Altercare Of Cuyahoga Falls Ctr For Rehab & Nursin
Inspection history, citations, penalties and survey trends for this long-term care facility in Cuyahoga Falls, Ohio.
- Location
- 2728 Bailey Rd, Cuyahoga Falls, Ohio 44221
- CMS Provider Number
- 365287
- Inspections on file
- 25
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Altercare Of Cuyahoga Falls Ctr For Rehab & Nursin during CMS and state inspections, most recent first.
A resident with chronic health conditions was found lying on a bed with visibly stained linens, and staff confirmed infrequent sheet changes. Facility-wide, carpets in resident rooms and common areas were sticky, stained, and had persistent urine odors, with staff and family members reporting long-standing cleanliness issues. The facility lacked a regular carpet cleaning schedule and had used inadequate equipment for years, resulting in an unclean and uncomfortable environment for many residents.
Several deficiencies were identified, including delayed administration of a prescribed inhaler for a resident, failure to timely report a critical INR lab result to a physician for another resident, lack of timely scheduling for a dermatology appointment for a resident with a widespread fungal infection, and incomplete admission assessment and documentation for a resident with a PEG tube, resulting in delayed recognition of a non-functional tube.
Insufficient nursing staff led to multiple residents not receiving scheduled showers, incontinence care, and restorative services. Staff often worked alone on units, making it impossible to complete all required care, and documentation was missing or inaccurate. Residents were left in soiled briefs, one developed a UTI and required hospitalization, and restorative exercises were not completed as ordered. Staff and residents confirmed that care was missed due to inadequate staffing.
Surveyors found that staff inconsistently implemented infection control measures, including placing bedpans directly on the floor without containment, failing to use required PPE such as gowns and gloves during care of residents on Enhanced Barrier Precautions or contact precautions, and improperly discarding soiled materials onto the floor. Environmental hygiene issues were also noted, with urine and feces observed on carpets and privacy curtains due to improper use and cleaning of bedside commodes.
Several residents with complex medical conditions were not offered, screened, educated, or documented for pneumococcal vaccination, as required. Immunization records lacked evidence of vaccination, consent, or education, and interviews with the DON and a regional nurse consultant confirmed that the facility prioritized influenza and COVID-19 vaccines instead of pneumococcal vaccines.
A resident with dementia and psychiatric diagnoses experienced significant anxiety after a CNA made repeated comments about the President coming to get her, knowing this was a trigger for the resident. Although the CNA was disciplined internally, the incident was not documented in the resident's record or reported to the State Agency as required by facility policy, and staff interviews confirmed the lack of external reporting.
A resident with end stage renal disease did not consistently have pre-assessment forms completed before dialysis, and there was a lack of reliable communication and documentation exchange between facility staff and the dialysis center. Staff were often unaware of what paperwork was sent or received, and communication forms from the dialysis center were rarely uploaded into the medical record, resulting in a failure to provide person-centered care consistent with professional standards.
A resident with PTSD was not fully assessed for trauma triggers and effective interventions, as required by facility policy. The trauma-informed care observation form was left incomplete, omitting key questions about traumatic experiences and coping strategies. Staff interviews confirmed the assessment was not completed, despite the resident's care plan including interventions for trauma and PTSD.
A resident with dementia and major depressive disorder experienced significant anxiety and distress after a CNA repeatedly made comments about the President coming to attack her, despite staff being aware that such topics triggered the resident's fears. The CNA's actions contradicted the resident's care plan and facility policy, resulting in the resident staying in the common area overnight due to fear.
A resident with severe cognitive impairment and multiple fractures required a comprehensive care plan, but the care conference was held without participation from food and nutrition services. Staff interviews confirmed that neither the dietitian nor the dietary coordinator attended care conferences, and the nutrition section was completed by another discipline using the medical record, contrary to facility policy requiring all disciplines' participation.
Multiple residents with significant medical needs did not receive scheduled showers, incontinence care, or proper assistance with positioning and feeding. Staff interviews and documentation revealed that care was missed due to inadequate staffing, incomplete records, and lack of follow-through, resulting in residents remaining unclean, uncomfortable, or without necessary support for daily living activities.
A resident with quadriplegia and contractures did not consistently receive physician-ordered passive range of motion (PROM) exercises as care planned. Chart reviews showed multiple missed or incomplete PROM sessions, with staff and the resident confirming that care was often not provided due to understaffing and workload. Documentation did not support claims of resident refusal, and the facility's policy for restorative nursing care was not followed.
A resident with multiple sclerosis and other conditions experienced a fall while transferring from bed to wheelchair. The facility's post-fall investigation was incomplete and inconsistent, as only one RN's witness statement was included, while interviews with the resident and a CNA revealed conflicting accounts and the CNA did not provide a statement. The facility's policy required statements from all staff in the area, but this was not followed.
