Altercare Somerset Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Somerset, Ohio.
- Location
- 411 South Columbus Street, Somerset, Ohio 43783
- CMS Provider Number
- 365750
- Inspections on file
- 21
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Altercare Somerset Inc. during CMS and state inspections, most recent first.
A resident with multiple medical conditions did not receive documented assistance with ADLs, including eating and personal care, over a two-day period. Family observed the resident in unchanged clothes and without help during meals, and the facility could not provide evidence or policy for ADL care when requested.
Sensitive medical information, including code status forms and medication orders for three residents with multiple diagnoses, was left visible and unattended at the nurses station, with no staff present and the computer screen unlocked. A family member raised concerns about the exposure of HIPAA-protected information, and a CNA confirmed the visibility of this information. The facility did not provide a policy on protecting resident-identifiable information.
The facility failed to provide scheduled showers to three residents who were dependent on staff for personal care. Despite being scheduled for showers three times a week, documentation revealed that these residents frequently missed their scheduled showers. The Director of Nursing acknowledged the issue, attributing it to staffing challenges.
The facility failed to ensure a safe and clean environment in its shower rooms, affecting 42 residents. Observations revealed missing toilet seats, dirt and grime in grout lines, peeling vinyl flooring, and a strong mildew odor. A resident reported these issues had persisted for over a year, with the facility delaying repairs.
A resident lent $20 to a housekeeper who requested $10, and the money was not repaid. The housekeeper admitted to borrowing the money, and the facility's investigation concluded that misappropriation did not occur due to the resident's consent. However, the facility's policy prohibits staff from asking residents for money, highlighting a deficiency in compliance.
The facility failed to provide scheduled showers to three residents who were dependent on staff for personal care. One resident missed five scheduled showers, another missed five showers in a month, and a third missed one shower. There was no documentation of showers being offered or refused, and the DON confirmed the lack of evidence for these missed showers.
A facility failed to document a resident's meal and fluid intake during a respite stay, despite physician's orders to monitor nutritional status. The resident had multiple health conditions, including Alzheimer's and malnutrition. The DON confirmed the absence of documentation, which prevented evidence of adequate nutrition and hydration monitoring.
A facility failed to document ADL care for a resident with multiple health issues during a respite stay. The resident's care plans required assistance with mobility, incontinence, and hygiene, but records showed no documentation of care for the first two days. The DON confirmed the oversight, unable to explain the lack of documentation.
A resident with cognitive impairment and multiple medical conditions experienced significant weight loss due to the facility's failure to implement a recommended nutritional program. Despite a dietitian's recommendation for a house supplement, it was not administered until weeks later, and the resident's weight was not monitored adequately. Communication gaps and incorrect care plans contributed to the deficiency.
The facility failed to provide consistent assistance with activities of daily living (ADLs) for several residents, leading to missed showers and inadequate hygiene care. Staffing shortages and documentation discrepancies were noted, with residents not receiving care according to their preferences. Interviews and observations confirmed the lack of proper assistance, highlighting deficiencies in staffing and record-keeping.
A resident with multiple health conditions, including quadriplegia, did not receive a scheduled shower as per her preference. The facility's records inaccurately indicated that a shower was refused, signed by an STNA who was absent due to illness. The facility could not provide evidence of the shower being offered, highlighting a failure to follow the shower policy.
A facility failed to notify a resident's guardian about excess funds exceeding Medicaid limits. The resident, with severe cognitive impairment and multiple diagnoses, had a guardian who was not documented to have received the required notification. The Social Service Coordinator communicated with the guardian about using the funds for funeral arrangements, but lacked documentation to support these efforts.
The facility failed to implement comprehensive care plans for two residents. One resident, with multiple medical conditions, lacked a care plan for ADL assistance until it was requested. Another resident, dependent on staff for eating and rarely understood, had no care plan addressing hydration needs. These deficiencies were confirmed by facility staff.
A resident with severe cognitive impairment and multiple physical disabilities was observed to be improperly positioned in a custom wheelchair, lacking a dycem mat as ordered. Despite modifications, the resident continued to slide down, with no further attempts to improve positioning noted.
Two residents in an LTC facility experienced deficiencies in incontinence care and medication administration, leading to UTIs. One resident did not receive proper perineal hygiene, and another did not complete the prescribed antibiotic course. The DON confirmed these failures.
A facility failed to document urostomy care for a resident with chronic kidney disease, dementia, and bladder cancer. The care plan required specific interventions and care every shift, but records showed no evidence of completion. The Administrator confirmed the lack of documentation beyond output monitoring.
