Arc At Cincinnati
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 4001 Rosslyn Drive, Cincinnati, Ohio 45209
- CMS Provider Number
- 365044
- Inspections on file
- 41
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Arc At Cincinnati during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dependence for mobility, and a history of left femur fracture reported an unwitnessed fall and developed left leg and knee pain with swelling. An NP assessed the resident, documented pain and limited ROM in the left leg, but initially entered STAT imaging orders for the wrong limb, leading to X-rays of the right hip and knee that only showed arthritis. Nursing documentation of the fall was absent, and assessment notes contained contradictions about the left leg findings. Orders for X-rays of the left hip and knee were written the following day, along with oral pain medications and a Lidocaine patch, but the left-sided imaging was not completed until several days later, when a suspected distal femur fracture was finally identified. The resident was then transferred to the hospital, where a bicondylar distal femur fracture was confirmed and treated surgically with ORIF. Surveyors determined the facility failed to provide timely treatment of the fracture, resulting in actual harm to the resident.
A resident with a history of repeated falls and multiple comorbidities had a care plan that included non-skid strips on the floor beside the bed as a fall prevention intervention. During surveyor observation, the resident’s bedside area lacked these non-skid strips. A CNA, maintenance staff, and the DON each confirmed that non-skid strips were not in place, and maintenance reported that none were available in the facility. This failure to implement the care-planned intervention occurred despite a facility policy requiring comprehensive person-centered care plans to be developed and implemented.
A resident with multiple care needs and a care plan requiring two-person assistance for all personal care was provided a bed bath by a single CNA. During care, the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. Staff interviews confirmed that care was routinely provided by only one CNA, contrary to the documented care plan and facility policy.
A resident with multiple complex medical conditions who was dependent on staff for mobility did not attend scheduled outside medical appointments due to failures in scheduling and arranging transportation. Confusion and poor communication between nursing staff and the transportation coordinator led to missed appointments, with no documentation that transportation was arranged or that appointments were attended, despite physician orders and facility policy requiring such arrangements.
A resident who required two staff for bathing was left unattended by only one staff member, resulting in a fall and fractures to both legs. Other deficiencies included a resident keeping a prohibited electric coffee pot in their room, medications left at the bedside without proper orders or labeling, and a room with a loose metal chair rail and splintered wood, all of which were unaddressed by staff and posed safety hazards.
A resident with chronic pain and opioid dependence missed multiple doses of prescribed methadone due to pharmacy dispensing issues, prescription diagnosis errors, and delays in obtaining new prescriptions or prior authorizations. This led to increased pain, withdrawal symptoms, and emergency room visits. Staff interviews revealed inconsistent medication reordering practices and inadequate documentation, resulting in actual harm to the resident.
Staff conducted verbal shift reports at the nurses' station where residents could overhear protected health information, including diagnoses and medications. Multiple residents with intact cognition reported overhearing confidential details, and an LPN confirmed that this practice occurred and constituted a HIPAA violation. The DON stated that private areas were available for such reports, and facility policy required confidentiality, but these procedures were not followed.
Several nurses did not receive required training on abuse, neglect, and exploitation during orientation or annually, as mandated by facility policy. Employee file reviews and staff interviews confirmed missing documentation of this training, despite expectations set by facility leadership and policy requirements. This deficiency had the potential to affect all residents in the facility.
Surveyors identified expired medications stored in medication rooms and carts, as well as missing and incomplete temperature monitoring for medication refrigerators. An LPN and the DON indicated unclear staff responsibilities and inconsistent training regarding these duties, resulting in expired drugs being accessible and temperature logs not being maintained as required by facility policy.
Staff failed to follow infection control protocols by discarding used towels on the shower room floor and allowing shared use of unlabeled personal care items among residents. Additionally, two residents with respiratory conditions had their nebulizer and CPAP equipment left uncovered and improperly stored, despite staff awareness of correct procedures. Both the DON and Administrator confirmed expectations for individual labeling and proper storage, but these practices were not consistently followed.
The facility did not maintain ongoing communication with dialysis providers for two residents requiring hemodialysis. Staff interviews and record reviews showed that information was not consistently sent to or received from the dialysis center, and required communication sheets were not regularly used. This resulted in a lack of documentation and exchange of critical care information between the facility and the dialysis provider.
Three residents experienced significant medication errors when staff failed to administer medications as ordered, including not updating an eye drop order after an optometrist visit, giving an antipsychotic at the wrong time of day, and missing doses of an antiplatelet medication without documentation or physician notification. Nursing staff and the DON confirmed that these errors resulted from missed order updates and transcription mistakes.
A resident with chronic pain and opioid dependence was prescribed methadone, but nursing staff signed the MAR as if the medication was administered on several occasions when it was not, as confirmed by the absence of narcotic sheet documentation and staff interviews. The resident also reported missed doses due to pharmacy supply issues, and facility leadership acknowledged that this resulted in inaccurate medical records.
A resident with multiple chronic conditions was found unresponsive after an unwitnessed fall, and staff did not complete a required post-fall investigation as outlined in facility policy. Interviews with the DON, ED, ADON, and an RN confirmed the omission, resulting in a deficiency related to fall management.
A resident with cognitive impairment and multiple medical conditions underwent several room changes without proper documentation of the reasons or written notification to the resident and their representative. Staff interviews and record reviews confirmed the absence of required notifications and documentation.
Staff failed to consistently recheck and notify providers about abnormal blood pressure readings for a resident with multiple chronic conditions. On two occasions, the resident had significantly high and low blood pressure readings without follow-up or provider notification, contrary to facility policy and staff expectations as confirmed by interviews with nursing and medical staff.
