Astoria Place Of Waterville
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterville, Ohio.
- Location
- 555 Anthony Wayne Trail, Waterville, Ohio 43566
- CMS Provider Number
- 365747
- Inspections on file
- 31
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 41 (1 serious)
Citation history
Health deficiencies cited at Astoria Place Of Waterville during CMS and state inspections, most recent first.
A resident with bipolar disorder, schizoaffective disorder, major depressive disorder, epilepsy, and other comorbidities experienced a gradual dose reduction of Abilify without timely psychiatric reassessment and with inconsistent behavior documentation. In the weeks before the incident, staff and psychology notes described depression, low energy, poor concentration, anhedonia, and later increased aggression, arguing, medication refusal, and throwing objects, but these behaviors were not consistently charted, and no medication changes were implemented. On an overnight shift, a CNA observed the resident talking to himself, shouting profanities, and becoming highly agitated and unapproachable, while an LPN documented verbal aggression, threatening gestures, and lack of sleep, but hospice was not notified as directed and no effective interventions were implemented. The next morning, the resident was found outside on a snowy hillside about 100 feet from his window, lightly clothed, combative, stating he wanted to die, and showing signs of hypothermia and injury; EMS and hospital records documented altered mental status, psychosis, delusions, hypothermia, frostbite, and placement on an Emergency Application for a suspected suicide attempt. The facility lacked a policy for behavioral or psychological needs and did not follow its change-in-condition policy requiring physician consultation for significant mental or psychosocial changes.
A resident with multiple chronic conditions and moderate cognitive impairment exited the building through a window and was later found outside, prompting staff to call 911 and remain with the resident until EMS arrived. Although internal notifications were documented, review of the state CALS system showed no report of the elopement to the Ohio Department of Health. In an interview, the Administrator confirmed the elopement and acknowledged that ODH was not notified, stating unawareness of the reporting requirement despite a facility policy directing that such incidents be reported to the Administrator and, when applicable, to ODH within required time frames.
A resident with a history of schizophrenia and moderate cognitive impairment, who had no prior documented aggressive behaviors, was found in a room with another resident who was discovered deceased with ligatures tightly wrapped around her neck. Staff had last seen both residents in the hallway earlier in the evening. The facility failed to prevent resident-to-resident abuse, resulting in the death of a resident by strangulation, as confirmed by coroner and police reports.
The facility did not provide food prepared in a form tailored to meet the individual needs of residents, resulting in meals that were not consistently modified for specific dietary or physical requirements.
The facility did not ensure staff consistently followed dietary restrictions and supervision requirements, resulting in a resident's death from choking after receiving unapproved food, and additional incidents where residents with special dietary needs were left unsupervised or accessed inappropriate food items.
Surveyors identified multiple environmental deficiencies, including holes in drywall, water accumulation under sinks, missing or broken light cords and covers, and stained ceilings in several resident rooms. The Regional Director of Maintenance confirmed these issues, which affected eight residents and indicated a failure to maintain a homelike environment.
Two residents with self-care deficits did not receive adequate nail care as required by their care plans. One resident was repeatedly observed with dirty fingernails containing a dark brown substance, despite staff awareness of her behaviors and care needs. Another resident had long fingernails and expressed a desire for them to be trimmed, but staff were unclear about responsibility for this task. Facility policy required staff to follow ADL care plans, including nail care, but this was not consistently done.
Two residents experienced deficiencies in supervision and safety: one was not properly assessed after an unwitnessed fall, and another, with a history of taking food from others, was able to access and consume food not permitted in her prescribed pureed diet. Staff were aware of these behaviors but did not implement additional interventions to prevent recurrence.
The facility did not ensure an RN was present for the required eight hours on a specific day, as confirmed by schedule and timesheet reviews and staff interview. This lapse affected all 68 residents, as there was no RN available to provide necessary nursing care and oversight.
A housekeeper used personally purchased household cleaning products instead of facility-approved agents to clean resident rooms and common areas on one unit, with the knowledge and approval of her supervisor. The cleaning products were not intended for industrial or sanitizing use, and the facility lacked a policy specifying required cleaning agents.
A resident with severe cognitive impairment and high fall risk was assisted to the bathroom without his walker by two CNAs, resulting in a fall and a fractured femur. The incident was not reported to the nurse, and the facility's investigation was incomplete, lacking documentation of the resident's use of a walker and environmental conditions. The care plan did not include the use of a walker, and the facility's fall policy was not adequately followed.
