Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Aventura At Oakwood Village during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow RD-planned breakfast menus or provide appropriate nutritional substitutions when items were unavailable. On multiple mornings, residents who were supposed to receive scrambled eggs or egg substitutes instead received only toast and bacon, and a resident on a cardiac diet was served bacon despite diet restrictions. Staff reported there were no eggs or sufficient milk available, used bacon as an assumed protein substitute, and did not reference the specialized diet spreadsheet during meal service. On another morning, mandarin oranges listed on the menu were not served to residents, and no alternative fruit was provided except applesauce for those on pureed diets, contrary to facility policy requiring documented menu substitutions.
A resident with multiple chronic conditions and intact cognition, care planned for fall risk and restful sleep, became agitated and combative during a night shift. After medication was given and the resident later transferred to bed, a CNA placed a mattress upright against one side of the bed and secured it with a locked chair, while the other side of the bed was against the wall, effectively preventing the resident from exiting the bed. Incoming CNAs observed the resident asleep with bedding and pillows arranged in a way that further restricted movement, and the DON confirmed the resident had been restrained in violation of the facility’s restraint policy.
Surveyors found that the facility exceeded the acceptable medication error rate when, during a morning med pass, an RN was unable to administer an ordered dose of Synthroid to a resident with diabetes, hypothyroidism, and hypertension because it was not available in the med cart or emergency box, and also failed to remove a scheduled dose of glipizide from the medication card until prompted by the surveyor. These two omission errors, identified during observation and confirmed in staff interviews and record review, resulted in a 7% medication error rate for 28 observed medication opportunities.
Staff failed to follow hand hygiene requirements during incontinence and wound care for two residents. A CNA caring for a fully dependent, incontinent resident with multiple chronic conditions changed soiled briefs, cleansed the perineal area, applied lotion, and assisted with dressing while repeatedly changing gloves without performing hand hygiene between glove changes. In a separate incident, an LPN performing a coccyx pressure ulcer dressing change for a dependent resident with dementia and COPD removed the old dressing, cleansed the wound, applied calcium alginate, and placed the new dressing and brief without changing gloves or performing hand hygiene until after the entire procedure was completed. These actions did not comply with the facility’s handwashing/hand hygiene policy, which requires hand hygiene before clean tasks, after contact with bodily fluids, before moving from a soiled to a clean body site, and immediately after glove removal.
A resident with severe cognitive impairment and a history of aggressive behaviors repeatedly exhibited physical and verbal aggression toward staff and another resident, who reported feeling unsafe and fearful. Despite care plans and interventions, the aggressive behavior persisted, and staff did not consistently report or document all incidents, leading to a failure to protect residents from abuse.
A resident with severe cognitive impairment and a history of aggressive behaviors verbally assaulted and physically threatened another resident, who then expressed fear for his safety. Despite ongoing incidents of aggression documented by staff and concerns raised by the affected resident, the facility did not thoroughly investigate or report the abuse allegations to the State Agency as required by policy. Staff interviews confirmed that the incident was discussed internally but not escalated or documented appropriately.
A resident with severe cognitive impairment and multiple diagnoses was identified as high risk for falls, yet required fall prevention interventions were not consistently in place. Observations showed the call light was not within reach, the bed was in a high position, and the fall mat was not correctly placed, despite the care plan specifying these measures. Staff confirmed these lapses, and the resident had a recent history of multiple falls.
Three medication administration errors were identified, resulting in an 11% error rate. Two residents received incorrect medications: one was given a discontinued drug, and another received Vitamin B6 without a specified dosage and a lower-than-ordered dose of Tylenol. LPNs involved confirmed the errors during interviews.
Multiple residents with cognitive and physical impairments did not receive required fall prevention interventions, such as perimeter mattresses, low bed positioning, and fall mats, as outlined in their care plans. Staff failed to consistently implement and document these interventions, and neurological checks were not always performed after unwitnessed falls. In one case, a resident was transferred without a mechanical lift, resulting in bilateral femur fractures.
The facility did not follow its water management policy by failing to perform required quarterly water flow rate checks and by maintaining water temperatures below the threshold needed to prevent legionella growth. Additionally, a CNA assisted a resident with a meal by handling food with bare hands, violating infection control protocols.
Multiple residents and staff reported and confirmed the presence of ants in several rooms, with ants found on personal items and living areas. Observations revealed ants on floors, beds, and tables, and ant traps were present in some rooms. The facility's pest control program was not effective in preventing or addressing the infestation.
