Aventura At Carriage Inn
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 5040 Philadelphia Drive, Dayton, Ohio 45415
- CMS Provider Number
- 365876
- Inspections on file
- 28
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Aventura At Carriage Inn during CMS and state inspections, most recent first.
Nine residents did not receive coleslaw with their lunch meal when the kitchen ran out, and no substitutions were provided, despite facility policy requiring substitutions when menu items are unavailable. The Dietary Manager confirmed the omission and lack of substitution.
A resident with multiple serious medical conditions experienced significant rectal bleeding and was transferred to the hospital. Although the physician was notified, there was no documentation that the resident's representative was informed of this change in condition. The DON confirmed the absence of notification and stated the facility only had a policy for physician notification.
A resident with multiple complex medical conditions was admitted with a surgical wound, but staff failed to document measurements or provide a description of the wound as required by facility policy. An LPN confirmed that no such documentation was present during the resident's stay, despite policy requirements for detailed wound assessment and recording.
A resident with multiple comorbidities did not receive wound care as ordered for an arterial ulcer on the right foot, and comprehensive assessment of a surgical wound following amputation was not completed. Documentation was lacking for both the administration of wound care and the assessment of the surgical site, as confirmed by facility leadership.
Two residents experienced significant medication errors when staff failed to follow prescriber orders for antibiotic and anticoagulant administration. One resident received an antibiotic at the wrong frequency, while another was given an anticoagulant that should have been held and did not receive a prescribed antibiotic as ordered. These errors were confirmed through record review and staff interview.
A resident with multiple medical conditions was prescribed IV Vancomycin with orders to obtain Vancomycin levels weekly. The facility began administering the antibiotic but did not obtain the required Vancomycin level until several days after starting treatment, despite pharmacy recommendations and standing orders. This delay in laboratory monitoring was confirmed by both the pharmacist and the administrator during the investigation.
Surveyors found that kitchen equipment and food storage areas were not maintained in a clean and sanitary manner, including wet stacked containers, dirty knives, food debris on equipment, buildup of debris in steam table wells, ice accumulation in the freezer, and rust, leaks, and stagnant water in the cooler. These deficiencies were confirmed by the Dietary Manager and had the potential to affect all residents consuming food by mouth.
Four residents with physician orders for pureed diets received pureed foods prepared with water as a thinning agent, contrary to facility policy, which requires the use of more nutritious liquids such as juices, broths, or milk. A staff member confirmed using water during food preparation, resulting in pureed foods that did not conserve nutritive value, flavor, or appearance.
Staff did not consistently wear required PPE, such as gowns, when providing care to residents on enhanced barrier precautions, including those with tracheostomies, gastrostomies, and stage three pressure ulcers. Additionally, proper hand hygiene was not performed between medication administration for different residents and after wound care, despite facility policies outlining these requirements. Staff interviews confirmed knowledge of the protocols but acknowledged lapses in compliance.
A resident with multiple medical conditions was left with an albuterol nebulizer treatment in their room by an LPN, despite not having a physician's order to self-administer medications. Facility policy required such an order and interdisciplinary team approval, which were not obtained.
A resident with multiple diagnoses had a physician order for Diltiazem to be withheld if systolic blood pressure was below 110. An LPN withheld the medication when the resident's blood pressure was 104/66 and disposed of the dose, but later signed the MAR as if the medication had been given, without documenting a blood pressure recheck. The DON confirmed the discrepancy and lack of required documentation.
A facility failed to follow its policy for checking the placement of a resident's G-tube before administering medication. A resident with severe cognitive impairment and dysphagia, dependent on a feeding tube for nutrition, had medication administered by an RN who used water to check tube placement, contrary to the facility's policy. The policy required checking the pH of the aspirate to confirm placement, which was not done, potentially risking harm.
The facility reported a medication error rate of 7.89%, exceeding the acceptable threshold. Errors included incorrect aspirin and vitamin B12 administration to one resident and an overdose of levetiracetam to another. Staff failed to adhere to medication administration protocols, leading to these errors.
