Allen View Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Ohio.
- Location
- 2615 Derr Road, Springfield, Ohio 45503
- CMS Provider Number
- 365514
- Inspections on file
- 36
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Allen View Healthcare Center during CMS and state inspections, most recent first.
A resident with quadriplegia and neurogenic bladder, dependent on staff for toileting, had a care plan and physician order for a 12F/10 cc Mitrofanoff catheter to be changed monthly. Record review showed no documented catheter change for the month in question, and progress notes did not mention any catheter changes. During observation, an LPN verified that the resident instead had a 14F/10 cc catheter in place and was unable to state how long the incorrect catheter had been used.
A resident with ESRD on hemodialysis, HTN, and prior MI had an order for daily diltiazem ER 120 mg that was not administered as prescribed, with the MAR indicating the drug was unavailable. Nursing documentation stated medications had not yet arrived and some were pulled from the emergency medication bank, while the pharmacy confirmed it received the order early that morning and delivered the medications, including diltiazem, that afternoon with staff signature. The resident, cognitively intact, twice contacted law enforcement/911 reporting not receiving medications, and later vital signs showed elevated BP. The DON verified that nursing staff did not notify the physician that the ordered diltiazem dose was not given and was unaware the medication had been delivered but not administered, and the facility’s medication administration policy did not address holding medications pending pharmacy delivery.
A resident with hemiplegia, urinary incontinence, and total dependence for toileting received incontinent care during which a CNA used a single pair of gloves throughout the entire procedure, including removal of a soiled brief, cleansing of the perineal and rectal areas with wipes reused over multiple skin folds, handling and applying a clean brief, and applying barrier cream, without changing gloves or performing hand hygiene. After removing gloves, the CNA did not perform hand hygiene before assisting with blankets, handling a trash bag, and touching the soiled linen closet handle. In an interview, the CNA confirmed these actions, and the DON acknowledged that gloves should have been changed and hand hygiene performed at key points in the care process.
The facility did not update its Legionella water management plan or complete required monitoring, and staff failed to follow infection control precautions for residents with C. difficile and those requiring enhanced barrier precautions. Staff did not use appropriate PPE or adhere to posted precautions during care activities, and some were unaware of the required protocols.
Several residents who were dependent on staff for ADLs, including bathing and grooming, did not receive regular showers or bed baths as scheduled. Documentation showed missed care opportunities, and observations revealed residents with unclean hair and skin. Interviews with residents, families, and staff confirmed that required hygiene care was not consistently provided, and facility policy for routine care was not followed.
Multiple resident rooms were found with broken or missing flooring, doors that did not close properly, and unclean conditions such as dried urine and vomit on surfaces. These deficiencies were confirmed by maintenance and housekeeping staff, who acknowledged the issues and delays in cleaning and repairs.
Two residents with complex medical conditions had conflicting advance directive documents in their charts, with both DNRCC and DNRCC-A forms present, leading to unclear code status. The Divisional Director of Clinical Operations confirmed the inconsistency, which was not in line with facility policy requiring clear and accurate documentation of advance directives.
Two residents had inaccurate MDS assessments: one resident's fall was not documented in the MDS despite being recorded in the medical record, and another resident's discharge location was incorrectly coded as a hospital transfer instead of a discharge to home with family. These errors were confirmed through staff interviews and record review.
A resident with a history of traumatic brain injury and intact cognition was given a new diagnosis of major depressive disorder, recurrent. Following this significant change in mental health status, the facility did not complete a significant change PASARR or notify the state mental health authority, as confirmed by record review and staff interview.
Two residents did not have care plans addressing their specific clinical needs: one resident on an anticoagulant lacked a care plan for medication use and monitoring for side effects, while another with vision impairment and a recommendation for cataract surgery had no care plan for vision needs or follow-up. These omissions were confirmed by record review, staff, and family interviews.
The facility did not consistently provide residents the opportunity to participate in their care plan development, nor did it ensure that care plan meetings included the required interdisciplinary team members. For example, a resident with diabetes and depression had no care conferences for over six months, and another with a brain injury had only one care conference in more than seven months. Additionally, care conferences for a resident with chronic kidney disease lacked participation from the full IDT, contrary to facility policy.
Staff did not use interpreter services or translation devices when communicating with a resident who only spoke Haitian Creole and had cognitive and communication deficits. Despite the care plan requiring such supports, staff interacted with the resident in English during care and medication administration, resulting in the resident not being able to fully understand or participate in his care.
A resident with complex medical needs did not receive weekly skin checks as care planned, and wound treatments were not consistently performed according to physician orders. Staff continued to sign off on outdated orders, including monitoring sutures that had already been removed, and did not clarify conflicting wound care instructions. Facility policies requiring adherence to physician orders and proper wound care were not followed.
A resident with cognitive impairment and multiple medical conditions did not receive recommended follow-up for cataract surgery or ophthalmology consult after an eye exam. The care plan lacked documentation of vision impairment or follow-up needs, and staff interviews confirmed no evidence of arranging or completing the recommended vision services, despite facility policy requiring such referrals.
A resident with cognitive impairment and multiple medical conditions experienced several falls from bed during late evening and early morning hours, each time being found incontinent. The facility did not document or track when the resident was last toileted or provided incontinence care prior to the falls, and post-fall investigations lacked this information. Staff confirmed there was no system in place to monitor toileting assistance, and required steps to identify fall causes were not followed.
