Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rae Ann Suburban during CMS and state inspections, most recent first.
A CNA was identified by police as the alleged perpetrator of credit card fraud involving multiple residents’ accounts, including a resident who reported prior fraudulent activity and another resident whose card information was found in the CNA’s Amazon account. Additional residents were later identified as potential victims after suspicious bank and Cash App charges were reported, and the CNA admitted to using a resident’s credit card number without authorization.
Kitchen sanitation and food storage deficiencies: The kitchen had rusted refrigerator shelves, crumbs and debris on multiple surfaces, sticky residue on the oven, tray line, prep table, and warming table, dirty vents and ceiling spots, and dirty can racks and walls. Kitchen Manager #307 also confirmed improper food storage, including unrefrigerated BBQ sauce, undated spices with unsecured lids, a supplement drink container with mold on the lid, a container with a dead fly on top, and moldy grapes and cantaloupes in the walk-in fridge.
Failure to Maintain a Clean and Homelike Environment: Observation and interview with the MD and Administrator found exposed drywall from a prior ceiling leak, peeling wallpaper, dusty vents, dust and debris around a laundry room door, a water stain near the attic area, cracked exit door windows, an unattached wood trim panel with exposed nails, heavy dust and splatter stains on wall panels, and extremely dusty dining room ceiling fans running over residents during meals. Facility policy required a clean, sanitary, and orderly environment.
Medication administration errors exceeded the allowed rate after surveyors observed three errors during 31 opportunities. An LPN failed to give a resident’s scheduled insulin lispro when oral meds were administered, and an RN crushed and gave a delayed-release divalproex tablet to another resident. The residents had multiple chronic conditions, including diabetes, neurocognitive disorders, and other significant medical diagnoses.
Improper Garbage and Refuse Disposal: The outside dumpster area had multiple pieces of old flooring, trash, plastic water bottles, cans, gloves, plastic wrap, screws, and other debris on the ground. A laundry room vent was blowing lint outside, and a pillowcase and plastic wrap were also observed in the area. Facility policy required refuse to be properly contained and disposal areas kept free from waste.
Surveyors found unsanitary conditions in the kitchen, including dirty utensils, debris in drawers, improper milk storage, and a lack of testing strips or records for sanitizer levels. These issues had the potential to affect all residents receiving food from the kitchen.
A review of the facility's arbitration agreement found a confidentiality clause that could discourage residents or their representatives from communicating with federal, state, or local officials and advocacy agencies about the arbitration process or its outcome. The Administrator confirmed the presence of this language, which had the potential to affect all 79 residents.
Both dryers in the laundry room were found with excessive lint build up in their lint traps, and the Housekeeping Director confirmed they had not been cleaned. This issue had the potential to affect all 79 residents in the facility.
The facility did not properly document and track COVID-19 infections for several residents over multiple months, and failed to ensure staff followed infection control protocols during blood glucose testing for a resident with diabetes. A nurse did not perform hand hygiene before and after glove use or use a barrier for glucometer supplies, contrary to facility policy. These deficiencies were confirmed by staff interviews and record reviews.
Four residents with documented level II mental illness had their PASRR status incorrectly coded as negative on their MDS assessments, despite state determination of their condition. The error was confirmed through record review and staff interview, affecting individuals with diagnoses such as schizophrenia, schizoaffective disorder, and other mental health conditions.
A resident with moderate cognitive impairment and multiple medical conditions repeatedly expressed a preference to have ACE wraps applied to his legs after his morning shower, as documented in the EMAR and confirmed in interviews. Despite this, staff did not consistently follow his wishes, resulting in the resident's legs being left unwrapped after showers. The DON and a CNA confirmed that staff were not honoring the resident's stated preference.
A resident with cognitive impairment and her advocate repeatedly requested access to her full medical records, including medication and treatment administration records, but were denied these documents by the facility's corporate compliance office despite following the required procedures. Facility policy allowed for release of all medical information with written consent, but the process resulted in incomplete records being provided.
The facility did not provide complete Notice of Medicare Non-Coverage (NOMNC) forms for three residents, as the forms lacked specific information about which services would be discontinued. This omission was confirmed by the Social Service Designee.
A resident with significant respiratory needs was discharged home with a portable oxygen tank, but the facility failed to ensure timely delivery of prescribed home oxygen equipment. Despite orders and arrangements for supplemental oxygen, the DME supplier did not deliver the equipment as planned, and staff did not confirm delivery or follow up effectively. As a result, the resident was without necessary oxygen for several days after discharge.
