Buckeye Terrace Rehabilitation And Nursing Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain a clean, safe, and sanitary environment in resident care and common areas, affecting all 62 residents in the building. Surveyor observations on the first floor showed a mattress propped against a dining room wall with two wheelchairs holding it up, holes and torn wallpaper behind it, and a broken chair part under the mattress edge. There was also a large streak-like hole in the wall near the dining room entrance. Hallways on the first floor had dirt and brown smears, were littered with small white paper pieces, and two nursing station trash cans were overflowing. Additional structural issues included a handrail pulled away from the wall, unpainted re-plastered wall sections, and multiple areas where walls and corners had separated, including near the soiled utility room, between a resident room and the resident/family lounge, and near the courtyard door. Seven cigarette butts were observed in the hallway between the courtyard and ambulance doors, and the elevator floor had multiple brown spots. On the second floor, surveyors observed white streaks on the floor from the elevator to a resident room that appeared to be paint streaks, as well as dirty hallways with brown spots and scattered small white paper pieces similar to those on the first floor. A CNA stated she did not know what the white streaks were but thought they looked like paint. The maintenance staff member confirmed the presence of the mattress, damaged walls, litter, overflowing trash, loose handrail, unpainted plaster, separated walls, cigarette butts, and dirty elevator floor, and explained that the white streaks on the second floor were paint streaks resulting from moving a heavy door. The maintenance staff member also verified that the overall appearance of the facility was not in a homelike manner. Housekeeping staff reported that the person who previously stripped and waxed floors was no longer employed because the position was considered unnecessary, and that housekeeping hours were limited to a budgeted 30 hours per week, resulting in housekeepers typically working only about four hours per day. According to housekeeping, cleaning efforts were focused on “important areas” such as bathrooms, nurses’ stations, main hallways, and a limited number of resident rooms, with staff doing only what they could within their limited hours and CNAs assisting with spills when housekeeping was not present. Subsequent observation confirmed missing handrail corners on two halls, which the Administrator verified at the time. Review of facility policies showed that floors were required to be maintained in a clean, safe, and sanitary manner with daily cleaning, and that maintenance services were required to keep the building, grounds, and equipment in good repair and free from hazards, which was not achieved as evidenced by the observed conditions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain proper written justification for pharmacy recommendations that were declined for four residents reviewed for unnecessary medications. For Resident #7, who had diagnoses including paranoid schizophrenia, muscle weakness, hypertension, insomnia, and a cognitively intact MDS assessment, the consultant pharmacist recommended a gradual dose reduction for Risperdal 3 mg nightly, but the nurse practitioner disagreed without documenting any explanation. For Resident #23, who had diagnoses including diabetes, major depressive disorder, schizoaffective disorder, psychosis, insomnia, dementia, hallucinations, and delusional disorder, the consultant pharmacist recommended a gradual dose reduction for melatonin 6 mg at bedtime to 3 mg at bedtime, but the nurse practitioner disagreed without documenting a rationale. For Resident #25, who had diagnoses including generalized anxiety, mood disorder, insomnia, and schizoaffective disorder bipolar type, the pharmacy recommended re-evaluation and later dose reduction of Trazodone 50 mg and Zoloft 100 mg, with instructions to document the clinical rationale if gradual dose reduction was contraindicated. The physician disagreed with the recommendations, but no rationale was documented. For Resident #9, who had cellulitis of the perineum, muscle weakness, and a non-pressure chronic ulcer of the left ankle, the pharmacy recommended weekly CK monitoring while the resident received Daptomycin 700 mg daily, but the physician disagreed without documented justification. The facility also failed to ensure proper monitoring and oversight for unused as-needed pain medications for Resident #23. Her orders included Motrin 800 mg every 8 hours as needed, Norco 5-325 mg every 8 hours as needed, and Tylenol 650 mg every 4 hours as needed. The MAR showed Motrin and Norco were not administered from July 2025 through December 2025, and the pharmacy reviews for that period contained no recommendations or documentation addressing why those medications remained ordered despite not being used. The DON stated the resident preferred Tylenol and did not have an explanation for why Motrin and Norco remained on the orders or why pharmacy had not documented a review.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Provide and implement an infection prevention and control program was not ensured when staff failed to disinfect a shared blood glucose meter after use for a resident with diabetes mellitus type 1, morbid obesity, hypertension, and cholecystitis. The resident’s record showed he was cognitively intact and required assistance from staff with toileting, transfers, dressing, and personal hygiene. His physician orders included Accu Check in the morning every other day and orders to disinfect the glucometer between each use every shift and as needed for infection control. During observation of medication administration, an RN used a glucometer to obtain a blood sugar reading for the resident and wiped the device with an alcohol pad, then wiped it with a bleach wipe and placed it in the top drawer of the nurse’s cart. The RN stated the glucometer was one of two shared for her assignment and confirmed she did not allow the glucometer to remain visibly wet for 4 minutes as required by the bleach wipe instructions. The Safety Data Sheet for the bleach wipes stated they are for hard, non-porous surfaces and should be used according to label directions, including keeping the surface visibly wet for four minutes and allowing it to air dry.