading to periods when residents were left unsupervised while staff attended to individual care needs. Staff and family interviews expressed concerns about resident safety and the lack of engagement, stimulation, and supervision. Families reported not being informed about the benefits of memory care and expressed expectations for more specialized activities and higher staffing levels. The facility's own policies and job descriptions outlined requirements for individualized activity programming and assessments, which were not met for the memory care residents.
Failure to Administer Facility Resources and Maintain Adequate Dietary Staffing
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, impacting all 35 residents. Multiple invoices and shut-off notices from utility companies and the Fire Marshal's office were overdue, with some accounts at risk of service interruption. The Business Office Manager consistently forwarded these notices to corporate accounts payable, but payments were often delayed or only partially made. Staff interviews revealed concerns about delayed supplies, financial instability, and lack of responsiveness from administration and corporate leadership. The Medical Director also experienced delayed payments, and the Fire Marshal's office confirmed outstanding bills dating back to the previous year. Administrative staff, including the Administrator, were frequently absent or inaccessible, with several staff members reporting that the Administrator was rarely present and did not engage with staff or residents. Concerns raised by staff were often ignored, and there was a general perception that administration and corporate did not prioritize the needs of the residents or the facility. The Administrator's job description outlined responsibilities for budgeting, financial oversight, and ensuring quality care, but these duties were not fulfilled as evidenced by the ongoing financial issues and lack of timely bill payments. Additionally, the facility failed to employ sufficient dietary staff as outlined in its facility assessment. The dietary department was consistently understaffed, with the Dietary Director and other staff members required to cover multiple roles and avoid overtime, leading to incomplete kitchen tasks and delays in meal and snack preparation. The facility assessment called for more dietary staff than were actually employed, and the short staffing resulted in CNAs having to leave resident care duties to retrieve snacks. Training for dietary staff was also inadequate, with planned training sessions not occurring and the Dietary Director lacking sufficient support. These deficiencies were confirmed by staff interviews and review of staffing schedules.
Inaccurate Facility Assessment Leads to Inadequate Staffing for Resident Care
Penalty
Summary
The facility failed to conduct an accurate and thorough facility-wide assessment to determine the necessary resources required to care for residents competently during both routine operations and emergencies, including nights and weekends. Review of resident data revealed that the number of residents dependent on staff for activities of daily living (ADLs) such as toileting, dressing, bathing, and transferring significantly exceeded the facility's stated capacity in its assessment. Specifically, there were 15 residents dependent on staff for toileting, 14 for dressing, 14 for bathing, and 9 for transferring, while the facility assessment only accounted for the ability to care for five residents in each of these categories. Additionally, the assessment outlined staffing requirements that were not met, including the need for four full-time RNs, four full-time LPNs, and fourteen full-time CNAs, while actual staffing levels were lower in several categories. Interviews with the Director of Nursing (DON), Facility Administrator, and Dietary Director confirmed discrepancies between the facility assessment and actual staffing levels, including insufficient numbers of direct care and dietary staff to meet the needs of the current resident population. The DON and Facility Administrator acknowledged that the facility-wide assessment was not completed accurately, resulting in inadequate staffing to provide timely and quality care for residents. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Follow Physician Orders and Provide Comprehensive Resident-Centered Care
Penalty
Summary
The facility failed to provide comprehensive, resident-centered care as evidenced by multiple deficiencies in following physician orders, documenting care, and notifying providers of significant changes in residents' conditions. For several residents, there were repeated lapses in the administration and documentation of prescribed treatments, such as wound care and nutritional supplements. For example, one resident with multiple comorbidities including diabetes and skin breakdown did not consistently receive ordered wound treatments or nutritional supplements, and there was no documentation of provider notification when these treatments were missed. Additionally, this resident received insulin outside of the prescribed sliding scale without appropriate physician orders or notification when blood glucose levels exceeded the threshold requiring provider contact. Other residents experienced similar failures in care. One resident with a history of stroke and impaired mobility had orders for weekly skin checks, but there were multiple periods where no documentation of these assessments was found. Another resident, at risk for pressure ulcers and with significant medical complexity, also did not have weekly skin checks documented as ordered. In the case of a resident with congestive heart failure, there was a significant, rapid weight gain over several days, but the physician was not notified in a timely manner as required by facility protocol and physician orders. Staff interviews confirmed a lack of awareness of the resident's diagnoses and a failure to conduct thorough record reviews, contributing to the missed notifications. Additionally, a resident on anticoagulant therapy did not have weekly skin assessments completed for an extended period, and significant bruising was observed but not documented or monitored as required by the care plan. This resident also experienced interruptions in receiving a prescribed protein supplement due to supply issues, with no evidence that the provider was notified or alternative options were considered. These deficiencies were confirmed through record reviews, staff interviews, and direct observations, affecting multiple residents and demonstrating a pattern of non-compliance with physician orders and care protocols.