A resident with chronic health conditions and total incontinence did not receive proper perineal care when a CNA placed clean washcloths in a sink, applied soap directly, and failed to use separate washcloths for cleansing and rinsing. The CNA also did not dry the perineal or buttocks areas before applying a new incontinence brief, and did not follow infection control protocols as required by facility policy. These actions were confirmed by both the CNA and an RN Unit Manager.
The facility did not ensure that its CNAs received the mandated 12 hours of annual in-service training, with records showing only 4.5 hours completed within the first year of employment and no evidence of prior training. This deficiency had the potential to impact all 79 residents, as essential education in dementia care and abuse prevention was not documented.
A facility failed to apply the complete physician-ordered treatment for a resident's sacral pressure ulcer. The resident, with multiple health conditions, required specific wound care, including the application of zinc ointment around the ulcer. An LPN did not apply the zinc ointment, citing concerns about tape adherence, despite the physician's order and facility policy.
The facility's kitchen was found in unsanitary conditions, with a malfunctioning dishwasher drain causing water accumulation, open sanitizer attracting fruit flies, and improper food storage practices. Observations included a greasy oven door, leaking water beneath coffee pots, and undated food items in storage areas.
The facility was found to have an unsanitary dumpster area during a complaint investigation. An inspection revealed food debris, plastic gloves, and other trash, which was confirmed by a dietary aide who was not surprised by the findings. This was noted as an incidental finding of non-compliance.
A resident's grievances were not addressed promptly by the facility. Despite emails from the resident's sister and POA regarding incidents involving another resident, the facility's Administrator delayed responding due to personal reasons, and the DON hesitated to engage, fearing escalation. This inaction violated the facility's policy on prompt grievance resolution.
A resident with an indwelling catheter and cognitive intactness reported pain during urination. The NP ordered a urinalysis with culture and sensitivity testing (UA C&S) and Pyridium, but the UA C&S was not completed as per the physician's order. This deficiency was confirmed through medical record review and staff interview.
Misappropriation of Resident Property Linked to CNA Fraud Investigation
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of property after a police investigation identified a CNA as the alleged perpetrator of credit card fraud involving resident accounts. The investigation began after a self-reported incident was opened for suspected fraud involving Resident #91, and the police later reported that the CNA had received packages from Amazon with Resident #91 and Resident #89 credit card information uploaded into her Amazon account. The police also found charges linked to Resident #88’s credit card. Resident #88 told police she had closed her debit card because of fraudulent activity that had occurred months earlier and said most of the charges were from Insta Cart. Resident #91 told police her card had previously had fraudulent activity and that the facility’s Business Office had assisted her with reporting the fraud to her bank and canceling the card. The facility initially unsubstantiated the incident while it was still gathering information, and staff questionnaires and resident interviews at that time did not identify concerns about theft or missing property. After the police provided the report identifying the CNA as the alleged perpetrator, the facility interviewed the CNA, who admitted to obtaining Resident #91’s credit card number and using the card without authorization. The police then identified additional potential victims, including current and former residents, and the facility was notified that Resident #86 had a suspicious Cash App charge and that Resident #21 had been contacted by his bank about fraudulent charges. The report also identified former Resident #92 and current Resident #77 as additional potential victims, and Resident #89 was noted to have passed away.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to ensure a sanitary and clean kitchen. During observation and interview of the kitchen with Kitchen Manager #307, the refrigerator by the tray line had rusted shelves and crumbs and debris on the bottom, the oven had crumbs on the handles and a built-up sticky residue on the glass, and behind the stove there was an oven mitt on the ground with other debris. The bottom of the tray line had crumbs and various debris, and two brown plastic container bins with spices under the tray line were sticky and had crumbs and debris. The spices were not dated, some were not standing upright with unsecured lids causing spices to spill out, and a container of BBQ sauce that said to keep refrigerated was stored in the bin; Kitchen Manager #307 confirmed the BBQ should have been kept in the refrigerator. Additional findings included a tray line warming table with built-up brown sticky residue and other debris, a prep table by the walk-in fridge with crumbs in the utensil drawers and dirty, sticky fronts, and debris with brown and black residue buildup on the prep table. The ceiling had numerous black spots and dust throughout, the vent by the 2-part sink had visible black dust buildup, and the metal mobile aluminum can racks were dirty with crumbs throughout. There were unknown trash items underneath the fridge by the dining room door, missing tile in the corner of the floor by the dining room door, and dirty walls and wall tile throughout the kitchen with residue and splatter spots. In the pull-out fridge by the dining room door, there was one container of 2.0 supplement drink with mold on the lid and one container with splatter and a dead fly on top. In the walk-in refrigerator, there were multiple packets of individual grapes that were moldy and multiple cantaloupes in a cardboard box that were moldy. All findings were confirmed with Kitchen Manager #307.