Arbors At Marietta
Inspection history, citations, penalties and survey trends for this long-term care facility in Marietta, Ohio.
- Location
- 400 Seventh Street, Marietta, Ohio 45750
- CMS Provider Number
- 365687
- Inspections on file
- 39
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Arbors At Marietta during CMS and state inspections, most recent first.
Surveyors found that meals were not being served according to the dietitian-approved cycle menus and that menu substitutions were not consistently or accurately documented. On the observed lunch service, the kitchen served a completely different meal than what was listed on the current cycle menu and used an outdated diet guide sheet from a prior year. The Menu Substitution Log showed numerous substitutions over several months but lacked entries for the current month and did not fully capture all items that were changed for the observed meal. Staff reported that many substitutions were made based on the preferences of a small group of residents attending resident council, and acknowledged that some changes were not communicated to all residents. A resident reported frequent unannounced menu changes and inconsistent meal items among residents on the same hall, contrary to the facility’s written policy requiring menus to be served as written and all substitutions to be logged.
A resident with cancer, obesity, and edentulism, who was cognitively intact and on a regular diet with thin liquids, choked while eating a meal that included facility-provided chicken and family-provided blueberries and yogurt. CNAs initially observed no concerns when delivering the tray and bringing in a visitor, but later found the resident with a blue face, pointing and pounding at his throat/chest, and showing signs of choking. Staff immediately initiated back thrusts and the Heimlich maneuver after confirming the resident’s DNRCC-A status, but were unable to dislodge the obstruction, and EMS later pronounced the resident deceased. The facility completed an internal incident report and obtained staff witness statements, but the Administrator did not submit a self-reporting incident to the State survey agency, despite acknowledging that this unusual occurrence resulting in death should have been reported as possible neglect under the facility’s abuse/neglect policy.
Two residents experienced deficiencies in safety and fall prevention, including one who suffered a head injury during transport due to improper wheelchair securement by a transport aide, and another who did not have required fall interventions such as traction strips and accessible call light in place. These failures occurred despite care plans and policies outlining necessary precautions for residents at risk.
A resident reported that shower rooms were not always cleaned well and had a persistent stain on her shower curtain. Observations confirmed a bowel movement on the shower room floor, a used washcloth left on a handrail, and a stain on the resident's shower curtain. Housekeeping and floor staff did not ensure prompt cleaning between uses, resulting in unsanitary conditions.
Surveyors found that MDS assessments were not completed accurately for three residents, including incorrect documentation of catheter use, dental status, and fall injuries. Staff interviews and record reviews confirmed discrepancies between actual resident conditions and what was recorded in the MDS, with failures to follow facility policy for assessment accuracy.
Three residents did not have complete or accurate care plans addressing their specific medical needs, including IV access, indwelling catheter care, and oral/dental status. Staff interviews and record reviews revealed missing or incomplete documentation, lack of clarity about current treatments, and failure to follow facility policy for timely, comprehensive care planning.
A resident with significant hearing loss did not consistently wear prescribed hearing aids due to one device being missing, and the facility failed to report or document the missing hearing aid as required. Staff were unaware of the loss, and the issue was not communicated to the audiology provider or recorded in the missing items log, resulting in the resident not receiving needed assistance with hearing.
A resident with multiple chronic conditions and a risk for skin impairment was observed to have dark blue, cool, and dry, flaky skin on both lower extremities. Despite these findings, the care plan did not include interventions for the discoloration and dry skin, and the issue was not documented in the Minimum Data Set. Staff confirmed the skin condition, but the care plan had not been updated to address these non-pressure skin issues as required by facility policy.
Two residents with indwelling urinary catheters did not receive appropriate care and documentation. One resident's catheter bag was observed improperly positioned both above the bladder and on the floor, while another resident had no care plan, physician orders, or accurate assessment for catheter care. Staff interviews confirmed lapses in awareness and documentation, contrary to facility policy requiring proper catheter management.
A resident with multiple serious diagnoses was nearly given an overdose of Methadone when a nurse misinterpreted a medication order and prepared four bottles instead of one. The error was discovered during a narcotic count, and the resident refused the extra medication, preventing further harm. The incident resulted from incorrect order entry and misunderstanding of the medication supply and documentation.
A resident with complex medical needs was given an incorrect dose of Methadone due to a transcription error and confusion over pharmacy supply. The error was not promptly identified, and documentation did not accurately reflect the administration or proper waste of the controlled substance. The remaining Methadone was improperly disposed of by flushing, without a second nurse witness as required by policy.
