Autumn Hills Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Niles, Ohio.
- Location
- 2565 Niles Vienna Rd, Niles, Ohio 44446
- CMS Provider Number
- 365672
- Inspections on file
- 36
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Autumn Hills Care Center during CMS and state inspections, most recent first.
The facility failed to update a cognitively intact resident’s care plan after two separate incidents in which the resident entered another resident’s room despite staff instruction. Following the first incident, staff verbally directed the resident not to enter the other resident’s room and demonstrated an alternate route to the back area for smoking and activities to avoid passing that room. A second incident occurred with the same two residents, and staff again reminded the resident to leave the room. Although the resident had dementia and existing care plan interventions addressing cognitive function and need for verbal cues, the care plan was not revised to include the new, specific interventions related to avoiding the other resident’s room and using the alternate route, as confirmed by the DON.
A resident with diabetes and neuropathy, dependent on staff for showers, sustained a toe injury when her foot became caught on loose and missing tiles in a shower room. The incident was confirmed by staff and the resident, and it was found that the damaged tiles had not been repaired prior to the injury, in violation of facility policy requiring a safe environment.
Four residents who required staff assistance for activities of daily living did not receive scheduled showers, with facility records and interviews confirming missed showers and lack of documentation for refusals. The issue was acknowledged by the administrator, who noted ongoing difficulties after changes to the shower aide system.
A resident with severe pain and physician orders for oxycodone every four hours as needed did not receive timely pain medication. The resident's call light was not answered for over an hour, and pain medication was administered significantly later than scheduled. An LPN reported being unaware of the exact timing for the next dose and confirmed the delay in response and administration.
A resident with dysphagia was given a bratwurst by a contracted aide who failed to verify the resident's prescribed mechanically soft diet, resulting in a choking incident that required the Heimlich maneuver. The aide did not check the dietary logbook as required by facility policy, and this deficiency had the potential to affect other residents needing modified diets.
Multiple rooms were found with significant dirt, debris, and unclean surfaces, including used medical items and dried spills, with no routine cleaning after certain hours. Staff confirmed the accumulation had occurred over more than one day, and residents reported dissatisfaction with the cleanliness of their environment.
Several residents who required substantial or maximal assistance with ADLs did not receive showers or hygiene care according to their preferences or the facility's shower schedule. Observations and interviews revealed that residents were left unkempt, with unwashed hair and soiled clothing, and documentation of care was incomplete or missing. The facility's recent change in shower aide assignments contributed to the missed care, and the DON and Administrator confirmed the deficiency.
A resident with significant medical and vision needs did not receive prescribed eyeglasses after being evaluated by optometrists and given updated prescriptions. The resident was observed using a magnifying glass and old glasses to read, and staff confirmed the eyewear was never provided due to a change in the facility's contracted provider.
A resident with severe cognitive impairment and hemiplegia was not provided with a physician-ordered palm guard, despite staff documentation indicating daily application. Observations and interviews confirmed the device was not worn as ordered, and staff failed to document the resident's refusals, resulting in inaccurate records.
A resident with significant physical impairments, who was care planned as a supervised smoker, was found to have unsupervised access to cigarettes and a lighter, which were kept in a bag attached to her wheelchair instead of being secured by staff as required by facility policy. Staff confirmed that smoking materials were not stored as directed, resulting in a deficiency.
A resident with a history of MSSA infection, diabetes, and endocarditis was placed on contact isolation and required IV antibiotics via PICC line. An LPN failed to perform hand hygiene before donning PPE and before accessing the PICC line, despite facility policy requiring hand washing prior to medication administration. The LPN handled personal items and room equipment before administering the medication, and both the LPN and DON confirmed that proper hand hygiene was not performed.
A resident with multiple chronic conditions and moderate cognitive impairment was found unable to access their overbed table and call light, as both were placed out of reach. The resident was unable to call for assistance or access personal items, and staff confirmed the items were not positioned appropriately to meet the resident's needs.
The facility failed to maintain a sanitary environment, with dust and dirt build-up observed in the main lobby, dining room, and several resident rooms. A Hoyer lift was visibly dirty, and the shower room had hair, soap scum, and mildew issues. The Housekeeping Supervisor noted that cleaning protocols were not adequately followed, contributing to the unsanitary conditions.
A facility failed to notify a resident's family of a medication change involving Depakote, despite the resident's known allergy to the drug. The resident, who was cognitively impaired and had significant medical conditions, received Depakote multiple times without the Healthcare Power of Attorney being informed. Interviews confirmed the lack of notification, contrary to the facility's policy requiring prompt communication of changes in resident condition.
A resident with a documented allergy to Depakote was administered the medication multiple times without proper verification of safety. The facility failed to consult with the primary care physician, pharmacy, or family regarding the allergy. Despite the allergy being noted in the medical records, the medication was dispensed and administered until family concerns prompted a review and discontinuation.