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment for residents, staff, and the public. During observation and interview with the Maintenance Director, the ceiling outside one room had an estimated 1 1/2 feet of exposed drywall where a prior leak had occurred and had never been painted over. The wallpaper was peeling on the wall to the right of that room, the ceiling vent near the room had dust buildup, and the door by the laundry room had dust and debris around the window ledges with a dusty wall vent. There was also a water stain on the ceiling near the area that opened to the attic, and the Maintenance Director stated the pipes produce condensation and will leak. Additional observations showed the exit door on Side 2 had a crack in the window on the left side, the wood wall outside the library had an unattached trim panel with exposed nails, and the wood wall panel outside the library had heavy dust buildup and splatter stains throughout. The exit door by another room had a crack in the window on the right side. Later observation with the Administrator in the dining room revealed the ceiling fans were extremely dusty with visible black dust on the blades, and two of the fans were running above where residents were eating. The facility policy titled Homelike Environment stated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. During an observation of medication administration involving four licensed nurses and four residents, surveyors identified three errors out of 31 opportunities, resulting in a 10 percent medication error rate. The deficiency affected two residents and was documented during a complaint investigation. For one resident with diagnoses including heart failure, neurocognitive disorder, diabetes mellitus, major depressive disorder with severe psychotic symptoms, high blood pressure, cholesterol, thyrotoxicosis, PTSD, peripheral vascular disease, suicidal ideation, dementia, and insomnia, the record showed orders for both scheduled and sliding-scale insulin lispro before meals. During the observation, an LPN administered several oral medications, checked the resident’s blood sugar at 217 mg/dL, and gave the oral medications, but did not administer the scheduled lispro insulin that was due at the same time. The LPN later acknowledged that the insulin had not been given when the oral medications were administered. For another resident with diagnoses including intellectual disabilities, high blood pressure, osteoarthritis, fracture of metatarsal bones, neurocognitive disorder, diabetes mellitus, adjustment and mood disorder, anxiety, and depression, the record showed orders for multiple morning medications including divalproex sodium delayed-release tablets. During the observation, an RN dispensed the oral medications, crushed the delayed-release divalproex, mixed it with pudding, and administered it to the resident. The RN later stated the delayed-release medication should not have been crushed and verified on the medication card that it was ordered as delayed release.
Improper Garbage and Refuse Disposal
Penalty
Summary
Garbage and refuse were not properly disposed of in the outside dumpster area. During observation and interview with the Kitchen Manager, multiple pieces of old flooring, various trash items including plastic water bottles and cans, gloves, and plastic wrap were seen on the ground around the dumpster area. The vent from the laundry room was blowing lint onto the ground outside, and additional gloves, screws, and trash were observed around the door to the building and the dumpster. During a later observation and interview with the Maintenance Director, a pillowcase was seen in the grass behind the dumpster and plastic wrap was observed around a tree. Facility policy titled Sanitization stated that garbage and refuse containers are to be in good condition, waste properly contained in dumpsters or compactors with lids or otherwise covered, and garbage disposal areas maintained free from odors, waste fats, and pests.
Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
During a kitchen inspection, surveyors observed multiple sanitation issues, including crumbs and dirt in a drawer under a food processor, a dirty knife in a food preparation area drawer, and crumbs and debris in the drawer containing serving utensils. Additionally, milk crates with containers of milk were stored directly on the refrigerator floor. The facility also lacked testing strips to check the chemical levels in the three-compartment sink and sanitizer buckets, and no records were kept for checking sanitizer levels. These findings were confirmed by the Dietary Manager during the inspection. The report notes that all 77 residents who received food from the kitchen had the potential to be affected by these deficiencies, while two residents did not receive food from the kitchen. The facility census at the time was 79.
