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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenue At Brooklyn during CMS and state inspections, most recent first.
The facility failed to protect residents at risk for falls and injuries by not following ordered fall interventions, not completing safe transfers, and not properly assessing or investigating falls and unexplained bruising. A resident with severe cognitive impairment was lifted from the floor by one LPN and thrown back into bed without an injury assessment, despite orders for multiple bed safety devices and 2-person transfers, and later was hospitalized with a thoracic burst fracture and bruising. Another resident with dementia and dependence for transfers developed worsening chest bruising and rib fractures before the facility initiated an investigation, and other residents had unwitnessed falls with incomplete fall investigations and missing fall risk assessment documentation.
Insufficient staffing led to delayed call light response, delayed incontinence care, and incomplete ADL support. Residents reported long waits for help, including mechanical lift transfers and brief changes, while staff described short aide coverage, uncovered call-offs, and difficulty completing showers, checks, and two-person transfers. Observations showed residents left wet or waiting for care, and an LPN and ADON were observed not completing requested assistance when they entered resident rooms.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. Review of the nursing schedule and staff time punches showed no RN present in the facility, and the Administrator confirmed he could not provide evidence that an RN worked the required 8 hours. The deficiency had the potential to affect all 95 residents.
Ineffective administration led to multiple failures in fall management, staffing, nutrition, immunization education, and abuse prevention. The facility did not follow fall interventions or complete accurate fall assessments and investigations, and two residents sustained serious injuries, including rib fractures and a thoracic burst fracture after an improper transfer. The report also cites inadequate RN coverage, insufficient staffing, missed dialysis transport, inaccurate documentation, falsified bathing records, failure to provide snacks and adaptive equipment, and abuse-related issues including verbal abuse and misappropriation of resident funds and property.
A facility failed to provide timely ADL assistance for multiple residents, including incontinence care, bathing, grooming, bed positioning, and meal help. One resident was found with dried urine on bedding and long, dirty fingernails; another waited hours for brief changes and had a mattress that slid away from the headboard; a third waited over an hour for incontinence care; bathing records showed repeated missed showers; and video showed a dependent resident left without meal assistance while staff entered and exited the room without feeding him.
Failure to provide ordered adaptive eating equipment and utensils. Three residents with severe cognitive impairment and eating assistance needs did not receive the items listed on their diet tickets: one resident ordered disposable silverware received regular silverware, one resident ordered a divided plate received a regular plate, and one resident ordered no butter knife but had a butter knife on the tray. A DA verified the errors during meal tray preparation, and the facility policy stated adaptive assistive eating devices shall be provided for all meals.
A cognitively intact resident who was dependent on staff for toileting and personal care reported that a CNA made degrading comments about his bowel incontinence and odor during care. The resident said the CNA spoke rudely, rushed care, and used improper items during cleanup. The AD, SWD, Administrator, and DON confirmed the resident’s complaint and the CNA’s rude comments, while the Administrator did not initially view the incident as abuse.
Two residents were involved in misappropriation findings. One resident with major depressive disorder, HF, and DM had a resident fund account with direct deposit income, a monthly allowance, and Medicaid patient liability issues tied to MITS and county income reporting. Another resident with COPD, oxygen dependence, and HF reported giving a former AA his bank card for purchases, and the state investigation found the AA misappropriated the resident’s property through fraudulent bankcard purchases.
A resident with dementia and severe cognitive impairment developed bruising, hematoma, and multiple bilateral rib fractures with hospital concerns for neglect and/or abuse. The facility did not immediately investigate or report the injury of unknown origin, and staff could not explain how the injuries occurred. The resident’s condition worsened over several days before transfer to the ER and hospital admission.
Failure to report abuse allegations to the State Agency involved a resident-to-resident incident and a separate allegation of verbal abuse by a CNA. One resident reported another resident had run over her feet with a wheelchair, while another resident reported a CNA made degrading comments about his incontinence care and odor. The Administrator confirmed the incidents were investigated or discussed, but the allegations were not reported as required, and the facility policy required immediate reporting of abuse-related allegations.
A resident with acute kidney failure, CHF, and PVD had a cardiology appt ordered, but the appt was missed and documentation stated it was rescheduled when it had not been. The resident's son said he was told the appt would be rescheduled but was not given the new appt info, and an RN confirmed there were no upcoming cardiology appts scheduled.
Delayed Incontinence Care: A resident with bowel and bladder incontinence, impaired mobility, and dependence on staff for ADLs was observed wet in bed and asking to be changed and cleaned up. An LPN checked the brief, confirmed it was wet, but left the room without providing care and was later observed at a med cart during another staff member’s med pass. The resident stated she had last been changed the night before and that it had been a long time.
Failure to Follow Feeding Assistance and Swallowing Orders: A resident with severe cognitive impairment, malnutrition, and dysphagia was supposed to receive meal assistance, no straws, and supervised feeding with modified liquids and textures. Surveyors observed staff setting up meals and leaving the resident alone, and also observed the resident using a straw despite restrictions. Therapy and the DOR stated the resident needed supervision, cueing, and staff present during meals, while an LPN confirmed medications were being given whole in applesauce without a physician order.
A resident with ESRD, DM2, and dependence on dialysis missed a scheduled hemodialysis treatment because transport was not arranged after a hospital return. The resident was observed waiting in the lobby for pickup, and staff later stated the dialysis center had not been updated about the hospitalization. The SSD and RT both acknowledged the facility was responsible for notifying the dialysis center and arranging transport, and the dialysis agreement and dialysis monitoring policy reflected that responsibility.
A resident with multiple chronic conditions and intact cognition had an antibiotic order intended for Augmentin, but the order was transcribed as amoxicillin and the wrong medication was administered for the full course. The CNP confirmed the intended drug and the DON confirmed the medication error occurred and was not reported as a significant medication error.
A resident with documented food allergies was served a tray containing carrots despite physician orders, the care plan, and the diet ticket all noting a carrot allergy. The resident reported repeated issues receiving foods he was allergic to, and a DA verified the carrots were on the plate when the tray was observed.
Failure to provide substantial evening snacks for residents on the memory care unit when the interval between dinner and breakfast was 15.5 hours. Three residents with severe cognitive impairment and nutritional diagnoses had no documentation of a substantial after-dinner snack. Staff confirmed there was no scheduled snack pass, evening refreshments were not provided after the activity assistant left, and the RD verified no substantial snack tracking was done for these residents.
Falsified Shower Sheets in Medical Record: An LPN Unit Manager was observed completing shower sheets after the fact while blank and completed sheets were visible in a back office. The DON confirmed the sheets had not all been completed and stated they should be completed the same day. The resident involved had intact cognition and required moderate assistance with bathing, and shower sheets were identified as part of the medical record.
A resident with type 1 diabetes and multiple comorbidities reported low blood glucose to a CNA, who provided a snack but failed to notify the nurse or monitor the resident further. The nurse did not verify blood glucose readings or perform required rounds throughout the night. The resident was later found unresponsive by a family member, and resuscitation was unsuccessful. Staff did not follow policies for reporting, assessment, or monitoring of changes in condition, resulting in the resident's death.
Three residents experienced lapses in dignity and respect, including being left exposed in bed, having an uncovered drainage bag visible from the hallway, and receiving a meal tray placed next to a full urinal. Staff observed these situations but did not take appropriate action to maintain resident dignity, despite facility policy requiring such standards.
Surveyors found that the facility did not maintain a medication error rate below 5%, with three errors observed among twenty-nine opportunities. Errors included an LPN crushing and administering the wrong form of Aspirin to a resident, a resident missing a scheduled dose of Phenobarbital due to unavailability, and an RN administering a chewable Aspirin tablet not in accordance with the physician's order. These actions were not consistent with facility policy requiring medications to be given as prescribed.
A resident with epilepsy and other medical conditions experienced multiple missed doses of prescribed Phenobarbital due to medication unavailability, incomplete documentation, and staff not utilizing available medication in the facility's automated dispensing system. Staff interviews and record reviews confirmed that the medication was not administered as ordered, and facility policy for medication administration was not followed.
The facility failed to maintain cleanliness and sanitation in the kitchen and nursing unit refrigerators, as observed during a survey. Issues included oil spills, food debris, and grease stains in various areas, as well as unlabeled food items and standing water in a refrigerator. The Mobile Dietary Manager verified these findings, which were contrary to the facility's sanitation policy.
The facility failed to maintain a sanitary dumpster area, potentially affecting all 105 residents. Observations revealed open dumpster lids, a trash bag on the ground, and scattered debris, including an empty cigarette package and used latex gloves. The Mobile Dietary Manager confirmed the observation, noting maintenance was responsible for the area. Facility policy required the area to be clean and debris-free.
