Below 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 West Park during CMS and state inspections, most recent first.
Undated food items were observed during a kitchen tour, including multiple bags of hamburger buns, a half loaf of bread, a half full bag of Asian stir-fry, and two bags of tater tots. A CSM confirmed the undated items, and the facility policy stated that foods should be dated upon opening.
The facility failed to implement a water management program to reduce the risk of Legionella, despite its infection control policy describing a water management team and program. The Maintenance Director and Administrator confirmed no Legionella water management plan was in place. The facility also failed to complete required TB screening for several employees, including RNs, CNAs, the BOM, and the Administrator; the ICP and HRM confirmed the missing new hire and annual TB screenings, and the facility policy required TB screening before employment and ongoing screening based on risk.
Unsafe Water Temperatures and Unsanitary Bathroom and Shower Conditions: The facility failed to provide appropriate water temperatures in resident bathrooms and the shower room, with sink and shower water measured as cold or only 83 to 92 degrees F after running for several minutes. A CNA and residents reported cold water, weak shower pressure, darkened areas from out lights, insects in light fixtures, and dirty floors, walls, and fan buildup in the shower room; the DON and Administrator confirmed an ongoing issue with cold water temperatures and only one of three hot water pumps operating.
A resident with severe protein-calorie malnutrition, dysphagia, COPD, and other comorbidities was care planned as being at risk for altered nutrition and hydration, and a physician ordered monitoring of meal intake. A nutritional assessment and dietary notes documented that the resident consumed 25–50% of three daily meals, and RDs reported that these conclusions were based on NA meal-tracking sheets. However, review of the record showed no NA documentation of meal intake for two consecutive months, and the DON confirmed the facility could not provide any such records, despite a facility policy requiring complete and accurate charting of resident care and responses.
The facility failed to secure medications in a locked storage area, affecting 12 mobile residents. An LPN retrieved medication from an unlocked storage room, which had been left unsecured since the removal of the electronic keypad lock. Observations confirmed the door was often left ajar, and an employee noted it was usually unlocked.
The facility failed to ensure timely signing of physician progress notes for three residents, with delays ranging from several days to weeks. The DON confirmed these delays during a complaint investigation.
A facility failed to ensure a resident was seen by a physician every 60 days, as required. The resident, with diagnoses including stage 3 chronic kidney disease and rheumatoid arthritis, had not been seen since December 2024. This was confirmed by both the physician and the DON during interviews, highlighting a deficiency in compliance with required physician visit schedules.
A resident with Alzheimer's and dementia experienced verbal abuse during a transfer by an STNA who used inappropriate language. The resident, who required assistance, became resistive, leading to the STNA's inappropriate response. The facility's investigation confirmed the verbal abuse, which violated the resident's rights.
A former Business Office Manager misappropriated funds from deceased residents' accounts by writing unauthorized checks to herself and others. The deficiency affected three residents, with checks being cashed improperly instead of following the correct procedures for account closure. The issue was discovered during a resident trust audit after concerns were raised by a receptionist.
The facility failed to provide written Admission Agreements to new residents upon admission, affecting four residents with various medical conditions. The Business Office Manager could not provide evidence of these agreements, and the Administrator confirmed their absence. This deficiency was investigated under a specific complaint number.
The facility failed to maintain clean and sanitary carpeting on the third floor, affecting all residents residing there. Observations noted multiple stains in the main corridors and sitting area. Interviews with staff confirmed the condition, and while the Administrator mentioned plans to replace the flooring, no specific timeline was provided.
The facility failed to ensure medications were available to administer as ordered, affecting a resident with multiple diagnoses. The resident did not receive Morphine Sulfate as prescribed due to unavailability, and the medication was documented as given when it was not available. The DON confirmed the discrepancy, and the facility's policy on timely medication administration was not followed.
A resident with multiple diagnoses, including unspecified neoplasm of digestive organ and chronic ulcerative pancreatitis, was given double the prescribed dose of Morphine Sulfate over several days. The error was confirmed by an LPN and was due to the facility not following its medication administration policy.