Arbitration Agreement Discourages Communication with Authorities
Penalty
Summary
The facility failed to ensure that its arbitration agreement did not contain language that could prohibit or discourage residents or their representatives from communicating with federal, state, or local officials, as well as advocacy agencies such as the State Survey Agency and the Office of the State Long Term Care Ombudsman, regarding the arbitration process or the outcome of an arbitration settlement. Review of the facility's undated arbitration agreement revealed a confidentiality clause stating that neither the facility nor the resident could disclose any details of the legal controversy, dispute, or arbitration process without the consent of the other parties, except for minimal details required in court pleadings. The agreement emphasized confidentiality as a primary goal and stated that violating this provision would cause irreparable harm. An interview with the Administrator confirmed that this language could discourage communication with relevant authorities and advocacy agencies. This deficiency had the potential to affect all 79 residents in the facility, as indicated by the facility census.
Failure to Maintain Clean Dryer Lint Traps
Penalty
Summary
During an observation of the laundry room, both dryers were found to have a thick layer of lint built up in their lint traps, which appeared to be significantly more than what would be expected from a single dryer load. At the time of the observation, the Housekeeping Director confirmed that the dryers had not been cleaned and verified the presence of excessive lint build up. This deficiency had the potential to affect all 79 residents in the facility, as indicated by the facility census.
Failure to Track Infections and Maintain Infection Control Practices
Penalty
Summary
The facility failed to adequately track infections and maintain infection control measures, as evidenced by a lack of proper documentation and tracking of COVID-19 cases for multiple residents over a three-month period. Although several residents tested positive for COVID-19 in January, February, and March 2025, their infections were not documented in the infection control logs or the COVID-19 line list for those months. The Director of Nursing, who also served as the Infection Control Preventionist, confirmed that without accurate tracking and documentation, staff, residents, and visitors could not ensure appropriate care and services to prevent the spread of COVID-19. This failure was verified during interviews and through review of facility records and CDC guidance, which emphasized the need for processes to identify and manage individuals with suspected or confirmed COVID-19 infection. Additionally, the facility did not ensure proper infection control practices during blood glucose testing for a resident with a history of atherosclerotic heart disease and type II diabetes mellitus. Observation revealed that a registered nurse did not perform hand hygiene before donning gloves, did not use a barrier for glucometer supplies, and failed to perform hand hygiene after glove removal and before applying new gloves. Both the nurse and the Director of Nursing confirmed these lapses, which were inconsistent with facility policies requiring hand hygiene before and after glove use and the use of a clean barrier for equipment during procedures.
Inaccurate PASRR Status Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure accurate coding of the Preadmission Screening and Resident Review (PASRR) status on the Minimum Data Set (MDS) assessments for four residents with a documented level two mental illness. Record reviews showed that each of these residents had a PASRR level two assessment indicating serious mental illness, yet their most recent comprehensive MDS assessments incorrectly recorded their PASRR status as 'No' to the question regarding current consideration by the state level II PASRR process for serious mental illness or intellectual disability. The affected residents had diagnoses including schizophrenia, opioid dependence, delusional disorder, schizoaffective disorder, suicidal ideations, adjustment disorder, paranoid schizophrenia, muscle weakness, chronic obstructive pulmonary disease, and hypertension. Staff interview with the MDS nurse confirmed that these residents were determined by the state to have a level two mental illness and acknowledged the inaccurate coding of their PASRR status on the MDS assessments.
Failure to Honor Resident Preference for Compression Bandage Application
Penalty
Summary
Staff failed to honor a resident's stated preference regarding the timing of compression bandage application. The resident, who had a history of cellulitis, heart failure, and peripheral vascular disease, was cognitively impaired but able to express his wishes. Physician orders required ACE wraps to be applied to both lower extremities twice daily, with refusals documented. Multiple entries in the electronic medication administration record (EMAR) showed the resident repeatedly refused the application of ACE wraps in the early morning, stating he preferred them to be applied after his shower to prevent the wraps from getting wet or needing to be reapplied. Despite these documented preferences, staff continued to attempt application before the resident's shower and did not consistently accommodate his request. During interviews and observations, the resident reported that staff were not following his preference, resulting in his legs being left unwrapped after his shower. A CNA confirmed that the resident preferred post-shower application, but nurses did not always comply. Observation with the DON present confirmed the resident's legs were unwrapped after his shower, and the resident reiterated his preference for post-shower application. The DON initially stated the resident refused the wraps, but the resident clarified he only refused pre-shower application. The DON acknowledged that staff were not honoring the resident's preferences.