The facility failed to implement an effective pressure ulcer prevention program, resulting in harm to two residents. One resident, quadriplegic and in a persistent vegetative state, developed a Stage III pressure ulcer due to inadequate incontinence care and repositioning. Another resident developed an unstageable pressure ulcer on the foot, which was not identified in a timely manner. Staff and family interviews highlighted ongoing issues with care and documentation.
A facility failed to administer medications as ordered, affecting three residents and potentially all 106 residents. One resident with complex diagnoses did not receive medications like valproic acid and gabapentin on time. Another resident experienced delays in pregabalin and valproic acid administration, and Synthroid was not initiated as ordered. A third resident reported retaliatory delays in medication administration by an LPN. The facility's policy of administering medications within 60 minutes was not followed, as confirmed by the DON.
The facility failed to provide timely incontinence care, affecting several residents who were left in soiled conditions for extended periods. A resident with diabetes and heart failure reported lying in urine and bowel movements due to staff being occupied with other duties. Another resident in a persistent vegetative state was found with heavily soiled briefs, documented by his fiancee. Similar neglect was observed with other residents, indicating a pattern of non-compliance with the facility's incontinence care policy.
The facility failed to provide adequate staffing, resulting in neglect of residents' incontinence care and pressure ulcer prevention. A resident developed a Stage III pressure ulcer due to insufficient turning and repositioning, while others reported lying in urine and bowel movements for extended periods. Staff interviews confirmed that heavy workloads and insufficient staffing hindered timely care, violating facility policies.
A resident with multiple medical conditions experienced a lack of dignity and respect from an LPN, who responded rudely to questions about medication schedules and administered medications late. The LPN's behavior was confirmed by the DON, and the facility's policy on timely medication administration was not followed.
A facility failed to implement proper infection control measures and Enhanced Barrier Precautions (EBP) for a resident with significant medical needs, including a tracheostomy and PEG tube. Staff were observed providing care without gowns, and a nurse did not perform hand hygiene during wound care. Interviews revealed a lack of awareness and training on EBP requirements, despite clear facility policies and CMS guidelines.
A resident's medical records were found to be inaccurate due to a false signature on a form regarding a pressure ulcer. The resident, with multiple health issues, had a new Stage three pressure ulcer documented by an LPN, who printed an NP's name on the form without her knowledge. The NP confirmed she had not signed the form or discussed the wound, and the DON verified the inaccuracy. The facility's policy lacked guidance on preventing falsified information.
A resident's virtual colonoscopy was delayed due to a failure in pre-procedure preparation. The resident, with severe cognitive deficits and multiple health issues, did not receive timely bowel preparation because an LPN incorrectly transcribed the order. The DON confirmed the error, which affected one of six residents reviewed for appointments.
The facility failed to provide adequate nursing staff to meet residents' ADL needs, resulting in missed showers and delayed call light responses. Several residents, including those with conditions like epilepsy, morbid obesity, and multiple sclerosis, did not receive scheduled showers due to staff shortages. Interviews and observations confirmed that shower aides were often reassigned to cover call-offs, and call lights were not answered promptly, indicating insufficient staffing levels.
The facility failed to provide scheduled showers and incontinence care for several residents, leading to unmet needs and dissatisfaction. Residents with various medical conditions missed numerous scheduled showers due to staffing issues, such as aides being reassigned to cover call-offs. One resident was left without a call light for hours, highlighting the facility's inability to meet care requirements.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to request assistance. One resident, with cognitive impairment and multiple health issues, was observed by family without access to her call light. Another resident, dependent on staff for ADLs, reported her call light was tied behind her bed, making it inaccessible. Observations confirmed these deficiencies, which violated the facility's policy.
A resident with an indwelling urinary catheter did not receive the prescribed antibiotic, Cipro, with each catheter change as directed by their urologist. The MAR and TAR showed inconsistencies, with Cipro administered without a catheter change and catheter changes documented without Cipro administration. An LPN admitted to administering Cipro from an external source without documentation, and the DON confirmed the discrepancies, leading to a deficiency finding.
A facility failed to maintain a medication administration error rate below five percent, with errors affecting a resident with type II diabetes and heart failure. The resident did not receive prescribed Toujeo insulin since late July, and their blood pressure was not checked before administering Carvedilol, despite clear instructions. The LPN did not follow the order due to a lack of prompt in the electronic medical record, and the medication was unavailable. The Pharmacy Director confirmed the insulin was delivered, but the facility's attempts to reorder were denied as too soon.
The facility did not update the daily nurse staffing information for several days, affecting all 108 residents. The posted information was last updated on August 1, and the DON confirmed it had not been updated since. The scheduler responsible for updating the information was on vacation and unaware of the lapse, while the DON was supposed to ensure updates in the scheduler's absence.
A resident with bone cancer did not receive timely pain medication due to a delay in obtaining a signed order from the prescriber. The facility's attempt to access the medication was denied by the pharmacy, and the medication was not sent until two days later, resulting in a deficiency.
