Aventura At Oakwood Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Ohio.
- Location
- 1500 Villa Road, Springfield, Ohio 45503
- CMS Provider Number
- 365917
- Inspections on file
- 32
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Aventura At Oakwood Village during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow RD-planned breakfast menus or provide appropriate nutritional substitutions when items were unavailable. On multiple mornings, residents who were supposed to receive scrambled eggs or egg substitutes instead received only toast and bacon, and a resident on a cardiac diet was served bacon despite diet restrictions. Staff reported there were no eggs or sufficient milk available, used bacon as an assumed protein substitute, and did not reference the specialized diet spreadsheet during meal service. On another morning, mandarin oranges listed on the menu were not served to residents, and no alternative fruit was provided except applesauce for those on pureed diets, contrary to facility policy requiring documented menu substitutions.
A resident with multiple chronic conditions and intact cognition, care planned for fall risk and restful sleep, became agitated and combative during a night shift. After medication was given and the resident later transferred to bed, a CNA placed a mattress upright against one side of the bed and secured it with a locked chair, while the other side of the bed was against the wall, effectively preventing the resident from exiting the bed. Incoming CNAs observed the resident asleep with bedding and pillows arranged in a way that further restricted movement, and the DON confirmed the resident had been restrained in violation of the facility’s restraint policy.
Surveyors found that the facility exceeded the acceptable medication error rate when, during a morning med pass, an RN was unable to administer an ordered dose of Synthroid to a resident with diabetes, hypothyroidism, and hypertension because it was not available in the med cart or emergency box, and also failed to remove a scheduled dose of glipizide from the medication card until prompted by the surveyor. These two omission errors, identified during observation and confirmed in staff interviews and record review, resulted in a 7% medication error rate for 28 observed medication opportunities.
Staff failed to follow hand hygiene requirements during incontinence and wound care for two residents. A CNA caring for a fully dependent, incontinent resident with multiple chronic conditions changed soiled briefs, cleansed the perineal area, applied lotion, and assisted with dressing while repeatedly changing gloves without performing hand hygiene between glove changes. In a separate incident, an LPN performing a coccyx pressure ulcer dressing change for a dependent resident with dementia and COPD removed the old dressing, cleansed the wound, applied calcium alginate, and placed the new dressing and brief without changing gloves or performing hand hygiene until after the entire procedure was completed. These actions did not comply with the facility’s handwashing/hand hygiene policy, which requires hand hygiene before clean tasks, after contact with bodily fluids, before moving from a soiled to a clean body site, and immediately after glove removal.
A resident with severe cognitive impairment and a history of aggressive behaviors repeatedly exhibited physical and verbal aggression toward staff and another resident, who reported feeling unsafe and fearful. Despite care plans and interventions, the aggressive behavior persisted, and staff did not consistently report or document all incidents, leading to a failure to protect residents from abuse.
A resident with severe cognitive impairment and a history of aggressive behaviors verbally assaulted and physically threatened another resident, who then expressed fear for his safety. Despite ongoing incidents of aggression documented by staff and concerns raised by the affected resident, the facility did not thoroughly investigate or report the abuse allegations to the State Agency as required by policy. Staff interviews confirmed that the incident was discussed internally but not escalated or documented appropriately.
A resident with severe cognitive impairment and multiple diagnoses was identified as high risk for falls, yet required fall prevention interventions were not consistently in place. Observations showed the call light was not within reach, the bed was in a high position, and the fall mat was not correctly placed, despite the care plan specifying these measures. Staff confirmed these lapses, and the resident had a recent history of multiple falls.
Three medication administration errors were identified, resulting in an 11% error rate. Two residents received incorrect medications: one was given a discontinued drug, and another received Vitamin B6 without a specified dosage and a lower-than-ordered dose of Tylenol. LPNs involved confirmed the errors during interviews.
Multiple residents with cognitive and physical impairments did not receive required fall prevention interventions, such as perimeter mattresses, low bed positioning, and fall mats, as outlined in their care plans. Staff failed to consistently implement and document these interventions, and neurological checks were not always performed after unwitnessed falls. In one case, a resident was transferred without a mechanical lift, resulting in bilateral femur fractures.