A resident with multiple risk factors for skin breakdown did not receive required weekly skin assessments or consistent turning and repositioning, as documented by gaps in CNA records. When new pressure ulcers developed, there were delays and incomplete documentation of physician-ordered wound care. Staff interviews confirmed that assessments and interventions were not completed as ordered, resulting in the resident developing advanced stage pressure ulcers and experiencing actual harm.
A registered nurse left a resident's EMR containing confidential health information open and facing the hallway, making it visible to others while administering medications. The resident had multiple diagnoses and moderate cognitive impairment. This action was not in accordance with the facility's policy on medical record confidentiality.
An LPN administered Lorazepam and Modafinil, both controlled substances, to a resident with multiple medical conditions without verifying the medication count or signing out the medications in the controlled substance log, contrary to facility policy requiring proper documentation and accountability for controlled substances.
A nurse failed to administer two prescribed medications to a resident with multiple chronic conditions because the medications were unavailable, resulting in a medication error rate of 7.7% during observed medication passes. This exceeded the regulatory limit of 5% and was identified as a deficiency during the survey.
Surveyors observed that staff failed to follow infection control protocols during medication administration and wound care. An RN did not wear an isolation gown while assisting with wound care for a resident on EBP, and two nurses handled medications improperly—one by placing pills directly into bare hands, and another by picking up a dropped pill with a gloved hand and not performing hand hygiene between residents.
A resident with a history of bipolar disorder and schizophrenia was discharged from a facility without a 30-day notice and was initially sent to a homeless shelter, which refused him due to past behaviors. The facility did not attempt to find alternative placement and relied on a caseworker's plan, leading to the resident being taken to multiple hospitals before being admitted. The facility's policy on discharge was not followed.
The facility failed to prevent and treat pressure ulcers in residents, leading to the development of avoidable stage III pressure ulcers. Despite physician orders for interventions like heel protectors and a low air loss mattress, these were not implemented timely. The lack of a quick reference system for staff and failure to follow the facility's policy on skin assessment contributed to the issue.
The facility's phone system malfunctioned, preventing communication with staff and affecting all 84 residents. Observations over several days showed repeated failed attempts to reach personnel, with calls redirected to a generic message without options to transfer. The Administrator and Receptionist confirmed the issue, which was reported by a family member.
The facility failed to serve meals at palatable temperatures, affecting nearly all residents. During a meal service observation, food temperatures dropped significantly by the time they were served, with chili mac at 96°F, cornbread at 92°F, and milk at 50°F. Residents confirmed their meals were cold and bland, and the Dietary Manager acknowledged the issue, despite a policy to monitor food temperatures.
The facility failed to ensure a safe and homelike environment, affecting 23 residents. Observations revealed damaged drywall in a resident's room and multiple ceiling tiles with brown stains in the therapy gym and common areas, indicating potential water damage. These conditions were confirmed by the Maintenance Director.
A facility failed to implement its policy on injuries of unknown origin when a resident with severe cognitive impairment was found with scratches on her face. Initial documentation by an LPN was struck out by the Interim DON, who claimed the injury did not occur as described. Despite the facility's policy requiring immediate reporting and investigation, the incident was not properly addressed, leading to a deficiency.
A resident with severe cognitive impairment was found with scratches on her face, but the facility failed to report the injury of unknown origin to the state agency in a timely manner. Despite documentation by an LPN and witness statements from CNAs, the interim DON struck out the records, claiming the incident did not occur. The facility's policy required immediate reporting of such incidents, leading to a deficiency citation.
A resident with severe cognitive impairment was found with scratches on her face, but the facility failed to investigate the injury thoroughly. Despite initial documentation by an LPN and notifications to the physician and family, the interim DON struck out the records, claiming incorrect information. Interviews confirmed the injuries, but the facility did not adhere to its policy for investigating such incidents.
A resident admitted with multiple health conditions did not receive their prescribed medications on the evening of admission and the following morning. Despite the availability of some medications in the facility's Pyxis system, they were not administered, and the physician was not notified of the missed doses. The facility's policy on medication errors was not followed, as no incident report or nursing notes were completed.
A resident with severe cognitive impairment and multiple medical conditions was inappropriately restrained with a sheet by an STNA to prevent falls. The resident exhibited aggressive behavior and attempted to get out of the wheelchair, leading to the unauthorized use of the sheet as a restraint. The incident was documented and confirmed through staff interviews and observations.
The facility failed to update a resident's fall care plan with current interventions, despite the resident being at risk for falls and using a low bed and fall mats. This deficiency was confirmed through observations and staff interviews, revealing non-compliance with the facility's fall risk management policy.