Failure to Revise Care Plan After Repeated Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan in response to repeated resident-to-resident incidents and newly implemented staff interventions. Resident #7 was admitted on 11/15/22 with diagnoses including COPD, major depressive disorder, chronic viral hepatitis, mild dementia, and type 2 diabetes. Resident #13, admitted on 01/30/24 with cerebral palsy, osteogenesis imperfecta, type 2 diabetes, major depressive disorder, need for assistance with personal care, convulsions, and aortic stenosis, was involved in two separate incidents with Resident #7 in Resident #13’s room. A nursing note dated 09/27/25 documented that Resident #7 was found in Resident #13’s room, after which staff verbally instructed Resident #7 not to enter Resident #13’s room and demonstrated an alternate route to the back of the facility for smoking and activities so he could avoid passing by Resident #13’s room. A self-reported incident dated 12/07/25 showed a second incident in which Resident #7 was again found in Resident #13’s room and was reminded by staff that he could not be there and needed to leave. Review of Resident #7’s care plan, with a review date of 12/23/25, showed an identified problem of alteration in cognitive function secondary to dementia, with interventions such as assisting with decision making, monitoring for changes in condition and cognition, and offering verbal reminders and cues. However, the care plan contained no revisions to reflect the two resident-to-resident incidents on 09/27/25 and 12/07/25, nor did it include the specific interventions directing Resident #7 not to enter Resident #13’s room or to use the alternate route to the back of the facility. A quarterly MDS 3.0 assessment for Resident #7 indicated he was cognitively intact, did not exhibit behavior symptoms or rejection of care, was independent with transfers, could self-propel in his wheelchair, and required setup to moderate assistance for ADLs. In an interview, the DON confirmed there were two incidents between the residents in Resident #13’s room, that Resident #7 had been educated about not entering that room and about using an alternative route, and that these interventions were not added to Resident #7’s care plan.
Resident Injury Due to Unrepaired Shower Room Tiles
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic neuropathy, who required dependent assistance with showers, sustained an injury due to loose and missing tiles in a shower room. While being transported out of the shower area by a CNA, the resident's third and fourth toes on the left foot became caught on the uneven tiled area, resulting in lifted and partially removed toenails with moderate bloody drainage. The incident was confirmed by multiple staff interviews and the resident, who reported receiving subsequent evaluation and treatment for the injury. Observations and interviews revealed that the shower room had areas of loose and missing tiles at the time of the incident, which had not been addressed prior to the injury. Facility policy required maintenance of a safe and hazard-free environment, but the presence of the damaged tiles in the shower room constituted a failure to maintain such conditions, directly leading to the resident's injury.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to four residents who required assistance with activities of daily living due to various medical conditions, including diabetes mellitus, acute respiratory failure, morbid obesity, motor neuron disease, chronic obstructive pulmonary disease, malignant neoplasm of the cerebrum, epilepsy, hypertension, Huntington's disease, and dysphagia. These residents were dependent on staff for daily hygiene and showering, as documented in their care plans and Minimum Data Set (MDS) assessments. Review of facility records, including shower schedules and documentation, revealed that these residents did not receive showers on multiple scheduled dates, and there was no documentation of refusals or reasons for missed showers. Interviews with residents and the facility administrator confirmed the issue, with one resident reporting not receiving the scheduled number of showers per week and the administrator acknowledging ongoing problems with shower provision since the removal of the dedicated shower aide. The lack of documentation and missed showers affected four out of seven residents reviewed for showers, as verified by both record review and staff interviews.
Delayed Pain Medication Administration
Penalty
Summary
Resident #38, who was admitted with diagnoses including sepsis, a left pubic fracture, and a lumbar vertebral compression fracture, had a physician's order for oxycodone 10 mg by mouth every four hours as needed for pain. The resident was cognitively intact and reported severe pain. The care plan included administering pain medication as ordered and monitoring its effectiveness. On the date in question, the Medication Administration Record showed that the resident received his pain medication at 4:02 A.M., but the next dose was not given until 10:49 A.M., despite the order allowing for administration every four hours as needed. During this period, the resident activated his call light from 8:30 A.M. to 9:30 A.M. without response and eventually called the main phone line to request his pain medication, which he stated was due at 8:30 A.M. The nurse did not respond to the call light until around 10:40 A.M. and administered the medication at that time. The LPN caring for the resident that day confirmed she was not aware of the exact timing for the next dose and acknowledged the delay in responding to the call light and administering the medication. Facility policy requires prompt response to pain, but this was not followed in this instance.
