Autumnwood Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rittman, Ohio.
- Location
- 275 East Sunset Drive, Rittman, Ohio 44270
- CMS Provider Number
- 365563
- Inspections on file
- 30
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumnwood Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident receiving hospice care was physically restrained by an LPN using a bed sheet tied to a wheelchair after exhibiting combative and restless behavior. Despite having PRN medications available for pain, anxiety, and agitation, these interventions were not used prior to restraining the resident. The restraint was not ordered by a physician, was not part of the care plan, and was discovered by a hospice nurse, who found the resident unattended and in pain. The facility's investigation was incomplete and did not follow policy requirements for restraint use.
The facility failed to ensure required safety interventions were in place for multiple residents, resulting in one resident sustaining a severe burn during unsupervised smoking without a protective apron, and two other residents with cognitive impairment and fall risk found without necessary fall prevention measures such as accessible call lights and non-skid pads. Staff were unaware of or did not follow care plan interventions, and smoking materials were left unsecured and accessible to residents.
The facility did not consistently have an RN on duty for at least eight consecutive hours each day, as required, due to staffing shortages and recruitment challenges. This deficiency was confirmed through staffing records and interviews, and affected all residents in the facility during the period in question.
The facility did not ensure that food was served at a safe and appetizing temperature, as several residents reported the food was cold or unpalatable. Observation of a test tray during lunch service confirmed that hot foods were served below the required 125°F, with items measuring around 116°F and described as lukewarm. The Dietary Manager verified these findings during the meal service.
The facility did not properly sanitize dishware due to a malfunctioning dish machine and incorrect use of sanitizer solution, with staff failing to fully submerge dishes for the required time and using a solution below the recommended concentration. Additionally, expired food items and unsanitary conditions were found in a food storage area, with the DON confirming these issues. All residents were on oral diets and potentially affected by these deficiencies.
The facility did not accurately assess or document the presence of residents with psychiatric or mood disorder diagnoses in its facility-wide assessment, despite staff confirming that multiple residents had such conditions. The assessment also failed to identify the need for behavioral health services, resulting in a mismatch between documented resources and actual resident needs.
Two residents were found in rooms with temperatures below 70°F due to broken heaters, with maintenance staff confirming the issue had persisted for months and that room doors were left open as a temporary measure. Both shared shower rooms were observed to be dirty, odorous, and in disrepair, with broken tiles, standing water, and soiled items present. Staff and family members reported ongoing concerns about the cleanliness and maintenance of these areas, which were the only bathing options available.
The facility did not ensure that staff, including LPNs, CNAs, administrative, dietary, and activity personnel, received behavioral health training as required, despite having numerous residents with psychiatric or mood disorders who needed such care. Personnel files and staff interviews confirmed the lack of training documentation for these staff members.
A resident with severe obesity and heart failure, fully dependent on staff for bathing, was unable to receive showers for an extended period due to a broken bariatric shower bed. Staff confirmed that both this resident and another requiring the same equipment were limited to bed baths, as the facility had not repaired or replaced the only available shower bed.
A resident with severe cognitive impairment and multiple diagnoses was found to have an unsigned DNRCC-A order in their medical record. Although the plan of care and physician's orders indicated DNRCC-A status, the required documentation lacked a physician's signature, as confirmed by the DON, resulting in incomplete advance directive records.
A resident with multiple medical conditions was found to have a new, undocumented skin tear on the lower back by the ADON during wound rounds. The injury's cause and timing were unknown, and no investigation or required SRI report to ODH was completed, despite facility policy mandating such reporting for injuries of unknown origin.
Two residents experienced incidents involving potential abuse and injuries of unknown origin that were not thoroughly investigated. In one case, a resident developed a new skin tear with no documentation or investigation into its cause. In another, a resident was tied to a wheelchair by an LPN, but the facility's investigation did not include statements from hospice staff who witnessed the event, and the final report was submitted before all information was collected. Facility policy requiring comprehensive investigations was not followed.