Failure to Implement Fall Interventions and Secure Hazardous Chemicals
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions and post-fall assessments for two residents. One resident, with diagnoses including dementia, insomnia, and a history of falls, was care planned to have a floor mat at bedside as a fall prevention measure. Observation revealed that the floor mat was not present in the resident's room, and this was confirmed by an LPN, indicating the intervention was not in place as required by the care plan. Another resident, with multiple diagnoses including cerebral infarction, diabetes, and cognitive impairment, experienced an unwitnessed fall and was transported to the hospital. Review of the medical record showed that no post-fall assessment was documented after the resident returned from the hospital, a fact confirmed by the DON several hours after the incident. Additionally, the facility failed to ensure hazardous chemicals were properly stored and inaccessible to residents on the memory care unit. Observation found that cabinets behind the nurses station were left unlocked and unattended, containing items such as nail polish, nail polish remover, medication disposal compounds, bleach, disinfectant wipes, stainless steel cleaner, and needles. An LPN confirmed that all residents on the unit wandered and had access to these chemicals while staff were occupied in a resident's room. Review of the MSDS for these chemicals indicated potential for irritation, toxicity, and other health hazards upon exposure. These deficiencies affected multiple residents, including those with cognitive impairments and histories of wandering, and were identified through observation, interviews, record reviews, and policy and MSDS reviews. The facility's failure to implement care planned interventions, complete required assessments, and secure hazardous materials resulted in non-compliance with safety and accident prevention standards.
Incomplete Discharge Documentation and Instructions
Penalty
Summary
The facility failed to provide comprehensive discharge instructions and did not ensure that documentation of a resident's discharge was present in the medical record. Specifically, a resident with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease, hypertension, hyperlipidemia, heart failure, gastro-esophageal reflux disease, hyperkalemia, and insomnia, was discharged to their home. Review of the multidisciplinary discharge summary showed that discharge instructions were incomplete, with no evidence of education regarding diet or activities provided to the resident or their representative. Additionally, there was no documentation of a discharge note for the resident's discharge on the specified date. The Director of Nursing confirmed the incomplete documentation during an interview.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents. For one resident admitted with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy, only the dietary care plan was initiated within the required timeframe, while the remainder of the care plan was not completed until several days later. The care conference for this resident occurred after admission, but there was no evidence of a baseline care plan being established within 48 hours as required. Another resident admitted with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, chronic kidney disease, and heart failure, also did not have a complete baseline care plan within 48 hours. Only a nutrition/hydration risk care plan was initiated, with no other care plans documented. Additionally, the care conference summary for this resident lacked signatures from the resident, family, or representative, indicating incomplete involvement. Interviews with facility leadership confirmed that the care plans for both residents were not completed fully or in a timely manner, contrary to facility policy.
Failure to Provide Scheduled Showers According to Resident Preferences
Penalty
Summary
The facility failed to provide showers to residents according to their preferences and established shower schedules. Two residents with significant cognitive and physical impairments, including diagnoses such as Alzheimer's disease, dementia, and mobility issues, were identified as being dependent on staff for bathing. Documentation showed that both residents missed multiple scheduled showers over several months, despite care plans indicating their need for staff assistance and the use of mechanical lifts or supervision for bathing. The facility's own bathing policy stated that residents could choose the frequency and timing of their baths or showers. Interviews with staff and the Director of Nursing confirmed that the missed showers were not documented as being provided at alternative times, and in one case, staff reported that a resident's behavioral challenges led to skipped showers and changes. The lack of adherence to the shower schedule and resident preferences was verified through review of shower sheets and staff interviews, demonstrating a failure to meet the residents' needs for assistance with activities of daily living as outlined in their care plans and facility policy.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy was admitted to the facility by ambulance with oxygen in place at 2 liters per minute. Nursing documentation and observation confirmed the resident continued to receive oxygen therapy via nasal cannula and oxygen concentrator. However, review of the resident's medical record revealed there was no physician order for oxygen therapy at any point during the resident's stay. Both the Administrator and Director of Nursing confirmed that an order should have been in place for the administration of oxygen, and facility policy requires a physician order for oxygen except in emergencies.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with multiple serious diagnoses, including lung and brain cancer, chronic pain, and heart failure, was admitted to the facility and had physician orders for Tramadol and acetaminophen to manage pain. Despite these orders, there was a delay in obtaining the Tramadol, with the medication not being delivered to the facility until seven days after it was ordered. During this period, the resident consistently reported moderate to severe pain, with pain ratings ranging from four to six out of ten on several occasions. There was no documentation that alternative pain relief medications or methods were provided to the resident while experiencing pain during the delay in receiving the prescribed Tramadol. The resident reported being told by nursing staff that the facility was out of her pain medication and that efforts were being made to obtain it. The Director of Nursing confirmed the delay in medication delivery and the lack of documentation for alternative pain management interventions. Facility policy requires pain management to be based on professional standards, the care plan, and resident choices, but these standards were not met in this instance.