The facility's arbitration agreement failed to include a clause allowing residents or their representatives to communicate with federal, state, or local officials, affecting all residents. This omission was confirmed by a corporate nurse during an interview.
The facility's arbitration agreement failed to ensure a neutral and fair process for residents by mandating arbitration through the National Arbitration Forum (NAF) and not allowing other counsel except the American Arbitrators Association (AAA). The agreement also lacked provisions for selecting a neutral arbitrator or venue, affecting all 105 residents. This was confirmed by a review of records and an interview with a corporate nurse.
The facility failed to provide trauma-informed and culturally competent care to five residents with PTSD, as there were no assessments or care plans documented in their medical records. Despite the facility's policy requiring such documentation, it was confirmed by the Regional Director that no evidence of compliance existed.
A resident with a history of diabetes and related complications did not receive a timely ENT referral after an audiologist recommended it due to hearing issues. The Social Services Director was responsible for scheduling but failed to ensure the referral was completed, and the Director of Nursing was unaware of the issue until months later.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis services. The resident, with complex medical conditions including type I diabetes and end-stage renal disease, had missing dialysis communication forms for two months, despite physician orders requiring regular completion. The DON confirmed the deficiency, acknowledging the lapse in communication as per facility policy.
A resident received incorrect medication dosages due to errors in administration by an LPN, leading to a medication error rate of 13.8%. The resident, with a history of multiple medical conditions, was given 400 mg of magnesium oxide instead of the prescribed 500 mg, and other medications lacked specified dosages. The facility's policy on medication administration was not followed.
A facility failed to ensure proper communication between the facility and hospice services for a resident admitted with a stroke and pneumonia. The resident's POA reported a lack of updates on hospice services and medical care. The hospice contract did not specify a designated staff member or hospice representative for coordination of care, nor did it provide medical director information. The hospice agreement stated the resident's right to know caregivers and receive effective communication.
A resident with multiple health conditions experienced a delay in receiving incontinence care due to staffing shortages. The resident waited 53 minutes for assistance after using the call light, as staff were occupied with other duties and one aide was unavailable due to a fire watch. The resident was eventually found with a heavily wetted brief, though no skin damage was observed.
The facility failed to provide the required SNF ABN to three residents before discontinuing their skilled services under Medicare Part A. A resident with dementia, another with fractures and dementia, and a third with end-stage renal disease and diabetes did not receive the necessary financial liability notices. This was confirmed by a social worker who acknowledged the oversight.
A CNA improperly handled soiled linens after providing incontinence care to a resident by discarding them into a trash can and then carrying them unbagged against her body to the utility room. This was against the facility's policy, which required contaminated laundry to be bagged at the point of collection. The resident had multiple medical conditions and was always incontinent, requiring assistance for toileting and hygiene.
A resident with multiple diagnoses, including osteomyelitis, did not receive all prescribed IV antibiotics due to lapses in administration and documentation. Despite having RNs on duty, several doses of Vancomycin and Zosyn were missed, and communication issues among staff contributed to the deficiency. The facility's policy required proper documentation and administration, which was not followed, leading to a deficiency.
The facility did not maintain RN coverage for eight consecutive hours on two days, potentially affecting all 96 residents. This was confirmed by reviewing nursing schedules and an interview with the HR Director.
A resident experienced a cardiac emergency, and the facility failed to provide effective CPR. The resident was found vomiting and later lost consciousness. An LPN initiated CPR on the resident's mattress without a backboard or ambu bag, compromising the effectiveness of the chest compressions. The crash cart was not immediately accessible, arriving only when EMS did. The resident, who had a Full Code status, was transferred to the hospital and subsequently expired.
A facility failed to provide timely care for two residents experiencing changes in condition. One resident, with a history of diabetes and dementia, showed difficulty swallowing and became unresponsive, yet the physician was not notified, and medications were improperly administered. Another resident experienced high blood pressure and rapid breathing, but the physician was not informed, and oxygen therapy was mismanaged. These failures violated the facility's Change in Condition Policy, leading to Immediate Jeopardy for one resident.
An LPN in a long-term care facility failed to clean and disinfect a shared glucometer between uses for multiple residents with diabetes mellitus. The facility's policy required cleaning before and after each use to prevent infection transmission, but the LPN did not adhere to this, using the same glucometer for three residents without cleaning it. The LPN confirmed the lack of cleaning, stating she would clean the device at the end of her shift.
The facility failed to provide timely toileting and incontinence care, affecting several residents. One resident waited over an hour for bathroom assistance, leading to soiling herself, while another wore improperly fitted briefs due to a lack of appropriate sizes. A third resident, needing help with toileting, was left unattended despite repeated calls for assistance. Staffing issues contributed to these deficiencies, with police involvement due to unresponsive staff.
Two residents in a LTC facility experienced significant medication errors. One resident with a seizure disorder did not receive their prescribed vimpat due to unavailability, while another resident with diabetes received insulin after eating, contrary to physician orders. The LPN involved admitted to checking blood sugar levels during or after meals, leading to incorrect insulin administration. Facility policy on medication administration was not followed.
The facility failed to securely administer medications, leaving pills unattended on bedside tables for residents unable to self-administer. Staff interviews confirmed this practice, and the facility's policy lacked guidance on monitoring residents during medication administration.
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. A resident's daughter reported that her calls were not answered or returned. Observations and staff interviews confirmed that nursing staff were occupied with residents and unable to answer phone calls, and messages left by the BOM were not returned. The Administrator acknowledged that this issue had been previously discussed in staff meetings.
A resident with hemiplegia reported an incident where an STNA refused to give her the bed remote control, leading to a physical struggle and derogatory comments. Despite the resident's daughter communicating the incident to the DON, no immediate action was taken, and the DON failed to properly identify herself when addressing the issue, leaving the resident feeling unsupported and disrespected.
The facility failed to implement their abuse policy after a resident reported an incident involving a state tested nurse aide (STNA). Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to investigate or address the allegation. The alleged perpetrator continued to work shifts, and the investigation was delayed, breaching the facility's abuse prohibition policy.
A resident reported an incident involving two STNAs, where one STNA refused to give her the bed remote control, leading to a physical altercation and derogatory comments. The incident was communicated to the DON via text by the resident's daughter, but no immediate action was taken to investigate or report the incident. The facility's self-reported incident was not created until after surveyor intervention, indicating a delay in reporting the abuse allegation to the state agency.
A resident with hemiplegia and hemiparesis reported an incident where an STNA wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. Despite the resident's daughter communicating the incident to the DON via text, the DON did not initiate an investigation or speak to the resident until the following day. The facility failed to immediately suspend the alleged perpetrators and start an investigation, contrary to their abuse prohibition policy.
The facility failed to consistently get a resident with severe cognitive impairment out of bed, despite his medical history and care plan indicating the need for frequent engagement. Staff interviews revealed inconsistencies in care, with some STNAs unwilling to get the resident up and a lack of awareness among LPNs about the resident's recent activities.
The facility failed to ensure a resident with severe cognitive impairments and multiple diagnoses was consistently provided with activities that met his needs. Despite having a care plan that included music and reading, the resident was often observed lying in bed without engagement, and staff interviews revealed inconsistencies in following the care plan.