The facility did not follow its water management policy by failing to perform required quarterly water flow rate checks and by maintaining water temperatures below the threshold needed to prevent legionella growth. Additionally, a CNA assisted a resident with a meal by handling food with bare hands, violating infection control protocols.
Multiple residents and staff reported and confirmed the presence of ants in several rooms, with ants found on personal items and living areas. Observations revealed ants on floors, beds, and tables, and ant traps were present in some rooms. The facility's pest control program was not effective in preventing or addressing the infestation.
A resident with parkinsonism and malnutrition, dependent on staff for all ADLs and with intact cognition, was fed lunch by a CNA who stood over her throughout the meal despite the resident's request for the CNA to sit. The CNA did not acknowledge the request, and a chair was available nearby but not used. This action did not align with facility policy requiring staff to treat residents with dignity.
A resident with multiple serious health conditions and severe cognitive impairment experienced significant, rapid weight loss, but the facility did not notify the resident's medical POA as required by policy. Staff confirmed that no notification was made despite substantial weight changes documented in the medical record.
A resident with significant cognitive impairment and multiple diagnoses was prescribed PRN Ativan for anxiety and dyspnea without a required 14-day stop date, in violation of facility policy. The DON confirmed the order should have been time-limited, and the facility's policy mandates PRN psychotropic medications be restricted to 14 days unless otherwise indicated.
A resident with cognitive impairment and multiple diagnoses did not receive an individualized activity care plan reflecting her interests and needs. Despite documented preferences for religious activities, baking, and music, the care plan was not updated and only included generic one-on-one interventions. The resident received minimal activity participation, was observed isolated in her room without engagement, and staff confirmed care plans were not tailored to her cognitive status.
A resident with cognitive impairment and documented preferences for specific activities was not provided with adequate one-on-one activities as outlined in her care plan. Records and staff interviews confirmed that the resident received only a few visits over two months, and observations showed she was left in her room without engagement or stimulation, contrary to facility policy and her assessed needs.
The facility did not consistently obtain and document resident weights as ordered by physicians and required by policy for two residents, including one with end stage renal disease and another with parkinsonism and malnutrition. Missed daily weights and delays in reweighing after significant weight loss were confirmed by staff and residents, with no timely follow-up by the dietitian.
Two residents did not receive multiple prescribed medications on several occasions because the medications were not available from the pharmacy. Documentation and interviews confirmed that the missed doses included critical medications for chronic conditions, and the DON verified the failures were due to pharmacy supply issues, in violation of facility policy requiring timely administration of medications as ordered.
A resident with cognitive impairment and memory deficits was allowed to sign a binding arbitration agreement, despite being unable to understand or recall the agreement or basic personal information. The agreement was also incomplete, lacking required signatures and information. Facility leadership confirmed the resident's impaired cognition at the time of signing.
A resident with severe cognitive impairment and multiple medical conditions sustained a fracture of unknown origin, which the facility failed to report as required. The resident was involved in an incident with a mechanical lift, but the injury was not confirmed to have occurred during this event. The facility's records lacked documentation to determine the cause, and the injury was not reported to the state health agency, contrary to the facility's abuse policy.
A resident with severe cognitive impairment sustained a right hip fracture of unknown origin. The facility failed to conduct a thorough investigation as required by their policy. The incident involved a mechanical lift transfer, but the Medical Director later indicated the injury likely did not occur during this event. The facility's investigation was incomplete, lacking interviews with other residents and signed witness statements.
A resident with multiple health conditions did not have a urinalysis with reflex culture collected as ordered by a physician. The test was not picked up in time and was discarded, leading to a lapse in care. The resident was later treated for a UTI in the hospital. The facility's policy required staff to process test requisitions, which was not followed, resulting in non-compliance.
A facility failed to investigate an incident where a resident with dementia reportedly pushed another resident around the throat. Despite witness accounts and staff confirmation, the incident was not documented or investigated, leading to a deficiency citation.