Two residents did not receive appropriate care to promote continence or prevent UTIs. One resident, who was cognitively intact and able to request help, was not assisted with scheduled toileting despite physician orders and a care plan, resulting in prolonged waits and use of briefs instead of bathroom access. Another resident with an indwelling catheter was left in soiled briefs and with a full catheter bag for extended periods, leading to a UTI and hospitalization. Staff failed to complete required assessments, document symptoms, or follow facility policies for restorative and catheter care.
A resident with multiple complex medical conditions experienced a significant and unexplained weight loss, which was not assessed or addressed by the dietitian. Despite care plan requirements and varied meal intakes, there was no follow-up documentation or physician notification regarding the weight change, and the facility's policy lacked guidance on documenting significant weight loss.
Two residents did not receive pain management in accordance with physician orders and care plans, including failures to assess pain using a numerical scale, inconsistent administration of prescribed pain medications, and lack of documentation of non-pharmacological interventions. Staff did not always document pain levels or follow up on pain relief, and pain assessments were missed on several shifts, particularly for a resident with recent fractures.
A resident with a history of bleeding risk was prescribed enoxaparin 0.7 ml, but staff repeatedly administered 0.8 ml instead, as confirmed by record review, observation, and staff interviews. The error was observed by the resident's spouse and dismissed by staff, and lab results showed an elevated INR following the incorrect dosing.
Three residents with swallowing and nutritional issues were served food items inconsistent with their prescribed mechanical soft diets, including regular sliced turkey and canned fruit with pineapple tidbits, despite dietary tickets indicating the correct diet. Staff confirmed the errors, and the issue was identified during tray line observation before the trays reached the residents.
The facility did not maintain complete and accurate medical records for three residents, including missing social history assessments and inconsistent documentation of showers and care activities. Staff interviews confirmed that required assessments were left blank and that shower documentation did not accurately reflect the care provided, with discrepancies between electronic records and paper sheets.
The facility failed to supervise residents during smoking breaks and did not secure smoking materials, affecting several residents. Despite care plans requiring supervision, residents were observed smoking independently with cigarettes and lighters in their possession. The DON confirmed the facility's smoking policy was not enforced.
A resident with severe cognitive impairment and incontinence issues did not receive thorough incontinence care as per facility policy. An STNA failed to cleanse the resident's buttocks area or apply moisture barrier cream during care, despite the resident's care plan and facility policy requiring these actions. The deficiency was noted during a complaint investigation.
The facility failed to ensure that soiled linens were not placed directly on the floor in the rooms of two residents. Soiled linens were found lying on the carpeted floor, and staff interviews confirmed they had been left by the night shift. The Director of Nursing verified that linens should not be placed directly on the floor, as per facility policy.
The facility failed to store aerosol masks in sanitary protective barriers for two residents, as required by facility policy. Both residents had their aerosol masks laying directly on their bedside stands without protective barriers or dates indicating when they were last changed. This was confirmed by an Agency RN during observations.
The facility failed to maintain a medication error rate of less than five percent, resulting in a 32.2% error rate. An RN administered medications orally instead of via gastric tube as ordered and failed to administer two other medications, affecting a resident with multiple diagnoses.
A facility failed to administer medication as ordered for a resident with severe cognitive impairment and a feeding tube. An Agency RN administered medications orally instead of via gastric tube and failed to administer two prescribed inhalers. The facility's policy on medication administration was not followed, resulting in a significant medication error.
Failure to Maintain Clean and Homelike Environment Due to Inadequate Linen and Carpet Care
Penalty
Summary
A deficiency was identified regarding the facility's failure to maintain a safe, clean, comfortable, and homelike environment for its residents. One resident with chronic kidney disease, anxiety disorder, and mobility issues was observed lying on a bed with a fitted sheet that was visibly stained over half its surface. The resident reported that staff did not change the sheets frequently. This observation was confirmed by an activity coordinator, who stated the sheets were unacceptable and needed immediate changing. Further investigation revealed widespread issues with the facility's carpeting. Multiple areas throughout resident rooms and common spaces had sticky carpets, strong urine odors, and visible stains. Staff interviews confirmed that the carpets had not been thoroughly cleaned in several years, and there was no established schedule for carpet cleaning. Housekeeping staff reported that the carpets were persistently sticky and that a new carpet cleaning machine had only recently been acquired. Prior to this, only spot cleaning was performed, and the equipment used was inadequate for deep cleaning. Several residents and family members also reported concerns about dirty carpets and persistent odors, particularly from urine, which was attributed to spills from bedside commodes and leaking catheters. Documentation showed that the facility had professional carpet cleaning performed only a few times over the course of a year, and that the choice of carpet was influenced by concerns about moisture in the building's foundation. However, there was no evidence that a comprehensive moisture test had been completed to determine if alternative flooring could be installed. The lack of a systematic cleaning schedule and the use of inappropriate cleaning equipment contributed to the ongoing environmental deficiencies affecting a significant number of residents.
Medication, Lab Reporting, Assessment, and Appointment Scheduling Deficiencies
Penalty
Summary
Multiple deficiencies were identified involving the care and treatment of several residents. One resident with a history of peripheral vascular disease, hypertension, diabetes, and obstructive pulmonary disease was dependent for activities of daily living and required a fluticasone-salmeterol inhaler twice daily. The medication was not available for administration on several days, and although a refill was called in and delivered, it was not administered until two days after delivery. Staff could not provide a reason for the delay in reordering or administering the medication. Another resident with chronic obstructive pulmonary disease and a history of deep vein thrombosis was prescribed weekly Protime and INR lab tests due to anticoagulant therapy. The resident's INR result was significantly elevated, but there was no evidence that this result was reported to the physician as required by facility policy. Both the physician and LPN confirmed they were not notified of the abnormal result, and the physician stated that, had he been notified, he would have adjusted the resident's medication regimen. A third resident was admitted with a widespread fungal infection and had an order for a dermatology appointment. The appointment was not scheduled for 13 days after the order was written, and there was no documentation of attempts to schedule it during that period. Additionally, another resident admitted for osteomyelitis and with a PEG tube did not have vital signs documented upon admission, nor was the PEG tube checked for patency as expected. The PEG tube was found to be non-functional only after several hours, resulting in the resident being sent to the hospital. The required hospital observation assessment was not completed until several days after the resident's transfer.
Failure to Provide Sufficient Nursing Staff Results in Missed Care and Resident Neglect
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in multiple instances where residents did not receive required care. Several residents did not receive scheduled showers or bathing assistance as documented in their care plans and shower schedules. Staff interviews revealed that often only one aide was assigned to a unit, making it impossible to complete all required care tasks, including showers and hygiene. Documentation was missing or inaccurate, and some staff admitted to charting care that was not actually provided. Residents reported not receiving showers despite requesting them, and observations confirmed poor hygiene, such as oily and uncombed hair. Incontinence care was also not provided as required, with residents left in soiled briefs for extended periods. In one case, a resident was left in feces for at least 30 minutes, prompting friends to call the police and Adult Protective Services. Staff confirmed that due to staffing shortages, they had to triage care and prioritize based on urgency, resulting in delays or missed care. Another resident with an indwelling catheter was not changed or cleaned for an extended period, leading to a urinary tract infection and hospitalization. The resident reported calling 911 due to neglect, and hospital records confirmed the presence of infection and poor hygiene. Restorative care, such as passive range of motion exercises, was not completed as ordered for a resident with quadriplegia. Documentation showed that the required exercises were missed on multiple days, and staff interviews confirmed that care was not provided due to insufficient staffing. Residents and staff consistently reported that the lack of adequate staffing prevented them from meeting residents' needs, and the DON acknowledged being unable to follow up on missed care due to being overburdened with multiple roles.
Inconsistent Infection Control Practices and PPE Use
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control program, specifically related to the handling of bedpans, use of personal protective equipment (PPE), and management of soiled materials. In several instances, bedpans used by residents who lacked in-room bathrooms or sinks were placed directly on the floor under their beds without being contained in plastic bags or other containers. This practice was confirmed by both staff and residents, and it was noted as a common occurrence in rooms without bathrooms. The Director of Nursing was unaware of this practice and stated that bedpans should be bagged and stored on wardrobes, not on the floor. Staff inconsistently implemented Enhanced Barrier Precautions (EBP) and contact precautions for residents requiring them. For example, staff members providing care to a resident with an indwelling catheter and on EBP failed to don isolation gowns as required, despite signage and facility policy. One CNA reported being told by a nurse that only gloves were necessary, leading to confusion and non-compliance. Additionally, soiled incontinence briefs and linens were discarded directly onto the floor rather than into designated containers, contrary to facility policy. Environmental hygiene issues were also observed, particularly in rooms with carpeted floors and bedside commodes. Staff and environmental services confirmed that commodes often leaked or were missed, resulting in urine and feces on the carpet and privacy curtains. Observations confirmed the presence of bodily waste on both the carpet and curtains in a resident's room. In another case, a staff member entered the room of a resident on contact precautions without wearing any PPE, despite clear signage and physician orders requiring gown and glove use. These findings demonstrate a pattern of inconsistent infection control practices affecting multiple residents.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered, screened, educated, and received pneumococcal vaccinations as required. Record reviews for five residents revealed no documentation of pneumococcal vaccination, consent or declination, or education provided regarding the vaccine. These residents had various medical conditions, including fractures, hemiplegia, vascular dementia, diabetes, quadriplegia, and infections, and were admitted to the facility at different times. The absence of documentation affected all five residents reviewed for vaccinations, with the potential to impact all residents in the facility except those specifically identified as not eligible for the vaccine. Interviews with the DON and Regional Nurse Consultant confirmed that pneumococcal vaccines were not offered to residents, as the focus had been on influenza and COVID-19 vaccinations during the fall. The DON acknowledged awareness of the requirement to offer pneumococcal vaccines and indicated it would be prioritized in the future. Review of CDC guidance confirmed the recommendation for pneumococcal vaccination for adults 50 years or older and those at increased risk, emphasizing the need to follow the recommended immunization schedule.
