Continuing Healthcare Of Cuyahoga Falls

F 0697 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bruising on Resident #150, but the resident was not sent out for evaluation until a couple of weeks later.

LPN #241 stated when the bruising was first observed, it appeared to be smaller and did not appear to be concerning, and Resident #150 was unaware how it happened. The second time, a couple weeks later, the bruising was observed it was much larger and was yellowish, indicating an older bruise. Interview on 08/07/25 at 6:25 A.M. with CNA #228 revealed she first noticed the bruising in the middle of July, and it had already been reported. The bruising appeared small, and dark in color. Resident #150 appeared to be in pain despite the resident receiving pain medication. CNA #228 reported the bruising got worse and Resident #150 seemed more confused. On 07/16/25, prior to the x-ray, Resident #150 seemed to be in considerable pain, was moaning, and would grab her right thigh. Interview on 08/07/25 at 7:26 A.M. with CNA #234 revealed she reported Resident #150 having pain and rubbing her hip around 07/06/25 to RN #234 who talked with DON #283. A couple days later she reported Resident #150 was not eating or drinking well. When CNA #234 asked Resident #150 if she was in pain she nodded yes. CNA #234 stated when she washed her up on 07/10/25, the resident had pain, and she reported it to DON #283. The bruising appeared purple in color. Following reporting the resident's pain to DON #283, Resident #150 appeared to be in more pain and was not sent out until 07/17/25. Resident #150 was not wanting to get out of bed due to her pain and when she was being changed, she was moaning in pain. Interview on 08/07/25 at 12:25 P.M. with the Assistant Director of Nursing (ADON) revealed Resident #150 was unable to voice concerns about pain or bruising. RN #234 contacted her on 07/11/25 and they thought the bruising was from Resident #150 grabbing her thighs with her hands. On 07/16/25, when Resident #150 was having extreme pain, an x-ray was completed, and she was sent out for further evaluation of the right hip fracture.

The ADON confirmed she was unable to provide evidence that the physician was notified of continued breakthrough pain between 07/11/25 and 07/16/25 when the x-ray was ordered. Telephone interview on 08/07/25 at 12:48 P.M. with RN #237 revealed after 07/11/25, Resident #150's pain medications (Oxycodone 10 mg) were scheduled. RN #237 reported Resident #150 appeared to be more confused and her quality of life seemed to be declining. RN #237 stated she had reported her concerns, but the concerns were falling on deaf ears. RN #237 stated when communicating with the previous shift nurse, they both felt

the increased pain medications were causing Resident #150 to be less alert and not addressing the resident's pain. The two nurses had discussed Resident #150 and had concerns she would need to have

an x-ray examination or need to be sent out (to the hospital) to address her condition change. Interview on 08/07/25 at 2:33 P.M. with the Administrator revealed they were not aware of Resident #150 sustaining any falls and proceeded to investigate Resident #150's fracture as an injury of unknown origin following the x-ray examination results obtained on 07/17/25. The Administrator reported that the facility staff believed Resident #150's bruising was not suspicious, had been caused by her squeezing her leg, the bruising appeared to be Resident #150's handprint, and they did not open a SRI until 07/17/25. Review of the facility policy titled Change in Condition Communication revised 06/2019 revealed to notify the physician of the change in medical condition. The nurse will document all assessments and changes in the resident's condition in the medical record. All attempts to notify the physician and family members will be thoroughly documented in the resident's medical record. The guidelines are not intended to substitute for good nursing judgement. If the nurse feels uncomfortable with a situation, he/she should not delay contacting the physician or call 911 if it appears to be life-threatening event. The above applies 24 hours a day, seven days

a week. This deficiency represents non-compliance investigated under Complaint Number 2576681.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Cuyahoga Falls

300 East Bath Road Cuyahoga Falls, OH 44223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors. This affected one resident (#112) out of three residents reviewed for insulin administration. The facility identifieid ten residents who required insulin. The facility census was 50.

Findings include: Review of Resident #112's medical record revealed an admission date of 02/22/21 with diagnoses including chronic kidney disease, heart failure, type two diabetes mellitus, and protein calorie malnutrition.Review of Resident #112's care plan revised on 08/16/21 revealed the resident was at risk for hypoglycemic (low blood sugar) and hyperglycemic (elevated blood sugar) episodes related to diabetes.

Listed interventions included to monitor blood sugar levels as ordered, monitor for signs and symptoms of hypoglycemia and hyperglycemia, and to administer insulin as ordered. Review of Resident #112's physician orders revealed an order dated 06/18/25 for Novolog (a short acting insulin) inject 3 units subcutaneously twice daily for type two diabetes mellitus with diabetic neuropathy. Additional instructions stated to hold the dose for a blood sugar less than 110. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed Resident #112 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Resident #115 was assessed to require minimal or supervising assistance for activities of daily living (ADLs) and hygiene needs. Resident #112 was identified to require insulin injections

on seven out of seven days of the assessment reference period. Observation on 08/06/25 at 11:42 A.M. revealed Licensed Practical Nurse (LPN) #231 obtained Resident #112 ' s blood glucose level. LPN #231 cleansed her hands and the glucometer. LPN #231 proceeded to wipe Resident #112's finger with an alcohol swab, inserted the test trip into the glucometer, and used a single-use lancet to prick Resident #112's right pinky finger with the lancet. LPN #231 wiped the first drop of blood off with clean gauze and then placed the test strip over a small drop of Resident #112's blood to obtain a blood glucose result of 93.

LPN #231 then retrieved the multidose vial of Resident #112's Novolog insulin from the medication cart, cleansed the top of the vial with an alcohol swab, and drew up four units of insulin using an insulin syringe.

LPN #231 then performed hand hygiene and returned to Resident #112's room. LPN #231 administered the four units of insulin subcutaneously to Resident #112, injecting the insulin into the resident's right upper arm. Hand hygiene was performed after contact with the resident.Interview with the Director of Nursing (DON) on 08/06/25 at 1:30 P.M. verified the significant medication error with LPN #231 administering insulin to Resident #112 when the medication should have been held per provider order. The DON assessed Resident #112 for any signs and symptoms of hypoglycemia. Resident #112 displayed no negative effects from receiving the insulin dose. The DON documented the medication error in the electronic medical record and informed the resident and the physician of the occurrence. No new orders were obtained. Review of facility policy titled, Medication Administration and Management revised 06/2019, revealed authorized staff members administer subcutaneous injections. The nurse will review physician orders and follow the eight rights of medication administration. This deficiency represents non-compliance investigated under Complaint Number 2581097.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet