Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenue Care And Rehabilitation Center, The during CMS and state inspections, most recent first.
A facility allowed an Interim DON to serve and practice as a Registered Nurse with a lapsed and inactive license, despite reminders and assistance from HR to renew. The license remained inactive due to incomplete renewal, and both the Administrator and HR were unaware of the lapse until it was confirmed during a complaint investigation.
A resident with an ileostomy did not receive timely colostomy care as required by physician orders and care plan. The resident was left covered in stool for hours after her colostomy bag burst, despite activating her call light for assistance. Family intervention and photographic evidence confirmed repeated failures by staff to empty, burp, or change the ostomy bag as needed, resulting in the resident remaining soiled for extended periods.
Surveyors found that multiple dependent residents did not receive timely incontinence care, with some left in soiled briefs and bedding for extended periods. Staff and family interviews confirmed that residents were not checked or changed as required, resulting in saturated briefs, wet bedding, and skin irritation. Facility policy required checks every two to three hours, but this was not followed due to staffing shortages.
The facility failed to provide adequate nursing staff, resulting in multiple residents with complex medical needs not receiving timely incontinence care, hygiene, and assistance with daily living. Residents were left in soiled briefs and bedding for extended periods, and staff interviews confirmed that insufficient staffing led to delays in care, with some residents only checked or changed once or twice per 12-hour shift. Family members also reported having to provide care themselves due to lack of staff response.
Staff failed to follow Enhanced Barrier Precautions for a resident with a pressure injury requiring high-contact care, as CNAs did not wear required gowns and PPE was not available in or near the room. The EBP signage was not properly displayed, and staff were unaware of the resident's EBP status, with reports that gowns were often unavailable throughout the facility. This noncompliance had the potential to affect other residents on the same floor.
A resident with advanced cancer and cognitive impairment was found with a call light cord around their neck, indicating a significant change in condition. Although staff removed the cord, notified hospice, and contacted the family, the nurse delayed direct phone notification to the physician for over eight hours, contrary to facility policy requiring immediate action for acute changes. This deficiency was identified through review and staff interviews.
A resident with severe cognitive impairment and communication deficits was not protected from sexual abuse by another resident, despite a prior incident and staff awareness of her inability to consent. After an initial episode of inappropriate contact, staff failed to update the care plan or ensure adequate supervision, resulting in a second incident where the male resident was found in her room with his pants down.
The facility did not have an RN on duty for at least eight consecutive hours on two days, as confirmed by staff schedules and HR interview. This failure had the potential to impact all 87 residents in the facility.
Surveyors observed multiple instances of unclean and unsafe conditions, including stained carpets and bedding, damaged walls and fixtures, dirty medical equipment, and unsanitary bathrooms. These deficiencies were confirmed by the maintenance supervisor and were not in line with the facility's cleaning policies, potentially affecting all residents.
Surveyors found undated nectar thickened orange juice containers and expired thickener packets stored in pantries used for residents on thickened liquids. The Regional Director of Clinical Operations confirmed these findings during the inspection, and the deficiency had the potential to affect several residents receiving thickened liquids.
The facility did not maintain accurate and complete medical records for several residents, including missing physician orders for dialysis, incomplete documentation of medication administration and treatments, lack of documentation regarding diagnostic test results, and misfiled physician notes. These deficiencies were confirmed through staff interviews and review of the electronic health record.
Care plans were not revised and required care planning conferences were not held for multiple residents. One resident with stroke-related deficits, aphasia, a Stage IV sacral pressure ulcer, diabetes, and enteral feeding had outdated wound, sepsis, and rehospitalization care plans that were not revised or resolved even after the wound healed and sepsis ended. Other residents with significant diagnoses such as CVA, severe cognitive impairment, COPD, and hemiplegia had missing or incomplete care conference documentation, and an SSD confirmed that some scheduled conferences did not occur and notices were not documented.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
Three residents were not provided with appropriate accommodations, including a bed that fit a tall and heavy resident and accessible call lights for two residents, one of whom was blind and required extensive assistance. Staff confirmed that call lights were out of reach and the bed provided did not meet the resident's needs.
A resident with multiple serious diagnoses was transferred to and from the hospital several times without documentation that the family or responsible party was notified, despite facility policy requiring such notification. An LPN confirmed the absence of documentation for these notifications, resulting in non-compliance with the facility's procedures.
The facility failed to properly document and justify the discharge of three residents, including one with severe cognitive impairment and another with no prior behavioral issues, resulting in their transfer or denial of return after hospitalization without adequate medical record support or discharge paperwork, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on staff for ADLs was observed on multiple occasions to have long, dirty fingernails, with no documentation or evidence that fingernail care was provided or refused. CNAs were unclear about their responsibilities regarding fingernail care, and the nurse was not informed of the need for trimming, resulting in inadequate personal hygiene for the resident.
The facility did not ensure that a resident received appropriate care for existing pressure ulcers and failed to implement preventive measures to avoid the development of new ulcers, as evidenced by surveyor observations and documentation review.
The facility did not consistently complete thorough fall investigations, update care plans with current fall interventions, or ensure that fall interventions were in place as ordered for three residents with cognitive and mobility impairments. One resident experienced multiple unwitnessed falls without proper care plan updates or accurate fall risk assessments, another had a fall without timely pain or fall risk assessments or documentation of vital signs, and a third was repeatedly observed without required bilateral floor mats. Staff interviews and record reviews confirmed these deficiencies in fall prevention and documentation.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, and that catheter care and UTI prevention measures were inadequate.
A resident with a UTI did not receive an ordered antibiotic as scheduled due to the medication being unavailable, resulting in missed doses over several days. The error was confirmed through medical record review and staff interviews, with the issue identified after two missed administrations.
The facility did not ensure that laboratory tests or services were provided or obtained as ordered and failed to promptly notify the ordering practitioner of the results, potentially affecting timely clinical decisions for a resident.
The facility failed to provide timely NOMNCs to two residents receiving Medicare Part A skilled services. For both residents, the notice stated that PT, OT, and speech therapy would end on the same day the notice was signed, giving no advance notice, and the SSD confirmed the notices were not provided at least 48 hours before services stopped.
Failure to Notify Ombudsman of Resident Hospitalizations: The facility did not ensure the Ombudsman was notified of hospital transfers and readmissions for three residents reviewed for discharges. A resident with ESRD, GI bleed, DM II, and AFib, another resident with CKD III, CVA, hemiplegia, and acute respiratory failure with hypoxia, and a third resident with acute respiratory failure with hypoxia, ESRD, DM II with neuropathy, CHF, and BPH all had hospitalizations documented in the EMR, but the Ombudsman log showed no notification. The SSD and BOM confirmed no notice had been sent and no evidence was provided that anyone else in the facility had done so.