Failure to Provide Prescribed Diet Texture Results in Choking Incident
Penalty
Summary
A resident with Huntington's disease and dysphagia, who required a mechanically soft diet with thin liquids, was given a bratwurst by a contracted behavioral health aide during an activity program. The aide did not check the facility's logbook, which lists each resident's dietary requirements, before providing the food. As a result, the resident began choking on the bratwurst and required the Heimlich maneuver to clear the airway. The incident was witnessed by another resident and confirmed by the aide, who stated it was only her second day at the facility and she had not verified the resident's diet as required by facility policy. The resident's care plan and physician's orders specified the need for a mechanically altered diet, and the facility's policy required staff to verify diet type and consistency before feeding. Despite these protocols, the failure to check the dietary logbook led to the resident receiving food that was not consistent with her prescribed diet. This deficiency affected one resident directly and had the potential to impact 18 additional residents identified as requiring modified diet textures.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by significant dirt accumulation and debris in multiple resident rooms. Observations revealed large amounts of dirt, paper, plastic, and used medical equipment such as an intravenous cap and a used coffee creamer cup on the floors, including under beds. Trash cans were found without liners, and dried spills were present on overbed tables and floors. These conditions were confirmed by both housekeeping and nursing staff, who acknowledged that the dirt and debris had accumulated over more than one day. Housekeeping staff were not available after 5:00 P.M., and nursing assistants were expected to address visible issues during those hours, but the rooms remained unclean. Residents affected by these conditions expressed concerns about the lack of routine cleaning, particularly in their rooms and bathrooms, where dirt build-up was noted around toilets and on floors. The facility's own housekeeping policy required maintenance of a clean and homelike environment, but this standard was not met. The deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Provide Scheduled Showers and Hygiene Assistance
Penalty
Summary
The facility failed to provide showers and bathing assistance to residents according to their preferences and the established shower schedule. Multiple residents who required substantial or maximal assistance for activities of daily living (ADLs), including bathing, did not receive showers as scheduled. Documentation and direct observations confirmed that several residents had not received showers or hair washing for extended periods, despite being dependent on staff for these tasks. The facility had recently changed its process by discontinuing dedicated shower aides and assigning all CNAs to handle shower duties, which contributed to the missed care. Specific residents affected included individuals with significant medical conditions such as lumbago with sciatica, chronic kidney disease, hemiplegia, malnutrition, and cognitive deficits. These residents were observed to be unkempt, with greasy or unwashed hair, and in some cases, soiled clothing. Interviews with the residents and the DON confirmed that showers and hygiene care were not provided as scheduled, and documentation was either missing or incomplete. Residents expressed dissatisfaction with their hygiene care, noting that they had not received showers or shaves as they preferred and as outlined in their care plans. Facility policy required that residents be interviewed about their bathing preferences upon admission and that these preferences be reviewed quarterly. However, the lack of adherence to the shower schedule and resident preferences, as well as the absence of proper documentation, demonstrated a failure to follow this policy. The DON and Administrator verified the missed showers and incomplete records, confirming the deficiency in providing necessary care and assistance for activities of daily living.
Failure to Provide Prescribed Eyeglasses to Resident
Penalty
Summary
A resident with multiple medical conditions, including spina bifida, paraplegia, and cognitive communication disorder, was identified as requiring corrective lenses according to her admission MDS assessment. Despite being seen by an in-house optometrist and receiving an updated prescription for new eyeglasses, the resident did not receive the prescribed eyewear. Observations showed the resident using a magnifying glass to read and continuing to wear old prescription glasses. The resident was later seen by another optometrist and given a new prescription, but still had not received the appropriate eyeglasses. Staff confirmed that the resident never received the prescribed eyeglasses due to a change in the facility's contracted provider.
Failure to Apply Palm Guard as Ordered and Inaccurate Documentation
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, and muscle wasting was not provided with a palm guard as ordered by the physician. The resident's medical record indicated a diagnosis following a cerebral infarction affecting the left side, and the resident was assessed as having severe cognitive impairment, requiring substantial or maximum assistance with all activities of daily living. The physician's order specified that the palm guard should be worn daily and removed only for hand hygiene and skin checks. Despite documentation in the Treatment Administration Record (TAR) that staff verified the palm guard was worn daily throughout the month, direct observations on two separate occasions revealed the resident was not wearing the device. The resident reported not often wearing the palm guard but was unsure of the reason. An LPN confirmed the resident was not wearing the palm guard and stated the resident often refused it, yet there was no documentation of refusals or behaviors in the TAR. The TAR continued to be signed off as if the device was applied daily, contrary to actual practice.
Failure to Secure Smoking Materials for Supervised Smoker
Penalty
Summary
A deficiency was identified when a resident with motor neuron disease, osteoarthritis, muscle wasting, and atrophy, who was dependent for most activities of daily living except eating, was found to have unsupervised access to smoking materials. The resident was cognitively intact and care planned as a supervised smoker, requiring staff to store her cigarettes and lighter. Multiple quarterly smoking assessments also documented the need for staff to secure her smoking materials. Despite these documented requirements, observations and interviews revealed that the resident's cigarettes and lighter were kept in a bag attached to her wheelchair, accessible to her at all times rather than being stored by staff. Staff confirmed that the smoking materials were not secured as per facility policy, which mandates that all cigarettes and lighters be kept in a secured area and only distributed by staff during supervised smoke breaks. The facility's failure to follow its own policy and the resident's care plan resulted in the deficiency.