Failure to Prevent Falls, Unsafe Transfers, and Inadequate Post-Fall Assessment
Penalty
Summary
The facility failed to ensure residents at risk for falls were protected by the ordered fall interventions and by adequate supervision during transfers and after falls. For Resident #113, who had severe cognitive impairment, dementia, spinal stenosis, hospice services, and orders for a perimeter mattress, bed bolsters, bilateral half side rails, floor mats, and two staff for transfers, video surveillance showed the resident on the floor mat beside the bed and then being lifted by one LPN and thrown back into bed without an assessment for injury. The video also showed that the ordered perimeter mattress, bed bolsters, and bilateral half side rails were not in place, and the nurse left the resident alone afterward. The resident later had a swollen right arm and hand and was hospitalized with a thoracic burst fracture and multiple bruises to the hands, wrists, forearms, and upper extremities. The facility also failed to timely identify and investigate unexplained injuries for Resident #56, who had dementia, severe impairment in decision-making, and was dependent on staff for ADLs and transfers with a mechanical lift and two staff assistance. Bruising under the right breast and mid-chest was first documented, then spread to the right upper extremity, shoulder, and breast with pain and edema. The resident was later sent to the hospital and diagnosed with multiple bilateral rib fractures and a large hematoma, with hospital paperwork noting bruising had started earlier than the facility documented. The record showed no progress notes for a period before the injury, and the facility did not initiate the investigation until after the hospital admission. The facility also failed to complete adequate fall assessments and investigations for Resident #115 and Resident #6. Resident #115, who had vascular dementia and a history of falls, was found with a bruise under the right eye after an unwitnessed fall, but the record did not contain an adequate investigation of what caused the fall, what interventions were in place, or what new interventions were implemented afterward, and staff statements were not obtained. Resident #6, who had moderate to severe cognitive impairment and dependence for rolling and ADLs, was found face down on the floor between the bed and window after a fall, and the record showed no fall risk assessment before the event. The report also states the facility failed to implement adequate interventions to prevent a fall, prevent accident hazards, conduct a safe resident transfer, provide appropriate assessment and care after a fall, and complete timely and accurate fall assessments, investigations, and care plans.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet resident needs and to maintain a licensed nurse in charge on each shift. Review of the Payroll Based Journal showed the facility had a one-star staffing rating and low weekend staffing for the second fiscal year quarter from 01/01/26 through 03/31/26. Interviews with residents and staff described delayed responses to call lights, delayed incontinence care, and difficulty completing showers, two-hour checks, and mechanical lift transfers because there were not enough aides scheduled or available to cover call-offs. Residents reported long waits for assistance. One resident stated call lights were not always answered timely. Another said there was not enough staff for mechanical lift transfers and that she frequently had to wait to get up. A third resident reported that on first shift and weekends there were not enough staff and care was not always timely. Another resident stated the facility was short-staffed on all shifts and call lights sometimes took at least an hour and a half to be answered. A resident’s daughter also reported concerns that care was not being provided timely. One resident said staff told him they would come back but did not return for several hours, and he stated night shift was really bad. Direct observations showed residents waiting for incontinence care while soiled. One resident was observed lying in bed pointing to her brief and stated she was wet and had last been changed the night before; an LPN checked the brief, confirmed it was wet, then left the room without changing her. Another resident was observed waiting for incontinence care and stated he had been waiting a long time to be changed before eating; his brief was saturated with urine, and staff confirmed he had waited about two to three hours. A third resident’s call light was observed blinking, and after an ADON briefly entered and left without doing anything, a CNA later provided care; that resident stated he had waited an hour to an hour and a half to be changed. Staff interviews also confirmed staffing shortages, including assignments where only two aides were on a unit, changes in assignments were not always communicated, call-offs were not always covered, and staff were not always able to complete showers, checks, changes, or two-person transfers in a timely manner.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of the nursing staff schedule and staff time punches for 06/06/26 showed there was no RN present working in the facility. During an interview on 07/28/26 at 10:18 A.M., the Administrator confirmed that he was unable to provide evidence that an RN was working for at least eight consecutive hours on 06/06/26. The deficiency was identified under Complaint Numbers 2735166, 2715490, and 1405090 (OH00167146) and had the potential to affect all 95 residents residing in the facility.
Ineffective Administration Affecting Falls, Staffing, Nutrition, Immunizations, and Abuse Prevention
Penalty
Summary
The facility failed to administer operations in a manner that used resources effectively and efficiently, with ineffective administration affecting multiple residents across several care areas. The report states that the facility did not maintain effective systems for fall prevention and accident hazard control, including failure to follow fall interventions and the smoking policy, and failure to complete accurate fall assessments, investigations, and care plans. These issues affected Residents #6, #9, #24, #56, #113, and #115, and the report notes actual harm to Resident #56, who sustained multiple right and left rib fractures, a hematoma to the right chest wall, bruising across the breasts, right flank, back, both arms, both sides of the ribs, and both legs, with no actual determination of the cause of injuries. The report also describes a serious injury to Resident #113 after a fall from bed, when staff inappropriately transferred the resident and she was thrown onto the bed. The resident sustained a thoracic burst fracture and multiple ecchymoses on both hands, wrists, forearms, and upper extremities. In addition, Residents #6, #9, #24, and #115 had falls with inadequate investigations, incomplete documentation, updated care plans, and inaccurate assessments. The facility also failed to provide effective dietary services by not ensuring substantial snacks for the secured memory care unit, honoring food preferences, and providing needed adaptive equipment, affecting Residents #29, #49, #80, #83, #86, #96, and #99. Other findings included inadequate nursing services and staffing, with no RN coverage at least eight hours daily and insufficient staffing to meet resident needs, affecting Residents #6, #12, #13, #16, #39, #40, #45, #88, #93, #99, and #110. The report states that nursing staff did not implement care-planned interventions for Resident #45, did not follow discharge instructions or provide timely incontinence care for Resident #13, did not ensure dialysis transport for Resident #106, did not accurately document advance directives for Resident #93, and did not accurately transcribe a physician order that led to a significant medication error for Resident #88; it also states that bathing documentation for Resident #88 was falsified. Additional deficiencies involved an ineffective immunization program for Residents #9, #24, #32, and #72, and failures in abuse, neglect, misappropriation, and exploitation prevention, including verbal abuse toward Resident #93, misappropriated funds from Resident #61, misappropriated personal property from Resident #117, unnecessary medications for Residents #25 and #30, and delayed abuse reporting and investigations for Residents #56, #82, #93, and #117.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide required assistance with activities of daily living for multiple residents, including timely incontinence care, bathing, meal assistance, grooming, and basic bed positioning. The report states that this deficient practice affected five residents out of seven reviewed for ADL needs. Facility policies required residents who were unable to perform ADLs to receive necessary services, including incontinence care, grooming, and bathing according to their care plans. Resident #45 had diagnoses including cerebral infarction, protein-calorie malnutrition, and adult failure to thrive, and his care plan called for assistance with toileting, incontinence care, and fingernail care. On observation, he had large dried urine areas on his sheet and bedspread, his sleep pants and brief were wet with urine, and he had a moderate bowel movement. His fingernails were about a half inch long, yellow, and had brownish-black material under them. Staff confirmed the sheets had not been changed in quite a while, and a CNA assigned to him had not changed his brief that morning. The DON later confirmed not all showers were completed and shower sheets were not available for the resident for the reviewed period. Resident #16 had diagnoses including hemiplegia and neurogenic bowel and bladder, and his care plan required checking and changing during care rounds and as needed for incontinence. He reported needing to be changed, but his brief remained unchanged for hours after he requested help, and his brief was saturated with urine when care was finally provided. He also reported that his mattress slid every day, and observation showed a gap between the mattress and headboard with the mattress hanging over the foot of the bed. Maintenance later confirmed no one had informed him of the repair need before it was pointed out during survey. Resident #93, who was cognitively intact and dependent on staff for toileting hygiene, bathing, dressing, and personal hygiene, was observed with his call light on and reported waiting an hour to an hour and a half for incontinence care; his brief was very wet with urine when staff finally assisted him. Resident #88’s shower documentation showed only 6 of 18 shower opportunities had completed shower sheets over the reviewed three-month period, despite a care need for bathing assistance. Resident #110, who was dependent on staff for eating and other ADLs, was captured on video with a meal tray left on the overbed table while no staff assisted him with eating; the nurse entered the room, asked if he was hungry, and left without providing meal assistance. Later video showed food brought back to the room hours afterward, and police responded to a neglect allegation related to the resident’s care. The Administrator confirmed the video showed the resident in bed with the meal tray against the wall and no staff assisting with the meal.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure residents were provided with adaptive eating equipment and utensils as ordered. Review of the facility policy stated that adaptive assistive eating devices shall be provided to residents who need them for all meals. During observation, Dietary Aide #910 prepared meal trays for residents and placed them in the food cart, but three residents did not receive the equipment specified on their diet tickets and orders. Resident #86 had diagnoses including unspecified protein-calorie malnutrition, depression, and diverticulitis of the intestine, and had severely impaired cognition and required supervision or touching for eating. Although the diet order specified disposable silverware for resident safety, the tray observed contained regular silverware instead of disposable silverware. Resident #80 had diagnoses including Parkinson's Disease, Alzheimer's Disease, and anxiety disorder, had severely impaired cognition, and required supervision or touching for eating; her diet ticket specified a divided plate, but her meal was served on a regular plate with no dividers. Resident #29 had diagnoses including bipolar disorder, unspecified protein-calorie malnutrition, and Alzheimer's Disease, had severely impaired cognition and required moderate assistance for eating; his diet ticket specified no butter knife, but his tray contained a butter knife.
Verbal Abuse Toward Resident During Incontinence Care
Penalty
Summary
The facility failed to ensure a cognitively intact resident was free from staff-to-resident verbal abuse. The resident had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, heart failure, an acquired absence of the right leg above the knee, and peripheral vascular disease. He was dependent on staff for toileting hygiene, bathing, dressing, and personal hygiene, and he was always incontinent of urine and bowel during the assessment look-back period. A grievance form documented that a CNA made comments about the smell of the resident’s bowel movements and said the resident was lucky to stay in bed, soil himself, and have someone like that CNA take care of him. The resident reported that the CNA had a smart mouth, told him it must be nice to be lying in bed soiling himself and waiting to be cleaned up, and repeatedly commented on how much he went and how bad it smelled. The resident also stated the CNA was in a hurry, did not do a good job with incontinence care, and used paper towels and even a pillowcase during care. During interviews, the resident said he reported the incident to the AD and Central Supply Clerk, and the AD confirmed the resident had raised concerns but was directed to the SWD. The SWD stated the resident was upset and reported the CNA’s comments about how much he defecated and how it smelled. The Administrator and DON acknowledged the resident’s account and stated the CNA had been rude, but the Administrator also stated he did not think the situation was abusive and had not initiated an investigation with the CNA or other residents at that point.
