Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant Lake Villa during CMS and state inspections, most recent first.
Food was not ensured to be palatable and served at acceptable temperatures. Residents reported that meals were cold, and during a tray observation with the DM and RFSD, several items were below expected hot-food temperatures, including ham and vegetables that were not hot to taste and milk served within the cold-food range but other items served below the expected hot range.
Kitchenettes on multiple units were found with food debris, dried splatter, stains, lime buildup, frost, and other soiling in microwaves, refrigerators, freezers, water/ice machines, and stovetops. Several food items were also unlabeled or undated, and one milk container was past its use-by date. The findings were verified by the DT and had the potential to affect three residents who were NPO.
Dirty resident rooms and common areas on the Rosewood unit were observed, including crumbs, stains, dust, and debris under and around beds, dressers, heaters, and along walls. A resident reported housekeeping did not routinely pick up trash or sweep and mop floors, and staff confirmed that daily cleaning was expected but the areas had not been cleaned recently.
Inaccurate MDS smoking status documentation affected four residents with active smoking care plans and supervised smoking assessments. Although each resident was an active smoker with significant medical histories including COPD, CHF, cancer, and respiratory conditions, annual MDS assessments repeatedly coded smoking as not noted. MDS nurses said residents were documented as nonsmokers if they did not smoke during the look-back period, and the Administrator and DON acknowledged the facility did not track when or how often residents smoked.
A facility failed to ensure oxygen therapy orders were in place for two residents and failed to follow ordered oxygen therapy for two others. Two residents with emphysema/COPD were observed receiving O2 via NC at 2 LPM even though no current physician order was in the chart, and two other residents with ordered O2 had missing oxy ears/posey straps during observation; one was also receiving O2 at 2.5 LPM instead of the ordered 2 LPM. Staff confirmed the discrepancies.
Medication storage and labeling were not maintained appropriately. An LPN left dry Metamucil on a resident’s overbed table, multiple insulin products on a cart lacked required resident names and open or expiration dates, an expired vitamin B-6 bottle remained on a cart, a resident’s meds were found in a cup in a cart drawer with no one knowing who placed them there, and an open Tuberculin vial was labeled with dates that did not match the product’s 30-day after opening requirement.
Late Administration of Ordered Bedtime Medication: A resident with type 1 diabetes, anxiety, and depression had an order for amitriptyline 100 mg at bedtime for depression, but the MAR showed multiple doses were given well after the 9:00 P.M. due time, including late evening and early morning administrations. The DON stated the resident was often not in her room and staff had to hunt her down to give the medication in a timely manner.
A resident with an indwelling urinary catheter and neuromuscular bladder dysfunction did not receive catheter care every shift as ordered and per facility policy. The resident reported missed care, and during observation a large amount of smegma was found in the genital fold and under the foreskin. The CNA confirmed the buildup showed catheter care had not been provided as required, while the DON reviewed task sheets marked complete despite the observed condition.
A resident with dementia and severe cognitive impairment had orders for Vimpat and hydrocodone-acetaminophen, but the MAR and controlled drug records did not align. Controlled medication tracking was missing for several scheduled doses of both medications, and staff confirmed the facility lacked appropriate narcotic flow records. The resident’s family supplied the medications until the pharmacy shipment arrived, and nursing staff later signed off doses documented on the MAR.
EBP were not maintained for two residents with orders for high-contact care. An LPN did not wear a gown during gastrostomy tube medication administration for one resident and used no PPE during IV medication administration through a PICC for another resident. Both residents had significant medical conditions and device-related EBP orders, and the LPN stated she was unaware a gown was required.
Delayed Reweights and Provider Notification for Significant Weight Loss: A resident with CVA-related hemiplegia, CKD3, dysphagia, and malnutrition had repeated significant weight loss documented on wt checks, but reweights were not obtained promptly and the NP/MD were not timely notified. Nutrition notes flagged large wt changes and requested reweights, yet subsequent NP notes recorded no wt changes, and the NP later stated he was first made aware of the loss only later. The resident was on a mechanically altered/puree diet with variable intake and some refusals.