A resident's urinary catheter collection bag was found on the floor beside the bed and later hanging from a wheelchair above bladder level, contrary to facility policy requiring proper positioning and securing of catheter bags. Staff confirmed the improper placement, which was done at the family's request due to the resident's confusion.
A resident with multiple chronic conditions did not receive any routine dental care for over six months after admission, despite being cognitively intact and requiring assistance with oral hygiene. Both the resident and staff confirmed the lack of dental services, which was not in accordance with facility policy to assist residents in obtaining routine dental care.
The facility did not ensure accurate and thorough documentation in medical records for two residents. One resident had conflicting and outdated wound care orders, with staff continuing to document care for sutures that had already been removed. Another resident's code status was changed to DNR CC A without any documented discussion or agreement, despite the resident being cognitively intact and previously requesting full code status. Facility policies requiring proper documentation of provider orders and advance directive discussions were not followed.
Three cognitively intact residents signed arbitration agreements that specified the venue for arbitration would be in the facility's county unless both parties agreed otherwise, without explicitly providing for a mutually convenient venue. This was confirmed by record review and staff interview.
Two residents with complex medical needs were found to be living in rooms with broken flooring and loose tiles, which harbored a significant number of gnats. Facility staff confirmed the presence of pests, and records showed that pest control services had not treated or monitored these rooms for gnats, despite facility policy requiring monthly spraying and additional visits as needed.
A resident with cognitive intactness and significant physical disabilities was verbally abused by the facility administrator during a discharge discussion, with multiple staff, including the DON, witnessing or overhearing the administrator's raised voice and derogatory remarks. Despite the incident being audible throughout the hallway and causing the resident emotional distress, no staff intervened to stop the abuse or remove the administrator from the situation.
The facility failed to accommodate resident preferences by closing the common dining room without notice due to staffing shortages, affecting 10 residents. Interviews with staff and residents revealed that the closure was due to insufficient nurse aides, a situation occurring periodically, often on weekends. The Administrator and DON were unaware of the closure, which should have required permission.
The facility failed to maintain sufficient staffing levels, leading to the closure of the common dining room, affecting 10 residents who regularly dine there. Staff interviews confirmed the closure was due to a lack of nurse aides, occurring periodically, especially on weekends. The facility's policy requires adequate staffing to meet residents' needs, which was not met, resulting in non-compliance.
The facility did not update and post daily nurse staffing information as required, affecting all 116 residents. Observations showed outdated staffing information, and the Administrator admitted to not knowing why it was not updated. The facility's policy requires daily posting and maintenance of staffing data for public viewing.
A facility failed to provide adequate staffing to meet resident needs, as evidenced by a resident who did not receive regular showers or assistance with dressing. Interviews with CNAs and LPNs revealed consistent understaffing, impacting care delivery. Staffing schedules confirmed insufficient coverage, leading to unmet care needs.
The facility failed to maintain sanitary conditions during meal preparation and service, affecting all residents except two with NPO orders. Observations revealed that trays were soaked with dishwater, leading to contamination of food on the service line. A staff member continued to serve food with soiled gloves, causing cross-contamination. The Kitchen Manager confirmed these issues, noting that dishes sometimes required multiple washes to be clean.
A resident felt humiliated and emotionally abused during incontinence care when staff left her exposed to the hallway while laughing. The incident was reported to the facility's Administrator and DON, but they did not report it to the State agency within the required timeframe, believing it was a customer service issue rather than abuse.
A facility failed to readmit a paraplegic resident after hospitalization, discharging them to a homeless shelter despite their need for substantial assistance. The resident had behavioral issues, including an incident with an LPN, leading to an emergency discharge. The facility claimed the resident's health had improved and their needs could not be met, but hospital staff confirmed the facility refused readmission and sought alternative placement.
A facility failed to honor a resident's choice of home health agency upon discharge. The resident, who required supervision for daily activities and had multiple health diagnoses, was discharged without receiving their preferred home health service. The Social Services Designee did not follow up with the resident for an alternative choice after the preferred agency did not return calls, instead selecting a service themselves, contrary to the facility's policy.
A resident requiring substantial assistance with ADLs did not receive adequate care, including showers and dressing, due to low staffing levels. Observations confirmed the resident's claims of neglect, with disheveled hair, a soiled gown, and unkempt nails. Staff interviews revealed consistent issues with insufficient staffing, impacting the facility's ability to meet residents' care needs.
A resident with paraplegia and a history of trauma was involved in an incident where an LPN physically restrained him by blocking his wheelchair, leading to the resident punching the LPN. The resident had grabbed his medication and attempted to leave, contrary to physician orders. This action violated the facility's Resident Rights policy, which ensures residents are free from restraints. The incident was witnessed by staff, and authorities were notified.
An LPN in a facility failed to administer medications in a clean and sanitary manner, affecting three residents. The LPN dropped medications onto the medication cart and picked them up with bare hands before administering them. The LPN acknowledged the error, attributing it to having a band-aid on her thumb. The facility's policy requires that medications not be touched when opened and that dropped medications be discarded.
Two residents experienced unresolved equipment issues due to maintenance failures. A resident's call light malfunctioned, leaving her without a reliable way to alert staff, while another resident's over-the-bed light was not working for weeks. The facility lacked maintenance staff and did not track repair requests, leading to these deficiencies.
The facility failed to provide timely and complete discharge summaries for three residents, affecting their transition from care. One resident with severe cognitive impairment and multiple diagnoses had their summary completed three days post-discharge. Another resident, cognitively intact, was discharged with an incomplete summary, while a third resident's summary was completed a week after discharge. The administrator confirmed these deficiencies.