Failure to Follow Infection Control Practices During IV Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow appropriate infection control practices during the administration of intravenous medication through a peripherally inserted central catheter (PICC) line for a resident. The resident had a history of methicillin susceptible staphylococcus aureus (MSSA) infection, type two diabetes, and infective endocarditis, and was under contact isolation precautions. The LPN entered the resident's room, donned gloves and a gown without performing hand hygiene, prepared the antibiotic solution, and handled personal items before accessing the PICC line. The LPN scrubbed the hub of the PICC access cap and administered the medication without performing hand hygiene or changing gloves after touching room equipment and clothing. The LPN confirmed during an interview that she forgot to perform hand hygiene prior to donning personal protective equipment and before accessing the PICC line. The Director of Nursing also verified that hand hygiene should have been performed at these points. Facility policy required hand washing with soap and water and glove application before medication administration and after resident contact, but these procedures were not followed during the observed medication administration.
Failure to Maintain Call Light and Overbed Table Within Resident's Reach
Penalty
Summary
A deficiency was identified when a resident with chronic respiratory failure, congestive heart failure, chronic kidney disease, and moderate cognitive impairment was observed sitting in a wheelchair, unable to access their overbed table and call light. The overbed table, which held personal items including a beverage and television remote, was placed across the room out of the resident's reach. The call light was found wrapped around the bed rail behind the resident's wheelchair, also out of reach. The resident reported being unable to reach the overbed table and unable to call for staff assistance due to the inaccessible call light. The resident's care plan indicated a need for assistance with activities of daily living due to decreased mobility, shortness of breath, and altered cognition, and included an intervention to encourage use of the call light for assistance. During the observation, facility staff confirmed that both the call light and overbed table were not within the resident's reach, which did not accommodate the resident's needs and preferences as required.
Sanitation Deficiency in Facility Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for its residents, as observed during a survey. The main lobby had a drinking fountain with a moderate build-up of dust, and the floor was only partially clean with mop swirls and dust build-up between floor mats. The main dining room had visible dirt and a large blackened area on the floor, with dust accumulation on a small dining table and a piano. In several resident rooms, there were issues such as black dirt on the floor, dead flower petals, cobwebs, food crumbs, and dried food on bedrails. A Hoyer lift in the 200 hall was visibly dirty. The shower room on the 200 hall had hair and soap scum build-up on drains, an orange slimy build-up on tiles, and black build-up in grout. The Housekeeping Supervisor revealed that resident rooms were supposed to be cleaned daily, including mopping behind doors, and shower rooms were cleaned weekly. However, the acrylic caulking in the shower room quickly grew mildew, and a leaking shower handle contributed to the orange build-up. The facility's housekeeping policy stated that the environment should be maintained to meet a homelike standard, which was not achieved, leading to the deficiency.
Failure to Notify Family of Medication Change for Resident with Known Allergy
Penalty
Summary
The facility failed to timely notify the family of a medication change for a resident with significant medical conditions, including acute and chronic respiratory failure, dependence on a respirator, and cognitive impairment. The resident had a known allergy to Depakote, which was documented in their medical record and Medication Administration Record (MAR). Despite this, Depakote was ordered and administered multiple times over several days without notifying the resident's Healthcare Power of Attorney (POA), who was listed as the resident's sister. Interviews with the Director of Nursing (DON) and the resident's sister confirmed that the family was not informed of the addition of Depakote to the medication regimen. The facility's policy required prompt notification of the resident, attending physician, and responsible party of changes in the resident's condition or status, which was not adhered to in this case. The Psychiatric Nurse Practitioner who wrote the order for Depakote also confirmed that the family was not notified, highlighting a breakdown in communication and adherence to policy.
Failure to Address Drug Allergy in Medication Administration
Penalty
Summary
The facility failed to collaborate with pharmacy services to ensure a medication listed as a drug allergy was not dispensed and administered to a resident until it was determined to be safe. The resident, who was cognitively impaired, had a documented allergy to Depakote, a medication used for mood stabilization. Despite this, Depakote was ordered and administered multiple times without consulting the primary care physician, nurse practitioner, or pharmacy to verify the safety of administering the medication given the allergy. The resident's medical records from a prior hospital visit indicated an adverse reaction to Depakote, which was not addressed by the facility upon admission. The Medication Administration Record documented Depakote as an allergy, yet the medication was still administered. The facility did not contact the family to understand the nature of the allergy or to discuss the medication's administration. It was only after the family raised concerns that the medication was placed on hold, and the physician was consulted. Interviews with facility staff and the pharmacist revealed a breakdown in communication and procedure. The Director of Nursing acknowledged that the allergy should have been questioned by both the nurse and the pharmacist. The pharmacist admitted that the allergy was missed during the drug utilization review process. The Psychiatric Nurse Practitioner who prescribed the medication did not discuss the order with the family, assuming the facility would handle communication. This oversight led to the resident receiving six doses of Depakote without adverse effects being reported.