Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aventura At Carriage Inn during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate when an LPN gave one resident only one senna tablet instead of two and could not administer magnesium hydroxide because it was unavailable. For another resident, ordered brimonidine tartrate eye drops and artificial tears were not available, and dorzolamide HCL-timolol eye drops were given to both eyes instead of the left eye only. The facility had a 15% medication error rate based on 5 errors in 33 opportunities.
A resident with dementia and other comorbidities, who was cognitively impaired and totally dependent on staff for care, fell from bed during incontinence care when a CNA rolled the resident away instead of toward herself, despite both side rails being raised. The resident was found on the floor beside the bed and sustained multiple bruises, abrasions, and a skin tear, though imaging showed no fractures. Facility records and a clinical resource indicated that proper turning technique requires moving and turning the patient toward the caregiver, which was not followed in this incident.
Nine residents did not receive coleslaw with their lunch meal when the kitchen ran out, and no substitutions were provided, despite facility policy requiring substitutions when menu items are unavailable. The Dietary Manager confirmed the omission and lack of substitution.
A resident with multiple serious medical conditions experienced significant rectal bleeding and was transferred to the hospital. Although the physician was notified, there was no documentation that the resident's representative was informed of this change in condition. The DON confirmed the absence of notification and stated the facility only had a policy for physician notification.
A resident with multiple complex medical conditions was admitted with a surgical wound, but staff failed to document measurements or provide a description of the wound as required by facility policy. An LPN confirmed that no such documentation was present during the resident's stay, despite policy requirements for detailed wound assessment and recording.
A resident with multiple comorbidities did not receive wound care as ordered for an arterial ulcer on the right foot, and comprehensive assessment of a surgical wound following amputation was not completed. Documentation was lacking for both the administration of wound care and the assessment of the surgical site, as confirmed by facility leadership.
Two residents experienced significant medication errors when staff failed to follow prescriber orders for antibiotic and anticoagulant administration. One resident received an antibiotic at the wrong frequency, while another was given an anticoagulant that should have been held and did not receive a prescribed antibiotic as ordered. These errors were confirmed through record review and staff interview.
A resident with multiple medical conditions was prescribed IV Vancomycin with orders to obtain Vancomycin levels weekly. The facility began administering the antibiotic but did not obtain the required Vancomycin level until several days after starting treatment, despite pharmacy recommendations and standing orders. This delay in laboratory monitoring was confirmed by both the pharmacist and the administrator during the investigation.
Surveyors found that kitchen equipment and food storage areas were not maintained in a clean and sanitary manner, including wet stacked containers, dirty knives, food debris on equipment, buildup of debris in steam table wells, ice accumulation in the freezer, and rust, leaks, and stagnant water in the cooler. These deficiencies were confirmed by the Dietary Manager and had the potential to affect all residents consuming food by mouth.
Four residents with physician orders for pureed diets received pureed foods prepared with water as a thinning agent, contrary to facility policy, which requires the use of more nutritious liquids such as juices, broths, or milk. A staff member confirmed using water during food preparation, resulting in pureed foods that did not conserve nutritive value, flavor, or appearance.
Staff did not consistently wear required PPE, such as gowns, when providing care to residents on enhanced barrier precautions, including those with tracheostomies, gastrostomies, and stage three pressure ulcers. Additionally, proper hand hygiene was not performed between medication administration for different residents and after wound care, despite facility policies outlining these requirements. Staff interviews confirmed knowledge of the protocols but acknowledged lapses in compliance.
A resident with multiple medical conditions was left with an albuterol nebulizer treatment in their room by an LPN, despite not having a physician's order to self-administer medications. Facility policy required such an order and interdisciplinary team approval, which were not obtained.
A resident with multiple diagnoses had a physician order for Diltiazem to be withheld if systolic blood pressure was below 110. An LPN withheld the medication when the resident's blood pressure was 104/66 and disposed of the dose, but later signed the MAR as if the medication had been given, without documenting a blood pressure recheck. The DON confirmed the discrepancy and lack of required documentation.