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide effective pain management for one resident who required pain services. The resident was admitted with diagnoses including chronic pain syndrome, anxiety, depression, polyneuropathy, and irritable bowel syndrome. Her MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and she required staff assistance with showering and bathing. Physician orders included oxycodone 5 mg every 4 hours as needed for pain, gabapentin 600 mg three times daily for neuropathy, and pain assessment/pain monitoring every shift. Review of the MAR from August 2025 through December 2025 showed multiple instances in which the PRN oxycodone was administered and then reported to the nurse as ineffective, with pain levels documented as 5, 6, or 7 on several occasions. The medical record contained no documentation of follow-up interventions or physician notification after these ineffective pain management episodes. During interview, the DON stated nurses were expected to offer non-pharmacological interventions, attempt to identify the cause of pain, and call the physician for a temporary solution when PRN pain medication was ineffective, and she confirmed the ineffective pain episodes and lack of follow-up documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Failure to maintain hospice notes and records on-site was identified for one resident receiving hospice services. The resident was admitted with hemiplegia, vitamin D deficiency, osteoarthritis of the knee, osteoporosis, hypertension, rheumatic heart disease, and dementia, and her MDS dated 10/02/25 showed severe cognitive impairment. Review of the facility’s physical hospice binder found no hospice notes for the last three months. Further review showed hospice notes and records dated 09/15/25 through 11/26/25 had been delivered to the facility by the hospice agency on 12/10/25. During interview, the Regional Director of Clinical Services confirmed the facility received the hospice notes from the hospice agency and stated the documents should have been in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely and adequate vision services were provided to a resident with intact cognition and a history that included left femur fracture, asthma, diabetes type 2 with diabetic neuropathy, chronic diastolic heart failure, and need for assistance with personal care. The resident’s MDS showed a BIMS score of 14 out of 15 and indicated assistance was needed with toileting, bathing, and dressing. Review of progress notes from November 2025 to December 2025 found no documentation that ancillary services were offered or that the resident requested to be seen by an optometrist. During observation and interview, the resident was wearing glasses with a piece of white tape visible on the middle of the frame near the nose pieces and stated the eye pads on the glasses had been broken for about a month. The resident reported asking an unidentified nurse to see the eye doctor to get the glasses fixed and said she was still waiting for someone to help set up an appointment. The DON stated she was unaware the resident had broken glasses and had requested an optometrist visit. The HRD stated the facility had no evidence of tracking residents for ancillary services or offering consents for those services, and confirmed the resident did not have a consent for ancillary services and had never been assisted with scheduling such services by the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a psychiatric consult as ordered for one resident reviewed for behavioral services. The resident was admitted with diagnoses including COPD, depression, hyperlipidemia, hypertension, alcohol abuse, polyneuropathy, and GERD, and his MDS assessment indicated he was cognitively intact. A physician order dated 08/13/25 documented a psychiatric evaluation to be completed, but review of the resident’s medical record from 08/13/25 through discharge showed no completed psychiatric evaluation. During interview, the DON and RDCS confirmed that no psychiatric consult had been completed for the resident, that the psychiatric consult was a standing order entered for admissions, and that not all such consults were completed. They also confirmed there was no documentation showing a discussion with the resident or his family about whether the psychiatric consult should or should not be completed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a large portion of a resident's wall, measuring approximately three feet wide by two feet long, was found missing beside the right side of the resident's bed. This issue was observed on multiple occasions and confirmed by both staff and maintenance personnel. The resident affected had a history of schizophrenia, seizures, morbid obesity, muscle weakness, transient ischemic attack, gastro-esophageal reflux disease, chronic pain syndrome, and difficulty walking, and was assessed as having severe cognitive impairment. Staff interviews revealed that the damage to the wall had existed for an extended period, though the exact duration was unknown. The certified nurse aide confirmed that such damage would have taken time to develop and acknowledged that staff are responsible for reporting room damage to maintenance in a timely manner. Maintenance staff and the administrator were unaware of how or when the damage occurred and only became aware of it after being informed by staff. The facility began repairs after the issue was reported.