Failure to Provide Medically-Related Social Services for Psychosocial Well-Being
Penalty
Summary
The facility failed to provide medically-related social services to support a resident's psychosocial well-being, specifically for a resident with a history of major depression, anxiety disorder, and alcohol dependence in remission. The resident was identified as being at risk for psychosocial issues due to social isolation, depression, and physical limitations, and his care plan included interventions such as access to psychiatric services and opportunities for social engagement. Despite these identified needs, the resident was unable to attend Alcoholics Anonymous (AA) meetings, which he considered his primary source of social interaction and support, after the facility's transportation van broke down. Interviews revealed that the resident missed multiple AA meetings due to the lack of transportation, and no alternative arrangements were made to support his psychosocial needs during this period. The resident reported not being aware of the facility's social worker and stated that no one had offered him additional support while he was unable to attend AA. The social worker acknowledged not following up with the resident or providing in-house services to address his needs during the transportation disruption. Other staff members confirmed the importance of AA meetings to the resident's well-being and noted a decline in his mood when he was unable to attend. The facility's social services job description outlined responsibilities for addressing residents' emotional adjustment and ensuring appropriate psychosocial interventions, but these were not fulfilled in this case. The lack of timely and appropriate social services intervention resulted in the resident not receiving the support necessary to maintain his highest possible quality of life, as required by facility policy and regulatory standards.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring timely receipt and administration of prescribed medications. One resident, with multiple diagnoses including hemiplegia, GERD, anxiety, depression, COPD, and others, had a physician's order for Debrox Otic Solution for ear wax removal. Documentation showed that over a four-day period, the medication was not available and was not administered as ordered. Progress notes repeatedly indicated the facility was awaiting the medication from the pharmacy, and there was no evidence that the physician was notified about the unavailability or missed doses. Interviews with nursing staff and the DON confirmed the medication was not received or administered, and the physician was not informed. Another resident, with diagnoses including lung cancer, COPD, diabetes, brain cancer, chronic pain, and heart failure, had an order for Tramadol for pain management. The medication was ordered from the pharmacy several days after the physician's order and was not delivered for seven days. The resident reported being in pain and not receiving the medication, and staff interviews confirmed ongoing issues with timely receipt of both prescription and OTC medications from the pharmacy. Facility staff described frequent delays and the need to purchase OTC medications from outside sources due to inconsistent pharmacy deliveries. The facility's policy required medications to be administered according to orders and within required time frames, which was not followed in these cases.
Failure to Provide Palatable and Appetizing Food to Residents
Penalty
Summary
Surveyors found that the facility failed to provide palatable, appetizing, and safe food to residents, specifically affecting two individuals reviewed for food quality. One resident with severe cognitive impairment, multiple chronic conditions, and a mechanically altered, pureed diet was observed receiving pureed meals that were stringy, lumpy, watery, and lacked flavor. The dietary staff confirmed during preparation that the pureed sugar snap peas, breaded fish, and roasted potatoes were not palatable, with issues in both texture and taste. The resident had a documented history of significant weight loss and was at risk for malnutrition, with care plans and orders specifying the need for appropriate diet preparation. Another resident, with diagnoses including dementia and mild protein-calorie malnutrition, was observed eating a lunch meal that was reported to have no flavor. The resident expressed dissatisfaction, stating the meal tasted as if they "might as well eat dirt." Both observations and interviews confirmed that the food provided was not palatable or appetizing, directly contravening the requirement to ensure residents receive nutritive, palatable food and drink.
Failure to Provide Food in Appropriate Texture for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of two residents. One resident, with diagnoses including type 2 diabetes, hypertension, GERD, and cognitive impairment, was ordered a low concentrated sweets diet with mechanical soft texture. Despite no documentation of refusal of the modified diet, this resident was observed being served a whole hot dog, which did not meet the mechanical soft texture requirement. The error was only corrected after staff intervention at the time of service. Another resident, with severe cognitive impairment and multiple chronic conditions, was ordered a pureed texture diet. During meal preparation, staff were observed pureeing food items for this resident, but the resulting pureed foods did not achieve a smooth consistency as required. The pureed peas were stringy and lacked flavor, the breaded fish was watery and lumpy, and the potatoes were lumpy and flavorless. These issues were confirmed by dietary staff and the dietary director, and were not in accordance with the facility's policy for texture and consistency modified diets.
Failure to Accurately Document and Perform Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure the accuracy of resident records and documentation for a resident with an indwelling suprapubic catheter. The resident, who had multiple diagnoses including neuromuscular bladder dysfunction and was dependent on staff for activities of daily living, had physician orders for monthly suprapubic catheter changes. Documentation in the treatment administration records indicated that the catheter was changed as ordered each month by various LPNs. However, interviews with the LPNs revealed that none of them had actually performed the catheter change, and some believed the documentation referred only to changing the catheter bag, not the catheter itself. One LPN stated they had no training on how to perform the procedure and were unaware of any such order. Further review showed that the resident's physician was not notified that the catheter changes were not being performed as ordered. The Director of Nursing confirmed that the catheter exchange was documented as completed when it had not been done. The deficiency was identified through record review, staff interviews, and communication with the resident's power of attorney, who also confirmed through messages with staff that the catheter had not been changed as required.
Catheter Bag Found on Floor—Infection Control Lapse
Penalty
Summary
The facility failed to maintain proper infection control practices when a resident's catheter bag was repeatedly observed lying on the floor. The resident involved had a history of quadriplegia, pure hypercholesterolemia, and neuromuscular dysfunction of the bladder, and was admitted with an indwelling catheter in place per physician order. Despite a care plan indicating severely impaired cognition and frequent bladder incontinence, observations on multiple occasions showed the catheter bag on the floor while the resident was resting in bed. This was confirmed by an LPN during an interview, indicating a lapse in infection prevention and control protocols for catheter care.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During a wound care procedure for a resident with quadriplegia, diabetes mellitus, neurogenic bladder, and peripheral vascular disease, staff failed to follow appropriate infection control practices. The resident had an unstageable right hip pressure ulcer and an indwelling urinary catheter, with physician orders for daily wound treatments and enhanced barrier precautions (EBP), which require the use of gown and gloves during high-contact care. Observation revealed that both the LPN and the Assistant Director of Nursing entered the resident's room without donning gowns, despite EBP signage and supplies being available. The LPN performed the wound care using improper technique, including using the same gauze to clean multiple areas of the wound, handling bandage scissors without cleaning them between uses, and placing potentially contaminated scissors back with clean supplies. Additionally, when a dressing fell onto the bed, it was discarded, but the scissors were again used without cleaning before cutting a new dressing. Interviews with both the LPN and the ADON confirmed that the wound care was not completed as ordered and that EBP protocols were not followed. Policy reviews indicated that the facility's procedures required the use of gloves and gowns for such care, as well as proper hand hygiene and equipment cleaning. The failure to implement these infection control measures was observed directly and verified by staff, constituting a deficiency in the facility's infection prevention and control program.