A resident with Parkinson's disease, seizures, and COPD had hospice revoked because health had improved, then declined and resumed hospice. The facility did not complete a significant change MDS assessment when the resident came off hospice, and the MDS nurse verified the omission.
A resident with hemiplegia and aphasia later had new psych diagnoses documented, including delusional disorder, dementia, and major depressive disorder. The facility completed an initial PASRR at admission, but no additional PASRR evals were completed and no PASRR was submitted to ODMH for the resident’s significant mental health change.
Failure to Initiate Baseline Care Plan Within 48 Hours: A resident with dementia, ESRD on HD, DM, and a CVA was admitted and later enrolled in hospice after refusing further dialysis, but the initial baseline care plan was not completed within 48 hours of admission. The record showed no care plans were started until later, and the DON confirmed the admission care plan was not completed as required; the facility policy required an interim care plan within 48 hours including key orders and care information.
A resident with COPD, URI, SOB, and bilateral lower-extremity edema did not receive timely implementation of ordered interventions. Staff repeatedly observed the resident sitting in a wheelchair with ACE wraps not applied or with wraps on but legs not elevated, and the resident stated staff did not elevate her legs or place her feet on the wheelchair rests unless she was taken out of her room. An LPN and UM confirmed the resident should have had ACE wraps and leg elevation, but the active order had been missed after a hospital return.
Unsecured oxygen tanks were found in three residents' rooms during a facility tour. The MS observed free-standing E-tanks that were not chained or supported in a proper cylinder stand or cart, and the MS verified the findings. The facility policy required oxygen units to be stored upright, portable units off the floor, and E-tanks in a cart rack or chained to a wall.
Failure to use PPE and safely handle contaminated linens occurred when a CNA provided morning and incontinence care to a resident on enhanced barrier precautions without donning a gown. The CNA also dropped the resident’s bed linens on the floor and then placed them on the bed and later on a trash can before bagging them. The resident had DM, ESRD, depression, and other significant diagnoses, and the care plan required disposable gowns and gloves for high-contact care activities.
COVID-19 Vaccine Consent Documented but Not Administered The facility did not ensure that three residents received the COVID-19 vaccine after informed consent was documented. One resident’s consent form did not clearly show consent or refusal, one resident had POA consent documented, and one resident had resident consent documented, yet none of the three had received the vaccine per the medical record. The IP stated she was the only staff member administering the vaccine and could not explain why the vaccines were not given or provide additional documentation.
Side rails on the beds of three residents were observed to be extremely loose and not tightly affixed during an environmental tour. The MS confirmed the rails were not securely attached, and the manufacturer’s instructions stated that after any adjustment, repair, or service, all attaching hardware must be tightened securely.
Outdated nursing staff information was posted in the facility. Observation showed the staffing posting was dated three days earlier, and the Administrator confirmed it was not current. The issue affected the facility census of 87 residents.
A resident with severe cognitive impairment eloped from a facility without staff knowledge, resulting in her death due to environmental exposure. The facility failed to recognize her absence, did not perform routine checks, and did not respond to door alarms. Staff assumed the resident was on a leave of absence without verification, and the facility's elopement policies were not adequately followed.
A resident with severe cognitive impairment and at risk for elopement was not checked routinely by staff, leading to their elopement and death outside the facility. The incident was not reported to the State Agency as required by the facility's policy.
The facility failed to honor the bathing and transfer preferences of several residents, leading to deficiencies in care. Residents who preferred showers were only given bed baths, and those requiring assistance were not given a choice. Additionally, residents faced restrictions on transfers, affecting their ability to receive timely care. These issues persisted despite being reported to facility management.
Two residents in an LTC facility did not receive timely incontinence care, leading to saturated clothing and strong odors. One resident, who was always incontinent, was not checked or changed for several hours, while another, who required a Hoyer lift, was reluctant to receive care due to being told she would have to stay in bed afterward. Staff interviews confirmed the lack of adherence to the facility's policy of checking and changing residents every two hours.
A resident with bilateral above the knee amputations and balance deficits was injured during a mechanical lift transfer when staff failed to position him correctly in the chair, causing him to slide and reopen his incision. The resident required emergency care and did not return to the facility.
A resident with multiple diagnoses was found with a medicine cup containing numerous pills, indicating that the LPN did not observe the resident ingest the medications as required by facility policy. The LPN confirmed she left the medications in the room and did not watch the resident take them.
Interim DON Practiced with Lapsed RN License
Penalty
Summary
The facility failed to ensure that nursing staff were licensed in accordance with state laws, specifically allowing an individual to serve as Interim Director of Nursing (DON) while her Registered Nurse (RN) license was inactive and had lapsed. The Interim DON assumed the role in October 2025 after the previous DON resigned. Verification on the Ohio e-licensure website confirmed that the Interim DON's license had expired as of 10/31/25 and was not renewed. Despite reminders posted at the time clock and direct assistance from Human Resources (HR) to complete the renewal application, the license remained inactive due to incomplete renewal. Interviews with the Administrator and HR revealed that both were unaware the Interim DON's license was still inactive, even after attempts to prompt renewal. HR had assisted the Interim DON with the application process, but did not follow up to ensure completion. The deficiency was identified during a complaint investigation and had the potential to affect all 83 residents in the facility, as the Interim DON continued to practice without an active nursing license.