Failure to Report Resident Mistreatment to State Agency
Penalty
Summary
The facility failed to report an allegation of resident mistreatment to the State Agency as required by policy. A resident with dementia, depression, and psychosis, who was cognitively intact, reported being verbally targeted by a CNA who made repeated comments about the President coming to get her, knowing this was a source of fear and anxiety for the resident. The incident resulted in the resident experiencing significant distress, including staying awake all night and remaining in the common area due to fear, as confirmed by staff witness statements. Documentation revealed that the CNA received disciplinary action for intimidating a resident, but there was no evidence in the resident's medical record or facility self-reported incidents log that the event was reported to the State Agency. Staff interviews confirmed awareness of the incident and its impact on the resident, with one nurse stating that the situation was reported internally due to the resident's heightened anxiety. However, the Director of Nursing acknowledged that no self-reported incident was initiated or submitted to the State Agency, citing a lack of awareness of the reporting requirement. The facility's policy required immediate reporting of all allegations of abuse, mistreatment, neglect, or exploitation to both the administrator and the State Agency. Despite this, the incident involving the resident and the CNA was not documented in the progress notes nor reported externally, constituting a failure to follow established procedures for reporting suspected mistreatment.
Failure to Ensure Consistent Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure consistent and effective communication and collaboration with the dialysis center for a resident requiring dialysis services. The resident, who had end stage renal disease and was cognitively intact, did not consistently have pre-assessment forms completed by the facility prior to dialysis appointments, with several dates missing documentation. Additionally, the facility did not reliably send paperwork with the resident to the dialysis center, and the dialysis center did not consistently send communication back with the resident after treatments. Interviews with staff revealed uncertainty about what paperwork was being sent or received, and documentation from the dialysis center was rarely uploaded into the resident's medical record. Further investigation showed that the only communication sheet from the dialysis center uploaded into the medical record was from a single date, despite multiple treatments occurring during the review period. Staff interviews confirmed that communication forms from the dialysis center were rarely received, and when not received, staff often assumed there were no changes in the resident's condition. The facility's policy required comprehensive monitoring and exchange of information with the dialysis center, but this was not consistently followed, resulting in a lack of person-centered care and failure to meet professional standards of practice for dialysis services.
Failure to Complete Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to adequately assess a resident with a diagnosis of post-traumatic stress disorder (PTSD) for trauma triggers and effective interventions to prevent re-traumatization. Upon admission, the resident was cognitively intact and had a history of PTSD, anxiety, depression, and a recent fall with fracture. The admission Minimum Data Set (MDS) indicated the resident required substantial assistance with activities of daily living and was always incontinent. The facility's Trauma-Informed Care Observation form for this resident was incomplete, with several key questions about traumatic experiences, emotional impact, triggers, and coping strategies left unanswered. The resident's care plan included goals and interventions related to trauma and PTSD, such as identifying triggers and utilizing coping strategies, but the necessary assessment to inform these interventions was not completed. Interviews with facility staff, including the Social Services Coordinator and Regional Nurse, confirmed that the trauma-informed care assessment was not fully completed as required by facility policy. The facility policy stated that all residents should be assessed for a history of trauma upon admission using the designated observation tool, which was not done in this case.