A facility failed to follow its policy for checking the placement of a resident's G-tube before administering medication. A resident with severe cognitive impairment and dysphagia, dependent on a feeding tube for nutrition, had medication administered by an RN who used water to check tube placement, contrary to the facility's policy. The policy required checking the pH of the aspirate to confirm placement, which was not done, potentially risking harm.
The facility reported a medication error rate of 7.89%, exceeding the acceptable threshold. Errors included incorrect aspirin and vitamin B12 administration to one resident and an overdose of levetiracetam to another. Staff failed to adhere to medication administration protocols, leading to these errors.
A resident with severe cognitive impairment was found with unauthorized medications at their bedside, including saline nasal spray, Dulcolax, and digestive aids, which were not prescribed. Despite multiple observations, staff failed to remove the medications, indicating a lapse in adherence to medication management protocols. Interviews with a CNA and an LPN revealed a lack of awareness and action, while the DON confirmed the resident's inability to self-administer medications.
An LPN was observed handling medications with bare hands during administration, contrary to infection control policies. This was witnessed by an RN who did not intervene. Interviews revealed a lack of training and adherence to the facility's policy, which prohibits touching medications with bare hands.
A facility failed to notify a resident's representative about a new Stage III pressure ulcer and treatment plan, despite the resident having severe cognitive impairment and multiple medical conditions. The facility's policy requires prompt notification of changes in a resident's condition, but documentation confirming this notification was absent.
A facility failed to follow infection control procedures for a resident with a Stage III pressure ulcer. Despite having a physician's order for wound treatment, Enhanced Barrier Precautions (EBP) were not documented or implemented. Staff interviews and observations confirmed that gowns were not worn during wound care, contrary to the facility's policy requiring gloves and gowns to prevent the transfer of multi-drug resistant organisms.
A facility failed to develop a baseline care plan for a newly admitted resident with multiple diagnoses, including osteoarthritis and diabetes. The lack of documentation was confirmed by the DON during a complaint investigation, affecting one of three new admissions reviewed.
A resident with severe cognitive impairment and multiple diagnoses, including major depressive disorder, expressed suicidal ideation and was placed on one-on-one supervision. Despite this, the facility failed to update the resident's care plan to address suicide risk. The resident was later found with a call light wrapped around his neck, leading to emergency hospitalization for psychiatric evaluation.
A facility failed to document urinary catheter care for a resident with an indwelling catheter. Despite the facility's policy requiring documentation of catheter care every shift, the resident's medical record showed no such documentation from admission to discharge. The DON and a regional nurse confirmed this oversight during an interview.
A facility failed to monitor a resident's blood glucose level before administering insulin, as required by their policy. The resident, with type two diabetes mellitus, received insulin glargine on two occasions without prior glucose checks. This oversight was confirmed by the DON and a Regional Nurse, who acknowledged the necessity of monitoring, especially since it was the resident's first insulin administration at the facility.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in five medication errors out of 33 opportunities for a 15% error rate. The deficiency involved two residents, both of whom had moderate cognitive impairment and required varying levels of staff assistance with activities of daily living. The report states that the facility census was 65 and that the issue was investigated under Complaint Number 2998003. For one resident with diagnoses including COPD, morbid obesity, CHF, constipation, and chronic kidney disease stage III, the medication administration observation showed that an LPN prepared morning medications and placed one senna tablet into the medication cup even though the order was for two tablets. The same observation showed magnesium hydroxide oral suspension was not available for administration. During interview, the LPN confirmed that only one senna tablet had been given and that the magnesium hydroxide could not be administered because it was not available and had to be ordered from the pharmacy. For the second resident with diagnoses including CHF, COPD, atrial fibrillation, hypertension, bilateral hypertensive retinopathy, and glaucoma, the observation showed an LPN prepared ordered oral medications and potassium chloride solution, but could not locate brimonidine tartrate ophthalmic solution or artificial tears in the medication cart or storage room. The LPN administered dorzolamide HCL-timolol ophthalmic solution to both eyes even though the order was for the left eye only. The LPN confirmed that the eye drops and artificial tears were not administered because they were not available and that the dorzolamide HCL-timolol drops were given to both eyes instead of the left eye as ordered.