A facility failed to ensure proper PPE use for a resident on droplet precautions, risking COVID-19 spread. A CNA entered the resident's room without the required PPE, citing difficulty breathing in an N-95 mask. The resident had a history of kidney transplant and diabetes, with impaired cognition and dependency on staff. The facility's policy mandated specific PPE, which was not adhered to, affecting 29 residents on the unit.
A resident with cognitive impairment and a self-care deficit was found with long, dirty fingernails and chin hair, despite a care plan indicating the need for nail care. The resident expressed embarrassment and a desire for cleaner nails. An LPN confirmed the resident's condition, which was not in compliance with the facility's ADL policy.
The facility failed to date insulin pens upon opening, affecting five residents with type II diabetes. Observations of two medication carts revealed that insulin pens were in use without being dated, contrary to the facility's policy. Interviews with nursing staff confirmed the oversight, highlighting a lapse in medication management.
The facility failed to follow guidelines for changing disposable respiratory equipment weekly for three residents, leading to deficiencies in care. One resident with pneumonia and heart failure had undated oxygen tubing and unused new equipment. Another resident with dementia had tubing unchanged since March, and a third with acute respiratory failure had undated nasal cannula tubing. Staff confirmed the lapses, which violated the facility's policy.
The facility failed to ensure wound treatments were completed as ordered for a resident with multiple diagnoses, leading to a wound infection. Documentation revealed missed dressing changes, and staff interviews confirmed the lapses in care.
A resident with eosinophilic esophagitis, diabetes mellitus, and dependence on renal dialysis was administered expired budesonide liquid for six days and experienced delays in receiving a new supply of the medication. The expired medication was identified on 03/01/24, and it took a few days to obtain a new supply from a specialty pharmacy.
A resident with multiple diagnoses, including atrial fibrillation, did not receive the prescribed anticoagulant medication on several occasions. The DON confirmed that the medication was not administered on dialysis days, leading to significant medication errors.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable and served at safe, appetizing temperatures. Review of the Food Committee minutes for April 2026 showed residents stated the food was not served as hot as they would like. During resident interviews on 05/26/26, Residents #97 and #178 reported that the food was cold, and on 05/28/26 Resident #63 also stated that the food was cold. During lunch tray observation on 05/28/26 with the Dietary Manager and Regional Director of Food Services, the sample tray temperatures were below expected levels for several items: baked potato at 146 degrees F, key west vegetable blend at 96 degrees F, honey baked ham at 109 degrees F, milk at 47 degrees F, and coffee at 139.2 degrees F. Staff verified the ham and vegetables were not hot to taste, and the report cited ServSafe guidance that hot foods are generally expected to be served between 140 degrees F and 180 degrees F, while cold foods are considered palatable between 40 degrees F and 50 degrees F.
Kitchenettes Not Kept Clean and Food Not Properly Labeled
Penalty
Summary
The facility failed to ensure the nursing unit kitchenettes were maintained in a clean and sanitary manner and that food was properly labeled and dated. During observations of seven kitchenettes with the Diet Technician, multiple areas were found with food debris, dried splatter, stains, lime buildup, frost, and other soiling in refrigerators, freezers, microwaves, water/ice machines, and stovetops. In several units, items were observed without labels or dates, including an unlabeled cup with a milky substance, a pitcher with a light brown liquid, a cupcake wrapper in a napkin, a frozen red substance in a cup, a plastic bag of melting ice, and a container of food in a plastic bag. Additional findings included a half-gallon of milk with a use-by date of 05/12/26, brownish stains and splatters inside a refrigerator and freezer, a balled-up paper towel on a refrigerator shelf, and a paper towel stuck to a microwave plate with dried substances beneath it. The observations were verified by Diet Technician #603. The report states the issue had the potential to affect three residents who received nothing by mouth, identified as residents #69, #110, and #207, and the facility census was 170.