A resident with sepsis and MRSA infection had physician orders for weekly lab tests, including a CBC, sed rate, CRP, and Vancomycin trough level, which were not completed on two occasions. The resident was out for appointments on the scheduled lab days, but the facility's nurses did not draw the labs upon the resident's return. The Administrator confirmed the absence of lab results for the specified dates, acknowledging the failure to follow the physician's orders.
Three residents with various medical conditions did not receive scheduled showers due to insufficient staffing, particularly on weekends. The facility confirmed the lack of showers on specific days, and documentation issues were noted, including false entries by absent staff. The Administrator acknowledged prioritizing medical needs over shower preferences when staffing was inadequate.
Failure to Provide ADL Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident who required help due to multiple medical conditions, including a displaced midcervical fracture of the left femur, respiratory failure, chronic obstructive pulmonary disease, and hypertension. Record review showed no documentation that the resident received assistance with ADLs such as bed mobility, transfers, eating, toileting, bathing, or incontinence care over a two-day period prior to discharge. Family members reported that during visits, the resident's clothes had not been changed, she had not received help with eating, and was left lying flat while eating, resulting in food on her clothes and face. The administrator confirmed the absence of documentation for ADL assistance on the specified dates, and the facility was unable to provide a policy for ADL care when requested by the surveyor. This deficiency was identified during a complaint investigation and affected one resident out of six reviewed for ADL assistance, with a facility census of 71.
Failure to Safeguard Resident Confidential Information at Nurses Station
Penalty
Summary
The facility failed to protect residents' confidential information as required by accepted professional standards. During record review, observation, and interviews, it was found that code status forms for three residents with various diagnoses, including type II diabetes, muscle weakness, respiratory failure, osteomyelitis, altered mental status, syncope, and congestive heart failure, were left visible on the nurses station desk. Additionally, a computer screen displaying a resident's medical orders was left unlocked and unattended, making sensitive information accessible to visitors and others in the area. A family member reported concerns about resident information being visible, and a Certified Nursing Assistant confirmed that the information was accessible at the nurses station. The facility was unable to provide a policy regarding the protection of HIPAA-protected information.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for personal care received the assistance needed to receive showers as scheduled. This deficiency affected three residents who were reviewed for activities of daily living (ADL). Resident #3, who was admitted with multiple diagnoses including a dislocation of his right hip prosthesis and diabetes mellitus, required substantial assistance with showers and transfers. However, documentation revealed that he missed six out of twelve scheduled showers between late November and late December, with no evidence of receiving a shower or bath on those days. Resident #9, who had diagnoses including orthopedic aftercare and adult-onset diabetes mellitus, was also dependent on staff for showers. Despite being scheduled for showers three times a week, documentation showed that he did not receive showers on ten scheduled days, although he did receive showers on four non-scheduled days. This inconsistency in care was noted during his stay until his discharge in late December. Resident #30, with diagnoses such as hypertension and chronic pain syndrome, required partial assistance for showers. She was scheduled for showers three times a week but did not receive them on five scheduled days, according to documentation. An interview with the resident confirmed the accuracy of the documentation regarding missed showers. The facility's Director of Nursing acknowledged the lack of documentation for the showers and attributed the issue to staffing challenges, as the current shower aide was also assisting on the floor.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment for its residents, as evidenced by the conditions observed in the main shower rooms on Unit 1 and Unit 2. On Unit 1, the commode was missing a toilet seat, and there was a black substance on the vinyl floor near the shower stall, which transferred to a paper towel when wiped. The grout lines in the tiled shower stall were filled with dirt and grime, and the vinyl flooring was peeling back, exposing the underlayment. A metal transition strip separated the tiled floor from the vinyl flooring, and standing water was observed in the area where the vinyl was peeling. On Unit 2, similar issues were noted, including dirt and grime in the grout lines, torn vinyl flooring with loose sealant, and a strong mildew odor. A brown substance resembling feces was found on the shower stall floor, and the DON confirmed that the shower stall should be cleaned between each resident use. Resident interviews revealed concerns about mold and the condition of the shower rooms. One resident expressed that the issues had persisted for a year or more, with the facility claiming they were waiting on something to fix it. The resident also noted the missing toilet seat in Unit 1's shower room had been an issue for over a month. These observations and interviews indicate a failure to provide a safe and clean environment, affecting 42 of the 67 residents, as 25 residents were identified not to use the facility's two shower rooms.
