Aventura At Assumption Village
Inspection history, citations, penalties and survey trends for this long-term care facility in North Lima, Ohio.
- Location
- 9800 Market Street, North Lima, Ohio 44452
- CMS Provider Number
- 365783
- Inspections on file
- 32
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Aventura At Assumption Village during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and moderate cognitive impairment did not have the administration of PRN Percocet accurately documented. On several occasions, the controlled drug record showed the medication was removed, but there was no corresponding entry on the MAR. This discrepancy was identified after the resident alleged an LPN gave the wrong medication and took her Percocet. Investigation confirmed that required documentation procedures were not followed, leading to incomplete records for controlled substances.
Staff did not follow proper hand hygiene and glove-changing protocols during incontinence care for two residents who were dependent on staff for all ADLs and always incontinent. In both cases, CNAs failed to change gloves or perform hand hygiene after providing peri care and before applying clean briefs or touching the environment, contrary to facility policy and CDC guidelines.
A resident with chronic pain and multiple health conditions did not receive six scheduled doses of Lyrica due to a delay in prescription renewal and miscommunication among staff, resulting in increased pain and headaches. The facility failed to ensure pain management medication was administered as ordered.
A nurse failed to prime an insulin pen before administering a prescribed dose to a resident with diabetes, despite manufacturer instructions requiring priming to ensure accurate dosing. The nurse was unsure of the correct priming procedure, and the facility's policy to follow physician orders and manufacturer instructions was not adhered to during the observed medication administration.
A resident with hypertension and other conditions was prescribed Carvedilol with instructions to hold the dose if systolic BP was below a certain threshold. Nursing staff administered the medication without documenting BP readings prior to each dose, and the MAR did not prompt for this documentation. Interviews confirmed BPs were checked but not recorded in the EMR, and any written records were discarded, resulting in incomplete and inaccurate medical records.
The facility did not provide substantial evening snacks to residents when the time between dinner and breakfast exceeded 14 hours, affecting 92 residents. Observations showed meal delivery intervals exceeded 14 hours, and residents reported not being offered snacks. The Dietary Manager confirmed the issue, and the facility policy required snacks or resident agreement for such meal plans, which was not followed.
The facility failed to maintain sanitary conditions in food storage, preparation, and serving, affecting 92 residents. Observations revealed undated and exposed food items, expired foods, and unsanitary practices during tray line processes. The facility's policies on food safety and sanitation were not followed, leading to potential risks for residents.
The facility failed to follow its weekly and always available menus, affecting several residents. Budget constraints and delivery issues led to frequent menu substitutions, such as chicken tenders for meatballs and toast for donuts. Residents expressed dissatisfaction with the inconsistency between the menu and meals served, and the Ombudsman noted systemic concerns with food quality and choices.
The facility failed to provide palatable and appropriately heated meals to residents, affecting eight individuals and potentially impacting nearly all residents receiving meals. Residents expressed dissatisfaction with food quality, noting it was often cold and lacked flavor. An observation confirmed that peas served were at an inadequate temperature and flavor, which was corroborated by a dietitian. The facility's policy to ensure palatable food was not followed.
A resident experienced a significant unplanned weight loss of 9.3%, but the facility failed to notify the physician and resident representative as required by policy. The dietitian did not contact the resident's representatives due to their work schedules and only thought she informed the nurse practitioner, who confirmed there was no written notification in the chart.
A resident with multiple health conditions, including hemiplegia and dementia, did not receive the necessary meal setup assistance as outlined in her care plan. Staff consistently left meal trays with lids intact and did not assist in cutting food or opening packages, despite the resident's need for such help. This was confirmed through observations, interviews, and documentation review.
The facility failed to monitor a resident's weekly weights as ordered, impacting her nutritional care, and did not adhere to another resident's fluid restriction, risking his health. Despite orders and care plans, weights were missed, and fluid intake exceeded limits, with no accurate tracking system in place.