Dirty resident rooms and common areas on Rosewood unit
Penalty
Summary
The facility failed to ensure a clean and sanitary resident environment on the Rosewood unit, affecting 44 residents on that unit. During an interview, Resident #32 reported that housekeeping did not routinely pick up trash or sweep and mop the floors. Observation of the resident’s room showed crumbs and stains between, under, and behind both beds, under the heater, along the wall under the window, and between the dressers and the television, with dried stains also noted on the heater. The Housekeeping Supervisor stated that residents’ rooms and common areas were to be cleaned daily, and observation of the floor near the Rosewood nurses’ station showed it was visibly dirty with numerous scratch marks; the supervisor confirmed the floor required stripping and waxing. In a separate observation, the shared room of Residents #57 and #192 had multiple brown and yellow stains on the floor throughout the room, along with dust and debris on the floor around the dressers and on the wall-side of the bed. A CNA confirmed the observations and stated housekeeping was expected to clean floors daily, acknowledging that it was evident the floor had not been cleaned recently. Facility policy required housekeeping surfaces, including floors and tabletops, to be cleaned regularly, when spills occur, and whenever surfaces are visibly soiled, and the resident rights policy stated residents have the right to a safe and clean-living environment.
Inaccurate MDS smoking status documentation
Penalty
Summary
The facility failed to ensure MDS 3.0 assessments were completed accurately for four residents who were active smokers. Resident #9 was admitted with diagnoses including hemiplegia/hemiparesis, COPD, diabetes, chronic kidney disease, nicotine dependence, depression, and insomnia. Although the resident’s care plan addressed safe smoking and multiple smoking evaluations identified the resident as a supervised smoker, annual MDS assessments dated 07/19/22, 09/27/23, and 07/22/25 documented smoking as not noted. Resident #22 was admitted with diagnoses including hemiplegia/hemiparesis, COPD, diabetes, heart disease, CHF, depression, and insomnia. Despite an ongoing smoking care plan and smoking assessments from 02/15/22 through 03/31/26 identifying the resident as a supervised smoker, annual MDS assessments from 06/28/18 through 12/23/25 consistently documented smoking as not noted. Resident #88 was admitted with diagnoses including temporal lobe cancer, hemiplegia, convulsions, emphysema, nicotine dependence, hypertension, and tachycardia. The resident’s annual MDS assessments dated 12/28/24 and 12/03/25 recorded smoking as not noted even though the resident had a safe smoking care plan and supervised smoking assessments from 08/27/24 through 04/01/26. Resident #142 was admitted with diagnoses including hypertensive heart disease, pneumonia, diabetes, chronic respiratory failure, asthma, schizoaffective disorder, CHF, major depressive disorder, bradycardia, insomnia, unspecified psychosis, and history of self-harm. Annual MDS assessments dated 01/25/22 through 10/28/25 documented smoking as not noted despite a safe smoking care plan and multiple supervised smoking assessments between 06/25/25 and 04/27/26. Interviews with the four residents confirmed they were active smokers who smoked regularly and went out for all smoke breaks. MDS nurses stated that if residents did not smoke during the MDS look-back period, they documented them as nonsmokers, and they acknowledged residents were not tracked consistently during smoking breaks. The Administrator and DON also acknowledged the facility did not track when or how often residents smoked.