A resident with a complex medical history, including severe cognitive impairment, was found unresponsive and without vital signs. Despite being designated as a full code in the physician orders and care plan, staff did not initiate CPR. Interviews with RNs, LPNs, and a PA confirmed awareness of the resident's full code status but revealed that CPR was not performed. This incident highlighted a critical gap in the facility's emergency response protocols, resulting in the resident being pronounced dead.
The facility failed to ensure all food temperatures were checked prior to meal service, with a dietary cook only checking one item and assuming the rest were hot. The chicken was initially below the required temperature and was reheated, but no other food temperatures were taken or logged.
The facility failed to maintain kitchen equipment in a sanitary manner and ensure staff wore appropriate hair restraints while preparing food. The kitchen hood was overdue for cleaning, and multiple staff members were observed preparing food without proper facial hair restraints, contrary to facility policy.
The facility failed to implement its Legionella Water Management Program by not completing water temperature checks for the entire year of 2023, as confirmed by records and the Maintenance Director. This lapse had the potential to affect all 78 residents.
The facility failed to conduct required care conferences for four residents, including those with severe cognitive impairments and multiple health conditions. The Social Services Director and residents or their representatives confirmed the lapses, which violated the facility's policy for quarterly care plan meetings.
The facility failed to properly prepare pureed food, affecting five residents on a pureed diet. A dietary cook used an incorrect ratio of water to vegetables, resulting in a runny mixture. The cook confirmed he made the food watery to prevent choking, but a dietetic technician stated this compromised the food's nutritive value. The facility's recipe specified a lower amount of water for a mashed potato consistency, which was not followed.
A resident with multiple health conditions alleged that two STNAs ignored her requests to stop lifting her, causing her to pass out from pain and fall. Despite the facility's policy requiring immediate suspension of accused staff, the STNAs continued to work for several hours after the incident was reported.
The facility failed to properly transfer a resident using an appropriate assistive lift device, leading to the resident sliding out of a sit-to-stand lift and landing on the floor. Despite recommendations for a Hoyer lift, staff continued to use the incorrect device, violating the facility's policy on safe lifting procedures.
The facility failed to implement nutritional recommendations for a resident with weight loss. Despite a dietitian's recommendation to increase the house supplement to twice daily, the physician's orders were not updated, resulting in the resident not receiving the necessary nutritional support. The resident's weight showed a significant downward trend, and the Director of Nursing confirmed the oversight.
The facility failed to implement physician orders following pharmacy recommendations for three residents. Delays and failures in discontinuing or adjusting medications as recommended by the pharmacist were confirmed by the DON and ADON, contrary to the facility's Medication Therapy policy.
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate during a medication administration observation. An LPN omitted two prescribed medications for a resident but signed them off as administered. The LPN admitted to being nervous and unfamiliar with the residents, contributing to the error.
The facility failed to ensure that insulin pens were properly labeled and stored, affecting two residents. Insulin pens for two residents were found opened without an open date, contrary to the facility's medication administration policy. This was confirmed by an LPN and observed during a review of the medication cart.
The facility failed to provide timely pneumococcal vaccinations to three residents. One resident did not receive the required follow-up vaccine after PPSV23, another resident also missed the follow-up vaccine, and a third resident was not offered the vaccine at all since admission. The ADON confirmed these deficiencies, which were against the facility's policy.
Undated Food Stored in Kitchen
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed a rack with bread products that included 4 full bags of hamburger buns, 2 partial bags of hamburger buns, and one half loaf of bread, all undated. In the refrigerator, surveyors also observed a half full bag of Asian stir-fry and two bags of tater tots that were not dated. A Corporate Support Manager confirmed the undated foods in the kitchen during the observation. Review of the facility policy titled Food Storage (Dry, Refrigerated and Frozen), dated 08/12/23, showed that foods should be dated upon opening.
