Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchaven Retirement Village during CMS and state inspections, most recent first.
A cognitively impaired resident with multiple neurological conditions who required total assistance for ADLs was subjected to verbal and physical mistreatment during care. A CNA shouted in the resident’s ear, cursed, and forcefully transferred the resident from an unlocked wheelchair to bed, causing the resident to cry and plead for the behavior to stop. After the resident was in bed and still crying, an RN entered, leaned over the resident, pointed a finger, and repeatedly yelled for the resident to stop, despite the resident not being combative. A witnessing CNA reported the conduct as abusive, and leadership later confirmed the incident as substantiated verbal abuse, with no subsequent abuse education or training provided to staff.
The facility failed to implement its abuse policy after a cognitively impaired, fully dependent resident was allegedly subjected to physical and verbal abuse by a CNA and verbal abuse by an RN during a nighttime transfer. A witness CNA reported that the CNA yelled and cursed at the resident, forcefully grabbed his arm, shoved him from an unlocked wheelchair, and aggressively threw him into bed while the resident cried and asked her to stop, and that the RN later entered and repeatedly yelled at the crying, non-combative resident. The DON was not promptly notified, the accused CNA remained on the unit until shift end, and there was no documented immediate assessment, no physician or representative notification, no nursing note describing the incident and assessment findings, and no investigation completed within the timeframe required by the facility’s abuse policy.
A resident with severe cognitive impairment, dementia, Parkinson’s disease, and dependence in all ADLs was allegedly subjected to verbal and physical abuse by a CNA, including yelling, cursing, forcefully grabbing the resident’s arm, shoving the resident from a wheelchair, and aggressively throwing the resident into bed, with an RN also initially alleged to have been verbally abusive. Another CNA witnessed the incident and reported it to an LPN within minutes and submitted a written statement within about an hour, but the DON was not notified for several hours, and the alleged perpetrator remained on the unit providing care until the end of the shift. These actions and delays did not follow the facility’s abuse policy requiring immediate reporting to supervisors and prompt notification of administration and state authorities.
A resident with severe cognitive impairment, dementia, Parkinson’s disease, and total dependence for ADLs was allegedly subjected to physical and verbal abuse by a CNA and verbal abuse by an RN during nighttime care. A CNA witness reported that the involved CNA yelled and cursed at the resident, forcefully grabbed the resident’s arm, shoved the resident from an unlocked wheelchair, and aggressively threw the resident into bed while the resident cried and asked for the behavior to stop. The same witness stated that an RN then entered, leaned over the resident in bed, and repeatedly shouted at the resident in an aggressive tone. In subsequent interviews, the witness reaffirmed these accounts, while the RN could not recall the incident. The facility’s investigation documentation did not address the alleged physical abuse by the CNA or the alleged verbal abuse by the RN, and leadership later acknowledged that no investigation into these specific abuse allegations had been completed, despite an abuse policy requiring timely investigation of all allegations.
The facility did not serve food according to the menu and dietary spreadsheet, affecting 29 residents. During a meal service, broccoli cheddar soup was served using a four-ounce ladle instead of the specified six-ounce portion. Chef confirmed the error.
The facility failed to properly label, date, and dispose of food items in unit refrigerators, affecting residents on the Birch, Cedar, and Dogwood units. Observations revealed unlabeled and undated food items, including sandwiches, containers with unknown substances, and leaking containers. Staff confirmed these items should have been disposed of, impacting 45 residents in a facility with a census of 90.
The facility failed to implement proper infection control practices for COVID-19 and EBP, affecting six residents. Observations revealed that residents who tested positive for COVID-19 were not properly isolated, and staff did not consistently wear or dispose of PPE as required. Additionally, hand hygiene practices were not followed, and residents on EBP did not receive care with the necessary precautions.
The facility failed to ensure residents received education and provided consent for COVID-19 vaccinations prior to administration or refusal, affecting five residents. Medical records lacked documentation of vaccine information, consent, or refusal. An interview with the DON revealed the absence of a form and policy for COVID-19 vaccine consent, contributing to the deficiency.
The facility failed to treat residents with dignity and respect. A resident experienced a significant delay in receiving their meal, while two other residents had their lunch interrupted for physical examinations by a CNP. The facility lacks a specific policy on dignity, relying instead on general residents' rights.