Incorrect Urinary Catheter Size Used Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident with an indwelling urinary catheter received the correct catheter size as ordered by the physician and outlined in the care plan. The resident was admitted with diagnoses including quadriplegia and neuromuscular dysfunction of the bladder, and had intact cognition but required total staff assistance for bed mobility, transfers, and toileting. The resident’s care plan specified a Mitrofanoff catheter 12 French (F) with a 10 cubic centimeter (cc) balloon to be changed every 30 days, and the physician’s order directed that this 12F/10 cc Mitrofanoff catheter be changed on the 28th of each month. Review of the medical record showed no documentation on the medication administration record of any urinary catheter change for the resident in the month of March prior to the observation of the incorrect catheter. Progress notes from 03/01/25 to 03/22/25 were also silent regarding any catheter changes. During an observation with an LPN on 03/17/26, the resident was found to have a 14F/10 cc catheter in place instead of the ordered 12F/10 cc catheter. The LPN confirmed the catheter size was incorrect and stated that the catheter should be 12F/10 cc, but did not know how long the 14F/10 cc catheter had been in place.
Failure to Administer Ordered Cardiovascular Medication and Notify Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed cardiovascular medication was administered as ordered for one resident. The resident had diagnoses including end stage renal disease with hemodialysis, essential hypertension, and a history of myocardial infarction, and had intact cognition with minimal assistance needs. The care plan included administering medications per physician orders and monitoring cardiovascular status. A physician’s order dated 12/27/25 directed that the resident receive diltiazem extended-release 120 mg orally once daily. Review of the December 2025 MAR showed that this medication was not administered as ordered and was marked as unavailable by the nurse. An electronic MAR note on 12/27/25 at 11:36 A.M. documented that the diltiazem was not given because medications had not yet arrived from the pharmacy. Progress notes showed that the resident was readmitted to the facility on 12/26/25 after hospitalization for altered mental status, and on 12/27/25 at 4:24 P.M. the resident called the police reporting that he had not received his medications. The same note stated that the pharmacy had not delivered that morning, the nurse pulled available medications from the emergency medication bank, and that medications were delivered shortly afterward and the resident was reminded he did receive his medications. However, the pharmacist reported that the pharmacy did not receive the medication orders until 12/27/25 at 4:21 A.M. and that the medications, including diltiazem, were delivered at 3:30 P.M. and signed for by facility staff. A nurse’s note on 12/28/25 at 2:45 A.M. documented that the resident called 911 via cell phone to be transferred to the hospital, with vital signs including blood pressure 154/87. The DON confirmed that the nurse did not notify the physician that the diltiazem had not been administered as ordered and stated she was not aware the medication had been delivered and not given. The facility’s medication administration policy was silent regarding holding medications until arrival from the pharmacy.
Improper Glove Use and Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves a failure to ensure proper infection prevention and control practices during incontinent care for Resident #95. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a stroke and urinary incontinence, had intact cognition, required setup assistance for eating, moderate assistance for bed mobility, and was totally dependent for toileting, with toileting transfers not attempted due to medical or safety concerns. The care plan indicated that two helpers were required for toileting hygiene assistance. During an observed episode of incontinent care, a CNA entered the room, provided privacy, gathered supplies, donned a single pair of gloves, removed the blankets, untaped the soiled incontinent brief, and tucked the ends between the resident’s upper thighs. The CNA then used moistened wipes to cleanse the anterior perineal area, using the same area of a wipe for multiple strokes over different skin folds. After completing anterior perineal hygiene, the CNA assisted the resident to her left side, removed and discarded the soiled brief, and continued perineal care. The CNA used a disposable wipe to clean the buttocks from the outer area toward the inner gluteal folds, including wiping from the top of the intergluteal cleft to and past the rectal area, and also wiping from the vaginal area to the rectum, making several swipes with the same wipe before discarding it. Without changing gloves or performing hand hygiene, the CNA then handled a clean incontinent brief, placing and adjusting it under the resident, and subsequently dispensed barrier cream onto the same gloved hand and applied it to the inner thighs. The CNA removed the gloves, failed to perform hand hygiene, assisted with blanket placement, tied and removed the trash bag, and used the soiled linen closet handle before leaving the area. In a subsequent interview, the CNA confirmed that she used one pair of gloves for the entire task and did not perform hand hygiene before applying the clean brief or leaving the room. The DON stated that the staff member should have changed gloves and washed hands after removing the soiled brief, applied new gloves before applying the clean brief, and performed hand hygiene prior to leaving the room.
Failure to Update Water Management Plan and Implement Infection Control Precautions
Penalty
Summary
The facility failed to maintain and update its Legionella water management plan, as evidenced by the use of an outdated plan last revised in 2018, which still contained the names of former staff and had the facility's current name handwritten over the previous one. Required routine monitoring activities, such as fixture flushing, water temperature checks, and other water safety measures, had not been documented or completed since August 2024. This lapse was confirmed by the Divisional Director of Clinical Operations, who acknowledged the lack of updates and monitoring logs. Additionally, the facility did not implement appropriate infection control precautions for residents with specific needs. One resident who tested positive for C. difficile did not have any contact or isolation precautions ordered or implemented, and there was no signage or personal protective equipment (PPE) available at the room entrance, contrary to facility policy requiring high-level contact precautions for such cases. This was confirmed by both medical record review and staff interviews. The facility also failed to ensure staff adherence to enhanced barrier precautions (EBP) for residents with indwelling medical devices. Observations showed that staff did not wear gowns during high-contact care activities for residents with urinary catheters, tracheostomies, or feeding tubes, despite posted EBP signage and existing physician orders. Staff interviews revealed a lack of awareness regarding EBP requirements, and policy review confirmed that gowns and gloves should be used during specified care activities for these residents.
Failure to Provide Regular Showers and Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide regular assistance with activities of daily living (ADLs), specifically showers and grooming, to residents who were dependent on staff for these tasks. Multiple residents with significant cognitive and physical impairments, including diagnoses such as morbid obesity, muscle weakness, schizophrenia, hemiplegia, dementia, and renal disease, did not receive scheduled showers or bed baths as required by their care plans. Documentation revealed missed opportunities for bathing, with gaps of several days to over a week where no care or refusals were recorded, and in some cases, there was no documentation at all. Observations and interviews confirmed that residents often appeared unkempt, with oily or matted hair, unwashed skin, and in one case, visible blood on the mouth and blanket. Residents and their families reported that scheduled showers or bed baths were not consistently provided, and personal hygiene tasks such as shaving were neglected for extended periods. Staff interviews corroborated these findings, acknowledging that residents did not receive the minimum required number of showers or baths per week and that documentation was incomplete or missing for several periods. The facility's own policy required routine care, including bathing, to maintain resident dignity and quality of life, but this standard was not met. The deficiency was identified through record reviews, direct observation, and interviews with residents, family members, and staff, all of which consistently indicated a failure to provide adequate ADL support for residents who were unable to perform these tasks independently.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain resident rooms in a clean and homelike manner, as evidenced by multiple observations and staff interviews. Several resident rooms had doors that did not close or latch properly, with some doors being chipped and requiring excessive force to close. In one instance, a room had a wet shine on the floor, later identified as dried urine, and a wall with splattered, dried vomit. The same room also had a broken dresser with a missing drawer and several pieces of broken or missing flooring that were loose and easily movable. These conditions were confirmed by both the Maintenance Director and the Housekeeping Director, who acknowledged the presence of the issues and the lack of timely cleaning or repair. Additional observations revealed that several other resident rooms had broken or missing flooring, with the Maintenance Director confirming the extent of the damage. The Maintenance Director stated that while materials to fix the flooring were available, repairs had not been completed, and he was unaware of all the rooms needing attention due to the absence of a comprehensive audit. The Housekeeping Director also confirmed that cleaning had not been performed in a timely manner in at least one room, with no explanation provided for the delay.
Failure to Maintain Clear Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives were clearly maintained and accurately documented in their medical records. For two residents with complex medical histories, including conditions such as diabetes, dementia, schizoaffective disorder, multiple sclerosis, and respiratory failure, there were inconsistencies in the documentation of their code status. In both cases, the residents' paper charts contained conflicting documents: one indicating Do Not Resuscitate Comfort Care (DNRCC) and another, signed by a physician, indicating Do Not Resuscitate Comfort Care-Arrest (DNRCC-A). During interviews, the Divisional Director of Clinical Operations confirmed the presence of both DNRCC and DNRCC-A documents in the residents' charts. Facility policy required that copies of advance directives be placed in the hard chart medical record, and defined the differences between DNRCC and DNRCC-A. However, the presence of both types of documentation for each resident created ambiguity regarding the residents' actual code status, demonstrating a failure to maintain clear and consistent records as required by facility policy.
Inaccurate MDS Coding for Falls and Discharge Location
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents. One resident, with a history of traumatic brain injury and functional quadriplegia, experienced a fall when his wheelchair slid out from under him while it was not locked. Despite this incident being documented in the medical record, the subsequent quarterly MDS assessment did not reflect the fall. In another case, a resident who was discharged from the facility was incorrectly coded in the MDS as having an unplanned discharge to the hospital, when in fact, documentation and staff interview confirmed the resident left to live with his daughter. These inaccuracies were verified through staff interviews and record reviews.
Failure to Notify State Mental Health Authority After Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority and complete a significant change Preadmission Screening and Resident Review (PASARR) for a resident who experienced a notable change in mental health condition. The resident, who was admitted with a diagnosis of unspecified focal traumatic brain injury and was cognitively intact per a recent Minimum Data Set (MDS) assessment, received a new diagnosis of major depressive disorder, recurrent. Despite this significant change in mental health status, there was no documentation of a significant change PASARR or notification to the state mental health authority following the new diagnosis. This was confirmed through record review and staff interview, which verified that the required notification and assessment were not completed after the change in the resident's condition.
Failure to Develop Care Plans for Anticoagulant Use and Vision Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. One resident, who was cognitively intact and had a diagnosis of paroxysmal atrial fibrillation, was prescribed Apixaban, an anticoagulant, for peripheral vascular disease. Despite this, the resident's care plan did not address the use of the anticoagulant or include monitoring for potential side effects, as confirmed by both record review and staff interview. Another resident, who was cognitively impaired and diagnosed with Alzheimer's disease, dementia, and failure to thrive, had documented vision issues and a recommendation for cataract surgery with follow-up by an eye provider. However, the care plan did not reflect the resident's vision impairment or the recommended follow-up for the cataract procedure. This omission was verified through record review, family interview, and staff confirmation. The facility's policy requires resident-centered care plans that address all psychosocial, physical, and emotional needs, which was not met in these cases.