Failure to Treat Resident with Dignity and Respect Due to Inappropriate Staff Conduct
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) made repeated comments to a resident with dementia and major depressive disorder, knowing that the resident was fearful of the President of the United States (POTUS). The CNA told the resident that the POTUS was going to come into her room at night and attack her, and continued to make jokes about the POTUS coming to get her. This was confirmed by witness statements from staff and the resident, who reported increased anxiety, fear, and an inability to sleep in her room, instead staying in the common area for several hours due to distress. The resident's care plan indicated a history of paranoid delusions, verbal aggression, and sensitivity to overstimulation, with specific interventions to maintain a calm environment and avoid triggers. Staff were aware that political discussions, especially those involving the POTUS, could escalate the resident's anxiety and delusional thinking. Despite this, the CNA engaged in behavior that directly contradicted the care plan and facility policy, which required residents to be treated with respect, kindness, and dignity. Documentation in the resident's progress notes did not reflect the incident or the resident's fear and change in behavior on the night in question. Interviews with staff confirmed that the CNA's actions were inappropriate and not respectful or dignified. The Director of Nursing acknowledged that staff were instructed not to discuss politics around the resident due to her known triggers, and verified that the CNA's conduct was not in line with expected standards of resident care.
Failure to Include Food and Nutrition Services in Care Conference
Penalty
Summary
The facility failed to ensure that a member from food and nutrition services participated in the care conference for a resident who was reviewed for care planning. The resident in question had multiple diagnoses, including severe cognitive impairment, Alzheimer's disease, depression, and several fractures, and required significant assistance with daily activities such as eating, hygiene, and mobility. The care conference, documented in the resident's medical record, was attended by the resident, her husband, the Assistant Director of Nursing, and the Social Service Coordinator, but no representative from the dietary department was present. Interviews with facility staff revealed that the dietitian was present in the facility four days a week but did not attend care conferences, nor did the new dietary coordinator, who was under the impression that the dietitian was responsible for attending. The Social Services Coordinator confirmed that no one from dietary attended the meetings and that she completed the nutrition section of the care conference documentation by referencing the medical record. Facility policy required all disciplines to participate in care plan meetings and contribute insights into resident assessments and needs, but this was not followed in the case reviewed.
Failure to Provide Required ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for multiple residents who were unable to perform these tasks independently. Several residents with significant medical conditions, including chronic obstructive pulmonary disease, muscle weakness, dementia, hemiplegia, and dysphagia, did not receive scheduled showers, incontinence care, or proper assistance with positioning and feeding. Documentation was missing or incomplete for required care, and there was no evidence that residents refused these services. One resident, who required substantial assistance for toileting, dressing, and bathing, did not receive any showers as scheduled, despite being cognitively intact and expressing willingness to participate. Staff interviews confirmed that showers were not provided due to inadequate staffing, and documentation was sometimes falsified to indicate care was given when it was not. Another resident, dependent for toileting and dressing, was found with significant fecal incontinence that had not been addressed for several hours, resulting in soiled linens and discomfort. Staff could not confirm timely incontinence care, and records did not show refusals of care. Additional deficiencies included a resident with impaired mobility and swallowing difficulties who was not properly positioned for meals, leading to discomfort and missed meals. Staff failed to use prescribed positioning aids, and the resident's environment was left unclean after meal spills. Another resident reported not receiving scheduled showers, with staff citing lack of available personnel as the reason. Facility policies required documentation of care and refusals, but records were incomplete or missing, and staff interviews confirmed that care was not consistently provided as planned.
Failure to Provide Ordered Passive Range of Motion Exercises
Penalty
Summary
The facility failed to implement care planned interventions and follow physician orders for passive range of motion (PROM) exercises for a resident with quadriplegia, muscle weakness, major depressive disorder, and contractures of both hands. The resident was dependent on staff for all activities of daily living and mobility, and required a restorative PROM program to prevent further decline in range of motion. Physician orders specified PROM to both upper and lower extremities, 15 repetitions for two sets, twice daily, four to seven times per week as tolerated. However, review of aide charting over a five-week period revealed that PROM was not completed as ordered on multiple days, with only two days showing full compliance. On several days, only one session was completed instead of two, and there was no evidence of follow-up attempts when the resident refused, except on one occasion. Observations and interviews confirmed the deficiency. The resident reported that PROM was often not completed and that he did not refuse the care. A CNA corroborated that the resident's range of motion was limited due to inconsistent implementation of PROM. Another CNA admitted that PROM was sometimes not done due to being understaffed and too busy, and that lack of documentation usually meant the care was not provided. The Director of Nursing stated the resident refused care at times, but there was no documentation to support this for the period reviewed. The facility's policy required restorative programs to be delivered and documented by nursing staff, but this was not consistently done.