A resident with severe cognitive impairment was found with unauthorized medications at their bedside, including saline nasal spray, Dulcolax, and digestive aids, which were not prescribed. Despite multiple observations, staff failed to remove the medications, indicating a lapse in adherence to medication management protocols. Interviews with a CNA and an LPN revealed a lack of awareness and action, while the DON confirmed the resident's inability to self-administer medications.
An LPN was observed handling medications with bare hands during administration, contrary to infection control policies. This was witnessed by an RN who did not intervene. Interviews revealed a lack of training and adherence to the facility's policy, which prohibits touching medications with bare hands.
A facility failed to notify a resident's representative about a new Stage III pressure ulcer and treatment plan, despite the resident having severe cognitive impairment and multiple medical conditions. The facility's policy requires prompt notification of changes in a resident's condition, but documentation confirming this notification was absent.
A facility failed to follow infection control procedures for a resident with a Stage III pressure ulcer. Despite having a physician's order for wound treatment, Enhanced Barrier Precautions (EBP) were not documented or implemented. Staff interviews and observations confirmed that gowns were not worn during wound care, contrary to the facility's policy requiring gloves and gowns to prevent the transfer of multi-drug resistant organisms.
A facility failed to develop a baseline care plan for a newly admitted resident with multiple diagnoses, including osteoarthritis and diabetes. The lack of documentation was confirmed by the DON during a complaint investigation, affecting one of three new admissions reviewed.
A resident with severe cognitive impairment and multiple diagnoses, including major depressive disorder, expressed suicidal ideation and was placed on one-on-one supervision. Despite this, the facility failed to update the resident's care plan to address suicide risk. The resident was later found with a call light wrapped around his neck, leading to emergency hospitalization for psychiatric evaluation.
A facility failed to document urinary catheter care for a resident with an indwelling catheter. Despite the facility's policy requiring documentation of catheter care every shift, the resident's medical record showed no such documentation from admission to discharge. The DON and a regional nurse confirmed this oversight during an interview.
A facility failed to monitor a resident's blood glucose level before administering insulin, as required by their policy. The resident, with type two diabetes mellitus, received insulin glargine on two occasions without prior glucose checks. This oversight was confirmed by the DON and a Regional Nurse, who acknowledged the necessity of monitoring, especially since it was the resident's first insulin administration at the facility.
Failure to Provide Menu Item and Substitution During Meal Service
Penalty
Summary
The facility failed to serve food according to the planned menu, as nine residents did not receive coleslaw with their lunch meal. The facility menu for the specified lunch included baked pork chop, baked beans, creamy coleslaw, cornbread, and whipped jello parfait. During observation of the lunch service, it was noted that the kitchen ran out of coleslaw, resulting in these residents not receiving the item on their trays. The Dietary Manager confirmed that the coleslaw was unavailable and that no substitutions were provided for the affected residents. Review of the facility's policy indicated that substitutions should be made when menu items are not available, but this was not followed in this instance.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's representative of a significant change in the resident's condition. The resident, who had diagnoses including right femur fracture, COPD, dementia, chronic kidney disease Stage IV, and pneumonitis, was admitted with severely impaired cognition and was dependent on staff for most activities of daily living. On the date in question, nursing documentation indicated the resident experienced a copious amount of rectal bleeding, and the on-call physician was notified, but no new orders were given. Despite this significant change in condition and subsequent transfer to the hospital for rectal bleeding, there was no documentation in the medical record to show that the resident's representative was informed of the event. The Director of Nursing confirmed during interview that there was no evidence of such notification and stated that the facility only had a policy for notifying physicians of changes in condition, not resident representatives.