A resident with parkinsonism and malnutrition, dependent on staff for all ADLs and with intact cognition, was fed lunch by a CNA who stood over her throughout the meal despite the resident's request for the CNA to sit. The CNA did not acknowledge the request, and a chair was available nearby but not used. This action did not align with facility policy requiring staff to treat residents with dignity.
A resident with multiple serious health conditions and severe cognitive impairment experienced significant, rapid weight loss, but the facility did not notify the resident's medical POA as required by policy. Staff confirmed that no notification was made despite substantial weight changes documented in the medical record.
A resident with significant cognitive impairment and multiple diagnoses was prescribed PRN Ativan for anxiety and dyspnea without a required 14-day stop date, in violation of facility policy. The DON confirmed the order should have been time-limited, and the facility's policy mandates PRN psychotropic medications be restricted to 14 days unless otherwise indicated.
A resident with cognitive impairment and multiple diagnoses did not receive an individualized activity care plan reflecting her interests and needs. Despite documented preferences for religious activities, baking, and music, the care plan was not updated and only included generic one-on-one interventions. The resident received minimal activity participation, was observed isolated in her room without engagement, and staff confirmed care plans were not tailored to her cognitive status.
A resident with cognitive impairment and documented preferences for specific activities was not provided with adequate one-on-one activities as outlined in her care plan. Records and staff interviews confirmed that the resident received only a few visits over two months, and observations showed she was left in her room without engagement or stimulation, contrary to facility policy and her assessed needs.
The facility did not consistently obtain and document resident weights as ordered by physicians and required by policy for two residents, including one with end stage renal disease and another with parkinsonism and malnutrition. Missed daily weights and delays in reweighing after significant weight loss were confirmed by staff and residents, with no timely follow-up by the dietitian.
Two residents did not receive multiple prescribed medications on several occasions because the medications were not available from the pharmacy. Documentation and interviews confirmed that the missed doses included critical medications for chronic conditions, and the DON verified the failures were due to pharmacy supply issues, in violation of facility policy requiring timely administration of medications as ordered.
A resident with cognitive impairment and memory deficits was allowed to sign a binding arbitration agreement, despite being unable to understand or recall the agreement or basic personal information. The agreement was also incomplete, lacking required signatures and information. Facility leadership confirmed the resident's impaired cognition at the time of signing.
A resident with severe cognitive impairment and multiple medical conditions sustained a fracture of unknown origin, which the facility failed to report as required. The resident was involved in an incident with a mechanical lift, but the injury was not confirmed to have occurred during this event. The facility's records lacked documentation to determine the cause, and the injury was not reported to the state health agency, contrary to the facility's abuse policy.
A resident with severe cognitive impairment sustained a right hip fracture of unknown origin. The facility failed to conduct a thorough investigation as required by their policy. The incident involved a mechanical lift transfer, but the Medical Director later indicated the injury likely did not occur during this event. The facility's investigation was incomplete, lacking interviews with other residents and signed witness statements.
A resident with multiple health conditions did not have a urinalysis with reflex culture collected as ordered by a physician. The test was not picked up in time and was discarded, leading to a lapse in care. The resident was later treated for a UTI in the hospital. The facility's policy required staff to process test requisitions, which was not followed, resulting in non-compliance.
A facility failed to investigate an incident where a resident with dementia reportedly pushed another resident around the throat. Despite witness accounts and staff confirmation, the incident was not documented or investigated, leading to a deficiency citation.
A facility failed to communicate family concerns to the physician regarding the discontinuation of a resident's medication, Brexpiprazole (Rexulti), due to cost. The resident, diagnosed with dementia and anxiety, experienced a decline in condition after the medication change. Despite family concerns, the Nurse Practitioner was not informed, as confirmed by staff interviews.