A CNP discussed a resident's medical condition and treatment in the dining room with other residents present, violating the facility's privacy policy and HIPAA. The resident was being treated for pain with tramadol and was cognitively intact. The CNP did not adjust her rounds based on residents' schedules, leading to the breach of confidentiality.
A resident with severe cognitive impairment had bruising on their forearm that was noticed by a CNA but not reported to facility management until the resident's family informed the ADON. This delay in reporting led to a deficiency in addressing potential abuse or neglect.
The facility failed to conduct thorough investigations for injuries of unknown origin for two residents. One resident with Alzheimer's was found with bruising, and another with dementia had redness and swelling on her hand. In both cases, the facility did not perform skin checks on other residents on the same hall who could not be interviewed, contrary to their policy. This was confirmed by the Administrator and DON.
A facility failed to provide a translator phone for a Spanish-speaking resident, as ordered by a physician. Despite attempts to use personal phone applications, staff were unable to communicate effectively with the resident. The resident's daughter and staff confirmed the absence of a translator phone, and the ADON was unsure of the effectiveness of a tablet application intended for communication.
A facility failed to monitor and implement constipation interventions for a resident at high risk due to health conditions and opioid use. The care plan required monitoring bowel movements and administering medications, but records showed gaps in documentation and medication administration. The DON confirmed these lapses, acknowledging the protocol was not followed.
A facility failed to ensure proper interventions to prevent aspiration for a resident receiving enteral nutrition. The resident, who was severely cognitively impaired and dependent on staff, required the head of their bed to be elevated to 45 degrees during tube feeding. Observations revealed the bed was barely elevated, and staff interviews confirmed the deficiency, with an LPN mistakenly believing the required elevation was 30 degrees.
A resident with pneumonia required oxygen therapy at two liters per minute as per the physician's order. However, observations showed the oxygen was set at four liters per minute, contrary to the order. This discrepancy was confirmed by an RN, indicating a failure to follow the facility's policy on verifying physician orders for oxygen administration.
The facility failed to administer the influenza vaccine to a resident who consented and did not offer another resident the necessary information or consent options for influenza and pneumococcal vaccines. One resident, with multiple health conditions, consented to the influenza vaccine, but there was no record of administration. Another resident, cognitively impaired, had no documentation of vaccine consent or refusal, and the facility did not obtain verbal consent from the Power of Attorney.
Failure to Protect Cognitively Impaired Resident From Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by staff. A male resident with multiple neurological and cognitive diagnoses, including neurocognitive disorder with Lewy bodies, dementia, Parkinson's disease, and severe impairment in decision-making, required assistance with all activities of daily living. On the night in question, a CNA became aggravated while assisting the resident with transfers between his wheelchair and bed. According to a witness statement and the facility’s substantiated self-reported incident, the CNA shouted at the resident in an aggressive tone, yelled in his ear, cursed at him, and forcefully handled him by grabbing his arm, shoving him out of an unlocked wheelchair, and aggressively throwing him into bed while continuing to shout and argue with him. The resident verbally pleaded for the CNA to stop and began to cry during this interaction. After the resident was in bed, still crying and not being combative, an RN entered the room. The RN stood beside the bed, leaned over the resident, and repeatedly pointed a finger at him while loudly and aggressively stating, "you're going to stop right now and stop right now" at least five times, according to the witnessing CNA. The witnessing CNA reported that this was upsetting to observe and believed the resident was verbally and physically abused by the CNA and verbally abused by the RN. During a later interview, the RN stated he could not recall the incident or any details surrounding it. Facility leadership interviews confirmed that the incident was investigated and substantiated as verbal abuse, and that no abuse education or training had been provided to staff following this substantiated allegation.