Oxygen Therapy Orders Not Present or Not Followed
Penalty
Summary
The facility failed to ensure orders were in place for oxygen therapy for two residents and failed to ensure oxygen therapy orders were implemented as ordered for two other residents. Resident #95, who had diagnoses including emphysema, hypertension, and osteoarthritis and was cognitively intact, was observed receiving oxygen via concentrator at 2 LPM through a nasal cannula even though the current physician orders contained no oxygen therapy order. A nurse confirmed the medical record did not contain an oxygen order while the resident was actively receiving oxygen. Resident #122, who had diagnoses including centrilobular emphysema, essential hypertension, and anxiety disorder and was cognitively intact, was also observed on oxygen via concentrator at 2 LPM through a nasal cannula despite no current physician order for oxygen therapy. Resident #207, who had Parkinson's disease without dyskinesia, COPD, pleural effusion, and moderate cognitive impairment, had a physician order for oxygen at 3 LPM via nasal cannula with oxy ears or a posey strap every shift, but observation showed the oxy ears were not in place as ordered. Resident #236, who had diagnoses including hyperlipidemia and hypothyroidism, had a physician order for oxygen at 2 LPM via nasal cannula with oxy ears or a posey strap every shift, but observation showed the oxygen was infusing at 2.5 LPM and the oxy ears were not in place as ordered. Staff confirmed the missing oxy ears for both residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medications and biologicals were not stored and labeled in accordance with accepted professional principles. On the Silverpine unit, Resident #120 had dry Metamucil left in a 30 mL plastic cup on the overbed table, and the resident confirmed the nurse left it there. The LPN who observed the resident confirmed she had left the Metamucil on the table and believed the resident had consumed it even though it was not mixed with water. On the Rosewood unit back hall medication cart, multiple insulin products were found without required dates or resident identifiers, including an Aspart KwikPen with an open date written as 09/24/25, a Lantus vial without an open or expiration date, a Basaglar KwikPen without an open or expiration date, two Lispro KwikPens without a resident name or open or expiration date, and a Novolog vial and a Lispro vial without a resident name, open date, or expiration date. The Med Tech confirmed the insulins were opened and used and that the expired medications and unlabeled insulins were not discarded appropriately. Additional storage issues were found when a bottle of vitamin B-6 on the Rosewood front hall cart was expired, Resident #189’s medications were found in a plastic cup in the Oakwood cart drawer with no one knowing who placed them there, and an open vial of Tuberculin in the Rosewood med room was labeled with an open date of 04/01/26 and an expiration of 05/2027 even though the solution expires 30 days after opening. The DON confirmed the residents receiving insulin from the back hall cart and the three new admissions who received tuberculin from the Rosewood med room refrigerator.
Late Administration of Ordered Bedtime Medication
Penalty
Summary
The facility failed to ensure Resident #233’s medications were administered as ordered by the physician. Resident #233 was admitted with diagnoses including type 1 diabetes, anxiety disorder, and depression, and the admission MDS indicated intact cognition. A physician order dated 03/31/26 directed amitriptyline 100 mg by mouth at bedtime for depression, due at 9:00 P.M., and the resident’s psychotropic medications care plan included an intervention to administer medications per physician order. Review of the MAR from 04/01/26 through 04/30/26 showed the amitriptyline due at 9:00 P.M. was given late on multiple occasions, including at 11:09 P.M., 11:02 P.M., 1:45 A.M., 10:59 P.M., 10:45 P.M., 11:28 P.M., and 11:09 P.M. During interview, the DON stated the resident would not be in her room on multiple occasions and staff would have to hunt her down to administer the medications, and she felt the resident was not available for staff to administer the medications in a timely manner. The facility’s Person-Centered Care Med Pass Policy and Procedure stated medications would be scheduled twice daily to the extent feasible without compromising care to enhance resident-centered care.
Catheter Care Not Completed as Ordered
Penalty
Summary
Indwelling urinary catheter care was not completed every shift as ordered and as required by facility policy for a resident admitted with multiple orthopedic injuries and neuromuscular bladder dysfunction. The resident had a care plan addressing infection risk related to the catheter, and the admission MDS showed a BIMS of 15, indicating intact cognition, with dependence on staff for all ADLs, hygiene, transfers, and mobility. The resident told staff on interview that catheter care was not being provided every shift. During observation of catheter care, a large amount of accumulated smegma was found in the genital fold and under the foreskin, requiring multiple attempts to remove. The CNA acknowledged that the buildup indicated catheter care had not been provided every shift. The DON reviewed CNA task sheets showing catheter care was marked completed, but also acknowledged the buildup and the need for staff reeducation. Facility policy required catheter care at least twice daily and after defecation or bowel incontinence, including assessment for encrusted material and drainage at the meatus.