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of acute kidney failure, muscle weakness, neuromuscular dysfunction of the bladder, and paraplegia was admitted to the facility and assessed as requiring self-care assistance. The resident's care plan included interventions for multiple pressure ulcers due to immobility, specifically the use of Prevalon boots every shift to relieve pressure on the heels and prevent further skin breakdown. The resident had an unstageable pressure ulcer on the left heel, and physician orders required the application of Prevalon boots every shift. Despite these orders, multiple observations over two days revealed that the resident was not wearing the Prevalon boots at any time. The resident confirmed that staff had not placed the boots on him for over a month. This was further corroborated by the unit manager, who acknowledged that the resident was not wearing the boots as ordered. The failure to implement the prescribed pressure relief intervention constituted a deficiency in the facility's care for residents with pressure ulcers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer medications to residents in a timely manner as prescribed, affecting three out of five residents reviewed for medication administration. Medical record review showed that one resident with diagnoses including intraspinal abscess, syphilis, anxiety, and bipolar disorder received trazodone for insomnia more than 90 minutes late on multiple occasions. Another resident with acute kidney failure, muscle weakness, neuromuscular dysfunction of the bladder, and paraplegia received oxycodone for pain more than 90 minutes late on several nights. A third resident with a left femur fracture, muscle weakness, dysphagia, and chronic kidney disease received gabapentin for pain more than 90 minutes late on two occasions. Staff interviews confirmed that medications were often administered late at night due to insufficient nursing staff, and the facility's policy requires medications to be administered within one hour of the prescribed time. The late administration of medications was verified for each resident on the specific dates listed in the medical administration records. This deficiency was identified during a complaint investigation and is documented under the relevant complaint number.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary and adequate care for a resident with a PleurX chest tube. The nursing staff were not properly educated on the management of the PleurX chest tube, which is used to drain fluid from the pleural space to ease breathing. The resident, who had a history of Stage IV breast cancer with metastases and other serious health conditions, was admitted to the facility with the PleurX chest tube in place. However, there was no assessment or care plan addressing the use of the PleurX chest tube, and no physician orders were in place for its care during the resident's stay. The resident's medical records and progress notes revealed that the PleurX drain was not addressed upon admission, and the resident's care plan did not include any instructions for managing the chest tube or monitoring for potential infections. Despite recommendations for intermittent drainage to manage shortness of breath, the facility did not have a drain kit available, and the resident's PleurX was not drained during their stay. This oversight led to the resident experiencing shortness of breath and being sent to the hospital, where it was confirmed that the PleurX had not been drained since the resident's discharge from the hospital to the facility. The lack of proper assessment, monitoring, and physician orders for the PleurX chest tube, along with the absence of staff training on its use, contributed to the deficiency. The resident's condition, including acute on chronic hypoxic respiratory failure and pneumonia, was exacerbated by the failure to manage the PleurX chest tube appropriately. The facility's oversight in ensuring the necessary care and monitoring for the resident's medical device resulted in the resident being transferred to the hospital for further treatment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a dignified dining experience for a resident with dementia, dysphagia, and hemiplegia. The resident required partial to moderate assistance with eating, as documented in their care plan. However, the care plan did not include an intervention for standing while feeding. Observations revealed that a State tested Nursing Assistant (STNA) stood while feeding the resident and held the back of the resident's head during meals. This practice was contrary to the facility's policy, which emphasized feeding residents with attention to safety, comfort, and dignity, specifically advising against standing over residents while assisting them with meals. The deficiency was identified during an investigation under Complaint Number OH00158608.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an incident of alleged sexual abuse to the state survey agency and did not implement their abuse policy following the allegation. This deficiency affected one resident, who was admitted with diagnoses including schizophrenia, post-traumatic seizures, traumatic brain injury, and depression. The resident had a BIMS score indicating intact cognition. The incident involved another resident placing the affected resident's hand on his clothing over his penis, which made the resident uncomfortable. The resident reported the incident to the Business Office Manager, Social Worker, and Administrator on the same day it occurred. Despite the report, the facility did not file a self-reported incident with the state survey agency as required by their policy, which mandates reporting within two hours of an allegation. The resident was moved to another floor three days after the incident, but the facility's policy also required immediate action to protect the resident, including preventing access during the investigation. Interviews with