Als Mount Vernon Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Ohio.
- Location
- 1135 Gambier Road, Mount Vernon, Ohio 43050
- CMS Provider Number
- 366412
- Inspections on file
- 19
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Als Mount Vernon Inc during CMS and state inspections, most recent first.
A resident with multiple complex conditions and severe cognitive impairment was issued a NOMNC by phone, then transferred to the hospital for elevated heart rate. The transfer form contained only clinical information and lacked evidence of a written transfer/discharge notice. The resident was taken off the census the same day, and after the BFCC-QIO later upheld the end of Medicare coverage, there was no documentation that the resident or representative was offered the option to return or stay on a private-pay basis or informed of service costs. The Administrator confirmed that no bed-hold notice or option to hold the bed was provided, the bed was not held during hospitalization, and the bed was reassigned so no bed was available when the resident was ready to return.
A resident with severe cognitive impairment and multiple complex medical conditions was transferred twice to the hospital, but the facility failed to provide required bed-hold notices and written transfer/discharge notices to the resident or representative at the time of either transfer. Documentation showed only clinical information sent to the hospital and a telephone Notice of Medicare Non-Coverage, with no evidence that bed-hold rights or written discharge notices were issued, even after the facility decided the resident would not be allowed to return. The Administrator and Regional Business Office Manager stated that bed-hold notices were only given to Medicaid residents, and the DON was unable to explain the bed-hold process, despite facility policy requiring written bed-hold information and acknowledgment for all residents regardless of payor source.
The facility failed to maintain complete medical records for five residents, affecting their treatment and monitoring. Orders for weight monitoring, skin preparation, behavior and pain monitoring, and medication side effect checks were not documented as completed. The DON confirmed the absence of documentation for these treatments, indicating a systemic issue with record-keeping.
The facility failed to provide adequate supervision for residents at choking risk during meals. Two residents with dysphagia were left unsupervised in the dining room, with one resident observed coughing and having food dripping down her chin. Staff were not present in the dining room, and the facility lacked a completed assessment to determine sufficient staffing levels.
The facility did not have a documented facility-wide assessment to determine necessary resources for resident care during routine and emergency situations. This deficiency was confirmed by the absence of the assessment in the facility's records and an interview with the Administrator, potentially impacting all 19 residents.
The facility did not maintain the required RN coverage of eight hours a day, seven days a week. A review of the June 2024 staff schedule showed multiple days without an RN, including weekends. Staff interviews confirmed the absence of an RN on the schedule, with the DON covering on some days, but no explanation was given for weekend coverage.
The facility failed to involve residents and their representatives in care planning meetings, affecting four residents. A resident with COPD and impaired cognition was not included in care planning after a fall, and the family was not informed about an orthopedic consult. Another resident with Huntington's Disease had no documented care conferences for over a year. A resident with a traumatic brain injury had only one care conference, and another resident did not have an initial care conference upon admission. The facility did not uphold its policy of involving residents in care planning.
A resident's room in the facility was found to have significant damage, including missing paint and drywall on the outer doorframe and large gouges on the wall beside the bed, exposing drywall material. This was confirmed by maintenance staff, indicating a failure to adhere to the facility's policy on maintaining a safe and comfortable environment.
Two residents in a LTC facility had inaccuracies in their MDS 3.0 assessments. One resident's fall resulting in a fractured clavicle was not correctly documented as a major injury, while another resident's use of oxygen therapy was inaccurately recorded. These errors were identified through observations and staff interviews.
A facility failed to complete a physician-ordered orthopedic consult for a resident with a clavicle fracture and did not change dressings as ordered for another resident with a skin tear. The orthopedic consult was not documented, and the family was not informed, while the dressing change was not performed as scheduled, contrary to the facility's policies.
The facility failed to implement effective fall prevention measures for two residents at high risk for falls. One resident, with Huntington's Disease, was observed with a walker out of reach and improperly worn socks, leading to a near fall. Another resident, with dementia, was found without a prescribed fall mat in place, despite a recent fall. Staff interviews confirmed the deficiencies, and the DON acknowledged the ineffectiveness of current interventions.