Incomplete and Inaccurate Post-Fall Investigation
Penalty
Summary
The facility failed to ensure that post-fall investigations were accurate and complete for a resident with multiple sclerosis, muscle weakness, and type II diabetes, who was at risk for falls. The resident's care plan included interventions such as bilateral assist bars and encouragement to use the call light for transfers. The resident experienced a fall in her room, which was documented as witnessed by an RN, who reported seeing the resident lose balance and slide to the floor while transferring from bed to wheelchair. The RN completed a post-fall assessment and educated the resident on using the call button, but the fall investigation only included a single witness statement from the RN. However, interviews with the resident and a CNA revealed inconsistencies in the account of the fall. The resident stated her door was closed and no staff were present at the time of the fall, and that she waited on the floor for staff to find her. The CNA reported finding the resident on the floor with the door closed and stated the fall was unwitnessed, contradicting the RN's account. The CNA did not provide a witness statement for the investigation. The facility's fall risk management policy required obtaining statements from all staff in the area, but this was not followed, resulting in an incomplete and inaccurate investigation.
Failure to Provide Scheduled Toileting and Appropriate Catheter Care
Penalty
Summary
The facility failed to provide scheduled toileting and promote continence for a resident who was cognitively intact and able to request assistance. Despite physician orders for prompted toileting and a care plan indicating the resident was a candidate for a prompted bowel program, staff did not assist or encourage the resident to use the bathroom or a bedside commode. The resident reported long waits for assistance, lack of access to a bathroom or commode, and being placed in briefs instead of being helped to the toilet. Observations confirmed the absence of a bedside commode and that staff routinely performed 'check and change' care rather than scheduled toileting. Therapy staff indicated the resident was capable of using the bathroom with minimal assistance, but there was a lack of communication between therapy and nursing staff regarding the resident's toileting abilities and needs. The required clinical admission assessment to identify bowel and bladder needs was not completed upon readmission, and staff relied on previous assessments without updating the care plan based on current needs. Another resident with an indwelling catheter and a history of urinary retention and uropathy did not receive appropriate catheter care to prevent and treat urinary tract infections (UTIs). The resident was dependent on staff for toileting and hygiene and had a care plan that included assistance with incontinence care and application of moisture barrier cream. However, there was no documentation of urinalysis or monitoring of urinary symptoms prior to the resident being hospitalized for a UTI. The resident reported being left in soiled briefs and with a full catheter bag for extended periods, leading to her calling the police for assistance. Hospital records confirmed the presence of a UTI, and interviews with staff corroborated that the resident's catheter bag was sometimes left full and leaking, with staff failing to document or report abnormal urine appearance or odor as required by facility policy. Interviews with staff revealed inadequate communication, insufficient documentation, and a lack of adherence to facility policies regarding restorative nursing care and catheter care. Staff did not consistently monitor or report changes in residents' urinary status, and there was a failure to ensure timely and appropriate toileting and incontinence care. These deficiencies resulted in residents not receiving the necessary care and services to promote continence and prevent urinary tract infections.
Failure to Assess and Address Significant Weight Loss
Penalty
Summary
A significant weight loss in a resident was not properly assessed by the facility's dietitian, despite the resident being at high risk due to multiple medical conditions including dysphagia, diabetes, chronic heart failure, chronic kidney disease, and dementia. The resident was dependent on staff for eating, had varied meal intakes, and was on a mechanically altered therapeutic diet. The care plan required notification of the dietitian and physician in the event of significant weight change. The initial nutrition assessment was completed, but the resident's usual body weight was not documented, and estimated nutritional needs were not fully met by the prescribed diet and supplements. Subsequent weight records showed a dramatic and unexplained weight loss, with no follow-up assessment or documentation by the dietitian to address or determine the cause of the weight loss. The dietitian acknowledged not assessing the weight loss or notifying the physician, and there was no documentation in the medical record regarding the significant weight change prior to the resident's discharge. Additionally, the facility's weight policy did not specify when significant weight loss should be documented, contributing to the lack of appropriate response.