Delayed and Incorrect Imaging Orders Resulting in Untimely Treatment of Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and accurate treatment of a resident’s left leg fracture following a reported unwitnessed fall. The resident had multiple diagnoses, including prior fractures of the left femur, ischemic cardiomyopathy, cerebral infarction, type II diabetes, and heart failure, and was care planned as being at risk for pain with interventions to evaluate the effectiveness of pain interventions. The resident had severely impaired cognition, verbal behaviors, and was dependent on staff for toileting, mechanical lift transfers, and bed mobility. On the date of the incident, the nurse practitioner (NP) acutely evaluated the resident after reports of a possible fall out of bed, with the resident stating he rolled out of bed onto the floor on his right side with knees colliding. There was no nursing documentation of a fall or change-in-plane status. The NP’s documentation regarding the left leg was contradictory, noting both no crepitus or difficulty with passive range of motion (ROM) and that the resident reported pain with passive ROM and did not participate in active ROM. The NP documented that STAT imaging was ordered and gave verbal orders for acetaminophen and a Lidocaine patch, with a plan to re-evaluate the resident in the morning. Later that afternoon, a registered nurse documented that the resident reported an unwitnessed fall on the previous shift and complained of left knee pain with apparent swelling. The RN notified the NP, who assessed that the resident was unable to participate in ROM to the left leg due to pain and placed new orders for an X-ray to the left leg, a one-time dose of acetaminophen, and a Lidocaine patch to the left leg. However, the actual physician orders entered on that date were for a STAT X-ray of the right hip and a Lidocaine patch to the right posterior hip, along with acetaminophen. X-rays completed that evening were of the right knee and right hip, both showing only modest arthritis and osteoarthritis, respectively. The next day, an untimed progress note documented left knee swelling related to the unwitnessed fall and referenced the right hip X-ray findings. New orders were then placed for X-rays of the left hip and left knee, as well as oral anti-inflammatory medication, a muscle relaxer, and a Lidocaine patch to the left posterior hip for pain. Despite the orders for left hip and knee imaging being written the day after the initial evaluation, the X-rays of the left knee and hip were not completed until two days later. When performed, the imaging showed the left knee was highly suspicious for a minimally displaced distal femoral metaphyseal fracture, while the left hip showed only mild degenerative changes without acute fracture or dislocation. The NP later documented reviewing the left-sided X-ray results and arranged for the resident to be sent to the hospital for further evaluation of a suspicious, non-confirmed fracture of the left leg. Hospital records showed the resident was admitted and treated for a closed bicondylar fracture of the left distal femur with open reduction and internal fixation. The resident reported having fallen out of bed on the left side while at the facility but could not provide more information due to baseline dementia, and the hospital was unable to obtain further details from facility staff. Interviews confirmed that the NP acknowledged placing the initial orders for the wrong limb and that the facility’s medical director was not informed of the alleged fall, the fracture requiring surgery, or the incorrect orders until a later date. The facility’s policy on attending physician responsibilities required appropriate and timely medical orders and treatments to enable safe, effective continuing care. Surveyors concluded that the facility failed to ensure timely treatment of the resident’s left leg fracture, resulting in actual harm. The sequence of events included an unwitnessed fall without nursing documentation, contradictory assessment notes, incorrect initial imaging orders for the right side instead of the left, and a delay of several days before the correct left-sided imaging was completed and the fracture identified. This failure affected one resident reviewed for care post fall out of a facility census of 89.
Failure to Implement Care-Planned Non-Skid Floor Strips for Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as being at risk for falls. The resident had multiple diagnoses, including multiple rib fractures, unspecified bipolar disorder, recurrent major depressive disorder, unspecified anxiety disorder, chronic pain syndrome, repeated falls, and stage IV chronic kidney disease. An annual MDS assessment documented that the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. The resident’s care plan, dated 08/14/24, identified fall risk related to refusing environmental modifications, self-medicating, alcohol use, use of mobility devices, and clutter in the room. Among the listed interventions were a cushion in the wheelchair, anti-roll backs to the wheelchair, encouraging use of the call light, a new bed/mattress, education on appropriate footwear, encouraging the resident to keep the bed in the lowest position, non-skid strips to the floor next to the bed, and family decluttering the room. Surveyor observation on 01/27/26 at 12:07 P.M. showed that the resident did not have non-skid strips on the floor beside the bed, despite this being a care-planned intervention. A CNA confirmed at the same time that there were no non-skid strips at the bedside. Later that day, a maintenance staff member verified that the resident did not have non-skid strips on the floor in the room and stated that non-skid strips would have to be ordered because none were available in the facility. On 01/28/26, the DON also confirmed that the resident did not have non-skid strips at the bedside as specified in the care plan. Review of the facility’s Comprehensive Person-Centered Care Plans policy, dated March 2022, indicated that each resident was to have a comprehensive care plan developed and implemented to meet physical, psychological, and functional needs. This deficiency was cited under a complaint investigation and was a recite to a prior annual survey.
Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Fractures
Penalty
Summary
The facility failed to implement person-centered care planned interventions for a resident who was dependent on staff for all aspects of personal care, including bathing and bed mobility. The resident, who had diagnoses such as absolute glaucoma, muscle weakness, difficulty walking, and required total assistance, had a care plan specifying that two staff members were required for all care. Despite this, a single CNA provided a bed bath without assistance, during which the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The care plan and MDS documentation clearly indicated the need for two-person assistance, but this intervention was not followed. Interviews with staff confirmed that the resident was always cared for by one CNA, despite the care plan's directive. The CNA involved stated that she never received help from other staff members when providing care to this resident. The incident resulted in the resident being transported to the hospital and not returning to the facility. Facility policy required staff to follow care planned interventions and to implement measures to prevent falls, but these were not adhered to in this case.
Failure to Arrange and Document Transportation for Scheduled Medical Appointments
Penalty
Summary
The facility failed to ensure that a resident was taken to scheduled outside medical appointments, as required by physician orders and the resident's care plan. The resident in question was admitted with multiple complex diagnoses, including paraplegia, autonomic dysreflexia, neuromuscular bladder dysfunction, anxiety disorder, chronic pain syndrome, and major depressive disorder. The resident was dependent on staff for all mobility needs and required stretcher transportation due to being bedbound. Upon admission, the resident had existing appointments scheduled and orders for additional appointments, with instructions for staff to arrange transportation. Despite these requirements, a review of the medical record and interviews with staff revealed that the necessary appointments were not scheduled or attended. The process for arranging appointments and transportation involved multiple staff members, including nurses and the transportation coordinator, but there was confusion and lack of clear responsibility. Nurses were responsible for scheduling appointments and notifying the transportation coordinator, who would then arrange transportation. However, conflicting information, missed communications, and lack of documentation led to appointments not being made or attended. Staff interviews confirmed that there were ongoing issues with communication between nursing and transportation staff, resulting in missed appointments. Further review showed no documentation that the resident attended the scheduled appointments or that transportation was arranged. The Director of Nursing and the Administrator confirmed that there was no evidence in the records of appointments being made or attended, and attempts to verify appointments with outside providers were unsuccessful. The facility's policy required assistance with arranging transportation, but this was not carried out as needed for the resident.