A facility failed to obtain a physician's order for oxygen therapy for a resident with multiple health issues, including pneumonia and heart failure. The resident was observed receiving continuous oxygen therapy without a current physician's order, despite facility policy requiring such orders. An LPN confirmed the oversight, noting the resident had been using oxygen since admission.
The facility failed to follow physician-ordered medication parameters for two residents, leading to unnecessary drug administration. One resident received Carvedilol and Lisinopril outside prescribed limits, while another was given Midodrine without required blood pressure documentation. The ADON confirmed these discrepancies.
A facility failed to conduct routine AIMS assessments for a resident on Olanzapine, an antipsychotic medication, as required by their policy. The resident, with Huntington's Disease and other conditions, had a significant gap in assessments, with the last one completed months ago. The DON confirmed the oversight, which affected one resident out of five reviewed for unnecessary medications.
A resident with a history of diabetes, myocardial infarction, and dementia was missing bottom dentures for four months without the facility's recognition or timely referral to a dental provider. Despite having an order to see a dentist, there was no record of a dental visit since admission. Staff interviews revealed a lack of awareness about the resident's denture status, and the medical record did not document the missing dentures or actions to ensure proper nutrition. The resident was eventually scheduled for a dental visit, but the issue was not noted in the examination list.
Failure to Provide Bed-Hold Notice and Permit Resident Return After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return after hospitalization and to provide required transfer/discharge and bed-hold notices. The resident, who had multiple complex diagnoses including nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, dysphagia, cognitive communication deficit, muscle weakness, gait abnormalities, and severe cognitive impairment (BIMS score of two), was admitted to the facility in early January. A Notice of Medicare Non-Coverage (NOMNC) was issued by social services via telephone to the resident’s responsible party, advising that Medicare coverage would end and that financial liability would begin on a specified date, and informing them of appeal rights. The resident was then transferred to the hospital for elevated heart rate and admitted for observation and treatment. The transfer documentation reflected only clinical and communication information sent to the hospital and did not show that a written notice of transfer or discharge was provided to the resident or representative at the time of transfer. The resident’s record showed that the resident was discharged from the facility and removed from the census on the same day as the hospital transfer. A subsequent BFCC-QIO determination letter documented that the resident lost the appeal of the NOMNC and no longer met Medicare coverage requirements for SNF services, and that the resident or representative was notified by telephone of the decision and of financial responsibility for continued services after Medicare coverage ended. However, there was no documentation in the medical record that the resident or representative was offered the option to return or remain at the facility on a private-pay basis or informed of the cost of services once Medicare coverage ended. The Administrator confirmed that no bed-hold notice was provided, no option to hold the bed was offered when the resident went to the hospital, the bed was not held during the hospitalization, and that by the time the resident was ready to return, the bed had been given to another resident and no bed was available for readmission.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold notices and transfer/discharge notices to a resident and/or the resident’s representative at the time of hospital transfers. The resident, admitted on 01/09/2026, had multiple significant diagnoses including nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, aortic valve stenosis, malignant neoplasm of the prostate, dysphagia, gait abnormalities, and cognitive communication deficit. An MDS assessment documented a BIMS score of two, indicating severe cognitive impairment. The resident was transferred to the hospital on 01/16/2026 and again on 02/10/2026, with both transfers resulting in hospital admissions for treatment or observation. Record review showed that the discharge/transfer record dated 01/16/2026 did not contain documentation that a bed-hold notice was provided to the resident or the resident representative at the time of transfer, and there was no progress note related to the 01/16/2026 discharge. A Notice of Medicare Non-Coverage was provided by social services to the responsible party by telephone on 02/09/2026, advising that Medicare coverage would end on 02/11/2026 and that financial liability would begin on 02/12/2026, and informing of appeal rights. However, the transfer documentation dated 02/10/2026 only reflected clinical and communication information sent to the hospital and did not show that a written notice of transfer or discharge was provided to the resident or representative at the time of that hospital transfer. Progress notes from 02/10/2026 to 02/12/2026 also lacked documentation that a written discharge notice was issued after the facility determined the resident would not be permitted to return. Further review of the medical record confirmed there was no documentation that bed-hold rights were explained, no bed-hold notice was provided at either the 01/16/2026 or 02/10/2026 transfers, and no signed bed-hold notice was present. The record also lacked any documentation that a transfer/discharge notice was provided to the resident or representative. Interviews with the Administrator and the Regional Business Office Manager established that the facility’s practice was to provide bed-hold notices only to Medicaid residents and not to residents with Medicare or private pay, and the Administrator confirmed that no bed-hold notice was offered or provided in this case and that the bed was not held during hospitalization, leaving no bed available when the resident was ready to return. The DON reported not being knowledgeable about when bed-hold notices should be issued and could not clarify the process followed for the resident’s hospital transfer. Review of the facility’s undated Bed Hold Notice/Policy showed that written information about bed-hold duration, reserve bed payment, and conditions for return was required to be provided to all residents regardless of payment source, with signed and dated acknowledgment, which did not occur for this resident.