Missing Legionella Water Management Plan and TB Screening Gaps
Penalty
Summary
The facility failed to ensure a comprehensive water management plan was implemented to minimize the risk of waterborne pathogens, including Legionella. Review of the infection control documents showed there was no water management plan in place, and the Maintenance Director and Administrator both confirmed during interview that the facility did not have a plan to prevent the growth of Legionella. The facility policy titled Legionella Water Management Program stated the facility was committed to the prevention, detection, and control of water-borne contaminants and described a water management program overseen by a water management team, but this program was not implemented as part of the infection prevention and control program. The facility also failed to complete TB screening for new employees and/or annual TB screening for current employees. Review of employee files showed that Registered Nurses #345 and #343, Business Office Manager #213, the Administrator, and CNAs #473, #381, and #393 did not have the required TB new hire screening and/or annual screening completed. The Infection Control Preventionist confirmed staff are offered TB testing as part of the new hire process and that each employee should complete a TB risk questionnaire annually because the facility was determined to be at low risk for TB. The Human Resource Manager also confirmed the listed employees had not completed the required TB screening. The facility policy titled Tuberculosis, Employee Screening stated all employees are to be screened for latent TB and active TB and TB symptoms prior to beginning employment.
Unsafe Water Temperatures and Unsanitary Bathroom and Shower Conditions
Penalty
Summary
The facility failed to ensure appropriate water temperatures in the north hallway shower room and in individual resident bathrooms, and it failed to maintain bathrooms and shower rooms in a clean and sanitary manner. During observation, a CNA allowed the bathroom sink water in Resident #7’s room to run for several minutes and obtained a temperature of 83 degrees F, and the same CNA obtained a temperature of 83 degrees F from Resident #12’s bathroom sink. Resident #78 stated the water in his room was too cold and that he did not take a shower because the water in the shower room was also too cold. In Resident #78’s room, the hallway light outside the bathroom door was out, the bathroom light fixture contained multiple bugs, and the sink water was cold when tested. In the east shower room, the hallway light was out, the shower room floor and walls were dirty, the light fixture contained multiple insects, one bulb was not working, and there was a buildup of dirt and debris on the fan. The CNA confirmed the dirty conditions, the insects in the light fixture, and the nonfunctioning bulb, and stated several residents had complained about the shower room water temperature, weak water pressure, and general lack of cleanliness. The DON and Administrator confirmed the facility had an ongoing concern with cold water temperatures throughout the facility and that only one of three hot water pumps was operating.
Failure to Accurately Document Nutritional Intake for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete documentation of a resident’s meal intake in accordance with professional standards and its own documentation policy. A resident admitted with metabolic encephalopathy, kidney calculi, severe protein-calorie malnutrition, bipolar disorder, oropharyngeal dysphagia, and COPD had a care plan identifying risk for altered nutrition and hydration due to severe malnutrition, altered mental status, dysphagia, low BMI, and recent significant weight loss. An MDS assessment documented the resident as cognitively intact, and a nutritional assessment by an RD indicated the resident was consuming 25–50% of three daily meals. A physician’s order directed staff to monitor the resident’s meal intake. Despite this order and the resident’s identified nutritional risks, review of NA tracking sheets for November and December showed no recorded meal intake for the resident. Dietary progress notes and the RD’s nutritional assessment, which both stated the resident consumed 25–50% of three daily meals, were confirmed by the RDs to have been based on these NA tracking sheets, even though the facility could not produce any such documentation. The DON confirmed the facility was unable to provide documentation of meal intake tracking for the resident for those two months. The facility’s policy on documentation stated that charting should provide a complete account of care, treatment, responses, signs and symptoms, guidance for prescribers, a tool for measuring quality of care and developing care plans, and serve as a legal record, underscoring the discrepancy between policy and practice in this case.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to secure all medications in a locked storage area and to limit access to authorized personnel, which had the potential to affect 12 independently mobile residents on the 400 floor. During an observation of medication administration, an LPN was seen retrieving medication from an unlocked medication storage room on level 4. The LPN confirmed that the room had not been locked since the electronic keypad lock was removed. Further observation revealed that the door to the medication storage room was ajar, and an employee restocking a wound supplies cart mentioned that the door was usually left unlocked. This deficiency was confirmed through interviews and observations, indicating a lapse in securing medications properly.