Failure to Follow RD-Planned Menus and Provide Appropriate Nutritional Substitutions at Breakfast
Penalty
Summary
The deficiency involves the facility’s failure to follow menus planned by the Registered Dietitian (RD) and to provide the specified foods and nutritionally appropriate substitutions to residents. Menu spreadsheets for multiple days showed that all diets were to receive two ounces of scrambled eggs at breakfast, with residents on cardiac diets to receive an egg substitute product and no bacon. Review of temperature guides and menu spreadsheets showed either no notation of substitutions or inaccurate documentation of substitutions. Observations and interviews confirmed that on several days residents did not receive eggs or egg products as planned, and there was no documentation of appropriate substitutions. Multiple residents reported not receiving eggs on the specified days and instead receiving small portions of toast and bacon, with one resident stating the portion was not enough food and that he wanted some type of protein. A resident on a cardiac diet reported receiving bacon, which he was not supposed to have, and stated he should have received an egg substitution product when eggs were on the menu. Staff interviews, including a CNA and a housekeeper, corroborated that residents on the skilled unit did not receive eggs or milk on certain days and instead received limited portions of toast and bacon, with no other protein on the breakfast trays. Dietary staff confirmed that there were no eggs in the kitchen to prepare and that bacon was used as a substitute for eggs, and that only about half of the residents received milk on one of the days because the kitchen ran out. Dietary staff, including diet aides, a diet manager, and another kitchen staff member, stated they did not have a listing of appropriate protein substitutes and believed bacon was a protein substitute for eggs. They also reported that the specialized diet spreadsheet was not used during meal service as a reference, and that the meals were not served from the spreadsheet of specialized diets. The RD verified that bacon was not a nutritionally equivalent substitution for egg protein and that cooks should follow the approved spreadsheet for specialized diets. Additionally, on another day, the menu spreadsheet indicated that all diets were to receive mandarin oranges at breakfast, but observations showed that no residents received mandarin oranges except those on pureed diets, who received applesauce. Dietary staff confirmed there were no mandarin oranges available, no time to prepare another substitute, and that no other fruit was provided in place of the mandarin oranges for most residents, despite facility policy requiring menu changes and substitutions when items are not available for service.
Resident Restrained in Bed Using Mattress and Chair Without Proper Authorization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from unnecessary physical restraints. The resident had diagnoses including cirrhosis with ascites, diabetes mellitus, COPD, and depression, with an MDS showing intact cognition, partial assistance with ADLs, supervision with transfers, and independence with bed mobility. The resident’s care plan addressed a need for restful sleep and identified fall risk, with interventions such as keeping the room quiet, dimming lights, offering a back rub or snack, and using a fall mattress on the floor next to the bed or a perimeter-defining mattress. On the night in question, nursing documentation indicated the resident became agitated, restless, combative, attempted to toss herself to the floor, and was yelling for her son. A hospice nurse assessed the resident and obtained an order for Ativan every four hours, after which the resident became calm. Later during the night shift, a CNA reported that the resident was restless, grabbing at the air, not responding to direction, and attempting to throw herself out of a chair. At approximately 5:45 a.m., this CNA transferred the resident to bed, covered her with a bedsheet, and placed a mattress upright against the open side of the bed, secured in place with the resident’s locked chair, while the other side of the bed was against the wall. Day-shift CNAs arriving later that morning observed the resident asleep in bed with a mattress pressed against one side of the bed, held in place by a locked chair, and the opposite side of the bed against the wall. One CNA reported that a sheet and blanket were tucked under the mattress over the resident, along with pillows positioned in a way that prevented the resident from exiting the bed, making it impossible for her to get out. Another CNA confirmed seeing the mattress and locked positioning chair against the bed. The DON confirmed that the facility verified the CNA had restrained the resident in bed by placing the mattress against the bed in this manner, resulting in the resident being unable to exit the bed, contrary to the facility’s policy that residents have the right to be free from physical restraints and that any ordered restraint must be the least restrictive and used for the least amount of time with ongoing reevaluation.
Medication Omission Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 28 medication administration opportunities and two medication omission errors, resulting in a 7% error rate. The deficiency involved one resident who had been admitted with diagnoses including type 2 diabetes mellitus, hypothyroidism, and hypertension. Physician orders for this resident included Synthroid 50 mcg once daily and glipizide 10 mg every morning. During a morning medication pass, an RN was observed attempting to administer the resident’s medications and was unable to locate the ordered Synthroid in the medication cart or emergency box, resulting in a missed dose. During the same observation, the RN pulled the resident’s glipizide card from the medication drawer but did not remove the scheduled dose before returning the card to the drawer. Before the RN administered the morning medications, the surveyor intervened and questioned whether the glipizide dose had been removed, at which point the RN confirmed it had not and then retrieved the medication for administration. In subsequent interviews, the RN confirmed that Synthroid was not available for administration and that glipizide was only given after the surveyor’s intervention. The DON acknowledged that these two omission errors for Synthroid and glipizide, out of 28 opportunities, resulted in a 7% medication error rate for the observed medication pass.