Failure to Provide Timely Colostomy Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely colostomy care to a resident with a history of rectal cancer and an ileostomy. The resident had physician orders for staff to empty the ostomy every shift and as needed, and to change the appliance weekly and as needed. Despite these orders, the resident reported that her colostomy bag burst open and, after activating her call light, a nurse entered the room, turned off the call light, and left without providing care. The resident remained covered in stool for at least two hours, ultimately calling a family member for assistance. The family member arrived to find the resident still soiled, took photographs, and cleaned her up before reporting the incident to the unit manager. The family member stated that similar issues had continued to occur. Observations confirmed the resident's colostomy bag was often not emptied or changed in a timely manner, with the bag being half full of liquid stool during one interview and the resident found covered in stool during another observation. Photographic evidence provided by the family member showed dried, liquid stool on the resident's gown and bedding, and the colostomy bag not attached to the abdomen. The Interim DON acknowledged awareness of frequent leaks but was unaware of the lack of timely emptying. These findings demonstrate a failure by staff to provide appropriate and timely ostomy care as required by the resident's care plan and physician orders.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to provide timely incontinence care for four residents who were dependent on staff for activities of daily living, specifically toileting and hygiene. Observations and interviews revealed that residents were left in soiled briefs and clothing for extended periods, sometimes for over nine hours, without being checked or changed. Staff members, including CNAs, confirmed that due to insufficient staffing, residents were not checked or changed as frequently as required, with some residents only receiving incontinence care twice during a 12-hour shift. Residents were observed with saturated briefs, wet bedding, and in some cases, dried stool and urine on their skin, resulting in foul odors and visible skin irritation. One resident with hemiplegia and dementia was placed in a chair at 5:00 A.M. and was not checked or changed until 2:45 P.M., at which time staff confirmed the resident's brief was heavily saturated and the resident had an odor of urine. Another resident, who was cognitively intact but had bilateral leg amputations and was always incontinent, reported to surveyors that she was left soaked in urine and that staff did not respond promptly to her requests for assistance. Staff confirmed that this resident had not been checked or changed for several hours, and her brief and bed pad were saturated with urine. A third resident, with hemiplegia and moderate cognitive impairment, was found with a saturated brief containing urine and stool, with dried stool on the skin and deep red, sensitive areas on the body from prolonged exposure. Family members of a fourth resident reported that staff failed to provide incontinence care despite repeated requests, resulting in the family having to change the resident themselves after waiting several hours. The facility's own policy required residents to be checked and changed every two to three hours, but this standard was not met for the residents reviewed.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
Surveyors identified that the facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in multiple instances where residents did not receive timely incontinence care and assistance with activities of daily living. Several residents with significant medical conditions, such as hemiplegia, aphasia, visual loss, and dementia, were observed or reported to have waited extended periods—sometimes several hours—before being checked or changed. In one case, a resident's call light was activated for over 28 minutes before staff responded, and the resident was found sitting in a wet brief with a strong odor of urine. Another resident reported not being changed since early morning, resulting in a saturated brief and wet bedding, with staff confirming that due to staffing shortages, residents were sometimes only checked and changed twice in a 12-hour shift. Additional observations and interviews revealed that residents were left in soiled conditions for prolonged periods, with one resident found with dried stool and urine, deep red and sensitive skin, and soiled bedding. Family members of a former resident reported having to change their loved one themselves after staff failed to respond to repeated requests for assistance over several hours, and provided photographic evidence of saturated bedding and briefs. Staff interviews consistently indicated that there were not enough CNAs and nurses to provide timely care, with some residents only receiving incontinence care once or twice per shift, and showers often being replaced with bed baths due to lack of staff. The facility's own assessment documented the need for a specific number of licensed nurses and CNAs per shift to meet resident acuity needs, but interviews and observations confirmed that these staffing levels were not consistently met. Staff reported being unable to complete daily care tasks, and residents who were dependent on staff for mobility, hygiene, and toileting were not assisted in a timely manner. The deficiency affected multiple current and former residents and had the potential to impact the majority of the facility's population.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident requiring Enhanced Barrier Precautions (EBP) to prevent the transmission of multidrug-resistant organisms (MDROs). The resident, who was moderately cognitively impaired and had an unstageable pressure injury, required substantial assistance with mobility, toileting, and hygiene. The care plan and physician orders specified the use of disposable gowns and gloves during high-contact care activities, such as dressing changes, bathing, toileting, and wound care. However, during observation, it was noted that the EBP sign had fallen to the floor, and there was no personal protective equipment (PPE), including gloves or gowns, available inside or near the resident's room. Certified Nursing Assistants (CNAs) providing incontinence care and changing linens for the resident did not wear isolation gowns, as required by the EBP protocol. Both CNAs confirmed they did not use gowns, and one was unaware that the resident was on EBP. They also reported that gowns were often not readily available throughout the facility. The lack of adherence to EBP protocols and unavailability of PPE had the potential to affect additional residents on the same floor, as staff could provide care to multiple residents during their shifts. The facility's policy required gown and glove use for high-contact care activities, but this was not followed during the observed care.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to the physician when a resident exhibited a significant change in condition. The resident, who had diagnoses including malignant neoplasm of the colon and liver, was admitted to hospice care and had impaired cognition and depression. According to the care plan, staff were to monitor and report any risk for self-harm or suicidal ideation. On the night in question, a certified nursing assistant found the resident with a call light cord around his neck, which was a notable change from his baseline behavior. The registered nurse on duty was alerted and removed the cord, then notified the resident's physician, hospice, and family member. However, the nurse initially texted the physician after the incident but did not receive a response and did not make a phone call to the physician until over eight hours later. During this time, the resident was monitored by staff and hospice was contacted, but the delay in direct physician notification was contrary to facility policy, which required immediate phone notification in the event of an acute change in condition. Interviews with staff confirmed that any suspected self-harm or suicidal ideation should prompt immediate physician notification by phone, and the facility's policy specified that if the physician could not be reached within thirty minutes, emergency services should be contacted. The deficiency was identified through record review, observation, and interviews, and was found to be a continuation of non-compliance from a previous survey.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment, communication difficulties, and a history of paranoid schizophrenia from sexual abuse by another resident. The resident was dependent on staff for hygiene, dressing, and transfers, and her care plan had not been updated for an extended period. Despite her inability to provide informed consent, she was observed in two separate incidents involving inappropriate sexual contact with another resident. In the first incident, a nurse observed the two residents kissing in a common area and intervened to separate them. The event was reported to management, and staff were instructed to keep the residents apart. However, the care plan for the cognitively impaired resident was not updated following this event, and there was no documented reassessment of her vulnerability or supervision needs. A second, more serious incident occurred when a staff member found the same male resident in the female resident's room, on her bed with his pants down. The male resident was removed and placed on one-on-one observation only after this event. The female resident was sent to the emergency room for a rape kit, which was later reported as negative. The facility's policy required protection of residents who may lack capacity to consent to sexual activity, but the failure to maintain separation and update care planning led to a repeat incident.