Physician Note Signing Delays
Penalty
Summary
The facility failed to ensure that physicians signed progress notes at the time of service for three residents. Resident #51, who had multiple diagnoses including emphysema and dementia, had a physician visit on 01/27/25, but the progress note was not signed until 02/09/25. The physician claimed to sign notes immediately after completion, but this was contradicted by the Director of Nursing (DON) who confirmed the delay. Similarly, Resident #52, with diagnoses such as chronic kidney disease and rheumatoid arthritis, had two physician visits on 09/10/24 and 10/07/24, with both progress notes signed only on 10/19/24. Resident #60, diagnosed with conditions including pulmonary embolism and chronic pain syndrome, had a physician visit on 10/21/24, with the note signed on 11/16/24. The DON verified these delays, which were discovered during a complaint investigation.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at least every 60 days, as required. This deficiency was identified during a review of the medical records, physician interviews, and staff interviews, specifically affecting one resident out of three reviewed for physician visits. The resident in question, who was admitted with diagnoses including stage 3 chronic kidney disease, depression, and rheumatoid arthritis, had intact cognition and required varying levels of assistance for daily activities. The last documented physician visit for this resident was on December 23, 2024, which was confirmed by both the physician and the Director of Nursing during interviews conducted on March 27, 2025. This oversight was part of a complaint investigation under Complaint Number OH00162751.
Verbal Abuse Incident During Resident Transfer
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, specifically affecting one resident who had a history of Alzheimer's disease, anxiety disorder, dementia with behavioral disturbance, and other medical conditions. The resident, who had severely impaired cognition, was involved in an incident where a State Tested Nursing Assistant (STNA) was verbally inappropriate during a transfer. The resident, who required assistance with transfers, experienced a behavioral episode and became resistive to care, leading to a situation where the STNA attempted to move the resident without proper assistance. During the incident, the STNA was reported to have used inappropriate language, telling the resident to "get your ass up" after the resident had gone limp and was lowered to the ground. The facility's investigation, which included reviewing video footage provided by the resident's family, confirmed that the STNA's actions constituted verbal abuse. The STNA admitted to making the inappropriate comment, which was against the facility's policy on resident rights to freedom from abuse. The facility's policy clearly states that residents have the right to be free from abuse, including verbally aggressive behavior. The investigation revealed that the STNA did not follow the proper protocol by attempting to assist the resident without notifying a nurse, and the language used was deemed unacceptable. The incident was reported to the police, and the facility took immediate action to address the situation.
Misappropriation of Deceased Residents' Funds by Former BOM
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money, specifically involving the misappropriation of funds from deceased residents' accounts. This deficiency affected three residents who had passed away in the facility. The former Business Office Manager (BOM) was found to have written checks to herself and others from the accounts of these deceased residents, which was discovered during a resident trust audit initiated by the facility. Resident #21, who was cognitively intact, had a check written from their account for $567.49 by the former BOM, which was then cashed. Similarly, Resident #22, who had mild to moderate cognitive deficits, had a check for $1,548.58 made out to a receptionist, allegedly to be handed over to the resident's daughter, which never occurred. Resident #23, with moderate to severe cognitive deficits, had a check for $300 made out to petty cash by the former BOM. These actions were unauthorized and against the facility's policy for handling deceased residents' accounts. The misappropriation was brought to light when a receptionist raised concerns about the accuracy of the resident trust accounts. The facility's Administrator conducted a comprehensive investigation, which confirmed the illegal activities of the former BOM. The investigation revealed that the former BOM had not followed the proper procedures for closing accounts, which should have involved sending funds to the funeral home or the Attorney General's Office, rather than cashing checks for personal use.