Failure to Perform Required Hand Hygiene During Incontinence and Wound Care
Penalty
Summary
The deficiency involves failures in staff adherence to the facility’s hand hygiene policy during incontinence care and wound care. For one resident with COPD, dementia, aphasia, atrial fibrillation, hypertension, and total dependence for personal hygiene and dressing, a CNA was observed providing incontinence care using prepackaged wipes and changing a soiled brief. After removing the soiled brief, cleansing the perineal area, and applying a clean brief, the CNA removed gloves and immediately donned new gloves without performing hand hygiene. The CNA then applied lotion to the resident’s chest, again removed gloves, and donned new gloves without hand hygiene before assisting the resident with dressing. The CNA later confirmed awareness that hand hygiene should have been performed after glove removal and before donning clean gloves. A second deficiency was observed during wound care for another resident with senile brain degeneration, COPD, chronic bronchitis, unspecified psychosis, dementia, hypertension, and a stage 3 pressure ulcer on the coccyx. The resident had an order for daily dressing changes that included cleansing the wound, patting it dry, applying alginate to the wound bed, and covering it with a dry clean dressing. During an observed dressing change, an LPN removed the resident’s brief and old dressing, cleansed the wound with water and gauze, applied calcium alginate to the wound dressing, placed the dressing on the resident, applied a clean brief, and repositioned the resident, all without changing gloves or performing hand hygiene between steps. The LPN only removed gloves and washed hands after completing the entire procedure and exiting the room, and acknowledged that she should have removed gloves and washed hands after cleaning the wound and before applying the new dressing. The facility’s hand hygiene policy required hand hygiene before clean tasks, after contact with bodily fluids or contaminated surfaces, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse, specifically involving a resident with severe cognitive impairment and problematic behaviors, including physical and verbal aggression. The resident, who had diagnoses such as Parkinson's disease, epilepsy, and intellectual disabilities, exhibited frequent episodes of yelling, hitting, and throwing objects at both staff and other residents. Despite having a care plan with multiple interventions to address these behaviors, documentation shows that the resident continued to be aggressive and unable to be redirected, with daily reports of physical and verbal aggression toward others. Another resident, who had moderate cognitive impairment and a history of anxiety and depressive symptoms, expressed fear for his safety due to his roommate's violent behavior. Progress notes and staff interviews confirm that the aggressive resident yelled at, cursed, and threatened his roommate, causing the latter to feel unsafe in his own room. The roommate reported being scared and stated that if the aggressive resident could hit staff, he could also harm him. Although the aggressive resident did not physically harm his roommate, the ongoing verbal aggression and threats created a hostile and unsafe environment. Staff interviews revealed that the incidents were not consistently reported to facility leadership, and not all residents at risk were interviewed regarding potential abuse. The Director of Nursing was unaware of the incident until later, and the Social Worker Director did not document all relevant interviews, believing them to be unimportant. The facility's policy required protection from abuse, but the actions taken were insufficient to prevent resident-to-resident abuse, resulting in a deficiency.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of resident-to-resident abuse to the State Agency, specifically when one resident with severe cognitive impairment and a history of problematic behaviors, including verbal and physical aggression, verbally assaulted another resident and exhibited physical aggression toward an unknown resident. Documentation in the medical record showed repeated incidents where the resident yelled, hit, and threw objects at staff and other residents, and was unable to be redirected despite multiple interventions. Progress notes and psychiatric evaluations indicated that these behaviors were ongoing and included both verbal and physical aggression almost daily. One resident, who had moderate cognitive impairment and a history of anxiety and depressive disorder, expressed fear for his safety due to his roommate's violent behavior. Staff documented that this resident was afraid because his roommate was yelling, cursing, and threatening him, and that the roommate had previously hit staff and other residents. The roommate was eventually moved to a private room, but there was no evidence that the incident was reported as required, nor that a thorough investigation was conducted. Interviews with staff, including LPNs, the DON, and the Social Worker Director, revealed that the incident was discussed internally but not reported to the Administrator or the State Agency. The facility's own policy required that resident-to-resident altercations be reviewed as potential abuse situations and that such incidents be reported. However, review of self-reported incidents showed no reports were made for the alleged events, and not all potentially affected residents were interviewed. The Social Worker Director also failed to document an interview with the resident who expressed fear, believing it was not important.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for a resident identified as high risk for falls. Medical record review showed the resident had multiple diagnoses, including palliative care, Parkinson's disease, COPD, and dementia, and was assessed with severe cognitive impairment. The care plan included specific fall prevention measures such as keeping the call bell within reach, maintaining the bed in the lowest position, ensuring the fall mat was on the left side of the bed, and not leaving the resident unattended in certain areas. Despite these interventions being documented, observations revealed that the call light was not within the resident's reach and was found wrapped under the bed wheel. Additionally, the resident's bed was observed in a high position with no staff present, and the fall mat was placed on the right side of the bed instead of the left as specified in the care plan. Staff interviews confirmed these observations, with CNAs verifying the call light was not accessible and the bed was not in the correct position. The resident had a documented history of multiple falls within the review period. The facility's policy required all accidents and incidents to be investigated and reported, but the lack of adherence to the care plan interventions contributed to the deficiency. This failure affected one resident out of three reviewed for falls in a facility with a census of 100.