Failure to Document and Assess Surgical Wound per Facility Policy
Penalty
Summary
The facility failed to properly assess and document a surgical wound for a resident with multiple medical diagnoses, including a right femur fracture, chronic obstructive pulmonary disease, dementia, chronic kidney disease Stage IV, and pneumonitis. Upon admission, the resident was noted to have a surgical site on the right hip with 29 staples, but the initial assessment did not include measurements or a detailed description of the wound. Subsequent weekly skin observations also lacked documentation regarding the surgical site, its measurements, or a description of the wound. An LPN confirmed that during the resident's stay, there was no documentation of the surgical wound's measurements or description in the medical record. The facility's wound care policy required documentation of wound type, assessment data (including size and wound bed color), and other relevant information, but these requirements were not met for this resident. This deficiency was identified during a review of the medical record, staff interviews, and policy review, and was investigated under specific complaint numbers.
Failure to Provide Ordered Wound Care and Comprehensive Wound Assessment
Penalty
Summary
The facility failed to provide wound care as ordered for an arterial ulcer on a resident's right foot and did not complete a comprehensive wound assessment for a surgical wound on the same resident. Medical record review showed that the resident, who had diagnoses including COPD, diabetes mellitus, and peripheral vascular disease, was admitted with an arterial ulcer on the right foot second digit. Orders were in place for daily and as-needed application of barrier spray/wipes, but documentation on the Treatment Administration Record did not support that these treatments were completed as ordered. The wound physician's note and physician orders specified the required care, but the order was incorrectly entered into the electronic health record as 'as needed' only, rather than 'daily and as needed.' The resident later complained of the toe being dead, was hospitalized, and subsequently underwent amputation procedures. Further review of the medical record after the resident's return from the hospital revealed incomplete documentation regarding the surgical wound. Admission and weekly skin assessments noted the presence of amputated toes but did not include measurements or descriptions of the surgical site. Interviews with the Administrator and DON confirmed the lack of documentation for both the wound care provided and the assessment of the surgical wound, which was not in accordance with the facility's wound care policy that requires detailed recording of wound care and assessments.
Significant Medication Administration Errors Identified
Penalty
Summary
Facility staff failed to administer medications as ordered for two residents, resulting in significant medication errors. For one resident with a history of infection and inflammation of a hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension, hospital discharge orders specified Levaquin 750 mg once daily by mouth. However, the medication was administered twice daily over a four-day period, contrary to the prescriber's instructions. This discrepancy was confirmed through medical record review and staff interview. Another resident, admitted with nontraumatic subarachnoid hemorrhage, atrial fibrillation, and COPD, had hospital discharge orders to hold Eliquis 5 mg until a specified date and to administer cefuroxime 500 mg twice daily for three days. Despite these orders, Eliquis was administered on days it should have been held, and cefuroxime was not signed off as administered. These findings were corroborated by review of the medication administration records and confirmed in an interview with the Administrator. The facility's policy requires medications to be administered according to prescriber orders, including timing, which was not followed in these cases.
Failure to Obtain Timely Vancomycin Levels as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered for a resident with multiple complex diagnoses, including infection and inflammation of an internal hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension. Upon return from the hospital, the resident had discharge orders for intravenous Vancomycin every 12 hours and for Vancomycin levels to be obtained every Monday. The medical record showed that the first dose of Vancomycin was administered on 04/06/25 at 8:00 P.M., but the required Vancomycin level was not obtained until 04/14/25, despite the standing order and pharmacy recommendations to obtain a pre-dose level prior to the fourth dose. Interviews with the facility pharmacist and administrator confirmed that Vancomycin levels should have been drawn prior to the fourth dose for safe dosing and that the pharmacy had communicated this requirement to the facility. The administrator also confirmed that the Vancomycin level was not obtained as ordered, resulting in a delay in laboratory monitoring for the resident. This deficiency was identified during a complaint investigation and affected one of three residents reviewed.
