Buckeye Terrace Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Buckeye Terrace Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 3, 2024

  Based 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 [DATE] 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. […]

• Actual harm, isolatedF760Mar 6, 2023

  Based on medical record review, review of physician notes, review of administration time reports, review of a concern form and interview the facility failed to ensure residents were free of significant medication errors when intravenous (IV) antibiotic therapy was not provided as ordered for the treatment of infections and to prevent complications. This affected three residents (#13, #16, and #61) of three reviewed for IV antibiotics. Actual Harm occurred to Resident #16 when the facility failed to ensure IV antibiotics were administered as ordered and failed to ensure laboratory testing (Vancomycin trough levels) were completed as ordered to determine proper dosing of the antibiotic to effectively treat the resident's infection resulting in the resident requiring an additional 15 days of… […]

• No harm, potential for more than minimal, widespreadF921Mar 24, 2026

  Based 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.Findings include:Observations on 03/23/26 beginning at 7:43 A.M. revealed in the first-floor dining room there was a mattress against the wall near the corner cabinet. There were two wheelchairs pushed in front of mattress to hold the mattress up. The wall behind the mattress had holes in it where the wallpaper had been torn off. There was a part of a broken chair under the mattress edge. There was a hole in the wall to the right of the entrance door to the dining room. […]

• No harm, potential for more than minimal, widespreadF803Feb 9, 2024

  Based 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. Findings include: 1. Observation on [DATE] at 8:17 A.M., of the resident notification board revealed no evidence the meals for [DATE] were posted. The lunch and dinner meals were posted for yesterday [DATE]. Interview on [DATE] at 8:27 A.M., with the Dietary Manager (DM) #58 confirmed he doesn't post breakfast menus and he hasn't posted the lunch and dinner menus yet but was getting ready to. […]

• No harm, potential for more than minimal, widespreadF761Sep 14, 2023

  Based 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. Findings include: 1. Observation on [DATE] at 07:28 A.M. revealed in the facility's main medication storage area had four unopened bottles of Aspirin 325 milligrams with the written date of ,d+[DATE]. Observation of the manufacturer's expiration date revealed date of ,d+[DATE]. […]