A resident with a history of aggressive behavior physically abused two other residents, causing significant injuries. The facility's interventions, such as 15-minute checks and psychological evaluations, were insufficient, and the investigation lacked comprehensive assessments. The facility's policy on abuse prevention was not effectively implemented, contributing to repeated incidents of abuse.
The facility failed to timely report resident-to-resident abuse incidents involving a resident with dementia who caused injuries to two other residents. The incidents were not promptly filed in the Self-Reported Incident (SRI) database, and local law enforcement was not notified as required by the facility's policy. This resulted in non-compliance with state regulations.
Failure to Assess and Respond to Resident’s Acute Mental Health Decline Leading to Harm
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, document, and address a resident’s mental health decline and behavioral changes, despite the resident’s significant psychiatric history and hospice status. The resident had diagnoses including bipolar disorder, schizoaffective disorder, major depressive disorder, epilepsy, COPD, and CKD, and was receiving hospice services. Antipsychotic medication (Abilify) had been gradually reduced from 10 mg to 5 mg on 11/11/25 and then to 2.5 mg on 12/11/25 as a gradual dose reduction. Psychology notes from 12/10/25 and 12/24/25 documented depression, low energy, poor concentration, and lack of motivation, but no psychosis, hallucinations, or suicidal ideation at those times. Behavior documentation from 12/07/25 through 01/02/26 showed no recorded behaviors, despite later staff reports of aggression and mood changes. On 12/22/25, nursing documentation noted low energy, inability to sleep, quiet and flat affect, and a behavior note described anhedonia and sadness. A PHQ-9 interview on 12/23/25 recorded no mood symptoms and indicated no need for a staff mood interview. On 12/24/25, psychology documented depressed affect, low energy, poor concentration, lack of interest, and sadness, but still no psychosis or suicidal ideation. On 12/30/25, a nursing progress note stated hospice was advised of increased aggression and that a PNP would adjust medications; however, there was no corresponding documentation of the resident’s aggression in the behavior charting, no record that the PNP actually saw the resident that day, and no evidence of any medication changes. A later interview with an RN clarified that the resident had been arguing with a roommate, refusing medications, and throwing things in his room, but these behaviors were not captured in the behavior documentation. During the night shift of 01/01/26–01/02/26, a CNA reported that the resident was “not right” and “actually scary,” lying in bed talking quietly to himself, shouting profanities when staff walked by, and becoming more agitated when approached, acting as if he would get out of bed. The CNA, who had cared for the resident for two to three years, stated this behavior was very out of character and reported her concerns to the LPN. The LPN attempted to give evening medications around 7:30 P.M., which the resident refused, and stated the door was kept open to observe him. The LPN later sent a text to the physician at 6:07 A.M. about the behaviors and lack of sleep but did not contact hospice as instructed by the DON and did not receive a response before leaving at 6:36 A.M. Behavior charting for 01/02/26 at 5:59 A.M. documented that the resident was verbally aggressive, yelling profanities, making threatening gestures, unapproachable, highly agitated, awake all night, and talking loudly with aggressive, profane language to himself; it also stated that the physician and on-call provider were notified, but there was no evidence of interventions implemented throughout the night. On the morning of 01/02/26, the DON reported receiving a call around 6:00 A.M. from the hall nurse about the resident talking to himself and to people who were not there and instructed the nurse to call hospice. The DON arrived at approximately 7:00 A.M., was told the resident was sleeping, and did not check on him. Hospice later confirmed the facility did not contact them about the change in mental status and that hospice only became aware when their nurse arrived for a routine visit and saw EMS assisting the resident. Around 7:50 A.M., a transportation driver arriving at the facility saw something in the snow and discovered the resident outside approximately 100 feet from his window, on his knees in the snow, agitated, stating he wanted to die, with abrasions, bright red skin, and wearing only light clothing. Facility staff and EMS reports indicated the resident was combative, aggressive, and psychotic, with altered mental status, injuries, and signs of hypothermia in temperatures around 21°F. EMS and hospital records documented that the resident was found kneeling in the snow with a cold wet blanket, with drag marks suggesting he had rolled down a hill from a first-floor window approximately 77 inches above the ground. The resident was pale with purple extremities, abrasions, and nonblanchable skin over heels and knees, and required soft restraints and sedative medication due to combative behavior. At the hospital, he was described as cold to the touch, with a core temperature of 95.6°F, delusions (including stating he was pregnant), and paranoia. He was admitted with hypothermia due to exposure, stage one frostbite to the heels, and delusions, and was placed on an Emergency Application for suspected suicide attempt after reportedly jumping from his window and remaining in the snow. Interviews with the PNP and hospice staff revealed discrepancies in Abilify dosing between hospice and facility records, lack of timely psychiatric reassessment after the GDR, and inconsistent or missing documentation of behavioral concerns. The facility’s Administrator and Vice President of Clinical Operations confirmed there was no facility policy related to meeting residents’ behavioral or psychological needs, and the facility’s change-in-condition policy required physician consultation for significant changes in mental or psychosocial status, which was not consistently followed in this case.