Misappropriation of Resident Funds and Personal Property
Penalty
Summary
The facility failed to ensure Resident #61 was free from misappropriation of resident funds. Resident #61 was admitted with diagnoses including major depressive disorder, heart failure, and diabetes mellitus, and was documented as alert and oriented with a BIMS score of 13/15. The resident had a resident fund management services account with direct deposit of Social Security and pension income, a monthly allowance of $75.00, and a Medicaid patient liability of $672.00. Review of the resident fund records showed a current balance of $34,245.19 and quarterly statements showing repeated deposits and automatic withdrawals tied to care costs and patient liability. Facility staff stated the resident’s account was high because the county Medicaid Benefits Center did not receive the resident’s income information correctly, and the Medicaid supervisor stated the facility did not have the right to adjust the patient liability submitted in MITS. The facility also failed to ensure Resident #117 was free from misappropriation of personal property. Resident #117 was admitted with diagnoses including COPD, dependence on supplemental oxygen, and heart failure, and was documented as alert, oriented, and able to make decisions with intact cognition. The resident reported that he had used an outside bank account regularly and that he sometimes gave money or his bank card to a former activity aide to make purchases for him. The resident stated that on one occasion the debit card was given to the aide to purchase items for him and to assist with his Medicaid spend-down. The investigation and state findings identified that the former activity aide had misappropriated the resident’s property by making fraudulent purchases with the resident’s bank card. The employee file showed the aide had previously been terminated for unauthorized possession or use of property belonging to the facility. The ODH investigation record and letter stated that the allegation had a reasonable basis and that the Director adopted the finding of misappropriation against the aide. The facility’s abuse prohibition policy stated residents had the right to be free from abuse and misappropriation of resident property and/or funds.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy related to an injury of unknown origin for a resident with dementia, transient cerebral ischemic attack, severe cognitive impairment, and dependence on staff for activities of daily living. The resident’s record showed new diagnoses of multiple bilateral rib fractures and a right thorax contusion after bruising and hematoma were identified on the chest and upper body. The resident also had impaired upper and lower extremities and required two-staff assistance for ADLs and transfers. The resident’s skin changes were first documented as bruising under the right breast, right nipple, and middle of the chest, followed by spread of bruising to the right upper extremity, shoulder, and breast, along with pain and edema. A chest x-ray showed no acute findings, but the resident later required transfer to the hospital for further evaluation because of worsening bruising, hematoma, redness, edema to the right hand, and increased pain. Hospital paperwork documented multiple bilateral nondisplaced rib fractures and a large intramuscular hematoma, with concerns of neglect and/or abuse, and noted that bruising had started earlier than the facility documented. The facility did not initiate its investigation until after the resident was admitted to the hospital and did not report the incident immediately. The facility’s own timeline showed several days between the first observed skin change and the initiation of the self-reported incident. Staff interviews confirmed that no explanation for the injuries was identified, that the facility believed a bear-hug type repositioning may have occurred even though that technique was not taught or used, and that the facility reported the injury of unknown origin after the resident’s hospital admission. The administrator confirmed there was no immediate reporting and that the investigation began only after the hospital admission.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report abuse allegations to the State Agency for three residents. The deficiency involved a former resident, a current resident, and another current resident, and the report states the facility census was 95. The facility policy titled Abuse Prohibition required alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property to be reported immediately, but not later than two hours or 24 hours depending on the circumstances. For one resident, the record showed a report that another resident grazed her left foot with a wheelchair, with no injury found on assessment and an x-ray showing no fracture. The resident later stated that the former resident had run over her feet with a wheelchair, while the Administrator and SSD confirmed the facility investigated the matter and determined it did not occur. The Administrator later confirmed that the physical altercation between the two residents was not reported to the State Agency. For another resident, the record and interviews showed the resident complained that a CNA made repeated rude and degrading comments about his bowel movements and incontinence care, including remarks about the smell and about him being lucky to stay in bed soiled while the CNA cared for him. The resident reported the comments to staff, and multiple interviews confirmed the CNA had spoken to him in a disrespectful manner. The Administrator stated he did not think the situation was abuse and therefore did not report it to the required State Agency. The facility’s self-reported incident record for this event identified the allegation as emotional/verbal abuse, but the report was not completed.
Missed cardiology appointment was not rescheduled
Penalty
Summary
The facility failed to ensure physician orders were followed for a cardiology appointment for one resident. The resident was admitted with diagnoses including acute kidney failure, acute chronic diastolic congestive heart failure, and peripheral vascular disease. Her care plan identified altered cardiovascular status related to hypertension, peripheral vascular disease, and hyperlipidemia, with an intervention for follow-up with cardiology as ordered. A physician order dated 07/10/26 scheduled a cardiology appointment for 07/14/26 at 8:00 A.M. Progress notes showed the resident's son contacted the facility about follow-up appointments and later stated he could not take the resident to the appointment and agreed to reschedule. A note at 8:11 A.M. on 07/14/26 stated the cardiology appointment was rescheduled. However, the resident's son later reported he was told the appointment had been missed and that it would be rescheduled, but he was not given the new information. During interview, RN #818 reviewed the record and stated there were no upcoming cardiology follow-up appointments scheduled and that although a note said the appointment was rescheduled, it had not been rescheduled. The facility policy stated residents had a right to adequate and appropriate medical treatment and nursing care.
Delayed Incontinence Care
Penalty
Summary
Timely incontinence care was not provided for Resident #13. The resident was admitted with diagnoses including acute kidney failure, acute chronic diastolic congestive heart failure, and peripheral vascular disease. Her care plan documented impaired mobility, bowel and bladder incontinence, dependence on staff for ADLs, and interventions to assist with toileting needs throughout the day and to check and change her as needed. The MDS showed a BIMS score of 15/15, and the resident was impaired in both upper and lower extremities and dependent on staff for ADLs. During an observation and interview on 07/22/26 at 7:37 A.M., Resident #13 was in bed pointing to her brief and stated she was wet and needed to be changed and cleaned up. She said she had last been changed the night before and that it had been a long time. At 7:39 A.M., an LPN observed in the room checked the brief, confirmed the resident was wet, fastened the brief back together, pulled up the covers, washed her hands, and left the room stating she would be back. The LPN was then observed standing next to a medication cart watching a medication pass by another surveyor and did not change the resident at that time. The facility policy titled Incontinence Care stated the facility had a policy to ensure residents who were incontinent of bowel and/or bladder received appropriate treatment and services.
Failure to Follow Feeding Assistance and Swallowing Orders
Penalty
Summary
The facility failed to ensure Resident #45’s care-planned interventions were implemented and physician orders were followed for eating assistance and adaptive equipment. Resident #45 was admitted after a hospital stay with discharge diagnoses including failure to thrive, unsteady gait, and severe malnutrition, and his records also listed cerebral infarction, unspecified protein-calorie malnutrition, and adult failure to thrive. The hospital discharge instructions included a soft, bite-sized diet with thin liquids, aspiration precautions, one-to-one supervision, slow feeding, upright positioning, no straws, and medications whole in puree, but the facility’s physician orders did not include an order to give medications whole in applesauce or pudding. The record showed that Resident #45’s physician orders included assistance with all meals and no straws, and the care plan included eating assistance and no straws. Speech therapy evaluated him for dysphagia and recommended nectar-thick liquids and mechanical soft/ground textures. Therapy documentation also noted that on one occasion he had thin liquids at the bedside despite being on nectar-thick liquids, and the thin liquid was removed after staff education. The admission MDS reflected severe cognitive impairment and that he required supervision or touching assistance with eating. Survey observations showed Resident #45 eating without staff present after meal setup, including one observation where he was seated with a meal tray and no staff assisting him, and another where staff set up the meal and left the room. The DOR stated he needed supervision, a lot of cueing, small bites, alternating bites and sips, and that staff should stay in the room while he ate. Additional observations showed Resident #45 using a straw even though he was not supposed to have straws, and the DOR confirmed the straw was not allowed. An LPN confirmed that medications were given whole in applesauce even though no physician order was present for that method.