Failure to Maintain Required RN Coverage
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, as required by regulations. Review of nursing staff schedules and information revealed that no RNs were present and working in the facility on two specific days. This was confirmed during an interview with the Human Resources Director, who verified the absence of an RN on those dates. The deficiency was identified during the investigation of three separate complaints and had the potential to affect all 87 residents in the facility at the time.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe environment for its 87 residents, as evidenced by multiple observations during an environmental tour. Surveyors noted stained and debris-laden carpets throughout resident rooms and common areas, holes in walls, dislodged air conditioning covers, partially secured wall trim, and broken telephone outlets. Additionally, supplemental tube feeding poles had dried tube feed residue, and several private bathrooms and bedding items were found with brown stains. Wet clothing was left on a bathroom floor, producing a strong musty odor, and multiple rooms had water stains on the ceiling, severely scratched and chipped walls, and crumbling areas above air conditioning units. Dirty, torn, and tattered fall mats were also observed in use. These findings were confirmed by the Maintenance Supervisor at the time of observation. The facility's own Environmental Services Cleaning Guidebook, which outlines cleaning methods for infection control and presentation, was in place but not followed as intended. The deficiency was identified during the investigation of two specific complaints and had the potential to affect all residents in the facility.
Outdated and Undated Thickened Liquids and Additives Found in Storage
Penalty
Summary
During a facility tour, surveyors observed two 46-ounce containers of nectar thickened orange juice stored in unit pantries without any date indicating when they had been opened, despite a use by date of June 2025. Additionally, eight individual packets of thick and easy instant food and beverage thickener with a use by date of 10/29/23 were found in the same pantries. These items were accessible in areas serving residents who required thickened liquids. The Regional Director of Clinical Operations confirmed the presence of both the undated juice containers and the expired thickener packets during the inspection. This deficiency was identified as part of a complaint investigation and had the potential to affect four residents who were receiving thickened liquids at the time of the survey.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for several residents were accurate and complete, as required by professional standards. For one resident with end stage renal disease and multiple comorbidities, there was no physician order for dialysis in the electronic record, despite the resident receiving dialysis at the facility. Additionally, documentation was missing for medication administration and treatments during specific shifts, and staff interviews confirmed lapses in documentation and the absence of required orders. Another resident, admitted with multiple chronic conditions and using a noninvasive ventilator, had incomplete documentation regarding a scheduled CT scan. While respiratory therapy and pharmacy reviews were documented, there was no record of the CT scan results or when it was completed, which was confirmed by the DON. For a third resident, the nursing admission assessment was left blank in the electronic health record, with the DON attributing this to a possible system glitch, but no assessment information was present in the record. Additionally, the review of another resident's electronic medical record revealed that physician notes for a different resident were incorrectly filed in their record. The facility's policy requires that medical records be complete, accurately documented, and systematically organized, but these findings demonstrate that the facility did not meet these standards for multiple residents.
Care plans not revised and required care conferences not held
Penalty
Summary
The facility failed to revise care plans as required and failed to ensure resident care planning conferences were held as required. This affected four of seven residents reviewed for care plans and care planning conferences in a facility with a census of 87. The report states that care plans were to be developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals, but the documented care planning process was not followed for the residents reviewed. For one resident with diagnoses including hemiplegia and hemiparesis after a stroke, aphasia, osteomyelitis of the sacral and sacrococcygeal region, diabetes, hypertension, obstructive and reflux uropathy, and early-onset Alzheimer’s disease, the record showed a Stage IV sacral pressure ulcer, incontinence of bowel and bladder, and enteral feeding. The resident had a care plan for pressure wounds that was last revised on 03/14/25 even though the left foot wound had healed by 05/28/25. The resident also had a care plan for sepsis initiated on 11/11/24 that was not revised or resolved, and another sepsis care plan initiated on 12/31/24 with no documented revision. A high-risk rehospitalization care plan initiated on 10/29/23 also had no revisions despite subsequent hospitalizations. The facility MDS nurse stated she was responsible for initiating, revising, and resolving care plans, but was unaware the wound had healed and could not explain why the plans were not updated. For the remaining residents, the records did not show required care planning conferences. One resident with cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic respiratory failure, paranoid schizophrenia, bipolar disorder, anxiety disorder, and muscle weakness had only one documented care conference, held with the son, and no other conferences were documented. Another resident with severe cognitive impairment had a care conference documented in 2023, but no additional conferences were documented through 08/05/25, and a scheduled May 2025 conference had no documentation that a notice was mailed to the responsible party or family. A third resident with COPD, asthma, and hemiplegia and hemiparesis following cerebral infarction had no documented care conference since 2023, no conference scheduled in May 2025, and no evidence that a notice was mailed to the responsible party about a conference. The SSD stated conferences were supposed to occur for new admissions within the first five days and quarterly, but confirmed the missing documentation and missed conferences.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Accommodate Resident Needs for Bed Size and Call Light Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents regarding appropriate bed size and accessibility of call lights. One resident, who was 6 feet 9 inches tall and weighed 387.2 pounds, was observed lying in a standard-sized bed (36 inches by 80 inches) that was too small for his height and weight. The resident reported difficulty rolling side-to-side due to the bed's width and stated that his pillow frequently fell off the bed. Observations confirmed that a makeshift foam piece placed to fill the gap between the mattress and footboard did not fit properly or provide adequate support. The resident expressed ongoing requests for a larger bed, which had not been fulfilled at the time of the observations. Additionally, two other residents were observed with their call lights on the floor and out of reach while they were in their wheelchairs. One of these residents was moderately cognitively impaired and completely blind, requiring extensive assistance with activities of daily living. Staff interviews confirmed the call lights were not accessible to the residents at the time of observation. These failures were identified through observation, resident and staff interviews, medical record review, and review of facility policy.
Failure to Notify Family of Resident's Change in Condition and Hospital Transfers
Penalty
Summary
The facility failed to ensure that a resident's family or responsible party was notified of multiple changes in the resident's condition, as required by facility policy. Medical record review for a resident with diagnoses including end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II, and paroxysmal atrial fibrillation showed several instances where the resident was sent to the hospital or returned to the facility without documentation that the family was informed. Specific nurse notes indicated the resident was transferred to the hospital or returned to the facility on multiple occasions, but there was no evidence in the electronic medical record that the family was notified at any of these times. An interview with the unit manager LPN confirmed that there was no documentation of family notification for any of the hospital transfers or returns. The facility's policy on resident change in condition requires prompt notification of the resident, attending physician, and responsible party when there is a change in the resident's condition or status. The lack of documentation and failure to notify the family of these significant events constituted non-compliance with the facility's own policy.