Failure to Safely Position Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate safety interventions to prevent an avoidable fall by not ensuring a resident was safely positioned in bed during incontinence care. The resident had dementia, hypertension, and kidney disease, was cognitively impaired, and required total dependence on one staff member for care, according to the MDS. During incontinence care, the CNA providing care rolled the resident away from herself instead of toward herself, contrary to standards of practice and clinical guidance. At the time of the incident, both side rails were raised, and the resident was later found on the floor beside the bed in a fetal position. As a result of the fall from the bed, the resident sustained multiple bruises and skin injuries, including a bruise below the right eye, abrasions to the left arm and middle of the back, a bruise on the left forearm, a skin tear on the right forearm, and an abrasion to the right elbow. X-rays obtained after the fall revealed no fractures. The facility’s investigation determined that the staff did not follow standards of practice when the CNA turned the resident away from herself during care. A referenced clinical resource from MedlinePlus describes proper technique for turning a person in bed, including moving the patient toward the caregiver and turning the person in the direction of the caregiver, which was not followed in this case.
Failure to Provide Menu Item and Substitution During Meal Service
Penalty
Summary
The facility failed to serve food according to the planned menu, as nine residents did not receive coleslaw with their lunch meal. The facility menu for the specified lunch included baked pork chop, baked beans, creamy coleslaw, cornbread, and whipped jello parfait. During observation of the lunch service, it was noted that the kitchen ran out of coleslaw, resulting in these residents not receiving the item on their trays. The Dietary Manager confirmed that the coleslaw was unavailable and that no substitutions were provided for the affected residents. Review of the facility's policy indicated that substitutions should be made when menu items are not available, but this was not followed in this instance.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's representative of a significant change in the resident's condition. The resident, who had diagnoses including right femur fracture, COPD, dementia, chronic kidney disease Stage IV, and pneumonitis, was admitted with severely impaired cognition and was dependent on staff for most activities of daily living. On the date in question, nursing documentation indicated the resident experienced a copious amount of rectal bleeding, and the on-call physician was notified, but no new orders were given. Despite this significant change in condition and subsequent transfer to the hospital for rectal bleeding, there was no documentation in the medical record to show that the resident's representative was informed of the event. The Director of Nursing confirmed during interview that there was no evidence of such notification and stated that the facility only had a policy for notifying physicians of changes in condition, not resident representatives.
Failure to Document and Assess Surgical Wound per Facility Policy
Penalty
Summary
The facility failed to properly assess and document a surgical wound for a resident with multiple medical diagnoses, including a right femur fracture, chronic obstructive pulmonary disease, dementia, chronic kidney disease Stage IV, and pneumonitis. Upon admission, the resident was noted to have a surgical site on the right hip with 29 staples, but the initial assessment did not include measurements or a detailed description of the wound. Subsequent weekly skin observations also lacked documentation regarding the surgical site, its measurements, or a description of the wound. An LPN confirmed that during the resident's stay, there was no documentation of the surgical wound's measurements or description in the medical record. The facility's wound care policy required documentation of wound type, assessment data (including size and wound bed color), and other relevant information, but these requirements were not met for this resident. This deficiency was identified during a review of the medical record, staff interviews, and policy review, and was investigated under specific complaint numbers.