Failure to Maintain Kitchen Equipment and Food Storage Areas in Sanitary Condition
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the cleanliness and maintenance of equipment and food storage areas. Plastic containers were found stacked while wet on the clean dish rack, preventing proper drying. The knife storage rack contained two knives with missing metal chips and three knives with visible residue. A metal plate warmer with food debris was stored on the clean dish drying rack, and the can opener attached to the prep table had dried food debris on its blade. The steam table wells also had a buildup of debris at the bottom. Further observations revealed environmental issues in the food storage areas. The walk-in freezer had a buildup of ice on the vinyl strip curtains and floor. The walk-in cooler had rusted metal floors and walls, with the flooring separating. The condenser in the cooler was leaking, with a bucket placed below it containing gray stagnant water and additional water on the floor. These conditions were verified by the Dietary Manager during interviews and had the potential to affect all residents who consumed food by mouth, with the exception of three residents who did not consume food orally.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to prepare pureed foods in a manner that conserved nutritive value, flavor, and appearance for four residents who had physician orders for pureed diets. On the specified date, the lunch menu included items such as beef burgundy, vegetable rice pilaf, green peas, mandarin oranges, dinner roll, and chocolate chip cookie, with beef stew substituted for beef burgundy. Observation revealed that a staff member prepared pureed peas and beef stew by adding water and thickener to the food processor, rather than using fruit or vegetable juices, meat broths, or milk as required by the facility's policy. The staff member confirmed using water as a thinning agent. Review of the facility's policy indicated that water should not be used for thinning pureed foods, and instead, more nutritious liquids should be used.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to don appropriate personal protective equipment (PPE), specifically gowns, when providing care to residents on enhanced barrier precautions (EBP). For one resident with cerebral atherosclerosis, tracheostomy, and gastrostomy, an LPN provided care without wearing a gown despite an active EBP order. In another instance, wound care was performed for two residents with stage three pressure ulcers and other significant diagnoses, but staff did not don gowns as required by EBP signage and orders. Staff interviews confirmed awareness of the EBP requirements but acknowledged non-compliance during care activities. Additionally, staff did not consistently practice proper hand hygiene. An LPN failed to perform hand hygiene after administering medication to one resident and before administering medication to another. During wound care for a resident with multiple complex conditions, staff removed gloves after care but exited the room without performing hand hygiene. Facility policies reviewed indicated that hand hygiene should occur before and after resident contact, after glove removal, and that staff should consult with nursing to determine appropriate PPE for transmission-based precautions.
Medication Left Unattended Without Self-Administration Order
Penalty
Summary
The facility failed to ensure that medications were not left unattended in resident rooms, as evidenced by an incident involving a resident with diagnoses of atrial fibrillation, malignant prostate cancer, and pneumonia. The resident, who had intact cognition and required moderate staff assistance with ADLs, did not have a physician's order to self-administer medications. During observation, an LPN placed an ampule of albuterol into the resident's nebulizer and informed the resident that the medication was available for use whenever he was ready, then left the room. Review of the facility's policy confirmed that self-administration of medications was only permitted with a physician's order and interdisciplinary team determination, which was not present in this case.
Failure to Accurately Document and Administer Blood Pressure Medication per Physician Parameters
Penalty
Summary
A deficiency occurred when staff failed to administer blood pressure medication according to physician-ordered parameters for a resident with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia. The physician's order specified that Diltiazem 120 mg should be withheld if the resident's systolic blood pressure was less than 110. During observation, an LPN withheld the medication when the resident's blood pressure was 104/66 and disposed of the dose in the sharps container. However, the Medication Administration Record (MAR) for that day showed that the LPN signed off as if the Diltiazem had been administered, and there was no documentation of a blood pressure recheck. The Director of Nursing confirmed the discrepancy between the MAR and the actual administration, as well as the lack of required documentation. Facility policy required medications to be administered as ordered by the physician, which was not followed in this instance.