A facility failed to communicate family concerns to the physician regarding the discontinuation of a resident's medication, Brexpiprazole (Rexulti), due to cost. The resident, diagnosed with dementia and anxiety, experienced a decline in condition after the medication change. Despite family concerns, the Nurse Practitioner was not informed, as confirmed by staff interviews.
Failure to Follow RD-Planned Menus and Provide Appropriate Nutritional Substitutions at Breakfast
Penalty
Summary
The deficiency involves the facility’s failure to follow menus planned by the Registered Dietitian (RD) and to provide the specified foods and nutritionally appropriate substitutions to residents. Menu spreadsheets for multiple days showed that all diets were to receive two ounces of scrambled eggs at breakfast, with residents on cardiac diets to receive an egg substitute product and no bacon. Review of temperature guides and menu spreadsheets showed either no notation of substitutions or inaccurate documentation of substitutions. Observations and interviews confirmed that on several days residents did not receive eggs or egg products as planned, and there was no documentation of appropriate substitutions. Multiple residents reported not receiving eggs on the specified days and instead receiving small portions of toast and bacon, with one resident stating the portion was not enough food and that he wanted some type of protein. A resident on a cardiac diet reported receiving bacon, which he was not supposed to have, and stated he should have received an egg substitution product when eggs were on the menu. Staff interviews, including a CNA and a housekeeper, corroborated that residents on the skilled unit did not receive eggs or milk on certain days and instead received limited portions of toast and bacon, with no other protein on the breakfast trays. Dietary staff confirmed that there were no eggs in the kitchen to prepare and that bacon was used as a substitute for eggs, and that only about half of the residents received milk on one of the days because the kitchen ran out. Dietary staff, including diet aides, a diet manager, and another kitchen staff member, stated they did not have a listing of appropriate protein substitutes and believed bacon was a protein substitute for eggs. They also reported that the specialized diet spreadsheet was not used during meal service as a reference, and that the meals were not served from the spreadsheet of specialized diets. The RD verified that bacon was not a nutritionally equivalent substitution for egg protein and that cooks should follow the approved spreadsheet for specialized diets. Additionally, on another day, the menu spreadsheet indicated that all diets were to receive mandarin oranges at breakfast, but observations showed that no residents received mandarin oranges except those on pureed diets, who received applesauce. Dietary staff confirmed there were no mandarin oranges available, no time to prepare another substitute, and that no other fruit was provided in place of the mandarin oranges for most residents, despite facility policy requiring menu changes and substitutions when items are not available for service.
Resident Restrained in Bed Using Mattress and Chair Without Proper Authorization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from unnecessary physical restraints. The resident had diagnoses including cirrhosis with ascites, diabetes mellitus, COPD, and depression, with an MDS showing intact cognition, partial assistance with ADLs, supervision with transfers, and independence with bed mobility. The resident’s care plan addressed a need for restful sleep and identified fall risk, with interventions such as keeping the room quiet, dimming lights, offering a back rub or snack, and using a fall mattress on the floor next to the bed or a perimeter-defining mattress. On the night in question, nursing documentation indicated the resident became agitated, restless, combative, attempted to toss herself to the floor, and was yelling for her son. A hospice nurse assessed the resident and obtained an order for Ativan every four hours, after which the resident became calm. Later during the night shift, a CNA reported that the resident was restless, grabbing at the air, not responding to direction, and attempting to throw herself out of a chair. At approximately 5:45 a.m., this CNA transferred the resident to bed, covered her with a bedsheet, and placed a mattress upright against the open side of the bed, secured in place with the resident’s locked chair, while the other side of the bed was against the wall. Day-shift CNAs arriving later that morning observed the resident asleep in bed with a mattress pressed against one side of the bed, held in place by a locked chair, and the opposite side of the bed against the wall. One CNA reported that a sheet and blanket were tucked under the mattress over the resident, along with pillows positioned in a way that prevented the resident from exiting the bed, making it impossible for her to get out. Another CNA confirmed seeing the mattress and locked positioning chair against the bed. The DON confirmed that the facility verified the CNA had restrained the resident in bed by placing the mattress against the bed in this manner, resulting in the resident being unable to exit the bed, contrary to the facility’s policy that residents have the right to be free from physical restraints and that any ordered restraint must be the least restrictive and used for the least amount of time with ongoing reevaluation.