Failure to Provide Adequate Supervision and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident who was dependent on two staff members for bathing. Despite care plan interventions specifying the need for two staff during all care, only one staff member was present when the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The staff member involved reported that she routinely provided care alone, as no one would assist her, and the resident confirmed that only one staff member was present during the incident. Facility leadership and documentation confirmed the resident's dependence on staff for all care and the expectation that care plans be followed. The facility also failed to ensure the environment was free from accident hazards for several residents. One resident was found to have a plugged-in electric coffee pot in their room, which was against facility policy due to the risk of burns or fire. Staff and leadership interviews confirmed that such appliances were not permitted, and the presence of the coffee pot had not been reported or addressed. Another resident had expired and unlabeled medications, including a bottle of nasal spray and a cup of white cream, left at the bedside without proper orders or assessment for self-administration. Staff acknowledged that medications should not be left at the bedside and that the resident did not have orders for self-administration. Additionally, a resident's room was observed to have a loose metal chair rail with sharp edges and splintered wood, creating a physical hazard. The maintenance director and DON confirmed that these conditions had not been reported and posed a risk of injury. The facility's failure to maintain a safe environment and to follow policies regarding supervision, medication administration, and environmental hazards resulted in actual harm and placed multiple residents at risk.
Failure to Provide Ordered Pain Medication Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure that ordered pain medication, specifically methadone, was available for administration to a resident with chronic pain syndrome and opioid dependence. The resident missed multiple doses of methadone over several days due to issues with pharmacy dispensing, prescription diagnosis errors, and delays in obtaining new prescriptions or prior authorizations. Documentation showed that the resident missed a total of nine doses over three days, resulting in increased pain and withdrawal symptoms, which led the resident to call 911 and be transferred to the emergency room for treatment. Medical record review and staff interviews revealed that the resident had a history of chronic pain, recent surgeries, and opioid dependence, and was prescribed methadone three times daily. Despite this, there were repeated instances where the medication was not available due to the pharmacy's inability to fill prescriptions with an opioid dependence diagnosis, insurance issues, and delays in obtaining updated prescriptions from the provider. Staff interviews indicated inconsistent practices in reordering medications, lack of timely follow-up with the pharmacy or provider, and inadequate documentation regarding missed doses and communication with the provider. The facility's own policy required that pain medications be administered as ordered and that staff monitor for withdrawal symptoms and communicate with the provider if pain or side effects were not controlled. However, the resident experienced actual harm, including increased pain and withdrawal symptoms, due to the facility's failure to ensure the availability of methadone. The deficiency affected at least one resident and was substantiated by medical records, staff and resident interviews, and pharmacy documentation.
Failure to Protect Resident Health Information During Shift Reports
Penalty
Summary
Staff failed to maintain the confidentiality of residents' personal and medical records by conducting verbal shift reports in areas where other residents could overhear protected health information. Multiple residents with intact cognition reported overhearing details about other residents' diagnoses and medications during staff conversations at the nurses' station. One resident stated that she and others became aware of confidential medical information due to these discussions, and another resident, a former nurse, confirmed that she could hear health information during staff shift reports. A staff LPN acknowledged that shift reports were held at the nurses' station and admitted that residents could overhear protected health information, recognizing this as a HIPAA violation. The DON stated that private areas were available for such reports and did not expect staff to discuss confidential information within earshot of residents. Facility policy required staff-to-staff communication, such as shift reports, to be conducted outside the hearing range of residents and the public, but this was not followed, resulting in a breach of confidentiality for all residents in the facility.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Nursing Staff
Penalty
Summary
The facility failed to ensure that four nursing staff members received required training on abuse, neglect, and exploitation during orientation and annually, as mandated by facility policy. Employee file reviews showed that three nurses hired within the past two years had no documented evidence of having completed abuse/neglect training within the last 12 months. Additionally, a recently hired nurse had no documentation of receiving this training at all. These findings were confirmed through staff interviews, where the Director of Nursing, Administrator, and Human Resources Director all acknowledged the expectation that staff complete required in-services and that management should monitor compliance. However, the Human Resources Director was unable to explain why the required abuse training was missing for these staff members. The facility's policy on abuse prevention and reporting, updated in 2018, requires all new employees to receive training on abuse policies during orientation and mandates annual training for all staff. The policy specifies that training must cover definitions of abuse, neglect, and exploitation, reporting requirements, and appropriate interventions. The lack of documented training for these four nurses represents non-compliance with both facility policy and regulatory requirements, with the potential to affect all residents in the facility, which had a census of 92 at the time of the review.
Expired Medications and Inadequate Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications were discarded and did not maintain proper monitoring of medication refrigerator temperatures. During observations, surveyors found 25 expired heparin lock flush solutions with expiration dates ranging from 03/2023 to 07/2022 in the medication room, as well as expired Solosite wound gel, enema saline laxative, and zinc oxide ointment on the medication cart. All expired items were unopened but accessible for use. Additionally, one medication refrigerator lacked a thermometer, and temperature logs for both medication refrigerators on two units showed significant gaps in daily monitoring and documentation, with several days and even weeks missing entries. Interviews with nursing staff and the DON revealed confusion and inconsistency regarding responsibility for checking medication refrigerators and monitoring for expired medications. The night shift was reportedly responsible for these tasks, but there was uncertainty about staff training and clear assignment of duties. Facility policy required nursing staff to maintain medication storage areas and to contact the pharmacy for instructions on handling outdated medications, but these procedures were not consistently followed, as evidenced by the presence of expired medications and incomplete temperature monitoring.