Three cognitively intact residents signed binding arbitration agreements without understanding their content, as none recalled being offered or viewing the required explanatory video, nor receiving an adequate explanation. The agreements were presented during admission and signed electronically, typically without a witness, contrary to facility policy requiring clear explanation.
Staff failed to follow infection control protocols when an LPN did not perform hand hygiene between glove changes during medication administration for a resident with a gastrostomy tube, and a CNA entered the room of a resident on contact precautions for C. diff without wearing appropriate PPE. These actions were not consistent with facility policy and affected two residents.
A registered nurse was hired without the facility verifying her residency status or completing the required FBI background check, as only a state BCI check and federal exclusion checks were performed. The facility's process at the time relied on verbal confirmation of residency without documentation, and the responsible HR staff member has since been replaced.
Failure to Follow Dietitian-Approved Menus and Accurately Document Menu Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to provide meals as written on the approved cycle menu and to accurately document all menu substitutions. Surveyors reviewed the facility’s Week #1 2025–2026 cycle menu, which listed a specific lunch for a Wednesday: cranberry orange chicken, roasted Brussels sprouts, garlic and rosemary roasted red skin potatoes, a dinner roll, and Mandarin oranges, with an alternate of cheese ravioli with marinara sauce and tossed salad. During an observation of the lunch meal service, the food being prepared and served did not match this menu. Instead, the kitchen was serving smothered chicken thigh with poultry gravy, broccoli florets, mashed potatoes, a dinner roll, and sliced pears, which corresponded to a different menu (a Tuesday meal from a 2023–2024 diet guide sheet) rather than the current 2025–2026 cycle menu. When surveyors requested the spreadsheet for the day’s menu to verify portion sizes and menu compliance, dietary staff produced a spreadsheet from the 2023–2024 Diet Guide Sheet rather than the correct 2025–2026 Week #1 menu. Review of the facility’s Menu Substitution Log for November 2025 through January 2026 showed 27 recorded substitutions deviating from the planned dietitian-approved cycle menu. However, there was no Menu Substitution Log for February, and the Administrator later added the 02/11/26 lunch substitutions onto a previously provided log. Even then, the added entry only noted that chicken thigh was substituted with chicken breast, Brussels sprouts with broccoli, and roasted potatoes with mashed potatoes, and did not document that cranberry orange chicken had been replaced with smothered chicken or that Mandarin oranges had been replaced with pears. Both the Administrator and a Regional Nurse confirmed that the meal served did not match the current cycle menu and that the substitution log did not fully or accurately reflect the substitutions made. Interviews with staff and a resident further described the pattern of unrecorded or inadequately recorded substitutions and deviations from the menu. The cook reported that the planned cranberry orange chicken, Brussels sprouts, and red skin potatoes were not served because residents at resident council had previously expressed dislike for those items, and that many substitutions were based on the preferences of the 15–25 residents who typically attended council meetings. She acknowledged that these preferences might not represent the entire resident population and that some menu changes based on known preferences were not communicated to residents, despite residents receiving a weekly “daily chronicle” listing upcoming meals. A resident reported frustration that the posted menus were often changed without notice, estimating that this occurred two or three times per week, and stated that residents on the same hall sometimes received different food items without explanation. The facility’s own menu policy required menus to be prepared in advance, served as written unless substitutions were made for preference, unavailability, or special meals, and required that a menu substitution log be maintained on file, but the observed practices and documentation did not align with these requirements.
Failure to Report Resident Choking Death as Possible Neglect
Penalty
Summary
The deficiency involves the facility’s failure to report a possible situation of neglect to the State survey agency after a resident choked during a meal and subsequently died. The resident had diagnoses including malignant neoplasm of the prostate and obesity, was cognitively intact, and required only setup or cleanup assistance with eating. He was on a regular diet with regular texture and thin liquids, had no documented history of coughing or choking with meals or medications, and was not receiving speech therapy. His care plans addressed risk for altered nutritional status and noted that he was edentulous, with interventions including providing meals per preference and order and assistance with meals as needed. On the day of the incident, documentation showed that a CNA delivered the resident’s lunch tray while he was sitting upright with no concerns noted. Shortly thereafter, another CNA brought a visitor into the room and again no concerns were noted. When a CNA later returned to the room to pick up trays, the resident was observed sitting upright with his face turning blue, pointing and pounding on his throat/chest area, and showing signs of choking. Staff immediately called for help and initiated back thrusts, followed by the Heimlich maneuver performed by nursing staff after verifying the resident’s DNR Comfort Care Arrest status. Despite continued efforts, the obstruction could not be visualized or dislodged, EMS was called, and the resident was ultimately pronounced deceased. Witness statements indicated the resident had been eating blueberries and yogurt brought by family, in addition to chicken from his lunch tray. The facility completed an internal incident report and collected multiple witness statements, including from the CNAs and nurses involved. The Administrator later acknowledged that no self-reporting incident was submitted to the State survey agency regarding this choking event and resulting death. The Administrator questioned whether reporting was required since the facility’s internal investigation concluded there was no wrongdoing and staff responded appropriately. However, he recognized that the event was an unusual occurrence resulting in a resident’s death that should have been reported as possible neglect, consistent with the facility’s abuse, neglect, and exploitation policy, which requires immediate reporting of alleged violations and events that could indicate noncompliance related to neglect, including those resulting in serious bodily injury.