Medication Omission Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 28 medication administration opportunities and two medication omission errors, resulting in a 7% error rate. The deficiency involved one resident who had been admitted with diagnoses including type 2 diabetes mellitus, hypothyroidism, and hypertension. Physician orders for this resident included Synthroid 50 mcg once daily and glipizide 10 mg every morning. During a morning medication pass, an RN was observed attempting to administer the resident’s medications and was unable to locate the ordered Synthroid in the medication cart or emergency box, resulting in a missed dose. During the same observation, the RN pulled the resident’s glipizide card from the medication drawer but did not remove the scheduled dose before returning the card to the drawer. Before the RN administered the morning medications, the surveyor intervened and questioned whether the glipizide dose had been removed, at which point the RN confirmed it had not and then retrieved the medication for administration. In subsequent interviews, the RN confirmed that Synthroid was not available for administration and that glipizide was only given after the surveyor’s intervention. The DON acknowledged that these two omission errors for Synthroid and glipizide, out of 28 opportunities, resulted in a 7% medication error rate for the observed medication pass.
Failure to Perform Required Hand Hygiene During Incontinence and Wound Care
Penalty
Summary
The deficiency involves failures in staff adherence to the facility’s hand hygiene policy during incontinence care and wound care. For one resident with COPD, dementia, aphasia, atrial fibrillation, hypertension, and total dependence for personal hygiene and dressing, a CNA was observed providing incontinence care using prepackaged wipes and changing a soiled brief. After removing the soiled brief, cleansing the perineal area, and applying a clean brief, the CNA removed gloves and immediately donned new gloves without performing hand hygiene. The CNA then applied lotion to the resident’s chest, again removed gloves, and donned new gloves without hand hygiene before assisting the resident with dressing. The CNA later confirmed awareness that hand hygiene should have been performed after glove removal and before donning clean gloves. A second deficiency was observed during wound care for another resident with senile brain degeneration, COPD, chronic bronchitis, unspecified psychosis, dementia, hypertension, and a stage 3 pressure ulcer on the coccyx. The resident had an order for daily dressing changes that included cleansing the wound, patting it dry, applying alginate to the wound bed, and covering it with a dry clean dressing. During an observed dressing change, an LPN removed the resident’s brief and old dressing, cleansed the wound with water and gauze, applied calcium alginate to the wound dressing, placed the dressing on the resident, applied a clean brief, and repositioned the resident, all without changing gloves or performing hand hygiene between steps. The LPN only removed gloves and washed hands after completing the entire procedure and exiting the room, and acknowledged that she should have removed gloves and washed hands after cleaning the wound and before applying the new dressing. The facility’s hand hygiene policy required hand hygiene before clean tasks, after contact with bodily fluids or contaminated surfaces, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse, specifically involving a resident with severe cognitive impairment and problematic behaviors, including physical and verbal aggression. The resident, who had diagnoses such as Parkinson's disease, epilepsy, and intellectual disabilities, exhibited frequent episodes of yelling, hitting, and throwing objects at both staff and other residents. Despite having a care plan with multiple interventions to address these behaviors, documentation shows that the resident continued to be aggressive and unable to be redirected, with daily reports of physical and verbal aggression toward others. Another resident, who had moderate cognitive impairment and a history of anxiety and depressive symptoms, expressed fear for his safety due to his roommate's violent behavior. Progress notes and staff interviews confirm that the aggressive resident yelled at, cursed, and threatened his roommate, causing the latter to feel unsafe in his own room. The roommate reported being scared and stated that if the aggressive resident could hit staff, he could also harm him. Although the aggressive resident did not physically harm his roommate, the ongoing verbal aggression and threats created a hostile and unsafe environment. Staff interviews revealed that the incidents were not consistently reported to facility leadership, and not all residents at risk were interviewed regarding potential abuse. The Director of Nursing was unaware of the incident until later, and the Social Worker Director did not document all relevant interviews, believing them to be unimportant. The facility's policy required protection from abuse, but the actions taken were insufficient to prevent resident-to-resident abuse, resulting in a deficiency.