Failure to Implement Abuse Policy After Alleged Staff Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy in response to substantiated allegations of staff-to-resident physical and verbal abuse. A male resident with neurocognitive disorder with Lewy bodies, dementia, Parkinson’s disease, major depressive disorder, cognitive communication deficit, gait and mobility abnormalities, and generalized muscle weakness was severely cognitively impaired per his most recent MDS, with both short- and long-term memory problems and severely impaired decision-making. He required assistance with all functional abilities, including hygiene, bathing, dressing, repositioning, transferring, toileting, and walking. Despite these vulnerabilities, there was no documentation in his medical record that he was assessed immediately after the alleged abuse incident, and no progress notes described the event. According to the facility’s substantiated Self-Reported Incident, at approximately 3:30 A.M. a CNA became aggravated with the resident, yelled and cursed in his ear, grabbed his arm forcefully, shoved him out of his wheelchair, and aggressively threw him into bed while continuing to shout at him. A witness CNA reported that the wheelchair was unlocked when the resident was shoved out, that the CNA slammed the wheelchair pedals shut aggressively, and that the resident cried and said “please stop” as his legs were thrown into bed. After the resident was in bed and crying, an RN entered the room, pointed a finger at the resident, and repeatedly yelled at him in an aggressive tone to “stop right now,” while the resident continued crying and was not combative. These events constituted verbal and physical abuse as documented in the SRI and witness statement. The facility did not follow its Abuse, Neglect, and/or Misappropriation of Resident Funds or Property Policy. The DON was not notified until approximately two hours and 24 minutes after the incident, and the CNA accused of physical abuse remained on the unit providing resident care until the end of her shift. There was no documentation that a nurse supervisor performed the required immediate assessment, including range of motion, full body assessment for signs of injury, and vital signs, and no documentation that the resident’s physician or representative were notified. The incident was not documented in the nurses’ notes with an accurate description of the event, assessment findings, notifications, or treatment. Additionally, the facility never conducted an investigation into the physical abuse by the CNA and verbal abuse by the RN, and therefore did not complete an investigation within the five working days required by its policy.
Failure to Timely Report and Respond to Alleged Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report alleged verbal and physical abuse of a resident and to immediately remove the alleged perpetrator from resident care. The affected resident had multiple significant diagnoses, including neurocognitive disorder with Lewy bodies, dementia, Parkinson’s disease, major depressive disorder, cognitive communication deficit, gait and mobility abnormalities, and generalized muscle weakness. His most recent quarterly MDS showed severely impaired cognitive skills for daily decision-making, with both short- and long-term memory problems, and a need for assistance with all functional abilities such as hygiene, bathing, dressing, repositioning, transferring, toileting, and walking. According to the facility’s substantiated self-reported incident, at approximately 3:30 A.M. a CNA became aggravated with the resident, yelled and cursed in his ear, grabbed his arm forcefully, shoved him out of his wheelchair, and aggressively threw him into bed. The same report indicated an RN was verbally abusive, though the facility’s investigation later concluded the RN did not yell at the resident but instead pointed at the CNAs and told them to stop. The events were witnessed by another CNA, who stated there was no supervisor working on the unit at the time. She reported the incident to the unit LPN approximately 10–15 minutes after it occurred and, per the LPN’s direction, wrote and emailed a statement within about an hour of the incident. Despite this, the DON was not notified until 5:54 A.M., approximately two hours and 24 minutes after the alleged abuse, and the CNA accused of abuse remained on the unit providing care until she punched out at 6:09 A.M. This sequence of events did not align with the facility’s Abuse, Neglect, and/or Misappropriation of Resident Funds or Property policy, which required staff to report all incidents immediately to their direct supervisor so that the Administrator and state agency could be notified and an investigation initiated. The delay in notification and failure to promptly remove the alleged perpetrator from the unit constituted the identified deficiency in timely reporting and response to suspected abuse.