Failure to Provide Admission Agreements to New Residents
Penalty
Summary
The facility failed to provide written Admission Agreements to new residents at the time of their admission, affecting four out of five residents reviewed for admission procedures. This deficiency was identified through a review of medical records and staff interviews. The residents involved had various medical conditions, including diabetes mellitus type II, lumbar disc degeneration, congestive heart failure, acute myocardial infarction, adult failure to thrive, non-pressure chronic ulcer, morbid obesity, acute kidney failure, depression, acute osteomyelitis, partial traumatic amputation, polyneuropathy, bilateral osteoarthritis, and edema. Despite these conditions, the facility did not have evidence of providing the necessary Admission Agreements to these residents. The Business Office Manager was unable to provide the requested evidence of written Admission Agreements for the residents in question. Subsequent interviews with the Administrator confirmed that the facility had no evidence of signed Admission Agreements for the affected residents. This deficiency was investigated under Complaint Number OH00154443, highlighting a lapse in the facility's admission procedures and documentation practices.
Carpeting Maintenance Deficiency on Third Floor
Penalty
Summary
The facility failed to maintain the carpeting on the third floor in a clean and sanitary manner, affecting all 10 residents residing on that floor. Observations revealed multiple stains throughout the main corridors and sitting area. Interviews with the Maintenance Aid and the Administrator confirmed the stained condition of the carpeting. Although the Administrator indicated that steps were being taken to replace the flooring, no specific timeline for completion was provided. This deficiency was investigated under Master Complaint Number OH00155422 and Complaint Number OH00154443.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were available to administer as ordered, affecting one resident. Resident #80, who had multiple diagnoses including unspecified neoplasm of the digestive organ, essential hypertension, and chronic ulcerative pancreatitis, was admitted to the facility and later expired there. The resident had physician orders for Morphine Sulfate to be administered for pain and shortness of breath, which were not consistently followed due to the unavailability of the medication. The Medication Reconciliation Sheet and Medication Administration Record (MAR) revealed discrepancies in the administration of Morphine Sulfate, with doses documented as given even when the medication was not available. The Director of Nursing (DON) confirmed that the resident did not receive the Morphine Sulfate as ordered from a specific time period, and the medication was documented as administered when it was not available. The facility's policy on administering medications stated that medications should be administered as prescribed in a safe and timely manner, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00154174.
Significant Medication Error: Double Dose of Morphine Administered
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when they administered double the dose of Morphine to a resident. Resident #80, who had multiple diagnoses including unspecified neoplasm of digestive organ, essential hypertension, and chronic ulcerative pancreatitis, was admitted to the facility and later expired there. The resident was receiving Hospice services and had a physician's order for Morphine Sulfate 20 mg per 5 ml solution, to be given 0.5 ml (2 mg) every hour for pain or shortness of breath. However, the facility administered multiple 0.5 ml (10 mg) doses of Morphine Sulfate 100 mg/5 ml from [DATE] to [DATE], which was double the prescribed dose. The error was confirmed during an interview with an LPN who verified that the resident had been given the incorrect dosage. The facility's policy on administering medications, which requires the person administering medications to check three times to ensure the correct medication and dose, was not followed. This deficiency was identified during a complaint investigation and represents noncompliance under Complaint Number OH00154174.
Failure to Administer CPR to Full Code Resident
Penalty
Summary
The facility failed to ensure that CPR was provided to a resident, identified as Resident #76, who was a full code and found unresponsive and without vital signs on a specific date and time. Despite the resident being designated as a full code, staff members did not immediately initiate CPR upon discovering the resident's condition. The failure to provide CPR to Resident #76, who was in need of immediate life-saving intervention, resulted in the resident being pronounced dead. This incident led to an Immediate Jeopardy situation, posing a serious risk of harm or death to the resident due to the lack of timely CPR administration. Review of the medical records and documentation revealed that Resident #76 had a complex medical history, including diagnoses such as left hip fracture, essential hypertension, paralytic ileus, pancytopenia, and various other conditions. The resident was noted to have severe cognitive impairment as per the comprehensive Minimum Data Set (MDS) assessment. Despite being identified as a full code in the physician orders and care plan, CPR was not promptly initiated when the resident was found unresponsive and without vital signs. The facility's failure to adhere to established protocols for residents designated as full code directly contributed to the deficiency in providing timely life-saving measures to Resident #76. Interviews with staff members, including RNs, LPNs, and the Physician Assistant (PA), confirmed that CPR was not initiated for Resident #76 despite the resident's full code status. Staff members acknowledged that they were aware of the resident's code status but did not take immediate action to perform CPR. The lack of timely response and failure to initiate CPR for a resident in need of such intervention highlighted a critical gap in the facility's emergency response protocols. The deficiency in providing CPR to Resident #76, as required by the facility's policies and guidelines, resulted in a serious incident that required immediate corrective actions to address the identified Immediate Jeopardy situation.