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of resident-to-resident abuse to the State Agency, specifically when one resident with severe cognitive impairment and a history of problematic behaviors, including verbal and physical aggression, verbally assaulted another resident and exhibited physical aggression toward an unknown resident. Documentation in the medical record showed repeated incidents where the resident yelled, hit, and threw objects at staff and other residents, and was unable to be redirected despite multiple interventions. Progress notes and psychiatric evaluations indicated that these behaviors were ongoing and included both verbal and physical aggression almost daily. One resident, who had moderate cognitive impairment and a history of anxiety and depressive disorder, expressed fear for his safety due to his roommate's violent behavior. Staff documented that this resident was afraid because his roommate was yelling, cursing, and threatening him, and that the roommate had previously hit staff and other residents. The roommate was eventually moved to a private room, but there was no evidence that the incident was reported as required, nor that a thorough investigation was conducted. Interviews with staff, including LPNs, the DON, and the Social Worker Director, revealed that the incident was discussed internally but not reported to the Administrator or the State Agency. The facility's own policy required that resident-to-resident altercations be reviewed as potential abuse situations and that such incidents be reported. However, review of self-reported incidents showed no reports were made for the alleged events, and not all potentially affected residents were interviewed. The Social Worker Director also failed to document an interview with the resident who expressed fear, believing it was not important.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for a resident identified as high risk for falls. Medical record review showed the resident had multiple diagnoses, including palliative care, Parkinson's disease, COPD, and dementia, and was assessed with severe cognitive impairment. The care plan included specific fall prevention measures such as keeping the call bell within reach, maintaining the bed in the lowest position, ensuring the fall mat was on the left side of the bed, and not leaving the resident unattended in certain areas. Despite these interventions being documented, observations revealed that the call light was not within the resident's reach and was found wrapped under the bed wheel. Additionally, the resident's bed was observed in a high position with no staff present, and the fall mat was placed on the right side of the bed instead of the left as specified in the care plan. Staff interviews confirmed these observations, with CNAs verifying the call light was not accessible and the bed was not in the correct position. The resident had a documented history of multiple falls within the review period. The facility's policy required all accidents and incidents to be investigated and reported, but the lack of adherence to the care plan interventions contributed to the deficiency. This failure affected one resident out of three reviewed for falls in a facility with a census of 100.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11% as three errors were identified out of 27 opportunities during medication administration. For one resident with chronic kidney disease and atrial fibrillation, a LPN administered oxybutynin after the order for the medication had expired, as verified by both observation and staff interview. The resident had intact cognition at the time of the incident. Another resident with a history of stroke, autistic disorder, and peripheral vascular disorder received Vitamin B6 without a documented dosage and was also given a lower dose of Tylenol than prescribed. The LPN administered 100 mg of Vitamin B6 despite the absence of a specified dosage in the physician's order and provided only 325 mg of Tylenol when the order was for 1,000 mg. The LPN acknowledged the need to clarify the Vitamin B6 order and confirmed the incorrect Tylenol dosage during the interview.
Failure to Implement and Document Fall Prevention and Safe Transfer Interventions
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and that adequate supervision and assistive devices were provided to prevent accidents for multiple residents. One resident with vascular dementia and significant physical dependencies was care planned to have a perimeter mattress to reduce fall risk, but observations on multiple dates confirmed that the perimeter mattress was not in place. Staff interviews corroborated that the required equipment was not provided, despite the resident's high risk for falls and cognitive impairment. Another resident with severe cognitive impairment and a history of falls was care planned to have the bed in the lowest position and fall mats in place at all times. However, observations revealed the bed was in a high position and the fall mats were not in place, with no staff present to supervise. Staff interviews confirmed that the interventions were not implemented as required, and that staff were resistant to using the double fall mat due to its inconvenience. This resident had experienced multiple falls, and the lack of adherence to the care plan placed the resident at further risk. A third resident, also with severe cognitive impairment and a high risk for falls, experienced multiple unwitnessed falls. The care plan required a perimeter mattress and other interventions, but fall investigations did not consistently document whether these interventions were in place at the time of each fall. Additionally, the facility failed to consistently initiate and document neurological checks after unwitnessed falls, as required by facility policy. The DON confirmed that documentation was lacking and that fall investigations were incomplete. In another incident, a resident who required a mechanical lift for transfers was transferred by a CNA without the lift or a second staff member, resulting in a fall and bilateral femur fractures. The DON confirmed the improper transfer and resulting injuries.
