Avenue At Broadview Heights

Based 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.

Findings include:

Review of the closed medical record for Resident #58 revealed an admission date of 05/19/25 and a discharge date of 07/29/25.

Diagnoses included but were not limited to acute respiratory failure with hypoxia, severe persistent asthma, type II diabetes with hyperglycemia, long term use of insulin, congestive heart failure, hypertensive heart disease and schizoaffective disorder, and post bariatric surgery status.

Review of the 07/29/25 discharge Minimum Data Set (MDS) 3.0 for Resident #58 revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition.

Review of the activities of daily living (ADLs) revealed Resident #58 was independent for meals. No weight was recorded on the MDS.Review of Resident #58's care plan last reviewed on 05/20/25 revealed potential for altered nutrition and hydration related to diagnosis of acute hypoxic respiratory failure, type II diabetes mellitus and history of bariatric surgery. Resident #58 also had physician-directed weight loss through the use of diuretics. A listed intervention included to monitor and record weights as physician ordered.Review of Resident #58's physician orders revealed an order dated 05/23/25 for daily weights to be obtained.

Review of the Medication Administration Record (MAR) for July 2025 revealed staff were signing of Resident #58's daily weights on the MAR as being complete with the exception of 07/11/25 which was blank and 07/26/25 where it noted the resident refused.

There were no actual weights recorded on the MAR.

Review of Resident #58's weights under the weights tab in the electronic medical record revealed the last recorded weight was 05/27/25 which listed Resident #58's weight at 260.2 pounds.Interview on 11/19/25 at 2:30 P.M. with Registered Dietitian #369 confirmed the actual daily weights were not recorded on the resident's MAR, rather they were just checked off as complete.

Registered Dietician #369 stated the weights should have been completed and recorded daily.

Interview on 11/19/25 at 2:45 P.M. with the Director of Nursing (DON) confirmed daily weights were signed off but no weights were recorded in Resident #58's medical record as ordered by the physician.

Review of the October 2024 revised facility policy called; Weight Policy and Procedure revealed residents will be weight monthly unless ordered otherwise by a physician.

Weights will be recorded in the resident's medical record.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Broadview Heights

1201 Akins Road Broadview Heights, OH 44147

SUMMARY STATEMENT OF DEFICIENCIES

During the interview, CNA #306 stated that Resident #13 seemed to experience anxiety, versus pain, during personal care, and that the anxiety and signs of discomfort go away once care is completed.

Interview on 11/25/25 at 2:34 P.M. with CNA #357 confirmed Resident #13 was able to make her needs known to staff and that it was anxiety, not pain, exhibited by Resident #13 during care.

During the interview, CNA #357 further revealed Resident #13 typically exhibits no signs of pain once care is completed and Resident #13 is repositioned as she specified to staff.

Interview on 11/25/25 at 4:00 P.M. with the Director of Nursing (DON) confirmed NA meant not applicable and was not an approved method of documenting a pain assessment.

The DON further revealed a pain assessment should be conducted to assess and understand the level of pain experienced by the resident prior to administering pain medication and then confirmed, regarding NA on the MAR, that she was seeing that all over the place on the pain assessments.

During the interview, the DON confirmed the MAR reflected the lack of consistent pain assessments prior to administration of an opioid analgesic and the lack of intervention attempts documented prior to pain medication administration to Resident #13.

Further interview revealed Resident #13 was capable of making her needs known to staff and that the DON was aware that Resident #13 did not like the use of controlled substances.

Review of the policy titled Pain Management last updated February 2023 revealed if a resident was assessed to have pain, the nurse was to explore both pharmacological and non-pharmacological interventions and implement the interventions listed in the resident's comprehensive care plan and professional standards of practice.

The policy further specified that pain relief strategies should be appropriate for the type of pain or pain related symptoms.

This deficiency represents non-compliance identified while investigating Complaint Number 1401319.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Broadview Heights

1201 Akins Road Broadview Heights, OH 44147

SUMMARY STATEMENT OF DEFICIENCIES

During the interview, RN #361 also confirmed the order was for an oral capsule and not chewable tablet and added that the facility did not carry the low dose aspirin in capsule form, just the enteric coated aspirin and the chewable tablets.

