Arc At Trotwood Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 5790 Denlinger Road, Dayton, Ohio 45426
- CMS Provider Number
- 365309
- Inspections on file
- 40
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Arc At Trotwood Llc during CMS and state inspections, most recent first.
Surveyors found that the kitchen grill’s drip pan had not been emptied for several days, causing grease to overflow, run down the grill, and collect in a metal pan and on towels on the floor, where it had solidified. The dietary manager reported that the drip pan handle had been broken for months and that maintenance usually opened it daily so staff could empty it, but this had not occurred. All residents received meals from this kitchen except two residents who did not receive meal trays from there.
Surveyors found that the AED on the Rehab Hall crash cart had no pads attached and no pads stored in the AED compartments or in the crash cart, despite daily checks being documented on a crash cart checklist that did not include verification of AED function or pad availability. During the observation, the ADON confirmed that no AED pads were readily available. The facility reported that this crash cart and AED would be used in an emergency for 18 of 19 residents on the Rehab Hall who were identified as Full Code.
A resident with multiple complex conditions, including anoxic brain damage, ESRD on hemodialysis, heart failure, trach, and sepsis, experienced a significant change in condition with abnormal vital signs, including tachycardia, tachypnea, hypotension, and use of accessory muscles. An LPN contacted the physician, who ordered Lopressor, followed by additional orders for midodrine, lab work (CBC, BMP, UA with C&S), and a chest radiograph after repeat vitals remained abnormal. Despite these significant changes and new medical orders, the resident’s representative was not notified, and the DON confirmed that no family notification occurred, in violation of facility policy requiring notification of the resident’s representative for significant changes in condition and medical care.
Surveyors found that the facility did not ensure scheduled baths/showers were offered or completed for two cognitively intact residents who required at least set-up or supervisory assistance with ADLs. Review of clinical records and shower logs showed multiple gaps where no documentation existed to show that bathing was offered or provided between scheduled shower dates, despite entries for completed showers, refusals, and times when a resident was not available. One resident reported that staff did not assist with showers as scheduled. The DON stated staff were expected to offer a bath/shower the next day if a resident was not available and to document refusals, and confirmed that such documentation was missing, in conflict with the facility’s ADL policy requiring provision and documentation of hygiene care and any refusals.
Surveyors found that the facility failed to secure a vaping device and prevent its use at bedside for a cognitively intact resident who required supervised smoking and was not permitted to store smoking materials, contrary to the facility’s smoking policy and outdated smoking evaluation. In a separate case, the facility did not investigate a cognitively intact resident’s fall, did not implement fall-related interventions, and did not complete or document neuro checks after unwitnessed falls, despite multiple documented falls and a written fall response procedure requiring assessment, documentation, neuro checks, and care plan updates.
Surveyors found that a cognitively intact resident with COPD, morbid obesity, DM, and chronic respiratory failure did not have documented administration of multiple ordered medications, including metformin, ferrous sulfate, loratadine, a multivitamin, montelukast, ibuprofen, methocarbamol, and calcium on several days. MAR review showed missing documentation on multiple dates, the resident reported not always receiving medications, and the Administrator confirmed the absence of documentation, contrary to facility policy requiring medications to be given safely, timely, and per prescriber orders.
A resident with DM, ESRD, COPD, and other complex conditions had multiple physician orders for insulin, antihypertensives with specific BP hold parameters, and other PEG-tube and inhaled medications. Review of the MAR showed that on several days there was no documentation that ordered medications, including insulin, were given, and on multiple other days BP medications were administered outside the ordered SBP/DBP parameters. An RN confirmed both the missing administration/documentation and the out-of-parameter dosing, demonstrating significant medication errors contrary to prescriber orders and facility policy.
A medication was left unsecured in a resident's room, allowing the resident access to Fluticasone Propionate Nasal Suspension without a self-administration order. An LPN discovered the medication on the bedside table during a medication pass, and both the LPN and DON confirmed that medications should not be left in resident rooms per facility policy.
Staff documented the administration of a nasal spray in the MAR as if it was given by an LPN, when in fact a resident with hemiplegia and other conditions had self-administered the medication without nursing supervision or an order to self-administer. The DON confirmed this documentation was not in accordance with facility policy.
An LPN failed to follow infection control procedures by returning a tablet of aspirin, which had fallen onto the medication cart, back into a stock bottle during medication administration for a resident with multiple chronic conditions. The incident was observed and later confirmed by the LPN and the DON, and was not in accordance with facility policy.
Six Medicaid recipients were not notified that their personal fund account balances exceeded the Medicaid resource limit, as required. The Business Office Manager confirmed that no spend down notification letters were sent, even though the residents' balances were over the allowable amount.
Quarterly MDS assessments were not completed within the required 92-day interval for a resident, and three other residents had their assessments signed as complete beyond the 14-day window after the ARD. The DON and Administrator acknowledged the delays, citing staff transitions as a contributing factor. Affected residents had complex medical histories, including heart failure, diabetes, dementia, and chronic kidney disease.
A resident with a history of respiratory conditions, including COPD and sleep apnea, was documented as receiving CPAP therapy during the MDS look-back period, but the MDS assessment failed to reflect the use of this non-invasive mechanical ventilator. Facility policy requires accurate coding based on documentation and observation, and both the DON and Administrator confirmed that the CPAP use should have been included in the assessment.