Failure to Document and Justify Resident Discharges
Penalty
Summary
The facility failed to ensure that residents were permitted to return following hospitalization and did not provide adequate documentation to support the need for discharge. In three cases, residents were either discharged or not allowed to return without proper documentation in their medical records to justify the discharge. One resident with severe cognitive impairment and multiple diagnoses was discharged for allegedly violating the rights of others, but the discharge notice was not supported by appropriate documentation. Another resident, cognitively intact and with no prior incidents of abuse or misappropriation, was discharged after being found in possession of another resident’s cell phone, with the discharge notice citing violation of others’ rights, again without supporting documentation. A third resident, moderately cognitively impaired and with a history of encephalopathy and dementia, exhibited agitated behavior and was sent to the emergency room for evaluation. After hospitalization, this resident was not allowed to return and was transferred to another facility, but there was no documentation in the medical record regarding the discharge or the resident’s subsequent placement. Staff interviews confirmed that discharge notices and documentation were lacking or incomplete, and the facility’s own policy required comprehensive discharge planning and documentation, which was not followed in these cases.
Failure to Provide Adequate Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who was dependent on staff for activities of daily living (ADLs) due to severe cognitive impairment and multiple medical diagnoses, including senile degeneration of the brain and anxiety disorder. Despite care plan interventions that included negotiating care times and re-approaching the resident if care was initially refused, there was no documentation in the medical record or shower sheets indicating that the resident refused fingernail care or that her fingernails were long and dirty. Observations on multiple occasions revealed the resident had long fingernails, measuring about half to three-quarters of an inch, with dark brown material underneath. Certified Nurse Aides (CNAs) confirmed the condition of the resident's fingernails and expressed uncertainty about whether fingernail care should be performed during bathing. Interviews with staff, including the Director of Nursing (DON), revealed that CNAs were expected to check and document fingernail care needs on bath days and report issues to the nurse, who was responsible for trimming fingernails. However, there was no evidence that this process was followed, as the nurse was not informed of the need for fingernail care, and the issue was not documented. The facility's policy required staff to provide necessary services for personal hygiene, but this was not adhered to in the case of this resident, resulting in inadequate fingernail care.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and progression of pressure ulcers among residents.
Failure to Complete Fall Investigations and Implement Care Plan Interventions
Penalty
Summary
The facility failed to ensure thorough fall investigations were completed, resident care plans were revised to reflect current fall interventions, and fall interventions were in place as ordered for three residents reviewed for falls. For one resident with severe cognitive impairment, hemiplegia, and a history of falls, there were multiple unwitnessed falls. Documentation revealed that required interventions such as low bed position and bilateral floor mats were not consistently included in the care plan or physician orders, and fall risk assessments were inaccurately completed, failing to reflect recent falls. Additionally, the care plan was erroneously marked as resolved, resulting in the omission of necessary fall prevention interventions. Another resident with moderate cognitive impairment and mobility limitations experienced a fall that was not properly documented in the progress notes, and required post-fall assessments, including pain and fall risk assessments, were not completed in a timely manner. Vital signs were not documented at the time of the fall, and there was no evidence that witness statements were obtained or recorded. The incident report did not clarify whether the call light was within reach or activated at the time of the fall, and follow-up documentation was delayed. A third resident, with a history of falls and cognitive deficits, was observed multiple times with only one fall mat in place despite care plan interventions specifying bilateral floor mats. Staff interviews confirmed the absence of the required fall mat on one side of the bed. Facility policy required immediate assessment, investigation, and implementation of interventions after a fall, as well as documentation of the incident and notifications, but these procedures were not consistently followed for the residents involved.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Antibiotic Administration Omission for UTI
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cellulitis, leg pain, anxiety disorder, and glaucoma did not receive an ordered antibiotic medication as prescribed for a urinary tract infection (UTI). The resident, who had intact cognition and required assistance with mobility and dressing, was ordered to receive Fosfomycin tromethamine 3 gm oral packets every Tuesday, Friday, and Sunday for three doses. The medication was to begin following a positive urine culture and specific antibiotic recommendations. However, the medication was not available on the scheduled administration dates, and the resident did not receive the antibiotic as ordered. Medical record review and staff interviews confirmed that the antibiotic was not administered on the intended dates, with documentation in the medication administration record indicating the medication was unavailable. The issue was identified after two missed doses, and the antibiotic was not given until several days after the initial order. Both the Assistant Director of Nursing and the Director of Nursing verified that the medication was not administered as scheduled, resulting in a significant medication error for the resident.
Failure to Promptly Communicate Lab Results to Practitioner
Penalty
Summary
The facility failed to provide or obtain laboratory tests or services when ordered and did not promptly inform the ordering practitioner of the results. This deficiency was identified based on a review of facility practices and documentation, which showed that laboratory results were not communicated to the practitioner in a timely manner as required. The lack of prompt notification could have impacted the clinical decision-making process for the affected resident(s).
Late Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure Notices of Medicare Non-Coverage (NOMNCs) were provided to Medicare Part A beneficiaries at least 48 hours before skilled services were discontinued. For Resident #110, who was admitted with diagnoses including alcohol abuse, metabolic disorder, and high blood pressure, the NOMNC signed on 05/08/25 stated that skilled PT, OT, and speech therapy would end on 05/08/25, providing no advance notice. For Resident #111, who was admitted with diagnoses including a right femur fracture, type II diabetes, and high blood pressure, the NOMNC signed on 06/09/25 likewise stated that skilled PT, OT, and speech therapy would end on 06/09/25, also providing no advance notice. The Social Service Designee confirmed that the NOMNCs for both residents were not given at least 48 hours prior to the discontinuation of skilled services as required.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of resident hospitalizations as required for three of five residents reviewed for discharges. Record review and staff interview showed that Resident #6, who had diagnoses including end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II, and paroxysmal atrial fibrillation, was hospitalized multiple times and returned to the facility, but the Ombudsman Notification Log of Community Transfer and Discharges did not document transfers or discharges for the relevant months, including no documentation for the resident’s hospitalization and readmission events. The Social Service Designee stated the previous SSD did not document any transfers or discharges for the whole month of February 2025, including Resident #6’s hospitalization. Resident #17, with diagnoses including chronic kidney disease stage III, cerebrovascular disease, hemiplegia affecting the left non-dominant side, and acute respiratory failure with hypoxia, was also hospitalized and returned to the facility, but the Ombudsman Notification Log contained no documentation that notification was sent. Resident #24, admitted with diagnoses including acute respiratory failure with hypoxia, end stage renal disease, diabetes mellitus II with diabetic neuropathy, chronic diastolic congestive heart failure, and benign prostatic hyperplasia with lower urinary tract symptoms, was hospitalized more than once and readmitted to the facility, and the log likewise showed no documentation of Ombudsman notification. The SSD and the Business Office Manager confirmed that neither had sent notice to the Ombudsman for Residents #6, #17, and #24 and provided no evidence that anyone else in the facility had done so.