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in the development of pressure ulcers in two residents. Resident #27, who was quadriplegic and in a persistent vegetative state, was dependent on staff for all activities of daily living. Despite being at very high risk for pressure ulcers, the facility did not provide timely incontinence care or ensure regular turning and repositioning. This led to the development of a Stage III pressure ulcer on Resident #27's sacrum, which was not identified until it had progressed significantly. Resident #109, who was also dependent on staff for all ADL care, developed an unstageable pressure ulcer on his left lateral foot. The facility's documentation did not show any evidence of the ulcer until it was found to be unstageable, indicating a lack of timely identification and intervention. The facility's failure to provide adequate care and monitoring contributed to the development and progression of these pressure ulcers. Interviews with staff and family members revealed ongoing issues with incontinence care and repositioning, as well as discrepancies in documentation and communication regarding the residents' conditions. The facility's policies on pressure ulcer prevention and risk identification were not effectively implemented, leading to harm for the residents involved.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered by the prescriber, affecting three residents and potentially impacting all 106 residents in the facility. Resident #1, with multiple complex diagnoses including anoxic brain damage and epilepsy, did not receive medications such as valproic acid, guaifenesin, baclofen, and gabapentin at the prescribed times. The medication administration record (MAR) and medication administration audit report (MAAR) from January 2025 showed repeated delays in administering the noon and PM doses, with some doses being administered simultaneously or not at all. The Director of Nursing (DON) confirmed these findings during an interview. Resident #27, also with severe medical conditions including quadriplegia and epilepsy, experienced similar issues with medication administration. The MAR and MAAR indicated that pregabalin and valproic acid were not administered at the scheduled noon times, with delays extending several hours past the prescribed window. Additionally, there was a significant oversight regarding the initiation of Synthroid for hypothyroidism. Despite a nurse practitioner's order in December 2024, the medication was not started until January 2025, a month later, which was confirmed by the DON and Administrator upon audit. Resident #86, diagnosed with conditions such as COPD and diabetes, reported a confrontation with an LPN, which allegedly led to retaliatory delays in medication administration. The MAR and MAAR showed that medications like midodrine, Vistaril, and gabapentin were consistently administered late. The facility's policy required medications to be administered within 60 minutes of the scheduled time, a guideline that was not adhered to, as verified by the DON. This deficiency was investigated under a master complaint number, indicating non-compliance with medication administration protocols.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for several residents, leading to significant discomfort and potential health risks. Resident #54, who was admitted with conditions such as diabetes and heart failure, reported lying in urine and bowel movement for extended periods due to staff being occupied with other duties. Despite being on diuretics, which increased her need for frequent changes, she was not changed every two hours as required. The CNA assigned to her care confirmed the delay, citing understaffing as a reason for not being able to attend to all residents promptly. Resident #27, who was in a persistent vegetative state and completely dependent on staff for care, was also found to be left in saturated incontinence products. His fiancee/POA documented the neglect with photographs showing heavily soiled briefs and linens, which she presented to the DON. Despite these concerns being raised, the facility's response was inadequate, and the resident continued to experience prolonged periods without being changed. Similar issues were observed with Resident #57 and Resident #1, both of whom were found with excessively filled incontinence briefs, indicating they had not been changed throughout the night. Interviews with staff and other residents revealed a pattern of neglect, with reports of call lights being ignored and residents left in soiled conditions for extended periods. The facility's policy on incontinence care, which aims to maintain skin integrity and prevent breakdown, was not adhered to, resulting in widespread non-compliance and discomfort for the residents.
Inadequate Staffing Leads to Neglect in Incontinence Care and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in several instances of neglect, particularly concerning incontinence care and the prevention of pressure ulcers. Resident #27, who was admitted with intact skin and was dependent on staff for all activities of daily living due to anoxic brain damage and quadriplegia, developed a Stage III pressure ulcer on the sacrum. This was attributed to inadequate turning, repositioning, and incontinence care, as evidenced by photographs taken by the resident's fiancee showing saturated incontinence briefs and urine-soaked linens. Despite the care plan's interventions, the resident was not changed or repositioned every two hours as required. Resident #54, who was incontinent of bowel and bladder and dependent on staff for toileting hygiene, reported lying in urine and bowel movement for extended periods. She stated that she informed a CNA of her need for changing, but the CNA was unable to attend to her promptly due to other duties, such as passing and collecting meal trays. The CNA confirmed the resident's claims, acknowledging the difficulty in providing timely care due to the heavy workload and insufficient staffing. Similar issues were reported for Residents #57, #1, and #107, who also experienced delays in receiving incontinence care. Interviews with staff, including CNAs and the DON, revealed that the staffing assignments were too heavy, with CNAs responsible for a large number of residents, many of whom required assistance with incontinence care. The facility's policy on incontinence care and pressure ulcer prevention was not adhered to, as evidenced by the lack of timely care and the development of pressure ulcers. The facility's assessment indicated that staffing levels were based on resident acuity and census, but the actual staffing did not meet these requirements, leading to the deficiencies observed.