The facility did not ensure that Level I PASARR forms accurately documented mental health diagnoses and psychotropic medication use for two residents. Both individuals had documented histories of mental disorders and were prescribed psychotropic medications, but their PASARR forms failed to reflect this information. Facility staff confirmed the inaccuracies and acknowledged lapses in the review process.
A resident with end stage renal failure who required regular dialysis was repeatedly provided with lunch trays that remained on the bedside table for over two hours while the resident was away for treatment. Upon return, the resident found the food cold and unappetizing, with no reheating or fresh tray offered unless specifically requested. Staff and dietary personnel were unaware of the issue, and facility policy requiring appetizing and safe food temperatures was not followed.
Staff were observed dispensing oral medications directly into their bare hands before placing them into medication cups for two residents with complex medical histories. Both an LPN and an RN acknowledged this was improper and contaminated the medications, which were then discarded. Facility leadership confirmed that medications should be dispensed directly into cups to prevent cross-contamination, but the written policy did not specify procedures for oral medication administration.
Two residents' grievances were not resolved or documented in accordance with facility policy. One resident's malfunctioning wheelchair was not repaired in a timely manner, and follow-up was incomplete. Another resident's repeated concerns about care, supplies, and staff responsiveness were not consistently reported or documented by staff, leaving management unaware and the issues unaddressed.
A nurse documented the administration of insulin for a resident before actually giving the medication, contrary to facility policy and standard practice. The resident, who had multiple chronic conditions and intact cognition, received the medication after it was already signed off in the MAR. This was confirmed through observation, record review, and staff interviews.
A resident with a history of incontinence and multiple medical conditions was not checked or provided incontinence care for several hours, resulting in a saturated bed and mattress. Staff interviews and observations confirmed that care was delayed due to competing duties, despite facility policy requiring checks every two hours.
The facility did not ensure accurate and complete documentation of medical records for two residents, resulting in missing entries for wound care treatments and medication administration. Staff interviews revealed that treatments and medications were sometimes provided but not documented, often due to computer and internet issues. Facility leadership confirmed that documentation was expected but not consistently completed.
A resident with multiple medical conditions developed pressure ulcers while in the facility, but the facility failed to document a comprehensive care plan addressing these ulcers. Despite having a baseline care plan for skin breakdown risk, no specific plan was created for the newly developed ulcers, as confirmed by the MDS Nurse. The RAI manual guidelines for care plan development were not followed.
A facility failed to follow infection control procedures during wound care for a resident with multiple medical conditions, including a deep tissue injury on the left heel. The Director of Nursing and a wound physician did not don a gown during the procedure, and there was no Enhanced Barrier Precautions (EBP) signage or personal protective equipment available near the resident's room. The DON confirmed the oversight, acknowledging the resident should have been under EBP.
A resident reported a stolen check cashed by another resident's relative, but the facility failed to conduct a thorough investigation. Despite the facility's policy to investigate misappropriation, interviews revealed a lack of awareness and action by the Administrator and DON.
A resident with severe cognitive impairment and an indwelling catheter was observed with an uncovered urine collection bag, compromising their dignity. Despite the facility's policy to maintain resident dignity by covering such bags, staff failed to do so, leaving the urine visible to others. This deficiency was identified during a complaint investigation.
A facility failed to maintain safe flooring in a resident's room, affecting a resident with acute encephalopathy and stage three pressure ulcers. The resident's room had missing flooring in two areas and a seam down the middle, which were moist and peeling back. Staff confirmed the condition had persisted since the resident's admission.
The facility failed to maintain safe operating conditions for laundry equipment, as observed with three dryers having thick lint on vents. The Maintenance Supervisor and a Laundry Worker confirmed the vents had not been cleaned for several loads, and no lint cleaning log was maintained. The Administrator acknowledged the need for cleaning after each load as per facility policy.
The facility failed to maintain sanitary conditions in the kitchen, affecting food storage, preparation, and distribution. Observations included a hole in the floor, rust and debris on food preparation surfaces, unlabeled and undated food items, and a broken garbage disposal with leaking sludge and gnats. The Dietary Director and Maintenance Supervisor confirmed these issues, which were contrary to the facility's sanitization policy.
A resident with a history of falls was not timely assessed or treated for injuries after a fall during incontinence care. The resident, who had pulmonary hypertension and chronic kidney disease, fell and was not documented or assessed until the following morning when pain and swelling were noted. An x-ray revealed multiple fractures, and emergency services were called. The facility's protocol for post-fall assessment and documentation was not followed.
A resident with a history of falls and chronic conditions experienced a fall resulting in multiple fractures. The facility failed to assess and manage the resident's pain promptly, administering routine Tylenol hours after the incident. The facility's pain management policy was not followed, as confirmed by the DON, leading to a deficiency in care.
A resident with multiple diagnoses, including cerebral palsy and diabetes, was observed receiving inadequate incontinence care. The resident's brief was heavily saturated, and an STNA used the same washcloth to clean both the front and back peri areas, contrary to facility policy. The DON confirmed this was not the correct procedure.