A resident with multiple health conditions and moderate cognitive impairment did not receive activities tailored to their interests and abilities, as required by their care plan. The activity program lacked staff-facilitated options in the afternoons, evenings, and weekends, relying instead on self-initiated activities that the resident could not perform. The sole, uncertified Activity Director did not provide individualized activities aligned with the resident's preferences, resulting in the resident remaining in bed and expressing boredom and dissatisfaction.
A resident with COPD and other conditions was provided continuous oxygen therapy without a physician's order, as confirmed by staff and the DON. Observations showed the resident receiving oxygen via nasal cannula, with lapses in equipment maintenance such as disconnected tubing and an empty humidifier bottle, leading to discomfort. Facility policy requires physician orders and proper equipment upkeep, which were not followed.
Staff did not consistently use Enhanced Barrier Precautions or follow proper hand hygiene protocols for residents with wounds or indwelling devices. For example, a resident with a PICC line was not on EBP, and an LPN failed to use a gown or perform hand hygiene after care. Another resident with a stage four pressure ulcer received care from a CNA who did not wear an isolation gown, and a third resident with diabetes was cared for by an LPN who did not change gloves or wash hands between tasks.
A resident with complex medical and behavioral issues was sent to the hospital for psychiatric evaluation after multiple behavioral incidents, including threats and substance use. Following hospitalization, facility leadership decided not to allow the resident to return, instead discharging the individual to a homeless shelter and delivering personal belongings there, despite facility policy requiring return after acute care unless specific criteria are met.
A resident with multiple medical and behavioral diagnoses was transferred to the hospital for psychiatric evaluation after repeated behavioral incidents and police involvement. The facility did not provide the required discharge notice when the resident was not permitted to return, despite policy requiring such notification prior to discharge.
Residents did not consistently receive their mail on weekends, as confirmed by both resident interviews and staff statements. The facility's policy requires that residents have access to their mail, but this was not ensured during weekends.
A review and interview confirmed that the grievance committee was made up of two staff and two residents, failing to meet the required ratio of no more than one staff for every two residents or representatives. This had the potential to affect all 54 residents in the facility.
The facility assigned an Activities Director who lacked required certification and experience, and whose personnel file did not include a signed job description. This was confirmed by interviews with the Activities Director, HR, and the Administrator, all of whom acknowledged the absence of necessary qualifications. The deficiency had the potential to impact all residents, as the Activities Director was solely responsible for the activities program.
A facility failed to notify a resident's alternate POA during a health decline when the primary POA was unreachable. The resident, with moderately impaired cognition and on hospice, had an alternate POA listed in admission paperwork, but this information was not entered into the electronic medical record. The oversight was confirmed by the facility's staff, including the administrator and DON.
The facility did not serve all menu items to residents, omitting baked potato soup from a meal. This affected all residents receiving meals, except one who was NPO. Staff failed to check the menu, leading to the oversight, contrary to the facility's policy on therapeutic diets.
A resident with multiple health issues, including Alzheimer's, was found to have a skin tear on the left elbow without a physician's order for treatment. The ADON observed a dressing on the wound with no documentation or order in the medical record. The origin of the skin tear and dressing application was unclear, as noted during a wound care observation.
The facility failed to complete a comprehensive skin assessment for a resident after readmission and did not maintain proper infection control practices during wound care for another resident. The deficiencies included not assessing wounds on admission and failing to follow hand hygiene protocols during wound care.