Failure to Ensure Resident Participation and Interdisciplinary Team Presence in Care Planning
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to participate in the development of their care plans and that care plan meetings included an interdisciplinary team (IDT) as required. For one resident with diagnoses including type two diabetes mellitus, major depressive disorder, and cellulitis, there was no evidence of any care conferences or opportunities for participation in care planning over a period of more than six months, despite the resident being cognitively intact. Another resident with a history of traumatic brain injury, functional quadriplegia, and multiple psychiatric diagnoses had only one care conference documented in over seven months, with no further opportunities for participation in care planning during that time, even though the resident was also cognitively intact. A third resident with chronic kidney disease, diabetes, and anxiety disorder had care conferences documented, but attendance was limited to social services, a unit manager, and the resident's family by phone, with no other IDT members present. Facility policy requires that the care planning team include a range of clinical and support staff, as well as the resident and/or their representative, to ensure a holistic approach to care. Interviews with staff confirmed that the required IDT members were not present at these care conferences and that residents were not consistently offered the opportunity to participate in their care planning.
Failure to Use Interpreter Services for Non-English Speaking Resident
Penalty
Summary
Staff failed to communicate with a resident who only spoke Haitian Creole in a manner the resident could understand, despite the care plan specifying the use of interpreter services and communication tools. Multiple observations and interviews revealed that staff routinely interacted with the resident in English without using translation devices or interpreter services, even though the resident had cognitive impairments and a communication deficit. The resident consistently responded with 'wi' (yes) to all questions, regardless of appropriateness, indicating a lack of understanding. During medication administration and daily care activities, staff did not use translation services to explain procedures or medications, and assumed the resident could communicate needs without assistance. The resident confirmed that staff did not typically use translation devices and expressed that he did not feel understood. Facility leadership acknowledged that staff should have been using translation devices to ensure the resident could actively participate in his care and understand his condition.
Failure to Complete Weekly Skin Checks and Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that weekly skin checks were completed as care planned, wound treatments were performed according to physician orders, and that physician orders for skin impairment treatments were clarified. A resident with multiple diagnoses, including a post-procedural hematoma, open wound of the left arm, end stage renal disease, malnutrition, and heart disease, was affected. The resident's care plan required weekly skin checks, monitoring of skin impairments, and administration of wound treatments as ordered. However, medical record review showed no documentation of weekly skin checks over a period of more than a month. Additionally, there were multiple active wound care orders, some of which conflicted with the most recent surgical follow-up recommendations, and staff continued to sign off on orders for suture monitoring even after the sutures had been removed. Observations and interviews revealed that the resident's wound dressing was saturated and that the resident reported wound care was not being performed as ordered. The Treatment Administration Record indicated that staff were signing off on completion of wound care orders, despite evidence that not all orders were being followed or updated to reflect the current wound status. The RN Divisional Director of Clinical Operations confirmed the lack of weekly skin checks and the presence of conflicting and outdated wound care orders. Facility policies required staff to follow physician orders and provide appropriate wound care, but these were not adhered to in this case.
Failure to Provide Recommended Vision Services
Penalty
Summary
The facility failed to ensure that vision services were provided as recommended by a vision specialist for a resident with multiple diagnoses, including Alzheimer's disease, dementia, and subdural hemorrhage. Medical record review showed that the resident was cognitively impaired and dependent on staff for mobility and activities of daily living. An eye exam documented a recommendation for cataract surgery and an ophthalmology consult, with a follow-up visit to occur in five to six months. However, there was no documentation in the medical record of any follow-up regarding the cataract surgery or subsequent eye provider visits. The resident's care plan did not include information about vision impairment or the recommended follow-up for the cataract procedure. Interviews with the resident's family and facility staff confirmed that no evidence existed of staff arranging or following up on the recommended ophthalmology consult or follow-up appointments. Facility policy required the social services department to make necessary referrals for eye care services, but this was not documented as completed.
Failure to Investigate and Address Causes of Repeated Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate and identify the causes of repeated falls for a resident with significant cognitive impairment and multiple medical diagnoses, including Alzheimer's disease, dementia, and kidney failure. The resident experienced multiple falls from bed, all occurring during late evening or early morning hours, and was consistently found incontinent of bowel and bladder at the time of each fall. Despite documentation of interventions such as a low bed and, later, bed mats, there was no evidence that staff tracked or documented when the resident was last toileted or provided incontinence care prior to the falls. The post-fall evaluations did not include information about the timing of incontinence care, and staff interviews confirmed the absence of a system to monitor or record toileting assistance for the resident. The care plan included interventions for fall prevention, such as keeping the bed in the lowest position, using a perimeter mattress, and scheduled toileting, but these measures were not consistently documented as being in place at the time of each fall. Staff acknowledged that the falls occurred close to the night shift and that the existing toileting schedule would not have prevented many of the incidents. The facility's policy required identification of risk factors and thorough post-fall investigations, including determining the last time the resident was seen or toileted, but these steps were not followed. As a result, the underlying causes of the falls were not adequately addressed, and appropriate interventions were not implemented in a timely manner.