A facility failed to maintain proper communication with a dialysis center for a resident with end-stage renal disease. The resident, who required dialysis thrice weekly, did not receive communication forms from the facility to take to the dialysis center. Although the resident brought back forms from the center, there were significant gaps in documentation. Staff interviews confirmed the lack of communication, and the LPN Manager acknowledged the missing forms, stating that the facility should have contacted the dialysis center when forms were not received.
Two residents were found with unattended medications at their bedsides, contrary to the facility's policy requiring nurse supervision during medication administration. One resident, with moderate cognitive impairment, had medications left out of reach, while another, requiring a mechanically altered diet, was unable to swallow potassium tablets without assistance. The facility's policy mandates that medications be administered safely and with supervision.
A resident with quadriplegia and dysphagia, on a mechanical soft diet, received coleslaw instead of green beans, contrary to their dietary requirements. The facility's policy mandates adherence to prescribed diets, but the meal provided did not meet the necessary consistency, as confirmed by staff. This incident suggests a broader issue with meal preparation for residents on specialized diets.
The facility failed to maintain proper infection control procedures, affecting three residents on isolation precautions. A resident with an antibiotic-resistant infection and another with a urinary catheter were not provided care with the required PPE by CNAs who were unaware of the enhanced barrier precautions. Additionally, a CNA failed to doff PPE after exiting a COVID-19 positive resident's room, contrary to facility policy.
A facility failed to implement a comprehensive care plan for a resident's leave of absence (LOA), resulting in the resident being stranded twice at a bus station due to a dead wheelchair battery. The resident, who had multiple medical conditions, left the facility without signing out or notifying staff, and the care plan did not address their LOA preferences or needs. Despite being aware of the resident's tendencies, the facility did not update the care plan to ensure safety during LOA.
A facility failed to refund an overpayment to a resident's family within the required 30 days after the resident's discharge. The resident, who had severe cognitive impairment and was admitted as a private pay, expired in the facility. Despite the spouse's inquiry, the refund was not processed, as confirmed by the Business Office Manager and Administrator.
Failure to Accurately Document Controlled Drug Administration
Penalty
Summary
The facility failed to accurately document the administration of a controlled medication, specifically Percocet, for a resident with multiple complex medical conditions including neuropathy, diabetes, chronic pain, and moderate cognitive impairment. Review of records showed several instances where Percocet was removed for PRN administration as documented on the controlled drug record (CDR), but there was no corresponding documentation on the medication administration record (MAR) to confirm that the medication was actually administered. This discrepancy occurred on multiple dates and times, indicating a pattern of incomplete or missing documentation for controlled substances. The issue came to light following an allegation by the resident that an LPN gave the wrong medication and stole her Percocet. Investigation revealed that the LPN in question was suspended, tested positive for benzodiazepines without a current prescription, and was later terminated. Interviews with staff and review of facility policy confirmed that nurses are required to document all administered controlled medications on both the MAR and CDR to prevent medication errors. The facility's failure to ensure accurate and complete documentation for controlled drug administration created the potential for significant medication errors and/or misappropriation.
Failure to Follow Hand Hygiene and Glove Use During Incontinence Care
Penalty
Summary
Staff failed to follow appropriate infection control practices during incontinence care for two residents who were dependent on staff for all activities of daily living and were always incontinent of bowel and bladder. In one instance, a CNA provided peri care to a resident, then, without changing gloves or performing hand hygiene, touched a barrier cream container, applied the cream, continued care to the resident's buttocks, and applied a new brief, all with the same soiled gloves. The CNA only removed gloves and washed hands after completing the care and handling soiled materials. The CNA confirmed in an interview that she did not change gloves or wash hands between steps as required. In another instance, a different CNA performed incontinence care for a resident, including removing a soiled brief, washing the resident's peri area and buttocks, and applying a clean brief, all without changing gloves or performing hand hygiene. The CNA then pulled up the covers and lowered the bed while still wearing the soiled gloves. The CNA confirmed in an interview that she did not change gloves or wash hands before applying the clean brief and handling the resident's environment. The facility's policy and CDC guidelines require glove changes and hand hygiene after contact with body fluids and before moving from a soiled to a clean site, which was not followed in these cases.