Failure to Provide Complete Medical Records Upon Resident Request
Penalty
Summary
The facility failed to ensure that a resident's request for access to and copies of her complete medical records was honored in a timely and comprehensive manner. The resident, who was cognitively impaired and required some assistance with activities of daily living, along with her elderly advocate, made multiple requests for her medical records, including medication and treatment administration records. Despite signing the required release form and following facility protocol, the resident and her advocate were repeatedly denied access to the full set of requested records. Staff interviews confirmed that the corporate compliance office directed them not to provide medication and treatment administration records, regardless of the resident's request or the completion of the release form. Facility policy stated that all information in the medical record could be released with written consent and that access should be provided within 24 hours, with hard copies available after 48 hours. However, the process involved sending the release form to the corporate compliance office, which then determined what records could be released. As a result, the resident did not receive all requested records, specifically the medication and treatment administration records, despite multiple attempts and clear communication of her needs. This deficiency was identified through medical record review, interviews with the resident, her advocate, staff, and review of facility policy.
Incomplete NOMNC Forms Lacking Required Service Details
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) forms for three residents contained all required information, specifically omitting details about which services would be discontinued. For each resident reviewed, the NOMNC forms either left blank or did not specify the services that were ending, despite being signed or acknowledged by the resident or their representative. This deficiency was confirmed by the Social Service Designee, who verified that the forms lacked the necessary specific information regarding discontinued services.
Failure to Ensure Timely Provision of Oxygen at Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory diagnoses, including acute respiratory failure with hypoxia, pneumonia, morbid obesity, and COPD, was discharged home without timely provision of necessary supplemental oxygen. The resident, who had intact cognition, was insistent on leaving the facility despite recommendations to remain for further care. Physician orders specified the need for oxygen therapy to maintain adequate oxygen saturation, and discharge planning included arrangements for home health services and supplemental oxygen. On the day of discharge, the resident was provided with a portable oxygen tank and discharge instructions, but the durable medical equipment (DME) supplier did not deliver the prescribed home oxygen as expected. The facility staff sent the oxygen prescription to the DME supplier, but there was confusion regarding the script, and the supplier did not confirm delivery or communicate any issues. The staff did not verify that the oxygen was delivered to the resident's home, and the resident was left without a continuous supply of oxygen for several days following discharge. The resident and her family attempted to resolve the issue by contacting the facility and the DME supplier, but were unsuccessful in obtaining the necessary equipment until a different supplier was contacted and delivered the oxygen. During this period, the resident did not have access to prescribed supplemental oxygen at home, despite the facility's documentation that arrangements had been made. The lack of timely coordination and confirmation of equipment delivery resulted in the resident being unprepared for a safe discharge.
Deficient Perineal and Incontinence Care Due to Improper Technique and Infection Control
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, right hip pain, and a history of repeated falls, who was always incontinent of bowel and bladder, did not receive appropriate perineal care. During an observed care episode, a CNA gathered supplies and prepared to provide perineal care but placed clean washcloths in the bottom of the resident's sink with running water, then applied shampoo and body wash directly to the washcloths in the sink. The CNA then transferred the washcloths to a basin and used them for cleansing and rinsing the perineal and buttocks areas, without patting the areas dry before applying a new incontinence brief. The CNA also failed to use separate washcloths for soaping and rinsing, and did not follow infection control protocols as outlined in facility policy. Interviews with the CNA and the RN Unit Manager confirmed that the perineal care was not performed according to facility policy, specifically regarding infection control and the use of basins and washcloths. The facility policy required equipment to be placed on the bedside stand, the use of a wash basin filled with warm water, and proper rinsing and drying of the area. The observed actions did not align with these procedures, resulting in a failure to provide appropriate incontinence and perineal care for the resident.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that its certified nurse aides (CNAs) received the required 12 hours of in-service training per year. Personnel records for two CNAs showed that each received only 4.5 hours of in-service training within their first year of employment, and all of these hours occurred in the following calendar year. There was no evidence of any in-service education provided to CNAs prior to that year. This deficiency was confirmed during an interview with the Administrator, who acknowledged the lack of required in-service hours for the CNAs in question. This lapse in training had the potential to affect all 79 residents in the facility, as the required education in dementia care and abuse prevention was not documented as completed for the CNAs reviewed.