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11% as three errors were identified out of 27 opportunities during medication administration. For one resident with chronic kidney disease and atrial fibrillation, a LPN administered oxybutynin after the order for the medication had expired, as verified by both observation and staff interview. The resident had intact cognition at the time of the incident. Another resident with a history of stroke, autistic disorder, and peripheral vascular disorder received Vitamin B6 without a documented dosage and was also given a lower dose of Tylenol than prescribed. The LPN administered 100 mg of Vitamin B6 despite the absence of a specified dosage in the physician's order and provided only 325 mg of Tylenol when the order was for 1,000 mg. The LPN acknowledged the need to clarify the Vitamin B6 order and confirmed the incorrect Tylenol dosage during the interview.
Failure to Implement and Document Fall Prevention and Safe Transfer Interventions
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and that adequate supervision and assistive devices were provided to prevent accidents for multiple residents. One resident with vascular dementia and significant physical dependencies was care planned to have a perimeter mattress to reduce fall risk, but observations on multiple dates confirmed that the perimeter mattress was not in place. Staff interviews corroborated that the required equipment was not provided, despite the resident's high risk for falls and cognitive impairment. Another resident with severe cognitive impairment and a history of falls was care planned to have the bed in the lowest position and fall mats in place at all times. However, observations revealed the bed was in a high position and the fall mats were not in place, with no staff present to supervise. Staff interviews confirmed that the interventions were not implemented as required, and that staff were resistant to using the double fall mat due to its inconvenience. This resident had experienced multiple falls, and the lack of adherence to the care plan placed the resident at further risk. A third resident, also with severe cognitive impairment and a high risk for falls, experienced multiple unwitnessed falls. The care plan required a perimeter mattress and other interventions, but fall investigations did not consistently document whether these interventions were in place at the time of each fall. Additionally, the facility failed to consistently initiate and document neurological checks after unwitnessed falls, as required by facility policy. The DON confirmed that documentation was lacking and that fall investigations were incomplete. In another incident, a resident who required a mechanical lift for transfers was transferred by a CNA without the lift or a second staff member, resulting in a fall and bilateral femur fractures. The DON confirmed the improper transfer and resulting injuries.
Failure to Implement Water Management and Food Handling Infection Control Policies
Penalty
Summary
The facility failed to implement its water management policy as required to prevent the presence of microorganisms, including legionella, in its water system. Review of the Chlorine Check off Sheets for multiple facility areas revealed that water flow rates had not been tested since late the previous year, despite policy requiring quarterly checks. Additionally, water temperatures recorded in all areas were below the policy-mandated minimum of 122 degrees Fahrenheit, which is necessary to inhibit the growth of legionella and other pathogens. The Maintenance Director confirmed these lapses, acknowledging that the required water flow rate checks and temperature thresholds had not been met. In a separate incident, a CNA was observed assisting a resident with a meal and handled a hamburger patty with her bare hand before handing it to the resident. The CNA confirmed during an interview that she had not used gloves or utensils when handling the food. These actions demonstrate a failure to adhere to proper infection control practices during food handling, as required by facility policy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and interviews confirming the presence of ants in several resident rooms. Six residents were directly affected, with ants found on personal items such as eyeglasses, beds, facial tissue boxes, wheelchairs, and bedside tables. Residents reported the issue to staff and, in one case, attempted to contact the Administrator regarding the ant infestation. Staff, including a CNA and the Maintenance Director, confirmed the presence of ants and acknowledged that the problem had been ongoing, particularly due to recent wet weather conditions. Observations conducted in the affected residents' rooms revealed ants crawling on floors, bedside tables, under beds, and on window sills. Multiple ant traps were also noted in some rooms, indicating ongoing attempts to address the infestation. Review of the facility's pest control policy showed that the facility is required to maintain an ongoing pest control program to keep the building free of insects and rodents, but the observed conditions demonstrated that this program was not effective at the time of the survey.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when staff failed to ensure a resident's dignity was maintained during mealtime assistance. The resident, who had parkinsonism, moderate protein-calorie malnutrition, and was dependent on staff for all activities of daily living, was observed being fed lunch by a Certified Nursing Assistant (CNA) who stood over her throughout the meal. The resident had intact cognition and specifically asked the CNA if she was going to sit down while feeding her, but the CNA did not respond or acknowledge the request and continued to stand. A chair was available nearby but was not used by the CNA. Interviews confirmed that the CNA stood for the entire feeding and that the resident had requested the CNA to sit. Review of the facility's Resident Rights Policy indicated that all staff must treat residents with respect and dignity, and provide care in a manner that promotes or enhances quality of life. The actions observed and confirmed by interviews did not align with this policy, resulting in a failure to honor the resident's right to dignity during mealtime.