Failure to Complete Significant Change MDS After Hospice Revocation
Penalty
Summary
The facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed for Resident #64 after a change in hospice status. Resident #64 was admitted with diagnoses including Parkinson's disease, seizures, and chronic obstructive pulmonary disease. The record showed hospice services were revoked because the resident's health had improved and the resident no longer met hospice criteria, but the resident then experienced a medical decline and resumed hospice services. Review of the MDS assessments showed no significant change assessment was completed after the resident came off hospice, and the MDS Nurse verified that the significant change assessment had not been completed when the resident was discontinued from hospice services.
Failure to Notify ODMH of Significant Mental Health Change
Penalty
Summary
The facility failed to notify the appropriate state agency, the Ohio Department of Mental Health (ODMH), of a significant change in a resident's mental health condition as required. Resident #38 was admitted with diagnoses including hemiplegia of the left side and aphasia, and the most recent psychiatric consult note documented diagnoses of delusional disorder, dementia, and major depressive disorder with onset dates after admission. Review of PASRR records showed an initial PASRR was completed at admission, but no additional PASRR evaluations were completed during the resident's stay to address the new mental health diagnoses. Social Services Designee #805 confirmed that no PASRR was submitted to ODMH for the resident's new mental health diagnoses.
Failure to Initiate Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure an initial baseline care plan was initiated within 48 hours of admission for Resident #105. The resident was admitted with diagnoses including senile degeneration of the brain, end stage renal disease dependent on hemodialysis, diabetes, a stroke, and vascular dementia without behavioral disturbance, and was later admitted to hospice with a diagnosis of end stage renal disease after refusing further dialysis treatments. The resident died on [DATE]. Review of the admission assessment and comprehensive admission MDS showed the resident was moderately cognitively impaired and required dialysis three times a week, but the initial baseline care plan was not completed upon admission. Review of the resident's care plans showed that no care plans were initiated until [DATE]. The DON stated during interview that the nurses do not know what to do with initial care plans that are to be completed upon admission and confirmed that Resident #105's admission care plan was not completed as required. Review of the facility policy titled, Care Plan and Advanced Care Plan Process, stated that an interim care plan will be completed within 48 hours of admission and should include, at minimum, the necessary healthcare information needed to properly care for a resident, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations.
Delayed Edema Treatment and Missed Leg Elevation Orders
Penalty
Summary
The facility failed to initiate orders timely and timely implement interventions for treatment of edema for one resident. Resident #88 was admitted and later readmitted to the facility with diagnoses including COPD, acute upper respiratory infection, and shortness of breath. The resident’s care plan addressed edema to both lower extremities with interventions to apply ACE wraps from toes to knees in the morning and remove them at night, and to elevate the legs while at rest. The record showed an ACE wrap order dated 11/22/22 that was discontinued on 01/02/25, then made active again on 04/15/25, but there was no current order for ACE wraps to be applied at a certain time. The resident also had a leg elevation order that was discontinued on 01/02/25 when the resident went to the hospital. Observations over multiple days showed the resident sitting in a wheelchair with bilateral legs not wrapped and not elevated, or wrapped but still not elevated. On 08/04/25, the resident stated staff did not elevate her legs, did not put her legs on the wheelchair foot pedals unless she was taken out of her room, and she never refused leg wrapping. CNA #771 later placed the leg rests on the wheelchair after verifying they were on the floor against the wall. LPN #738 stated she normally checked to make sure the ACE wraps were in place because night shift was supposed to wrap the resident’s lower extremities. UM #745 stated orders were sometimes missed when residents returned from the hospital and confirmed the resident should have had bilateral leg wraps and leg elevation due to edema and diagnoses, but the active order had not been made again until 08/11/25 after the missed order was verified.
Unsecured Oxygen Tanks in Resident Rooms
Penalty
Summary
The facility failed to ensure resident oxygen tanks were stored in a secured manner. During observations with the Maintenance Supervisor, one free-standing oxygen tank in Resident #57's room was not properly chained or supported in a proper cylinder stand or cart. Additional observations during a facility tour found one free-standing oxygen tank in Resident #75's room and one free-standing oxygen tank in Resident #30's room that were also not properly chained or supported in a proper cylinder stand or cart. The Maintenance Supervisor verified the unsecured oxygen tanks in all three residents' rooms at the times they were discovered. Review of the facility's Oxygen Storage policy stated that units must be stored upright, portable units should be stored off the floor, and E-tanks must be stored in a cart rack or chained to a wall.
Failure to Use PPE and Safely Handle Contaminated Linens
Penalty
Summary
The facility failed to ensure PPE was used when providing care for a resident on enhanced barrier precautions and failed to handle contaminated items in a safe manner. Resident #95 was admitted on 06/18/24 and had diagnoses including type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, end stage renal disease, and depression. The resident’s care plan, revised 04/15/25, stated enhanced barrier precautions were required related to hemodialysis, with disposable gowns and gloves to be used during high-contact care activities. During observation on 08/05/25 at 10:00 A.M., a sign outside Resident #95’s room indicated enhanced barrier precautions were in place and required hand hygiene and the use of gloves and a gown for high-contact resident care activities. CNA #772 was observed providing morning and incontinence care without putting on an isolation gown. The CNA also picked up the resident’s bed linens and dropped them directly on the floor, then picked them up and placed them directly on the foot of the resident’s bed before placing them on top of a small trash can and then into a plastic bag. The CNA confirmed she dropped the linens on the floor, placed them on the bed without a plastic bag, and did not don an isolation gown before providing care. The ADON, who was also the Infection Preventionist, stated she spoke with the CNA and said the CNA was confused, and stated the CNA knew PPE supplies were inside the resident’s room. The facility policy required staff and visitors to wear gloves and disposable gowns upon entering the room and remove them before leaving, with hand hygiene performed before leaving.