Incomplete Medical Records and Treatment Documentation
Penalty
Summary
The facility failed to ensure that resident medical records were complete, affecting five residents. Resident #4, diagnosed with Huntington's disease, major depressive disorder, and dementia, had multiple physician orders for daily weight monitoring, skin preparation, and monitoring for depression and medication side effects. However, there was no documented evidence that these treatments and monitoring were conducted on the morning of 03/07/25. The Director of Nursing confirmed the absence of documentation for these treatments. Resident #7, with diagnoses including dementia, type two diabetes mellitus, and chronic kidney disease, had orders for behavior and pain monitoring with non-pharmacological interventions. Similarly, Resident #11, diagnosed with cerebral infarction and multiple sclerosis, had orders for pain monitoring, head elevation, and wound care, among others. For both residents, there was no documentation of these orders being followed on the morning of 03/07/25, as confirmed by the Director of Nursing. Resident #12, with Alzheimer's disease and congestive heart failure, and Resident #20, with Huntington's disease and muscle weakness, also had multiple orders for behavior, pain, and medication side effect monitoring. The treatment administration records for both residents lacked evidence of these orders being carried out on the morning of 03/07/25. The Director of Nursing confirmed the lack of documentation for these treatments, indicating a systemic issue with record-keeping and treatment administration in the facility.
Inadequate Supervision of Residents at Choking Risk During Meals
Penalty
Summary
The facility failed to provide adequate nursing supervision for residents identified as choking risks while they were eating in the dining room. Specifically, two residents with dysphagia, who required pureed diets, were left unsupervised during meal times. Observations revealed that there was no staff present in the dining room while these residents were eating, and one resident was noted to cough multiple times and have food dripping down her chin. Staff members, including a Certified Nursing Aide and an LPN, were observed passing meal trays in the hall, out of sight from the dining room. Interviews with the LPN and the Director of Nursing confirmed that there was insufficient staffing to meet the needs of the residents, and that at least one staff member should be present in the dining room at all times during meals. The facility also lacked a completed facility assessment to determine the appropriate level of staffing needed based on the residents' conditions. Additionally, the facility's policy required staff presence in the dining room during meal times, which was not adhered to, leading to the identified deficiency.