Failure to Ensure Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to the administration and assessment of pain medication. For one resident with chronic pain and multiple comorbidities, staff did not consistently assess pain levels using a numerical scale as required by physician orders, nor did they document the effectiveness of pain interventions. Observations revealed the resident experiencing significant pain, including crying out when the affected area was touched, and reporting high pain scores. Despite physician orders specifying the use of Percocet for moderate to severe pain, the resident was sometimes given Tylenol instead, and non-pharmacological interventions were not documented as attempted prior to medication administration. Additionally, there were instances where pain medication was not administered as ordered due to staff not checking available medication supplies or following up with the pharmacy appropriately. The same resident's care plan included interventions such as administering pain medications as ordered, monitoring for effectiveness, and offering non-pharmacological interventions, but these were not consistently implemented. Documentation in the Medication Administration Record (MAR) often lacked pain scale ratings, and follow-up assessments of pain relief were not always completed. Staff interviews confirmed that pain was not always assessed or managed according to the care plan and physician orders, and that system limitations in the electronic record may have contributed to incomplete documentation. For another resident with multiple sclerosis and recent lower extremity fractures, the facility did not ensure pain assessments were completed every shift as ordered by the physician. Review of records showed missed pain assessments on several night shifts, particularly after a fall and subsequent diagnosis of multiple metatarsal fractures. The night shift Certified Medical Assistant (CMA) was not qualified to perform pain assessments, and the supervising LPN did not document the required assessments, despite being responsible for this task. These failures resulted in inadequate monitoring and documentation of pain for residents with significant pain management needs.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
A deficiency was identified when staff failed to administer medications as ordered for a resident with a history of wedge compression fracture of the lumbar vertebra, malignant neoplasm of the prostate, and prior cerebrovascular events. The resident was at risk for bruising and bleeding due to anticoagulant therapy. The medication administration record indicated an order for enoxaparin 0.7 ml, but the pre-filled syringes contained 0.8 ml, and staff were instructed to administer only 0.7 ml. However, review of records and direct observation revealed that staff administered the full 0.8 ml dose instead of the prescribed 0.7 ml on multiple occasions. On one occasion, a registered nurse was observed injecting 0.8 ml of enoxaparin and later confirmed the error upon reviewing the order. The resident's wife also reported witnessing a nurse in training administer the incorrect dose and voiced her concerns, which were dismissed by the staff member. Laboratory results showed an elevated INR following these incidents. Facility policy required verification of the correct dose prior to administration, but this was not followed, resulting in significant medication errors.
Failure to Provide Appropriate Mechanical Soft Diet Consistency
Penalty
Summary
The facility failed to provide food in the appropriate form for residents on a mechanical soft diet, as required by their physician orders and care plans. Three residents with diagnoses including dysphagia, malnutrition, poor dentition, and feeding difficulties were observed to have received food items inconsistent with their prescribed mechanical soft diets. Specifically, one resident was served regular sliced turkey instead of ground turkey, and multiple residents received canned mixed fruit containing pineapple tidbits, which was not permitted according to the facility's mechanical soft diet guidelines. During tray line observation, dietary tickets indicated the correct diet, but the actual food served did not match the required consistency for mechanical soft diets. Staff, including a dietary coordinator, confirmed that the meals provided to these residents did not meet the prescribed dietary modifications. The issue was identified before the trays reached the residents, and the incorrect food items were replaced after intervention by the surveyor. Interviews with facility staff, including a speech therapist, confirmed that residents on mechanical soft diets should receive ground meats and soft canned fruits that are easy to chew. The speech therapist also noted that she had observed residents receiving the wrong diet consistency at times. The deficiency was identified through observation, record review, and staff interviews, and it affected all residents observed for mechanical soft diets during the survey.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for three residents. For one resident with multiple fractures, Alzheimer's disease, and severe cognitive impairment, the Social Services Social History Assessment was left blank and marked as 'in progress' after admission. This assessment, which should have been completed within the first week, included essential questions about the resident's background, support system, discharge planning, and medical needs. The current Social Services Coordinator confirmed the assessment was not completed and could not provide a reason for the omission. Another resident with bipolar disorder, muscle weakness, and spinal conditions had inconsistencies in shower documentation. The electronic record indicated showers were provided during night shifts, but interviews with CNAs revealed that showers were only given during the second shift and that some entries were documented under the wrong area or entered late. This resulted in inaccurate records regarding the resident's care activities. A third resident with a history of cerebral infarction and mobility issues also had discrepancies in shower documentation. The records showed multiple showers on the same day and conflicting levels of assistance required, which staff confirmed did not reflect actual care provided. Staff interviews revealed confusion about documentation procedures, with some showers not properly recorded or corresponding between electronic records and shower sheets. The facility's policy required accurate documentation of these services, which was not followed.
Failure to Supervise Residents During Smoking Breaks
Penalty
Summary
The facility failed to ensure that residents were supervised during smoking breaks or signed out before smoking independently, as per the facility's smoking policy. This deficiency was observed in four residents who were reviewed for smoking, with the potential to affect additional residents who were smokers. The facility did not secure smoking materials, such as cigarettes and lighters, which were found in residents' possession, contrary to the facility's policy. Resident #56, who was cognitively intact and required oxygen therapy, was observed smoking unsupervised with cigarettes and lighters in his possession. Despite the care plan indicating that Resident #56 should be supervised while smoking, he confirmed that he smoked independently and kept his smoking materials with him. The Director of Nursing (DON) acknowledged that residents were allowed to smoke independently and that the facility's smoking policy was not enforced. Similar observations were made for Residents #52, #57, and #46, who were also found smoking independently without supervision and with smoking materials in their possession. The facility's policy required that smoking materials be secured and that residents be supervised during smoking sessions, but these measures were not implemented. The DON confirmed that the facility did not enforce the smoking policy, and there was no documentation of additional education provided to residents regarding noncompliance with the smoking policy.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide thorough incontinence care for a resident with severe cognitive impairment and multiple diagnoses, including diffuse traumatic brain injury and hemiplegia. The resident required substantial assistance with personal hygiene and was always incontinent of bowel and bladder. The care plan indicated the need for regular incontinence care and the application of moisture barrier cream to prevent skin breakdown and urinary tract infections. During an observation, a State tested Nurse Aide (STNA) was seen providing incontinence care to the resident. The STNA removed a visibly saturated brief and bed pad but failed to cleanse the resident's buttocks area or apply moisture barrier cream, despite the facility's policy requiring thorough cleaning of both the peri and buttocks areas. The Director of Nursing confirmed that staff were expected to cleanse both areas to ensure the skin was free of urine. This deficiency was identified during a complaint investigation.