Missed Dialysis Transport for Resident Requiring Hemodialysis
Penalty
Summary
The facility failed to ensure a resident who required hemodialysis was transported to treatment. Resident #106 was admitted with diagnoses including dependence on renal dialysis, end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and hypertensive heart and chronic kidney disease with heart failure and end stage renal disease. The care plan identified that he was dependent on dialysis and received hemodialysis three times a week. He had a BIMS score of 13, indicating no cognitive impairment, and was dependent on staff for activities of daily living with impaired upper and lower extremities bilaterally. After the resident returned from the hospital, physician orders continued hemodialysis three times weekly with a 6:15 A.M. pickup time and instruction to be in the lobby at 5:15 A.M. On the morning of the missed treatment, the resident was observed waiting in his wheelchair in the lobby and later stated he was waiting for dialysis transport. Staff later told him he had missed the appointment because transportation had not been set up. The SSD stated it was the facility's responsibility to call and alert the dialysis center of updates, including hospitalizations. The RT stated the dialysis transport was automatic, but when the resident transferred to the hospital the facility did not update the dialysis center, and the center stopped coming after unsuccessful pickup attempts. The facility's dialysis transfer agreement stated it was responsible for arranging transportation to and from the dialysis center, and the dialysis monitoring policy stated the facility would maintain the safety and health of residents receiving dialysis services.
Medication Order Transcription Error Led to Wrong Antibiotic Administration
Penalty
Summary
The facility failed to ensure medication orders were transcribed accurately, resulting in a significant medication error for one resident. Resident #88 had diagnoses including cerebral palsy, morbid obesity, type II diabetes, paraplegia, scoliosis, and post-traumatic stress disorder, and had a BIMS score of 15 indicating intact cognition. The record showed an order for Augmentin 875 mg orally twice daily for sinusitis, but the medication system identified a possible drug allergy and the order was entered as amoxicillin 875 mg instead. Physician orders and the MAR showed amoxicillin 875 mg was administered orally from 06/26/25 through 07/04/25, while the CNP confirmed Augmentin had been intended and that if amoxicillin was given, a medication error occurred. The CNP stated he was not made aware of the error. The DON also confirmed the order was intended for Augmentin, amoxicillin was given in error for the full seven days, and a significant medication error report was not completed.
Food Allergy Not Honored on Resident Tray
Penalty
Summary
The facility failed to honor a resident’s food allergy by serving carrots on the resident’s tray even though the resident’s physician orders and diet tray ticket documented an allergy to carrots. Resident #83 was admitted with diagnoses including chronic obstructive pulmonary disease, obsessive-compulsive disorder, and anxiety disorder, and the MDS indicated intact cognition and that the resident required supervision with eating. The physician orders for July 2026 specified a regular diet with regular texture, thin liquids, and double portions, and the care plan identified multi-food allergies and intolerances, including melons and carrots. Record review and observation showed that Resident #83’s diet tray ticket listed allergies to melons and carrots, yet the resident reported having issues receiving foods he was allergic to, including carrots and melon. During observation, the resident’s tray was prepared for delivery and carrots were present on the plate. The Dietary Aide verified at the time of the observation that the tray contained carrots despite the documented carrot allergy.
Failure to Provide Substantial Evening Snacks
Penalty
Summary
The facility failed to provide substantial evening snacks for residents on the memory care unit when the time between dinner and breakfast was greater than 14 hours. The posted meal schedule showed breakfast delivered to the memory care cart by 7:30 A.M. and dinner delivered by 4:00 P.M., creating a 15.5-hour interval. The facility policy stated meals must be served on a planned schedule allowing no more than 14 hours between dinner and breakfast unless an evening snack consisting of at least two food groups is offered, which could extend the interval to 16 hours. Record review showed that three residents with severe cognitive impairment and significant care needs had no documentation of a substantial after-dinner snack. Resident #49 had diagnoses including dementia, major depressive disorder, and mild protein-calorie malnutrition and required moderate assistance with eating. Resident #96 had vascular dementia, major depressive disorder, and unspecified protein-calorie malnutrition and required supervision with eating. Resident #99 had Alzheimer’s disease, major depressive disorder, and mild protein-calorie malnutrition and was dependent in activities of daily living. Interviews with staff confirmed there was no scheduled snack pass, evening refreshments were not provided by the activity assistant after 4:30 P.M., and the regional registered dietitian verified there was no substantial after-dinner snack tracking for these residents.
Falsified Shower Sheets in Medical Record
Penalty
Summary
The facility failed to ensure shower sheets were not falsified for one resident reviewed for showers. Resident #88 was admitted on 02/13/24 and had diagnoses including cerebral palsy, morbid obesity, type II diabetes, paraplegia, and scoliosis. The 05/22/26 MDS showed a BIMs score of 15, indicating intact cognition, and the resident required moderate assistance with bathing. During observation on 07/23/26 at 2:28 P.M., the DON, ADON #713, LPN Unit Manager #705, and CNA #943 were in a back office with the door closed, where blank and completed shower sheets were visible on the desk. The LPN Unit Manager was observed actively writing on a shower sheet and confirmed she was writing in the year on the date for Resident #39 and that it was not a current shower sheet, but rather a sheet from 05/13/26 that was not complete and was being finished before giving the requested shower sheets to surveyors. The DON later confirmed not all requested shower sheets had been completed and stated shower sheets should not be completed after the fact and should be completed the same day. The Administrator later confirmed the Unit Manager was suspended pending investigation, and then confirmed the DON and ADON were also suspended pending investigation related to falsification of documents. The Regional Director of Clinical Operations confirmed shower sheets are part of the medical record and should be placed in the medical record after completion.
Failure to Respond to Acute Change in Condition for Diabetic Resident
Penalty
Summary
A deficiency occurred when staff failed to timely identify and respond to an acute change in condition for a resident with type 1 diabetes, chronic kidney disease, and other significant comorbidities. The resident, known to be a brittle diabetic, activated her call light during the night and reported to a CNA that her blood glucose was low and requested a snack. The CNA provided a snack but did not notify the nurse on duty of the resident's report of low blood glucose, nor did she return to check on the resident after the initial interaction. No further nursing assessment or monitoring was performed for the resident throughout the night. The nurse on duty, an LPN, had last seen the resident earlier in the evening when administering scheduled medications and insulin, relying solely on the resident's verbal report of her blood glucose reading from a continuous glucose monitoring device, without verifying the reading herself. The LPN did not make any rounds or assessments of the resident for the remainder of the night shift. The resident was not checked on again until her husband arrived in the morning and found her unresponsive, not breathing, and without a pulse. Resuscitative efforts were initiated, and EMS was called, but the resident was pronounced deceased at the facility. During the code, a blood glucose check revealed a critically low reading. Interviews and record reviews confirmed that staff failed to follow facility policy regarding timely reporting and assessment of changes in condition, as well as routine rounding and verification of blood glucose readings, directly contributing to the resident's lack of care and subsequent death.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple observations and interviews involving three residents. One resident, who was alert and oriented but required assistance with activities of daily living (ADLs) due to physical impairments, was observed lying in bed uncovered and naked from the waist down, visible from the hallway. A CNA who noticed the situation did not intervene, stating the resident was not assigned to her care, and confirmed the resident's exposed state. Another resident, who was alert but cognitively impaired and dependent on staff for ADLs, was observed sitting in her room with her cholecystostomy drainage bag exposed and visible from the hallway. The resident reported that her drainage bag was never covered. An LPN confirmed that elimination bags should be covered for resident dignity and verified the observation at the time. A third resident, with quadriplegia and other significant medical conditions, required staff assistance for ADLs. A CNA delivered this resident's breakfast tray and placed it next to a urinal that was three-quarters full of urine, then left the room without emptying the urinal. The resident expressed discomfort with eating near the full urinal and stated he would not eat his breakfast because of it. The CNA and the LPN/Unit Manager both confirmed that the urinal should have been emptied before placing the meal tray nearby. Facility policy requires the maintenance of residents' personal dignity, well-being, and self-determination.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three errors observed out of twenty-nine opportunities, resulting in a 10.34% error rate. For one resident with Alzheimer's Disease, chronic kidney disease, and hypertension, a physician order specified Aspirin 81 mg delayed release, not to be crushed. However, an LPN crushed and administered a chewable Aspirin 81 mg tablet instead, contrary to the order. Another resident with a history of femur fracture, diabetes, epilepsy, and failure to thrive did not receive a scheduled dose of Phenobarbital 32.4 mg in the morning because the medication was not available in the narcotic drawer, and the nurse confirmed it could not be administered as ordered. A third resident, diagnosed with malignant neoplasm, secondary bone neoplasm, fibromyalgia, and chronic kidney disease, was ordered to receive Aspirin 81 mg by mouth in the morning. During medication administration, an RN provided a chewable Aspirin 81 mg tablet, which the resident swallowed, and later confirmed this was not in accordance with the physician's order. In all cases, facility policy required medications to be administered as per written physician orders, but these were not followed, leading to the cited deficiency.