Failure to Implement Water Management and Food Handling Infection Control Policies
Penalty
Summary
The facility failed to implement its water management policy as required to prevent the presence of microorganisms, including legionella, in its water system. Review of the Chlorine Check off Sheets for multiple facility areas revealed that water flow rates had not been tested since late the previous year, despite policy requiring quarterly checks. Additionally, water temperatures recorded in all areas were below the policy-mandated minimum of 122 degrees Fahrenheit, which is necessary to inhibit the growth of legionella and other pathogens. The Maintenance Director confirmed these lapses, acknowledging that the required water flow rate checks and temperature thresholds had not been met. In a separate incident, a CNA was observed assisting a resident with a meal and handled a hamburger patty with her bare hand before handing it to the resident. The CNA confirmed during an interview that she had not used gloves or utensils when handling the food. These actions demonstrate a failure to adhere to proper infection control practices during food handling, as required by facility policy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and interviews confirming the presence of ants in several resident rooms. Six residents were directly affected, with ants found on personal items such as eyeglasses, beds, facial tissue boxes, wheelchairs, and bedside tables. Residents reported the issue to staff and, in one case, attempted to contact the Administrator regarding the ant infestation. Staff, including a CNA and the Maintenance Director, confirmed the presence of ants and acknowledged that the problem had been ongoing, particularly due to recent wet weather conditions. Observations conducted in the affected residents' rooms revealed ants crawling on floors, bedside tables, under beds, and on window sills. Multiple ant traps were also noted in some rooms, indicating ongoing attempts to address the infestation. Review of the facility's pest control policy showed that the facility is required to maintain an ongoing pest control program to keep the building free of insects and rodents, but the observed conditions demonstrated that this program was not effective at the time of the survey.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when staff failed to ensure a resident's dignity was maintained during mealtime assistance. The resident, who had parkinsonism, moderate protein-calorie malnutrition, and was dependent on staff for all activities of daily living, was observed being fed lunch by a Certified Nursing Assistant (CNA) who stood over her throughout the meal. The resident had intact cognition and specifically asked the CNA if she was going to sit down while feeding her, but the CNA did not respond or acknowledge the request and continued to stand. A chair was available nearby but was not used by the CNA. Interviews confirmed that the CNA stood for the entire feeding and that the resident had requested the CNA to sit. Review of the facility's Resident Rights Policy indicated that all staff must treat residents with respect and dignity, and provide care in a manner that promotes or enhances quality of life. The actions observed and confirmed by interviews did not align with this policy, resulting in a failure to honor the resident's right to dignity during mealtime.