Resident Physically Restrained Without Clinical Justification or Use of Alternatives
Penalty
Summary
A deficiency occurred when a resident receiving hospice care was physically restrained by an LPN using a bed sheet tied around the resident's waist and secured to a wheelchair. The restraint was applied after the resident exhibited combative behavior, attempted to stand unassisted, and fell from the wheelchair. The resident was left unattended at the nurse's station, agitated, and reported severe pain. The restraint was discovered by a visiting hospice nurse, who found the resident unable to release himself and experiencing abdominal pain. The hospice nurse immediately untied the resident and stayed with him until his transfer out of the facility. Prior to the restraint, the resident had a history of anxiety, terminal illness, and recent behavioral changes, including agitation, restlessness, and combative actions such as pulling at his urinary catheter and attempting to stand or wander unsafely. The resident had multiple as-needed (PRN) medications ordered for pain, anxiety, and agitation, including Oxycodone, Ativan, Haldol, and Phenobarbital. Despite these available interventions, the LPN did not utilize the PRN medications or contact hospice for additional support before resorting to physical restraint. Documentation and interviews confirmed that the restraint was not ordered by a physician, was not part of the resident's care plan, and was not applied in accordance with facility policy, which prohibits restraints for staff convenience or as a substitute for other interventions. The facility's investigation into the incident was incomplete, as it did not include statements from hospice staff or a thorough review of hospice notes. The incident was not immediately reported to facility administration, and the final self-reported incident (SRI) was submitted before all relevant information was gathered. The facility's policy clearly defines physical restraint and outlines the requirements for its use, none of which were met in this case. The deficiency affected one resident, who was cognitively intact and receiving end-of-life care, and resulted in actual harm as the resident was physically restrained without appropriate clinical justification or adherence to policy.
Failure to Implement and Maintain Resident Safety Measures
Penalty
Summary
The facility failed to implement and maintain safety measures and interventions to prevent accidents and hazards for multiple residents. One resident with dementia and Alzheimer's disease, who was assessed as having impaired cognitive function and limited fine motor skills, was allowed to smoke without the required protective smoking apron. This resulted in the resident dropping a cigarette on his lap and sustaining a full-thickness burn with 100% slough, necessitating debridement. The resident's care plan specified the need for a smoking apron and direct supervision during smoking, but these interventions were not followed. Additionally, the smoking materials box at the nurse's station was left unlocked and unattended, making cigarettes and lighters accessible to other cognitively impaired, independently mobile residents. Another resident with a history of falls, cognitive impairment, and dependence on staff for mobility was found multiple times with the call light out of reach, including behind the headboard and inside a closed nightstand drawer. This resident had experienced several falls since admission, and the care plan required the call light to be within reach at all times. Staff interviews confirmed that the resident could not access the call light when it was not properly positioned, and staff were unable to account for how the call light was placed out of reach. A third resident, also with cognitive impairment and a history of falls, was observed without a required non-skid pad (dycem) in the recliner and with the call light not within reach. The care plan included specific fall prevention interventions, such as the use of a dycem and ensuring the call light was accessible. Staff were unaware of the required interventions and could not locate them in the resident's chart. These failures in implementing and maintaining individualized safety interventions directly contributed to accident hazards and actual harm.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Payroll Based Journal (PBJ) staffing data and schedule reviews revealed that on several dates, the facility did not meet the required RN coverage. Specifically, there were multiple days during the third and fourth quarters of the fiscal year 2024 when RN hours were insufficient. On some of these dates, the Director of Nursing (DON), who is an RN, was present, but the facility census was below 60 residents, which is relevant to the regulatory requirement. Interviews with the Administrator and review of staffing records confirmed ongoing challenges in hiring and retaining RNs during the period in question. The Administrator, who started in June 2024, acknowledged difficulties in recruiting RNs, which contributed to the lapses in required RN coverage. The deficiency had the potential to affect all 54 residents residing in the facility at the time.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a palatable and safe temperature, as evidenced by multiple resident interviews and direct observation of meal service. All 54 residents in the facility had oral diet orders and were potentially affected. Several residents reported dissatisfaction with the food, describing it as awful, cold, or horrible. During a lunch service observation, a test tray was plated, delivered, and its temperature measured, revealing that the creamed spinach, pork chop, and diced potatoes were all served at approximately 116 degrees Fahrenheit, which was confirmed by the Dietary Manager to be below the facility's minimum standard of 125 degrees Fahrenheit for hot food. The food was described as lukewarm upon tasting, and the Dietary Manager verified the substandard temperatures at the time of service.