Unsanitary Kitchen Conditions Due to Overflowing Grill Drip Pan
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation when an early morning observation of the kitchen revealed that grease had overflowed from the grill’s drip pan, running down the grill into a metal pan and onto towels placed on the floor, where the grease had solidified. The Dietary Manager confirmed that the grill’s drip pan handle had been broken for about four months, and that maintenance staff typically came daily to open the drip pan so kitchen staff could empty it. The Dietary Manager further confirmed that the drip pan had not been emptied for a few days, resulting in the overflow and accumulation of grease on the equipment and floor area. The facility reported that all residents received meals from the kitchen except two identified residents, who did not receive meal trays from this kitchen.
AED on Rehab Hall Crash Cart Lacked Pads for Full Code Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure an Automated External Defibrillator (AED) was ready for use for residents requiring basic life support, including CPR, prior to the arrival of emergency medical personnel. During an observation of the Rehab Hall crash cart with the ADON, the AED was found lying on top of the crash cart with no pads connected, and no pads were located in the AED compartments or in the crash cart. The crash cart had a daily checklist of items, all of which were marked as checked, but there was no checkbox to verify the AED’s working order or the presence of pads. In an interview at the time of the observation, the ADON confirmed that no AED pads were readily available. The facility reported that 18 of the 19 residents on the Rehab Hall were designated as Full Code and that this crash cart and AED would be used in the event of an emergency or code situation. This deficiency was investigated under Complaint Number 2725566. No additional resident-specific medical histories or conditions at the time of the deficiency were provided beyond the facility’s identification of 18 Full Code residents on the Rehab Hall.
Failure to Notify Resident Representative of Change in Condition and New Orders
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition and new physician orders, as required by facility policy. The resident was admitted with multiple serious diagnoses, including anoxic brain damage, HIV, end-stage renal disease with dependence on hemodialysis, heart failure, tracheostomy, and sepsis, and was documented as Full Code with impaired cognition and unable to respond. On the Medicare 5-day MDS, the resident was noted to have a trach, pain regimen, feeding tube, pressure ulcer, continuous oxygen therapy, and to be receiving anticoagulant and anticonvulsant medications. On the cited date, progress notes documented that an LPN assessed the resident and found a bounding heart rate of 140, respirations of 36, blood pressure of 95/62, temperature of 98.9°F, oxygen saturation of 93% with trach in place, and use of accessory muscles. The physician was contacted and gave a verbal order for Lopressor 50 mg and to repeat vital signs in 30 minutes. After repeat vitals showed a heart rate of 112, respirations of 24, and blood pressure of 80/50, the physician gave new orders for midodrine 10 mg now and every six hours as needed, CBC, BMP, urinalysis with culture and sensitivity, and a chest radiograph. Medical record review and staff interview, including confirmation by the Director of Nursing, showed that no family or resident representative was notified of this change in condition or the new medical orders, contrary to the facility’s written policy requiring notification of the resident’s representative for changes in medical care, nursing treatments, and significant changes in mental or physical condition.
Failure to Provide and Document Scheduled Bathing Assistance for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baths/showers were offered or completed as scheduled for residents requiring assistance with activities of daily living (ADLs). For one resident with cirrhosis of the liver, a left above-knee amputation, and diabetes mellitus, the quarterly MDS showed the resident was cognitively intact and required supervision or set-up assistance for several ADLs. Shower documentation over a several-week period showed specific dates when showers were either completed or refused, but there were gaps where no documentation existed to show that a bath or shower was offered or provided between certain dates, despite the facility’s expectation that such care be routinely provided. For another cognitively intact resident with chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and chronic respiratory failure, the annual MDS indicated independence with most ADLs and a need for set-up assistance with showers and transfers. Shower records over approximately one month documented instances of completed showers, refusals, and times when the resident was not available or not in the room, but again showed gaps with no documentation that showers were offered or provided between scheduled dates. This resident reported that staff did not provide assistance with showers as scheduled. The DON stated that when a resident is not available at the scheduled bath/shower time, staff are supposed to offer the bath/shower the next day and document any refusals, and confirmed that the records for both residents lacked documentation to support that baths/showers were provided or offered as scheduled, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care and refusals.