staff confirmed the delay in reporting and relocation of the resident, and a review of the EIDC portal showed no initial report of the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policy following an allegation of sexual abuse involving a resident. Resident #23, who has a diagnosis of schizophrenia, post-traumatic seizures, traumatic brain injury, and depression, reported an incident where another resident, Resident #38, placed her hand on his clothing over his penis. Despite Resident #23's intact cognition, as indicated by a BIMS score of 14, the progress notes in her medical record did not document the allegation of sexual abuse that occurred on 10/18/24. Resident #23 reported the incident to the Business Office Manager, Social Worker, and the Administrator on the same day it occurred. However, the facility did not take immediate action to protect Resident #23, as she was only moved to another floor away from Resident #38 three days later, on 10/21/24. This delay in response was confirmed by interviews with an LPN and a State-tested Nursing Aide. The facility's policy, which defines sexual abuse as non-consensual sexual contact and requires action to prevent access to the resident during an investigation, was not followed promptly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate supervision for a resident identified as a fall risk, leading to an incident where the resident fell while unattended in the shower room. The resident, who has diagnoses including epilepsy, muscle weakness, and post-traumatic stress disorder, was assessed to have moderate cognitive impairment and required supervision for showering and bathing. Despite these needs, the resident was left alone in the shower room by a State Tested Nursing Aide (STNA), resulting in a fall. The resident's care plan, which was initiated earlier in the year, identified the risk of falls due to factors such as abnormal posture and impaired gait, and included interventions to prevent falls, such as ensuring staff assistance during showers. However, these interventions were not followed, as confirmed by interviews with the resident, the STNA, and a Registered Nurse (RN). The facility's policy on falls and fall risk management, which states that residents should not be left unattended in the bathroom until adequate postural stability is established, was not adhered to, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate nail and skin care for a resident who was dependent on staff for personal hygiene. The resident, who had multiple medical conditions including anoxic brain damage and chronic kidney disease, was unable to complete a mental status interview and relied on staff for bathing and personal hygiene. Despite being scheduled for baths twice a week, records indicated that nail care was consistently not performed. Observations confirmed that the resident had long fingernails with a dark substance underneath and excessive dry, flaky skin on their feet. Interviews with the Director of Nursing and a Wound Nurse Practitioner confirmed the presence of long fingernails and significant dry skin on the resident's feet. The Wound Nurse Practitioner ordered ammonium lactate lotion to address the dry skin but noted that there were no wounds or pressure areas. The deficiency was identified during an investigation under a specific complaint number, highlighting the facility's non-compliance in providing necessary personal hygiene care for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess and treat pressure ulcers in a timely manner for three residents, leading to the development and worsening of pressure ulcers. Resident #3 was admitted with a Stage II pressure ulcer on the sacrum and was identified as high risk for pressure sores. Despite this, the facility did not implement timely treatments, resulting in the development of a Stage III pressure ulcer on the left buttock and later on the coccyx. The treatments prescribed by the wound nurse practitioner were delayed, and the pressure ulcer on the coccyx was not identified until it reached Stage III. Resident #1 was admitted with an unstageable pressure ulcer to the coccyx, but the facility failed to document measurements or descriptions of the wound. The pressure ulcer was not treated until two weeks after admission, and the wound progressed to a Stage III ulcer. The Director of Nursing confirmed the lack of documentation and delayed treatment. Resident #2 was admitted with a pressure ulcer to the coccyx, but the facility did not document measurements or descriptions until the ulcer was identified as Stage III. Treatment was delayed by three days after the wound was identified. The Director of Nursing verified the delay in treatment and lack of documentation. This deficiency was part of a continued non-compliance issue from a previous complaint survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to a deficiency. The resident, who was cognitively impaired and dependent on staff for transfers and toileting, was at risk for skin breakdown due to conditions such as type two diabetes mellitus and impaired mobility. Despite physician orders for weekly skin assessments and the application of barrier cream with each incontinent episode, the last recorded skin assessment was completed months prior to the survey. Additionally, bath sheets from multiple dates lacked nurse signatures, indicating a failure in documentation and oversight. During an observation, a reddened open area was found on the resident's right upper buttocks, which was confirmed as a stage two pressure ulcer. The STNA who provided care on a previous date admitted to noticing a 'scratch' but failed to document or report it to a nurse. Interviews with facility staff, including the DON and ADON, confirmed the lack of weekly skin assessments and the absence of nurse signatures on bath sheets. The corporate nurse also verified these lapses, highlighting a breakdown in communication and documentation processes within the facility.