Improper Dishware Sanitization and Food Storage Deficiencies
Penalty
Summary
The facility failed to properly sanitize dishware after washing, discard expired foods in a timely manner, and maintain food storage areas in a clean manner, potentially affecting all 54 residents who receive food from the kitchen. The dish machine had been experiencing ongoing issues and was not reaching the required minimum temperature of 180 degrees Fahrenheit for proper sanitization. Dietary staff attempted to compensate by using a sanitizer solution, but the concentration was measured at 150 ppm, below the manufacturer's recommended range of 200-400 ppm. Additionally, staff did not follow the required procedure of fully submerging dishes in the sanitizer for at least 60 seconds, instead dipping and immediately removing them. These practices were verified through observations, interviews, and review of manufacturer instructions. Further deficiencies were observed in food storage areas, where expired food items such as Jello and applesauce were found, and the mini fridge used for food storage had excessive ice buildup, hair on the shelf, and multiple spills. The Director of Nursing confirmed the poor condition of the fridge and the presence of expired food. All 54 residents had oral diet orders and no residents were NPO at the time of the survey. The Administrator and Dietary Manager acknowledged awareness of the dish machine issues and improper sanitization practices, with documentation showing the problem had persisted for several weeks.
Failure to Assess and Document Behavioral Health Needs in Facility Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to accurately determine the resources necessary to care for its resident population, specifically neglecting to identify and evaluate residents with psychiatric and/or mood disorder diagnoses. Record review showed that the facility assessment did not list any residents with such diagnoses, and staffing was marked as adequate for dementia and mental health conditions, with behavioral health services noted as not applicable. However, staff interviews confirmed that 37 residents residing in the facility at the time had psychiatric and/or mood disorder diagnoses, indicating a significant discrepancy between the documented assessment and the actual needs of the resident population.
Failure to Maintain Safe Temperatures and Clean Bathing Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies in room temperature control and the cleanliness and maintenance of bathing areas. Two residents were found to be living in rooms with air temperatures below the required 70 degrees Fahrenheit, with one resident reporting a non-functional heater and another's room measured at 68 degrees Fahrenheit. The Director of Maintenance confirmed that heater coils in some rooms had been broken since November 2024, and the facility's interim solution was to keep room doors open to maintain heat, as repairs would require shutting off heat to the entire building. Additionally, the facility's two shared shower rooms were observed to be in poor condition. A resident's family member expressed concern about the persistent uncleanliness and disrepair of both shower rooms, which was corroborated by direct observations. The North shower room had a strong foul, musty odor, corroded floor bases, broken tiles, standing water with discoloration, and soiled items left on the floor. The South shower room also had a strong musty odor, broken and dirty tiles, a broken toilet, visible fecal matter, peeling paint, and dirty, peeling grip tape on grab bars. Both rooms were confirmed by staff to be the only available bathing options for residents. Staff interviews and observations with the DON further confirmed the ongoing issues, including persistent odors, broken fixtures, and inadequate cleaning, despite previous attempts to address the problems. The facility's own policy requires maintaining a safe, clean, and comfortable environment, including proper maintenance of resident care equipment and bathing areas, but these standards were not met, affecting multiple residents and potentially impacting the majority of the facility's population.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received behavioral health training as required and as determined by the facility assessment. Personnel file reviews for multiple staff members, including LPNs, CNAs, the Human Resource Manager, the Administrator, a Dietary Aide, and the Activity Director, revealed no evidence of completed behavioral health training. Staff interviews confirmed that these individuals had not received the necessary training. The facility assessment indicated that care for residents with psychiatric or mood disorders was not provided, yet staff interviews revealed that 37 residents with such diagnoses were present and required assistance with behavioral health symptoms. The deficiency was identified through a combination of personnel file reviews, record reviews, and staff interviews. The Director of Nursing confirmed the presence of 37 residents with psychiatric and/or mood diagnoses at the time of the survey. Despite this, there was no documentation or evidence that staff responsible for their care had received behavioral health training, as required by regulations and the facility's own assessment.
