Buckeye Terrace Rehabilitation and Nursing Center

Inspectors wroteBased on record review, interview, Self-Reported Incident (SRI) review, and facility policy review the facility failed to timely report allegations of abuse. This affected two residents (#40 and #20) of three residents reviewed for abuse. The census was 64.

Inspectors wroteBased on review of Board of Executives of Long-Term Services and Support (BELTSS) documentation, and staff interview, the facility governing body failed to ensure the facility's Administrator, who was responsible for the management of the facility, had a current license in the State of Ohio. This had the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a clean, safe, and sanitary environment. This had the potential to affect all 62 residents living in the facility. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, resident interview, and facility policy review, the facility failed to obtain proper justification for decisions on pharmacy recommendations. This affected four (Residents #7, #9, #23 and #25) of five residents reviewed for unnecessary medications. Also, the facility failed to ensure there was proper monitoring/oversight for the use (unuse) of as needed pain medications. This affected one (Resident #23) of five residents reviewed for unnecessary medications. The census was 60.1. Resident #7 was admitted to the facility on [DATE]. His diagnoses were paranoid schizophrenia, muscle weakness, unspecified fracture of right ischium, neuromuscular dysfunction of bladder, dysphonia, hypertension, lack of coordination, insomnia, and xerosis cutis. Review of his minimum data set (MDS) assessment, dated 11/19/25, revealed he was cognitively intact. [...]

Inspectors wroteBased on observation, staff interviews and medical record review, the facility failed to ensure the blood glucose meter was sanitized after use for Resident # 39. This had the potential to affect six residents identified by the facility as receiving blood glucose monitoring from the East Hall nurse. The facility census was 60. Review of Resident # 39's medical record revealed he was admitted on [DATE] with diagnoses that included diabetes mellitus type 1, morbid obesity, hypertension and cholecystitis. Review of Resident # 39's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and that he required assistance from staff with toileting, transfers, dressing and personal hygiene. [...]

Inspectors wroteBased on medical record review, resident interview and staff interviews, the facility failed to ensure timely and adequate vision services were provided to Resident #26. This affected one (Resident #26) out of one resident reviewed for communication and sensory problems. Facility census was 60. Review of Resident # 26's medical record revealed an admission date of 06/07/25 with diagnoses that included but were not limited to left femur fracture, asthma, diabetes type 2 with diabetic neuropathy, chronic diastolic heart failure and need for assistance with personal care. Review of Resident #26's Minimum Data Set (MDS) dated [DATE], revealed a BIMS score of 14 out of 15 indicating intact cognition and that she required assistance from staff with toileting, showering/bathing and dressing. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide effective pain management for Resident # 18. This affected one (Resident #18) out of four residents reviewed for pain management. The facility census was 60. Review of Resident # 18's medical record revealed she was admitted on [DATE] with diagnoses that included chronic pain syndrome, anxiety, depression, polyneuropathy and irritable bowel syndrome. Review of Resident # 18's Minimum Data Set (MDS) dated [DATE], revealed resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition and required assistance from staff with showering and bathing. Review of Resident # 18's Physician's Orders dated December 2025, revealed the following orders: -Oxycodone (medication used for moderate to severe pain) HCL Oral tablet 5 mg (milligrams); [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to a psychiatric consult as ordered. This affected one (Resident #43) of four residents reviewed for behavioral services. The census was 60. Resident #43 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disease, depression, hyperlipidemia, hypertension, alcohol abuse, polyneuropathy, and gastro-esophageal reflux disease (GERD). Review of his minimum data set (MDS) assessment, dated 09/15/25, revealed he was cognitively intact. Review of Resident #43 physician orders, dated 08/13/25, revealed there was a psychiatric evaluation that was ordered to be completed. Review of Resident #43 medical records, dated 08/13/25 to 11/24/25 (date of discharge), revealed there was no completed psychiatric evaluation. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to maintain hospice notes and records on-site for all residents. This affected one (Resident #31) of one resident reviewed for hospice services. The census was 60. Resident #31 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia, vitamin D deficiency, osteoarthritis of knee, osteoporosis, hypertension, rheumatic heart disease, and dementia. Review of her minimum data set (MDS) assessment, dated 10/02/25, revealed she had a severe cognitive impairment. Review of Resident #31 hospice records in the facility, found there were no hospice notes in their physical hospice binder for the last three months. Review of Resident #31 hospice notes, dated 09/15/25 to 11/26/25, revealed all these hospice notes and records were delivered to the facility by the hospice agency on 12/10/25. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to maintain the facility in a safe, comfortable, and functional manner. This affected one (#22) of three residents reviewed for environment. The census was 58. Findings Include:Review of Resident #22's medical record revealed admission to the facility on [DATE]. Diagnoses included schizophrenia, seizures, morbid obesity, muscle weakness, personal history of transient ischemic attack, gastro-esophageal reflux disease, chronic pain syndrome, and difficulty walking. Review of Resident #22's Minimum Data Set (MDS) assessment, dated 06/16/25, revealed she had a severe cognitive impairment. Observation on 09/17/25 at 10:15 A.M. and 2:00 P.M., and on 09/18/25 at 6:15 A.M. and 9:30 A.M. revealed a large portion of Resident #22's wall was missing beside the right side of her bed. [...]