Failure to Ensure Resident Safety During Transportation and Fall Prevention
Penalty
Summary
The facility failed to ensure resident safety during facility-provided transportation and did not implement required fall interventions for residents at risk for falls. One resident, who was dependent on staff for transportation and had a history of cerebral infarction, generalized weakness, and was on blood thinning medication, was injured during transport when the transport aide did not properly secure the wheelchair straps. As a result, the resident was dislodged from the wheelchair during a bus turn, fell, and sustained a head laceration that required medical treatment, including staples. The resident reported that only one side of the wheelchair was locked, and despite questioning the aide, was assured everything was secure. The incident was confirmed by interviews and documentation, and the resident expressed fear and pain following the event. Another resident, with diagnoses including hypertension, diabetes, and end-stage renal disease, experienced two falls and was identified as being at risk for further falls. The care plan for this resident included specific interventions such as 15-minute checks, traction strips to the floor, and ensuring the call light was within reach. However, during observation, the resident's call light was not accessible, and traction strips were not present as ordered. The resident stated she relied on her roommate to call for assistance, indicating that the prescribed interventions to prevent falls were not in place at the time of review. Policy review indicated that the facility was required to assess each resident's fall risk and implement appropriate interventions, including environmental modifications and care planning. Despite these requirements, the facility did not ensure that interventions were consistently implemented for residents at risk for falls or that transportation safety protocols were followed, resulting in actual harm to at least one resident and placing others at risk.
Failure to Maintain Clean and Sanitary Shower and Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in both the shower room and a resident's room. During an interview, a resident reported that the shower rooms were sometimes not cleaned well and noted a persistent stain on her shower curtain since admission. Observations by the Housekeeping Supervisor and Maintenance Staff confirmed the presence of a quarter-sized, soft bowel movement on the floor next to the drain in the third stall of the first-floor shower room, as well as a used washcloth hanging over the handrail in the second stall. Additionally, a round stain was observed on the resident's shower curtain. The Housekeeping Supervisor stated that while housekeeping staff mop the floors each morning and scrub them weekly, floor staff are responsible for cleaning the shower room between residents. A review of a CNA's statement indicated that after giving the resident a shower, she intended to clean the shower room afterward. However, subsequent observation found no sign of the CNA or the resident in either the room or the shower area. The facility's policy requires maintaining a safe, clean, and homelike environment, ensuring that the building and equipment are kept sanitary. The failure to promptly clean the shower room and address the stain on the resident's shower curtain led to the deficiency.
Inaccurate MDS Assessments for Catheter, Dental, and Fall Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for several residents, specifically regarding falls, dental status, catheter use, and continence status. For one resident admitted with an indwelling urinary catheter, nursing documentation and direct observation confirmed the presence of the catheter, yet the MDS assessment and continence evaluation incorrectly indicated no catheter use and did not rate urinary continence. There were also no documented orders for catheter care, and both MDS nurses and the Director of Nursing confirmed they were unaware the catheter remained in place. Another resident's MDS assessment failed to accurately reflect the presence of broken and missing teeth, despite the resident's report and staff confirmation of this dental status. Additionally, a third resident's MDS assessment incorrectly indicated a fall with major injury, although records and staff interviews confirmed only a minor fall with no major injury had occurred. The facility's policy requires adherence to the MDS Resident Assessment Instrument (RAI) manual for accurate assessment and documentation, which was not followed in these cases.