Failure to Notify POA of Significant Weight Loss
Penalty
Summary
The facility failed to notify the medical power of attorney (POA) for a resident who experienced significant weight loss. Medical record review showed that the resident, who had diagnoses including aspiration pneumonia, COPD, prostate cancer, type 2 diabetes, moderate protein-calorie malnutrition, and dementia with behavioral disturbance, had severely impaired cognition and was dependent on staff for most activities of daily living. The resident's weight dropped from 146.2 pounds to 129.8 pounds and then to 109 pounds over a short period, representing a loss of more than 25% in one month. Despite these significant changes, there was no documentation that the resident's POA was notified of the weight loss events on multiple occasions. Staff interviews confirmed that the registered dietitian had not informed the POA about the resident's weight changes, with the last contact occurring during a care conference prior to the documented weight loss. Facility policy required notification of the POA for any weight change of 5% or more from the last weight, defining severe weight loss as greater than 5% in one month or 10% in six months. The lack of notification was verified through medical record review, staff interview, and policy review.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not limiting the use of as-needed (PRN) psychotropic medications to 14 days, as required by facility policy. Record review showed that a resident with diagnoses including cerebrovascular disease, hemiplegia, malnutrition, vascular dementia, and unspecified psychosis had a physician order for Ativan 0.5 mg to be given every four hours as needed for anxiety or dyspnea, starting on 04/25/25. The order did not include a stop date and was not limited to 14 days, contrary to facility policy and regulatory requirements. The resident's care plan indicated a history of aggression and resistance to care, with interventions to administer medications as ordered and monitor behaviors and side effects. The Minimum Data Set assessment documented significant cognitive impairment. During an interview, the DON confirmed that the PRN Ativan order should have had a stop date and should not have been ordered for more than 14 days. Facility policy on psychotropic medication management also specified that PRN psychotropic medications are to be limited to 14 days unless otherwise justified.
Failure to Provide Resident-Centered Activity Care Plan
Penalty
Summary
Facility staff failed to ensure that the activity care plan for a resident was appropriately individualized and resident-centered. The resident, who had diagnoses including senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis, was noted to be cognitively impaired with a BIMS score of 00 and was rarely understood. Despite documented interests in religious activities, baking, country music, television, movies, and dogs, the care plan only included generic interventions for one-on-one activities and was not updated to reflect the resident's preferences or cognitive decline. Activity assessments indicated unchanged preferences, but the care plan did not incorporate specific or meaningful activity options tailored to the resident's needs. Record review showed that the resident was only offered a limited number of one-on-one visits in recent months, with no visits documented in the previous ten days. Observations on multiple dates revealed the resident remained in her room, with no lights, television, or music, and had not participated in any activities or been encouraged by staff to do so. Staff interviews confirmed that activity care plans were not updated to reflect the resident's interests or cognitive status, and the facility's policy required care plans to include resident needs and interests.