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure interventions for pressure relief were administered to residents with pressure ulcers as ordered. This affected one (#30) of three residents reviewed for pressure ulcers. The census was 58.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to administer medications to residents in a timely manner as prescribed. This effected three (#54, #30, and #27) of five residents reviewed for medication administration. The facility census was 58.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital visit summary review, hospital discharge summary review, review of drainage guidelines for the PleurX, (a thin, flexible tube that's placed in your chest to drain fluid from your pleural space, to make it easier to breathe) and interview, the facility failed to provide necessary and adequate care for Resident #60 who had a PleurX chest tube. The facility failed to ensure nursing staff were properly educated on the tube and failed to ensure the PleurX chest tube was routinely monitored, assessed (for proper placement), monitored for signs/symptoms of infection, accessed, and drained. This affected one resident (#60) of one resident reviewed for chest tubes. The facility census was 58. Findings Include: [...]

Inspectors wroteBased on medical record review, observation, staff interview and review of a facility policy, the facility failed to provide a dignified dining experience. This affected one (Resident #61) of two residents reviewed for feeding assistance. The facility census was 62 residents.

Inspectors wroteBased on medical record review, resident and staff interview. review of the Electronic Information Dissemination and Collection (EIDC) portal and review of a facility policy, the facility failed to report an incident of alleged sexual abuse to the state survey agency andfailed to implement their abuse policy after an allegation of sexual abuse. This affected one (Resident #23) of three residents reviewed for abuse. The facility census was 62.

Inspectors wroteBased on medical record review, resident and staff interview and review of facility policy, the facility failed to implement their abuse policy after an allegation of sexual abuse. This affected one (Resident #23) of three residents reviewed for abuse. The facility census was 62.

Inspectors wroteBased on medical record review, resident and staff interviews and policy review, the facility failed to provide appropriate levels of superstition for residents identified as fall risks. This affected one resident (Resident #42) of three residents reviewed for falls.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to provide nail and skin care for Resident #3, who was dependent on staff for personal hygiene. This affected one (Resident #3) out of three residents reviewed for activities of daily living (ADL). The facility census was 59.

Inspectors wroteBased on record review and staff interview, the facility failed to assess pressure ulcers and put treatments in place in a timely manner for Residents #1, #2, and #3. The facility also failed to identify a pressure ulcer Resident #3 developed until it was a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer. This affected three (Resident #1, #2, and #3) out of three residents reviewed for pressure ulcers. The facility census was 59.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure the residents had weekly skin assessments per physician orders, failed to record skin breakdown identified during a bath, and failed to report the skin breakdown to the nurse. This affected one (Resident #57) of three residents reviewed for pressure ulcers. The facility identified seven current residents with pressure ulcers. The facility census was 58.

Inspectors wroteBased on record review, review of the facility assessment, hospital record review, review of police reports, review of facility policies, and interviews, the facility failed to identify potential risks/hazards for residents with a substance use disorder, develop and implement comprehensive and individualized care plans and provide adequate supervision to prevent unintentional/intentional drug overdoses for residents in the facility. This resulted in Immediate Jeopardy and actual harm/death on 03/31/24 when Resident #1 overdosed by shooting opioid medications in his peripherally inserted central catheter (PICC) line after he obtained a syringe from the trash bin on the facility medication cart. Resident #1 had a history of intravenous illicit substance abuse prior to admission and had an intravenous line while at the facility. [...]

Inspectors wroteBased on observations, record review, and family, resident, and staff interview, the facility failed to timely repair a resident's sink and ensure it was functional for the resident's use. This affected one (Resident #27) of three residents reviewed for functional sinks in resident rooms. The facility census was 63.