Failure to Properly Handle Soiled Linens
Penalty
Summary
The facility failed to ensure that soiled linens were not placed directly on the floor in the rooms of two residents. During an observation, soiled linens were found lying directly on the carpeted floor in the doorway of the room shared by two residents. Interviews with staff members, including an Agency Registered Nurse and a State-tested Nursing Assistant, confirmed that the linens had been left on the floor by the night shift and had remained there until the morning shift began. The Director of Nursing also verified that linens should not be placed directly on the resident's floor, as per the facility's policy on handling soiled laundry and bedding. The medical records of the two residents involved revealed multiple diagnoses, including congestive heart failure, cirrhosis of the liver, peripheral vascular disease, and severe protein-calorie malnutrition, among others. The facility's policy on soiled laundry and bedding aims to prevent gross microbial contamination of the air and persons handling the linen. This deficiency was investigated under Complaint Number OH00153037 and affected two of the three residents reviewed for a safe, clean environment in a facility with a census of 69.
Failure to Store Aerosol Masks in Protective Barriers
Penalty
Summary
The facility failed to ensure aerosol masks were stored in a sanitary protective barrier while not in use for two residents. Resident #25, who had multiple diagnoses including congestive heart failure, pneumonia, and respiratory failure, was observed with his aerosol mask laying directly on his bedside stand without a protective barrier or a date indicating when it was last changed. This was confirmed by an Agency Registered Nurse who acknowledged the mask should be stored in a protective barrier and dated. The facility policy required nebulizer setups to be stored in a plastic bag between treatments and changed weekly, marked with the resident's name and date. Similarly, Resident #50, who had severe cognitive impairment and multiple diagnoses including peripheral vascular disease, atrial fibrillation, and severe protein-calorie malnutrition, was also observed with his aerosol mask laying directly on his bedside stand without a protective barrier or a date indicating when it was last changed. The same Agency Registered Nurse confirmed the deficiency and stated she would get a bag for the mask. The facility policy was not followed in both cases, leading to the deficiency being noted during the investigation of specific complaints.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a medication error rate of 32.2%. This deficiency affected one resident who had multiple diagnoses, including convulsions, encephalopathy, and cerebral infarction, among others. The resident had orders for several medications to be administered via gastric tube, but during an observation, an agency RN administered these medications orally in applesauce, contrary to the physician's orders. Additionally, the RN failed to administer two other medications, which were found in her pocket after she had signed off on them in the computer system. The RN admitted to giving the medications orally based on a report she received, despite the physician's orders specifying administration via gastric tube. The Director of Nursing confirmed that there was no order for oral administration of the medications, although the resident was on a mechanically soft diet. The facility's policy on medication administration emphasized the importance of following the five rights of medication administration and conducting a triple check process, which was not adhered to in this instance.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication as ordered for Resident #5, who had a complex medical history including severe cognitive impairment and a feeding tube. Despite physician orders specifying that medications should be administered via gastric tube, an Agency RN crushed the medications and administered them orally in applesauce. Additionally, the RN failed to administer the prescribed budesonide-formoterol aerosol inhaler and fluticasone propionate nasal spray, instead placing them in her pocket and signing off on the medications as if they had been given. The RN admitted to being told during the report that some medications could be given orally, but this was not reflected in the physician's orders. The Director of Nursing confirmed that there was no order for oral administration of the medications, although the resident was on a mechanical soft diet and could take medications orally without issues. The facility's policy on medication administration emphasizes that medications must be administered as prescribed, following the five rights of medication administration: right resident, right drug, right dose, right route, and right time. The policy also mandates a triple check system to ensure these rights are adhered to. The failure to follow these guidelines resulted in a significant medication error, as the medications were not administered via the correct route, and some were not administered at all. This deficiency was identified during a complaint investigation and affected one resident out of four observed for medication administration, in a facility with a census of 69 residents.
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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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