Improper Maintenance of Urinary Catheter Collection Bag
Penalty
Summary
A deficiency was identified when a resident's urinary catheter collection bag was observed on the floor beside the bed while the resident was lying in bed. Staff interviews confirmed that the collection bag was intentionally left on the floor at the request of the resident's family due to the resident's confusion. However, both the Divisional Director of Clinical Services and a Registered Nurse confirmed that the catheter collection bag should not be placed on the floor, as this is inconsistent with facility policy. Further observation showed that the same resident's catheter collection bag was later found hanging from the back of a wheelchair at shoulder level, which is above bladder level. A Licensed Practical Nurse confirmed this improper positioning. Review of the facility's catheter care policy indicated that the collection bag should not be on the floor and must be secured to allow for proper drainage and prevent urine reflux. The resident involved had multiple diagnoses, including type two diabetes mellitus, hypertension, hyperlipidemia, atrial fibrillation, and malnutrition.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that a resident received routine dental care as required. Review of the medical record for a resident admitted with multiple diagnoses, including type 2 diabetes mellitus, morbid obesity, uropathy, muscle weakness, anemia, hypothyroidism, hyperlipidemia, major depressive disorder, tachycardia, edema, chronic ulcer, and cellulitis, showed no evidence of routine dental care provided from admission through a period of over six months. The resident was cognitively intact, independent with eating, and required set up assistance with eating and oral hygiene. Both the resident and a staff member in medical records confirmed that no routine dental care had been received during this time. Facility policy stated that assistance would be provided to obtain routine dental services, but this was not followed for the resident in question.
Failure to Maintain Accurate and Thorough Medical Records
Penalty
Summary
The facility failed to ensure the accuracy and thoroughness of documentation in resident medical records, as evidenced by findings in two residents' records. For one resident with multiple complex diagnoses, including end stage renal disease and a stage four pressure wound, there were conflicting and outdated wound care orders in the medical record. Staff continued to sign off on orders for suture monitoring even after documentation from a surgical follow-up indicated the sutures had been removed. Additionally, two different wound care orders were active simultaneously, and both were being marked as completed, despite not matching the current clinical situation. The facility's policy required nursing staff to follow provider orders, but this was not consistently done. In another case, a resident's code status was changed in the physician's orders to Do Not Resuscitate Comfort Care Arrest (DNR CC A) without any documentation of a discussion or agreement from the resident, who was cognitively intact and had previously expressed a desire to remain full code. The care plan and progress notes did not reflect any conversation or consent regarding the change in code status. The facility's policy required that discussions and decisions about advance directives be documented in the medical record, but this was not followed.
Arbitration Agreements Lacked Provision for Mutually Convenient Venue
Penalty
Summary
The facility failed to ensure that arbitration agreements provided for the selection of a venue that was convenient to both parties. Record review for three residents revealed that each of their arbitration agreements specified the venue would be in the county where the facility was located, unless both parties agreed otherwise. This language did not explicitly provide for a mutually convenient venue selection process. The agreements were signed by the residents on their respective dates of admission or shortly thereafter. Interviews and documentation confirmed that the arbitration agreements for all three residents did not allow for the selection of a venue that was convenient to both parties. The Divisional Director of Clinical Operations verified that the agreements only specified the facility's county as the default venue, without further provisions for convenience. The residents involved had varying medical conditions and levels of independence, but all were cognitively intact at the time of signing the agreements.
Failure to Ensure Pest-Free Environment Due to Untreated Resident Rooms
Penalty
Summary
The facility failed to maintain a pest-free environment for two residents, both of whom had significant medical conditions including malnutrition, diabetes, cerebrovascular disease, hemiplegia, dysphasia, and cognitive impairments. Observations and interviews with the Maintenance Director and Housekeeping Director confirmed that both residents' rooms had broken or missing flooring and loose floor tiles, which, when disturbed, released a significant number of gnats from beneath the flooring. Review of pest control invoices showed that these rooms had not been treated for or monitored for gnats, and no pest control treatments had been completed for these specific rooms during the reviewed period. The facility's pest control policy required monthly spraying of all areas and additional visits if problems developed, but this was not followed for the affected rooms.
Failure to Protect Resident from Verbal Abuse by Administrator
Penalty
Summary
A resident with a history of traumatic brain injury, functional quadriplegia, and mood disorders, who was cognitively intact and independent in activities of daily living, was subjected to verbal abuse by the facility's former administrator. The administrator, accompanied by the DON, entered the resident's room to discuss discharge planning. During the conversation, the administrator raised her voice, used derogatory language, and made statements such as telling the resident he was a 'despicable human,' that he 'didn't deserve to be there,' and that he 'needed mental help.' Multiple staff members, including the DON and other nurses, either witnessed or overheard the administrator yelling at the resident, with the incident being audible throughout the hallway and nurse's station. Despite the presence of other staff, including the DON and RN Unit Manager, no one intervened to stop the verbal abuse or remove the administrator from the situation. Witness statements from several staff members confirmed hearing the administrator's raised voice and disparaging remarks, and some staff expressed concern for the resident but did not take action, citing the presence of the DON in the room. The resident was visibly upset and reported feeling abused and discriminated against, later communicating his distress to staff and in an email to the DON. The facility's own investigation, as well as police involvement, confirmed that the administrator's conduct was witnessed by staff and resulted in the resident being emotionally distressed. The facility's abuse policy defines verbal abuse as the use of disparaging or derogatory language, regardless of intent to harm. The administrator was subsequently suspended and terminated, but the deficiency centers on the failure to protect the resident from verbal abuse and the lack of intervention by staff who witnessed the incident.
Dining Room Closure Due to Staffing Shortage
Penalty
Summary
The facility failed to accommodate resident preferences and create a home-like environment when the common dining room was closed without notifying the residents. This affected 10 residents who frequently dined in the common dining room. The closure occurred on 02/02/25 due to insufficient staffing, as confirmed by interviews with dietary aides, residents, and a certified nurse aide. The dietary aides reported that a nurse aide informed them of the staffing shortage, which led to the decision to close the dining room for the day. This situation was noted to happen periodically, approximately once a month, often on weekends. Residents expressed their lack of awareness regarding the reason for the dining room closure, and staff interviews revealed a lack of communication and protocol adherence. The Administrator and the Director of Nursing were unaware of the closure and stated that permission should have been obtained before closing the dining room. They mentioned that the dining room should only be closed for reasons such as maintenance issues, like heating repairs. This deficiency was investigated under Complaint Number OH00162006.