Medication and Treatment Carts Left Unlocked and Unattended on Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when medication and treatment carts were left unlocked and unattended on the locked memory care unit. During an observation, both carts were found unsupervised and unlocked at the nurses' station, with no staff present in the immediate area. The only staff member on the unit at the time, a CNA, was serving breakfast trays in the dining room, while the LPN was downstairs administering medications. This left the medication and treatment carts accessible and out of view of any staff. Medical record reviews confirmed that seven residents on the memory care unit were severely impaired in daily decision-making, ambulatory, and capable of independently moving throughout the unit. Interviews with staff verified that these residents wandered the unit and could open the drawers of the carts. Facility policy required that medication carts be locked when out of sight or unattended, a standard not met during the observed incident.
Incomplete MDS Assessment Components for Resident
Penalty
Summary
The facility failed to complete all required components of comprehensive assessments for one resident. Medical record review showed that a resident with multiple diagnoses, including quadriplegia, chronic pain, diabetes mellitus, neurogenic bladder, major depressive disorder, and peripheral vascular disease, was admitted to the facility. The annual Minimum Data Set (MDS) 3.0 assessment for this resident did not include the required Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview. Additionally, the quarterly MDS assessment for the same resident was missing the required Pain Assessment interview. These omissions were confirmed during an interview with the Assistant Director of Nursing.
Failure to Develop Comprehensive Care and Discharge Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required. For one resident admitted with hypertension, a pancreatic disorder, and a colostomy, the medical record showed that although the resident was cognitively intact and had a goal to return to the community, there was no active discharge plan, no referrals, and the local contact agency was unknown. The resident was routinely assessed for pain and received Tylenol for mild to moderate pain, but there was no evidence of a comprehensive pain care plan or a discharge care plan documented in the record. Similarly, another resident admitted with cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy was also cognitively intact and had a goal to return to the community. However, there was no active discharge plan, no referrals, and the local contact agency was unknown. The medical record did not contain evidence that a discharge plan of care had been developed for this resident. These findings were confirmed by interview with the Assistant Director of Nursing.
Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, diabetes mellitus, and peripheral vascular disease, was admitted without skin impairments and later assessed as being at moderate risk for skin breakdown. Despite this, the resident developed three new facility-acquired pressure ulcers, including an unstageable pressure ulcer on the right hip. The prescribed treatment for this ulcer was to use a silver alginate dressing, which provides both autolytic debridement and antimicrobial action, but the resident was instead treated with calcium alginate, which lacks antimicrobial properties, for nearly two weeks. This discrepancy was not identified until a survey was conducted. During direct observation of a dressing change, an LPN and the ADON failed to follow proper infection control protocols, including not donning required personal protective equipment and not adhering to enhanced barrier precautions. The LPN also used unclean bandage scissors to cut dressings, reused contaminated instruments, and did not follow the wound care policy for dressing removal and hand hygiene. The ADON confirmed that the treatment was not completed as ordered and that infection control practices were not properly implemented. Facility policies required consistent treatment protocols and individualized care, which were not followed in this instance.
Failure to Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care as ordered for two residents who required such services. One resident, admitted with diagnoses including hypertension, pancreatic disorder, and a colostomy, had physician orders for colostomy care to be provided once per shift. Review of the Treatment Administration Records (TAR) showed that colostomy care was documented as completed on only 18 of 35 opportunities in February, 53 of 62 in March, and 24 of 30 in April. The resident's care plan also specified that the ostomy appliance should be changed as ordered. Another resident, admitted with diagnoses including cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy, had orders for ostomy care every shift. The TAR for April indicated that ostomy care was provided on 28 of 30 opportunities. Both residents were assessed as cognitively intact for daily decision-making. During an interview, the Assistant Director of Nursing confirmed that ostomy care was not completed as ordered for these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by seven errors out of 26 observed medication administration opportunities, resulting in an error rate of 26.9%. For one resident with chronic atrial fibrillation, cerebrovascular disease, hypertension, congestive heart failure, and diabetes mellitus, a registered nurse administered prescribed morning medications outside the required timeframe. The nurse acknowledged administering the medications late, citing unfamiliarity with the hallway and being behind schedule. For another resident with dementia, diabetes mellitus, hypertension, anxiety disorder, and major depressive disorder, an LPN prepared and initially administered incorrect dosages of buspar and Effexor, and provided enteric coated aspirin instead of the ordered chewable form. The LPN confirmed the errors after being questioned and corrected the dosages, and later obtained the correct form of aspirin from the supply cabinet. Facility policy required medications to be administered as ordered and within a specific timeframe, which was not followed in these instances.
Inadequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for two residents, leading to the development of pressure ulcers. Resident #13, who was admitted with diagnoses including hyperlipidemia, hypertension, and altered mental status, was identified as being at moderate risk for developing pressure ulcers. Despite this, the resident's care plan did not adequately address the risk, and the resident developed a Stage II pressure ulcer on the coccyx. The facility's records showed insufficient documentation of incontinence care, which was not provided every two hours as required, contributing to the skin breakdown. Similarly, Resident #22, admitted with rheumatoid arthritis, muscle weakness, and altered mental status, was also at risk for skin integrity issues due to impaired mobility and incontinence. The resident's care plan included interventions for turning and repositioning, but these were not consistently implemented. The resident developed a Stage II pressure ulcer on the right buttock, and there was a lack of documentation regarding the care provided and the condition of the ulcer. The facility's failure to provide adequate incontinence care and pressure-relieving devices, as ordered, contributed to the development of the pressure ulcer. Interviews with staff revealed concerns about inadequate staffing levels, which impacted the ability to provide necessary care, including regular incontinence checks and repositioning. Observations confirmed that the required pressure-relieving mattresses were not in place for both residents, further indicating a lack of adherence to physician orders and facility policies. The facility's policies on incontinence management and pressure injury risk assessment were not effectively implemented, leading to the deficiencies noted in the report.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and served in a sanitary manner, potentially affecting all 33 residents who receive food from the facility. During an initial tour of the kitchen, expired and undated food items were found in both the walk-in and standing refrigerators, as well as in the dry storage area. Specifically, expired cream, Dijon mustard, and chili powder were noted, along with undated leftovers, coleslaw, fruit, salad, and dessert. Additionally, the dishwasher was unable to reach the required rinse temperature of 180 degrees, which was confirmed by the Dietary Supervisor, who noted this was the first occurrence of such an issue. Further observations revealed improper hand hygiene practices by a staff member during food preparation. The staff member was observed changing gloves multiple times without washing hands in between, which was confirmed during an interview. The facility's policies on food safety and hand washing, dated 2021, were reviewed and indicated that food should be stored to prevent contamination and that hands should be washed to prevent cross-contamination during food preparation. These policies were not adhered to, leading to the identified deficiencies.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations and interviews. The floors, walls, air vents, and rooms were not properly maintained, leading to unsanitary conditions. Specific issues included discolored and dirty tile and grout around toilets, rusty air vents, torn walls, and sticky floors. Additionally, Resident #32's room was found to be particularly unkempt, with soiled bedding, cluttered window sills, and multiple meal trays left in the room. Flies were observed in the room, and staff confirmed the presence of flies and the sticky condition of the floors. Interviews with staff revealed that the facility had not had a maintenance person for over a month, and maintenance issues were not being promptly addressed. The staff also noted that the floors had been sticky for years, possibly due to excessive soap use, and that they had reported this issue previously. The facility had a quarterly contract with an exterminator, but there was no indication of treatment for flies. The lack of timely maintenance and cleaning contributed to the unsanitary conditions observed in the facility, affecting the residents' right to a safe and comfortable environment.
Inconsistent Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that Resident #186 had an order in place for advanced directives upon admission. Resident #186, who was admitted with multiple diagnoses including a displaced bimalleolar fracture, muscle weakness, and severe intellectual disabilities, did not have a documented code status in either the physical or electronic medical records. This oversight was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that an order for code status should have been established upon the resident's admission. The facility's policy on advanced directives, dated December 2016, mandates that residents be provided with information about their rights to accept or refuse medical interventions and to formulate advanced directives, which should be prominently displayed in their medical records. Additionally, the facility failed to maintain consistent documentation of Resident #7's advanced directives across different record formats. Resident #7, admitted with severe sepsis, major depressive disorder, and congestive heart failure, had conflicting code status orders in their electronic and paper medical records. The electronic health record indicated a Full Code status, while the paper chart listed a Do Not Resuscitate Comfort Care (DNR-CC) status. The DON confirmed the discrepancy and emphasized that the records should match to avoid confusion regarding the resident's care in emergencies. The facility's policy requires that information about advanced directives be clearly displayed in the medical record.