COVID-19 Vaccine Consent Documented but Vaccines Not Given
Penalty
Summary
The facility did not ensure residents received COVID-19 immunizations as requested after education and informed consent were documented. Medical record review showed that Resident #66 had a COVID-19 vaccine informed consent form reviewed verbally on 10/28/24, but the form did not indicate whether the resident consented or refused the vaccine, and the resident had not received a COVID-19 vaccine since 05/23/23. Resident #86 had a COVID-19 vaccine informed consent form dated 02/20/24 showing verbal consent from the POA, but the medical record showed the resident never received a COVID-19 vaccine. Resident #55 had a COVID-19 vaccine informed consent form dated 10/28/24 showing verbal consent from the resident, but the medical record showed the resident had not received a COVID-19 vaccine since 12/14/22. During interview, the Infection Preventionist stated COVID-19 vaccines were only administered by her and she could not provide additional documentation for Residents #66, #86, and #55 or explain why the vaccines were not given after informed consent was obtained. Resident #86 could not recall whether the vaccine had been received, and Residents #55 and #66 were unable to confirm receipt due to cognitive impairment.
Loose Bed Side Rails Not Securely Attached
Penalty
Summary
The facility failed to ensure side rails were securely attached and in place on the beds of Resident #50, Resident #55, and Resident #79. During an environmental tour on 08/06/25 between 1:00 P.M. and 1:55 P.M. with Maintenance Supervisor #748, surveyors observed that the side rails on these three residents’ beds were not secure, were extremely loose, and were not tightly affixed to the sides of the beds. At the time of discovery, Maintenance Supervisor #748 confirmed that the side rails were loose and not securely attached to the beds. Review of the undated manufacturer’s instructions for the bed rails used by these residents stated that after any adjustments, repair, or service and before use, all attaching hardware must be tightened securely.
Outdated Nursing Staff Posting
Penalty
Summary
The facility failed to ensure the posted nursing staff information was current. Observation of the nursing staff posting on 08/11/25 at 6:20 A.M. showed it was dated 08/08/25, three days earlier. The Administrator confirmed during interview on 08/11/25 at 6:25 A.M. that the nursing staff posting was not current. The facility census was 87 residents.
Resident Elopement and Death Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from leaving the facility without staff knowledge. The resident, who had diagnoses of metabolic encephalopathy, malnutrition, and adult failure to thrive, was last seen inside the facility at approximately 8:40 P.M. Staff identified the resident was not in the facility at various times but failed to take sufficient action to determine her whereabouts. The resident was found outside the facility the following morning, cold, wet, and unresponsive, and was later pronounced deceased due to environmental exposure. The deficiency was exacerbated by the staff's failure to recognize the resident's absence and respond appropriately to the situation. Despite the resident's cognitive impairment and recent admission status, the facility's elopement assessment did not identify her as at risk for elopement. Staff members did not perform routine checks, and there was a lack of urgency in responding to the situation. The door alarm system was not effectively monitored, and staff did not conduct a thorough search or headcount in a timely manner. The facility's policies and procedures for elopement and emergency response were not adequately followed. Staff members were unaware of the resident's whereabouts and assumed she was on a leave of absence without verifying this information. The failure to respond to door alarms and conduct immediate searches contributed to the resident's prolonged absence and subsequent death. The incident highlighted significant lapses in communication, supervision, and adherence to safety protocols within the facility.
Removal Plan
- LPN #500 phoned RN #484 and informed her Resident #95 was missing and attempts to reach the resident's brother were unsuccessful. RN #484 provided instructions to activate a code purple.
- RN #484 notified Certified Nurse Practitioner (CNP) #502.
- RN #484 arrived at the facility.
- The local police department was notified Resident #95 was missing.
- Officer #506 responded and collected information and staff statements.
- The facility remained in a code purple and continued to search for Resident #95.
- Housekeeping Staff #485 informed RN #484 of a wheelchair he observed in a lower-level stairwell. Housekeeping Staff #485 escorted RN #484 to the wheelchair.
- RN #484 identified the chair as Resident #95's, proceeded up the stairs, and opened the exit door (to the outside) at the top of the stairs. RN #484 identified Resident #95 was lying outside of the facility door and yelled for help.
- The facility's elopement policy was reviewed by Corporate Regional Nurse #505. No updates or revisions were made.
- Corporate Regional Nurse #505 re-educated the Administrator and Director of Nursing (DON) on the facility's elopement policy and procedures including assessment, identification, monitoring, and managing the elopement policy.
- The Administrator began education with all staff on the elopement policy and procedure, including door alarms and prompt response. Education was additionally provided on abuse, neglect and misappropriation. Nursing staff members received further education on nurse-to-nurse responsibilities regarding census. The education was completed.
- Corporate Regional Nurse #505, Corporate Director of Operations #507, Corporate Director of Clinical Services #508, and the Former Administrator #504 walked the building and checked all doors to ensure the doors alarmed and worked properly.
- A head count of all residents was completed by LPN #438. All residents were accounted for except for Resident #95.
- A contracted door alarm company was contacted to check doors, change door keypad codes, and discuss options to enhance the sounding of the door alarms. The door alarm company installed six additional remote sounders in different locations of the facility, including inside the door at the top of the stairs Resident #95 used to exit the facility. These sounders were installed.
- All residents residing in the facility were assessed by RN #379 and RN #407. No residents were identified to have any injuries or adverse effects. The resident assessments were completed.
- All residents were re-assessed for elopement risk by LPN Unit Manager (UM) #434. The assessments were completed. The facility identified zero in-house residents at risk for elopement. Ongoing audits would be completed by the DON or designee upon admission, re-admission, quarterly, with significant changes, and as needed.
- LPN #438 verified all elopement risk assessments were completed with no residents at risks. No care plan revisions related to elopement were required for in-house residents. This was completed.
- An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held. In attendance were Former Administrator #504, the DON, ADON #411, Maintenance Supervisor #381, Social Service Designee (SSD) #447, LPN #438, Human Resources (HR) Staff #601, Business Office Manager (BOM) #404, Corporate Regional Nurse #505, Corporate Director of Clinical Services #508, Corporate Director of Operations #507. Medical Director (MD) #503 attended via phone. During the meeting, the corrective action plan for Resident #95's elopement was presented by the Administrator and approved by the interdisciplinary team (IDT).
- The facility implemented random and unannounced elopement drills to be performed three times weekly for four weeks, monthly on all shifts for four months, then monthly on rotating shifts. The elopement drills were coordinated by the Administrator or designee. The results of the drills would be reviewed by the IDT in monthly QAPI meetings.
- Ongoing audits were implemented to ensure staff hears and responds to alarms timely and appropriately three times weekly for four weeks. The results of the audits would be reviewed by the IDT in monthly QAPI meetings.
- Ongoing audits were implemented to ensure that with each change of nurse shift, a head count was performed and verified with census records. The results of the audits would be reviewed by the DON or designee daily for 30 days. The results of the audits would be reviewed by the IDT in monthly QAPI meetings.