Failure to Follow G-Tube Placement Policy
Penalty
Summary
The facility failed to ensure that staff followed the policy for checking the placement of a resident's gastrostomy tube (G-tube) before administering medication. This deficiency was identified during an observation of medication administration for a resident with severe cognitive impairment and a diagnosis of moderate protein-calorie malnutrition and dysphagia. The resident was dependent on staff for all activities of daily living and received more than half of their total calories and fluid intake through a feeding tube. The care plan for the resident included instructions to check residuals per orders and to verify G-tube placement every shift. During the observation, a registered nurse (RN) prepared and administered medication through the resident's G-tube without properly checking the tube's placement according to the facility's policy. The RN used water to check the placement, which was against the policy that required checking the pH of the aspirate to confirm proper placement. The Director of Nursing and the Administrator both confirmed that the use of water was inappropriate and could potentially cause harm if the tube was not correctly positioned. The facility's policy outlined specific procedures for confirming tube placement, including observing gastric residual volume and checking the pH of the aspirate, which were not followed in this instance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.89% due to three medication errors out of 38 opportunities. This affected two residents during medication administration. For one resident, the LPN administered an enteric-coated aspirin instead of the prescribed chewable aspirin and gave an incorrect dosage of vitamin B12. The LPN admitted to not thoroughly checking the medication order, which led to these errors. The Director of Nursing (DON) confirmed that the medications given did not match the physician's order, constituting medication errors. Another resident received an incorrect dosage of levetiracetam, an anti-seizure medication, due to the RN misreading the medication administration record (MAR). The RN administered 10 ml instead of the prescribed 5 ml, which could potentially lead to levetiracetam toxicity. The DON emphasized the importance of administering the correct dose to the right resident, as per the facility's policy on medication administration, which requires checking the medication label three times to ensure accuracy.
Failure to Remove Unauthorized Medications from Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were not left unattended at the bedside of a resident with severe cognitive impairment. The resident, diagnosed with neurocognitive disorder with Lewy bodies and aphasia, was observed with two bottles of saline nasal spray, an opened bottle of Dulcolax, and two bottles of digestive aid on their nightstand and in the top drawer. These medications were not prescribed by a physician, and the resident was unable to recall who provided them or how to use them. Despite multiple observations over two days, the medications remained at the bedside, indicating a lapse in staff vigilance and adherence to medication management protocols. Interviews with staff, including a CNA and an LPN, revealed a lack of awareness and action regarding the unauthorized medications at the resident's bedside. The CNA stated she would report such findings to a nurse, but did not notice the medications during her visit. The LPN, responsible for the resident's care, claimed he would remove unauthorized medications and notify the DON and physician, yet failed to observe the medications during his shift. The DON confirmed that the resident was not capable of self-administering medications and emphasized the need for a physician's order and assessment for self-administration. The facility's policy required staff to report and remove unauthorized medications, which was not followed in this instance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control procedures during medication administration, affecting one of four residents observed. During a medication pass, an LPN was observed removing medications from their packaging and placing them directly into her bare hands. The medications included amlodipine, Plavix, Lexapro, Microzide, and Lopressor. This action was witnessed by an RN, who did not intervene or provide immediate education to the LPN regarding the potential contamination risk of handling medications with bare hands. Interviews conducted with the LPN, RN, Infection Preventionist, and Director of Nursing revealed a lack of adherence to the facility's infection control policy, which prohibits touching medications with bare hands. The LPN admitted to not receiving training on this aspect of medication handling, while the RN acknowledged the oversight but did not provide an explanation for her inaction. The Infection Preventionist and Director of Nursing both expressed that they expected the RN to stop the LPN and provide education on proper procedures, as outlined in the facility's policy revised in August 2024.