Failure to Provide Ordered Wound Care and Comprehensive Wound Assessment
Penalty
Summary
The facility failed to provide wound care as ordered for an arterial ulcer on a resident's right foot and did not complete a comprehensive wound assessment for a surgical wound on the same resident. Medical record review showed that the resident, who had diagnoses including COPD, diabetes mellitus, and peripheral vascular disease, was admitted with an arterial ulcer on the right foot second digit. Orders were in place for daily and as-needed application of barrier spray/wipes, but documentation on the Treatment Administration Record did not support that these treatments were completed as ordered. The wound physician's note and physician orders specified the required care, but the order was incorrectly entered into the electronic health record as 'as needed' only, rather than 'daily and as needed.' The resident later complained of the toe being dead, was hospitalized, and subsequently underwent amputation procedures. Further review of the medical record after the resident's return from the hospital revealed incomplete documentation regarding the surgical wound. Admission and weekly skin assessments noted the presence of amputated toes but did not include measurements or descriptions of the surgical site. Interviews with the Administrator and DON confirmed the lack of documentation for both the wound care provided and the assessment of the surgical wound, which was not in accordance with the facility's wound care policy that requires detailed recording of wound care and assessments.
Significant Medication Administration Errors Identified
Penalty
Summary
Facility staff failed to administer medications as ordered for two residents, resulting in significant medication errors. For one resident with a history of infection and inflammation of a hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension, hospital discharge orders specified Levaquin 750 mg once daily by mouth. However, the medication was administered twice daily over a four-day period, contrary to the prescriber's instructions. This discrepancy was confirmed through medical record review and staff interview. Another resident, admitted with nontraumatic subarachnoid hemorrhage, atrial fibrillation, and COPD, had hospital discharge orders to hold Eliquis 5 mg until a specified date and to administer cefuroxime 500 mg twice daily for three days. Despite these orders, Eliquis was administered on days it should have been held, and cefuroxime was not signed off as administered. These findings were corroborated by review of the medication administration records and confirmed in an interview with the Administrator. The facility's policy requires medications to be administered according to prescriber orders, including timing, which was not followed in these cases.
Failure to Obtain Timely Vancomycin Levels as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered for a resident with multiple complex diagnoses, including infection and inflammation of an internal hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension. Upon return from the hospital, the resident had discharge orders for intravenous Vancomycin every 12 hours and for Vancomycin levels to be obtained every Monday. The medical record showed that the first dose of Vancomycin was administered on 04/06/25 at 8:00 P.M., but the required Vancomycin level was not obtained until 04/14/25, despite the standing order and pharmacy recommendations to obtain a pre-dose level prior to the fourth dose. Interviews with the facility pharmacist and administrator confirmed that Vancomycin levels should have been drawn prior to the fourth dose for safe dosing and that the pharmacy had communicated this requirement to the facility. The administrator also confirmed that the Vancomycin level was not obtained as ordered, resulting in a delay in laboratory monitoring for the resident. This deficiency was identified during a complaint investigation and affected one of three residents reviewed.
Failure to Maintain Kitchen Equipment and Food Storage Areas in Sanitary Condition
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the cleanliness and maintenance of equipment and food storage areas. Plastic containers were found stacked while wet on the clean dish rack, preventing proper drying. The knife storage rack contained two knives with missing metal chips and three knives with visible residue. A metal plate warmer with food debris was stored on the clean dish drying rack, and the can opener attached to the prep table had dried food debris on its blade. The steam table wells also had a buildup of debris at the bottom. Further observations revealed environmental issues in the food storage areas. The walk-in freezer had a buildup of ice on the vinyl strip curtains and floor. The walk-in cooler had rusted metal floors and walls, with the flooring separating. The condenser in the cooler was leaking, with a bucket placed below it containing gray stagnant water and additional water on the floor. These conditions were verified by the Dietary Manager during interviews and had the potential to affect all residents who consumed food by mouth, with the exception of three residents who did not consume food orally.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to prepare pureed foods in a manner that conserved nutritive value, flavor, and appearance for four residents who had physician orders for pureed diets. On the specified date, the lunch menu included items such as beef burgundy, vegetable rice pilaf, green peas, mandarin oranges, dinner roll, and chocolate chip cookie, with beef stew substituted for beef burgundy. Observation revealed that a staff member prepared pureed peas and beef stew by adding water and thickener to the food processor, rather than using fruit or vegetable juices, meat broths, or milk as required by the facility's policy. The staff member confirmed using water as a thinning agent. Review of the facility's policy indicated that water should not be used for thinning pureed foods, and instead, more nutritious liquids should be used.