Failure to Administer Ordered Pain Medication Due to Prescription Renewal Delay
Penalty
Summary
A resident with multiple chronic conditions, including multiple sclerosis, chronic pain, and paraplegia, was admitted to the facility and had a care plan that included both scheduled and as-needed pain medications. The resident was prescribed Lyrica 100 mg twice daily for pain, among other pain management medications. Review of the medication administration record revealed that the resident did not receive six scheduled doses of Lyrica over several days. Documentation showed that some doses were held without a reason, while others were not administered because the medication was on order or awaiting a prescription renewal from the nurse practitioner. Progress notes indicated a delay in obtaining the necessary prescription, resulting in missed doses. Interviews with the resident confirmed that the missed doses led to increased pain and more frequent, severe headaches during the period when Lyrica was not administered. Nursing staff and the Assistant Director of Nursing acknowledged that there was a miscommunication regarding the timely renewal of the prescription, which led to the interruption in pain management. Facility policy required pain to be managed according to the care plan and professional standards, but the failure to ensure timely medication renewal and administration resulted in the resident not receiving ordered pain management as required.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a registered nurse failed to properly administer insulin to a resident with type 2 diabetes mellitus and multiple other diagnoses, including hypertension and peripheral vascular disease. The resident had a physician's order for Humalog (Insulin Lispro) to be administered subcutaneously before meals according to a sliding scale based on finger-stick blood sugar (FSBS) results. During a medication administration observation, the nurse checked the resident's blood sugar, which was 238, and prepared to administer three units of insulin as ordered. However, the nurse did not prime the insulin pen prior to dialing the dose and administering the medication. Interview with the nurse confirmed that the insulin pen needle was not primed before use, and the nurse was uncertain about the specific priming instructions. Review of the manufacturer's instructions for the Insulin Lispro KwikPen indicated that the pen should be primed with two units before administration to ensure accurate dosing. The facility's policy required medications to be administered according to physician orders and manufacturer instructions, but this was not followed in this instance, resulting in the resident potentially receiving an incorrect dose of insulin.
Failure to Document Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of specified assessment criteria for a resident receiving medication with blood pressure (BP) parameters. A resident with multiple diagnoses, including hypertension and peripheral vascular disease, had a physician order for Carvedilol to be administered twice daily, with instructions to hold the medication if systolic BP was less than 130. During medication administration observation, the nurse did not document the BP prior to giving the medication, and the last recorded BP in the medical record was several days prior. There was no evidence in the medical record that BP was checked and met the ordered parameters before each dose, as required by the medication order. Further review revealed that the medication administration record (MAR) did not prompt or provide a place for nurses to document BP readings before each Carvedilol dose, only requiring monthly vital signs. Interviews with nursing staff confirmed that BPs were typically checked before administration but not documented in the electronic medical record, and any written notes were discarded. The Assistant Director of Nursing confirmed the lack of documentation and that nursing administration was not informed of the issue prior to the survey. Facility policy required documentation of services and objective observations in the resident's medical record, which was not followed in this case.