Dining Room Closure Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient staffing levels to keep the common dining room open for resident use, affecting 10 residents who frequently dine there. On a specific day, a sign was placed on the dining room door indicating its closure due to insufficient staff. Interviews with dietary aides and residents confirmed that the dining room was closed because there were not enough nurse aides available to assist with meal service. This situation was reported to occur periodically, particularly on weekends. Interviews with the facility's staff, including a Licensed Practical Nurse and the Dietary Manager, revealed that the dining room closure was due to staffing issues, although the exact cause was unclear. The Administrator and the Director of Nursing were unaware of the closure, except for instances when the dining room heating was being repaired. The facility's policy mandates providing sufficient staff to meet residents' needs, but this was not adhered to, resulting in non-compliance with the required standards.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was updated and posted daily as required, affecting all 116 residents. Observations on multiple occasions revealed that the posted nurse staffing information was outdated, showing a date of 12/24/24, despite the current dates being in February 2025. The Administrator, upon interview, admitted to not knowing why the information was not updated and confirmed that it should be changed daily. She acknowledged updating the information on 02/04/25 to reflect the correct date. The facility's policy mandates that daily nurse staffing information be posted for public viewing and maintained for a minimum of 18 months or as required by State law. This deficiency was discovered incidentally during a complaint investigation.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by the experiences of Resident #104. This resident, who was admitted with multiple medical conditions including a femur fracture, COPD, dementia, and heart disease, required substantial assistance with activities of daily living. Despite being cognitively intact, Resident #104 reported not receiving adequate care, such as regular showers and assistance with dressing, since admission. Observations confirmed the resident's disheveled appearance and unkempt nails, indicating a lack of personal care. Interviews with multiple CNAs and LPNs revealed a consistent theme of understaffing, which impacted the ability to provide necessary care to residents. Staff members reported that due to low staffing levels, tasks such as showering were often delayed or skipped, and residents had to wait for care. The facility's staffing tool and schedules corroborated these claims, showing instances where staffing levels were below the required hours of care per resident per day. The facility's policy on nurse staffing emphasized the need for sufficient staff to meet resident needs, yet the actual staffing levels fell short. The deficiency was further highlighted by the facility's inability to replace staff during call-offs, leading to inadequate coverage and unmet care needs. This situation was investigated under specific complaint numbers, confirming the non-compliance with staffing requirements.
Non-Sanitary Meal Preparation and Service
Penalty
Summary
The facility failed to ensure that resident meals were prepared, distributed, and served in a clean and sanitary manner, which could potentially affect all residents except two who were identified with orders for no oral intake. During observations, it was noted that trays were soaked with dishwater, and plates placed on these trays dripped water into the food on the service line. A staff member, while wearing gloves, allowed the handle of a serving utensil to fall into a tray of cheesy potatoes, contaminating it. The staff member continued to serve food without changing gloves or performing hand hygiene, leading to further cross-contamination. The Kitchen Manager confirmed the observations, acknowledging that the facility sometimes needed to run dishes through the dishwasher twice to ensure cleanliness. The manager also confirmed that trays and plates had significant water on them during meal service, and food particles were dropped into other food serving areas. The facility's policy on food preparation, dated February 2023, requires proper handwashing techniques, glove use, and the cleaning and sanitizing of utensils and food contact equipment after every use, which were not adhered to during the observed meal service.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State agency within the required timeframe. The incident involved a resident who was cognitively intact and dependent on staff for certain activities of daily living. During an episode of incontinence care, the resident felt humiliated and emotionally abused when staff left her exposed to the hallway with the door and curtain open, while laughing at her. This incident was reported to the facility's Administrator and Director of Nursing (DON) by the resident and her family, but the facility did not report it to the State agency as required. The facility's policy on abuse, neglect, and misappropriation mandates that all alleged violations of abuse and neglect be reported within 24 hours to the State survey agencies. However, the Administrator and DON, along with the Regional Clinical Operations (RCO), confirmed that the allegation was not reported within the required timeframe. They believed the incident was more of a customer service issue rather than abuse, and thus did not plan to file the abuse allegation. This inaction was contrary to the facility's policy, which defines abuse as the willful infliction of pain and mental anguish.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure a resident, who was hospitalized, was able to return to the facility following their hospital stay. The resident, who was paraplegic and required substantial assistance for daily activities, was discharged to a homeless shelter despite needing care that could not be provided in such an environment. The resident had a history of behavioral issues, including an incident where they punched an LPN, which led to an emergency discharge. The facility's discharge summary indicated that the resident's health had improved sufficiently, and their needs could not be met at the facility, which justified the discharge. Interviews with facility staff and hospital personnel revealed discrepancies in the facility's actions. The Social Services Director mentioned that psychiatric hospitals refused the resident due to their payor type, and the facility lacked the staff for one-on-one care, leading to the decision to discharge the resident to a homeless shelter. However, the hospital's Behavioral Health Social Worker confirmed that the facility refused to readmit the resident and requested the hospital to hold the patient until alternative placement was found. The facility's Transfer and Discharge Policy stated that a resident could be readmitted to the next available and appropriate bed, but the facility did not provide documentation that the resident was approved to return.