Penalty

Inspection fine: $140,84954 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify potential risks and hazards for residents with a substance use disorder, develop and implement comprehensive and individualized care plans, and provide adequate supervision to prevent unintentional or intentional drug overdoses. This resulted in Immediate Jeopardy and actual harm/death when a resident overdosed by injecting opioid medications into his PICC line after obtaining a syringe from the trash bin on the facility medication cart. The resident had a history of intravenous illicit substance abuse prior to admission and had an intravenous line while at the facility. The resident was found unresponsive on the bathroom floor and subsequently passed away. A plastic jar with various pills, used syringes, and an unopened syringe were found in the resident's nightstand drawer after the incident. Another resident with a history of substance abuse disorder was found unresponsive in his room from a drug overdose. The resident had obtained medications from a former resident and had stored them in his room for several days prior to the incident. The resident was transferred to the emergency room with altered mental status and unresponsiveness due to an intentional opiate overdose. The toxicology report revealed the resident had overdosed on prescribed opiates and non-prescribed Fentanyl. The facility identified 26 residents with a history of substance use disorder, but failed to provide adequate supervision and individualized care plans for these residents. The facility's assessment revealed there were 15 residents with active or current substance use disorders for the first quarter of 2023. However, the facility did not implement interventions to address the residents' history of intravenous drug use. The facility also failed to perform mouth sweeps after medication administration and did not use tamper tape or locked caps for intravenous access lines. The facility's policies on medication storage and resident self-administration of medication were not adequately followed, leading to unsecured medications and drug paraphernalia being found in residents' rooms.

Removal Plan

• Licensed Practical Nurse (LPN) #100 called emergency medical services (EMS) for possible drug overdose for Resident #1. Police arrived shortly after EMS.
• LPN #100 notified Assistant Director of Nursing (ADON) #102 that Resident #1 was being sent out for possible drug overdose. The LNHA was notified of Resident #1's possible drug overdose.
• The facility began their investigation into Resident #1's possible drug overdose. The LNHA spoke to the hospital and obtained an official police report. The LNHA interviewed Resident #67 (roommate of Resident #1) and Resident #29 about any information related to Resident #1's overdose.
• LNHA reviewed video footage of the front reception camera for any packages being delivered to the facility. This was completed due to information received from an interview with Resident #29. No evidence was observed on camera footage of any packages being delivered.
• The DON provided education on the new process changes to five registered nurses (RNs) and twelve LPNS on the following system changes: effective Immediately, all syringes will only be disposed of in a sharp container including all needles syringes and mouth sweeps will be performed on all resident's post medication administration. Any agency nurses would be educated by the DON prior to the start of their shift on the above system changes if needed.
• Physician orders were written by the DON for all residents to have mouth sweeps after administration of medication. These were to appear on the medication administration record (MAR) for the nurses to sign and validate that this task was performed.
• The DON completed writing physician orders for all residents to say, Crush medications if suspected 'cheeking' medications (concealing a medication in the mouth i.e. between the teeth and the cheek, to avoid swallowing it).
• An audit was initiated by the DON for the disposal of syringes into the appropriate sharp container and not in the medication trash bin on the side of the medication cart. This audit would be completed by the DON/Designee three times per week for two weeks then two times a week for two weeks and then weekly for eight weeks. Results of the audits to be reviewed in monthly QA for further need of monitoring and/or enhancement.