Failure to Check Food Temperatures Prior to Meal Service
Penalty
Summary
The facility failed to ensure all food temperatures were checked prior to the start of meal service, potentially affecting all 78 residents. During an interview, a dietary cook confirmed that he only checked the temperature of one food item on the steam table at the beginning of each meal, assuming that if one item was hot, the rest would be as well. On the observed date, the cook tested the temperature of the chicken, which initially read 140 degrees Fahrenheit, below the required 165 degrees Fahrenheit. The chicken was then reheated and rechecked, reaching 179 degrees Fahrenheit, but no other food temperatures were taken or logged for that meal. A review of the food temperature log revealed that only the temperature of the chicken was documented for the observed date, with no other entries made since a previous date. The facility's policy mandates that all hot food items must be held and served at a temperature of at least 135 degrees Fahrenheit, and temperatures should be taken often to ensure safe food holding temperatures. An interview with a registered dietetic technician confirmed that the temperature of all foods should be checked prior to meal service.
Failure to Maintain Sanitary Kitchen Conditions and Proper Hair Restraints
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary manner and ensure staff wore appropriate hair restraints while preparing food. During an observation, the hood in the kitchen, which covered the fryer, stove, grill, and steamers, was found to be covered with a black and grey fuzzy substance. The last cleaning of the hood was recorded in June 2023, which was confirmed by the Food Service Manager to be past due. The facility policy indicated that stove hoods and filters should be cleaned at least monthly and professionally cleaned at least yearly, which was not adhered to in this instance. Additionally, multiple staff members were observed preparing food without proper hair restraints. Dietary Cook #430 and Dietary Cook #445 were both seen with uncovered facial hair while preparing food. Even after bringing facial hair covers into the kitchen, DC #445 did not fully contain his facial hair. Dietary Aide #338 was also observed assisting with meal service and food preparation without any facial hair restraint. The facility policy required all employees to wear hair restraints to prevent hair from contacting exposed food, which was not followed by the staff members involved.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to properly implement its Legionella Water Management Program, which had the potential to affect all 78 residents. Specifically, the facility did not complete water temperature checks for the entire year of 2023, a key control measure for monitoring Legionella. This was confirmed through a review of the facility's water management records and temperature logs, which showed that water temperatures were only recorded from January 2024 through March 2024. An interview with the Maintenance Director confirmed the lapse in monitoring. The facility's policy, dated July 2017, emphasized the importance of taking water temperatures to prevent, detect, and control water-borne contaminants, including Legionella.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct care conferences as required, affecting four residents. Resident #16, admitted with multiple diagnoses including necrotizing fasciitis and type two diabetes mellitus, had only one documented care conference on 10/27/23. The Social Services Director confirmed no further care conferences were held for this resident. Resident #23, with severe cognitive impairment and multiple diagnoses including congestive heart failure and Alzheimer's disease, had a care conference on 08/14/23, but no further conferences were documented. The Social Services Director confirmed this lapse in care planning. Resident #19, with severe cognitive impairment and other significant health issues, did not have care conferences for the second and third quarters of 2023 or the first quarter of 2024, despite being continuously in the facility. The resident's representative confirmed this deficiency. Resident #41, with intact cognition and multiple health conditions, did not have a care conference in the first quarter of 2024. Both the resident and the Social Services Director confirmed this lapse. The facility's policy requires quarterly care plan meetings, which were not adhered to in these cases.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to properly prepare pureed food, affecting five residents on a pureed diet. During an observation, a dietary cook was seen using an incorrect ratio of water to vegetables, resulting in a runny and liquified mixture. The cook confirmed that he intentionally made the food watery to prevent choking. However, a registered dietetic technician later confirmed that this ratio was excessive and compromised the nutritive value of the food. The facility's recipe for pureed vegetables specified a much lower amount of water to achieve a mashed potato consistency, which was not followed.