Infection Control Failures in Shower Room and Respiratory Equipment Storage
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices in the facility's shower rooms and in the storage of respiratory equipment. Observations revealed that used towels were discarded on the shower room floor, and large bottles of shower supplies and hairbrushes were not designated for individual resident use. Multiple staff interviews confirmed that unlabeled personal care items were used by multiple residents, and staff were unsure of the ownership of certain items. Both the Director of Nursing and the Administrator acknowledged that each resident was expected to have their own labeled bath supplies, and that sharing such items posed an infection control concern. Additionally, the facility did not ensure proper storage of respiratory equipment for two residents with significant respiratory needs. One resident, in a persistent vegetative state with a tracheostomy and chronic respiratory failure, had a nebulizer machine and accessories left uncovered on the over-bed table between uses, rather than being stored in a plastic bag as required. Staff interviews confirmed knowledge of the correct storage procedure, but it was not followed due to oversight. The Director of Nursing and Administrator both stated that respiratory equipment should be covered when not in use. Another resident with COPD, asthma, and obstructive sleep apnea used a CPAP machine, but the CPAP mask was repeatedly observed lying uncovered on the resident's dresser rather than being stored in a plastic bag. Staff interviews confirmed that CPAP masks were expected to be stored in bags, but the facility did not have a formal policy for this practice. The Director of Nursing and Administrator both stated their expectation for proper storage, but this was not consistently implemented.
Failure to Ensure Ongoing Communication with Dialysis Providers
Penalty
Summary
The facility failed to ensure ongoing communication with dialysis providers for two residents who required hemodialysis. Both residents had diagnoses including end stage renal disease and were receiving dialysis three times a week. Review of their medical records and care plans indicated that staff were directed to encourage attendance at dialysis appointments, but there was no documentation of communication between the facility and the dialysis center. Staff interviews revealed that information was not consistently sent with residents to the dialysis center, and when residents returned, the facility typically did not receive or review information from the dialysis center, except occasionally for laboratory work. Nurses reported that communication sheets were not being used regularly, and the dialysis center confirmed they had not received information from the facility for several months. The Director of Nursing stated that nurses were responsible for completing and sending dialysis communication sheets with residents for every treatment, and that returned sheets should be uploaded to the electronic medical record and placed in the paper chart. However, this process was not being followed, as evidenced by the lack of documentation and staff statements. Facility policy required arrangements with the contracted dialysis provider to include how information would be exchanged, but this was not occurring, resulting in a deficiency related to the management and communication of dialysis care for residents.
Failure to Administer Medications as Ordered Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in significant medication errors affecting three of six residents reviewed. For one resident with a diagnosis of allergic rhinitis and severely impaired vision, a physician's order for prednisolone acetate eye drops was changed to be administered only in the right eye each morning following an optometrist visit. However, the medication administration records showed that staff continued to administer the drops in both eyes, and the new order was not transcribed or updated in the records. Interviews with nursing staff and the Director of Nursing confirmed that the order change was missed and not implemented as required. Another resident with chronic viral hepatitis C, opioid dependence, and HIV had a physician's order for quetiapine 50 mg to be administered nightly. Upon admission, the medication was incorrectly entered into the medication administration record to be given in the morning instead of at night. This error persisted for several days until the order was corrected. Staff interviews revealed that the error occurred due to oversight during the transcription of hospital orders, and there was no documentation of adverse effects during the period the medication was administered at the wrong time. A third resident with acute respiratory failure, ventricular tachycardia, and atherosclerotic heart disease had a physician's order for clopidogrel bisulfate (Plavix) 75 mg daily. The medication administration records indicated that the medication was not administered on several specified dates, with no documentation or physician notification regarding the missed doses. Staff interviews confirmed that the medication should not have been held without appropriate clinical justification or documentation. Facility policy required medications to be administered as prescribed and within the specified time frame, which was not followed in these cases.
Inaccurate MAR Documentation for Controlled Substance Administration
Penalty
Summary
The facility failed to ensure accurate documentation on the Medication Administration Record (MAR) for a resident with a history of chronic pain syndrome and opioid dependence. The resident was prescribed methadone three times daily for pain management. Review of the MAR for October and November revealed that methadone was signed as administered on several occasions, but there was no corresponding Controlled Drug Record (narcotic sheet) to indicate the medication was available or actually given on those dates and times. Interviews with nursing staff confirmed that they had signed the MAR indicating administration of methadone when, in fact, the medication was not given, attributing the errors to accidental documentation. The resident also reported that there were multiple instances when the facility was unable to obtain methadone from the pharmacy. Facility policy required that medications be administered as prescribed and that staff document administration accurately, including signing the MAR only after giving the medication. The Director of Nursing and the Administrator both confirmed that signing the MAR for medications not administered results in inaccurate medical records. The deficiency was identified through record review, staff and resident interviews, and policy review, and was investigated under a specific complaint number.
Failure to Conduct Post-Fall Investigation
Penalty
Summary
The facility failed to conduct a post-fall investigation for a resident who was found unresponsive on the bathroom floor following an unwitnessed fall. Medical record review showed that the resident, admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and schizoaffective disorder, did not have documentation of an investigation into the cause of the fall. Staff interviews with the DON, ED, ADON, and an RN confirmed that no post-fall investigation was completed, despite facility policy requiring staff to investigate falls to determine underlying causes and implement appropriate interventions. This deficiency was identified during a review of three residents for falls, with a facility census of 91 residents.