Resident Dignity and Medication Administration Deficiency
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a confrontation between the resident and an LPN. The resident, who had multiple medical conditions including chronic obstructive pulmonary disease, diabetes, and depression, reported that the LPN responded rudely when questioned about the medication schedule. The LPN allegedly retaliated by administering the resident's medications late, after attending to other residents first. The resident described the LPN's behavior as dismissive and unresponsive to her concerns. A review of the resident's medication administration record revealed multiple instances of late medication administration by the LPN, with noon doses being given several hours late on multiple days. The Director of Nursing confirmed these findings. During an interview, the LPN admitted to the confrontation and displayed a defensive and dismissive attitude, which hindered the survey process. The facility's policy required medications to be administered within 60 minutes of scheduled times, which was not adhered to in this case.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to ensure proper infection control measures were followed during wound care and the application of Enhanced Barrier Precautions (EBP) for a resident with significant medical needs. The resident, who was in a persistent vegetative state, had multiple diagnoses including anoxic brain damage, chronic respiratory failure, quadriplegia, and required a tracheostomy and PEG tube for feeding. Despite these conditions, the facility did not have appropriate EBP orders in place until it was brought to their attention, and the care plan lacked specific instructions regarding EBP during activities of daily living and wound care. Video evidence provided by the resident's fiancee/POA showed staff failing to wear gowns while providing care, which included incontinence care and wound dressing changes. The videos revealed that staff, including LPNs and CNAs, were only wearing gloves and masks, and not gowns, as required by EBP guidelines. Additionally, during a wound care procedure, a nurse did not perform hand hygiene after removing an old dressing, which is a critical step in preventing infection. Interviews with staff confirmed a lack of awareness and training regarding EBP requirements. The CNA and LPN involved in the care admitted to not wearing gowns and not being aware of the necessity for EBP. The facility's policy on Enhanced Barrier Precautions and the CMS and HHS memorandum clearly outlined the need for gown and glove use during high-contact resident care activities, especially for residents with wounds and indwelling medical devices. However, these guidelines were not followed, leading to the deficiency noted in the report.
Inaccurate Medical Records Due to Unauthorized Signature
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, identified as Resident #27, whose records contained false information. Resident #27, who was admitted with conditions including anoxic brain damage, chronic respiratory failure, quadriplegia, and a persistent vegetative state, was found to have a new Stage three pressure ulcer. The wound was documented by a Wound Nurse/LPN, who completed a form indicating the pressure ulcer was unavoidable due to the resident's impaired mobility and other health conditions. However, the form falsely included the printed name of a Nurse Practitioner (NP) on the physician's signature line without the NP's knowledge or involvement. The NP confirmed in an interview that she had not seen the form, had not signed it, and had not discussed the resident's wound with the facility, as a wound company managed such cases. The Director of Nursing (DON) was unaware of the false signature and confirmed the inaccuracy of the medical record. The facility's documentation policy did not address the prevention of falsified information, such as unauthorized signatures, contributing to the deficiency. This issue was investigated under a specific complaint number, indicating non-compliance with safeguarding resident-identifiable information and maintaining accurate medical records.
Failure to Provide Pre-Procedure Preparation Delays Resident's Procedure
Penalty
Summary
The facility failed to provide the necessary pre-procedure preparation for a resident, resulting in a delay of a scheduled virtual colonoscopy. The resident, who had a severe cognitive deficit and multiple diagnoses including hemiplegia, diabetes mellitus type two, and unspecified aphasia, was scheduled for a virtual colonoscopy. However, the bowel preparation order was not transcribed correctly by an LPN, leading to the procedure being put on hold as the preparation was not initiated in time. The Director of Nursing confirmed that the virtual colonoscopy did not occur as scheduled due to the transcription error, which resulted in the bowel preparation not being started the day before the procedure as required. This deficiency was identified during an investigation under a specific complaint number, affecting one resident out of six reviewed for appointments in a facility with a census of 102.
Inadequate Staffing Leads to Missed Showers and Delayed Call Light Response
Penalty
Summary
The facility failed to maintain sufficient levels of nursing staff services to provide activities of daily living (ADL) assistance to residents according to their plan of care. This deficiency affected six residents and had the potential to affect all 108 residents residing in the facility. The report highlights that residents did not receive scheduled showers, and there were issues with call light response times, indicating inadequate staffing levels. Resident #2, with diagnoses including epilepsy, schizoaffective disorder, and morbid obesity, required assistance with ADLs. The resident was scheduled for showers three times a week but received only 16 out of 39 scheduled showers. Similarly, Resident #24, who was dependent on staff for ADLs due to conditions like morbid obesity and anxiety disorder, received only 14 out of 48 scheduled showers. Other residents, such as Resident #54, #61, #62, and #70, also experienced similar issues with missed showers and inadequate assistance with ADLs. Interviews with residents and staff confirmed that showers were not completed as scheduled, often due to shower aides being reassigned to cover call-offs. The Director of Nursing confirmed that residents were to receive showers three times a week per facility policy. Additionally, observations revealed that call lights were not answered promptly, with Resident #70's call light being ignored by multiple staff members. The facility assessment lacked a staffing plan to meet the acuity needs of the residents, contributing to the deficiency.