Failure to Apply Complete Physician-Ordered Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to ensure the complete physician-ordered treatment was applied to a resident's sacral pressure ulcer. The resident, who had a history of iron deficiency anemia, obesity, surgical wound, atrial fibrillation, rheumatoid arthritis, and a pressure ulcer of the sacral region, was dependent on staff for activities of daily living. The physician's order required the wound to be cleansed with normal saline, packed with silver alginate, covered with an absorbent pad, secured with paper tape, and changed daily. Additionally, zinc ointment was to be applied around the sacral pressure ulcer daily. During an observation, an LPN was seen performing the wound care but failed to apply zinc or any cream or ointment to the skin surrounding the resident's wound, as required by the physician's order. The LPN confirmed the omission, stating that applying zinc would prevent the tape from adhering to the resident's skin. This oversight was noted despite the facility's policy requiring verification that the physician's order matches the wound care procedure.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to maintain its kitchen area in a clean and sanitary condition, as observed during a survey. A large puddle of water was found in the dishwasher area due to a malfunctioning drain that had been unresolved for months. Additionally, a sanitizer bucket under the dishwasher was left open, attracting a swarm of fruit flies. A package of bacon was improperly defrosting in a pool of yellow-colored water with food particles on the steam table. The convection oven's door was heavily stained with grease, and the hood suppression system had a noticeable buildup of grease and rust. Water was leaking from an unknown source beneath the coffee pots. In the walk-in cooler, a rotten green bell pepper, discolored celery, and undated sandwiches were found, indicating improper food storage practices. The dry storage area contained undated and opened containers of cherries and vanilla extract. These observations were verified by dietary aides during the survey. The facility's policy on preventing foodborne illness, dated 07/01/14, was not adhered to, as it required food to be stored, prepared, handled, and served to minimize the risk of foodborne illness. This deficiency was investigated under Complaint Number OH00160140.
Unsanitary Dumpster Area Found During Investigation
Penalty
Summary
The facility failed to maintain its dumpster area in a clean and sanitary condition, as observed during a complaint investigation. On December 15, 2024, at 9:05 A.M., an inspection of the dumpster area with a dietary aide revealed multiple areas of food debris, plastic gloves, and other trash. The dietary aide confirmed the unsanitary condition of the area and expressed a lack of surprise at the findings. This deficiency was identified as an incidental finding of non-compliance during the investigation.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly address the grievances of a resident, identified as Resident #65, who had been admitted on 06/29/20 with diagnoses including dementia, depressive disorder, bipolar disorder, psychosis, schizoaffective disorder, and alcohol abuse. The concern log form from 03/11/24 to 10/30/24 showed no recorded grievances for Resident #65. However, email correspondences revealed that Resident #65's sister, who is also the Power of Attorney (POA), raised concerns about incidents involving another resident, Resident #14, who threw a dish at Resident #65 and pulled the hair of Resident #65's private caregiver. These concerns were communicated via email to the Director of Nursing (DON), the Administrator, and the ombudsman on 10/10/24, but no response was received until 10/26/24. The Administrator acknowledged the delay in response, attributing it to her absence due to a Jewish holiday, and suggested that Resident #65's sister could have called the facility for a more immediate response. The DON expressed reluctance to respond to the email, fearing it might escalate the concerns. The facility's policy on Resident Rights, dated January 2022, mandates prompt efforts to resolve grievances, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00158843.
Failure to Conduct Ordered Urinalysis
Penalty
Summary
The facility failed to follow physician orders to obtain a urinalysis with culture and sensitivity testing (UA C&S) for a resident who was experiencing a change in condition. The resident, who was admitted with diagnoses including retention of urine, muscle weakness, and lack of coordination, was cognitively intact and had an indwelling catheter. On a specific date, the resident reported pain associated with urination, prompting the nurse practitioner to order a UA C&S and start Pyridium, an analgesic for urinary tract infections. However, the UA C&S was not completed as ordered. The medical record review and staff interview confirmed the non-compliance with the physician's order. The Licensed Practical Nurse verified that the UA C&S was not conducted, which was a requirement following the nurse practitioner's directive. This deficiency was identified during an investigation under a specific complaint number, affecting one of the three residents reviewed for a change in condition, with the facility having a census of 87.
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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 Westlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rae-ann Westlake | 0.6 mi | ★★★★★ | 0 | 0 |
| Huntington Woods Care & Rehab Center | 1.2 mi | ★★★★★ | 6 | 0 |
| O'neill Healthcare Bay Village | 1.3 mi | ★★★★★ | 23 | 0 |
| Lutheran Home | 1.4 mi | ★★★★★ | 1 | 0 |
| Brookdale Westlake Village | 1.7 mi | ★★★★★ | 4 | 0 |
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