Failure to Maintain Shower Bed Limits Resident Bathing Options
Penalty
Summary
The facility failed to maintain equipment used for activities of daily living (ADLs), specifically a bariatric shower bed, in good working condition. One resident with chronic diastolic congestive heart failure and severe obesity, who was totally dependent on staff for bathing, was unable to receive showers due to the broken shower bed. The resident expressed a preference for showers over bed baths, but had not received a shower since the equipment became unusable. Observation confirmed the resident's hair was oily, and interviews with staff indicated the shower bed had been out of service for approximately two to three months due to broken wheel bearings. Staff, including a CNA and the ADON, confirmed that both this resident and another who required the bariatric shower bed were only receiving bed baths because the facility had no other suitable equipment. The maintenance director acknowledged the bearings had been worn out for about a month and that replacement parts had arrived but had not yet been installed. Review of shower records corroborated that the resident had not received a shower since the time the shower bed broke, and bed baths were provided instead.
Incomplete Advance Directive Documentation for DNRCC-A Status
Penalty
Summary
The facility failed to ensure that a resident's advance directive orders and information were accurate and complete throughout the medical record. Specifically, a resident with diagnoses including Alzheimer's Disease, bipolar disorder, and post-traumatic stress disorder was admitted with a physician's order for Do Not Resuscitate Comfort Care Arrest (DNRCC-A) status. However, review of the hard medical chart revealed that the DNRCC-A order was unsigned by a physician and only contained the resident's name. The plan of care and physician's orders both indicated DNRCC-A status, but the required documentation was incomplete. The Director of Nursing confirmed that the DNRCC-A form lacked a physician's signature, contrary to facility policy supporting residents' rights regarding treatment and advance directives.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the Ohio Department of Health (ODH) as required by policy. A resident with diagnoses including severe protein calorie malnutrition, altered mental status, COPD, and weakness was readmitted to the facility after a hospital stay, with no documented skin concerns upon return. Several weeks later, during wound rounds, the Assistant Director of Nursing (ADON) discovered a new skin tear on the resident's lower back, measuring 7.0 cm by 15.0 cm by 0.1 cm, with scant drainage. There was no documentation in the medical record regarding how or when the skin tear occurred. Interviews with the ADON, the Administrator, and the Regional Director of Clinical Services confirmed that the injury was new, of unknown origin, and that no investigation was conducted to determine its cause. Additionally, no Serious Reportable Incident (SRI) was completed or submitted to ODH for this injury, despite facility policy requiring notification of all injuries of unknown source within 24 hours. Review of the ODH Certification and Licensure System confirmed the absence of a report for this incident.
Failure to Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate incidents of potential abuse and injuries of unknown origin for two residents. In the first case, a resident with severe protein calorie malnutrition, altered mental status, COPD, and weakness was found to have a new skin tear on the lower back during wound rounds. There was no documentation in the medical record regarding how or when the skin tear occurred, and no Self-Reported Incident (SRI) was completed. Interviews with the ADON, DON, and Regional Director of Clinical Services confirmed that no investigation was initiated to determine the cause of the injury, despite facility policy requiring such action for unexplained injuries. In the second case, a resident with CHF, anxiety disorder, and uropathy, who was also on hospice care, was found to have been tied to a wheelchair with a sheet by an LPN in an attempt to prevent the resident from standing unassisted or falling. The incident was reported by hospice staff, and an SRI was initiated. However, the facility's investigation was incomplete, as it did not include statements or notes from hospice staff who witnessed the event. The investigation file only contained statements from facility staff, and the final SRI was submitted before all relevant information was gathered. The DON later acknowledged that hospice staff statements were not included in the investigation, and the Regional Director of Clinical Services was unaware of all the information regarding the restraint incident. Facility policy requires that all unexplained injuries and allegations of abuse, neglect, or misappropriation be thoroughly investigated, including interviewing all witnesses and obtaining relevant documentation. In both cases, the facility did not follow its own protocols, resulting in incomplete investigations and a failure to respond appropriately to alleged violations.