Failure to Administer Seizure Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Phenobarbital for seizure control. The resident, who had diagnoses including epilepsy, left femur fracture, type 2 diabetes mellitus, and adult failure to thrive, had multiple missed doses of Phenobarbital as ordered by the physician. Review of the medication administration records (MAR) for May revealed nine missed morning doses and four missed bedtime doses, with documentation inconsistencies and incomplete nursing notes regarding the reasons for the missed doses. In several instances, the medication was not available in the facility, and pharmacy delivery delays or prescription issues were cited, but not always clearly documented. Observations confirmed that the medication was not present in the locked narcotic drawer during medication pass, and staff interviews revealed a lack of awareness and follow-up regarding the missed doses. The nurse practitioner was not informed of the extent of the missed doses and expressed concern, noting that the medication is critical for seizure prevention. Further review indicated that the medication was actually available in the facility's AlixaRX system and could have been administered, but this resource was not utilized by staff. Facility policy requires medications to be administered in accordance with physician orders and established schedules, but these protocols were not followed in this case. The resident's Phenobarbital blood level was found to be at the lower end of the therapeutic range, and the facility's own records showed that the medication was available but not accessed. The deficiency was substantiated by interviews, record reviews, and direct observation, confirming that the resident was not protected from significant medication errors as required.
Sanitation Deficiencies in Kitchen and Refrigerators
Penalty
Summary
The facility failed to maintain the kitchen and nursing unit refrigerators in a clean and sanitary manner, as observed during a survey. During an initial tour of the kitchen, several issues were noted, including a large oil spill under a container of cooking oil, food debris on top of the oven, and an oven mitt on the floor. The deep fryer had food crumbs and grease stains, and the floor beneath it had a brownish substance and food crumbs. Shelves under the steam table, which held clean steam table pans, had various crumbs and food debris. The reach-in freezer and refrigerator under the steam table contained food debris, and a sliced tomato and lettuce leaf were found wrapped in saran without a date or label. Additionally, the side of the steam table had crumbs and food debris, and a container holding utensils had food debris and stains. An unattached tubing for the juice/pop machine was on the floor, and the ice machine had a moderate amount of dried whitish substance on its exterior. Further observations revealed that the reach-in refrigerator near the juice/pop machine had standing water inside, and there was food splatter on the doors of the refrigerator. The nursing unit refrigerator had a dried reddish substance on the bottom of the freezer and running down the inside door. These findings were verified by the Mobile Dietary Manager, who acknowledged the issues, including the lime buildup on the ice machine. The facility's policy on general sanitation of the kitchen, which was undated, stated that food and nutrition services staff would maintain kitchen sanitation through compliance with a written comprehensive cleaning schedule.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain the outside dumpster area in a sanitary condition, which had the potential to affect all 105 residents. During an observation, two dumpsters were found with their lids open, and a large clear trash bag was on the ground next to one of the dumpsters. Additionally, various trash items, including an empty cigarette package and several used latex gloves, were scattered on the ground around and between the dumpsters. An interview with the Mobile Dietary Manager confirmed the observation and indicated that maintenance was responsible for the upkeep of the dumpster area. The facility's undated policy on Trash Handling stated that outside dumpsters and their surrounding areas should be kept clean and free of debris.
Arbitration Agreement Lacks Required Communication Clause
Penalty
Summary
The facility failed to ensure its arbitration agreement contained all required information, affecting all residents with a census of 105. Upon reviewing the facility's admission packet, it was found that the arbitration agreement and requirements were included on pages nine and ten of the admission agreement. However, the agreement did not state that residents or their representatives could communicate with federal, state, or local officials, including federal and state surveyors, health department employees, and representatives of the Office of the State Long-Term Care Ombudsman. This omission was confirmed during an interview with Corporate Nurse #999, who acknowledged that the agreement should have included this information.
Lack of Neutral Arbitration Process in Facility Agreements
Penalty
Summary
The facility failed to provide a neutral and fair arbitration process for its residents. The arbitration agreement, included in the admission packet on pages nine and ten, mandated arbitration through the National Arbitration Forum (NAF) and did not allow residents or their representatives to seek other counsel except the American Arbitrators Association (AAA) for binding arbitration disputes. Additionally, the agreement lacked provisions for selecting a neutral arbitrator or a mutually agreed-upon venue for arbitration proceedings. This deficiency affected all 105 residents of the facility, as confirmed by a review of resident medical records and an interview with Corporate Nurse #999, who verified the absence of information related to a neutrally agreed-upon arbitrator or venue in the agreement.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to residents diagnosed with PTSD, affecting five residents. These residents, who had various cognitive impairments and required different levels of assistance with activities of daily living, did not have any assessments, care plans, or documentation related to their trauma diagnoses or culturally competent care in their medical records. This lack of documentation was confirmed by the Regional Director during an interview. The facility's policy on Trauma Informed Care, dated October 4, 2022, mandates the completion of assessments to identify residents with mental and psychosocial disorders, including PTSD, and the development of resident-specific care plans addressing cultural preferences. However, the facility did not adhere to this policy, as evidenced by the absence of relevant documentation for the affected residents.
Failure to Schedule ENT Referral for Resident
Penalty
Summary
The facility failed to ensure a timely referral for an ear, nose, and throat (ENT) appointment for a resident, which was identified during a review of records and interviews. The resident, who had a history of type I diabetes mellitus with multiple complications, including diabetic retinopathy and neuropathy, was seen by an audiologist who recommended an ENT consult due to asymmetrical hearing loss, tinnitus, and dizziness. This recommendation was communicated to the Social Services Director (SSD), who was responsible for scheduling the appointment. However, the referral process was not completed as expected. The SSD stated that the referral was passed to a nurse, but she was unsure which nurse received it, and no appointment was made. The Director of Nursing (DON) was only made aware of the issue months later and was uncertain about the referral's status since it occurred before her tenure at the facility. This oversight affected the resident's access to necessary ENT services, as no appointment was scheduled following the audiologist's recommendation.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center for a resident requiring dialysis services. This deficiency was identified through a review of medical records, staff interviews, and facility policy and procedures. The resident involved had multiple complex medical conditions, including type I diabetes mellitus with various complications, chronic pancreatitis, hypotension, cardiomegaly, dependence on renal dialysis, end-stage renal disease, and epilepsy. The resident was noted to have intact cognition and was independent with activities of daily living, receiving dialysis as part of their care. The deficiency was specifically related to the lack of completed dialysis communication forms, which are essential for maintaining ongoing communication and collaboration with the dialysis facility. The physician orders required that dialysis monitoring forms be completed every day shift on Mondays, Wednesdays, and Fridays. However, the review revealed missing communication forms for January and February 2025, despite having forms completed in the previous months. The Director of Nursing confirmed the absence of these forms, acknowledging the deficiency in maintaining proper communication as per the facility's policy revised in December 2022.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate above 5%. During an observation of medication administration for a resident, an LPN prepared and administered medications that did not match the prescribed orders. Specifically, the resident was given 400 mg of magnesium oxide instead of the prescribed 500 mg. Additionally, the orders for vitamin D-3, cranberry, and Gas-X did not specify the correct dosages, leading to further medication errors. The resident involved had a medical history that included a femur fracture, major depressive disorder, dementia, and a gastric ulcer. The errors were confirmed through an interview with the LPN, who acknowledged the discrepancies between the administered medications and the prescribed orders. The facility's medication administration policy, which emphasizes the five rights of medication administration, was not adhered to, resulting in four errors out of 29 observed opportunities, equating to a 13.8% error rate.
Lack of Communication Between Facility and Hospice Services
Penalty
Summary
The facility failed to provide appropriate and timely ongoing communication between the facility and hospice services for Resident #63, who was one of three residents reviewed for hospice services. Resident #63 was admitted to hospice services with diagnoses including a stroke affecting the left side and pneumonia. The resident's power of attorney (POA) reported a lack of communication between the facility and hospice services, stating that the facility did not designate a staff member to address the resident's medical care and did not provide updates on hospice services or the resident's medical condition. The review of Resident #63's hospice contract revealed that it did not specify a designated staff member, hospice representative, or medical director information for coordination of care and communication between the hospice provider and the facility. The Regional Nurse confirmed that the hospice contract lacked this information. The hospice agreement stated that the resident and/or guardian has the right to know who the caregivers are, their professional titles, and their roles, as well as the right to effective verbal and written communication.
Delayed Incontinence Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #22, who was occasionally incontinent and required substantial assistance for toileting. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, HIV disease, aphasia, and neurogenic bowels, reported waiting up to 30 minutes for assistance after using the call light. On one occasion, the resident's call light was observed to be on for 53 minutes before receiving incontinence care, during which time multiple staff members entered and left the room without providing the necessary care. The delay in care was attributed to staffing shortages, as confirmed by a CNA who was responsible for over 20 residents and noted that the facility was working short-staffed with only four aides available. The CNA mentioned that one aide was unavailable due to a fire watch requirement. The resident was eventually found with a heavily wetted brief, although there was no clear evidence of moisture-related skin damage. This incident was part of a broader investigation under specific complaint numbers.