Failure to Thoroughly Investigate Alleged Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of physical and verbal abuse toward a resident and to prevent potential further abuse. The resident, admitted with multiple neurologic and cognitive diagnoses including neurocognitive disorder with Lewy bodies, dementia, Parkinson’s disease, and generalized muscle weakness, had severely impaired cognitive skills and both short- and long-term memory problems, and required assistance with all functional abilities such as hygiene, bathing, dressing, repositioning, transferring, toileting, and walking. A quarterly MDS assessment documented that a BIMS score could not be determined due to the resident’s cognitive state. According to the facility’s substantiated Self-Reported Incident (SRI), in the early morning hours a CNA became aggravated with the resident, yelled in his ear, cursed at him, grabbed his arm forcefully, shoved him out of his wheelchair, and aggressively threw him into bed. The SRI also identified that an RN was verbally abusive to the resident during the same episode. A witness CNA’s written statement described that while she was attempting to help the resident safely to a wheelchair, the involved CNA intervened, shouted at the resident in an aggressive tone, forced him to sit, and slammed the wheelchair pedals shut aggressively. The statement further detailed that when assisting the resident to bed, the CNA screamed in the resident’s ear to stand up, grabbed his arm, and forcefully shoved him out of the unlocked wheelchair, then threw him into bed, aggressively throwing his legs into the bed while shouting, refusing to cooperate, and cursing, during which the resident said “please stop” and began to cry. The same witness statement reported that after the resident was in bed, under the covers, and crying, the RN entered the room, stood beside the bed, leaned over the resident, pointed a finger, and repeatedly shouted in a loud and aggressive tone, “you’re going to stop right now and stop right now,” at least five times, while the resident continued crying and was not combative. In a later interview, the CNA witness reiterated her belief that the resident had been verbally and physically abused by the CNA and verbally abused by the RN, and confirmed that the RN’s shouting was directed at the resident. The RN, when interviewed, could not recall the incident or any details. The facility’s investigation documentation concluded that the RN had not yelled at the resident but had pointed at the CNAs and told them to stop, and it did not include an investigation into the alleged physical abuse by the CNA or the alleged verbal abuse by the RN. In a joint interview, the ADON, DON, and Administrator acknowledged that the facility had not completed an investigation into the physical abuse allegation against the CNA or the verbal abuse allegation against the RN, despite a policy requiring that allegations or suspicions of abuse be investigated and completed within specified time frames.
Improper Portioning of Broccoli Cheddar Soup
Penalty
Summary
The facility failed to ensure that food was served according to the facility menu and dietary spreadsheet, which had the potential to affect 29 residents on the Cedar and Dogwood units. During a meal service observation, it was noted that the broccoli cheddar soup was being served using a four-ounce ladle instead of the six-ounce portion specified in the menu spreadsheet. This discrepancy was confirmed in an interview with Chef #441, who acknowledged that the soup should have been served using a six-ounce ladle.
Improper Food Storage Practices in Facility Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in unit refrigerators, as well as the removal of expired food items. During an observation on the Birch-hall unit refrigerator, an unlabeled pack of two small sandwiches was found, which should have been disposed of according to Certified Nursing Assistant (CNA) #579. Additionally, the refrigerator near the dining area for the Birch-hall contained three unlabeled and undated disposable plastic containers with unknown substances, an unlabeled and undated glass jar with an unknown red substance, and a grocery bag with three unlabeled and undated disposable containers, one of which was leaking. These findings were verified by Hospitality Aide #497. Further observations on the Cedar-hall unit refrigerator revealed an unlabeled and undated bag with an unknown frozen substance and another bag with an unknown brown substance, which Activities Staff Member #501 confirmed should have been disposed of. Additionally, the refrigerator near the dining area for the Cedar and Dogwood halls contained an unlabeled and undated clear-plastic bag with an unknown food item. These deficiencies in food storage practices had the potential to affect 45 residents residing on the Birch, Cedar, and Dogwood units, with a facility census of 90.