Failure to Provide Activities Meeting Resident Needs and Preferences
Penalty
Summary
The facility failed to provide activities that met the needs and preferences of a resident with severe protein calorie malnutrition, altered mental status, COPD, and weakness, who was moderately cognitively impaired. The resident expressed interest in music, pets, keeping up with the news, and going outside for fresh air, and had a history of enjoying hunting, country music, trivia, and exercise. The care plan indicated a need for encouragement to participate in activities and suggested interventions such as verbal reminders and providing sensory stimulation through television and music. However, activity calendars showed a lack of scheduled activities in the afternoons, evenings, and weekends, with most activities being self-initiated and not staff-facilitated, which the resident was unable to do. Multiple observations confirmed the resident remained in bed and did not participate in activities, and both the resident and family reported dissatisfaction with the lack of engagement and opportunities to leave the room. Interviews with the Activity Director revealed that she was the sole staff member responsible for activities, was not certified, and only provided one-on-one visits with the resident two to three times a month. She acknowledged not offering the resident music, trivia, or exercise materials, despite knowing these were his interests. The Activity Director also confirmed that most activities outside her working hours were self-initiated, which the resident could not participate in. The facility's policy required ongoing programs to support residents' activity choices based on assessments and care plans, but this was not implemented for the resident in question.
Failure to Obtain Physician Order and Maintain Oxygen Therapy Equipment
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD), adult failure to thrive, and weakness had a physician's order for oxygen therapy and that oxygen supplies were properly maintained. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, was observed on multiple occasions receiving oxygen via nasal cannula at four liters per minute without a corresponding physician order in the medical record. Staff interviews confirmed that the resident was receiving continuous oxygen therapy without an order, and the Director of Nursing acknowledged that the resident had been on oxygen prior to hospice services being initiated, still without a physician's order. Additionally, observations revealed lapses in the maintenance of oxygen equipment. On one occasion, the oxygen tubing was found disconnected from the concentrator and lying on the floor while the concentrator was running. On another occasion, the humidifier bottle attached to the concentrator was empty, and the resident reported nasal dryness and soreness. Staff confirmed these findings and acknowledged that the humidifier bottle should not be allowed to run empty. Facility policy requires that oxygen be administered only under a physician's order, except in emergencies, and that equipment be properly maintained.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding the use of Enhanced Barrier Precautions (EBP), appropriate personal protective equipment (PPE), and proper hand hygiene. Observations and staff interviews revealed that residents with indwelling medical devices and wounds were not consistently placed on EBP, and staff did not always use the required PPE during high-contact care activities. For example, one resident with a peripherally inserted central catheter (PICC) line was not on EBP, and the assigned LPN was unaware of the device, did not use a gown, and failed to perform hand hygiene after providing care and handling the PICC line. The dressing on the PICC line was also found to be loose and undated, further indicating lapses in infection control practices. Another resident with a stage four pressure ulcer was not provided care under EBP, as the CNA responsible for incontinence care did not wear an isolation gown despite PPE being available outside the room. The CNA acknowledged the requirement but stated she forgot to don the gown. Additionally, a third resident with diabetes received blood sugar monitoring and insulin administration from an LPN who failed to remove gloves or perform hand hygiene between tasks, including documenting in the electronic system and re-entering the resident's room with the same gloves. Review of facility policies and CDC guidance confirmed that EBP should be used for residents with wounds or indwelling medical devices, and that hand hygiene is required before and after glove use, as well as between resident contacts and after handling potentially contaminated items. The facility's failure to ensure adherence to these protocols was observed to affect at least three residents, as staff did not consistently follow established infection control procedures during care activities.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