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to don appropriate personal protective equipment (PPE), specifically gowns, when providing care to residents on enhanced barrier precautions (EBP). For one resident with cerebral atherosclerosis, tracheostomy, and gastrostomy, an LPN provided care without wearing a gown despite an active EBP order. In another instance, wound care was performed for two residents with stage three pressure ulcers and other significant diagnoses, but staff did not don gowns as required by EBP signage and orders. Staff interviews confirmed awareness of the EBP requirements but acknowledged non-compliance during care activities. Additionally, staff did not consistently practice proper hand hygiene. An LPN failed to perform hand hygiene after administering medication to one resident and before administering medication to another. During wound care for a resident with multiple complex conditions, staff removed gloves after care but exited the room without performing hand hygiene. Facility policies reviewed indicated that hand hygiene should occur before and after resident contact, after glove removal, and that staff should consult with nursing to determine appropriate PPE for transmission-based precautions.
Medication Left Unattended Without Self-Administration Order
Penalty
Summary
The facility failed to ensure that medications were not left unattended in resident rooms, as evidenced by an incident involving a resident with diagnoses of atrial fibrillation, malignant prostate cancer, and pneumonia. The resident, who had intact cognition and required moderate staff assistance with ADLs, did not have a physician's order to self-administer medications. During observation, an LPN placed an ampule of albuterol into the resident's nebulizer and informed the resident that the medication was available for use whenever he was ready, then left the room. Review of the facility's policy confirmed that self-administration of medications was only permitted with a physician's order and interdisciplinary team determination, which was not present in this case.
Failure to Accurately Document and Administer Blood Pressure Medication per Physician Parameters
Penalty
Summary
A deficiency occurred when staff failed to administer blood pressure medication according to physician-ordered parameters for a resident with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia. The physician's order specified that Diltiazem 120 mg should be withheld if the resident's systolic blood pressure was less than 110. During observation, an LPN withheld the medication when the resident's blood pressure was 104/66 and disposed of the dose in the sharps container. However, the Medication Administration Record (MAR) for that day showed that the LPN signed off as if the Diltiazem had been administered, and there was no documentation of a blood pressure recheck. The Director of Nursing confirmed the discrepancy between the MAR and the actual administration, as well as the lack of required documentation. Facility policy required medications to be administered as ordered by the physician, which was not followed in this instance.
Failure to Follow G-Tube Placement Policy
Penalty
Summary
The facility failed to ensure that staff followed the policy for checking the placement of a resident's gastrostomy tube (G-tube) before administering medication. This deficiency was identified during an observation of medication administration for a resident with severe cognitive impairment and a diagnosis of moderate protein-calorie malnutrition and dysphagia. The resident was dependent on staff for all activities of daily living and received more than half of their total calories and fluid intake through a feeding tube. The care plan for the resident included instructions to check residuals per orders and to verify G-tube placement every shift. During the observation, a registered nurse (RN) prepared and administered medication through the resident's G-tube without properly checking the tube's placement according to the facility's policy. The RN used water to check the placement, which was against the policy that required checking the pH of the aspirate to confirm proper placement. The Director of Nursing and the Administrator both confirmed that the use of water was inappropriate and could potentially cause harm if the tube was not correctly positioned. The facility's policy outlined specific procedures for confirming tube placement, including observing gastric residual volume and checking the pH of the aspirate, which were not followed in this instance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.89% due to three medication errors out of 38 opportunities. This affected two residents during medication administration. For one resident, the LPN administered an enteric-coated aspirin instead of the prescribed chewable aspirin and gave an incorrect dosage of vitamin B12. The LPN admitted to not thoroughly checking the medication order, which led to these errors. The Director of Nursing (DON) confirmed that the medications given did not match the physician's order, constituting medication errors. Another resident received an incorrect dosage of levetiracetam, an anti-seizure medication, due to the RN misreading the medication administration record (MAR). The RN administered 10 ml instead of the prescribed 5 ml, which could potentially lead to levetiracetam toxicity. The DON emphasized the importance of administering the correct dose to the right resident, as per the facility's policy on medication administration, which requires checking the medication label three times to ensure accuracy.