Review of the policy titled Medication Administration - General Guidelines last revised August 2014 revealed medications were to be administered as prescribed, the medication order should be verified against the medication label, and the person giving the medication was to ensure the right medication was given to the right resident, adhering to the right dose, right route, and right time.

This deficiency represents non-compliance investigated under Complaint #1401318.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Broadview Heights

1201 Akins Road Broadview Heights, OH 44147

SUMMARY STATEMENT OF DEFICIENCIES

Observation on 11/20/25 between 9:18 A.M. and 9:19 A.M. revealed LPN #303 entered the room of Resident #12, handed Resident #12 the medicine cup containing eight pills, verified Resident #12 had water, and then left the room as Resident #12 was picking up the first pill from the medicine cup and placing it into his mouth.

Continued observation revealed LPN #303 returned to the medication cart and began preparing medications for another resident in the hallway, with no view of Resident #12, from 9:19 A.M. to 9:20 A.M. LPN #303 then locked the medications cart and left the unit, stating a needed medication was not on the cart and needed picked up from the pharmacy. As LPN #303 was observed walking away from the unit at 9:20 A.M., Resident #12 was observed continuing to independently take the medications handed to him, one by one, until the last one was swallowed at 9:22 A.M. (LPN #303 was not on the unit at that time).

Interview on 11/20/25 at 9:23 A.M. with Resident #12 confirmed the medicine cup with pills is sometimes left in the room for him and reported that some nurses did that because they know they can count on me and then added, I just took them all, referring to the pills.

Interview on 11/20/25 at 9:35 A.M. with LPN #303 confirmed Resident #12 liked to take time to look at each pill, one by one, and let his wife know what each pill was that he received.

During the interview, LPN #303 confirmed handing the medication cup with pills to Resident #12, verifying a drink was available to help swallow the pills, and leaving after he began taking the pills, though LPN #303 also denied that the medication was left at the bedside or that the medications were not considered nurse-administered, reasoning that the pills were handed directly to Resident #12 in the medication cup, after already being dispensed by the nurse from the containers.

Further interview confirmed LPN #303 did leave the unit just after leaving the medications with Resident #12.

Review of the list of residents the facility identified as able to self-administer medications did not include Resident #12.

Review of the policy titled Self-Administration of Medications last revised August 2014 revealed the ability to self-administer medications was to be reassessed on a quarterly basis and with a significant change in condition.This deficiency represents non-compliance investigated under Complaint Number 1401318.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Broadview Heights

1201 Akins Road Broadview Heights, OH 44147

SUMMARY STATEMENT OF DEFICIENCIES

Review of the Clinical Census revealed Resident #61 was out of the facility for greater than 24 hours, beginning on 10/13/25, with re-entry listed as 10/15/25.

Pertinent diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of the bladder, type two diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, Stage three chronic kidney disease, anxiety disorder, major depressive disorder, post laminectomy syndrome, and primary osteoarthritis of the right knee.

Review of the incident logs revealed Resident #61 had an unwitnessed fall on 09/20/25.

Review of the clinical assessment history revealed Resident #61 had a Nursing: Fall Risk Assessment - V 1 completed on 03/11/25 for the initial admission and did not have another fall risk assessment completed until 09/20/25 after sustaining an unwitnessed fall.

There was no record of quarterly fall risk assessments or a fall risk assessment being completed with readmission on [DATE].

Review of the Discharge with Return Anticipated Minimum Data Set (MDS) 3.0 assessment completed on 10/13/25 revealed Resident #61 had moderate cognitive impairment and was dependent for transfers.

Further review of the MDS revealed Resident #61 had one fall with injury since admission, re-entry or the last assessment.

Interview on 11/25/25 between 4:20 P.M. and 4:30 P.M. with the DON confirmed there had been no quarterly or readmission fall risk assessments completed between Resident #61's initial admission date and the date of the fall (09/20/25).

Review of the policy titled Fall Management last updated December 2022 revealed a licensed nurse was to assess each resident for fall risk through the Fall Risk Assessment on admission, quarterly, and with significant changes.

This deficiency represents non-compliance investigated under Complaint Numbers 2560788 and 1401316.

Facility ID: