Astoria Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Ohio.
- Location
- 3537 12th Street, Nw, Canton, Ohio 44708
- CMS Provider Number
- 366391
- Inspections on file
- 36
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Astoria Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident who required two staff for mechanical lift transfers was moved by a single CNA, resulting in the lift tipping and the resident sustaining a right hip fracture. The CNA did not request assistance, and the transfer was not performed according to facility policy or manufacturer guidelines. The incident led to the resident being hospitalized.
A cognitively impaired resident with a known history of wandering eloped from the facility after staff failed to reapply a required wander guard device following a hospital visit. Despite ongoing exit-seeking behaviors and multiple door alarms, staff did not verify the device's presence or function, and family members were allowed to use the door code to enter and exit without staff assistance. The resident was later found by law enforcement walking in the road, highlighting a lapse in supervision and safety protocols.
A resident with a PICC line and multiple infections did not receive routine dressing changes as required, with no documentation of dressing care until the line was replaced. Facility policy required dressing changes every five to seven days, but the resident reported only two changes since admission, and staff could not locate records of earlier dressing changes.
A resident with a tracheostomy, history of respiratory failure, and recent COVID-19 diagnosis exhibited labored breathing and minimal secretions, but the LPN on duty did not notify the physician or escalate care, relying instead on remote advice from an RT. The resident was later found unresponsive, CPR was initiated, and the resident was transferred to the hospital, where she died. The facility failed to recognize and respond to a significant change in condition, as required by policy.
Surveyors identified multiple sanitary issues in the kitchen, including dirty trash cans, soiled equipment, improper food storage, and undated perishable items. These deficiencies were confirmed by the Dietary Manager and affected all but three residents who did not receive food from the kitchen.
A resident with a history of respiratory failure, tracheostomy, and recent pneumonia experienced labored breathing and fluctuating oxygen levels, but the physician was not notified of these changes. Nursing staff relied on input from the RT, who indicated the condition was baseline, and did not escalate care or inform the family of the respiratory distress. The resident was later found unresponsive, transported to the hospital, and subsequently passed away. This failure to notify the physician of a significant change in condition was confirmed through record review and staff interviews.
A resident with multiple chronic conditions reported that facility-provided washcloths and towels were stained, dingy, and uncomfortable to use. Observations confirmed that linens throughout the facility were discolored, stained, and worn, with staff attributing the issue to the discontinuation of incontinence wipes and repeated use of the same linens. The deficiency had the potential to impact all residents relying on facility linens.
A resident with multiple medical conditions missed a scheduled postoperative surgical appointment because the facility did not arrange transportation as ordered. When the appointment was rescheduled, the resident arrived late and was not taken for required X-rays prior to seeing the surgeon, contrary to the physician's order. Communication gaps between staff and the medical office contributed to the deficiency.
A resident with multiple risk factors and existing pressure ulcers did not receive timely and consistent pressure ulcer interventions, including delayed provision of a low air loss mattress and inconsistent use of heel offloading devices. The resident and a family member reported that necessary equipment and repositioning assistance were only provided after complaints to external authorities, and documentation showed that wounds worsened before improvement. Staff interviews and observations confirmed lapses in following the care plan and facility policy.
A resident with multiple chronic conditions and a history of dental issues reported a lost tooth, prompting a physician order for antibiotics and a prompt dental appointment. The facility did not schedule the dental appointment as ordered, and the resident later required hospital care for dental pain before the appointment was finally arranged.
A CNA failed to maintain proper infection control during incontinence care for a resident with multiple medical conditions by repeatedly using a feces-soiled washcloth and contaminating clean linens, contrary to facility policy requiring cleanliness to prevent infection.
A resident using a BiPAP machine complained about the taste of distilled water, which was not replaced daily as required by facility policy and manufacturer's guidance. The RT replaced the water weekly, unaware of the policy, and informed the Administrator and DON, who initially supported the weekly change. The facility's policy required daily changes to prevent infection.
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN inaccurately measured polyethylene glycol for a resident, and an RN forgot to administer a nasal spray to another resident. The facility's policy requires medications to be administered safely and as prescribed, with errors documented and reviewed.
A facility failed to ensure proper infection control during medication administration for two residents. A nurse did not perform hand hygiene before and after glove use and failed to disinfect the glucometer before and after obtaining blood sugar levels. The residents had conditions like heart disease and diabetes. Facility policies and CDC guidance on infection control were not followed.
A resident in an LTC facility was mistakenly administered a discontinued medication, Percocet, by an RN who failed to verify the current medication orders in the computer system. The RN administered the medication after finding it in the narcotic drawer, realizing the error only after attempting to document the administration.
A male resident with severe cognitive impairment was involved in multiple incidents of sexual abuse with two female residents in an LTC facility. The facility failed to implement effective interventions or update care plans to address the male resident's sexual behaviors, resulting in repeated incidents. The facility's policies lacked definitions of sexual abuse and consent, contributing to inadequate responses and failure to report the incidents as abuse.
A resident with complex medical needs, including diabetes and Huntington's disease, was found unresponsive in his wheelchair after being left unattended overnight. Despite an elevated blood glucose level of 400 mg/dl recorded at 10:00 P.M., no follow-up care or monitoring was provided. The resident required CPR and was transported to the hospital with a blood glucose level of 607 mg/dl, where he later passed away. The facility failed to adhere to care plans for monitoring and incontinence checks, contributing to the resident's death.
A resident with complex medical needs was neglected due to inadequate staffing, resulting in the resident being left unattended in a wheelchair and later found unresponsive. The facility was understaffed, with only one STNA on duty, leading to insufficient care and delayed response to the resident's needs.
The facility failed to maintain a clean and sanitary kitchen, affecting 58 residents. Observations revealed gnats, water damage, mold, and food residue in the kitchen and storage areas. The facility's sanitation and pest control policies were not followed.
The facility failed to investigate and report resident-to-resident abuse involving two residents with severe cognitive impairments. Despite multiple incidents where residents were found in compromising situations, the facility did not document or report them as abuse. Additionally, a resident was reported to have been inappropriately touched by another, but the facility did not conduct a thorough investigation. The facility's policy lacked definitions of sexual abuse and consent, contributing to the inadequate response.
A facility failed to report alleged sexual abuse incidents involving two residents to the State Agency. One resident with dementia was found in a bathroom with another resident, both with pants down, and later allegedly grabbed another resident's breast. Despite staff witnessing the incidents, they were not documented or reported as abuse. The facility's policies lacked definitions of sexual abuse and guidelines on consent, contributing to the oversight.
A facility failed to investigate and report allegations of sexual abuse involving two residents with severe cognitive impairments. Despite multiple incidents, including inappropriate behavior in a spa room and unwanted physical contact, the facility did not document or report these as abuse. The facility's policies lacked definitions and guidelines on handling such incidents, contributing to non-compliance.
A resident was discharged without ensuring an adequate supply of narcotic medications until her post-discharge appointment. Despite having multiple health conditions, the facility's policy did not allow for medications to be sent home without physician authorization, which was not obtained. Interviews revealed that medications were called into the pharmacy, but the resident's lack of a primary care physician and the facility's discharge policy contributed to the deficiency.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on two staff members and a mechanical (Hoyer) sling lift for all transfers, was transferred by only one Certified Nursing Assistant (CNA) using the lift. During this unsupervised transfer, the lift tipped over, causing the resident to fall to the floor and sustain a right hip fracture. The resident was subsequently transferred to the hospital for treatment and did not return to the facility after discharge. The resident had a history of multiple rib fractures, syncope, and anxiety disorder, and was assessed as having an activity of daily living (ADL) deficit, requiring a mechanical lift for transfers. The care plan and facility policy both specified that at least two staff members were required for safe use of the mechanical lift. The manufacturer's guidelines also recommended two assistants for all lifting and transferring procedures. Despite these requirements, the CNA performed the transfer alone, without requesting assistance from other available staff. Interviews with staff confirmed that the CNA did not ask for help before attempting the transfer. Other CNAs and the nurse on duty were only called to assist after the resident had already fallen. The facility's investigation verified that the transfer was not conducted according to policy or manufacturer instructions, directly resulting in the resident's injury.
Failure to Prevent Elopement of Cognitively Impaired Resident Due to Lapses in Supervision and Wander Guard Use
Penalty
Summary
A severely cognitively impaired resident, with diagnoses including senile degeneration of the brain, anxiety disorder, encephalopathy, and type 2 diabetes mellitus, was identified as high risk for wandering and elopement upon admission. The resident's assessments indicated severe cognitive impairment, disorientation, and a history of wandering, with interventions including the use of a wander guard device. On the night of the incident, the resident had experienced a seizure and was transported to the hospital by paramedics, during which the wander guard was removed. Upon the resident's return from the hospital, there was no verifiable evidence that the wander guard was reapplied, and the nurse responsible for re-admission was unaware of the need for the device. Throughout the night, staff observed the resident wandering the building, attempting to redirect him with snacks, television, and conversation, but were unsuccessful in keeping him in his room. Multiple staff members noted the resident's persistent wandering and attempts to exit, with door alarms sounding at various times. Despite these behaviors and the resident's known risk, staff did not verify the presence or function of the wander guard, and there was no documentation indicating it was reapplied after the hospital visit. Additionally, staff allowed family members of other residents to enter and exit the facility using the door code without staff assistance, which created an opportunity for the resident to follow someone out of the building. The resident ultimately exited the facility unnoticed during the early morning hours and was found by a concerned citizen walking in the middle of the road, approximately 0.55 miles away from the facility, dressed in a t-shirt, pajama pants, and without shoes, in 46-degree weather. Facility staff were unaware of the resident's absence until notified by local law enforcement. The facility's failure to ensure the wander guard was in place and to provide adequate supervision and control of exit doors directly led to the resident's elopement.
Removal Plan
- Local law enforcement called facility and spoke with Licensed Practical Nurse (LPN) #107 to notify about Resident #12 being found and taken to the hospital.
- LPN #107 and Registered Nurse (RN) #108 completed a head count of all residents to ensure all were present and accounted for.
- LPN #107 attempted to notify Resident #12's Responsible Party and left a message.
- LPN #107 notified RN Manager #109 of Resident #12 leaving the facility and being taken to the hospital; RN Manager #109 notified the Administrator.
- RN Manager #109 attempted to contact Resident #12's Responsible Party and left a message.
- RN Manager #109 called and spoke with the hospital nurse for an update on Resident #12.
- RN #111 spoke with Resident #12's Responsible Party and notified them of the incident.
- Resident #12 returned to the facility accompanied by paramedics; RN #111 obtained vital signs and assessed Resident #12.
- Resident #12's wander guard was placed back on by RN #111 and Resident #12 was placed on one-on-one (1:1) supervision.
- Facility staff were educated on the Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions were in place for residents with exit seeking behaviors, ensuring interventions were put back in place when residents returned from the hospital, and not giving residents or families the door code.
- RN #101 audited resident orders and care plans for wander guards; any variances were corrected immediately.
- Receptionist #114 and Maintenance Director #115 audited all residents with wander guards for functioning, placement, and expiration; all were placed properly, functioning appropriately, and not expired.
- Maintenance Director #115 audited all exit doors and the wander guard system at all doors to ensure proper function.
- RN #101 audited current resident progress notes to ensure if behaviors consistent with exit seeking were noted, then residents had appropriate interventions in place.
- Resident #12's Nurse Practitioner (NP) #116 was notified of Resident #12 leaving the facility and being taken to hospital by law enforcement with return to facility.
- Administrator audited the facility records of exit door function checks.
- ADON #103 completed elopement and wandering risk assessments on all in-house residents.
- An elopement drill was completed by Maintenance Director #115.
- An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the facility correction plan including ongoing compliance.
- ADON #103 educated all current resident responsible parties via phone that they were to ensure staff let them in and out the doors when the front door was locked and should not enter the code themselves or let anyone else out without staff assistance.
- SecureCare was called and the front door code was changed by Maintenance Staff #117.
- The Care Conference form was updated by the Administrator to include education for new families and a reminder for others to request staff assistance with doors when locked, not put in code themselves or assist anyone else out of facility.
- Resident #12's care plan was updated by RN #101 to include wandering and elopement risk with interventions including 1:1 as needed, monitor and report changes in behaviors, orient to new surroundings, provide diversional activities of interest as needed, redirect as needed, and wander guard with placement and function checks as ordered.
- Nursing staff would monitor the effectiveness of interventions for Resident #12 by reviewing point of care (POC) documentation and conducting a review for weekend POC.
- CNAs would report behaviors to the charge nurse if behaviors were not resolved with interventions.
- 1:1 (staff) supervision would continue for Resident #12 until discharge.
- If a call off occurred for a person doing 1:1 supervision, the Administrator would be immediately notified and re-assign floor staff, management staff, or other department staff to cover 1:1 as appropriate. The Administrator would oversee 1:1 coverage scheduling.
- All new hires and agency staff would be educated regarding the facility's Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions are in place for residents with exit seeking behaviors, ensuring interventions are put back in place when residents return from the hospital, and not giving residents or families the door code.
- The Administrator or designee would review all door checks to ensure all doors were checked and functioning appropriately. All variances would be corrected upon discovery and education/follow-up would be provided as deemed necessary.
- Maintenance Director #115 or designee would conduct elopement drills to ensure staff respond accordingly. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would assess all residents with wander guards to ensure proper placement, function and expiration. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The Administrator or designee would audit the wander guard system and resident accessible exit doors to ensure they were functioning properly to ensure all doors were intact and functioning properly, including alarm. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would complete elopement and wandering risk assessments for facility residents to ensure no changes in behavior patterns or acute changes in condition affecting mental status were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would audit progress notes to ensure any residents with behaviors that increase risk for elopement or exit seeking have appropriate interventions in place.
- The Administrator or Designee would interview visitors to ensure visitors were aware they were not to enter door codes when the door was locked and should wait for staff assistance to exit facility, as well as not let anyone else out without staff assistance.
- The facility Quality Assurance (QA) committee would review audits to ensure compliance. Variances would be corrected immediately upon discovery and education provided.
- Results of these audits would be reported to the facility quality assurance committee. Ongoing compliance would be maintained by recommendations of the facility quality assurance committee.
Failure to Perform Routine PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure that dressing changes for a resident's peripherally inserted central catheter (PICC) line were performed on a routine, ongoing basis as required. Upon admission, the resident had a double lumen PICC line and an order for intravenous antibiotics, but there were no documented orders regarding PICC line care at that time. Medical record review and staff interviews confirmed that there was no documentation of PICC dressing changes until the PICC line was replaced, despite the facility's policy requiring dressing changes at least every five to seven days and as necessary. The resident reported that the dressing had been changed no more than twice since admission, and the dressing in place was dated several days after the initial placement. The resident's diagnoses included methicillin-resistant staphylococcus aureus infection, bacteremia, and a post-surgical site infection, all of which require careful management of central lines to prevent further complications. A nursing note indicated the PICC line became clogged, leading to its replacement. Orders for routine dressing changes and site monitoring were only written after the replacement, and staff were unable to locate documentation of prior dressing changes. The facility's policy emphasized the importance of keeping dressings clean, dry, and intact to prevent catheter-related infections, but this standard was not met for the resident in question.
Failure to Timely Identify and Treat Change in Respiratory Condition
Penalty
Summary
A deficiency occurred when the facility failed to timely identify and respond to a significant change in a resident's respiratory condition, resulting in actual harm. The resident, who was a full code, non-verbal, and had a tracheostomy, exhibited labored breathing, tested positive for COVID-19, and was being treated for pneumonia. Despite these risk factors and a history of respiratory complications, the LPN on duty did not notify the physician about the resident's labored breathing or the absence of secretions during suctioning. The LPN, unfamiliar with the resident, relied on information from a respiratory therapist (RT) via Facetime, who indicated the resident's breathing was at her baseline, and did not escalate care or seek further assistance until the resident was found unresponsive. The resident's medical record showed multiple complex diagnoses, including respiratory failure, pneumonia, encephalopathy, and tracheostomy status. Documentation revealed that the resident had previously required frequent suctioning for thick secretions and had a history of mucous plugs, which could cause acute respiratory distress. On the night of the incident, the LPN noted labored breathing and minimal secretions during suctioning but did not recognize these as signs of a potential mucous plug or acute deterioration. The RT, who was off-site, advised that the resident's condition was normal based on prior experience, but had not personally assessed the resident that day. There was no evidence in the records that labored breathing was normal for this resident, and the physician later confirmed she was not contacted about the change in condition. The facility's policy required prompt notification of the physician and responsible party for significant changes in a resident's condition. However, the LPN did not notify the physician or seek additional help until the resident was found without vital signs, at which point CPR was initiated and the resident was transferred to the hospital. Hospital records indicated the resident was admitted for acute on chronic respiratory failure with hypoxia, with findings suggestive of a possible mucous plug and severe sepsis. The resident ultimately passed away at the hospital. Interviews with staff and review of documentation confirmed that the failure to recognize and act upon the resident's change in respiratory status, and the lack of timely physician notification, directly contributed to the deficiency.
Sanitary Deficiencies Observed in Kitchen
Penalty
Summary
Surveyors observed multiple sanitary concerns in the facility's kitchen during a tour with the Dietary Manager. Three trash cans were found dirty with a dark substance on their sides, and the bottom shelf of a steel table was soiled with an orange substance, which a staff member confirmed was present at the start of her shift. A flour container was found with a measuring cup left inside, and two black three-tiered carts were visibly dirty with a buildup of various spilled substances. The refrigerator contained two packages of American cheese wrapped in aluminum foil without any dates indicating when they were opened or their expiration, and the cheese was hard and discolored at the edges. Additionally, an opened package of deli ham slices was found with no date of opening. These issues were all verified by the Dietary Manager during the inspection. The facility's policy requires the food service area to be maintained in a clean and sanitary manner, but these observations indicated non-compliance. All residents except three who did not receive food from the kitchen were affected.
Failure to Notify Physician of Change in Condition for Resident with Respiratory Distress
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a significant change in condition for a resident with complex medical needs, including respiratory failure, pneumonia, tracheostomy, and recent COVID-19 diagnosis. The resident, who was a full code and dependent on staff for all activities of daily living, returned from a hospital stay with new orders for antibiotics and continued to require oxygen and suctioning. Documentation showed that the resident experienced labored breathing and fluctuating oxygen saturations, but there was no evidence that the physician was notified of these changes during the night prior to the resident's death. Nursing and respiratory therapy staff noted increased secretions, labored breathing, and the need for frequent suctioning. Despite these observations, the nurse on duty relied on input from the respiratory therapist, who was contacted via Facetime and indicated that the resident's condition appeared to be her baseline. The nurse did not escalate the situation or seek further assistance, and there was no documentation of physician notification regarding the resident's respiratory distress. The resident's family was not informed of the labored breathing, and the physician later confirmed she was not contacted during the critical period. Interviews with staff revealed uncertainty and lack of familiarity with the resident's baseline condition, as well as a lack of clear communication and documentation regarding the resident's respiratory status. The facility's policy required prompt notification of the physician and responsible party for significant changes in condition, but this was not followed. The resident ultimately experienced respiratory failure and was transported to the hospital, where she passed away. The deficiency was substantiated by review of medical records, staff interviews, and facility policy.
Failure to Provide Clean, Stain-Free Linens for Resident Care
Penalty
Summary
The facility failed to ensure that linens provided to residents were free from stains and maintained in a clean, comfortable, and homelike condition. During interviews and observations, it was found that a resident reported the washcloths and towels were stained, dingy, and not white, expressing discomfort with using them for personal hygiene. Direct observation of the linen closets confirmed that the available washcloths, hand towels, and bath towels were light brown in color, had several large brown stains, and appeared worn and thin. Staff confirmed that all linens were in similar condition and attributed the staining to the use of washcloths and towels for cleaning up bowel movements after the facility stopped purchasing incontinence wipes. The laundry manager stated that the same linens had been in use for an extended period, and new supplies ordered had not yet arrived. She also noted that the facility had been experiencing shortages of washcloths and towels since discontinuing incontinence wipes, leading to repeated use and further deterioration of the linens. The affected resident had multiple chronic medical conditions, including chronic respiratory failure, diabetes, kidney disease, and cognitive impairment, and was dependent on the facility for daily living supports. The deficiency had the potential to affect all residents utilizing facility linens.
Failure to Arrange Transportation and Pre-Appointment X-rays for Postoperative Follow-Up
Penalty
Summary
The facility failed to ensure that transportation was arranged for a resident's postoperative appointment as ordered by the physician. The resident, who had multiple complex diagnoses including cervical disc disorder, spinal stenosis, diabetes, and recent spinal surgery, was admitted with orders for a follow-up surgical appointment. The medical record and staff interviews confirmed that the resident missed the initial postoperative appointment because transportation was not set up by the facility. The appointment had to be rescheduled, and there was a lack of communication between the facility and the neurosurgery office regarding the resident's follow-up care. When the appointment was rescheduled, the resident arrived late and was not taken to radiology for X-rays prior to seeing the surgeon, as specified in the physician's order. The resident ultimately had the X-rays completed after the appointment instead. Interviews with staff revealed uncertainty about the transportation arrangements and the requirements for pre-appointment X-rays. The resident also confirmed that he was not informed about the need for radiology prior to the appointment and that transportation arrangements were not properly communicated or executed.
Failure to Timely Implement Individualized Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement timely, individualized, and effective interventions for pressure ulcer care for one resident with significant risk factors and existing pressure ulcers. The resident was admitted with multiple diagnoses, including hemiplegia, contractures, incontinence, and existing pressure ulcers on both heels. Upon admission, assessments identified the resident as high risk for pressure injuries, and documentation showed the presence of unstageable and Stage III pressure ulcers with heavy drainage and necrotic tissue. The care plan included interventions such as pressure-relieving devices, nutritional supplements, moisture barriers, and assistance with mobility and hygiene. Despite these documented interventions, there were delays and inconsistencies in their implementation. The resident did not receive a low air loss mattress until eight days after admission, despite requesting it on the first day and being at high risk for further skin breakdown. The resident also reported that staff did not consistently assist with turning, repositioning, or offloading the heels unless specifically requested. Observations confirmed that the resident's heels were directly on the bed without protective boots, and interviews with staff verified that the boots were not in use at the time of observation. The resident and a family member both indicated that necessary equipment and interventions were only provided after complaints were made to external authorities. Further review of wound care notes showed that the pressure ulcers increased in size before eventually showing some improvement, and that debridement was delayed due to the resident's pain and refusal, with some interventions only initiated after repeated documentation of wound status. The facility's policy required assessment and documentation of risk factors and timely intervention, but the evidence indicated that these were not consistently or promptly followed, resulting in a failure to provide adequate pressure ulcer care and prevention.
Failure to Timely Arrange Dental Appointment Following Physician Order
Penalty
Summary
The facility failed to arrange a dental appointment as ordered for a resident who experienced a dental issue. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, schizoaffective disorder, and a history of dental problems, reported to nursing staff that a tooth had fallen out. Although the resident did not initially report pain, the physician was notified and ordered Clindamycin and a dental appointment to be scheduled as soon as possible. Documentation review showed that the dental appointment was not scheduled or completed following the initial order. Subsequently, the resident called 911 for toothache pain and dizziness and was transported to the hospital. Upon return, new orders for antibiotics were given for dental caries and a periapical abscess. It was only after this hospital visit that a dental appointment was scheduled, several weeks after the original physician order. Interviews with facility staff confirmed that the dental appointment was not set up until after the resident's hospital visit, despite the earlier order to do so.
Inappropriate Infection Control During Incontinence Care
Penalty
Summary
During an observation of incontinence care, a Certified Nursing Assistant (CNA) provided care to a resident with multiple diagnoses, including malignant neoplasm of the colon, duodenal ulcer, dementia, urinary retention, depression, chronic pain syndrome, gastritis, and moderate protein-calorie malnutrition. The CNA used two washcloths and a bath towel to perform perineal and rectal care. After washing the resident's perineal and rectal area, the CNA continued to use a visibly soiled washcloth, using a different part of the same cloth, and placed the soiled washcloth on a clean towel. The CNA then dried the resident with the towel that had come into contact with the contaminated washcloth. The CNA proceeded to wipe the resident from the perineal area to the rectum with the same soiled washcloth, and upon noticing additional feces, used tissues from the bedside stand to clean the area. The CNA then continued to use the feces-soiled washcloth to wipe the resident two more times before being stopped by the surveyor, who instructed her to obtain a clean washcloth. The CNA confirmed in an interview that she had used a feces-soiled washcloth during the care. Facility policy on perineal care requires cleanliness to prevent infection and skin irritation, which was not followed in this instance.
Failure to Replace Distilled Water for BiPAP Machine
Penalty
Summary
The facility failed to ensure the proper replacement of distilled water used in respiratory therapy, specifically for a resident using a BiPAP machine. The resident, who had multiple health conditions including chronic obstructive pulmonary disease and obstructive sleep apnea, complained about the taste of the distilled water, which he claimed made him feel nauseous and affected his breathing. Despite the resident's complaints, the respiratory therapist (RT) and staff did not replace the distilled water daily as requested by the resident. Instead, the RT replaced the water once a week, contrary to the facility's policy and the manufacturer's guidance, which required the water to be changed every 24 hours or when it had an unusual taste. The RT was unaware of the facility's policy regarding the use of distilled water for respiratory equipment and believed that changing the water weekly was sufficient. The RT had informed the Administrator and the Director of Nursing (DON) about the resident's request, but they initially supported the RT's practice of weekly changes. However, the DON later stated that the distilled water should be changed every 24 hours, as per the facility's policy. The facility's policy and the manufacturer's guidance both emphasized the importance of changing the distilled water to prevent infection and ensure the safety of the resident using the BiPAP machine.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an eight percent error rate during the observation period. This deficiency affected two residents during medication administration. For Resident #50, the error involved the incorrect measurement of polyethylene glycol powder by an LPN, who filled the cap below the required white line, leading to an inaccurate dosage. The LPN confirmed the mistake upon review of the medication instructions, which specified filling the cap to the white line to achieve the correct 17 grams dosage. For Resident #3, the error occurred when an RN failed to administer the Azelastine Hydrochloride nasal spray as prescribed. The RN acknowledged forgetting to give the nasal spray during the medication pass. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered safely, timely, and as prescribed, with errors documented and reviewed by the QAPI committee. This deficiency was investigated under two complaint numbers, indicating non-compliance with the facility's medication administration policy.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration for two residents. During an observation, a registered nurse did not perform hand hygiene before and after glove use while administering medications to a resident. The nurse also failed to disinfect the glucometer before and after obtaining blood sugar levels for two residents. This lack of adherence to infection control protocols was confirmed during an interview with the nurse. The residents involved had multiple medical conditions, including heart disease, diabetes, and neurological conditions. The facility's policies on medication administration and blood sampling required adherence to infection control procedures, such as hand hygiene and disinfection of reusable medical devices. The Centers for Disease Control guidance also emphasized the importance of hand hygiene in healthcare settings, which was not followed in this instance.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, affecting one resident out of four reviewed for medications. The resident, who was readmitted with diagnoses including pneumonia, depression, and acute respiratory failure with hypoxia, had an order for hydrocodone/Tylenol (Percocet) to be given every six hours as needed for up to five days. This order was discontinued on 10/01/24. However, a review of the Controlled Drug Record form showed that a Percocet tablet was administered on 12/08/24 at 11:45 P.M. by a registered nurse, despite the medication being discontinued. The registered nurse confirmed in an interview that she accidentally administered the Percocet without checking the computer records first. She admitted to looking in the narcotic drawer and noticing the Percocet, which led her to administer it. It was only after attempting to sign off the medication in the resident's medical record that she realized the medication had been discontinued. This incident was a violation of the facility's policy, which requires medications to be administered safely, timely, and as prescribed.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from incidents of sexual abuse, specifically involving a male resident with severe cognitive impairment and two female residents. On two occasions, the male resident was found in compromising situations with a female resident who was also severely cognitively impaired. The first incident occurred when the female resident was found naked in the spa room with the male resident, who was dressed. Later the same day, the male resident was observed with his pants down, engaging in inappropriate sexual behavior with the same female resident. There was no evidence that the female resident had consented or was capable of consenting to the interaction. The facility did not implement effective interventions to prevent these incidents from occurring or to protect the female resident and others from the male resident. Despite the male resident's care plan not being updated to address his sexual behaviors until after the incidents, the facility failed to ensure adequate supervision and safety measures were in place. This lack of action resulted in another incident where the male resident was observed grabbing the breast of a different female resident without her consent. The facility's policies on abuse prevention and reporting did not include definitions of sexual abuse or consent, contributing to the inadequate response to the incidents. The facility did not complete a self-reported incident for the events involving the male and female residents, as they did not believe it constituted abuse. This oversight and failure to recognize the severity of the incidents led to a deficiency in ensuring resident safety and protection from abuse.
Removal Plan
- Resident #4 and Resident #61 were immediately separated. Resident #4 and Resident #61 were placed on 1:1 supervision.
- Resident #4 and Resident #51 were immediately separated, and Resident #4 was placed back on 1:1 supervision with staff.
- Regional Quality Assurance Registered Nurse (RQARN) #800 reviewed the progress notes of Resident #4 since his admission to the facility to ensure there were no other documented occurrences of like behaviors.
- Facility Assistant Administrator (FAA) #801 completed interviews with 28 of 28 alert and oriented residents with Brief Interview of Mental Status (BIMS) scores of 12 and higher. All 28 residents denied any like concerns and denied abuse and mistreatment by staff and/or other residents.
- Unit Manager Licensed Practical Nurses (UMLPN) #802 and #803 performed skin sweeps on 33 of 33 residents with BIMS scores less than 12. No new or unidentified skin impairments, psychosocial distress or signs of abuse or mistreatment were noted for these 33 residents.
- Regional Director of Operations (RDO) #501 educated 18 of 18 administrative staff on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and re-educated on 1:1 supervision requirements.
- The Administrator and other staff re-educated 98 of 99 facility staff on the facility Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and re-educated on 1:1 supervision requirements.
- RDO #510 visually confirmed Resident #4 to be on 1:1 supervision.
- RDO #510 educated the Administrator, Assistant Administrator #801, the DON, the ADON, and UMLPNs #802 and #803 on federal regulation F609: Reporting of Alleged Violations and F610: Response to Alleged Violations.
- The care plan of Resident #4 was updated to include the 1:1 supervision.
- RDO #510 notified the Medical Director via phone of the Immediate Jeopardy and abatement plan.
- SSD #809 performed a psychosocial assessment on Resident #51 who showed no signs of psychosocial distress.
- RQARN #800 reviewed progress notes for the last 90 days for all current facility residents for any related sexually inappropriate behaviors.
- STNA #817, who was assigned to Resident #4's 1:1 supervision, was terminated from employment at the facility for not maintaining 1:1 supervision.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the facility Immediate Jeopardy and removal plan.
- The DON or designee would verify 1:1 was in place for Resident #4 and the staff person assigned to the 1:1 had full understanding of the requirement for providing 1:1, each shift seven days a week for a period of one week and each shift five times a week for a period of three weeks thereafter.
- The DON or designee would interview eight staff members five times weekly for a period of four weeks to ensure understanding of the 1:1 education provided.
- The DON or designee would review progress notes of current residents five times a week for a period of four weeks to ensure any notable changes in sexual behavior had an appropriate and timely intervention.
- The Administrator or designee would interview 10 residents weekly, for a period of four weeks regarding abuse and mistreatment.
- The DON or designee would assess 10 non-interviewable residents weekly for a period of four weeks to ensure residents remain free of signs of unknown skin impairment and abuse and/or mistreatment.
- RDO #510 or designee would review all allegations of abuse three times a week, for a period of four weeks to ensure timely follow-up, completion of full investigation, documentation of allegation, reporting, and appropriate intervention implementation.
- The Administrator would audit 100% of new hires five times a week for four weeks for education on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy.
- RDO #510 would review all audits weekly for a period of four weeks to ensure completion and compliance.
Failure to Monitor and Provide Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate and timely care to Resident #42, who was dependent on staff for various needs, including transfers, incontinence care, and diabetes management. The resident, who had a complex medical history including Huntington's disease, diabetes, and was at risk for falls, was found unresponsive in his room, slumped over in his wheelchair with blood on his face and clothing. The last documented interaction with the resident was at 10:00 P.M. when an LPN checked his blood glucose level, which was elevated at 400 mg/dl, and administered 40 units of Glargine insulin. However, there was no follow-up or monitoring of the resident's condition throughout the night. The resident was not checked again until 4:30 A.M. when a nursing assistant found him unresponsive. Despite the elevated blood glucose level earlier, no further assessments or interventions were documented. The resident required CPR and was transported to the hospital, where his blood glucose was recorded at 607 mg/dl. He was admitted to the intensive care unit and subsequently passed away. The facility's failure to monitor the resident's condition and provide necessary care contributed to the resident's deterioration and eventual death. Interviews and record reviews revealed that the resident was supposed to be checked every two hours for incontinence care and was care planned to be in a common area when in his wheelchair due to fall risk. However, these interventions were not followed, and the resident remained in his room unattended. Staff statements indicated a lack of communication and follow-through on the resident's care needs, leading to a significant lapse in care that resulted in immediate jeopardy and actual harm.
Removal Plan
- Regional Quality Assurance Registered Nurse (RQARN) #800 audited residents with physician orders for blood sugar checks to ensure parameters for notifying the physician were included.
- Assistant Director of Nursing (ADON) #403 audited residents with physician orders for blood sugar checks to ensure compliance with physician's orders and appropriate follow-up.
- Regional Director of Operations (RDO) #510 educated facility leadership on following individualized care plans related to incontinence checks and resident monitoring.
- RQARN #800 educated nursing leadership on the facility policy Nursing Care of the Resident with Diabetes Mellitus, including obtaining follow-up blood sugar checks if indicated.
- Facility Medical Director was notified of the Immediate Jeopardy related to quality of care and treatment.
- Facility leadership educated all nursing staff on following individualized care plans related to incontinence checks and resident monitoring.
- RQARN #800, the DON, ADON #403, and UMLPNs educated all licensed nursing staff on the facility policy Nursing Care of the Resident with Diabetes Mellitus.
- Clinical Resource Specialist LPN #816 audited all current resident care plans to ensure fall interventions reflect resident preferences and refusals are addressed.
- Clinical Resource Specialist LPN #816 audited all current resident care plans to ensure incontinence care plans include resident preferences and refusals.
- RDO #510 added facility education for following individualized care plans and the facility policy Nursing Care of the Resident with Diabetes Mellitus to the facility General Orientation manual.
- Clinical Operations Specialist RN #992 completed an audit of progress notes for active residents with physician's orders for blood sugar checks.
- Ad hoc Quality Assurance Performance Improvement (QAPI) meeting held to discuss the plan of action.
- Regional Quality Assurance RN/Designee to review all residents with physician's orders for blood sugar checks.
- DON/designee to interview staff members to ensure understanding of individualized care plans.
- DON/Designee to review progress notes of current residents with physician orders for blood sugar checks.
- DON or Designee to audit new hires to ensure education on facility policy for care plans and diabetes management.
- DON or designee to audit all residents with physician orders for blood sugar checks to ensure parameters for physician notification are included.
- DON or designee to audit all residents with fall care plans to ensure interventions are in place and followed.
- DON or designee to audit all residents with incontinence care plans to ensure standard of care is followed.
- RDO #510 to review all audits to ensure completion and compliance.
- QA Committee to monitor the results of all audits and follow-up as needed.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to maintain sufficient staffing levels to meet the care needs of all residents, specifically affecting Resident #42. This resident had a complex medical history, including respiratory failure, diabetes, and severe protein-calorie malnutrition, among other conditions. The care plan for Resident #42 included interventions for fall risk, incontinence, and diabetes management, requiring regular monitoring and assistance from staff. However, the facility's staffing shortages led to inadequate care, as evidenced by the resident being left unattended in a wheelchair for an extended period. On the night of the incident, staffing was insufficient, with only one State Tested Nursing Assistant (STNA) working on the unit where Resident #42 resided. The STNA was overwhelmed with responsibilities and unable to provide timely assistance to all residents. Despite being informed that Resident #42 needed to be laid down, the STNA was unable to attend to this task due to the high workload and lack of support. This situation was exacerbated by another STNA calling off, leaving the unit understaffed and unable to meet the residents' needs effectively. The deficiency was further highlighted when Resident #42 was found unresponsive in his wheelchair, having not been laid down as required. The nursing staff attempted resuscitation, but the delay in care due to staffing issues may have contributed to the severity of the situation. Interviews with staff revealed that working alone was a common occurrence, indicating a systemic issue with staffing levels at the facility. This deficiency was identified during the investigation of specific complaint numbers, underscoring the potential risk to all residents due to inadequate staffing.
Sanitation and Pest Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect 58 residents receiving meals. During an observation, it was noted that extra dish racks were stored on old milk crates under the sink, and when moved, gnats were seen flying out from under the sink. There was significant water damage with missing tiles and a large hole in the wall, from which the gnats were emerging. The Dietary Manager confirmed the presence of the hole and gnats, although he was unsure of how long the damage had been present. A dietary aide confirmed that the wall had been in disrepair for some time, with water occasionally leaking into an adjacent dining room. A follow-up visit revealed that while the tile had been replaced, the wall behind it had food splatter, and a pipe above had chunks of food, with gnats still present around the dish machine. The walk-in refrigerator had mold on three shelves, food residue, paper pieces, and a broken egg on the floor. Additionally, a box of thickener in the dry storage area was improperly wrapped, labeled, and dated. The walk-in freezer had water on the floor outside it, which had been leaking for a week. The facility's policies on sanitation and pest control, dated 2008, were not adhered to, as the kitchen areas were not kept clean or free from pests, and the pest control program was ineffective.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy to thoroughly investigate and report all allegations of resident-to-resident abuse, affecting two residents. Resident #61, who had severe cognitive impairments and a history of mood and behavioral issues, was involved in an incident with Resident #4, who also had severe cognitive impairments and a history of behavioral disturbances. On multiple occasions, both residents were found in compromising situations in the spa room, with their pants down. Despite these incidents, the facility did not document or report them as abuse, nor did they conduct a thorough investigation. Resident #4 was involved in another incident with Resident #51, who had moderately impaired cognition and a history of mental health issues. Resident #4 was reported to have grabbed Resident #51's breast, but the facility did not document this incident in the progress notes or conduct a thorough investigation. The facility's policy on abuse, neglect, and exploitation did not include a definition of sexual abuse or information on consent to sexual activity, which may have contributed to the lack of appropriate response. Interviews with staff and family members revealed inconsistencies in the facility's handling of these incidents. Staff reported that Resident #4 was supposed to have 1:1 supervision, but this was not consistently provided. The facility also failed to complete a Self-Reported Incident (SRI) for the incidents involving Resident #4, as they did not believe the situations constituted abuse. The lack of documentation, investigation, and reporting of these incidents highlights a significant deficiency in the facility's implementation of its abuse policy.
Failure to Report Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the State Agency, affecting two out of five residents reviewed for abuse. Resident #61, who had a history of dementia and other cognitive impairments, was found in the bathroom with Resident #4, both with their pants down. Despite being placed on one-on-one supervision, the facility did not document the incident properly or report it as a potential case of abuse. The facility's investigation noted no skin-to-skin contact or distress, but conflicting accounts from staff and family members suggested inappropriate behavior by Resident #4. Resident #4, who also had dementia and other cognitive impairments, was involved in another incident with Resident #51, where he allegedly grabbed her breast. Despite staff witnessing the incident, it was not documented in the progress notes, and the facility did not report it to the State Agency. The facility's policies on abuse prevention and reporting did not include definitions of sexual abuse or guidelines on consent, contributing to the oversight in reporting these incidents. Interviews with staff and family members revealed discrepancies in the facility's handling of the incidents. Staff reported missing witness statements, and there was a lack of consistent one-on-one supervision for Resident #4. The facility's failure to report these incidents as potential abuse cases and the lack of thorough documentation and investigation highlight significant deficiencies in their abuse prevention and reporting protocols.
Failure to Investigate and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse involving two residents. Resident #61, who had severe cognitive impairment and a history of mood and behavioral issues, was found in the spa room with Resident #4, both with their pants down. Despite being placed on one-on-one supervision, there was no documentation of an earlier incident on the same day. The facility's investigation lacked a written statement from a key witness, and the facility did not report the incident as abuse, believing it was a misunderstanding. Resident #4, who also had severe cognitive impairment and a history of behavioral disturbances, was involved in multiple incidents of inappropriate sexual behavior. On one occasion, he was found with Resident #61 in the spa room, and on another, he allegedly grabbed the breast of Resident #51. Despite these incidents, there was no thorough investigation or documentation, and the facility did not report the incidents as abuse. The facility's policy on abuse reporting and investigation did not include a definition of sexual abuse or guidelines on consent. The facility's failure to investigate and report these incidents as abuse represents a deficiency in their handling of resident safety and compliance with regulatory requirements. The lack of documentation, missing witness statements, and inadequate supervision contributed to the facility's non-compliance. The facility's policies were insufficient in guiding staff on handling and reporting sexual abuse, leading to a lack of appropriate action in response to the incidents.
Inadequate Medication Supply for Safe Discharge
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #63, had an adequate supply of narcotic medications for a safe discharge until her post-discharge physician appointment. Resident #63, who had multiple diagnoses including ADHD, anxiety, arthritis, and fibromyalgia, was discharged to her home without confirmation of having enough medication to last until her scheduled follow-up appointment. The facility's policy required that medications be called into the resident's pharmacy of choice, but did not allow for medications to be sent home unless specifically ordered by a physician. In this case, the physician did not authorize the release of narcotics, and there was no documentation confirming whether the resident had sufficient medication at home. Interviews with facility staff revealed that the discharge process involved calling in a 10-day to two-week supply of medications to the resident's pharmacy, but did not include sending medications home with skilled Medicare residents. The Social Services Director and the Director of Nursing confirmed that medications were not sent home unless ordered by a physician. Additionally, it was noted that Resident #63 had difficulty maintaining a primary care physician due to her boyfriend's actions, which contributed to the lack of a PCP at the time of discharge. The facility's policy on discharge medications required physician authorization for releasing controlled substances, which was not obtained in this case, leading to the deficiency.
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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