Inaccurate PASRR Documentation for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with major depressive disorder and unspecified psychosis. The medical record review, staff interview, and facility policy review revealed that the PASRR documentation for the resident, dated 05/24/19, did not indicate these psychiatric diagnoses in section D, which is meant for serious mental disorders. The resident's care plan included plans for depression and psychosis, and the Minimum Data Set (MDS) indicated active diagnoses of depression and psychotic disorder, along with the administration of antidepressant medication. The Director of Nursing confirmed that the PASRR documentation did not reflect the resident's psychiatric diagnoses and that a resident review had not been completed in light of these diagnoses. The facility's policy, updated in January 2023, stated that if a resident was admitted with a negative level I PASRR result and later showed evidence of a serious mental illness, a resident review should be conducted. This policy was not followed, leading to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for residents to address their specific diagnoses, medications, and activities of daily living (ADLs). This deficiency affected three residents. Resident #5, who was admitted with diagnoses including dementia, major depressive disorder, hallucinations, insomnia, and diabetes mellitus, did not have a comprehensive care plan addressing these conditions or the use of psychotropic medications and insulin. The facility's Registered Nurse confirmed the care plans were incomplete and noted that the care planning process was being managed by an off-site MDS nurse and the facility's nurse managers. Resident #4, admitted with cerebral infarction, atherosclerotic heart disease, hypertension, and hyperlipidemia, lacked care plans for anticoagulation medications and the associated risk of bruising and bleeding. The Director of Nursing verified the absence of these care plans. Additionally, Resident #33, with diagnoses including dementia, hypothyroidism, anxiety disorder, and insomnia, did not have a care plan for ADLs despite requiring various levels of assistance. The Director of Nursing confirmed the lack of an ADL care plan. The facility's policy required individualized comprehensive care plans to be developed within seven days of the MDS assessment, but this was not adhered to.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for Resident #32, who was dependent on staff for bathing, shaving, and oral care. The resident, who had multiple diagnoses including dementia, Alzheimer's disease, and muscle weakness, required substantial to maximum assistance for personal hygiene tasks. Despite a care plan indicating the need for total assistance with bathing, the resident did not consistently receive showers or bed baths as scheduled, with gaps of up to ten days between showers. Observations and interviews revealed that Resident #32 was often left unshaven and without proper oral care supplies. The resident was found in a state of undress and with wet clothing, indicating a lack of assistance with toileting. Staff interviews confirmed that the resident's personal hygiene supplies were stored out of reach, and there was no consistent follow-up after the resident refused showers. The facility's Director of Nursing acknowledged the lack of a clear policy on handling shower refusals and confirmed the lapses in providing scheduled showers. The facility's bathing policy allowed residents to choose the frequency and timing of their baths, but it did not specify procedures for handling refusals or ensuring consistent care. This lack of guidance contributed to the failure to provide necessary assistance to Resident #32, resulting in inadequate personal hygiene care over an extended period.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to ensure that activities were available for resident participation, specifically affecting one resident. This resident had a medical history that included mild protein calorie malnutrition, anxiety, and alcohol dependence, among other conditions. The resident's care plan indicated a need for participation in activities three to five times weekly, including music, group activities, and religious services. However, a review of the activity participation calendar for October and November 2024 showed that the resident did not meet this requirement, participating in only a few activities such as arts and crafts, religious services, and special events. The resident was often observed in her room with no activities or entertainment, such as music or television, indicating a lack of engagement in planned activities. Interviews with the resident's family and facility staff revealed further issues. The family member noted that the resident had poor vision and rarely participated in activities, while the Activity Director mentioned staffing challenges since the onset of COVID-19, which affected the ability to conduct activities. The Activity Director also noted that she was the only activity staff member and was sometimes pulled to work in other areas, leading to scheduled activities not being completed. The facility's policy required daily activities, including weekends, but the lack of adequate staffing and resources resulted in the resident not receiving the necessary engagement as outlined in her care plan.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement skin prevention interventions for a resident with a known pressure ulcer as per the plan of care. The resident, who was admitted with an unstageable pressure ulcer and other medical conditions such as reduced mobility and dementia, was identified as having two Stage II pressure ulcers and two deep tissue injuries. Despite having physician's orders to apply Prevalon boots to her feet to alleviate pressure and promote healing, observations on two consecutive days revealed that the resident's heels were not offloaded, and the Prevalon boots were not in place as ordered. An LPN confirmed that the resident did not have the Prevalon boots on and acknowledged that the resident was supposed to have them to help alleviate pressure off her heels. The LPN admitted that the resident did not like to wear the boots and would kick them off, and that the boots were not found in the resident's room. Despite this, the treatment administration record was signed off to reflect that the boots were being used as ordered. The LPN retrieved a pair of Prevalon boots from the storage closet and applied them to the resident after obtaining her consent.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for residents at risk for falls, affecting three residents. Resident #5, who had a history of mild dementia and required assistance with transfers, was found on the floor without non-skid footwear, which was part of her care plan. Despite the intervention being communicated to staff, observations revealed that the resident was not wearing non-skid socks on multiple occasions, and staff were unaware of the resident's fall risk status. Resident #28, with a history of a femur fracture and impaired mobility, was also not provided with the necessary fall prevention measures. Observations showed that the resident did not have fall mats at her bedside, was not wearing non-skid socks, and lacked a sign to remind her to call for assistance, all of which were part of her care plan. The LPN confirmed the absence of these interventions and was unaware of the requirement for fall mats. Resident #11, who had a history of falls and was at risk due to multiple fractures and dementia, was observed without the required Dycem under her wheelchair cushion. Although Dycem was found between the lift pad and the cushion, it was not placed as ordered. The LPN verified the absence of Dycem under the cushion, indicating a failure to adhere to the prescribed fall prevention measures.
Inadequate Pain Management After Resident Fall
Penalty
Summary
The facility failed to adequately assess, monitor, and manage the pain of a resident, identified as Resident #33, following a fall. Resident #33, who had diagnoses including dementia and anxiety disorder, was admitted to the facility with no initial reports of pain. However, after a fall on October 21, 2024, where she hit her head, Resident #33 began to exhibit signs of pain, particularly in her right hip. Despite these complaints, the facility did not have a comprehensive care plan related to pain management for her, and there was a lack of documentation regarding pain assessments or the effectiveness of administered pain medication. On October 22, 2024, Resident #33 underwent a mobile x-ray due to complaints of pain with movement, but the results showed no acute skeletal injuries. Despite this, the resident continued to express pain, particularly during movement, and was noted to be screaming in pain during transfers and when touched on her hip. The facility's staff, including LPNs and STNAs, observed these behaviors but did not consistently administer pain medication or document the resident's pain levels and responses to medication. The situation escalated when Resident #33 was sent to the emergency room on October 24, 2024, due to excruciating pain in her right hip. A CT scan at the hospital revealed a fracture in the right femur and a sacral fracture, which had not been identified by the initial in-house x-rays. Interviews with facility staff, including the Director of Nursing, confirmed that there was a failure to administer pain medication promptly and to document pain assessments and interventions effectively, leading to inadequate pain management for Resident #33.