Controlled Medication Tracking Not Maintained for a Resident
Penalty
Summary
The facility failed to ensure Resident #217’s controlled medications were appropriately monitored and tracked. The resident was admitted with diagnoses including dementia, atrial fibrillation, and anxiety disorder, and the discharge MDS indicated severe cognitive impairment. The record showed orders for Vimpat (lacosamide) 100 mg twice daily for seizures and hydrocodone-acetaminophen 7.5-325 mg, 0.5 tablet twice daily for severe pain and 0.5 tablet every 8 hours as needed for moderate pain. The MAR documented administration of Vimpat and Norco on multiple days, but the facility’s controlled drug records did not match the MAR documentation. For Vimpat, the record lacked evidence of appropriate controlled medication tracking for the morning and evening doses on 06/05/25, the evening dose on 06/06/25, and the morning and evening doses on 06/07/25. For Norco, the record lacked appropriate narcotic tracking for the morning and evening doses on 06/05/25, the evening dose on 06/06/25, and the morning and evening doses on 06/07/25. The facility-issued controlled drug forms showed some doses received and administered, but they did not account for all doses documented on the MAR. Progress notes and interviews showed the resident’s family supplied the medications until the pharmacy shipment arrived, and staff later verified the medications when they arrived. The DON and ADON confirmed the facility did not have the appropriate narcotic flow records for accurate narcotic tracking and stated the family administered the narcotics to the resident with nursing staff present, after which nursing staff signed off the doses on the MAR. The facility policy stated medications brought in by family members were to be reported to the provider pharmacy and added to the resident profile to maintain a complete and accurate drug profile.
EBP PPE Not Used During Device-Related Care
Penalty
Summary
Enhanced barrier precautions were not maintained for two residents with physician orders for EBP. Resident #207 had diagnoses including Parkinson’s disease, hemiplegia and hemiparesis following cerebral infarction, dysphagia, COPD, contracture of hand, history of falling, hyperlipidemia, hypertension, and a gastrostomy tube. The physician’s order required EBP for high-contact resident care, including dressing, bathing, showering, transfers, hygiene care, changing linens, assisting with toileting, dressing changes, and care of any device such as a tube feeding. During observation of medication administration through the gastrostomy tube, the LPN did not wear an isolation gown as required, and stated she was unaware that a gown was needed during the medication administration. Resident #176 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, metabolic encephalopathy, dementia, severe protein-calorie malnutrition, heart disease, major depressive disorder, dysphagia, and non-pressure chronic ulcers of the back and left heel. The care plan and physician’s order required EBP for high-contact care related to an indwelling urinary catheter, wounds, PICC, and other device care. During observation of IV medication administration through the PICC, no PPE was used. The LPN stated she was unaware that she was required to don an isolation gown when administering IV medications for a resident with EBP orders, and the DON verified that EBP should have been maintained per the orders and facility policy.