Inspectors wroteBased on record review, interview, self-reported incident (SRI) review, and policy review, the facility failed to protect Resident #24 from being verbally abused by Resident #9. This affected one (Resident #24) out of three residents reviewed for abuse. The facility census was 62.

Inspectors wroteBased on record review, interview, self-reported incident (SRI), and policy review, the facility failed to follow the abuse policy when there were allegations of verbal abuse towards Resident #24. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62.

Inspectors wroteBased on record review, review of self-reported incident (SRI), interview, and policy review, the facility failed ensure an allegation of verbal abuse against Resident #24 was reported immediately. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62.

Inspectors wroteBased on record review, review of self-reported incident (SRI), interview, and policy review, the facility failed to thoroughly investigate an allegation of verbal abuse to Resident #24 and failed to prevent further potential abuse to Resident #24. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62.

Inspectors wroteBased on record review and interview, the facility failed to provide adequate bathing and hygiene for residents who required staff assistance with activities of daily living including personal hygiene. This affected two (Resident #26 and #71) out of three residents reviewed for bathing and hygiene. Facility census was 62.

Inspectors wroteBased on record review and interview, the facility failed to provide treatment to a resident with diagnosed mental disorders. This affected one (Resident #1) out of three residents reviewed for medication administration.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident received appropriate foot care. This affected one (Resident #71) out of three reviewed for foot care. Facility census was 62.

Inspectors wroteBased on review of menus, review of food service invoices, observation, and interview, the facility failed to ensure adequate supply of food, post menu's timely, and failed to follow the menu. This had the potential to affect all 64 residents who received meals from the kitchen. The facility census was 64.

Inspectors wroteBased on medical record review, fall investigation review, staff interview, and guardian interview, this facility failed to ensure a residents guardian was notified of a change in condition including a witnessed fall. This affected one (Resident #119) of the five residents reviewed for notification. The facility census was 59.

Inspectors wroteBased on medical record review, fall investigation review, review of photo, staff interview, and guardian interview, this facility failed to complete a thorough investigation for an injury of unknown origin. This affected one (Resident #119) of the five residents reviewed for incident investigations. The facility census was 59.

Inspectors wroteBased on medical record, discharge planning report, equipment invoice review, staff interview, and case manager interview, this facility failed to ensure a resident discharging from the facility was sent home with a sufficient supply of insulin and needed shower chair. This affected one (Resident #115) of the four residents reviewed for proper and safe discharging. The facility census was 59.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an odor free environment. This directly affected one (#48) resident with potential to affect the additional 48 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #25, #26, #28, #29, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #51, #53, #55 and #56) who resided on the first floor of the facility. The census was 56.

Inspectors wroteBased on observation, medical record review, and resident and staff interviews, the facility failed to provide a dependent resident with oral hygiene. This affected one (#15) of three residents reviewed for activities of daily living (ADLs). The census was 56.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of mechanical lift manufacturer's instructions, the facility failed to safely operate a mechanical lift during a resident transfer. This affected one (#13) of three residents reviewed for accidents. The census was 56.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, and review of facility policy, the facility failed to maintain intravenous (IV) access in a proper manner. This affected two (#22 and #33) of two residents reviewed for IV access. The census was 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly and discarded by expiration or use by date. This affected two residents (Resident #39 and Resident #49) out of five residents reviewed for pharmacy medication reviews and had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on medical record review, observations, staff interview, and facility policy review, the facility failed to monitor and determine Resident #39's ability to safely self administer all acquired medications. This affected one (Resident #39) of the five residents reviewed for unnecessary medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete a comprehensive resident centered care plan for the use of a positioning splint device. This deficient practice affected one resident (Resident #45) out of one resident reviewed for a positioning splint device. The facility census was 58.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to revise Resident #8's comprehensive care plan after a change in condition. This affected one (Resident #8) of 25 residents reviewed for comprehensive care plans. Findings Include: Resident #8 was admitted to the facility on [DATE]. His diagnoses were type I diabetes, difficulty walking, hereditary and idiopathic neuropathy, acquired absence of right foot, peripheral vascular disease, myasthenia gravis, hypertension, hypothyroidism, bipolar disorder, borderline personality disorder, major depressive disorder, old myocardial infarction, hypo-osmolality and hyponatremia, hypokalemia, and anemia. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 06/13/23, revealed he was cognitively intact. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide personal hygiene to Resident #1 who dependent on staff for care. This deficient practice affected one resident (Resident #1) out of two residents reviewed for personal hygiene. The facility census was 58.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to notify the physician of an abnormal blood glucose level. These deficient practice affected one resident (Resident #21) out of two residents reviewed for blood glucose levels. Findings Include:Reviewed of the medical record for Resident #21 revealed an admission date of 06/22/22. Diagnosis included type two diabetes mellitus, severe protein calorie malnutrition, and chronic pancreatitis. Review of Resident #21 quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #21 was noted to be 69 inches tall, weighted 133 pounds and was receiving insulin and diuretics daily. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to verify placement of a percutaneous endoscopic gastrostomy (PEG) tube prior to medication administration. These deficient practices affected one resident (Resident #5) out one resident reviewed for PEG tube. Findings Include: Review of Resident #5 medical record revealed Resident #5 was admitted to the facility on [DATE] with admitting diagnoses including Chronic Obstructive Pulmonary Disease (COPD), hemiplegia affecting left non-dominant side, dysphagia, adult failure to thrive and gastrostomy status. Further review revealed Resident #5 received medications via the PEG tube. Review of Resident #5 Minimum Data Set (MDS) Quarterly dated 07/04/23 revealed Resident #5 requires extensive assistance for activities of daily living (ADL) tasks and dependent assistance from staff for feeding and medication administration. [...]

