Avenue at Broadview Heights

Inspectors wroteBased on observation, closed record review, review of Emergency Medical Services report, review of hospital records, policy review and interview the facility failed to follow Resident #62's physician orders and implement care planned interventions to ensure Resident #62 was monitored appropriately and timely treated for an acute change of condition, and failed to ensure adequate skin monitoring was completed to timely identify and treat areas of Resident #62's skin breakdown. The facility also failed to ensure Resident #39's new medical diagnoses of type two diabetes was timely treated. Actual Harm occurred beginning on 02/18/25 at 7:47 P.M. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #11 received showers to her preference and in accordance with care planned interventions. This affected one resident (Resident #11) out of three reviewed for bathing. The facility census was 61.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #21 received adequate oral care. This affected one resident (Resident #21) out of three residents reviewed for oral care. The facility census was 61.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #62's nutritional care planned interventions, including record of meal intakes were implemented. This affected one resident (Resident #62) out of three residents reviewed for nutrition. The facility census was 61.

Inspectors wroteBased on observation, interview, record review and review of the local fire department report, the facility failed to ensure Resident #24's respiratory status was properly treated and monitored. This affected one resident (Resident #24) out of three residents reviewed for oxygen therapy. The facility census was 61.

Inspectors wroteBased on record review, interview, review of facility policy and review of Centers for Disease Control and Prevention guidelines, after Resident #62 was found to be positive for Candida Auris (a fungal infection that can cause severe, often drug resistant infection, the facility failed to ensure the facility tracked the infection for signs/symptoms and control of the infection within their infection control program, and failed to ensure the resident and family were timely educated and knowledgeable of the treatment and/or precautionary mechanisms required for the infection. This affected one resident (Resident #62) out of three reviewed for infection control. The facility census was 61.

Inspectors wroteBased on review of medical records, interviews, and review of facility policy, the facility failed to ensure appropriate and timely routine skin assessments were completed for two residents (#58 and #61) of three residents reviewed for appropriate care and treatment related to altered skin integrity. The facility census was 57.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure physician orders for weights were completed as ordered for one resident (#58). This had the potential to affect all residents residing in the facility. The facility census was 57.

Inspectors wroteBased on interview, review of the medical record, and review of facility policy, the facility failed to ensure resident drug regimens did not include the unnecessary use of opioids. This affected one resident (#13) of four residents reviewed for appropriate pain management. The facility census was 57.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure a medication error rate of less than five percent (%). This affected two residents (Residents #12 and #39) of five residents (Residents #5, #12, #13, #30, and #39) observed during medication administration when the observation resulted in an error rate of 8.33%. The facility census was 57.1. Review of the medical record for Resident #12 revealed an admission date of 12/06/23 with pertinent diagnoses including spinal stenosis, depression, type two diabetes mellitus, repeated falls, polyarthritis, nonexudative age-related macular degeneration, hyperlipidemia, obstructive reflux uropathy, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms and gastro-esophageal reflux disease. [...]

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure medications were not left with a resident to take independently who was not approved to safely store or self-administer medications. This affected one resident (#12) of five residents observed and reviewed for medication administration. The facility census was 57.

Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to ensure a resident's admission was timely completed and failed to ensure routine assessments were completed as required. This affected three residents (#60, #2, and #61) of six residents reviewed for accuracy of medical records. The facility census was 57.

Inspectors wroteBased on observation, interview, record review, review of the facility policy, and review of hospital records, the facility failed to properly assess and monitor Resident #43 and Resident #59's urinary condition to timely identify and treat signs and symptoms of a urinary tract infection. Actual Harm occurred on 06/13/25 at 9:07 A.M to Resident #59 when the resident's care planned interventions to monitor urine output and orders to irrigate the catheter were not implemented, symptoms of a UTI were not timely identified, and the resident presented with an emesis, tachycardia with a heart rate of 143, complaints of being cold, had a large diarrhea bowel movement and chills. On 06/13/25 at 1:12 P.M. Resident #59 requested to be transported to the hospital after she started having difficulty breathing and her oxygen saturations were 87 to 88 percent. [...]

Inspectors wroteBased on interview, record review, review of facility policy and review of hospital records the facility failed to ensure Resident #59's care planned interventions were implemented and physician orders were followed for oxygen therapy. This affected one resident (Resident #59) out of three residents reviewed for oxygen therapy. The facility census was 58.

Inspectors wroteBased on interview and closed record review, and hospital paperwork review, the facility failed to ensure they discharged a resident in a safe and orderly manner. This affected one resident (Resident #73) out of five residents reviewed for discharge. The facility census was 72.

Inspectors wroteBased on interview and closed record review, the facility failed to ensure there was a baseline care plan put in place. This affected one resident (Resident #73) out of five residents reviewed for care plans. The facility census was 72.

Inspectors wroteBased on observation, interview, record review, review of resident shower sheets, and review of facility policy,the facility failed to ensure residents received showers per facility schedule and preference. This affected one resident (Resident #25) out of five residents reviewed for showers. The facility census was 72.

