F835 · Administration

Based on interview and record review, the facility administration failed to ensure they were aware of the incident occurred to 1 of 4 reviewed residents, Resident #1, who was found unresponsive in the courtyard during inclement weather, had foam at the side of her mouth, was unresponsive, was applied ice/ice packs, and was transferred to a higher level of care. The facility's inactions and decisions of administering the facility contributed to the deficient practice and the deficient practice was not acted upon until a grievance was completed by Resident #1's Responsible Party three days post the incident.Findings include:Review of the Medical Director Services Agreement dated 3/9/2021 read, 3. …

Timberridge Nursing & Rehabilitation Center · Florida

Licensure Reference Number 175 NAC 12-006.01(A) Based on observations, record reviews, and interviews, the facility management failed to utilize its resources to attain or maintain the highest practicable physical and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 79. Findings are:A record review of the facility's Job Description And Performance Standards Administrator dated 04/22/2025 revealed the Administrator's position was responsible for establishing and maintaining systems in an effective and efficient manner and operate the facility in a manner to safely meet the needs of the residents in compliance with federal, state, and local requirements. …

Emerald Nursing & Rehabilitation Mercy · Nebraska

Based on medical record review, staff interview, observation, review of emergency medical service (EMS) records, review of hospital records, review of facility guidance, review of the facility's policy for cardiopulmonary resuscitation (CPR), and review of American Heart Association (AHA) guidance, the facility failed to be administered in a manner that utilized its resources effectively and efficiently to ensure resident safety. This deficient practice affected one (#49) of one residents found unresponsive in the facility with CPR initiated. This had the potential to affect 18 (#10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #22, #25, #27, #40, #41, #43, #47, and #48) designated with a full code resuscitation status. …

St Catherine's C C of Fostoria · Ohio

Based on interview, record review, and Employee Handbook review, the facility failed to ensure staff were awake at all times to effectively meet the needs of all residents. This had the potential to affect all 81 residents in the facility. Findings include:1. Review of employee personnel file for Dietary Aide (DA) #293 revealed a Disciplinary Action Form dated 12/19/25 for termination for sleeping on the job in the main lobby. Attached to the form was a statement dated 12/19/25 signed by Human Resource (HR) #230 and Administrator. HR #230 found DT #293 sleeping in the lobby and got the Administrator to witness. HR #230 woke DT #293 up and he apologized stating he did not fully intend to fall asleep but had not slept well the night before. Interview on 12/22/25 at 7:57 A.M. …

Tallmadge Health & Rehab Center · Ohio