Failure to Secure Vaping Device and Inadequate Fall Investigation and Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to keep smoking/vaping devices secured and away from the bedside, and to provide adequate supervision consistent with its smoking policy. One resident with cirrhosis of the liver, a left above-knee amputation, and diabetes mellitus had a quarterly MDS showing intact cognition and a need for supervision with toilet hygiene and transfers, and set-up assistance for eating and bed mobility. A smoking safety evaluation documented that this resident used tobacco, required staff supervision for smoking, could not store smoking materials, and did not use electronic cigarettes or vaping devices. However, the smoking care plan did not specify whether the resident was independent or required supervision with smoking, and the smoking evaluation had not been updated for several months. During observation, the resident was found lying in bed with a vaping device on the bed near his hand, and he confirmed it was his vape and that he sometimes used it in his room. The MDS nurse present confirmed the vaping device was at the bedside, stated she was unaware the resident used a vaping device, and acknowledged that the smoking evaluation had not been updated. The facility’s smoking policy stated that smoking is only permitted in designated outdoor areas, that smoking is not allowed inside the facility under any circumstances, and that electronic cigarettes are permitted only in designated areas and with supervision. The policy also stated that residents without independent smoking privileges may not keep smoking items except under direct supervision. The facility also failed to adequately investigate and respond to a resident’s fall and to complete neurological checks after unwitnessed falls. A second resident, with hypertensive heart and chronic kidney disease, end stage renal disease, and anemia, had a quarterly MDS indicating intact cognition and a need for partial/moderate assistance with bathing, bed mobility, and transfers, and supervision with toilet hygiene. A fall risk assessment indicated only one to two falls in the prior three months and that the resident was not at risk for falls, but nursing notes documented multiple falls over a period of time, including unwitnessed falls. After one unwitnessed fall, there was no documentation that neurological checks were initiated, and a change of condition evaluation referencing the unwitnessed fall lacked accompanying nurse progress notes about the fall. The facility incident log contained no evidence of an investigation or implementation of interventions for that fall, and an LPN confirmed that neurological checks were not documented after two of the falls and that no investigation or interventions were completed for one of the falls, contrary to the facility’s fall response procedure requiring immediate assessment, documentation, neurological checks for unwitnessed falls, and care plan updates.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
Surveyors identified a failure to administer medications as ordered by the physician for one resident. The resident was admitted with chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and chronic respiratory failure, and an annual MDS showed the resident was cognitively intact and largely independent with activities such as eating, bed mobility, toileting hygiene, and transfers with set-up assistance. Physician orders included metformin 500 mg twice daily, ferrous sulfate 325 mg daily, loratadine 10 mg daily, Theragran-M daily, montelukast sodium 10 mg daily, ibuprofen 800 mg three times daily, methocarbamol 750 mg three times daily, and Os-Cal 500-150 mg daily. Review of the November 2025 MAR for this resident showed no documentation that medications were administered as ordered on multiple specific dates, and the January 2026 MAR also lacked documentation that medications were given as ordered on two additional dates. The resident reported not receiving medications at times, and the Administrator confirmed that the medical record did not contain documentation to support that medications were administered as ordered on the identified dates. Facility policy on administering medications stated that medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including required time frames, which was not followed in this case.
Failure to Administer Insulin and Antihypertensives as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications, including insulin and blood pressure medications, were administered as ordered for one resident. The resident was admitted with diagnoses including acute and chronic respiratory failure, dysphagia, COPD, DM, and ESRD, and required assistance with most activities of daily living. Physician orders included midodrine with instructions to hold if systolic blood pressure (SBP) was greater than 110, metoprolol with instructions to hold if SBP was less than 100 or diastolic blood pressure (DBP) was less than 60, scheduled insulin lispro before meals and at bedtime, Lantus twice daily, and multiple other medications via PEG-tube and inhalation. The facility’s policy on administering medications required that medications be administered safely, timely, and in accordance with prescriber orders, including any required time frames. Medical record review showed that the December Medication Administration Record (MAR) contained no documentation that medications, including insulin, were administered as ordered on multiple specific dates in December. Further review of the January MAR showed that blood pressure medications (metoprolol and midodrine) were administered outside of the ordered blood pressure parameters on multiple specific dates in January. In an interview, an RN confirmed the absence of documentation supporting that the resident received medications, including insulin, on the identified December dates and confirmed that blood pressure medications were given outside the ordered parameters on the identified January dates. These findings demonstrated that the facility did not follow physician orders or its own medication administration policy, resulting in significant medication errors for this resident.
Unsecured Medication Left in Resident Room
Penalty
Summary
A deficiency occurred when a medication, specifically Fluticasone Propionate Nasal Suspension, was left unsecured in a resident's room. The resident, who had diagnoses including dysphagia following cerebral infarction, type two diabetes, and hemiplegia affecting the non-dominant side, was totally dependent on staff for mobility and self-care and did not have an order to self-administer medications. During a medication pass, an LPN discovered the nasal spray on the resident's bedside table after the resident indicated he had already used it, stating that the night shift had left it in his room the previous night. Interviews with the LPN and the Director of Nursing confirmed that medications should not be left in resident rooms and that the resident did not have authorization to self-administer. Review of facility policy also indicated that all medications and biologicals must be stored in locked compartments accessible only to authorized personnel. The failure to secure the medication and ensure it was not accessible to the resident without proper orders constituted a violation of medication storage protocols.
Inaccurate Medication Administration Documentation
Penalty
Summary
Facility staff failed to ensure the accuracy of a resident's medical record by documenting that a medication was administered by nursing staff when, in fact, the resident had self-administered the medication without nursing supervision. The resident, who had diagnoses including dysphagia following cerebral infarction, type two diabetes, and hemiplegia affecting the non-dominant side, required assistance with self-care and mobility and did not have an order to self-administer medications. Despite this, the resident was able to access and use a prescribed nasal spray independently, as the medication had been left at the bedside by the night shift. During a medication pass, an LPN prepared the resident's medication and entered the room, only to find that the resident had already used the nasal spray. The LPN subsequently signed the medication administration record (MAR) as if the medication had been administered by the nurse, contrary to facility policy, which requires staff to document only medications they have personally administered. The DON confirmed that the nurse should not have documented the medication as given when it was not witnessed.