A resident with multiple diagnoses, including chronic obstructive pulmonary disease, lung cancer, opioid dependence, anxiety disorder, hypertension, depression, and a history of alleged adult physical abuse, was admitted to the facility and later issued a 30-day discharge notice due to noncompliance with facility rules and a behavior contract. Despite the notice, the resident remained in the facility past the stated discharge date. The resident exhibited behavioral symptoms, including verbal outbursts and threats toward staff and other residents, and was involved in incidents that required police intervention. The facility's records show that the resident was sent to the hospital for a psychiatric evaluation following an escalation in behaviors, including possession of alcohol and threats, but there were no documented attempts to facilitate the resident's return to the facility after hospitalization. Interviews with facility staff confirmed that the decision not to permit the resident's return was made by facility leadership, despite awareness of the requirement to allow the resident to return after an acute care stay. The resident was ultimately discharged from the hospital to a homeless shelter, and the facility delivered his belongings there. The facility's own policy stated that residents transferred to acute care should be permitted to return upon discharge unless specific exemptions applied, but there was no documentation that these exemptions were met or that a safe discharge plan was ensured.
Failure to Provide Required Discharge Notice Prior to Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide a required discharge notice to a resident prior to discharge. The resident, who had a history of chronic obstructive pulmonary disease, lung cancer, opioid dependence, anxiety disorder, hypertension, depression, and a recent encounter following alleged adult physical abuse, was initially admitted and later issued a 30-day discharge notice due to noncompliance with facility rules and a behavior contract. Despite the notice, the resident remained in the facility past the stated discharge period. Subsequent documentation showed the resident exhibited ongoing behavioral issues, including threatening staff and other residents, possession of alcohol, and manic behaviors, which led to police involvement and a physician's order for psychiatric evaluation and hospital transfer. After the resident was transferred to the hospital and not permitted to return, there was no evidence in the medical record or facility documentation that a discharge notice was provided at that time. Interviews with the DON and Social Services Designee confirmed that no discharge notice was issued once the decision was made to not allow the resident to return. Facility policy required that a discharge notice be provided to the resident and their representative prior to discharge, but this was not followed in this case.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, as required by their policy and resident rights. During interviews, several residents reported that mail was only delivered Monday through Friday, and not on weekends. The Activities Director confirmed that resident mail was not always delivered on weekends and stated that the weekend manager was responsible for this task. Review of the facility's Resident Rights policy indicated that residents have the right to send and receive mail, including privacy of such communication, but this was not consistently upheld for weekend mail delivery.
Grievance Committee Not Properly Constituted
Penalty
Summary
The facility failed to establish a grievance committee in accordance with required ratios, as the committee was comprised of two staff members and two residents, rather than maintaining no more than one staff member for every two residents or representatives. This deficiency was identified through a review of the committee's membership records and confirmed during an interview with the Administrator. The issue had the potential to affect all 54 residents residing in the facility. No additional information regarding the medical history or condition of the residents involved was provided in the report.
Unqualified Activities Director Placed in Charge of Activities Program
Penalty
Summary
The facility failed to ensure that the Activities Director was qualified for the position, as required. Personnel file review for the Activities Director showed no evidence of experience or certification to serve in this role, and the file did not contain a signed job description. Interviews with the Activities Director and Human Resource Manager confirmed that the Activities Director had no prior experience in activities and was not certified. The Administrator acknowledged awareness of the lack of certification but had not addressed the issue. The Corporate Director of Life Enrichment and Memory Care confirmed that the Activities Director was hired without the required qualifications and described the expectations for the department, including staff training and activity scheduling. This deficiency had the potential to affect all 54 residents in the facility, as the Activities Director was solely responsible for the activities program.