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to ensure residents were protected during abuse investigations, affecting one resident. Resident #14, who had diagnoses including acute and respiratory failure, CHF, bipolar disorder, chronic kidney disease stage three, and type two diabetes mellitus, alleged that on 03/11/24, two STNAs raised her too high in a stand lift despite her requests to stop, causing her to pass out from pain and fall to the ground. The incident was reported to an RN, who assessed the resident and found no injuries besides shoulder pain. The STNAs were supposed to be suspended immediately during the investigation, as per facility policy. However, the daily staffing sheet and time clock records revealed that the STNAs continued to work for several hours after the Self-Reported Incident (SRI) was initiated. The Administrator confirmed that the STNAs were not suspended immediately, allowing them to work until late in the afternoon on the day the SRI was initiated. This failure to suspend the accused staff members immediately during the investigation was a direct violation of the facility's abuse policy, which mandates immediate suspension of employees accused of resident abuse.
Improper Use of Assistive Lift Device for Resident Transfer
Penalty
Summary
The facility failed to properly transfer Resident #14 using an appropriate assistive lift device, which led to the resident sliding out of a sit-to-stand lift and landing on the floor. Resident #14, who had diagnoses including acute and respiratory failure with hypercapnia, congestive heart failure, bipolar disorder, chronic kidney disease stage three, and type two diabetes mellitus, was assessed to require a Hoyer lift for transfers. Despite this, staff used a sit-to-stand lift, contrary to the care plan and physical therapy recommendations, resulting in the fall incident on 03/11/24. The resident was assessed for injuries and none were found, and the resident was subsequently transferred to bed using a Hoyer lift. The interdisciplinary team later confirmed the need for a Hoyer lift for all transfers to prevent further falls. Observation on 04/04/24 revealed that staff continued to use the sit-to-stand lift for transferring Resident #14, despite the established requirement for a Hoyer lift. Interviews with staff and review of the facility policy confirmed that the correct procedure was not followed. The facility policy on using mechanical lifts emphasized assessing the resident's condition to determine the appropriate transfer method, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00152118.
Failure to Implement Nutritional Recommendations for Resident with Weight Loss
Penalty
Summary
The facility failed to implement nutritional recommendations made by the licensed dietitian for a resident with weight loss. Resident #11, who had multiple diagnoses including polyneuropathy, cellulitis, anxiety, depression, dementia, cervical disc degeneration, and peripheral vascular disease, was identified as being at risk for malnutrition. The resident's care plan included interventions such as administering medications, honoring food preferences, offering substitutes, and providing supplements as ordered. Despite a recommendation from the dietitian to increase the house supplement to twice daily due to significant weight loss, the physician's orders were not updated to reflect this change. The resident's weight records showed a downward trend, with weights recorded as 122 pounds, 117 pounds, 113 pounds, 109 pounds, and 113 pounds over a span of several months. The Director of Nursing confirmed that the order for the increased supplement had not been implemented as recommended by the dietitian. The facility's policy on Weight Assessment and Intervention, dated August 2023, stated that staff would implement interventions for undesirable weight loss based on resident choices, preferences, and nutritional needs. However, the failure to update the physician's orders to reflect the dietitian's recommendation resulted in the resident not receiving the necessary nutritional support. This deficiency was identified through medical record review, staff interviews, and policy review, highlighting a lapse in the facility's adherence to its own policies and the dietitian's recommendations for managing the resident's nutritional needs.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to implement physician orders following pharmacy recommendations for three residents. For Resident #5, the pharmacist recommended discontinuing Seroquel 25 mg, which the physician agreed to on 07/17/23. However, the medication was not discontinued until 11/03/23. Resident #23 had a recommendation to increase lisinopril to 30 mg daily, agreed upon by the physician on 07/17/23, but the order was not implemented until 10/03/23. Additionally, a recommendation to increase Novolog insulin to six units three times daily was agreed upon on 02/13/24, but the order was never implemented. Resident #16 had a recommendation to start Insulin Lispro at two units daily, agreed upon by the nurse practitioner on 02/23/24, but the order was never implemented. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the delays and failures in implementing these pharmacy recommendations. The facility's policy on Medication Therapy, revised in April 2007, states that the facility and practitioner, with the assistance of the Consultant Pharmacist, should review a resident's medication regimen periodically to ensure appropriate use, dosage, and administration. The facility did not adhere to this policy, resulting in the deficiencies noted in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below five percent during a medication administration observation, resulting in an eight percent error rate. This deficiency affected one resident, who had diagnoses including diabetes, atrial fibrillation, insomnia, hypertension, and Asperger's syndrome. The resident required staff assistance with activities of daily living and had physician orders for pantoprazole and Flonase to be administered each morning. However, during an observation, the LPN administering the medications omitted these two medications but signed them off in the electronic medical record as administered. The LPN admitted to being nervous and unfamiliar with the residents on that hall, which contributed to the error. The Regional Director of Clinical Operations confirmed the medication error rate was eight percent for the observed medication administration. The facility's policy on administering medications, dated August 2022, stated that medications should be administered in a safe and timely manner, as prescribed, which was not adhered to in this instance.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
The facility failed to ensure that insulin pens were properly labeled and stored, affecting two residents. Resident #23, who has diagnoses including congestive heart failure, type two diabetes mellitus, and acute kidney failure, had a Lantus insulin pen that was opened without an open date. Similarly, Resident #55, who has diagnoses including type one diabetes mellitus, atrial fibrillation, and Asperger's syndrome, had both Humalog and Lantus insulin pens that were opened without an open date. These deficiencies were observed during a review of the medication cart on the 700 hall and confirmed by an LPN who acknowledged that insulin pens should be dated upon opening to ensure proper discard timing. The facility's policy titled 'Administering Medications' dated August 2022, mandates that medications be administered safely and timely, as prescribed, and that the expiration or beyond use date on the medication label be checked prior to administration. The policy also requires that the date of opening be recorded on multi-dose containers. The failure to adhere to this policy was confirmed through staff interviews and observations, highlighting a lapse in the facility's medication management practices.
Failure to Provide Timely Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide the pneumococcal vaccine in a timely manner to three residents. Resident #10, who was admitted with diagnoses including type two diabetes mellitus, generalized anxiety, depression, and chronic kidney disease stage three, received the PPSV23 vaccine on 02/01/13 but did not receive the subsequent PCV15 or PCV20 vaccine at least one year later as required. Similarly, Resident #11, admitted with generalized anxiety disorder, major depressive disorder, and dementia, received the PPSV23 vaccine on 07/01/18 but was not given the PCV15 or PCV20 vaccine at least one year later. Resident #21, admitted with hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, and depression, was not offered the pneumococcal vaccine at all since admission to the facility. The Assistant Director of Nursing confirmed that these residents were not up to date on their pneumococcal vaccines. The facility's policy, dated November 2023, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections and assessed for eligibility prior to or upon admission. The policy also indicated that the vaccine series should be offered within thirty days of admission unless medically contraindicated or if the resident had already been vaccinated. However, the facility did not adhere to this policy for the three residents mentioned.
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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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| Edith Lane Of Cincinnati | 0.6 mi | ★★★★★ | 4 | 0 |
| Ivy Woods Healthcare Center. | 1.5 mi | ★★★★★ | 10 | 0 |
| Harrison Pavilion Care Center | 1.5 mi | ★★★★★ | 24 | 0 |
| Terrace View Gardens | 2 mi | ★★★★★ | 6 | 0 |
| Hillebrand Nursing And Rehabilitation Center | 2.2 mi | ★★★★★ | 16 | 0 |
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