Delayed Reweights and Notification for Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely re-weights were obtained and failed to ensure the physician/nurse practitioner were notified in a timely manner of significant weight loss for Resident #127. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, CKD stage 3, mild protein-calorie malnutrition, dysphagia, muscle weakness, and cognitive communication deficit. Weights documented for the resident showed a decline from 155 lbs. on 01/28/26 to 136 lbs. on 04/07/26, then to 134 lbs. on 04/28/26, and 107.6 lbs. on 05/13/26. A nutrition progress note dated 04/09/26 documented that the 04/07/26 weight triggered significant weight loss alerts and that the resident had variable intake with some refusals. The dietetic technician noted a large weight loss, added supplementation, and requested a reweight. The quarterly MDS indicated the resident had significant unintentional weight loss and was receiving a mechanically altered diet. However, NP progress notes dated 04/21/26 and 05/12/26 documented no weight changes, and the NP later verified he was not aware of the resident’s weight loss at those times. A later nutrition note dated 05/14/26 again documented a significant weight loss alert from the 05/13/26 weight and requested a reweight, but the registered dietitian stated the 04/07/26 and 05/13/26 weights should have been reweighed sooner, at least within 24 hours. During interviews, the RD stated she verbally notifies the NP of significant weight changes, but there were no physician or NP notes showing awareness of the resident’s weight loss before 05/27/26. On 05/27/26, the NP documented the resident for weight loss and stated this was the first time he had heard of it.
Failure to Properly Don PPE for Resident on Droplet Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was donned correctly for a resident on droplet precautions, potentially preventing the spread of COVID-19 infections. During an observation, it was noted that a Certified Nursing Assistant (CNA) entered the room of a resident on droplet precautions without wearing the required PPE, which included a gown, N-95 mask, and face shield. The CNA admitted to not wearing the PPE because she found it difficult to breathe in an N-95 mask. A Registered Nurse (RN) did don PPE to assist the CNA in positioning the resident for lunch. The resident involved had a medical history that included a kidney transplant, type one diabetes mellitus with chronic diabetic kidney disease, pressure ulcers on both heels, and a history of urinary tract infections. The resident had moderately impaired cognition and was dependent on staff for bed mobility, toileting, and transferring. The facility's policy required staff to use specific PPE for residents on droplet precautions, but this was not followed, as evidenced by the CNA's actions. This deficiency was discovered during a complaint investigation and had the potential to affect 29 residents on the Sandalwood unit.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure proper personal hygiene for Resident #135, who was observed with long, dirty fingernails and hairs on her chin. Resident #135, who has diagnoses including diabetes mellitus, Alzheimer's disease, and anxiety disorder, was admitted on an unspecified date. Her care plan, dated 04/14/22, indicated a self-care deficit related to cognition and generalized weakness, with interventions including nail care as needed. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated 08/06/24 revealed that Resident #135 had moderately impaired cognition and required substantial/maximal assistance with activities of daily living (ADLs). On 09/14/24, during an observation and interview, Resident #135 expressed a preference for the length of her nails but wished they were cleaner and was embarrassed by the hairs on her chin. She mentioned that she used to manage these aspects of personal care when she was at home. An LPN verified the condition of Resident #135's nails and chin hair. The facility's policy on ADLs, dated 11/30/23, included maintaining personal hygiene tasks such as nail care and shaving. This deficiency was investigated under Complaint Number OH00157469.
Failure to Date Insulin Pens Upon Opening
Penalty
Summary
The facility failed to ensure that multiple dose medications, specifically insulin pens, were dated when opened, as required by their policy. This deficiency was identified during an observation of two medication carts, Oakwood front and Rosewood back, affecting five residents with type II diabetes. The insulin pens for these residents were found to be in use without any indication of the date they were opened, which is a violation of the facility's medication storage policy. The policy mandates that nurses date medications upon opening and adhere to the manufacturer's expiration date. Interviews with the nursing staff, including a Registered Nurse and the Director of Nursing, confirmed the oversight. The RN verified that the insulin for one resident was not dated when opened, and the DON acknowledged that the insulins for all five residents were not dated as per the facility's policy. The facility's policy, dated November 2021, clearly states that medications should be dated when opened, and the manufacturer's expiration date should be followed. This oversight in medication management was observed in a facility with a census of 181 residents.