Failure to Notify Resident and Representative of Room Changes
Penalty
Summary
The facility failed to properly notify a resident and the resident’s representative of multiple room changes, as required. Medical record review for a resident with diagnoses including dementia, spinal stenosis, cervical spine injury, neuromuscular dysfunction, bipolar disorder, and a history of opioid and alcohol abuse, revealed that the resident was cognitively impaired and dependent on staff for activities of daily living. The resident experienced room changes on three separate occasions, but there was no documentation in the medical record regarding the reasons for these moves or evidence that the resident or their representative had been notified in writing prior to the changes. Interviews with the facility Administrator and Social Services Director confirmed the absence of documentation for both the reasons for the room changes and the required notifications. Additionally, the resident’s representative confirmed that she had not been informed of the room changes. This lack of notification and documentation was identified during a complaint investigation and affected one of three residents reviewed for room changes.
Failure to Monitor and Report Abnormal Blood Pressure Readings
Penalty
Summary
Facility staff failed to appropriately monitor and respond to abnormal blood pressure readings for a resident with chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. Medical record review showed that on two separate occasions, the resident had significantly abnormal blood pressure readings—one low (91/40) and one high (203/99)—without documentation of a recheck or notification to a physician or provider. Interviews with staff revealed inconsistent practices regarding the rechecking of abnormal blood pressures and provider notification, with one LPN stating she only rechecks if time allows and does not notify providers, while an RN described a protocol of rechecking and notifying based on symptoms. The DON confirmed that staff are expected to recheck abnormal blood pressures within two hours and notify providers, regardless of symptoms. Further review of facility policy indicated that any blood pressure reading above 140/90 is considered hypertension and below 100/60 is hypotension, and that abnormal readings should be reported to a physician and documented at different times of the day. The physician interviewed confirmed that staff should recheck and notify providers if abnormal readings persist. The deficiency was identified during a complaint investigation and affected one resident out of 15 reviewed for blood pressure monitoring, with a facility census of 94 residents.
Failure to Prevent and Manage Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with multiple risk factors, including diabetes mellitus type 2, cerebral infarction, vascular dementia, and major depressive disorder. The resident's care plan identified a high risk for skin breakdown due to impaired mobility, incontinence, and impaired cognition, with interventions such as barrier ointment, frequent weight shifting, nutritional monitoring, and a low-air loss mattress. Despite these interventions, there was no documentation of required weekly skin assessments for the entire month of January, and certified nursing assistant (CNA) documentation showed extensive gaps in turning and repositioning the resident as required. Further review revealed that when new wounds were identified on the resident's sacrum and left buttock, there were delays and inconsistencies in implementing and documenting physician-ordered wound care treatments. The Treatment Administration Record (TAR) showed missing or incomplete documentation for several days, and progress notes did not reflect the completion of wound care as ordered. Additionally, shower sheets were not accurately completed, failing to indicate the condition of the resident's skin. The lack of timely and thorough skin assessments and wound care allowed the resident's pressure ulcers to progress to advanced stages, including a stage IV ulcer and an unstageable ulcer. Interviews with facility staff, including the Director of Nursing (DON) and the Wound Nurse Practitioner (WNP), confirmed that required assessments and interventions were not completed as ordered. The WNP stated that the pressure ulcers were pressure-related and should have been avoided with proper turning, repositioning, and timely incontinence care. Facility policy and national guidelines emphasize the importance of regular skin assessments, prompt intervention, and thorough documentation, all of which were not followed in this case, resulting in actual harm to the resident.
Failure to Secure Resident's Electronic Medical Record
Penalty
Summary
A deficiency occurred when a registered nurse left a resident's electronic medical record (EMR) open and visible in a hallway while administering medications in the resident's room. The EMR contained private and confidential health information, which was accessible to other staff and residents passing by. The resident involved had diagnoses including diabetes mellitus type two, vascular dementia, and major depressive disorder, and was assessed as having moderate cognitive impairment. The facility's policy required that medical records be kept confidential and only disclosed to authorized persons with the resident's consent, but this policy was not followed in this instance.
Failure to Account for and Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and signed out after administration. During an observation, an LPN administered Lorazepam 0.5 mg and Modafinil 100 mg, both schedule IV controlled substances, to a resident without verifying the medication count prior to administration and without signing out the medications from the controlled substance log. The LPN confirmed in an interview that she did not check the controlled medication counts or document the administration in the controlled substance log as required. The resident involved had diagnoses including cerebral infarction, generalized anxiety disorder, peripheral vascular disease, and chronic respiratory failure, and required substantial assistance with activities of daily living. Facility policy required that medications, especially controlled substances, be prepared, administered, and recorded by the same licensed nurse, with documentation on both the medication administration record and the individual controlled substance record. These procedures were not followed during the observed medication pass.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by regulation. During medication administration, a nurse did not provide two prescribed medications—Stress B/Zinc Oral tablet and Famotidine—to a resident because the medications were unavailable at the time of administration. This omission was confirmed by direct observation and staff interview. The affected resident had multiple diagnoses, including cerebral infarction, generalized anxiety disorder, peripheral vascular disease, gastroesophageal reflux disorder, and chronic respiratory failure, and required significant assistance with daily activities. A review of medication administration for four residents revealed that out of 26 medications administered by three nurses, two were omitted, resulting in a medication error rate of 7.7%. The facility's policy requires medications to be administered according to physician orders and outlines steps to be taken in the event of a medication error. The observed omissions and resulting error rate exceeded the acceptable threshold, constituting a deficiency as identified during the survey.
Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving three residents. For one resident with diabetes, vascular dementia, and impaired mobility, a registered nurse assisted with wound care without donning an isolation gown, despite the resident being on Enhanced Barrier Precautions (EBP) due to chronic wounds. The facility's policy required the use of gowns and gloves during wound care for residents under EBP, but this protocol was not followed, as confirmed by the nurse during interview. In two other cases, medication administration practices did not adhere to infection control standards. One nurse administered medications by popping pills directly into his bare hands before placing them in a pill cup for a resident with moderate cognitive impairment. Another nurse picked up a dropped medication from the cart with a gloved hand and administered it to a resident with significant ADL dependence, then proceeded to administer medications to another resident without performing hand hygiene. These actions were inconsistent with the facility's hand hygiene policy, which requires hand cleaning before and after direct resident contact.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #90, who was admitted for surgical after-care following knee surgery and had a history of bipolar disorder and schizophrenia. The resident was initially discharged to a homeless shelter at the request of a caseworker, but the shelter refused to accept him due to his past behaviors, including setting fires. Consequently, the resident was returned to the facility and later discharged again to a hospital, which had previously discharged him, without a confirmed placement. The facility's management was unaware of the resident's violent incidents during his hospital stay prior to admission, as these were not communicated in the hospital notes shared with the facility. Despite the resident not exhibiting violent behaviors while at the facility, the caseworker insisted on discharging him due to his history. The facility did not provide a 30-day discharge notice or attempt to find alternative placement, relying instead on the caseworker's plan, which ultimately led to the resident being taken to multiple hospitals before being admitted. Interviews with facility staff and the caseworker manager revealed that the resident was improperly placed in the facility and that the caseworker should not have taken responsibility for the resident's discharge. The facility's policy on notice of transfer and discharge was not followed, as the resident was not given a 30-day notice, and the discharge was not conducted in a safe and orderly manner, as required by the policy.
Failure to Prevent and Treat Pressure Ulcers in Residents
Penalty
Summary
The facility failed to adequately assess and monitor the skin conditions of residents, leading to the development of avoidable, facility-acquired pressure ulcers. Resident #75, who was admitted without pressure ulcers but was at risk due to conditions such as dementia and diabetes, developed multiple stage III pressure ulcers on the right heel, right flank, and sacrum. Despite physician orders for interventions like heel protectors and a low air loss (LAL) mattress, these were not implemented in a timely manner, contributing to the progression of the ulcers. The facility's lack of a quick reference system for staff to access care interventions further exacerbated the issue. Resident #05, who was also admitted without pressure ulcers, developed a stage III pressure ulcer on the sacrum. The facility failed to notify the physician or document the skin breakdown in a timely manner, delaying appropriate treatment. The resident was at risk for pressure ulcers due to conditions such as a recent hip replacement and impaired mobility. Despite orders for a LAL mattress, it was not put in place until months after the ulcer was identified, indicating a significant lapse in implementing necessary preventive measures. Interviews with facility staff, including the Interim Director of Nursing and various nurses, revealed a lack of awareness and documentation regarding the necessary interventions for pressure ulcer prevention and treatment. The facility's policy on skin condition assessment and monitoring was not followed, as evidenced by the absence of weekly skin assessments and timely physician notifications. The facility's failure to implement physician-ordered interventions and conduct regular skin assessments resulted in the development and progression of pressure ulcers in residents who were initially admitted without such conditions.
Phone System Malfunction Affects Resident Communication
Penalty
Summary
The facility failed to maintain a functional phone system, which had the potential to affect all 84 residents residing in the facility. Observations from November 13 to November 19, 2024, revealed 15 unsuccessful attempts to reach facility personnel via the phone system. Each attempt resulted in a message stating, 'Hello, you have reached the ARC of Cincinnati. It is our pleasure to serve you today. Please leave a message and we will be happy to return your call as soon as possible. Thank you and have a good day.' There was no option to transfer to an individual, department, or nursing unit. The Administrator learned of the phone system's malfunction on November 17, 2024, and the Receptionist confirmed the issue had been ongoing since at least November 14, 2024, when a family member reported the inability to reach staff.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a warm and palatable temperature, affecting nearly all residents except two who did not receive food from the facility's kitchen. During an observation of the meal service, it was noted that the dinner meal, which included chili mac, cornbread, salad, green beans, and carrots, was initially prepared at appropriate temperatures. However, by the time the food was served to the residents, the temperatures had significantly dropped, with the chili mac at 96 degrees Fahrenheit, cornbread at 92 degrees Fahrenheit, and milk at 50 degrees Fahrenheit. The Dietary Manager confirmed these temperatures and acknowledged that the food was not hot and was bland in taste, with an unappealing presentation. Interviews with residents confirmed that their meals were cold and bland, corroborating the observations made by the surveyor and the Dietary Manager. The facility's policy on monitoring food temperatures, dated September 2023, was reviewed and indicated that food temperatures should be monitored to prevent foodborne illness and ensure palatable temperatures. Despite this policy, the deficiency was noted under Complaint Number OH00158984, highlighting a failure in the facility's food service process.
Environmental Deficiencies in Nursing Unit
Penalty
Summary
The facility failed to maintain a safe, functional, and homelike environment for its residents, affecting 23 individuals in the Fountains Nursing Unit. During an observation conducted on November 5, 2024, several deficiencies were noted. Resident #23's room had a significant area of damaged drywall with brown and black discoloration near the window. Additionally, the therapy gym and multiple common areas throughout the unit exhibited ceiling tiles with brown ring stains, indicating potential water damage. These observations were confirmed by the Maintenance Director, highlighting the facility's non-compliance with maintaining a suitable living environment.