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices related to COVID-19 and Enhanced Barrier Precautions (EBP), affecting six residents. Observations revealed that residents who tested positive for COVID-19 were not properly isolated, as their room doors were left open, and there was a lack of appropriate signage and personal protective equipment (PPE) available. Staff members were observed entering rooms without wearing the required PPE, such as N95 masks, gowns, gloves, and face shields, and there were instances where PPE was not properly disposed of or disinfected after use. Resident #25, who tested positive for COVID-19, was observed without proper isolation measures in place, as there was no PPE cart or signage outside the room. Staff members were seen assisting the resident without wearing the necessary PPE. Similarly, Resident #28's room lacked proper signage and PPE, and staff were observed not disinfecting shared face shields after use. Resident #14 also tested positive for COVID-19, and similar deficiencies in PPE usage and signage were noted. For residents on EBP, such as Resident #72 and Resident #49, staff failed to wear the required gowns and gloves during high-contact care activities. Additionally, hand hygiene practices were not consistently followed, as staff did not wash or sanitize their hands after doffing PPE. Resident #82, who required EBP due to a tracheostomy and gastrostomy, reported that staff did not wear gowns or masks during care. These observations indicate a systemic failure in adhering to infection control protocols, as outlined in the facility's policy and CDC guidelines.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that residents received education and provided consent for COVID-19 vaccinations prior to administration or refusal. This deficiency affected five residents who were reviewed for COVID-19 vaccination. The medical records of these residents did not contain any forms indicating that they were given information about the COVID-19 vaccine, nor did they contain any documentation of consent or refusal of the vaccine. The residents involved had various medical conditions, including rhabdomyolysis, type II diabetes mellitus, obesity, cerebral infarction, chronic obstructive pulmonary disease, spinal stenosis, anemia, hyperlipidemia, hypertension, metabolic encephalopathy, cystitis, atherosclerotic heart disease, chronic congestive heart failure, long-term use of anticoagulation therapy, hypothyroidism, and chronic kidney disease. An interview with the Director of Nursing revealed that the facility did not have a form for refusal or acceptance of the COVID-19 vaccine and lacked a policy for offering the COVID-19 vaccine. While the influenza vaccine is offered from October through March, and the pneumococcal and COVID-19 vaccines are offered at any time, the absence of a formal process for documenting education and consent for the COVID-19 vaccine led to this deficiency. The facility census at the time was 90 residents.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting three residents. Resident #23, who was cognitively impaired and required assistance with eating, was observed in the dining room waiting for their meal while other residents had already been served and finished eating. Despite being seated at 11:30 A.M., Resident #23 did not receive their meal until 12:32 P.M., causing them to motion as if they were eating due to the delay. This was confirmed by Hospitality Aide #497, who acknowledged that Resident #23 had to wait longer than others to be served. Additionally, the facility did not respect the dignity of Residents #64 and #57, who were both cognitively intact, during their lunch. Clinical Nurse Practitioner (CNP) #399 interrupted their meals to conduct physical examinations in the dining room, which was confirmed by CNP #399 and noted in the progress notes. The Director of Nursing stated that the facility does not have a specific policy on dignity but follows residents' rights. The Residents Rights handbook emphasizes treating each resident with respect and dignity, promoting their quality of life and individuality.
Breach of Resident Privacy in Dining Area
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical information, as required by their policy and the Health Insurance Portability and Accountability Act (HIPAA). During an observation, a Clinical Nurse Practitioner (CNP) was seen discussing a resident's medical condition, treatment, and vital signs in the dining room where other residents were present. This discussion involved a resident who was cognitively intact and being treated for pain with tramadol, as per the physician's orders. The CNP confirmed in an interview that she discussed the resident's medical details in the presence of other residents and stated that she does not adjust her rounds based on the residents' schedules unless they are out of the building. The facility's policy clearly states that health information should be kept confidential and that precautions should be taken to prevent the incidental disclosure of Protected Health Information (PHI) to unauthorized individuals. This incident affected one resident out of the 90 in the facility census.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin and potential physical abuse involving a resident. The incident involved a resident who was severely cognitively impaired and required assistance for all activities of daily living. The resident's family member reported bruising on the resident's lower right forearm to the Assisted Director of Nursing (ADON) in the afternoon, which was the first time the facility management became aware of the issue. Prior to this, a Certified Nursing Assistant (CNA) had noticed the bruising during their shift but did not report it to the nurse on duty or any other staff. The facility's investigation revealed that the CNA observed the bruising before 6:00 A.M. but failed to report it, resulting in a delay in initiating a Self-Reported Incident (SRI). The Director of Nursing (DON) and the Administrator confirmed that the CNA did not report the bruising until after the family brought it to the facility's attention. This lack of timely reporting and communication within the facility led to a deficiency in addressing potential abuse or neglect, as the facility's management was not informed until the family intervened.