Failure to Remove Unauthorized Medications from Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were not left unattended at the bedside of a resident with severe cognitive impairment. The resident, diagnosed with neurocognitive disorder with Lewy bodies and aphasia, was observed with two bottles of saline nasal spray, an opened bottle of Dulcolax, and two bottles of digestive aid on their nightstand and in the top drawer. These medications were not prescribed by a physician, and the resident was unable to recall who provided them or how to use them. Despite multiple observations over two days, the medications remained at the bedside, indicating a lapse in staff vigilance and adherence to medication management protocols. Interviews with staff, including a CNA and an LPN, revealed a lack of awareness and action regarding the unauthorized medications at the resident's bedside. The CNA stated she would report such findings to a nurse, but did not notice the medications during her visit. The LPN, responsible for the resident's care, claimed he would remove unauthorized medications and notify the DON and physician, yet failed to observe the medications during his shift. The DON confirmed that the resident was not capable of self-administering medications and emphasized the need for a physician's order and assessment for self-administration. The facility's policy required staff to report and remove unauthorized medications, which was not followed in this instance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control procedures during medication administration, affecting one of four residents observed. During a medication pass, an LPN was observed removing medications from their packaging and placing them directly into her bare hands. The medications included amlodipine, Plavix, Lexapro, Microzide, and Lopressor. This action was witnessed by an RN, who did not intervene or provide immediate education to the LPN regarding the potential contamination risk of handling medications with bare hands. Interviews conducted with the LPN, RN, Infection Preventionist, and Director of Nursing revealed a lack of adherence to the facility's infection control policy, which prohibits touching medications with bare hands. The LPN admitted to not receiving training on this aspect of medication handling, while the RN acknowledged the oversight but did not provide an explanation for her inaction. The Infection Preventionist and Director of Nursing both expressed that they expected the RN to stop the LPN and provide education on proper procedures, as outlined in the facility's policy revised in August 2024.
Failure to Notify Resident's Representative of Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative about the development of a new pressure ulcer and the corresponding treatment plan. This deficiency was identified during a review of the medical record for a resident who was admitted with multiple medical diagnoses, including cerebral atherosclerosis and chronic obstructive pulmonary disease. The resident, who had severe cognitive impairment, was assessed in a quarterly Minimum Data Set (MDS) on June 17, 2024, which indicated no pressure ulcers at that time. However, a wound observation evaluation on July 25, 2024, revealed a Stage III pressure ulcer on the resident's left heel, and although the physician was notified and a treatment was ordered, there was no documentation that the resident's representative was informed. An interview with the facility's Administrator confirmed the absence of documentation regarding the notification of the resident's representative about the pressure ulcer and treatment plan. The facility's policy, revised in May 2017, mandates prompt notification of the resident, their attending physician, and representative about changes in the resident's medical or mental condition. This deficiency was investigated under Complaint Number OH00156810, highlighting a lapse in communication as per the facility's established procedures.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control procedures for a resident with a Stage III pressure ulcer. The resident, who was cognitively intact and required supervision with certain activities, had a medical history including heart failure, diabetes, and peripheral vascular disease. Despite having a physician's order for wound treatment, there was no documentation or implementation of Enhanced Barrier Precautions (EBP) for the resident. This included the absence of a posted EBP sign and a personal protective equipment (PPE) cart near the resident's room. Interviews and observations confirmed that staff did not wear gowns during wound care, only gloves, which was against the facility's policy for EBP. The policy required the use of gloves and gowns during high-contact care activities to prevent the transfer of multi-drug resistant organisms. The deficiency was identified during a complaint investigation, revealing that the facility had not implemented EBP for residents with wounds or indwelling devices.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident, which is a requirement to address the resident's immediate needs within 48 hours of admission. The resident, who had diagnoses including osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity, was admitted on an unspecified date and discharged on 05/19/24. Upon review of the resident's closed medical record, it was found that there was no documentation of a baseline care plan being developed. This deficiency was confirmed during an interview with the Director of Nursing on 06/05/24, who acknowledged that the baseline care plan had not been completed. This issue was identified during a complaint investigation and affected one of the three new admissions reviewed, with the facility having a census of 74 residents.