Failure to Implement Policy on Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its policy regarding injuries of unknown origin when a resident was found with injuries. Resident #11, who had severe cognitive impairment and was dependent on staff for toileting and transfers, was found with scratches on her left eyebrow and cheek. The incident was initially documented by LPN #401, who notified the physician and family, and initiated an abuse/neglect screening. However, the documentation was later struck out by the Interim DON, who claimed the injury did not occur as described. The facility's Incidents and Accidents Log showed an entry for the injury, which was also struck out by the Interim DON. Despite the initial documentation and notifications made by LPN #401, the Interim DON and ADON #333 later stated that the injuries described in the progress notes were incorrect. The ADON, who assessed the resident with the previous Administrator, claimed there were no injuries as documented, but offered no further explanation or documentation to support this claim. The facility's policy required immediate reporting and investigation of any incident or suspicion of abuse, neglect, or injuries of unknown origin. However, the facility did not follow this policy when Resident #11 was found with injuries. The Interim DON's decision to strike out the documentation without a thorough investigation or explanation led to a deficiency in the facility's handling of the incident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin involving a resident to the state agency. The resident, who had severe cognitive impairment and was dependent on staff for toileting and transfers, was found with scratches on her left cheek and eyebrow. These injuries were documented by an LPN, who also notified the physician and family, and initiated an abuse/neglect screening. However, the documentation was later struck out by the interim DON, who claimed the incident did not occur as described. The interim DON, who began employment after the incident, struck out all related documentation after being informed by the ADON that the injury did not happen. Despite the initial documentation by the LPN and witness statements from CNAs, the facility did not submit a Self-Reported Incident (SRI) to the state agency in a timely manner. The facility's policy required such incidents to be reported immediately, or within two hours if they involved abuse or serious bodily injury, and within 24 hours otherwise. Interviews with the LPN and CNAs confirmed the presence of the injuries on the resident, contradicting the interim DON and ADON's claims. The facility's failure to report the incident as per policy led to a deficiency being cited under a complaint investigation. The report highlights discrepancies in documentation and communication within the facility's administration regarding the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source involving a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and repeated falls. The incident occurred when the resident was found in another resident's room with scratches on her left cheek and eyebrow. Despite the documentation of the injuries by an LPN and notifications made to the physician and family, the interim DON later struck out the documentation, claiming incorrect information. The interim DON, who started employment after the incident, was informed by the ADON that the injury did not occur, leading to the removal of the documentation. However, interviews with the LPN and CNA who discovered the resident confirmed the presence of the injuries. The facility's policy mandates a thorough investigation of any incident involving injuries of unknown origin, which was not adhered to in this case. The facility's incident log and self-reported incidents did not reflect a timely or thorough investigation of the resident's injuries. The interim DON and ADON's actions contradicted the initial findings and documentation by the LPN, resulting in a deficiency for failing to investigate the injury properly.
Failure to Administer Medications Timely Upon Admission
Penalty
Summary
The facility failed to ensure timely ordering and administration of medications for a resident upon admission. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the lung, hepatic encephalopathy, and diabetes mellitus type II, did not receive physician-ordered medications on the evening of admission and the following morning. The medications included essential treatments such as rosuvastatin, melatonin, mirtazapine, olanzapine, omeprazole, and lactulose, which were not administered as per the physician's orders. The facility's Pyxis system had some of the medications available, yet they were not administered. The Interim Director of Nursing confirmed the oversight and acknowledged that the physician was not notified of the missed doses, nor were nursing notes or incident reports completed. The facility's policy requires immediate notification of the physician and documentation in the event of medication errors, which was not adhered to in this case. The consulting pharmacist indicated that a STAT order could have ensured timely delivery of the medications, but this was not done.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints, which affected one resident with severe cognitive impairment and multiple medical conditions. The resident was admitted with diagnoses including cerebral infarction, brain stem stroke syndrome, dysphagia, cognitive communication deficit, and hemiplegia. The resident required maximal assistance with daily activities and had no orders for physical restraints or assessments completed for such use. On the day of the incident, the resident was observed being aggressive and attempting to get out of his wheelchair. In response, a State Tested Nurse Aide (STNA) tied a sheet around the resident's waist to prevent him from falling, which was not an appropriate or authorized restraint. The resident continued to exhibit combative behavior, and staff, including a Licensed Practical Nurse (LPN), were involved in trying to manage the situation. The incident was documented in progress notes and an incident report, and it was confirmed that the use of the sheet as a restraint was not ordered or assessed. Interviews with staff and observations confirmed that the resident was restrained with a sheet, which was against the facility's policy on physical restraints and abuse. The facility's Director of Nursing (DON) and other staff were notified of the incident, and it was determined that the restraint was inappropriate. The facility's policy review and personnel files indicated that the STNA involved had been educated on abuse and restraint policies but still used the sheet to restrain the resident.
Failure to Update Fall Care Plan with Current Interventions
Penalty
Summary
The facility failed to ensure a resident's fall care plan was updated with current interventions. This deficiency was identified during a review of Resident #01's chart, which revealed that the resident had severe cognitive impairment and required extensive assistance with various activities of daily living. Despite the resident being at risk for falls and requiring specific interventions such as a low bed and fall mats, these interventions were not documented in the resident's fall care plan. Observations confirmed that the resident was using a low bed and fall mats, but these were not reflected in the care plan. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) verified that the fall mat and low bed were not updated in the resident's fall care plan. The facility's policy on managing falls and fall risk, dated March 2018, mandates that staff identify interventions related to the resident's specific risks to prevent falls and minimize complications. The failure to update the care plan with current interventions represents non-compliance and was investigated under Complaint Number OH00152855.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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