Failure to Maintain Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to maintain comprehensive, resident-centered care plans for three residents, as evidenced by incomplete or missing documentation and care planning for significant medical needs. For one resident with a PICC line for antibiotic therapy, the care plan did not specify the type of intravenous access or provide complete information regarding the IV status, despite orders and ongoing treatment. The Director of Nursing confirmed the care plan was incomplete in this regard. Another resident was admitted with an indwelling urinary catheter, but there was no care plan addressing catheter care, and staff interviews revealed confusion about whether the catheter had been removed. The resident continued to have the catheter in place, as observed by surveyors, but this was not reflected in the care plan or physician orders, and staff were unaware of the ongoing need for catheter care. A third resident with a history of acute respiratory failure, traumatic brain injury, tracheostomy, and severe malnutrition had broken and missing teeth, but the care plan did not address oral or dental status. Staff confirmed that oral care was provided and that the resident had significant dental issues, but there was no care plan in place to address these needs. The facility's policy requires comprehensive, person-centered care plans to be developed within seven days of the MDS assessment, including measurable objectives and timeframes, but this was not followed for the residents reviewed.
Failure to Ensure Use and Reporting of Missing Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident with a history of hearing loss consistently wore hearing aids as recommended and did not properly report or document the loss of a hearing aid. The resident, who had diagnoses including atrial fibrillation, COPD, heart failure, and hearing loss, was assessed by audiology and prescribed bilateral hearing aids to be worn daily with staff assistance. Despite these recommendations, observations revealed that the resident was not wearing the hearing aids, had difficulty understanding conversations, and reported that one hearing aid was missing. Staff interviews confirmed that the hearing aid had been missing for some time, but there was no evidence that this was reported to the appropriate personnel or documented in the facility's missing items log. Further review of the resident's care plan and medical records showed no documentation of refusal to wear the hearing aids or any indication that the aids were being used daily as directed. The social services director was unaware of the missing hearing aid and had not included it in the concern log. Additionally, the facility had not contacted the audiology provider regarding the missing device. These actions and omissions resulted in the resident not receiving the necessary assistance with hearing, as outlined in their care plan and audiology recommendations.
Failure to Develop Comprehensive Care Plan for Non-Pressure Skin Impairment
Penalty
Summary
The facility failed to provide a comprehensive treatment plan for a resident with altered skin integrity. The resident, who had multiple diagnoses including chronic obstructive pulmonary disorder, diabetes mellitus type two, peripheral vascular disease, congestive heart failure, and atrial fibrillation, was identified as being at risk for skin impairment. Although the care plan included interventions to decrease risk, it did not address the resident's bilateral lower extremities discoloration and dry skin, despite these conditions being observed. The Minimum Data Set did not document any skin impairment, and physician orders were in place for daily skin checks by CNAs and weekly skin assessments by nursing staff. During observations, the resident was noted to have dark blue, cool, and dry, flaky skin on both lower extremities. Interviews with the resident, a CNA, and an LPN confirmed the presence of these skin issues. The LPN acknowledged the findings and indicated that documentation and physician notification would occur, as well as an update to the care plan. However, at the time of the survey, the care plan had not been updated to include interventions for the discoloration and dry, flaky skin, which was inconsistent with the facility's policy requiring monitoring, assessment, and treatment of non-pressure skin impairments.
Failure to Provide Comprehensive Catheter Care and Documentation
Penalty
Summary
The facility failed to provide comprehensive and resident-centered care for residents with indwelling urinary catheters, as evidenced by observations, interviews, and record reviews. One resident with a neurogenic bladder and an indwelling catheter was observed with the catheter bag improperly positioned on two occasions: once hanging above the bladder and once on the floor. Both instances were confirmed by nursing staff, and the facility's policy required catheter care to reduce infections and maintain proper gravity drainage. Another resident admitted with an indwelling catheter for urinary retention did not have a care plan, physician orders, or accurate assessment documentation regarding the catheter. The resident's Minimum Data Set (MDS) was incorrectly coded to indicate no catheter use, and staff interviews revealed a lack of awareness about the presence of the catheter. The Director of Nursing and Unit Manager confirmed the absence of necessary documentation and care planning, despite daily interactions with the resident. Facility policy required catheter care in accordance with clinical standards, which was not followed in this case.