Failure to Provide Evening Snacks When Meal Intervals Exceed 14 Hours
Penalty
Summary
The facility failed to ensure that residents were offered a substantial snack in the evening when the time between dinner and breakfast exceeded 14 hours. This deficiency had the potential to affect 92 residents who received meals from the kitchen, excluding two residents who were identified as receiving nothing by mouth (NPO). Observations revealed that the time between dinner and breakfast delivery exceeded 14 hours for all meal delivery carts, with the longest interval being 15 hours and 40 minutes. The facility's policy stated that no more than 14 hours should elapse between a substantial evening meal and breakfast unless a nourishing snack was provided at bedtime, which was not the case. Interviews with residents during a Resident Council meeting indicated that they felt the time between dinner and breakfast was too long and that snacks were not being offered in the evening. Some residents had snacks provided by their families, but others did not have family support or the means to purchase snacks. The Dietary Manager confirmed that meal times had been adjusted, resulting in intervals greater than 14 hours between dinner and breakfast, and acknowledged that a substantial snack was not being offered to all residents. The facility's policy required resident group agreement for meal plans exceeding 14 hours between dinner and breakfast, which had not been obtained.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, potentially affecting all 92 residents who received food from the kitchen. Observations revealed multiple issues in the dry storage area, walk-in cooler, and walk-in freezer, including open and undated packages of food, food items exposed to air, and equipment with visible corrosion and food debris. The facility's policy required items to be dated when opened and discarded after three days, but these practices were not followed. Further observations in the skilled and intermediate unit refrigerators showed a lack of labeling and dating on various food items, including expired foods and items with offensive smells. The facility's policy mandated that all food and beverages be labeled with the resident's name and dated to ensure food safety, but this was not adhered to, leading to the presence of expired and potentially unsafe food items. During the tray line process, dietary aides were observed using soiled towels to dry trays and dome lids, which were placed on a dirty cart. This practice was confirmed by the dietitian as inappropriate, and the facility's policy required kitchen areas and equipment to be kept clean and free of grime. The county health inspection report also noted non-compliance in maintaining food in good condition and ensuring food contact surfaces were cleaned and sanitized.
Menu Inconsistencies and Substitutions Due to Budget and Delivery Issues
Penalty
Summary
The facility failed to ensure that the weekly and always available menus were followed, affecting seven residents and potentially impacting all residents except for two who were NPO. The facility's always available menu included items such as deli sandwiches, chef salads, and baked lemon pepper fish, among others. However, observations and interviews revealed that several items were missing from the menu, and substitutions were frequently made due to budget constraints and delivery issues. For instance, on multiple occasions, items like chicken tenders and toast were substituted for meatballs and donuts, respectively, due to late or incomplete deliveries. Interviews with the Dietary Manager and Dietary Aides confirmed that budget limitations and delivery schedules often resulted in unavailable menu items, leading to substitutions that did not match the planned menu. Residents expressed dissatisfaction with the inconsistency between the menu and the meals served, and the Ombudsman noted systemic concerns with food quality and choices. The facility's policy stated that substitutions should only occur in uncontrollable situations, yet the frequency of substitutions indicated a broader issue with inventory management and budget adherence.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. This deficiency affected eight residents and had the potential to affect nearly all residents receiving meals from the kitchen. During a review of the monthly Residents' Dietary Meeting minutes, it was noted that residents expressed a desire for food to be seasoned more and served hotter. Interviews with residents revealed dissatisfaction with the food quality, with one resident stating the food was terrible and relying on outside food. An ombudsman also reported systemic concerns regarding food quality, choices, and temperatures. An observation of the dinner tray line and a test tray revealed issues with food temperature. The test tray, which included milk, cranberry juice, cobbler, chicken, and peas, was found to have peas at a temperature of 109.5 degrees Fahrenheit, which was considered cold and lacking flavor. The dietitian confirmed these findings. Further interviews with residents during a council meeting indicated that meals were often cold and lacked good taste. The facility's policy stated that menus would be followed and food would be palatable, yet this was not adhered to, leading to the deficiency.
Failure to Notify of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician/nurse practitioner and resident representative of a significant weight change for a resident. The resident, who was admitted with diagnoses including hemiplegia, dysphagia, vascular dementia, lymphedema, and obesity, experienced a significant unplanned weight loss of 9.3% between October and November. Despite this significant weight change, there was no documented evidence that the physician or resident representative was informed, as required by the facility's policy. Interviews with the dietitian and nurse practitioner confirmed the oversight. The dietitian acknowledged the significant weight loss but admitted she had not contacted the resident's representatives due to their work schedules and only thought she had verbally informed the nurse practitioner. The nurse practitioner stated that if she had been notified, there would have been a written record in the chart. The facility's policy mandates that any weight change of five percent or more should be communicated to the physician and resident representative, which was not adhered to in this case.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to provide the necessary assistance to Resident #36 during meal times, as required by her care plan. Resident #36, who has a history of cerebral ischemia, dementia, hemiplegia, and other conditions, was observed to have difficulties with eating due to her physical impairments. Despite her care plan indicating the need for setup assistance with meals, staff consistently left meal trays with lids intact and did not assist in cutting food or opening packages. This lack of assistance was confirmed through interviews with the resident, her family, and staff members, as well as through observations of meal setups that were not completed as required. The deficiency was further highlighted by the documentation in the electronic medical record, which showed multiple instances where no setup or physical help was provided to Resident #36. Interviews with staff, including CNAs and LPNs, confirmed that the resident required setup assistance, which included opening food packages, removing lids, and ensuring accessibility of utensils. The facility's policy on Activities of Daily Living, revised in August 2022, mandates appropriate support for residents unable to perform ADLs independently, including meal assistance, which was not adhered to in this case.