• An audit was initiated by the DON for mouth sweeps to ensure a mouth sweep was performed post medication administration. The DON/Designee would complete this audit three times a week for two weeks, then twice a week for two weeks, and then weekly for eight weeks. Results would be reviewed in monthly QA for further need of monitoring and or enhancement.
• The facility reviewed the care plans for all the residents to identify any resident who had a history of substance abuse were identified and to make sure those identified as having a history of substance abuse had an appropriate care plan in place.
• Resident #2 was noted to be unresponsive by LPN #130. Resident #2's pulse was 55 and oxygen saturation was 66. LPN #130 applied oxygen to Resident #2 per non-rebreather and then called 911. LPN #130 administered two doses of Narcan (a medication to treat narcotic overdose in an emergency) prior to Emergency Medical Services (EMS) arrival. Resident #2 was arousing but not yet oriented. Police arrived on the scene and searched Resident #2's room. No medications were found in Resident #2's room.
• EMS made the decision to transport Resident #2 to the ED.
• The DON verified with LPN #130 the last time Resident #2 had received a dose of his medication and the medication was crushed as physician ordered.
• DON drove to the hospital and interviewed Resident #2 about details of the potential drug overdose.
• Facility Department Heads completed a full house sweep of 18 resident's rooms; residents who were on the facility substance use disorder (SUD) program per the contract agreement. No illegal substances were found in this sweep of residents' rooms. These 18 residents had signed a contract allowing staff to conduct room searches because they were identified at high risk.
• The facility department heads conducted a room sweep for 24 residents not on the SUD program who gave permission for the room sweep when asked. No illegal substances were found.
• An emergency Quality Assessment and Performance Improvement (QAPI) meeting was held with facility department heads and Medical Director #500 to discuss Resident #2's overdose and the facility's plan of correction and steps taken toward an abatement plan.
• The DON completed education to the facility nurses for policy review of medication storage and for no medication/substance to be kept in the resident's rooms. Five RN's,12 LPNS, and 19 State tested Nursing Assistants (STNAs) were educated. All assigned agency nurses would be educated by the DON prior to the start of their shift on the facility medication storage policy and no medications/substances to be unsecured in resident rooms.
• The LHNA completed in person education for all 53 residents residing in the facility on this date related to the facility policy for medication storage in the facility and there were to be no medications/substances in resident rooms.
• The facility initiated random room audits to check for unsecured medications/substances five times a week times for two weeks, then three times a week for two weeks, then times a week for two weeks, and then weekly for six weeks. Results would be reviewed in monthly QA for further need of monitoring and/or enhancement. This audit will be performed by the DON/Designee.
• Onsite surveyor observations revealed the nurses disposed of syringes and needles in the sharp' container. There were no syringes observed in the medication trash bins.
• Surveyors noted there were no medications observed in Resident #2's room.
• Surveyor review of Resident #2 and #3's medication administration records (MAR) revealed nursing was completing mouth sweeps after medication administration.
• Surveyor review of the facility's audits for medication sweeps post medication administration, the disposal of syringes into the appropriate sharp container, and checks for unsecured medications/substances revealed no negative findings from the audits completed through this time.

Penalty

Inspection fine: $140,84954 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely repair a resident's sink and ensure it was functional for the resident's use. Resident #27 had two maintenance requests placed on 02/14/24 and 03/14/24 for a clogged sink, both of which were marked as closed without resolving the issue. Interviews with staff, including a State Tested Nursing Aide (STNA) and the Director of Maintenance, confirmed knowledge of the clogged sink and the lack of water supply. The Director of Maintenance admitted that the sink was temporarily fixed by shutting off the water supply, but no follow-up appointments with a plumber were scheduled to permanently resolve the issue. The Director of Nursing (DON) and the Administrator were also unaware of the unresolved maintenance request, indicating a communication breakdown within the facility's management team. Resident #27 and the resident's daughter expressed concerns about the non-functional sink, stating that the water supply had been shut off since the resident's admission on 03/20/24. Observations on 04/25/24 and 04/30/24 confirmed that the sink remained non-functional, and the water supply was still turned off. The Administrator acknowledged that the facility did not respond timely and appropriately to the maintenance request, leading to a prolonged period without a functional sink for Resident #27. This deficiency was investigated under Complaint Number OH00153228.