Failure to Conduct Thorough Investigations for Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin for two residents. Resident #98, who had Alzheimer's disease and was dependent on staff for daily activities, was found with bruising on her legs. Although staff and other residents were interviewed, and a skin assessment was completed for Resident #98, there was no evidence that skin assessments were conducted on other residents residing on the same hall who could not be interviewed. This lack of comprehensive investigation was confirmed by the Administrator and Director of Nursing (DON). Similarly, Resident #68, who had major depressive disorder and dementia, was found with new redness and swelling on her right hand. Despite being interviewed and having a skin assessment, the facility did not perform skin checks on other residents on the same hall who were unable to be interviewed. The facility's policy on investigating injuries of unknown origin was not followed, as confirmed by the Administrator and DON, who acknowledged that skin checks were not completed on any residents other than the affected ones.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide alternative methods of communication for a resident who was admitted with a primary language of Spanish and required an interpreter to communicate with healthcare staff. Despite a physician's order for a translator phone, the facility did not provide this device, and staff were unable to effectively communicate with the resident. The resident's daughter confirmed that while some common phrases were posted in the resident's room, they were insufficient for day-to-day communication, and she was unaware of any translator phone or interpreter being available. Staff interviews revealed that attempts were made to use personal phone applications to communicate with the resident, but these were ineffective as they did not recognize the resident's voice. The Assistant Director of Nursing confirmed the absence of a translator phone and mentioned the use of a tablet with an application, though its effectiveness was uncertain. This lack of proper communication tools hindered the facility's ability to meet the resident's communication needs as per the physician's orders.
Failure to Monitor and Administer Constipation Interventions
Penalty
Summary
The facility failed to adequately monitor and implement interventions for constipation for Resident #42, who was at high risk due to multiple health conditions and opioid medication use. The resident's care plan required monitoring and documenting bowel movements every shift, and administering stool softeners or laxatives as ordered. However, the medical records showed gaps in documentation of bowel movements and the absence of color descriptions, as required by the care plan. Additionally, the administration records indicated that the prescribed medications, Miralax and Colace, were not administered during the specified period, despite the resident not having documented bowel movements for several days. The Director of Nursing confirmed these lapses in documentation and medication administration, acknowledging that the facility's protocol to offer interventions after three days without a bowel movement was not followed for Resident #42.
Failure to Elevate Bed During Tube Feeding
Penalty
Summary
The facility failed to implement necessary interventions to prevent aspiration for a resident receiving enteral nutrition. Resident #49, who was severely cognitively impaired and dependent on staff for all activities of daily living, required tube feeding due to dysphagia. The resident's care plan specified that the head of their bed should be elevated to 45 degrees during and for thirty minutes after tube feeding. However, during an observation, it was noted that the resident was lying on their back with the head of the bed barely elevated while the tube feeding was running. Interviews with staff confirmed the deficiency. A CNA verified that the head of the bed should have been elevated more, and an LPN acknowledged that the bed was not elevated to the required degree. The LPN mistakenly believed the head of the bed should be at 30 degrees and admitted there was no way to determine the exact elevation. This oversight in following the care plan for Resident #49's tube feeding regimen led to the deficiency noted in the report.
Failure to Administer Oxygen Per Physician's Order
Penalty
Summary
The facility failed to ensure that oxygen was administered to a resident according to the physician's order. A resident, who was admitted with a diagnosis of pneumonia and was cognitively intact, required oxygen therapy as per the admission Minimum Data Set. The physician's order specified that the resident should receive oxygen at two liters per minute via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen was set at four liters per minute, which was confirmed by a registered nurse. The facility's policy on oxygen administration requires verification of the physician's order, which was not adhered to in this case.
Failure to Administer and Offer Vaccinations
Penalty
Summary
The facility failed to ensure that one resident received the influenza vaccination after consenting and failed to offer another resident the information, consent, or refusal of the influenza or pneumococcal vaccine. Resident #82, who had diagnoses including metabolic encephalopathy, type II diabetes mellitus, and chronic obstructive pulmonary disease, consented to the influenza vaccine on 11/29/24, but there was no evidence in the medical record that the vaccine was administered. Resident #149, with diagnoses such as cystitis, atherosclerotic heart disease, and chronic obstructive pulmonary disease, had a blank form for the influenza and pneumococcal vaccines. The Director of Nursing admitted that the resident was cognitively impaired and unable to consent, and the Power of Attorney had not signed any documents. The facility did not obtain verbal phone consent, which was an option. The influenza vaccine is offered from October through March, and the pneumococcal vaccine is offered upon admission and yearly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Findlay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fox Run Manor | 0 mi | ★★★★★ | 0 | 0 |
| The Manor At Greendale | 2 mi | ★★★★★ | 0 | 0 |
| Heritage The | 2.3 mi | ★★★★★ | 10 | 0 |
| Briar Hill Health Campus | 9.1 mi | ★★★★★ | 0 | 0 |
| Serenity Spring Senior Living At Arlington | 10.5 mi | ★★★★★ | 0 | 0 |
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