Failure to Honor Resident's Choice of Home Health Agency
Penalty
Summary
The facility failed to ensure that a resident received the home health company of their choice upon discharge. The resident, who was cognitively intact and required supervision with various activities of daily living, was discharged with diagnoses including acute on chronic diastolic heart failure, chronic obstructive pulmonary disease, and ESBL resistance. Despite being asked on three occasions by the Social Services Designee about their preferred home health agency, the resident did not receive their choice of agency upon discharge. The Social Services Designee confirmed that they did not provide the resident with their choice of home health services because the preferred agency did not return calls. The designee did not follow up with the resident for an alternative choice and instead selected a home health service company themselves. This action was contrary to the facility's Transfer and Discharge Policy, which requires involving the resident in the development of the discharge plan and informing them of the final plan. This deficiency was investigated under Complaint Numbers OH00160628 and OH00160462.
Failure to Provide Adequate Assistance with ADLs Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that dependent residents received necessary assistance with activities of daily living (ADL), specifically affecting one resident. This resident, who was admitted with multiple diagnoses including a femur fracture, COPD, dementia with anxiety, and muscle weakness, required substantial assistance for showering, bathing, and dressing. Despite this, the resident reported not receiving adequate care, such as showers or assistance with dressing, since admission. Observations confirmed the resident's claims, noting disheveled hair, a soiled gown, and unkempt nails, indicating a lack of personal care. Interviews with staff and other residents revealed a consistent issue of low staffing levels, which hindered the ability to meet residents' care needs. Certified Nursing Aides (CNAs) reported that due to insufficient staffing, showers were often not completed, and residents had to wait for care. The facility's policy on routine resident care emphasized the importance of attending to residents' needs, but the lack of staff resulted in unmet care requirements, as evidenced by the condition of the affected resident and corroborated by multiple staff members.
Failure to Ensure Resident Rights and Appropriate Behavioral Health Management
Penalty
Summary
The facility failed to ensure appropriate nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of Resident #115, particularly in relation to mobility and behavioral health needs. Resident #115, who had diagnoses including paraplegia and a chronic ulcer, was cognitively intact and required varying levels of assistance for daily activities. The care plan highlighted the resident's risk for impaired psychosocial well-being due to a history of trauma, emphasizing the need for respectful and compassionate communication. However, an incident occurred where the resident grabbed his crushed pain medication from the medication cart and attempted to leave, leading to a confrontation with LPN #402. During the incident, LPN #402 blocked the resident's path and physically restrained him by placing her foot in the wheel of his wheelchair, as the resident was required to take his medication in front of the nurse. This action led to the resident punching the LPN in the hands. The facility's Resident Rights policy, which states that residents have the right to be free from restraints, was not adhered to in this situation. The incident was witnessed by other staff members, and the police, DON, and Administrator were notified. This deficiency highlights a failure in ensuring the resident's rights and appropriate handling of behavioral health needs.
Medication Administration Lapses in Cleanliness
Penalty
Summary
The facility failed to ensure medications were administered in a clean and sanitary manner, affecting three residents. During observations, an LPN was seen dropping medications onto the top of the medication cart and then picking them up with her bare hands before administering them to the residents. Specifically, a Norvasc 10 mg tablet was dropped and administered to one resident, a Vitamin D 25 mcg tablet to another, and two Oyster Calcium 500 mg tablets to a third resident. The LPN confirmed these actions during an interview, acknowledging that she should not have administered the medications after dropping them. She attributed the mishandling to having a band-aid on her thumb. The facility's Medication Administration Policy, which was undated, stated that medications should not be touched when opened from the dose package and that dropped medications should be discarded.
Maintenance Failures Affect Resident Safety
Penalty
Summary
The facility failed to ensure that equipment was maintained and in working order, affecting two residents. Resident #100, who was cognitively intact and dependent on staff for various activities, experienced issues with her call light, which did not function properly. Despite numerous complaints from the resident and her family, the facility did not provide an alternative method for the resident to alert staff to her needs. Observations confirmed that the call light only worked if the button was consistently held down, which was not feasible for the resident. Resident #99, also cognitively intact and requiring substantial assistance, faced issues with his over-the-bed light, which had not been working properly for three weeks. Despite informing multiple staff members, the issue remained unresolved. Observations confirmed that the top light bulb was out and not functioning, which was acknowledged by a CNA present during the observation. The facility had a gap in maintenance staff coverage between the departure of the previous Maintenance Director and the start of the new one. During this period, there was no maintenance staff, and the facility did not maintain a log of repair requests. Interviews with the Administrator and Regional Clinical Operations confirmed the lack of awareness regarding the broken equipment and the absence of a system to track maintenance requests, which contributed to the unresolved issues.
Failure to Provide Timely and Complete Discharge Summaries
Penalty
Summary
The facility failed to provide residents with timely and complete discharge summaries, affecting three residents who were reviewed for discharge. Resident #110, who had multiple complex diagnoses including severe sepsis and end-stage renal disease, was discharged without a completed discharge summary until three days after leaving the facility. This resident required varying levels of assistance for daily activities and had severely impaired cognition. Resident #111, who was cognitively intact and independent in daily activities, was discharged with an incomplete discharge summary. This resident had a range of medical conditions including hyperkalemia and heart failure. Similarly, Resident #112, who had moderately impaired cognition and required assistance for some activities, was discharged with a summary completed a week after discharge. The facility's administrator confirmed the deficiencies in the discharge process, which were investigated under a specific complaint number.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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