Facility Lacks Documented Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified during a review of the facility's assessment records, which revealed the absence of a documented facility assessment. The lack of this assessment meant that the facility could not determine the appropriate level of staffing needed based on the residents' conditions and limitations, as well as the services required. An interview with the Administrator confirmed that a completed facility assessment was not available for review, potentially affecting all 19 residents in the facility.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure compliance with the requirement of having a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This deficiency was identified through a review of the staff schedule for June 2024, which revealed multiple days without an RN scheduled, including weekends and specific weekdays. Interviews with staff, including an LPN and an RN, confirmed the absence of an RN on the schedule for the required hours. The LPN mentioned that the Director of Nursing (DON) was present on days when an RN was not scheduled, but no explanation or evidence was provided for RN coverage on weekends.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in initial and quarterly care plan meetings, affecting four residents. Resident #10, who had chronic obstructive pulmonary disease and severely impaired cognition, was not properly included in care planning. Despite having a significant change in condition due to a fall resulting in a clavicle fracture, there was no documentation of a care plan meeting being held or scheduled, and the family was not informed or involved in the decision-making process regarding an orthopedic consult. Resident #9, diagnosed with Huntington's Disease and severely impaired cognition, also experienced a lack of proper care planning. The only documented care conference was attended by the resident's power of attorney and the SSD, with no other staff members present. There was no documentation of any care conferences from March 2023 to June 2024, indicating a failure to conduct regular care planning meetings. Resident #13, with a traumatic brain injury and moderately impaired cognition, had only one documented care conference, and the family requested annual rather than quarterly meetings. However, there was no documentation of any care conferences from May 2023 to June 2024. Similarly, Resident #15, who required minimal assistance and had intact cognition, did not have an initial care conference upon admission, and there was no documentation of care conferences in the progress notes. The facility's policy states that residents have the right to participate in planning their care, which was not upheld in these cases.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the room of Resident #17, as observed during a survey. The outer doorframe of the resident's room had missing paint and drywall covering, with evidence of plastic covering previously taped around the doorframe. Inside the room, the wall to the left side of the bed had multiple large, vertical gouges approximately 12 inches long and half an inch deep, exposing the drywall material. The torn drywall covering was hanging loosely on the wall. Maintenance Staff #416 confirmed the extent of the damage during an interview. The facility's policy on Resident Environmental Quality, dated August 2022, mandates maintaining a safe, functional, sanitary, and comfortable environment, which was not adhered to in this instance.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments for two residents, leading to deficiencies in the accuracy of resident assessments. Resident #10, who had medical diagnoses including chronic obstructive pulmonary disease and muscle weakness, experienced a fall on 04/29/24, resulting in a major injury—a fractured clavicle. The MDS 3.0 discharge return anticipated assessment did not reflect this major injury, as it was initially recorded as a fall with a minor injury. The MDS Nurse was unaware of the fracture and did not modify the assessment to reflect the major injury, which was a requirement according to the Resident Assessment Instrument (RAI) Manual. Resident #11, who had diagnoses including pneumonia and heart failure, was observed receiving continuous oxygen therapy. However, the significant change MDS 3.0 assessment inaccurately indicated that the resident was not using oxygen therapy, despite the care plan specifying its use. This discrepancy was confirmed by the MDS Registered Nurse, who acknowledged the incorrect coding in the assessment. These inaccuracies in the MDS assessments for both residents highlight a failure in the facility's processes to ensure accurate and up-to-date resident assessments. The deficiencies were identified through observations, staff interviews, and record reviews, affecting the accuracy of the assessments for two out of eleven residents reviewed in a facility with a census of nineteen.
Failure to Complete Physician-Ordered Consult and Dressing Changes
Penalty
Summary
The facility failed to complete a physician-ordered orthopedic consult for a resident who had a fracture in the right clavicle. The resident, who had chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness, was hospitalized and upon return, an x-ray revealed an acute fracture. Despite orders for an orthopedic consultation and a sling, there was no evidence that the consultation was completed or that the family was informed. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) indicated a lack of documentation regarding the consultation and possible family refusal, which was not recorded. Another deficiency involved a resident with diabetes mellitus, a history of myocardial infarction, and dementia, who sustained a skin tear after a fall. The physician's orders required dressing changes every three days, but the dressing was not changed as documented. An observation revealed the dressing was still dated from the initial application, and the DON confirmed the dressing had not been changed as required. The facility's policies on physician-ordered services and wound care were not followed, as evidenced by the lack of documentation and failure to perform ordered treatments. These deficiencies affected the quality of care for the residents involved, as the necessary medical consultations and wound care were not provided as per the physician's orders.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement appropriate safety interventions for residents at high risk for falls, affecting two residents. Resident #9, diagnosed with Huntington's Disease and a history of falls, was observed in the dining room with a four-wheeled walker out of reach and wearing non-skid socks, one of which was improperly worn and dragging on the floor. Despite previous fall incidents and interventions, such as encouraging the resident to ask for help and using a walker, the staff did not assist Resident #9 in regaining balance or adjusting the sock, leading to a near fall incident. Resident #6, with diagnoses including dementia and a high fall risk score, was found in bed without the prescribed padded fall mat in place. The resident had previously fallen out of bed and was hospitalized for evaluation. The care plan included interventions like a perimeter mattress and a floor mat, but during observation, the mat was found folded and not in use, contrary to the care plan requirements. Interviews with staff confirmed the deficiencies in implementing the fall prevention measures. The Director of Nursing acknowledged the repetitive and ineffective nature of the interventions for Resident #9 due to cognitive impairments. The facility's policy on managing falls emphasized the need for resident-centered fall prevention plans, which were not adequately followed in these cases.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy for a resident. The deficiency was identified during an observation where a resident was seen receiving continuous two liters of oxygen therapy via nasal cannula tubing from an oxygen concentrator. The resident had been admitted with diagnoses including pneumonia, high blood pressure, heart failure, and rib fractures, and required assistance with activities of daily living due to moderately impaired cognition. The resident's care plan indicated the use of oxygen as ordered, and hospice progress notes showed a physician order for oxygen therapy. However, the physician orders dated later did not include the necessary order for oxygen therapy. An LPN confirmed the absence of a physician's order for the oxygen therapy, despite the resident having used oxygen since admission. The facility's policy requires oxygen to be administered under a physician's order.