- All exterior doors added a door alarm that required alarm de-activation to be turned off with a manual key entry. All doors with alarms were noted to be functioning properly.
Failure to Report Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident to the State Agency as required. The resident, who had diagnoses including adult failure to thrive, malnutrition, and metabolic encephalopathy, was admitted for short-term rehabilitation services. The resident was identified as having severely impaired cognition and was at risk for falls and elopement. Despite these risks, the facility did not perform routine checks on the resident, who subsequently eloped and was found unresponsive outside the facility. The facility's policy required immediate reporting and investigation of all allegations of abuse and neglect. However, the incident involving the resident's elopement and subsequent death was not reported to the State Agency as an incident of neglect. This oversight was confirmed during an interview with the facility's administrative staff. The deficiency was investigated under two complaint numbers, indicating a failure to adhere to the facility's abuse prohibition policy.
Failure to Honor Resident Preferences for Bathing and Transfers
Penalty
Summary
The facility failed to honor the bathing preferences of several residents, as evidenced by the medical record reviews, resident interviews, and staff interviews. Resident #21, who was cognitively intact and required assistance with daily living activities, had not received a shower since admission, despite preferring daily showers. The resident was only offered bed baths twice a week, contrary to his preference, and was told by staff that he could not be transferred more than once per shift. This restriction was frustrating for the resident, who preferred to get out of bed for breakfast and rest later in the day. Similarly, Resident #29, who was also cognitively intact and dependent on staff for showers, expressed concerns about not receiving showers during a Resident Council meeting. Despite being scheduled for showers twice a week, the resident reported only receiving bed baths and was woken up during the night for these, which he did not like. The facility's response to his concerns was inadequate, as the issue persisted despite being reported to the Unit Manager and the Director of Nursing. Residents #34 and #58 also experienced similar issues, with both residents preferring showers but only receiving bed baths. Staff interviews confirmed that residents who required assistance were not given a choice between a bed bath or a shower, and showers were scheduled based on room numbers rather than resident preferences. Additionally, Resident #65 faced issues with transfer preferences, as staff informed her that once she was in bed, she had to stay there, which affected her ability to receive timely incontinence care. The facility's policies on resident rights and personal care were not adhered to, leading to these deficiencies.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. Resident #16, who was cognitively impaired and always incontinent of bowel and bladder, was observed in a wheelchair with a strong odor of urine. Despite being transferred out of bed early in the morning, the resident was not checked or changed until late afternoon. Staff interviews confirmed that the resident was not offered incontinence care regularly, and when care was finally provided, the resident's clothing and wheelchair cushion were found to be saturated with urine. Resident #65, who was occasionally incontinent of bladder and always incontinent of bowel, was also affected by the facility's failure to provide timely care. The resident, who required a Hoyer lift for transfers, was left in a chair with a strong odor of stool in the room. The resident expressed reluctance to receive care due to being told she would have to stay in bed afterward. When incontinence care was eventually provided, the resident's pants were found to be saturated with urine and stool, indicating a lack of timely attention to her needs. The facility's policy on incontinence care, which mandates checking and changing residents every two hours and as needed, was not adhered to in these cases. Interviews with staff, including the Director of Nursing, confirmed the expectation for regular checks and care, but these were not consistently performed, resulting in the observed deficiencies. The report highlights the facility's noncompliance with its own policies, as evidenced by the conditions of the two residents involved.
Failure to Ensure Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure Resident #94 was provided a safe transfer via mechanical lift, resulting in a fall with injury. Resident #94, a bilateral above the knee amputee with balance deficits and moderate cognitive impairment, was dependent on staff for transfers. During a transfer from bed to chair using a mechanical lift, the resident began sliding to the floor after the bottom half of the lift sling was removed. Despite attempts by two State Tested Nursing Assistants (STNAs) to lower the resident to the ground, the resident's left amputation site hit the floor, causing the incision to reopen and bleed profusely. The resident was subsequently transferred to the emergency room and required 26 stitches. The resident did not return to the facility. The medical record review revealed that Resident #94 had multiple diagnoses, including pleural effusions, peripheral vascular disease, and type two diabetes mellitus. The resident was on Heparin, an anticoagulant, which increased the risk of bleeding. The resident's care plan indicated a need for assistance with transfers, and therapy evaluations noted significant balance deficits and a high risk for falls. Despite these assessments, the resident was not identified as a fall risk in the initial fall risk assessment. The incident occurred while the resident was being prepared for dialysis, and the nursing progress note documented the resident's pain and bleeding following the fall. Interviews with the DON and the two STNAs involved in the transfer confirmed the sequence of events leading to the fall. The STNAs reported that the resident was not positioned correctly in the chair, and when they attempted to adjust him, he began sliding forward. The STNAs tried to lower the resident to the ground, but the resident's pant leg knots caused additional trauma to the amputation sites. The facility's policies on fall management and mechanical lift usage were reviewed, highlighting the need for proper positioning and safety during transfers. The facility retrained the STNAs on mechanical lift transfers following the incident.
Failure to Ensure Resident Ingested Medications
Penalty
Summary
The facility failed to ensure that Resident #52 ingested all prescribed medications. The resident, who had diagnoses including cerebral infarction, asthma, hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was found with a medicine cup containing numerous pills on his breakfast tray. The resident reported that the nurse had given him the medications but did not watch him take them. The Licensed Practical Nurse (LPN) confirmed that she left the medications in the resident's room and did not observe him ingest them, as the resident did not like being watched while taking his medications. The LPN also confirmed that there were nine pills in the cup but was unsure if they were the same pills she had initially administered. The facility's policy on medication administration, dated December 2017, requires that residents be observed after administration to ensure the dose is completely ingested. If only a partial dose is ingested, it must be noted on the medication administration record, and appropriate action should be taken. This policy was not followed in the case of Resident #52, leading to a significant medication error. This deficiency was identified during a complaint investigation and affected one of the five residents reviewed for accidents, with the facility census being 87.
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Illustrative
What surveyors actually found near you
We read the 1,262 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Warrensville Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harvard Gardens Rehabilitation & Care Center | 0.6 mi | ★★★★★ | 35 | 0 |
| Suburban Healthcare And Rehabilitation | 0.6 mi | ★★★★★ | 1 | 0 |
| Phoenix Of Maple Heights | 1.5 mi | ★★★★★ | 0 | 0 |
| Shaker Gardens Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Beachwood Pointe Care Center | 2.4 mi | ★★★★★ | 11 | 0 |
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