Failure to Conduct AIMS Assessments for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct Abnormal Involuntary Movement Scale (AIMS) assessments for a resident receiving antipsychotic medication, which is necessary to monitor for side effects associated with such medication use. This deficiency was identified during a review of the medical records of a resident who was prescribed Seroquel for hallucinations. The resident's medical record lacked evidence of any AIMS assessment being completed since the initiation of the antipsychotic medication, which is crucial for establishing a baseline and monitoring for any development or worsening of abnormal involuntary movements. The Director of Nursing (DON) confirmed that residents on antipsychotic medications should have AIMS assessments conducted to monitor for side effects like extrapyramidal symptoms or tardive dyskinesia. The DON stated that these assessments should be performed upon initiation of the medication, then at 30, 60, and 90 days, and subsequently on a quarterly basis or after any dosage change. The absence of these assessments for the resident in question indicates a failure to adhere to these monitoring protocols.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of all residents, particularly in the Memory Lane secure unit. Observations and interviews revealed that there was only one State Tested Nursing Assistant (STNA) available to care for ten residents on the unit, as the nurse was administering medication in the connected assisted living area. This left the STNA responsible for providing morning care, assisting residents with activities of daily living, and serving breakfast without additional support. The situation was exacerbated by the fact that some residents were identified as fall risks and required two-person assistance, yet were left unattended in the dining room. Interviews with staff indicated that there was a lack of communication and coordination regarding staffing coverage when the nurse was away from the secure unit. An aide from the first floor was supposed to assist on the second floor during these times, but this did not consistently occur due to the busy morning schedule on the first floor. The Director of Nursing and the Administrator acknowledged the staffing challenges and the need for additional staff to ensure adequate coverage, especially during shift changes and when the nurse was occupied with duties in the assisted living area. The facility's assessment, updated in July 2024, outlined the staffing requirements based on the resident population and their needs. However, the report highlighted that the facility did not meet these staffing levels, particularly during night shifts and when agency aides called off. The deficiency was noted as part of a complaint investigation, indicating non-compliance with the required staffing standards to ensure resident safety and care.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, affecting 25 out of 33 residents. Observations in the second-floor Memory Care Unit revealed missing toilet paper holders in several rooms, paint damage on door frames, missing air conditioner covers, drywall damage, and a mouse trap under a heating unit. Interviews with maintenance staff and nursing personnel confirmed these issues, with maintenance acknowledging the presence of a mouse trap and the need for repairs. On the first floor, the surveyors observed coffee spills, dirty and cracked linoleum, damaged wallpaper, and clogged sinks. The hallway had a noticeable urine odor, and several door frames and thresholds were damaged, posing potential tripping hazards. Maintenance staff confirmed the flooring issues and explained that the sink clog was due to a plumbing issue originating from the second floor. The Director of Nursing verified the observations of soiled floors, damaged paint, and standing water.
Deficiencies in Discharge Process for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge procedures for two residents, leading to deficiencies in the discharge process. Resident #36, who had multiple medical conditions including dementia and hypertension, was discharged to another nursing facility without a proper discharge plan or necessary documentation. The resident's daughter, who was also the power of attorney, insisted on transferring her mother against medical advice (AMA) due to communication issues with the facility. The facility staff did not provide the receiving facility with the required Minimum Data Set (MDS) assessment or transfer level of care documentation, and there was no evidence of a discharge plan of care or social service notes in the resident's medical record. Similarly, Resident #34, who had a history of chronic systolic congestive heart failure and other serious health conditions, was transferred to another nursing facility without a complete discharge order or necessary documentation. The receiving facility did not receive the required transfer level of care documentation, and there were no social service notes or discharge plan of care in the resident's medical record. The facility's staff, including the Admissions/Social Services Staff and the Business Office Manager, were unable to provide the necessary documentation due to a lack of knowledge and communication. Interviews with facility staff revealed a lack of understanding and communication regarding the discharge process, contributing to the deficiencies. The Admissions/Social Services Staff admitted to not knowing how to complete a transfer level of care and failed to document the pending discharges in the residents' medical records. The Director of Nursing confirmed that the facility did not have the necessary discharge information for both residents, highlighting a systemic issue in the facility's discharge process.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure a discharge summary, including a recapitulation of the resident's stay, was completed for three residents. Resident #36, who had multiple diagnoses including dementia and hypertension, was discharged to another nursing facility without a discharge summary or plan of care. The resident's medical record lacked a Discharge Planning form, and the discharge was marked as Against Medical Advice (AMA) without proper documentation. Interviews with staff confirmed the absence of necessary discharge documentation. Similarly, Resident #34, with a history of chronic heart failure and diabetes, was discharged without a discharge order or a comprehensive discharge summary. The medical record only included minimal information, such as vital signs and the resident's condition, but lacked a discharge plan of care. Resident #35, who had conditions like COPD and dementia, was transferred to another facility after a fall and subsequent emergency room visit. The record did not contain a physician discharge recapitulation. Interviews with the DON confirmed the lack of interdisciplinary or physician discharge summaries for these residents.