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to notify the Ohio Department of Health (ODH) of a resident elopement as required. Medical record review showed that Resident #09, who had multiple diagnoses including localization-related symptomatic epilepsy with simple partial seizures, COPD, chronic kidney disease, bipolar disorder, schizoaffective disorder, morbid obesity, and major depressive disorder, was admitted on an identified date and later transferred to the hospital. An MDS assessment indicated the resident was moderately cognitively impaired without documented mood concerns or behaviors. A nursing progress note documented that on a specific date the nurse was notified the resident was outside, 911 was called, and the nurse remained with the resident until emergency services arrived, stating that all parties were notified. Review of the Certification, Licensure, and Survey (CALS) system for the relevant time period revealed no evidence that the facility reported the resident’s elopement to ODH. During an interview, the Administrator confirmed that the resident had exited the building through his window and was found outside the facility, and acknowledged that ODH had not been notified. The Administrator stated that hospice had informed her they were required to report the incident to ODH, but she was not aware that she was also required to do so. Review of the facility’s Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property policy showed that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and all injuries of unknown source must be reported immediately to the Administrator or designee, and that if abuse was alleged or serious bodily injury identified, the Administrator/designee would notify ODH immediately but not later than two hours after the allegation or identification of serious bodily injury.
Failure to Prevent Resident-to-Resident Abuse Resulting in Homicide
Penalty
Summary
A deficiency occurred when the facility failed to prevent resident-to-resident abuse, resulting in the death of one resident. The incident involved a resident with a history of schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder, who was initially admitted to a secured dementia unit, later moved to a behavior unit, and then returned to the dementia unit. This resident had no documented history of aggressive behaviors toward staff or other residents during their stay, and their care plan included interventions for cognitive loss and impaired judgment. Another resident, with diagnoses including major depression, bipolar disorder, severe cognitive impairment, and other medical conditions, resided on the secured dementia unit and was independently ambulatory with severe cognitive impairment noted on assessment. On the evening of the incident, staff were unable to locate the resident with schizophrenia for medication administration. After searching, staff found the resident in a room with the door closed, standing inside and perspiring. Behind a privacy curtain, another resident was found lying supine on the floor with towels and a pillowcase tightly wrapped around her neck, her face purple, and blood in her mouth. The staff immediately called for help, assessed the unresponsive resident, and contacted emergency services and law enforcement. The resident was pronounced deceased at the scene, and the cause of death was determined to be homicide by strangulation, as confirmed by the county coroner and autopsy findings. Interviews and documentation revealed that staff had last seen both residents in the hallway earlier that evening, and there was no indication of prior aggressive behavior from the resident who committed the act. The facility's policy on abuse, mistreatment, and neglect was reviewed, which defines abuse as the willful infliction of injury resulting in physical harm. The incident was investigated by police, and the resident responsible was taken into custody. The deficiency was cited for the facility's failure to protect residents from abuse, resulting in actual harm and death.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures. The report does not provide further details about the residents involved or their medical conditions at the time of the deficiency.
Failure to Enforce Dietary Restrictions and Supervision Leading to Choking Incidents
Penalty
Summary
The facility failed to provide adequate administrative oversight, resulting in a resident's death due to choking after being given food items that were not approved for their diet. Despite a requirement for staff to use diet order cards on snack trays to ensure residents received appropriate food, observations revealed that staff were not consistently utilizing these cards during snack distribution. Additionally, a resident who required supervision while eating was observed eating alone and subsequently began choking, with staff intervention needed to resolve the incident. Another resident on a pureed diet was seen taking bacon from another resident's meal tray left unattended in the hallway, despite staff being aware of this resident's tendency to take food from others and the need for close monitoring. Medical record reviews confirmed that the residents involved had specific dietary restrictions and supervision requirements that were not followed. Staff interviews corroborated that the required practices, such as using diet order cards and supervising residents during meals, were not consistently implemented. The facility's policies and job descriptions outlined the responsibility of administration to ensure proper procedures and quality of care, but these were not effectively enforced, leading to multiple incidents where residents received inappropriate food or were left unsupervised during meals.