Failure to Notify POA of Significant Weight Loss
Penalty
Summary
The facility failed to notify the medical power of attorney (POA) for a resident who experienced significant weight loss. Medical record review showed that the resident, who had diagnoses including aspiration pneumonia, COPD, prostate cancer, type 2 diabetes, moderate protein-calorie malnutrition, and dementia with behavioral disturbance, had severely impaired cognition and was dependent on staff for most activities of daily living. The resident's weight dropped from 146.2 pounds to 129.8 pounds and then to 109 pounds over a short period, representing a loss of more than 25% in one month. Despite these significant changes, there was no documentation that the resident's POA was notified of the weight loss events on multiple occasions. Staff interviews confirmed that the registered dietitian had not informed the POA about the resident's weight changes, with the last contact occurring during a care conference prior to the documented weight loss. Facility policy required notification of the POA for any weight change of 5% or more from the last weight, defining severe weight loss as greater than 5% in one month or 10% in six months. The lack of notification was verified through medical record review, staff interview, and policy review.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not limiting the use of as-needed (PRN) psychotropic medications to 14 days, as required by facility policy. Record review showed that a resident with diagnoses including cerebrovascular disease, hemiplegia, malnutrition, vascular dementia, and unspecified psychosis had a physician order for Ativan 0.5 mg to be given every four hours as needed for anxiety or dyspnea, starting on 04/25/25. The order did not include a stop date and was not limited to 14 days, contrary to facility policy and regulatory requirements. The resident's care plan indicated a history of aggression and resistance to care, with interventions to administer medications as ordered and monitor behaviors and side effects. The Minimum Data Set assessment documented significant cognitive impairment. During an interview, the DON confirmed that the PRN Ativan order should have had a stop date and should not have been ordered for more than 14 days. Facility policy on psychotropic medication management also specified that PRN psychotropic medications are to be limited to 14 days unless otherwise justified.
Failure to Provide Resident-Centered Activity Care Plan
Penalty
Summary
Facility staff failed to ensure that the activity care plan for a resident was appropriately individualized and resident-centered. The resident, who had diagnoses including senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis, was noted to be cognitively impaired with a BIMS score of 00 and was rarely understood. Despite documented interests in religious activities, baking, country music, television, movies, and dogs, the care plan only included generic interventions for one-on-one activities and was not updated to reflect the resident's preferences or cognitive decline. Activity assessments indicated unchanged preferences, but the care plan did not incorporate specific or meaningful activity options tailored to the resident's needs. Record review showed that the resident was only offered a limited number of one-on-one visits in recent months, with no visits documented in the previous ten days. Observations on multiple dates revealed the resident remained in her room, with no lights, television, or music, and had not participated in any activities or been encouraged by staff to do so. Staff interviews confirmed that activity care plans were not updated to reflect the resident's interests or cognitive status, and the facility's policy required care plans to include resident needs and interests.
Failure to Provide Activities of Interest to Resident
Penalty
Summary
The facility failed to provide activities of interest to a resident, as required by their care plan and activity assessment. The resident, who had diagnoses including senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis, was noted to be alert and oriented with some confusion at the time of assessment, and later assessed as cognitively impaired with a BIMS of 00 and rarely understood. The resident's documented preferences included religious activities, baking/cooking, country music, television, movies, and dogs, with a care plan indicating a need for one-on-one activities. Despite these documented interests and needs, records showed the resident was only offered three one-on-one visits in one month and two in the following month, with no visits in the ten days prior to the survey. Observations revealed the resident was repeatedly found in her room without lights, television, or music, and had not been out of bed or participated in any activities on the observed dates. Staff interviews confirmed that the resident had not received the minimum expected frequency of one-on-one visits and that her preferences could have been accommodated, such as by providing television or music. The facility's policy required activity evaluations to reflect residents' interests and needs, but this was not followed for the resident in question.
Failure to Obtain and Document Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain and document resident weights in accordance with physician orders and facility policy for two residents reviewed for nutrition. One resident with end stage renal disease, diabetes, heart failure, and chronic obstructive pulmonary disease had a physician order for daily weights due to congestive heart failure, but multiple days were identified across several months where weights were not obtained as ordered. The Director of Nursing confirmed that these weights were missed, and facility policy required weights to be recorded at intervals established by the interdisciplinary team. Another resident with parkinsonism and moderate protein-calorie malnutrition experienced a significant weight loss of 14 pounds (11.4%) over a one-month period. The dietitian was aware of the weight change and requested a reweight, but this was not completed within the expected 48-hour timeframe. The resident reported not being reweighed after the initial weight loss was identified, and there was no evidence in the medical record that the dietitian had acknowledged the weight change or that a timely reweight was performed, as required by facility policy.