Failure to Provide Activities of Interest to Resident
Penalty
Summary
The facility failed to provide activities of interest to a resident, as required by their care plan and activity assessment. The resident, who had diagnoses including senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis, was noted to be alert and oriented with some confusion at the time of assessment, and later assessed as cognitively impaired with a BIMS of 00 and rarely understood. The resident's documented preferences included religious activities, baking/cooking, country music, television, movies, and dogs, with a care plan indicating a need for one-on-one activities. Despite these documented interests and needs, records showed the resident was only offered three one-on-one visits in one month and two in the following month, with no visits in the ten days prior to the survey. Observations revealed the resident was repeatedly found in her room without lights, television, or music, and had not been out of bed or participated in any activities on the observed dates. Staff interviews confirmed that the resident had not received the minimum expected frequency of one-on-one visits and that her preferences could have been accommodated, such as by providing television or music. The facility's policy required activity evaluations to reflect residents' interests and needs, but this was not followed for the resident in question.
Failure to Obtain and Document Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain and document resident weights in accordance with physician orders and facility policy for two residents reviewed for nutrition. One resident with end stage renal disease, diabetes, heart failure, and chronic obstructive pulmonary disease had a physician order for daily weights due to congestive heart failure, but multiple days were identified across several months where weights were not obtained as ordered. The Director of Nursing confirmed that these weights were missed, and facility policy required weights to be recorded at intervals established by the interdisciplinary team. Another resident with parkinsonism and moderate protein-calorie malnutrition experienced a significant weight loss of 14 pounds (11.4%) over a one-month period. The dietitian was aware of the weight change and requested a reweight, but this was not completed within the expected 48-hour timeframe. The resident reported not being reweighed after the initial weight loss was identified, and there was no evidence in the medical record that the dietitian had acknowledged the weight change or that a timely reweight was performed, as required by facility policy.
Failure to Administer Medications as Ordered Due to Pharmacy Supply Issues
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents. For one resident with end stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease, there was a physician's order for Renvela 800 mg once daily. Review of the Medication Administration Records (MAR) over several months revealed that Renvela was not administered on numerous dates, and progress notes indicated the medication was not available from the pharmacy on those occasions. The Director of Nursing confirmed these missed administrations. For another resident with a history of cerebral infarction, hemiplegia, hemiparesis, anxiety disorder, and moderate cognitive impairment, multiple medications were not administered as ordered on several dates. These included Metoprolol, Pramipexole, Doxepin, Citalopram, Divalproex, Atorvastatin, and Apixaban. Nurse notes consistently documented that the medications were not available or were awaiting arrival from the pharmacy. The resident confirmed not receiving medications over a weekend, and the Director of Nursing verified the missed doses due to pharmacy supply issues. Facility policy requires that medications be administered in accordance with prescriber orders and within required time frames. However, the documented failures to provide ordered medications as scheduled, due to unavailability from the pharmacy, resulted in noncompliance with this policy for the two residents identified in the report.
Failure to Ensure Resident Comprehension Before Signing Arbitration Agreement
Penalty
Summary
A resident with diagnoses including emphysema, hypertension, malnutrition, and peripheral vascular disease was admitted to the facility and assessed as having moderately impaired cognition. Medical record reviews indicated the resident was alert but exhibited confusion and both long-term and short-term memory deficits, with the ability to make only limited decisions requiring simple understanding. Despite these cognitive limitations, the resident signed a binding arbitration agreement as part of the admission process. The agreement itself was incomplete, lacking the facility representative's signature and missing the date and resident name at the top of the form. During a subsequent interview, the resident was unable to recall basic information such as the current month, year, duration of stay, or the facility's name, and could not explain or remember signing the arbitration agreement. The Regional Director of Clinical Operations confirmed that the resident had impaired cognition at the time of signing and acknowledged that residents should be capable of understanding such agreements before signing. This sequence of events demonstrates that the facility failed to ensure the resident was capable of understanding the arbitration agreement prior to obtaining their signature.