Inspectors wroteBased on observation, interview, record review, and review of manufacturer instructions revealed the facility failed to ensure proper administration of insulin was followed. This affected one resident (Resident #52) out of five residents reviewed for medication administration. The facility census was 72.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed infection control policy and procedures related to hand hygiene and proper use of Personal Protective Equipment when administering medications and when administering medications to residents in Enhanced Barrier Precaution isolation rooms. This affected three residents (Residents #4, #25, and #33) out of five residents reviewed for infection control related to hand hygiene and proper Personal Protective Equipment. The facility census was 72.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure Resident #19's choices were honored with rising out of bed in the morning. This affected one (Resident #19) out of two residents reviewed for choices concerning care. The facility census was 67.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure standard nursing practices were followed for safe meidcation administration. This affected two (Residents #8 and #44) of six residents observed for medication administration. The facility census was 67.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure Resident #169 was assisted with toileting as needed. This affected one (Resident #169) out of five residents reviewed for activities of daily living. The facility had a census of 67.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure an anchoring device for Resident #51's suprapubic catheter was implemented to prevent accidental pain or injury from excessive tension to the suprapubic catheter. This affected one (Resident #51) of one resident reviewed for catheters. The facility census was 67.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure Resident #36's head of the bed was elevated safely per the physician's order, during continuous enteral feedings. This affected one (Resident #36) of three residents reviewed for enteral feedings. The facility census was 67.

Inspectors wroteBased on record review, interview, and review of the facility policy and procedure, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (Resident #22) of five residents (Residents #13, #22, #38, #51, and #62) reviewed for drug regimens. The facility census was 67.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to provide routine monitoring for behaviors and side effects for psychotropic medications. This affected three residents (#22, #38 and #51) of five residents reviewed for unnecessary medications. Facility census was 67.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure medications were properly stored and secured. This affected one (Resident #40) out of one resident reviewed for improperly stored medications. The facility census was 67.

Inspectors wroteBased on observation, staff and resident interviews, record review, and policy review, the facility failed to ensure Resident #25's bedside commode was emptied in a timely manner. This affected one (Resident #25) of three residents reviewed for physical environment. The facility census was 65.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, to timely identify new pressure ulcers, and to ensure wound care was completed as ordered to ensure Resident #72 skin was maintained and the resident did not develop an in-house stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to the left buttock. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure Resident #38's incontinence care was completed timely. This finding affected one resident (#38) of three residents reviewed for incontinence care. The facility census was 69.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure medications were administered in a safe manner. This affected one resident (#58) of five residents reviewed for medication administration. The facility census was 66.

Inspectors wroteBased on record review and interviews the facility failed to conduct a thorough investigation and implement interventions to assist in preventing further skin impairment for Resident #63. This affected one (Resident #63) of three residents reviewed for skin conditions. The facility census was 62.

Inspectors wroteBased on observations, record reviews, and resident, family, and staff interviews, the facility failed to ensure the residents received incontinence care timely. This affected two (Resident #34 and #62) of three residents reviewed for incontinence care. The facility census was 67.

Inspectors wroteBased on record review, observation and interview the failed to to provide the required assistance for personal hygiene. This affected one of three residents reviewed, Resident #3. The census was 66.

Inspectors wroteBased on record review, observations and interview the facility failed to ensure an appropriate sized dressing was applied to a Stage four pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Rolled edges, undermining and/or tunneling often occur. Depth varies by anatomical location). This affected one of three residents reviewed for wounds, Resident #57. The census was 66.

Inspectors wroteBased on record review and interview the facility failed to maintain accurate medical records in regards to wound treatments. This affected two of three residents reviewed for wound care, Residents #57 and #59. Census was 66.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure physician orders and care plans were in place for the care of intravenous (IV) lines to prevent infection/complications. This affected five of five residents identified by the facility as having IV access, Residents #1, #3, #16, #18 and #57.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place throughout the medical record. This affected two residents (#3 and #19) of two residents reviewed for advanced directives. The facility census was 47.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure a resident/or resident representative was provided written notification of a resident transfer to the hospital. The facility also failed to notify the ombudsman of the resident's transfer. This affected two (#30 and #40) of two residents reviewed for hospitalization and had the potential to affect all residents. The facility census was 47.

Inspectors wroteBased on record review and staff interview the facility failed to ensure bed hold notices were given to residents and/or their representatives upon transfer to the hospital. This affected two (#30 and #40) of two residents reviewed for hospitalization and had the potential to affect all resident. The facility census was 47.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident care plans were revised to include all fall interventions. This affected one resident (Resident #3) of one resident reviewed for falls. The facility census was 47.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate nail care was provided for Resident #12. This affected one of one residents reviewed for nail care. The total census was 47.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate and ordered range-of-motion interventions were provided for Resident #12. This affected one of one residents reviewed for mobility care. The total census was 47.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Foley catheters were maintained in a way to prevent possible infection and trauma. This affected two of two residents reviewed for catheter care (Resident #12 and #23). The total census was 47.

Inspectors wroteBased on record review and interview, the facility failed to ensure paper lab orders were transcribed into the computer orders and acted upon. This affected one of five residents reviewed for unnecessary medications (Resident #23). The total census was 47.