Resident's Money Misappropriated by Staff
Penalty
Summary
The facility failed to protect a resident's personal money from being misappropriated by a staff member. The incident involved a resident who lent $20 to a housekeeper after she requested to borrow $10. The resident, who had a friendly relationship with the housekeeper, did not report the incident immediately as he did not have concerns at the time. However, the money was not repaid, leading to the resident eventually mentioning it to another staff member. The housekeeper admitted to borrowing the money and acknowledged that she had not repaid it. She stated that she had a good relationship with the resident and had never borrowed money from any other residents. The facility's investigation included interviews with the resident and the housekeeper, as well as a review of the facility's policies. Despite the housekeeper's admission, the facility unsubstantiated the allegation, concluding that misappropriation did not occur because the resident had consented to the loan. The facility's policy defines misappropriation as the wrongful use of a resident's belongings or money without consent. The Director of Nursing acknowledged that staff members are not permitted to ask residents for monetary assistance, as it could be perceived as coercion or undue influence. The facility's investigation was reviewed by a state investigator, but no further action was taken. The incident was documented as a deficiency in compliance with the facility's policies.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with bathing and showers to residents who were dependent on staff for personal care. This deficiency affected three residents who were reviewed for showers. Resident #8, who had multiple fractures and pressure ulcers, was scheduled for showers three times a week but did not receive them on five occasions. There was no documentation of the showers being refused, and the Director of Nursing (DON) confirmed the lack of evidence for these missed showers. Resident #14, diagnosed with polyosteoarthritis and muscle weakness, was also scheduled for showers three times a week. However, she did not receive showers on five scheduled days within a 30-day period. The resident reported that she often received only two showers a week due to staffing issues, although the DON denied that staffing was a factor. Again, there was no documentation of the showers being offered or refused. Resident #20, who had difficulty walking and other medical conditions, missed one scheduled shower day. The DON confirmed there was no documentation to support that the shower was offered or refused. The lack of documentation and failure to provide scheduled showers for these residents represent a deficiency in the facility's care practices.
Failure to Document Nutritional Monitoring
Penalty
Summary
The facility failed to adequately monitor a resident's nutritional status by not recording meal percentages and fluid intake amounts during her stay. The resident, who was admitted for a respite stay, had several diagnoses including Alzheimer's disease, dementia, unspecified protein calorie malnutrition, hypertensive heart disease with heart failure, and a pressure ulcer. Despite having physician's orders in place for monitoring her meal and fluid intakes, no documentation was recorded for the duration of her stay. The Director of Nursing confirmed that there was no documentation of the resident's meal and fluid intakes, acknowledging that staff should have entered this information into the computer. Without this documentation, the facility could not provide evidence of the resident receiving adequate nutrition and hydration, nor could they demonstrate proper monitoring of her nutritional status. The lack of documentation was unexplained, and the deficiency was noted as an incidental finding during a complaint investigation.
Incomplete Documentation of ADL Care for Resident
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, specifically regarding the documentation of activities of daily living (ADL) care provided to the resident. This deficiency affected a resident who was admitted for a respite stay and had multiple diagnoses, including Alzheimer's disease, dementia, malnutrition, hypertensive heart disease with heart failure, pressure ulcers, muscle contractures, and a history of breast cancer. The resident's care plans included interventions for skin breakdown, existing wounds, and hospice care, which required assistance with bed mobility, incontinence care, personal hygiene, and oral care. Upon review of the resident's electronic medical record, it was found that there was no documentation of ADL care provided on the first two days of the resident's stay. The Point of Care History report showed that ADL assistance was only documented on the third day of the stay. An interview with the Director of Nursing confirmed the lack of documentation for the first two days, although the resident was reportedly assisted with ADL care. The Director of Nursing could not explain why the staff failed to document the care provided.
Failure to Implement Nutritional Program Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive and individualized nutritional program for a resident, leading to significant weight loss. The resident, who was cognitively impaired and had multiple medical conditions including protein-calorie malnutrition and unspecified dementia, experienced a severe weight loss over a period of time. Despite a dietitian's recommendation on May 19th for a house supplement to be administered twice daily, this was not implemented until June 6th, after being recommended again on June 5th. During this period, the resident's weight was not monitored adequately, with no documented weights from May 8th to May 18th, and incorrect weight entries were noted. The resident's weight continued to decline, with a severe 8.5% weight loss noted by June 24th. The facility's failure to act on the dietitian's initial recommendation and the lack of timely nutritional assessments contributed to the resident's deteriorating condition. The resident's care plan was not updated appropriately to reflect her nutritional needs, and significant weight changes were not addressed in a timely manner. Interviews with the dietitian and the Director of Nursing revealed gaps in communication and implementation of nutritional interventions. The dietitian worked remotely and was not always aware of the resident's status, while the Director of Nursing confirmed that the supplement was not started when the resident returned from the hospital. The resident's nutrition plan of care was also found to be incorrect, as it did not reflect her status after she stopped receiving hospice care.