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving an injury of unknown origin as required by their policy. This incident affected a resident who had a severe cognitive impairment and multiple medical conditions, including a fracture of the right femur, cerebrovascular disease, and dementia. The resident was involved in an incident on 12/13/24 where her arm was caught in a mechanical lift, resulting in a small skin tear. However, there was no documentation indicating a fall or injury to her legs during this incident. The following day, the resident was sent to the emergency room due to swelling and discoloration in her left leg/pelvic area, and a subsequent hospital examination revealed a fracture of her right hip with an unknown mechanism of injury. The facility's medical records from 11/01/24 to 12/19/24 did not provide evidence or documentation to determine the cause of the injury. The facility's self-reported incidents during the same period also showed no evidence that the injury was reported to the state health agency. Interviews with the facility's administrator and medical director revealed that the injury was not reported because the facility believed it occurred during the mechanical lift incident. However, the medical director could not confirm this, noting that the injury likely did not occur on 12/13/24 due to calcification around the fracture, indicating it happened earlier. The facility's abuse policy lacked a definition for injury of unknown origin and required notification to the department of health, which was not done in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an injury of unknown origin for a resident, which is a violation of their policy. The resident, who had a severe cognitive impairment and multiple medical conditions, was involved in an incident while being transferred via a mechanical lift. During this incident, the resident's arm was caught in the machine, resulting in a skin tear. However, there was no documentation of a fall or any injury to her legs during this incident. Subsequently, the resident was sent to the emergency room for swelling and discoloration in her left leg/pelvic area, where it was discovered that she had a fracture in her right hip. The hospital documentation noted the injury's mechanism was unknown and considered referring the case to social services for potential elder abuse. The facility's investigation included interviews with the nurse and aide involved in the incident, but these statements were not signed or dated. The facility concluded that the injury occurred during the mechanical lift incident, based on a conversation with the Medical Director, although he later stated he did not confirm this. The facility's abuse policy requires a comprehensive investigation of injuries of unknown origin, including interviews with various individuals and a review of the resident's records. However, the facility did not follow these procedures thoroughly, as they did not interview other residents or staff beyond those directly involved, nor did they obtain signed witness statements. The Medical Director later expressed confidence that the injury did not occur during the incident on the mechanical lift, as there was calcification around the fracture, indicating it happened earlier.
Failure to Obtain Ordered Laboratory Test
Penalty
Summary
The facility failed to obtain a laboratory test as ordered by a physician for one of the residents. The resident, who had diagnoses including heart failure, chronic kidney disease, hypertension, type two diabetes mellitus, and peripheral vascular disease, was admitted with intact cognition and occasional urinary incontinence. A physician's order was placed for a urinalysis (UA) with reflex culture to be collected on a specific date. However, the medical record review revealed that the UA with reflex culture was not collected as ordered, and no laboratory results were documented. The Director of Nursing (DON) confirmed during an interview that the UA with reflex culture was not obtained because it was not picked up in time and was subsequently discarded. The test was not re-collected, leading to a lapse in the resident's care. The resident was later treated for a urinary tract infection (UTI) in the hospital. The facility's policy required staff to process test requisitions and arrange for tests, but this was not followed in this instance, resulting in non-compliance as investigated under a specific complaint number.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents. Resident #4, who was admitted with dementia and other mental health diagnoses, was reported to have engaged in aggressive behavior, including swatting at staff and exit-seeking. On a specific date, a nurse's note initially documented that Resident #4 grabbed another resident by the throat, but this was later corrected by the Director of Nursing (DON) to indicate that Resident #4 merely touched the other resident's neck without force. However, a witness statement from a staffing coordinator described Resident #4 as having pushed Resident #21 around the throat, causing her head to move back. Despite these accounts, the incident was not documented in the facility's incident log, nor was a Self-Reported Incident (SRI) completed, indicating that no formal investigation was conducted. Interviews with staff confirmed the occurrence of the incident and the lack of documentation or investigation. The DON acknowledged the incident but did not believe it warranted an investigation, despite the witness's statement confirming the physical interaction. This oversight led to a deficiency being cited under Complaint Number OH00158828.
Failure to Communicate Family Concerns About Medication Change
Penalty
Summary
The facility failed to communicate with the physician regarding family concerns about the discontinuation of a medication for a resident diagnosed with dementia, anxiety, and other mental health issues. The resident, who was cognitively impaired and required various levels of assistance with daily activities, had their medication Brexpiprazole (Rexulti) discontinued due to cost. The family expressed concerns that the resident might no longer be in a stable mindset after the medication change, but these concerns were not communicated to the Nurse Practitioner (NP) responsible for the resident's psychiatric care. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the family’s concerns were not relayed to the NP, who was available for consultation. The resident's spouse reported a decline in the resident's condition following the medication change, which was not addressed due to the lack of communication. This deficiency was identified during an investigation under a specific complaint number.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northwood Skilled Nursing And Rehabilitation | 0.5 mi | ★★★★★ | 4 | 0 |
| Villa Springfield Rehabilitation And Healthcare Ce | 0.7 mi | ★★★★★ | 0 | 0 |
| Allen View Healthcare Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Forest Glen Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Springfield Nursing & Independent Living | 2.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.