Failure to Monitor Nutritional Needs and Fluid Restrictions
Penalty
Summary
The facility failed to ensure that Resident #70's weekly weights were obtained as ordered, which was crucial for monitoring her nutritional status. Resident #70 had a complex medical history, including hemiplegia, dysphagia, vascular dementia, and significant weight loss, necessitating enteral feeding. Despite a physician's order for weekly weights to monitor trends, several weights were missed in October and November 2024. Interviews with the LPN Manager and Dietitian revealed that the weights were not consistently recorded, and there was uncertainty about the accuracy of the weights that were obtained. Additionally, the facility did not adequately monitor and follow Resident #57's fluid restriction, which was critical due to his end-stage renal disease and other related conditions. The care plan specified a 1000 ml fluid restriction, with dietary and nursing staff responsible for providing specific amounts. However, observations and interviews indicated that the resident received more fluids than allowed, and there was no system in place to accurately track fluid intake. The resident was unaware of the specifics of his fluid restriction, and staff did not consistently adhere to the prescribed limits. The facility's policies on weight assessment and fluid restriction were not effectively implemented, leading to deficiencies in the care of Residents #70 and #57. The lack of adherence to these policies resulted in missed weight measurements for Resident #70 and excessive fluid intake for Resident #57, highlighting a failure in monitoring and documentation processes within the facility.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident requiring dialysis services. Resident #57, who has end-stage renal disease and is dependent on renal dialysis, was affected by this deficiency. The resident was scheduled for dialysis every Tuesday, Thursday, and Saturday. However, there were significant gaps in the communication between the facility and the dialysis center, as evidenced by missing communication sheets from the dialysis center on multiple occasions. The facility did not send communication forms with the resident to the dialysis center, and there was no documented evidence of communication on dialysis days. Interviews with the resident and facility staff confirmed that the resident did not take any paperwork to the dialysis center, but brought back forms from the center, which were supposed to be placed in the medical chart. The LPN Manager acknowledged the missing communication forms and stated that if there was no communication from the dialysis center, the facility staff should have contacted the center. The renal RN from the dialysis facility confirmed that the facility never sent forms with the resident, but the dialysis center staff consistently sent forms back with the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were not left unattended, affecting two residents and potentially impacting 20 additional residents. Resident #27, who had moderate cognitive impairment and required assistance with personal care, was found with a medicine cup containing five pills on his bedside table, which he could not reach. The nurse confirmed leaving the medication unattended, contrary to the facility's policy that required nurses to remain with residents while they took their medicine. Resident #4, who had intact cognition but required a mechanically altered diet, was also found with a medication cup containing potassium tablets at her bedside. The resident confirmed that the nurse left the medication in her room without supervision, and she was unable to swallow the potassium tablets without assistance. The facility's policy stated that residents could only self-administer medications if deemed safe by the care planning team, which was not the case for Resident #4. Interviews with the Director of Nursing confirmed that the facility's policy required nurses to stay with residents until they finished taking their medication. The facility's policy on administering medications, revised in August 2022, emphasized that medications should be administered as prescribed and in a safe manner, which was not adhered to in these instances.