Failure to Follow Medication Parameters for Two Residents
Penalty
Summary
The facility failed to adhere to physician-ordered medication parameters for two residents, leading to the administration of unnecessary medications. Resident #4, who had a history of cerebrovascular accident, atrial fibrillation, coronary artery disease, and hypertension, was given Carvedilol despite having a heart rate below the prescribed threshold on multiple occasions in May and June 2024. Additionally, Resident #4 received Lisinopril when their systolic blood pressure was below the specified limit. These actions were contrary to the physician's orders, which required holding the medications under these conditions. Resident #5, diagnosed with diabetes mellitus, a history of myocardial infarction, and dementia, was prescribed Midodrine with instructions to hold the medication if the systolic blood pressure exceeded a certain level. However, the facility failed to document the necessary blood pressure readings before administering the medication in May and June 2024. An interview with the Assistant Director of Nursing confirmed these discrepancies, acknowledging that the medications were administered outside of the prescribed parameters and without the required documentation.
Failure to Conduct Routine AIMS Assessments for Psychotropic Medication
Penalty
Summary
The facility failed to complete routine assessments for monitoring the side effects of psychotropic medication for a resident diagnosed with Huntington's Disease, COPD, depression, anxiety, and a history of falls. The resident, who required assistance with activities of daily living and had severely impaired cognition, was prescribed Olanzapine, an antipsychotic medication. The facility's policy required that Abnormal Involuntary Movement Scale (AIMS) assessments be conducted when an antipsychotic medication is initiated and at least quarterly thereafter. However, the resident's medical records showed a significant gap in these assessments, with the first AIMS completed on 10/04/21 and the next not until 01/24/24, despite the resident's ongoing use of Olanzapine. The Director of Nursing confirmed that the AIMS assessments were not conducted as required, acknowledging that the last assessment was completed on 01/24/24 and none had been done since. This oversight in routine monitoring of the resident's medication side effects represents a failure to adhere to the facility's Medication Monitoring and Management policy, which aims to optimize therapeutic benefits and minimize adverse consequences. The deficiency affected one resident out of five reviewed for unnecessary medications, within a facility census of 19.
Failure to Address Missing Dentures for Resident
Penalty
Summary
The facility failed to recognize and address the missing bottom dentures of a resident, who had been without them for approximately four months. The resident, who had a history of diabetes mellitus, myocardial infarction, and dementia, was admitted to the facility on 02/03/23. Despite having an order to see a dentist as needed, there was no evidence in the medical record that the resident had seen a dental provider since admission. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition and required set-up assistance for eating, but did not report any issues with chewing or dental appliances. Interviews with staff, including State tested Nurse Aides (STNAs) and a Registered Nurse (RN), revealed a lack of awareness regarding the resident's denture status. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were also unaware of the missing dentures. Despite the resident having reported the issue to staff, the medical record did not reflect the missing dentures or any actions taken to ensure the resident's ability to eat or drink properly. The resident was eventually scheduled to see a dentist, but the list did not mention the missing dentures or the reason for the examination.
Latest citations in Ohio
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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