Failure to Provide Required SNF ABN Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents prior to the discontinuation of their skilled services under Medicare Part A. This deficiency affected three residents, each with significant medical conditions. Resident #85, diagnosed with dementia, protein malnutrition, and high blood pressure, was discharged from skilled services and returned to his community residence. Resident #95, with diagnoses including fractures of both femurs, dementia, and visual hallucinations, transitioned to hospice services at the facility. Resident #304, suffering from end-stage renal disease, type two diabetes, and major depressive disorder, was discharged and returned to her community residence. A review of their financial liability notices revealed that none of these residents received the SNF ABN as required. This was confirmed during an interview with Social Worker #400, who acknowledged that the forms were not provided to the residents as mandated.
Improper Handling of Soiled Linens by CNA
Penalty
Summary
The facility failed to ensure proper handling and transport of soiled linens after providing incontinence care to Resident #37. During an observation, CNA #300 was seen discarding a urine-soaked brief and soiled washcloths, towels, and draw sheets into a trash can lined with a plastic bag. CNA #300 then used gloved hands to retrieve the soiled linens from the trash can, cradled them in her bare arm against her chest, and carried them unbagged into the hallway to the soiled utility room. This action was contrary to the facility's policy, which required contaminated laundry to be bagged or contained at the point of collection and not held close to the body during transport. Resident #37, who was cognitively intact, had a range of medical conditions including cerebral infarction, atherosclerotic heart disease, and flaccid hemiplegia, and was always incontinent of bowel and bladder, requiring assistance for toileting and hygiene. Interviews with CNA #300 and CNA #359 confirmed the improper handling of soiled linens, with CNA #300 stating there were not enough plastic bags available and that staff were not allowed to bring soiled linen barrels to resident rooms. The deficiency was identified during a complaint investigation and had the potential to affect additional residents receiving care from CNA #300.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that all intravenous (IV) antibiotics were administered to a resident as ordered by the physician. The resident, who was admitted with multiple diagnoses including osteomyelitis, pressure ulcers, and quadriplegia, was receiving antibiotic therapy as part of their treatment plan. However, a review of the medical records revealed that several doses of Vancomycin and Zosyn were not documented as administered on multiple occasions in November and December. The medication administration records (MAR) and progress notes lacked evidence of administration for specific dates and times, indicating a failure to follow the physician's orders. Interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed the lapses in medication administration. LPNs reported that there were instances when no Registered Nurse (RN) was available to administer the IV antibiotics, leading to missed doses. The DON acknowledged communication issues among staff regarding RN availability for IV administration and confirmed that there were RNs on duty during some of the times when doses were missed. However, the DON could not verify that all undocumented doses had been administered, as there was no documentation to support this. The facility's policy on medication administration required that medications be administered according to prescriber orders and documented in the MAR by the administering nurse. The policy also stipulated that staff should not end their work duty without ensuring all administered medications were documented. The failure to adhere to these guidelines resulted in a deficiency, as the facility did not ensure that the resident received their prescribed IV antibiotics as ordered, and there was a lack of documentation to confirm administration.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of nursing schedules and an interview with the Human Resources Director. Specifically, there was no RN coverage for eight consecutive hours on two days, 08/31/24 and 09/01/24, which had the potential to affect all 96 residents residing in the facility. The Human Resources Director confirmed the lack of RN coverage on these dates during an interview conducted on 09/11/24.
Failure to Provide Effective CPR During Cardiac Emergency
Penalty
Summary
The facility failed to provide effective cardiopulmonary resuscitation (CPR) to a resident who experienced a cardiac emergency. During the incident, the resident was found vomiting and later lost consciousness and pulse. Licensed Practical Nurse (LPN) #207 initiated CPR on the resident while she was still on her mattress, which decreased the effectiveness of the chest compressions. Additionally, there was a failure to provide mechanical ventilation as the ambu bag was not available, and the crash cart was not immediately accessible. The staff's response to the emergency was inadequate, as LPN #206 left the room to call 911, and State Tested Nursing Assistant (STNA) #310 left to have another LPN print transfer documents instead of assisting with CPR. STNA #310 was unable to locate the crash cart promptly, and it only arrived at the resident's room simultaneously with the Emergency Medical Services (EMS). The absence of a backboard and ambu bag during the CPR attempt compromised the quality of care provided to the resident. The resident, who had a Full Code status, was admitted to the facility for surgical aftercare following digestive system surgery and was cognitively intact. Despite the staff's efforts, the resident remained without a pulse or respirations upon EMS arrival and was subsequently transferred to the hospital, where she expired. The facility's failure to ensure the availability of necessary emergency equipment and adequately trained staff to perform CPR effectively resulted in Immediate Jeopardy and actual harm to the resident.
Failure to Respond to Residents' Change in Condition
Penalty
Summary
The facility failed to timely identify and provide adequate care for a resident who experienced an acute change in condition. The resident, who had a history of type two diabetes mellitus, unspecified dementia, aneurism of the ascending aorta without rupture, and hypertension, began showing signs of difficulty swallowing and had their diet downgraded to pureed. Despite these changes, the physician was not notified, and no nursing assessments or monitoring were completed. Over the course of two days, the resident's oral intake was poor, and they eventually became unresponsive. A nursing assistant found the resident unresponsive and notified an LPN, who failed to assess the resident or notify the physician. The LPN continued to administer medications by placing them in the resident's mouth despite their unresponsive state. Another resident experienced a change in condition characterized by high blood pressure, rapid respirations, and shortness of breath, requiring oxygen therapy outside of physician-ordered parameters. The resident's condition was not typical, and the LPN on duty failed to notify the physician of the change in condition. The resident's oxygen was set at a higher level than ordered, and the LPN did not adjust it or notify the physician. The LPN only notified another LPN, who also did not inform the physician or nurse practitioner of the resident's condition. The facility's failure to follow its Change in Condition Policy and Procedure resulted in Immediate Jeopardy for one resident and a significant deficiency for another. The lack of timely assessments, monitoring, and physician notification contributed to the residents' deteriorating conditions. The facility's policy required prompt notification of the physician and responsible party when a resident experienced a significant change in condition, but this was not adhered to in these cases.
Failure to Disinfect Shared Glucometer
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during blood glucose monitoring. Specifically, a shared glucometer was not cleaned and disinfected between uses for different residents. This deficiency was observed during medication administration by an LPN, who used the same glucometer for multiple residents without cleaning it between uses. The LPN confirmed that the glucometer was not cleaned before, between, or after use for three residents, and stated that she would clean it at the end of her shift. The deficiency affected three residents who were observed for blood sugar assessment, all of whom had a diagnosis of diabetes mellitus. The facility's policy required that glucometers be cleaned and disinfected before and after each use to prevent infection transmission. However, the LPN did not adhere to this policy, as confirmed by her actions and statements. The facility's policy was reviewed, and it was noted that the glucometer should be cleaned with a disinfectant wipe and allowed to sit for five minutes between uses.
Inadequate Incontinence Care and Staffing Issues
Penalty
Summary
The facility failed to provide timely and appropriate toileting and incontinence care for several residents, leading to significant distress and discomfort. One resident, who was cognitively intact, reported having to wait over an hour for assistance to use the bathroom, resulting in soiling herself. The staff was understaffed due to a no-show nurse, and the resident's daughter had to call the police for a wellness check after multiple unanswered calls to the facility. The police confirmed the resident's call light had been on for an extended period without response, and the facility was unable to provide call log audits for the incident. Another resident, who was always incontinent of urine, reported discomfort due to the facility not providing the correct size of incontinence briefs. The staff had to use multiple smaller briefs, which were bulky and uncomfortable for the resident. Observations confirmed the resident was wearing multiple improperly fitted briefs, and the staff acknowledged the lack of appropriately sized briefs, leading to the use of multiple smaller ones. A third resident, who required assistance with toileting, was observed sitting in her doorway, repeatedly calling for help. The toilet in her bathroom was covered with diarrhea, and despite her requests, staff did not assist her promptly. An STNA left the resident's room without providing help, and the resident attempted to clean the bathroom herself. Eventually, an LPN was requested to assist, finding the resident sitting on the toilet unassisted. This incident was part of a broader issue, as the police had received multiple calls from the facility regarding unresponsive staff.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #6, who was moderately cognitively impaired and had a seizure disorder, did not receive the prescribed morning dose of vimpat due to the medication being unavailable. The LPN responsible for administering the medication confirmed that she did not know why the medication was unavailable, and the Medication Administration Record corroborated that the dose was missed. Resident #8, also moderately cognitively impaired and diagnosed with diabetes mellitus, received insulin outside of the physician-ordered parameters. The LPN checked Resident #8's blood sugar after the resident had already consumed part of her breakfast, which was contrary to the physician's order to check blood sugar levels before meals. The LPN admitted to performing blood sugar checks during or after meals, which led to the administration of insulin based on incorrect timing. The facility's policy on medication administration was not adhered to, contributing to these errors.