Failure to Change Respiratory Equipment Weekly
Penalty
Summary
The facility failed to adhere to recommended guidelines for changing disposable respiratory equipment for three residents, leading to deficiencies in respiratory care. Resident #12, who had diagnoses including pneumonia and heart failure, was observed using undated oxygen tubing and aerosol equipment that had not been changed as per the facility's policy. The new tubing, dated 05/29/24, was found unused in a bag, indicating a lapse in the weekly replacement schedule. Licensed Practical Nurse (LPN) #916 confirmed that the equipment was not dated and had not been changed as required. Resident #15, diagnosed with dementia and heart disease, was found using oxygen tubing dated 03/05/24, with no physician's order to change it weekly until after surveyor intervention. The Director of Nursing (DON) verified the lack of a weekly change order and the absence of documented evidence of tubing replacement since March. Similarly, Resident #83, with acute respiratory failure, was using undated nasal cannula tubing, with the last change documented on 04/30/24. LPN #909 confirmed the lack of dating and the requirement for weekly changes. The facility's policy mandates weekly changes and dating of disposable respiratory supplies, which was not followed in these cases.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to ensure wound treatments were completed as ordered for Resident #152, who had multiple diagnoses including diabetes mellitus, dependence on renal dialysis, and calciphylaxis. The resident had a treatment order to cleanse a skin tear on the right elbow daily and apply a dressing. However, documentation revealed that the dressing change was not completed from 02/29/24 through 03/04/24 and on 04/01/23. This lapse in care led to a wound infection, for which a new order for doxycycline was issued on 03/03/24. Interviews with various staff members, including a Registered Nurse, Licensed Practical Nurses, and the Director of Nursing, confirmed that the dressing changes were not completed as ordered. The Director of Nursing verified that the resident did not receive the required dressing changes, and the Licensed Practical Nurses acknowledged that all dressings should be initialed, dated, and documented at the time of the dressing change. The resident was unable to provide information regarding the treatments due to confusion about the events leading to the skin tear.
Expired Medication Administration and Availability Issue
Penalty
Summary
The facility failed to ensure that Resident #152 was not administered expired medication and that the medication was available for administration. Resident #152, who had diagnoses including eosinophilic esophagitis, diabetes mellitus, and dependence on renal dialysis, was prescribed budesonide liquid to be taken by mouth one hour before meals. The medication was started on 02/11/24, discontinued on 03/29/24, and had an expiration date of 02/21/24. However, the medication was administered until 03/01/24, resulting in the resident receiving expired medication for six days. Additionally, the medication was not available for administration on several days in March 2024, specifically on March 1, 2, 3, 4, 5, 14, and 19, due to delays in obtaining a new supply from a specialty pharmacy after the expired medication was identified on 03/01/24. The Director of Nursing (DON) confirmed that the expired medication was administered and that it took a few days to obtain a new supply of the medication. The unit manager (LPN #369) identified the expired medication on 03/01/24, notified the family, and contacted the doctor. The nurses were subsequently educated on checking medications to ensure that expired medications were not being given to residents. This deficiency was investigated under Complaint Number OH00152308.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received an anticoagulant medication as ordered, leading to significant medication errors. Resident #152, who had multiple diagnoses including diabetes mellitus, dependence on renal dialysis, pulmonary hypertension, and calciphylaxis, was prescribed apixaban 2.5 mg twice daily for atrial fibrillation. However, the medication administration record revealed that the morning doses of apixaban were not administered on multiple days in February and March 2024, totaling 11 missed doses. An interview with the Director of Nursing (DON) confirmed that the resident was not receiving the apixaban on dialysis days, as the nurses were not administering it. The DON verified that the medication was not given as ordered. The Medscape website indicates that missing doses of apixaban increases the risk of thrombotic events, and the medication is not expected to be dialyzable. This deficiency was investigated under Complaint Number OH00152308.
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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 Parma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasantview Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| North Royalton Post Acute | 1.4 mi | ★★★★★ | 11 | 0 |
| Mt Alverna Home Inc | 1.4 mi | ★★★★★ | 9 | 0 |
| Greenbrier Health Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Royal Oak Nursing & Rehab Ctr | 3.1 mi | ★★★★★ | 0 | 0 |
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