Failure to Provide Scheduled Showers and Incontinence Care
Penalty
Summary
The facility failed to provide timely and adequate assistance with showers and incontinence care for residents who were dependent on staff for activities of daily living (ADLs). This deficiency affected eight residents out of 16 reviewed for showers. The residents had various medical conditions, including epilepsy, schizoaffective disorder, multiple sclerosis, and cognitive impairments, which required them to have scheduled showers multiple times a week. However, the facility did not adhere to these schedules, and residents often missed their showers due to staffing issues, such as shower aides being reassigned to cover call-offs. Resident #2, for example, was scheduled to receive showers three times a week but only received 16 out of 39 scheduled showers over three months. Similarly, Resident #24 was scheduled for 48 showers over four months but only received 14. Interviews with residents and their families confirmed that showers were frequently missed, and the lack of staff was cited as a primary reason. Residents expressed dissatisfaction with the care provided, noting that their preferences and needs were not being met. The deficiency was further highlighted by the case of Resident #70, who was left without a call light for several hours and did not receive incontinence care during that time. The resident's call light was activated by a surveyor, and it took nearly 20 minutes for staff to respond, despite multiple staff members walking past the room. The facility's policy required showers to be offered twice a week or as often as requested by the resident, but this was not consistently followed, leading to the identified deficiencies.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which is necessary for accommodating their needs and preferences. Resident #61, who had multiple medical conditions including cognitive impairment and required significant assistance with activities of daily living (ADLs), was observed by her family to not have her call light within reach during visits. This lack of accessibility to the call light meant that Resident #61 could not activate it when she needed assistance. Similarly, Resident #70, who had intact cognition but was dependent on staff for various ADLs due to conditions such as hydrocephalus, COPD, and a stage four sacral pressure ulcer, was found without her call light within reach. During an interview, Resident #70 reported that her call light was tied behind her bed's side rail, making it inaccessible since she was placed in her wheelchair. An observation confirmed that the call light remained out of reach, and the facility administrator verified this during a room visit. The facility's policy requires call lights to be within residents' reach, highlighting a failure to adhere to this policy.
Failure to Administer Antibiotic with Catheter Changes
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, specifically in administering an antibiotic as directed by the resident's urologist. The resident, who had a diagnosis of benign prostatic hyperplasia with a lower urinary tract infection, was supposed to receive Cipro 500 mg with each Foley catheter change. However, the medication administration record (MAR) and treatment administration record (TAR) revealed inconsistencies. On one occasion, the resident received Cipro without a corresponding catheter change, and on two other occasions, catheter changes were documented without the administration of Cipro. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed these discrepancies. The LPN admitted to administering Cipro from a bag of medications brought in by the resident's son but failed to document it on the MAR. The DON confirmed the lack of documentation for the administration of Cipro during catheter changes, despite the existing order on the MAR and TAR. This deficiency was identified during an investigation under Complaint Number OH00156388.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, with the error rate calculated at 6.06%. This deficiency involved Resident #107, who was affected by two medication errors out of 33 opportunities. The resident, diagnosed with type II diabetes mellitus, heart failure, and hypertension, was supposed to receive Carvedilol (Coreg) with a specific instruction to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. However, the Licensed Practical Nurse (LPN) administering the medication did not check the resident's blood pressure before administration, despite the order being clearly indicated in both the electronic medical record and on the medication card. Additionally, Resident #107 was scheduled to receive Toujeo insulin, which had not been administered since 07/30/24. The medication was not available during the observed administration, and there was no documentation explaining the absence of the medication or any notification to the physician or the resident's family. The Pharmacy Director confirmed that the Toujeo insulin was delivered to the facility, but subsequent attempts by the facility to reorder the medication were denied as it was too soon for a refill. This lack of administration and documentation contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information was updated daily as required, potentially affecting all 108 residents. On August 5, 2024, at 4:45 A.M., it was observed that the staffing information posted was dated August 1, 2024, and had not been updated for several days. An interview with the Director of Nursing (DON) confirmed that the staffing information had not been updated since August 1, 2024. The DON stated that it was the scheduler's responsibility to update the staffing information daily. However, Scheduler #813, who was responsible for this task, was on vacation during this period and was unaware that the information had not been updated. The scheduler indicated that if she was off work, it was the DON's responsibility to ensure the information was posted daily.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to ensure timely availability of pain medication for a resident diagnosed with multiple serious conditions, including bone cancer. The resident was admitted with a physician's order for Morphine 30 mg to be administered twice daily for pain management. However, the medication was not available for administration due to a delay in obtaining a signed order from the prescriber. The resident's family expressed concern over the unavailability of the medication, and the facility staff attempted to obtain a pull code for immediate access to the medication, which was denied by the pharmacy due to the lack of a signed order. The delay in providing the signed order to the pharmacy resulted in the resident not receiving the prescribed pain medication in a timely manner. The Director of Nursing confirmed that the signed order was not sent to the pharmacy until two days after the initial prescription, leading to a delay in the medication being sent to the facility. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed, which was not adhered to in this instance, resulting in a deficiency being noted during the survey.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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