Medication Administration Error Due to Order Misinterpretation
Penalty
Summary
Nursing staff failed to ensure the correct administration of Methadone to a resident with complex medical conditions, including acute respiratory failure, subdural and intracerebral hemorrhage, pneumonitis, and tracheostomy status. The resident was cognitively intact, as indicated by a BIMS score of 15. Multiple Methadone orders were entered and discontinued over several days, with the final order specifying Methadone liquid 60 mg/7.5 ml by mouth once daily. On the day of the incident, a nurse administered four bottles (30 ml) of Methadone instead of the prescribed one bottle (7.5 ml), due to a misunderstanding of the order and incorrect transcription in the medication administration record (MAR). The error was not discovered until the following day during a narcotic count, which revealed a discrepancy in the Methadone supply. The nurse involved confirmed preparing the incorrect dose, and the error was only prevented from escalating because the resident refused to take the additional medication, recognizing the correct dose. The facility's investigation found that the order was not entered correctly in the computer system, and the nurse misinterpreted the intended dose due to the way the medication was supplied and documented. The facility's medication reconciliation policy required verification of medication orders, but this process was not effectively followed, leading to the medication error.
Failure to Investigate Medication Error and Improper Controlled Substance Disposal
Penalty
Summary
The facility failed to thoroughly investigate a potential medication error and the disposition of controlled medications for a resident with multiple complex diagnoses, including acute respiratory failure, subdural and intracerebral hemorrhages, and tracheostomy status. The resident was prescribed Methadone, but due to incorrect transcription of the order and confusion regarding the supply from the pharmacy, a nurse administered four bottles (30 ml) of Methadone instead of the prescribed one bottle (7.5 ml). The error was not discovered until the following day during the scheduled morning dose, and documentation on the medication administration record did not match the narcotic sheet, which showed four bottles signed out. There was no documentation of the wasted Methadone. Further investigation revealed that the narcotic count was not completed correctly during shift changes, and the narcotic log did not include the required documentation of a second nurse witnessing the medication waste. The nurse involved confirmed she flushed the remaining Methadone down the toilet, which was against facility policy and Environmental Protection Agency regulations. The facility's investigation did not identify the lack of a second nurse as a witness to the medication waste, and the nurse could not recall who, if anyone, witnessed the destruction of the medication.
Failure to Ensure Resident Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the binding arbitration agreements they signed upon admission. Three residents with intact cognition, as indicated by their BIMS scores of 15, were reviewed and each had electronically signed the facility's Alternative Dispute Resolution Agreement. The agreement stated that residents had been offered or were able to view an audio/visual video explaining the agreement. However, interviews with all three residents revealed that none remembered signing the agreement, none recalled being offered or watching the explanatory video, and none understood the purpose of the agreement at the time of signing. The admissions process involved the Admissions Director presenting the arbitration agreement as part of the admission packet and asking residents to sign electronically, typically without a witness present. The facility's policy required that the agreement be explained in a manner understandable to the resident or their representative. Despite this, the residents interviewed did not recall receiving an explanation or being made aware of their right to refuse the agreement, and one resident expressed a desire to revoke the agreement after learning more about it.
Failure to Follow Infection Control Protocols During Medication Administration and Contact Precautions
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during medication administration and while maintaining contact isolation precautions. In one instance, an LPN administered medications via a gastrostomy tube to a resident with multiple complex medical conditions, including a tracheostomy and enteral feeding, who was on enhanced barrier precautions. The LPN changed gloves between medication tasks but did not perform hand hygiene as required by facility policy before proceeding to administer a nasal inhaler. In another instance, a CNA entered the room of a resident on contact precautions for Clostridium difficile to deliver a lunch tray but did not wear the appropriate personal protective equipment (PPE) as indicated by signage and facility policy. Both failures were confirmed by staff interviews and were not in accordance with the facility's infection prevention and control policies, which reference CDC guidelines for transmission-based precautions.
Failure to Complete Required FBI Background Check Prior to RN Hire
Penalty
Summary
The facility failed to implement its criminal background check policy for a registered nurse who was hired without proper verification of residency or completion of a required FBI background check. The personnel file for the nurse did not contain evidence that the facility determined whether she had resided in the state for the past five years, as required. Only a state Bureau of Criminal Investigation (BCI) check was completed, along with checks through the Office of Inspector General (OIG) and the System for Award Management (SAM), all with no findings. However, the necessary FBI background check was not performed prior to employment, despite the nurse not having lived in the state during the required period. The administrator confirmed that, at the time of hire, the facility's process only involved verbally asking the employee about their residency status, with no written documentation. The administrator also acknowledged that the human resources employee responsible for background checks at the time no longer holds that position. The facility's policy required all employees to undergo a criminal background check before an employment offer was finalized and to follow state regulations regarding such checks, but this was not followed in this instance.
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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