Failure to Prevent Cross Contamination During Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow proper infection prevention and control procedures during medication administration. During a medication pass, an LPN was observed retrieving a stock bottle of aspirin, dispensing a tablet into the lid, and accidentally dropping a tablet onto the medication cart. The LPN then picked up the dropped tablet from the cart surface and placed it back into the stock bottle with the other tablets, instead of discarding it. This action was witnessed during direct observation and later confirmed by the LPN in an interview, where she acknowledged that the tablet should have been thrown away. The affected resident had a history of chronic obstructive pulmonary disease, epilepsy, and nontraumatic intracerebral hemorrhage, and required assistance with activities of daily living. The facility's policy on medication administration required staff to follow established infection control procedures, which were not adhered to in this instance. The Director of Nursing confirmed that nurses are not permitted to touch medications with bare hands, further verifying the breach in protocol.
Failure to Notify Residents of Excess Personal Fund Balances
Penalty
Summary
The facility failed to notify six Medicaid recipients that their personal fund account balances exceeded the Medicaid resource limit by more than $200, as required. During a review of resident fund documentation, it was found that these residents all had account balances over $2,000. The Business Office Manager confirmed that no spend down notification letters had been sent to these residents, despite being aware of the excess balances and having the letters prepared but not distributed. This deficiency was identified through both record review and staff interview.
Failure to Complete and Sign Quarterly MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and sign quarterly Minimum Data Set (MDS) assessments within the required federal timeframes for several residents. Specifically, one resident's quarterly MDS assessment was not completed within 92 days of the previous assessment, resulting in the assessment being 27 days overdue. Additionally, three other residents had quarterly MDS assessments that were not signed as complete within 14 days of the Assessment Reference Date (ARD), as required by the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The facility's own policy also mandates adherence to these federal and state submission timeframes. Interviews with the Director of Nursing (DON) and the Administrator confirmed awareness of the overdue and incomplete MDS assessments. The Administrator attributed the delays to recent staff transitions, noting that the current MDS Coordinator had only been in the role for about two weeks. The residents affected had various medical histories, including heart failure, diabetes mellitus, dementia, cerebral infarction, hypertension, chronic kidney disease, and cerebrovascular disease. The deficiencies were identified through record review, policy review, and staff interviews.
Inaccurate MDS Coding for Non-Invasive Mechanical Ventilator Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded regarding the use of a non-invasive mechanical ventilator for a resident. According to facility policy, all portions of the MDS must be certified for accuracy and reflect the resident's status during the observation period. The resident in question had a medical history including heart failure, COPD, sleep apnea, lobar pneumonia, and dependence on supplemental oxygen. The quarterly MDS assessment indicated that the resident received oxygen therapy but did not use a non-invasive mechanical ventilator, despite documentation to the contrary. Review of the resident's Treatment Administration Record (TAR) showed that a CPAP, which is a non-invasive mechanical ventilator, was ordered and administered during the 14-day look-back period for the MDS assessment. Staff documented the use of the CPAP on multiple occasions within this period. Interviews with the DON and Administrator confirmed that the use of CPAP should have been included in the MDS assessment and that accurate documentation and observation are essential for proper coding. The failure to capture the use of the non-invasive mechanical ventilator on the MDS assessment constituted the deficiency.
Inaccurate PASARR Documentation for Mental Disorders and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Review (PASARR) forms accurately reflected all diagnosed mental disorders and prescribed psychotropic medications for two residents. According to the facility's policy, all potential admissions must be screened individually to determine if they meet criteria for serious mental illness, intellectual disability, or related conditions. However, for two residents, the PASARR forms did not document existing mental health diagnoses or the use of psychotropic medications, despite clear evidence in their medical records and medication administration records. One resident was admitted with diagnoses of post-traumatic stress disorder, major depressive disorder, and a history of suicide attempt, and was prescribed multiple psychotropic medications including antipsychotics, antidepressants, and antianxiety agents. The PASARR form for this resident, completed by the Social Services Director, incorrectly indicated that the resident had not received any psychotropic medications in the past six months. Interviews with facility staff confirmed that the PASARR form was inaccurate and that there was uncertainty about who was responsible for reviewing the forms for accuracy. Another resident was admitted with a diagnosis of schizophrenia and was prescribed antipsychotic, antidepressant, and mood stabilizer medications. The PASARR form for this resident failed to indicate the presence of a mental disorder or the use of psychotropic medications, despite documentation in the resident's records. Facility staff, including the DON and Administrator, acknowledged that the PASARR forms were incomplete and did not accurately reflect the residents' conditions or medication use at the time of admission.
Failure to Provide Palatable Food at Safe Temperature for Dialysis Patient
Penalty
Summary
Facility staff failed to provide a resident with food at an appetizing and safe temperature, as required by facility policy and federal guidelines. The resident, who had end stage renal failure and required dialysis three times a week, routinely had their lunch tray placed on the bedside table around noon, despite being away at dialysis until approximately 2:30 PM. Multiple observations confirmed that the lunch tray remained untouched on the bedside table for over two hours while the resident was absent. Upon returning, the resident reported that the food was cold and not reheated, and was unaware that a fresh tray could be requested. Staff interviews revealed that the tray was left in the room until the resident returned, and reheating was only done if specifically requested by the resident. The Dietary Director was not informed when the resident returned from dialysis and was unaware that the tray had been left out for an extended period. He stated that food should be discarded after two hours without refrigeration and that he expected to be notified to provide a fresh tray. The Director of Nursing and the Administrator both stated they were not aware of the practice of leaving trays out for extended periods and expected food to be served at proper temperatures. The facility's failure to coordinate meal service with the resident's dialysis schedule resulted in the resident being provided with cold, unappetizing food that had been left out for several hours.