Environmental Deficiencies and Lack of Homelike Environment
Penalty
Summary
Surveyors observed multiple environmental deficiencies affecting eight residents in the facility. In one resident's bedroom, there was a large hole in the drywall at door handle height and a smaller hole near the ceiling behind the door. The shared bathroom for two residents had a waste basket under the sink that was approximately one-quarter full of water. In another resident's bedroom, the light above the bed was missing a cord to turn it on, and the same shared bathroom had the water-filled waste basket. Two residents' room ceilings had large brown-colored areas of an unidentified substance throughout, and another resident's bedroom had a light above the bed with no pull cord. Additionally, another room's ceiling had similar brown-colored areas, and a different resident's light had a broken cover hanging from it. The Regional Director of Maintenance confirmed these findings during an interview and stated that the water under the sink was due to a part needed for repair. The director also confirmed the absence of pull cords for the lights above the beds and acknowledged that while water pipes had burst and been fixed in some rooms, the brown-colored spots on the ceilings had not been addressed. The broken light cover was also confirmed. These observations and confirmations indicate the facility failed to maintain a homelike environment as required.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for dependent residents, as evidenced by observations and interviews involving two residents with self-care deficits. One resident with dementia, Alzheimer's disease, and behavioral issues, including playing in her own feces, was observed on multiple occasions with dirty fingernails containing a dark brown substance. Despite care plan interventions specifying that nail length should be checked, trimmed, and cleaned on bath days and as necessary, the resident's nails remained soiled over several days, even while eating meals with her hands. Staff interviews confirmed the resident's behaviors and the ongoing issue with dirty nails. Another resident with multiple chronic conditions, including bipolar disorder and diabetes, was found to have long fingernails on repeated observations, although the nails were clean and not jagged. The resident expressed dissatisfaction with the length of his nails and requested they be trimmed, but staff were unaware of who was responsible for this task. The facility's policy required staff to follow the ADL care plan, which included nail care, but this was not consistently implemented for the residents reviewed.
Failure to Prevent Accidents and Ensure Dietary Supervision
Penalty
Summary
The facility failed to adequately assess a resident following an unwitnessed fall and did not provide sufficient supervision to prevent another resident from consuming food not included in their prescribed diet. In the first incident, a resident with diagnoses including paranoid schizophrenia, major depressive disorder, and pseudobulbar affect, who was cognitively intact and required supervision for ADLs, was found lying on the ground near the nurse’s station with her walker beside her. A housekeeper assisted the resident off the floor without notifying nursing staff, and the LPN on duty was unaware of the incident until informed by the surveyor. The required post-fall assessment and reporting procedures were not initiated immediately following the event. In the second incident, a resident with Alzheimer’s disease, dementia, oropharyngeal dysphagia, and schizoaffective disorder, who was on a pureed diet, was observed taking and consuming regular texture food from other residents’ trays on multiple occasions. Despite documentation of repeated incidents where the resident took food from trays or the trash and consumed it, staff interventions were limited to verbal redirection and education. During an observation, the resident was able to access the tray cart, remove bacon from another resident’s tray, and begin eating it before being stopped by a staff member. Interviews confirmed that staff were aware of the resident’s behavior but had not implemented additional interventions to prevent access to inappropriate foods. Both incidents demonstrate a lack of adequate supervision and failure to follow established protocols for resident safety and dietary management. The facility did not ensure that staff were consistently monitoring residents at risk for falls or for consuming foods not aligned with their prescribed diets, resulting in deficiencies affecting two residents reviewed for accidents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight hours daily, as required. Review of staff schedules and timesheets for May 2015 showed there was no RN coverage on one specific day. This was confirmed during an interview with Regional Clinical Support, who acknowledged the absence of documentation indicating an RN worked in the facility on that day. This deficiency affected all 68 residents in the facility, as there was no RN present to provide required nursing oversight and care during the identified period.