Inappropriate Meal Consistency for Resident on Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that residents on mechanical soft diets received meals with the appropriate consistency, affecting one resident specifically. Resident #6, who has diagnoses including quadriplegia, dysphagia, unspecified dementia, and macular degeneration, was identified as being on a mechanically altered diet. The resident's care plan and physician orders specified a regular diet with mechanical soft texture and thin consistency. However, during an observation, it was noted that Resident #6 received coleslaw with shredded cabbage instead of the prescribed green beans, which was not suitable for a mechanical soft diet. This inconsistency was confirmed by a Certified Nursing Assistant who removed the coleslaw from the tray. The facility's policy requires that menus be followed and food be served in a form designed to meet individual needs. Despite this, the meal provided to Resident #6 did not adhere to the dietary requirements outlined in the care plan and physician orders. The Speech Therapy staff confirmed that coleslaw was inappropriate for a mechanical soft diet, highlighting a lapse in the facility's adherence to dietary protocols. This incident was part of a broader issue, as the facility identified 13 residents on mechanical soft diets, indicating a potential systemic problem in meal preparation and delivery.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control procedures, affecting three residents who were observed for isolation precautions. Resident #68, who had a stroke with right-sided weakness and dementia, was on enhanced barrier precautions (EBP) due to an antibiotic-resistant infection. Despite a sign indicating the need for personal protective equipment (PPE) during high-contact activities, two certified nursing assistants (CNAs) entered the resident's room without donning PPE and provided incontinence and catheter care. Both CNAs were unaware of the EBP requirement. Similarly, Resident #148, who had a left femur fracture and urinary retention, was also on EBP due to an indwelling urinary catheter. A CNA entered the room without PPE and provided incontinence care, unaware of the EBP requirement. Resident #151, diagnosed with COVID-19 and dementia, was on droplet precautions. A sign on the door indicated the need for an N95 mask, gown, gloves, and face shield. A CNA exited the resident's room wearing PPE and proceeded to the nurse's station to obtain a straw, then returned to the room without doffing the PPE. The registered nurse confirmed that the CNA should have removed the PPE before exiting the room. The facility's policies on EBP and COVID-19 precautions were not followed, leading to these deficiencies.
Failure to Implement Comprehensive Care Plan for Resident's Leave of Absence
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident regarding their leave of absence (LOA) from the facility. The resident, who was cognitively intact and used a wheelchair for mobility, had multiple medical conditions including multiple sclerosis, paraplegia, diabetes, and pressure ulcers. Despite having a physician's order allowing LOA with medications, the care plan did not address the resident's preference for LOA or the necessary preparations for such absences, such as ensuring the resident's power wheelchair was fully charged and that they had a means of communication. On two occasions, the resident left the facility without signing out or notifying staff, resulting in them being stranded at a bus station due to a dead wheelchair battery. The resident was subsequently found by emergency services and taken to a hospital for evaluation. The facility's LOA book did not have records of the resident signing out on these dates, and the care plan lacked any mention of the resident's LOA preferences or needs, such as taking medications with them as per the physician's order. Interviews with staff and the resident revealed that the facility was aware of the resident's tendency to leave on Saturdays and their impulsive nature. However, the care plan was not updated to reflect these preferences or to ensure the resident's safety during LOA. The facility's policy required residents to sign out and receive medications for LOA, but there was no policy to include LOA preferences in the care plan, contributing to the oversight.
Failure to Refund Overpayment to Resident's Family
Penalty
Summary
The facility failed to provide a final accounting of overpayment to the spouse of a resident within thirty days of the resident's discharge, as required by their Resident Admission Agreement. The resident, who had severe cognitive impairment and was admitted with diagnoses including dislocation of an unspecified cervical vertebrae and respiratory failure, expired in the facility. The resident was admitted as a private pay resident, and the admission agreement, signed by the spouse, stipulated that refunds should be made within 30 days of discharge. Upon review, it was found that the facility received a payment of $3825.00 for the resident's stay, while the total cost was only $1020.00, resulting in an overpayment of $2805.00. Despite the spouse's inquiry about the refund in September 2023, the facility had not issued the refund. The Business Office Manager and the Administrator confirmed that all refunds are processed through their corporate office, and no refund check had been issued to the spouse. This deficiency was investigated under Complaint Number OH00154001.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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