Failure to Prevent Cross-Contamination During Medication Administration
Penalty
Summary
Facility staff failed to administer medications in a manner that prevents the transmission of communicable diseases and infections. During medication administration, staff were observed dispensing oral medications directly into their bare hands before placing them into medication cups for residents. This practice was observed with two residents, both of whom had intact cognition and complex medical histories, including conditions such as pulmonary embolism, heart failure, hypertension, diabetes, and hyperlipidemia. For one resident, an LPN dispensed multiple medications, including allopurinol, apixaban, gabapentin, sacubitril-valsartan, vitamin D, empagliflozin, and metoprolol, directly into her hand from blister cards before transferring them to a medication cup. The LPN acknowledged during the observation that this was not the correct procedure and that the medications were considered contaminated as a result. The contaminated medications were discarded, and the process was restarted. In a separate incident, an RN dispensed atorvastatin directly into his bare hand before placing it in a medication cup for another resident. The RN also recognized this as improper practice and discarded the medication. Interviews with the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, the Director of Nursing (DON), and the Administrator confirmed that the facility's expectation was for medications to be dispensed directly from the medication card into a medication cup, not into staff hands, to avoid cross-contamination. Facility policy on infection control was reviewed, but the medication administration policy did not specify procedures for oral medication administration. All interviewed staff agreed that dispensing medications into bare hands constituted an infection control issue.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to resolve and document grievances in a timely and complete manner for two residents. For one resident with a history of stroke and hemiplegia, a concern was raised regarding a malfunctioning personal wheelchair. The concern was reported by both the resident and a family member, and a concern form was completed. However, the facility did not ensure that the wheelchair manufacturer's representative was contacted for repairs, and the follow-up documentation was incomplete, lacking confirmation of the resident's satisfaction or the resolution of the issue. Multiple staff members, including the Social Services Director, Maintenance Director, Rehabilitation Director, and Administrator, were either unaware of the concern or did not take action to resolve it, despite the issue being discussed in a morning meeting. For another resident with cerebral palsy, heart failure, and COPD, multiple concerns were raised regarding care, including not receiving medications on time, inadequate incontinence care, and issues with supplies and staff responsiveness. These concerns were communicated verbally to various staff members, including nurse aides and management, but were not consistently documented or reported according to facility policy. Staff interviews revealed that concerns were often not written down or formally reported, with some staff assuming that management was already aware due to the resident's frequent complaints. The Social Services Director, Assistant Director of Nursing, and Director of Nursing all confirmed they were not aware of these ongoing concerns and that there was no documentation to support that the grievances had been addressed or resolved. The facility's grievance policy required prompt resolution and documentation of all grievances, whether verbal or written, typically within five business days. In both cases, the facility failed to follow its own policy by not ensuring timely resolution, proper documentation, and feedback to the residents regarding their concerns. This resulted in unresolved grievances and a lack of accountability in addressing resident complaints.
Medication Administration Documentation Prior to Actual Administration
Penalty
Summary
Staff failed to document the administration of medications in accordance with acceptable standards of practice. Specifically, a registered nurse documented the administration of Lantus insulin for a resident prior to actually administering the medication. The facility's policy and the statements from both the Director of Nursing and the Administrator confirmed that the expected process is to administer the medication before documenting it on the Medication Administration Record (MAR). However, the nurse signed off on the MAR before giving the medication, which was acknowledged as a mistake during an interview. The resident involved had a medical history including cerebral palsy, heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus, and was cognitively intact at the time of the incident. The nurse administered the resident's scheduled dose of Lantus insulin, but the MAR indicated it was documented as given before the actual administration. This discrepancy was observed and confirmed through interviews and record review.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Staff failed to provide timely incontinence care for a resident with a history of type 2 diabetes mellitus, urinary tract infection, overactive bladder, and dementia. The resident was always incontinent of urine and bowel, wore briefs, and was not on a toileting program. Facility policy and the resident's care plan both required that incontinent residents be checked and provided perineal care at least every two hours. On the morning in question, the resident was not checked for incontinence or provided care until 10:40 AM, despite reporting to staff earlier that their bed was soaking wet and they had not yet been changed. Multiple staff interviews confirmed that the expectation was to check and change the resident every two hours, but on this occasion, the assigned aide had not provided any personal care due to being delayed by other duties. Observations revealed the resident's bed and mattress were saturated, and the resident had been waiting for care for several hours. The deficiency was substantiated through interviews, record reviews, and direct observation, confirming non-compliance with the facility's incontinence care policy.