Failure to Notify Resident's Representative of Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative about the development of a new pressure ulcer and the corresponding treatment plan. This deficiency was identified during a review of the medical record for a resident who was admitted with multiple medical diagnoses, including cerebral atherosclerosis and chronic obstructive pulmonary disease. The resident, who had severe cognitive impairment, was assessed in a quarterly Minimum Data Set (MDS) on June 17, 2024, which indicated no pressure ulcers at that time. However, a wound observation evaluation on July 25, 2024, revealed a Stage III pressure ulcer on the resident's left heel, and although the physician was notified and a treatment was ordered, there was no documentation that the resident's representative was informed. An interview with the facility's Administrator confirmed the absence of documentation regarding the notification of the resident's representative about the pressure ulcer and treatment plan. The facility's policy, revised in May 2017, mandates prompt notification of the resident, their attending physician, and representative about changes in the resident's medical or mental condition. This deficiency was investigated under Complaint Number OH00156810, highlighting a lapse in communication as per the facility's established procedures.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control procedures for a resident with a Stage III pressure ulcer. The resident, who was cognitively intact and required supervision with certain activities, had a medical history including heart failure, diabetes, and peripheral vascular disease. Despite having a physician's order for wound treatment, there was no documentation or implementation of Enhanced Barrier Precautions (EBP) for the resident. This included the absence of a posted EBP sign and a personal protective equipment (PPE) cart near the resident's room. Interviews and observations confirmed that staff did not wear gowns during wound care, only gloves, which was against the facility's policy for EBP. The policy required the use of gloves and gowns during high-contact care activities to prevent the transfer of multi-drug resistant organisms. The deficiency was identified during a complaint investigation, revealing that the facility had not implemented EBP for residents with wounds or indwelling devices.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident, which is a requirement to address the resident's immediate needs within 48 hours of admission. The resident, who had diagnoses including osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity, was admitted on an unspecified date and discharged on 05/19/24. Upon review of the resident's closed medical record, it was found that there was no documentation of a baseline care plan being developed. This deficiency was confirmed during an interview with the Director of Nursing on 06/05/24, who acknowledged that the baseline care plan had not been completed. This issue was identified during a complaint investigation and affected one of the three new admissions reviewed, with the facility having a census of 74 residents.
Failure to Update Care Plan for Suicide Risk
Penalty
Summary
The facility failed to update a comprehensive care plan for a resident identified as being at risk for suicide. The resident, who was admitted on January 31, 2023, had multiple diagnoses including hypertensive kidney disease, major depressive disorder, bradycardia, impulsiveness, dementia, and congestive heart failure. The resident was severely cognitively impaired with a BIMS score of four out of 15. On May 9, 2024, the resident expressed thoughts of self-harm and had a plan to do so, which was communicated to a state tested nursing assistant. Following this, the resident was placed on one-on-one supervision until a psychiatric evaluation was conducted on May 10, 2024. Despite these events, the resident's comprehensive care plan did not include any focus or interventions related to suicide risk or suicidal ideation. On May 20, 2024, the resident was found with a call light wrapped around his neck after being discovered on the floor of his room, leading to an emergency hospital admission for psychiatric evaluation on May 21, 2024. The resident returned to the facility and was again placed on one-on-one supervision until another psychiatric evaluation on May 24, 2024. The Director of Nursing, Administrator, and Social Services Director confirmed that the care plan should have been updated to address the suicide risk, indicating a deficiency in the facility's care planning process.
Failure to Document Urinary Catheter Care
Penalty
Summary
The facility failed to provide urinary catheter care to a resident, which was identified during a review of medical records, staff interviews, and facility policy. The resident, who had an indwelling urinary catheter, was admitted with diagnoses including osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. The resident's medical record showed no documentation of urinary catheter care from admission to discharge. During an interview, the DON and a regional nurse confirmed the lack of documentation for catheter care, which should have been completed at least every shift. The facility's policy required documentation of catheter care, including the date, time, and caregiver's details, which was not adhered to in this case.
Failure to Monitor Blood Glucose Before Insulin Administration
Penalty
Summary
The facility failed to monitor a resident's blood glucose level before administering insulin, which is a requirement for ensuring the drug regimen is free from unnecessary drugs. The deficiency was identified during a review of medical records, staff interviews, and facility policy. Specifically, Resident #76, who had diagnoses including type two diabetes mellitus, was administered 60 units of insulin glargine on two consecutive days without prior blood glucose level checks. This oversight was confirmed by the Director of Nursing and a Regional Nurse, who acknowledged that the blood glucose levels should have been checked before insulin administration, especially since it was the first time the resident received insulin at the facility. The facility's policy on insulin administration, revised in September 2014, mandates checking blood glucose levels per physician order or facility protocol, and documenting the results. However, there was no documentation of blood glucose levels being checked before the administration of insulin to Resident #76 on the specified dates. The Medscape reference for insulin glargine emphasizes the necessity of regular blood glucose monitoring for patients receiving insulin therapy. This deficiency was investigated under Complaint Number OH00154127.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