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to provide adequate social services oversight and assistance to Resident #54 related to benefit(s)/continued placement in the facility. This affected one resident (#54) of one resident reviewed for insurance benefits. The census was 58. Findings Include: Resident #54 was admitted to the facility on [DATE]. His diagnoses were encephalitis, chronic obstructive pulmonary disease, nontoxic goiter, mood disorder, anxiety disorder, alcohol abuse, hypertension, difficulty walking, and cognitive communication deficit. Review of his Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident was cognitively intact. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed provide evidence all pharmacy recommendations were addressed for Resident 349 in a timely and thorough manner. This affected one (Resident #49) of five residents reviewed for unnecessary medications. The census was 58. Findings Include: Resident #49 was admitted to the facility on [DATE]. Her diagnoses were chronic obstructive pulmonary disease, emphysema, morbid obesity, myopia, tracheostomy status, anoxic brain injury, hypertension, anemia, personal history of transient ischemic attack, major depressive disorder, anxiety disorder, and opioid dependence. Review of her Minimum Data Set (MDS) assessment, dated 07/03/23, revealed she was cognitively intact. Review of Resident #49 census documentation revealed she was discharged to the hospital on [DATE] with an anticipation of return. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete annual performance evaluations for all State Testing Nursing Assistants (STNAs) as required. This had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure all staff protected and valued residents' private space when Laundry Manager #4 failed to knock or request permission to enter the shower room where Resident #25 was being assisted with a shower. This affected one resident (#25) of 61 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to provide pressure ulcer wound care for Resident #40 in a manner to prevent the spread of infection. This affected one resident (#40) of one resident reviewed for pressure ulcer care/treatment.

Inspectors wroteBased on observation, record review and interview the facility failed to provide tracheostomy care for Resident #40 in a manner to prevent the spread of infection. This affected one resident (#40) of one resident reviewed for tracheostomy care. Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including stroke, hemiplegia, chronic respiratory failure, tracheostomy, dysphasia, and the presence of a pressure injury to the sacrum region. Review of Resident #40's physician's orders revealed an order for tracheostomy care twice daily and replacement of the tracheostomy inner cannula daily. On 08/23/23 beginning at 9:00 A.M. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2 were observed performing tracheostomy care for Resident #40. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide a menu with a variety of foods and failed to create substitution logs and notify residents when the planned menu was not being followed. This had the potential to affect 46 of 46 residents who received meal trays from the kitchen. The facility identified two residents (#46 and #4) who received nothing by mouth. The facility census was 48.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure meals/food items from the kitchen were palatable and served at the proper temperature. In addition, the facility failed to ensure pureed food items were prepared properly to conserve appearance and palatability. This had the potential to affect 46 of 46 residents who received meal trays from the kitchen. The facility identified two residents (#46 and #4) who received nothing by mouth. The facility census was 48.

Inspectors wroteBased on record review, interview, and observations, the facility failed to consider the views of residents and act promptly upon resident concerns regarding the variety of food. This affected nine residents (Residents #7, #18, #20, #24, #33, #35, #38, #40, #43) with the potential to affect all 46 residents that consumed food from the kitchen.