Deficiencies in ADL Assistance and Documentation
Penalty
Summary
The facility failed to ensure that residents received the necessary assistance for activities of daily living (ADLs) according to their preferences, affecting four residents. Resident #40, who required substantial assistance with bathing, did not receive showers as scheduled due to staffing issues. Documentation discrepancies were noted, with staff initials falsely indicating that care was provided. The resident confirmed missing showers and not being offered alternatives, such as bed baths, on certain days. Resident #20, with intact cognition and requiring maximal assistance for bathing, also missed scheduled showers due to staff shortages, particularly on weekends. The resident expressed distress over the missed showers, which were not rescheduled. Observations confirmed poor hygiene, with dark material under the resident's fingernails, despite documentation falsely indicating that showers and nail care were provided. Resident #55, who preferred to be clean-shaven, did not receive regular assistance with shaving. Documentation was lacking, and interviews with staff confirmed that shaving was not consistently offered or documented. Resident #264, with severely impaired cognition, missed several scheduled showers, and documentation was inconsistent, with the DON completing forms without clear evidence of care being provided. The facility's failure to provide consistent and documented care for ADLs highlights significant deficiencies in staffing and record-keeping.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for personal care, received the assistance needed to complete activities of daily living according to her preferences. The resident, who had multiple diagnoses including toxic encephalopathy, muscle weakness, and quadriplegia, expressed a preference for three showers weekly. However, she reported not receiving a shower on a specific date, which was confirmed by the absence of a shower sheet entry for that day. Further investigation revealed discrepancies in the documentation. The shower sheet for the date in question was signed by a State Tested Nursing Assistant (STNA) who was not present at the facility due to illness. This was corroborated by timeclock records and an interview with the staff coordinator, confirming the STNA's absence. The facility was unable to provide evidence that the resident received a shower on the specified date, as per her preference, indicating a failure to adhere to the facility's shower policy.
Failure to Notify Guardian of Excess Resident Funds
Penalty
Summary
The facility failed to provide a spend down notification for a resident who received Medicaid benefits, affecting one of the five residents reviewed for funds. The resident, who had a guardian, was admitted with multiple diagnoses including senile degeneration of the brain, contracture of multiple muscle sites, dysphagia, schizoaffective disorder, depression, attention and concentration deficit, vascular dementia, and persistent mood disorder. The resident's comprehensive Minimum Data Set (MDS) assessment indicated severe cognitive impairment, and the resident was unable to complete the Brief Interview for Mental Status (BIMS) assessment. The resident's quarterly statements showed an increasing balance that exceeded Medicaid limits, but there was no evidence that the guardian received the required notification about the excess funds. The Social Service Coordinator (SSC) acknowledged that the resident's funds had exceeded Medicaid limits for some time and had been in communication with the guardian about using the funds for funeral arrangements. However, there was no documentation to support these communications, and the guardian had not provided the necessary information to proceed with the arrangements. The SSC reported that the guardian did not want the funds spent on anything other than funeral arrangements, but there was no evidence to substantiate this claim. The lack of documentation and failure to ensure the guardian received the spend down notification contributed to the deficiency identified in the facility's handling of resident funds.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for all residents, affecting two residents out of the 20 care plans reviewed. Resident #55, who was admitted with multiple complex medical conditions including fractures, diabetes, and Parkinson's disease, was assessed to need varying levels of assistance with activities of daily living (ADLs). However, there was no care plan developed for his ADL assistance until it was requested on 07/17/24, despite his need for assistance being evident. This was confirmed by the Assistant Director of Nursing during an interview. Similarly, Resident #28, who was admitted with conditions such as dysphagia, vascular dementia, and major depressive disorder, was found to have a care plan that did not address her hydration needs. The resident was dependent on staff for eating and was rarely or never understood, indicating a significant need for a comprehensive care plan. The absence of a hydration plan was verified by the Administrator during an interview.
Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to ensure proper positioning of a resident in a wheelchair, affecting one of the three residents reviewed for positioning. The resident, who has spastic quadriplegia, cerebral palsy, traumatic brain injury, and scoliosis, was observed to be improperly positioned in a custom wheelchair on multiple occasions. Despite having a physician's order for a dycem mat to prevent sliding, the mat was not present during observations. The resident's medical record indicated severe cognitive impairment and dependence on others for all activities of daily living. Observations revealed that the resident was sliding down in the wheelchair, with their head not positioned on the headrest and leaning to the left. Interviews with staff and the resident's brother confirmed dissatisfaction with the wheelchair's effectiveness in maintaining proper positioning. The occupational therapist acknowledged the resident's scoliosis and the challenges in maintaining upright seating, despite modifications made to the wheelchair. There was no evidence of further attempts to improve the resident's positioning after the initial modifications.
Inadequate Incontinence Care and Medication Errors Lead to UTIs
Penalty
Summary
The facility failed to provide appropriate incontinence care for two residents, leading to urinary tract infections (UTIs). Resident #8, who had a history of UTIs and was frequently incontinent, did not receive proper perineal hygiene. During an observation, a nursing assistant used dry toilet paper instead of wet wipes or a washcloth with soap and water to clean the resident's perineal area, leaving the area inadequately cleansed. This was contrary to the facility's policy, which required thorough washing and rinsing to prevent infections. Additionally, Resident #8 received more doses of an antibiotic than prescribed for a UTI, indicating a medication administration error. Resident #20, who was also frequently incontinent, did not receive the full course of prescribed antibiotics for a UTI. The resident's daughter expressed concerns about confusion, prompting a urinalysis that confirmed a UTI. However, the resident missed a morning dose of the antibiotic, resulting in only 12 out of the 14 prescribed doses being administered. The Director of Nursing confirmed the discrepancies in medication administration for both residents, highlighting a failure in ensuring proper treatment and services to prevent UTIs.
Failure to Document Urostomy Care
Penalty
Summary
The facility failed to provide evidence that urostomy care was completed as care planned and ordered for a resident. The resident, who had diagnoses including chronic kidney disease, dementia, mood disorder, and malignant neoplasm of the bladder, was admitted with an ostomy. The care plan required urostomy care every shift and as needed, along with specific interventions such as keeping the drainage bag below the bladder, using a leg strap, and changing the catheter bag per policy. However, the Medication Administration Record from April to July showed no evidence that the ostomy care was completed as ordered. An interview with the Administrator confirmed that the only documentation available was related to output monitoring, with no documented evidence of the required urostomy care being performed.
Failure to Complete Routine Laboratory Testing as Ordered
Penalty
Summary
The facility failed to ensure that routine laboratory testing was completed weekly as ordered by the physician for a resident. The resident, who was admitted with diagnoses including sepsis, MRSA infection in a diabetic ulcer, and adult-onset diabetes mellitus, had a physician's order for Vancomycin IV and weekly lab tests including a CBC with differential, sed rate, CRP, and Vancomycin trough level. However, there was no evidence that these labs were drawn on the specified dates of 07/09/24 and 07/16/24. The Director of Nursing confirmed that the resident was out for appointments on the days the labs were scheduled, but acknowledged that the facility's nurses could have drawn the blood upon the resident's return. The Administrator provided a lab result from 07/16/24 that was incomplete, missing the sed rate and Vancomycin trough level. The Administrator also confirmed the absence of lab results for 07/09/24, acknowledging the failure to obtain the labs as ordered by the physician.
Insufficient Staffing Leads to Missed Showers for Residents
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, particularly affecting three residents. Resident #20, who has diabetes, chronic obstructive pulmonary disease, and schizoaffective disorder, did not receive scheduled showers on multiple occasions due to staffing shortages, particularly on weekends. The resident expressed distress over not receiving showers as scheduled, and the facility confirmed the lack of showers on specific dates. Resident #40, with diagnoses including low back pain, muscle weakness, and unspecified dementia, also did not receive scheduled showers on several occasions. The resident reported receiving only two showers a week instead of three, and documentation confirmed the absence of showers on certain days. The Director of Nursing acknowledged the lack of documentation and the resident's preference for showers, which were not consistently provided. Resident #7, diagnosed with conditions such as toxic encephalopathy and quadriplegia, reported not receiving a shower on a scheduled day due to insufficient staffing. Documentation falsely indicated that a staff member who was not present had provided care. The facility's staffing schedule showed fewer staff on weekends, and the Administrator confirmed that medical needs were prioritized over shower preferences when staffing was inadequate.
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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