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure that residents' medical records were accurate and complete, as required by both facility policy and federal and state regulations. For one resident with paraplegia and multiple complex wounds, there were numerous instances where the Treatment Administration Record (TAR) lacked documentation that wound care treatments were provided as ordered. Specific dates and wound sites were identified where no evidence of treatment administration was recorded, despite staff interviews indicating that wound care was performed but not always documented. The Director of Nursing and the Administrator both confirmed that staff are expected to document treatments on the TAR when completed. For another resident with multiple chronic conditions, including diabetes, heart failure, and chronic obstructive pulmonary disease, the Medication Administration Record (MAR) showed multiple missing entries for the administration of prescribed medications such as Percocet, DuoNeb, Humalog, and Lantus. Staff interviews revealed that nurses and aides experienced frequent computer and internet issues, which sometimes prevented them from completing or saving documentation in the electronic medical record system. Some staff reported being unable to sign out medications on the MAR due to technical problems, and these issues were known to at least one member of management. The facility's own policy requires that all treatments and medications, including refusals, be accurately documented in the resident's medical record. Despite this, the records for both residents were incomplete, with missing documentation for both wound care and medication administration. The lack of documentation was confirmed through record review and staff interviews, and the facility leadership acknowledged the expectation for complete documentation.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who developed pressure ulcers while residing in the facility. The resident, who had a history of metabolic encephalopathy, diabetes mellitus, cerebral infarction, dysphagia, hypertension, and hypothyroidism, was admitted with no skin breakdown but later developed an unstageable pressure ulcer to the mid-sacrum. The initial skin assessment noted the ulcer on 09/30/24, and subsequent assessments showed worsening conditions, including a deep tissue injury to both buttocks. Despite these developments, the facility did not document a comprehensive care plan addressing the resident's pressure ulcers. The medical record review revealed that the facility had a baseline care plan indicating the resident was at risk for skin breakdown, with interventions such as encouraging good nutrition and providing pressure-relieving devices. However, there was no documentation of a comprehensive care plan for the newly developed pressure ulcers. An interview with the MDS Nurse confirmed the absence of such documentation, despite the facility's use of the RAI manual for care plan development. The RAI manual specifies that a comprehensive care plan must include measurable objectives and time frames, describing the services to be furnished to maintain the resident's well-being.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control procedures during wound care for a resident, which was identified during a complaint investigation. The resident, who had medical diagnoses including end-stage renal disease, diabetes mellitus, obesity, right-sided hemiparesis, and atherosclerotic heart disease, was noted to have a deep tissue injury on the left heel. The injury was first observed several months prior and was being treated with a barrier wipe/spray as per physician orders. However, there was no documentation supporting an order for Enhanced Barrier Precautions (EBP). During an observation, the Director of Nursing (DON) and a wound physician provided wound care to the resident without donning a gown, which is a breach of infection control protocols. Additionally, there was no sign posted for EBP or personal protective equipment available near the resident's room. The DON confirmed in an interview that the facility did not follow EBP for the resident, acknowledging that the resident should have been under such precautions. This deficiency was noted as an incidental finding during the investigation.
Failure to Investigate Misappropriation Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident. Resident #51, who was cognitively intact and had diagnoses including COPD, dementia, and anxiety, reported that a check was stolen and cashed by another resident's relative. The incident was substantiated, and the suspected abuser was prohibited from entering the community. However, the facility did not conduct a comprehensive investigation into the allegations. Interviews with the Administrator and the Director of Nursing revealed a lack of awareness and action regarding the need for a thorough investigation. The facility's policy on abuse prevention and reporting emphasizes the importance of promptly and aggressively investigating all reports of misappropriation, but this was not adhered to in this case. The deficiency was identified during an investigation under a specific complaint number.
Failure to Cover Urine Collection Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure a resident's urine collection bag was covered with a privacy bag, which compromised the resident's dignity. This deficiency was identified during a complaint investigation and affected one resident who was observed with an indwelling catheter and urine collection bag. The resident, who had severe cognitive impairment and was dependent on staff for toilet hygiene, expressed discomfort with having his urine visible to others. The staff had assisted the resident into his wheelchair and attached the urine collection bag without covering it, leaving the urine visible to staff, residents, and visitors. The facility's policy on dignity, revised in April 2018, mandates that care should be provided in a manner that maintains or enhances each resident's dignity, including refraining from practices such as leaving urinary catheter bags uncovered. Despite this policy, the observation and interviews confirmed that the resident's urine collection bag was not covered, violating the resident's right to a dignified existence. This incident highlights a lapse in adhering to the facility's dignity policy, as the staff failed to cover the urine collection bag, leading to the deficiency noted in the report.
Facility Fails to Maintain Safe Flooring in Resident's Room
Penalty
Summary
The facility failed to maintain a safe and homelike environment for Resident #17, as evidenced by the condition of the flooring in the resident's room. The resident, who was admitted with acute encephalopathy, stage three pressure ulcers, and sepsis, was found to have missing flooring in two areas by the foot of the bed and a seam down the middle of the floor. These areas measured approximately three inches long by six inches wide by 0.5 inches deep, and ten inches long by 1.5 inches wide by 0.5 inches deep, respectively. The resident confirmed that the flooring had been in this condition since their admission. Interviews with staff, including an LPN and a Maintenance Assistant, corroborated the resident's observations. Both staff members confirmed the presence of the damaged flooring and noted that the areas were moist and peeling back. This deficiency was identified during an investigation under Complaint Numbers OH00154760 and OH00154449, indicating non-compliance with the requirement to provide a safe and homelike environment for residents.