Inappropriate Use of Non-Approved Cleaning Agents in Resident Areas
Penalty
Summary
The facility failed to ensure that appropriate cleaning agents were used for cleaning resident rooms and common areas, affecting 32 residents on the upstairs unit. Housekeeper #302, assigned to the second floor, used cleaning products she personally purchased rather than facility-approved chemicals. She did this for convenience, as the facility's chemical supplies were located on the first floor. The housekeeper used two Pinalen brand products, one for floors and one for surfaces and toilets, and did not measure the cleaning solution, instead estimating the amount used. Her supervisor was aware of and approved the use of these products. The facility did not have a policy regarding the types of cleaning products required to meet its cleaning needs. Review of the Safety Data Sheet for Pinalen revealed it is a household multipurpose cleaner not intended for industrial use or as a sanitizing agent. The deficiency was identified through staff interviews, observation, and review of product instructions and documentation, and was confirmed by the facility administrator.
Failure to Ensure Safe Ambulation and Report Fall
Penalty
Summary
The facility failed to ensure the safety and proper supervision of a resident, leading to a fall and subsequent injury. The resident, who had severe cognitive impairment and was at high risk for falls, was assisted to the bathroom by two CNAs without the use of his prescribed walker. During this process, the resident's legs buckled, and he was lowered to the floor by the CNAs. The CNAs then assisted the resident onto the toilet and back to bed without reporting the incident to the nurse, as they did not recognize it as a fall. The resident was later found by the oncoming shift with bruising and swelling, and an x-ray revealed a displaced intertrochanteric fracture of the left femur. The resident required surgical repair and hospitalization. The facility's investigation into the incident was incomplete, lacking documentation of the resident's use of a walker, footwear, and environmental conditions at the time of the fall. Additionally, there was no evidence of a thorough investigation or assessment of the resident's injuries prior to moving him after the fall. The facility's care plan for the resident did not include the use of a walker, despite recommendations from physical therapy. The CNAs involved were unaware that lowering a resident to the floor constituted a fall and did not report the incident. The facility's fall policy was not adequately followed, as the incident was not documented or reported in a timely manner, and the care plan was not updated with appropriate interventions to prevent future falls.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in actual harm to residents. Resident #01, with a known history of aggressive behavior, struck Resident #02 in the face, causing a hematoma and a closed fracture of the right orbital floor. Despite Resident #01's history of aggression, the facility's interventions, such as 15-minute checks and psychological evaluations, were insufficient to prevent the incident. The facility's investigation lacked comprehensive interviews and assessments to understand the factors leading to the incident. In another incident, Resident #01 struck Resident #03 multiple times in the back while Resident #03 was asleep. The facility's response included separating the residents and placing Resident #01 on one-to-one monitoring, but the monitoring was not documented. The facility's investigation into this incident also lacked thorough assessments and documentation of Resident #01's behaviors prior to the incident. The facility's policy on abuse prevention was not effectively implemented, as ongoing assessments and appropriate interventions were not adequately documented or executed. Resident #01's medical records revealed a history of physical aggression, yet there was a delay in psychiatric evaluation and insufficient documentation of behavior assessments. The facility's failure to implement effective monitoring and intervention strategies contributed to the repeated incidents of resident-to-resident abuse. The Director of Nursing acknowledged the lack of documentation and assessments, indicating a gap in the facility's approach to managing residents with aggressive behaviors.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report allegations of resident-to-resident abuse, affecting three residents. On 08/09/24, Resident #01 was observed grabbing Resident #02's hair and punching her in the face, resulting in facial swelling and an orbital fracture. Although the incident was reported to the Director of Nursing (DON) on the same day, there was no evidence that it was filed in the Self-Reported Incident (SRI) database until 08/14/24. The facility's investigation lacked interviews with other staff or residents and did not include any resident interviews. The police were notified, but no report was made due to Resident #01's dementia diagnosis. Another incident occurred on 08/13/24, where Resident #01 struck Resident #03 multiple times in the back, causing a bruise. This incident was not reported to the SRI database until 08/14/24, and local law enforcement was not notified. The facility's policy requires that all allegations of abuse involving bodily injury be reported to the Ohio Department of Health (ODH) database immediately or within two hours. The facility's failure to adhere to this policy resulted in non-compliance with control numbers OH00156980 and OH0015690.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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