Failure to Notify Alternate POA During Resident's Health Decline
Penalty
Summary
The facility failed to timely notify the alternate Power of Attorney (POA) for a resident experiencing a decline in health status when the primary POA could not be reached. This deficiency affected a resident who had moderately impaired cognition and was on hospice care. The resident's medical record indicated that the primary POA was the resident's sister, and the alternate POA was the resident's niece. However, the alternate POA was not identified in the resident's profile, leading to a failure in communication during a critical change in the resident's condition. The deficiency was identified through interviews and record reviews, revealing that the former admissions director did not input the alternate POA information into the electronic medical record. The nursing staff, including the LPN who admitted the resident, did not verify or update the emergency contact information. Consequently, when the resident's condition worsened, and the primary POA was unreachable, the facility did not notify the alternate POA, as required by their policy. This oversight was confirmed by the facility's administrator, director of nursing, and the LPN involved.
Failure to Serve Menu Items as Prescribed
Penalty
Summary
The facility failed to serve all the food items listed on the menu to its residents, affecting all who received meals from the kitchen except for one resident who was ordered nothing by mouth. During an observation of the meal service, it was noted that the evening meal served included tuna salad sandwiches, cucumber salad, and cantaloupe, but did not include the baked potato soup that was listed on the facility menu for that day. This discrepancy was confirmed through a review of the facility menu and meal spreadsheet, which indicated that the dinner should have included six ounces of baked potato soup along with the other items. Interviews with the Dietary Manager and another staff member revealed that the baked potato soup was not served because the staff did not refer to the menu or meal spreadsheet. The Dietary Manager admitted to not checking the menu to ensure the correct meal was served, and another staff member confirmed that she only followed a sheet filled out by the previous cook, which did not mention the soup. The facility's policy on therapeutic diets emphasizes providing residents with foods that meet their nutritional needs as prescribed by a physician or interdisciplinary team, which was not adhered to in this instance.
Lack of Physician's Order for Wound Treatment
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for a treatment to his left elbow. The resident, who was admitted with multiple diagnoses including congestive heart failure, kidney disease, and Alzheimer's disease, was observed to have a skin tear on his left elbow. Despite the presence of a border foam dressing on the wound, there was no documentation or physician's order for this treatment in the resident's medical record. The Assistant Director of Nursing (ADON) confirmed the absence of an order and was unaware of when the dressing was applied or who placed it. The resident's medical record and progress notes from mid to late July 2024 did not document any skin tear or treatment order for the left elbow. During a wound care observation, the ADON noted a moderate amount of brown drainage on the dressing and acknowledged the need to clean the wound and obtain a treatment order. The ADON also mentioned that the resident had a shower the previous day, and the hospice nurse present did not report any skin issues, leaving the origin of the skin tear and dressing application unclear. This deficiency was investigated under a specific complaint number.
Failure in Comprehensive Skin Assessment and Infection Control
Penalty
Summary
The facility failed to ensure a comprehensive skin assessment was completed after admission for Resident #1 and did not maintain proper infection control practices and hand hygiene during wound care for Resident #58. Resident #1, who had diagnoses including diabetes, congestive heart failure, and Parkinson's disease, was readmitted to the facility with two Stage III pressure ulcers. However, no wound assessment or measurements were completed for five days following his readmission. The Director of Nursing confirmed that the nurse responsible for the assessment did not follow the protocol to assess wounds on admission. Resident #58, who had multiple diagnoses including chronic obstructive pulmonary disease, end-stage renal disease, and diabetes, was observed receiving wound care that did not adhere to proper infection control practices. During the wound care, the Nurse Practitioner and Licensed Practical Nurse failed to clean the scissors before use, did not wash hands or change gloves after removing the old dressing, and handled wound care materials with contaminated gloves. This was in direct violation of the facility's policy on clean dressing changes, which mandates hand washing and glove changes at specific steps to prevent infection and cross-contamination.
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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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