Failure to Update Care Plan for Suicide Risk
Penalty
Summary
The facility failed to update a comprehensive care plan for a resident identified as being at risk for suicide. The resident, who was admitted on January 31, 2023, had multiple diagnoses including hypertensive kidney disease, major depressive disorder, bradycardia, impulsiveness, dementia, and congestive heart failure. The resident was severely cognitively impaired with a BIMS score of four out of 15. On May 9, 2024, the resident expressed thoughts of self-harm and had a plan to do so, which was communicated to a state tested nursing assistant. Following this, the resident was placed on one-on-one supervision until a psychiatric evaluation was conducted on May 10, 2024. Despite these events, the resident's comprehensive care plan did not include any focus or interventions related to suicide risk or suicidal ideation. On May 20, 2024, the resident was found with a call light wrapped around his neck after being discovered on the floor of his room, leading to an emergency hospital admission for psychiatric evaluation on May 21, 2024. The resident returned to the facility and was again placed on one-on-one supervision until another psychiatric evaluation on May 24, 2024. The Director of Nursing, Administrator, and Social Services Director confirmed that the care plan should have been updated to address the suicide risk, indicating a deficiency in the facility's care planning process.
Failure to Document Urinary Catheter Care
Penalty
Summary
The facility failed to provide urinary catheter care to a resident, which was identified during a review of medical records, staff interviews, and facility policy. The resident, who had an indwelling urinary catheter, was admitted with diagnoses including osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. The resident's medical record showed no documentation of urinary catheter care from admission to discharge. During an interview, the DON and a regional nurse confirmed the lack of documentation for catheter care, which should have been completed at least every shift. The facility's policy required documentation of catheter care, including the date, time, and caregiver's details, which was not adhered to in this case.
Failure to Monitor Blood Glucose Before Insulin Administration
Penalty
Summary
The facility failed to monitor a resident's blood glucose level before administering insulin, which is a requirement for ensuring the drug regimen is free from unnecessary drugs. The deficiency was identified during a review of medical records, staff interviews, and facility policy. Specifically, Resident #76, who had diagnoses including type two diabetes mellitus, was administered 60 units of insulin glargine on two consecutive days without prior blood glucose level checks. This oversight was confirmed by the Director of Nursing and a Regional Nurse, who acknowledged that the blood glucose levels should have been checked before insulin administration, especially since it was the first time the resident received insulin at the facility. The facility's policy on insulin administration, revised in September 2014, mandates checking blood glucose levels per physician order or facility protocol, and documenting the results. However, there was no documentation of blood glucose levels being checked before the administration of insulin to Resident #76 on the specified dates. The Medscape reference for insulin glargine emphasizes the necessity of regular blood glucose monitoring for patients receiving insulin therapy. This deficiency was investigated under Complaint Number OH00154127.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Siena Woods Care Center | 0.4 mi | ★★★★★ | 14 | 0 |
| Riverside Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 21 | 1 |
| Maria Joseph Living Care Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Stonespring Of Vandalia | 1.9 mi | ★★★★★ | 0 | 0 |
| Arc At Trotwood Llc | 2.3 mi | ★★★★★ | 15 | 0 |
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