Medication Administration Deficiency
Penalty
Summary
The facility failed to securely administer medications according to professional standards, affecting four residents. Observations revealed that medication cups containing pills were left unattended on bedside tables for residents who were either asleep or unable to self-administer medications. Specifically, Resident #78 had six pills left on her table, which she could not reach, despite having an order not to self-administer medications. Resident #18 also had six pills left unattended, with no orders allowing self-administration, and an assessment indicating she could not safely self-administer medications. Resident #54 had two pills left unattended, with an order prohibiting self-administration. Resident #84 had five pills left on her table and required applesauce to swallow her medication, which was not provided, despite an order against self-administration. Interviews with staff confirmed these practices. RN #401 admitted to leaving medications at the bedside, believing it necessary as many residents would not take their pills before breakfast. He was unaware of any orders or assessments regarding the residents' ability to self-administer medications. The Director of Nursing confirmed that nurses were supposed to monitor residents during medication administration. A review of the facility's medication administration policy revealed it did not specify the need for nurses to observe residents when administering medications. This deficiency was investigated under Complaint Numbers OH00154232 and OH00154160.
Failure to Answer and Return Phone Calls
Penalty
Summary
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. Resident #42's daughter reported that her calls to the facility were transferred to the nurse's station but were never answered, and her messages were not returned. An observation confirmed that calls to the nursing station were not answered, and messages left by the Business Office Manager (BOM) were not returned. Interviews with nursing staff revealed that they were occupied with residents and unable to answer phone calls. The BOM confirmed that written messages were left at the nurses' station, and the Administrator acknowledged that this issue had been previously discussed in staff meetings. This deficiency was investigated under Complaint Number OH00152016.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat Resident #24 with dignity and respect during an incident involving two State Tested Nurse Aides (STNAs). Resident #24, who has hemiplegia and hemiparesis following a cerebral infarction, reported that one STNA refused to give her the bed remote control, leading to a physical struggle over the remote. The STNA then threw the remote at Resident #24 and made derogatory comments, which were laughed at by the second STNA. This incident left Resident #24 tearful and upset, feeling humiliated and disrespected. Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to address the concern. The daughter had been at the facility for an extended period without anyone coming to discuss the incident with her or Resident #24. When the DON finally addressed the issue, she did not identify herself properly to Resident #24, leading to further confusion and distress for the resident. The facility's policy on abuse prohibition, which includes physical, mental, and verbal abuse, was not adhered to in this case. The DON's failure to properly communicate and address the resident's and her daughter's concerns exacerbated the situation, leaving Resident #24 feeling unsupported and disrespected. The lack of documentation in the nursing progress notes further indicates a failure in proper reporting and follow-up on the incident.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement their abuse policy after allegations of staff-to-resident abuse involving a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was cognitively intact and usually understood, reported an incident where a state tested nurse aide (STNA) wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to investigate or address the allegation on the same day. The DON confirmed awareness of the text messages but did not initiate an investigation or speak to the resident until the following day. The facility's policy required immediate assessment and protection of the resident, removal of the alleged perpetrator, and timely reporting of the incident to the state agency. However, the alleged perpetrator continued to work shifts after the incident, and the investigation was delayed. Interviews with the DON and review of facility time sheets confirmed the presence of the two STNAs involved in the incident on the specified dates. The facility's failure to timely report the allegation, suspend the alleged perpetrators, and start an immediate investigation constituted a breach of their abuse prohibition policy. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for abuse, with a facility census of 98.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse to the state agency, affecting one resident. Resident #24, who was cognitively intact and had hemiplegia and hemiparesis following a cerebral infarction, reported an incident involving two state-tested nurse aides (STNAs) on a Sunday night. The resident claimed that one STNA refused to give her the bed remote control, leading to a physical altercation where the STNA threw the remote at her and made derogatory comments. The incident was communicated to the Director of Nursing (DON) via text by the resident's daughter, but no immediate action was taken by the DON to investigate or report the incident on the same day. The DON received a text message from the resident's daughter on the following day, detailing the incident and requesting a meeting. Despite acknowledging the message, the DON did not speak to the resident or her daughter until the next morning. The facility's self-reported incident (SRI) was not created until after surveyor intervention, indicating a delay in reporting the abuse allegation to the state agency. The facility's policy requires all alleged violations of abuse to be reported immediately, but this protocol was not followed. Interviews with the DON confirmed that the two STNAs involved were identified, and one of them continued to work shifts after the incident. The facility's failure to timely report the abuse allegation and initiate an investigation violated their own abuse prohibition policy, which mandates immediate reporting of such incidents. The deficiency was identified during a complaint investigation, highlighting a significant lapse in the facility's response to abuse allegations.
Failure to Timely Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely investigate an allegation of staff-to-resident abuse involving a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was cognitively intact and usually understood, reported an incident where a state-tested nurse aide (STNA) wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. The resident's daughter communicated the incident to the Director of Nursing (DON) via text, but the DON did not initiate an investigation or speak to the resident until the following day. The resident's daughter expressed her concerns to the DON through text messages, indicating that her mother had been involved in a fight with an aide. Despite receiving these messages, the DON did not take immediate action to investigate the allegation or ensure the resident's safety. The DON confirmed that she was aware of the text messages and the allegation but did not speak to the resident or her daughter until the next day, delaying the investigation process. Interviews with the DON revealed that the two STNAs involved in the incident were not immediately suspended, and an investigation was not promptly initiated. The facility's policy on abuse prohibition requires immediate assessment and protection of the resident, notification of the attending physician and legal responsible party, and interviews with all involved parties. The facility failed to adhere to these guidelines, resulting in a delay in addressing the abuse allegation and ensuring the resident's safety.
Inconsistent Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that Resident #57 was consistently gotten out of bed, affecting one of three residents reviewed for activities of daily living. Resident #57, who has diagnoses including encephalopathy, gastrostomy, dysphagia, pneumonia, blindness in the left eye, and a genetic-related intellectual disability, was observed lying in bed on multiple occasions without attempts to engage or communicate with him. The resident's medical record indicated severe cognitive impairment and a preference for not being touched due to irritability and discomfort. Despite a care meeting discussing the importance of getting Resident #57 up frequently, observations revealed that he was often left in bed with minimal interaction or engagement from staff. Interviews with various staff members, including State Tested Nurse Aides (STNAs) and Licensed Practical Nurses (LPNs), revealed inconsistencies in the care provided to Resident #57. Some staff members admitted that whether the resident was gotten out of bed depended on which STNA was working, with some STNAs unwilling to get him up. It was noted that Resident #57 never refused to get up and was rarely taken to any activities or out of his room when he was up. The Unit Manager and other LPNs were unsure of the last time Resident #57 was out of bed, indicating a lack of consistent care and attention to his needs. This deficiency was investigated under Master Complaint Number OH00152261 and Complaint Number OH00152016.
Failure to Provide Consistent Activities for Resident
Penalty
Summary
The facility failed to ensure Resident #57 was consistently provided with activities that met his needs. Resident #57, who has diagnoses including encephalopathy, gastrostomy, dysphagia, pneumonia, blindness in the left eye, and a genetic-related intellectual disability, was observed lying in bed on multiple occasions without engaging in any activities. Despite having a care plan that included activities he enjoyed, such as listening to music and having books read to him, these activities were not consistently provided. The resident's cognitive skills for daily decision-making were severely impaired, and he was rarely or never understood, making it crucial for the facility to adhere to his care plan to meet his needs. Interviews with staff revealed inconsistencies in getting Resident #57 out of bed and engaging him in activities. The State Tested Nurse Aide (STNA) mentioned that it depended on which STNA was working whether the resident got up or not, and that he never went to any activities. The Activities Director admitted to trying music but not reading books to the resident, and noted that the resident was on the room visits list but had not been consistently engaged. The Unit Manager was also unsure when the resident was last out of bed. These observations and interviews indicate a failure to provide Resident #57 with the necessary activities to meet his needs, as outlined in his care plan.
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What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadview Multi Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Parma Care Center | 2.6 mi | ★★★★★ | 1 | 0 |
| Greenbrier Health Center | 3 mi | ★★★★★ | 0 | 0 |
| Mt Alverna Home Inc | 3.2 mi | ★★★★★ | 9 | 0 |
| Westpark Healthcare Campus | 3.3 mi | ★★★★★ | 12 | 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 October 2026) and official state health department websites.