Failure to Maintain Safe Laundry Equipment
Penalty
Summary
The facility failed to maintain mechanical equipment in a safe operating condition, specifically in the laundry room where three dryers used for resident laundry had a thick layer of lint on the vents. This was observed during a survey on 05/28/24 at 8:47 A.M. with the Maintenance Supervisor, who confirmed that the lint was very thick and had not been cleaned for several loads or possibly days. The Maintenance Supervisor acknowledged that the vents should be cleared of lint after each load and that a lint cleaning log should be maintained, but no such record was available. A Laundry Worker confirmed that he had not cleaned the dryer vents since the previous day, despite completing several loads of laundry. The Administrator also confirmed that staff should clean the lint from the dryers after each load as an environmental safety measure. The facility's policy and job description for laundry workers emphasized the importance of safety precautions and maintaining a safe, clean, and comfortable environment for residents.
Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to store, prepare, and distribute food in a sanitary manner, potentially affecting 75 residents. During an initial tour of the facility kitchen, several deficiencies were observed, including a large hole in the floor with a missing tile, rust and metal flaking off the tray line counter used for food preparation, and food debris and splatter on the counter and trash cans. The trash cans lacked lids, and there was black dirt, smudges, and food debris along the walls and under appliances. Additionally, a large container of chemical cleaner was found in the food preparation area, and expired bread and hamburger buns were stored on a metal cart. The Dietary Director confirmed these observations during the tour. Further inspection of the walk-in refrigerator revealed multiple items, such as sliced tomatoes, cheese, pudding cups, mashed potatoes, sliced turkey, mechanical soft chicken, coleslaw, lettuce, tomato sauce, and green beans, that were either unlabeled or undated. The Dietary Director confirmed that all stored foods should be labeled and dated when opened. Additionally, the facility's garbage disposal was found to be broken, with rotten food debris and sludge leaking onto the floor, attracting gnats. The Maintenance Supervisor confirmed the disposal had been out of service for several months due to a lack of payment approval for repairs. The facility's policy on sanitization was reviewed, which stated that the food service area should be maintained in a clean and sanitary manner, free of litter, rubbish, and insects.
Failure to Timely Assess and Treat Resident Injuries After Fall
Penalty
Summary
The facility failed to timely assess and treat injuries for a resident following a fall. Resident #67, who had diagnoses including pulmonary hypertension and chronic kidney disease, was at risk for falls due to new surroundings and impaired safety awareness. On the night of the fall, the resident was being assisted with incontinence care when she fell. There was no documentation of the fall or a post-fall assessment in the resident's medical record on the day of the incident. The following morning, the resident was found to have pain, swelling, and bruising, and an x-ray revealed multiple fractures. The staff involved did not follow the facility's protocol for assessing and documenting the resident's condition after the fall. The resident initially refused to go to the hospital despite staff recommendations. The x-ray was ordered the morning after the fall, and emergency services were called after the results showed significant injuries. The facility's policy required staff to assess residents for changes in condition and notify the attending physician, which was not done in a timely manner in this case.
Inadequate Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident following a fall. The resident, who had a history of osteoarthritis, weakness, and falls, experienced a fall that resulted in multiple fractures. Despite the resident's care plan outlining specific interventions for pain management, the facility did not assess or document the resident's pain level immediately after the fall. The resident did not receive any pain medication until approximately three hours after the incident, and the initial assessment of pain was not documented until the following morning. The resident's medical record showed that she was admitted with diagnoses including pulmonary hypertension and chronic kidney disease. After the fall, the resident complained of severe pain, and an x-ray revealed fractures in the right tibia and fibula, as well as the left femur. Despite these injuries, the facility only administered routine Tylenol, which was not given until hours after the fall. Interviews with the resident and staff confirmed that the resident was in excruciating pain and did not receive timely pain relief. The facility's policy on pain management required acute pain to be assessed every 30 to 60 minutes and for the effectiveness of nonpharmacological interventions to be documented. However, the facility did not follow these guidelines, as there was no documentation of additional pain medication orders or nonpharmacological measures being implemented. The Director of Nursing confirmed the lack of pain assessment and timely medication administration, highlighting a significant lapse in the facility's pain management practices.
Inadequate Incontinence Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate incontinence care in a sanitary manner for Resident #13, who was admitted with diagnoses including cerebral palsy, heart failure, schizoaffective disorder, and type two diabetes mellitus. The resident was dependent on staff for toileting and was always incontinent of bowel and bladder, as noted in the quarterly Minimum Data Set (MDS) assessment. A physician's order required staff to apply zinc oxide topical ointment to the peri-area and buttocks after each incontinent episode. During an observation of incontinence care, two State tested Nursing Assistants (STNAs) were involved in the care of Resident #13. The resident's incontinence brief was heavily saturated with urine. STNA #11 used the same washcloth to clean both the front peri area and the buttocks of the resident, which was confirmed during an interview. This practice was against the facility's policy, as confirmed by the Director of Nursing (DON), who stated that staff should not use the same washcloth for cleaning a resident from front to back during incontinence care.
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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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