Inspectors wroteBased on review of the facility resident personal needs accounts (PNA) and staff interviews, the facility failed to ensure a surety bond was in place to potentially cover any loss of residents PNA account funds. This affects 21 of 21 residents (Resident #2, #3, #4, #6, #7, #10, #13, #19, #21, #22, #23, #24, #25, #28, #31, #35, #36, #38, #39, #40 and #41) whose personal funds were secured by the facility.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure all residents had a privacy curtain that would allow full visual privacy. This affected 21 residents (Resident #4, #6, #7, #8, #9, #11, #14, #16, #17, #18, #19, #21, #22, #27, #37, #43, #45, #46, #49, #201 and #452) of 21 residents reviewed for privacy.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to develop comprehensive plan of care for Resident #8, #14, #20, #26. This affected four residents (Resident's #8, #14, #20, and #26) of 24 residents reviewed for comprehensive care plans. Findings Include: 1. Review of Resident #8's medical record revealed an admission date of 04/27/20. Diagnoses included but were not limited to encephalotpathy, cerebral infarction with left sided hemiparesis, contracture of left hand, seizures, and Alzheimer's disease, dysphagia, essential hypertension, and dementia with behavioral disturbance. Review of the Resident #8's nursing admit/readmit screener, dated 04/27/20, revealed the resident had a contracture to his left arm and leg. [...]

Inspectors wroteBased on observation, facility policy and procedure review and interview the facility failed to ensure all multi-use medications were dated when opened and failed to ensure medications were discarded once expired. This affected five residents (#12, #6, #450, #16 and #33) and had the potential to affect 26 residents who resided on the Eastside unit and 14 residents who resided on the Westside unit who received medication(s) from the observed medication carts. The facility census was 48.

Inspectors wroteBased on observation, record review and interview the facility failed to follow a spreadsheet or diet guide for residents on a therapeutic diet and failed to ensure Resident #9 was provided a diet as ordered by the physician. This affected five residents (#3, #9, #23, #201 and #451) of 48 residents residing in the facility identified to receive a therapeutic diet.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to maintain appropriate infection control practices during a pressure ulcer dressing change for Resident #28 and during blood glucose monitoring using a shared glucometer to prevent the spread of infection. This affected one resident (#28) of three residents reviewed for pressure ulcers and five residents (#12, #34, #44, #17 and #450) of five residents observed for blood glucose monitoring.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure Resident #10 advanced directives were accurate. This affected one resident (Resident #10) out of three residents reviewed for advanced directives.

Inspectors wroteBased on record review, staff interview, and review of the facility policy review, the facility failed to ensure Resident #26's pre-admission screening and resident review (PASARR) was updated with current mental health diagnosis. This affected one resident (Resident #26) of the 24 residents reviewed for PASARR.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure two residents (Resident #8 and #19) who were dependent on staff for personal hygiene were shaved. This affected two residents (Resident #8 and #19) of three residents reviewed for activities of daily living.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Resident #26 had a pressure reducing mattress in place per physician orders. This affected one resident (Resident #26) of the three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure Resident #8's left arm splint and foot positioning device was in place to prevent a decline in range of motion (ROM). This affected one resident (Resident #8) of one reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, and record review, and facility policy review, the facility failed to ensure Resident #19's fall interventions were in place at all times and bed rails were safely installed and inspected to prevent risk of resident entrapment. This affected one resident (Resident #19) of one resident reviewed for accident hazards.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #46 was provided oxygen therapy as ordered. This affected one resident (#46) of two residents reviewed for respiratory services/oxygen.

Inspectors wroteBased on record review and interview the facility failed to comprehensively monitor and assess for weight changes to determine if the changes were a result of fluid loss/hemodialysis for Resident #14. This affected one resident (#14) of one resident reviewed for hemodialysis.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate pharmaceutical services to ensure medications for administration were not left unattended with Resident #40. This affected one resident (#40) of six residents reviewed for medication administration.

Inspectors wroteBased on record review and interview the facility failed to ensure pharmacy recommendations were addressed in a timely manner for Resident #33 and Resident #19. This affected two residents (#19 and #33) of seven residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #33 and Resident #19's medication regimens were free of unnecessary medications. The facility failed to obtain physician ordered daily weights to monitor the effectiveness of diuretic medication and failed to obtain laboratory testing (PT/INR) to monitor the effectiveness of anti-coagulant medication for Resident #33 and failed to ensure Resident #19 was not administered duplicate doses/excessive doses of anti-seizure medication. This affected two residents (#19 and #33) of seven residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #19, Resident #36 and Resident #51 were free from significant medication errors. This affected three residents (#19, #36 and #51) of seven residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #53 was transported back to the facility timely following a scheduled physician's appointment. This affected one resident (#53) of one resident reviewed for outside services.