Failure to Administer Medications and Monitor Residents with Edema
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with edema and congestive heart failure. Resident #21, who was admitted with multiple diagnoses including congestive heart failure and edema, did not receive the prescribed Lasix medication on a specific date, and there was no documentation of Neosporin application for skin lesions as ordered. Additionally, the resident was observed without the prescribed TED hose and Kerlix dressing, which were part of the treatment plan for edema and skin lesions. The Director of Nursing confirmed these lapses in care and documentation. Resident #32, also diagnosed with congestive heart failure, did not have daily weights or intake and output measurements recorded as ordered by the physician. These assessments are crucial for monitoring the resident's condition, yet there was no evidence of compliance on specific dates. The Director of Nursing verified that these essential monitoring tasks were not completed as required. These deficiencies were identified during a complaint investigation and were noted as continued non-compliance from a previous survey.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide comprehensive pressure ulcer care timely and as ordered for two residents. Resident #26, admitted with multiple diagnoses including metabolic encephalopathy and severe protein calorie malnutrition, had a Stage 1 pressure ulcer on the coccyx. The physician ordered daily cleansing and dressing of the ulcer, along with skin prep for the heels to prevent breakdown. However, the Treatment Administration Record (TAR) showed that the treatment scheduled for 08/25/24 was not completed. Interviews with the resident and RN confirmed the lapse in care, and the facility's policy on pressure injury treatment was not adhered to. Resident #14, with a history of a fractured right femur, type 2 diabetes, and an unstageable pressure ulcer, also did not receive the ordered treatment for a right heel pressure ulcer. The physician's orders included cleansing and applying specific dressings daily, but the TAR indicated the treatment was not completed as ordered on 08/25/24. Interviews with the resident and the Director of Nursing verified the non-compliance with the treatment orders. This deficiency was part of a continued non-compliance issue from a previous survey.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplements to residents with identified nutritional needs, affecting two residents. Resident #26, admitted with multiple diagnoses including severe protein-calorie malnutrition, was recommended to receive Healthshakes twice a day and weekly weights. However, the resident did not receive the supplements as there were no physician orders for them, and the Director of Nursing (DON) had not communicated the dietician's recommendations to the physician. Additionally, the resident's Medication Administration Record (MAR) showed that the Healthshake was not provided as ordered. Resident #32, with a history of severe sepsis, malnutrition, and other health issues, had a physician order for a Health Shake between breakfast and lunch. However, the Treatment Administration Record (TAR) indicated that the supplement was not provided on a specific date. The DON confirmed that the health shake was not administered as ordered. This deficiency was part of a continued non-compliance issue from a previous survey.
Improper Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for a resident with multiple diagnoses, including COPD and Alzheimer's disease. The resident had a physician's order for Albuterol nebulizer treatment every six hours as needed, with instructions to change the nebulizer set weekly and as needed for soiling. However, observations revealed that the nebulizer machine and mask were left on a heater in the dining room, with the mask not stored in a sanitary bag. The mask was dated over a week prior and had not been changed as per the treatment order. Interviews with staff confirmed the improper storage and maintenance of the nebulizer equipment. The treatment sheet showed that the nebulizer set was not signed off as changed on two specified dates. The facility's policy required cleaning and proper storage of nebulizer equipment, which was not adhered to in this case. This deficiency was identified during an investigation under a specific complaint number.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in a 7.69 percent error rate during a medication administration observation. This deficiency was identified when a Licensed Practical Nurse (LPN) administered medications to a resident with chronic obstructive pulmonary disease (COPD). The LPN did not adhere to the manufacturer's guidelines and the facility's policy regarding the administration of metered-dose inhalers. Specifically, the LPN failed to wait the required one minute between puffs of the inhalers, as instructed by both the Ventolin and Combivent manufacturer guidelines and the facility's policy. During the observation, the LPN administered two respiratory medications to the resident. The first medication, Ventolin HFA Aerosol Solution, was given without the required one-minute interval between puffs. Similarly, the second medication, Combivent Respimat Inhalation Aerosol Solution, was also administered without the necessary waiting period. The LPN acknowledged during an interview that she was unaware of the need to wait one minute between puffs, although she knew to wait ten minutes between different types of inhalers. This oversight contributed to the facility's non-compliance with the medication error rate standard.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered for three residents, affecting their medical management. Resident #19, admitted with multiple diagnoses including Alzheimer's disease and COPD, had physician orders for various lab tests every three months and every six months. However, there was no evidence of a baseline Hemoglobin A1C and Lipid Level, and the last set of tests was drawn in May 2024, with no tests conducted in August 2024 as required. The Director of Nursing (DON) confirmed that the laboratory tests were not completed as ordered. Similarly, Resident #21, with a complex medical history including dementia and acute kidney failure, had physician orders for regular lab tests every three and six months. The medical record showed no evidence that these tests were completed as ordered. The DON verified the omission of these tests. Additionally, Resident #3, with a history of hemophilia and type 2 diabetes, had orders for specific lab tests every six months, but there was no evidence of Lipid testing since admission. The DON confirmed the lack of laboratory testing for Lipids for this resident. This deficiency was investigated under Complaint Number OH00156671.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodsfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Woodsfield | 1.7 mi | — | 0 | 0 |
| The Enclave At Barnesville | 14.7 mi | — | 0 | 0 |
| Emerald Pointe Health And Rehab Ctr | 14.9 mi | — | 1 | 0 |
| Sistersville Center | 15.8 mi | — | 0 | 0 |
| New Martinsville Health & Rehab | 16 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Stellar Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.