Failure to Administer Medications as Ordered Due to Pharmacy Supply Issues
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents. For one resident with end stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease, there was a physician's order for Renvela 800 mg once daily. Review of the Medication Administration Records (MAR) over several months revealed that Renvela was not administered on numerous dates, and progress notes indicated the medication was not available from the pharmacy on those occasions. The Director of Nursing confirmed these missed administrations. For another resident with a history of cerebral infarction, hemiplegia, hemiparesis, anxiety disorder, and moderate cognitive impairment, multiple medications were not administered as ordered on several dates. These included Metoprolol, Pramipexole, Doxepin, Citalopram, Divalproex, Atorvastatin, and Apixaban. Nurse notes consistently documented that the medications were not available or were awaiting arrival from the pharmacy. The resident confirmed not receiving medications over a weekend, and the Director of Nursing verified the missed doses due to pharmacy supply issues. Facility policy requires that medications be administered in accordance with prescriber orders and within required time frames. However, the documented failures to provide ordered medications as scheduled, due to unavailability from the pharmacy, resulted in noncompliance with this policy for the two residents identified in the report.
Failure to Ensure Resident Comprehension Before Signing Arbitration Agreement
Penalty
Summary
A resident with diagnoses including emphysema, hypertension, malnutrition, and peripheral vascular disease was admitted to the facility and assessed as having moderately impaired cognition. Medical record reviews indicated the resident was alert but exhibited confusion and both long-term and short-term memory deficits, with the ability to make only limited decisions requiring simple understanding. Despite these cognitive limitations, the resident signed a binding arbitration agreement as part of the admission process. The agreement itself was incomplete, lacking the facility representative's signature and missing the date and resident name at the top of the form. During a subsequent interview, the resident was unable to recall basic information such as the current month, year, duration of stay, or the facility's name, and could not explain or remember signing the arbitration agreement. The Regional Director of Clinical Operations confirmed that the resident had impaired cognition at the time of signing and acknowledged that residents should be capable of understanding such agreements before signing. This sequence of events demonstrates that the facility failed to ensure the resident was capable of understanding the arbitration agreement prior to obtaining their signature.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving an injury of unknown origin as required by their policy. This incident affected a resident who had a severe cognitive impairment and multiple medical conditions, including a fracture of the right femur, cerebrovascular disease, and dementia. The resident was involved in an incident on 12/13/24 where her arm was caught in a mechanical lift, resulting in a small skin tear. However, there was no documentation indicating a fall or injury to her legs during this incident. The following day, the resident was sent to the emergency room due to swelling and discoloration in her left leg/pelvic area, and a subsequent hospital examination revealed a fracture of her right hip with an unknown mechanism of injury. The facility's medical records from 11/01/24 to 12/19/24 did not provide evidence or documentation to determine the cause of the injury. The facility's self-reported incidents during the same period also showed no evidence that the injury was reported to the state health agency. Interviews with the facility's administrator and medical director revealed that the injury was not reported because the facility believed it occurred during the mechanical lift incident. However, the medical director could not confirm this, noting that the injury likely did not occur on 12/13/24 due to calcification around the fracture, indicating it happened earlier. The facility's abuse policy lacked a definition for injury of unknown origin and required notification to the department of health, which was not done in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an injury of unknown origin for a resident, which is a violation of their policy. The resident, who had a severe cognitive impairment and multiple medical conditions, was involved in an incident while being transferred via a mechanical lift. During this incident, the resident's arm was caught in the machine, resulting in a skin tear. However, there was no documentation of a fall or any injury to her legs during this incident. Subsequently, the resident was sent to the emergency room for swelling and discoloration in her left leg/pelvic area, where it was discovered that she had a fracture in her right hip. The hospital documentation noted the injury's mechanism was unknown and considered referring the case to social services for potential elder abuse. The facility's investigation included interviews with the nurse and aide involved in the incident, but these statements were not signed or dated. The facility concluded that the injury occurred during the mechanical lift incident, based on a conversation with the Medical Director, although he later stated he did not confirm this. The facility's abuse policy requires a comprehensive investigation of injuries of unknown origin, including interviews with various individuals and a review of the resident's records. However, the facility did not follow these procedures thoroughly, as they did not interview other residents or staff beyond those directly involved, nor did they obtain signed witness statements. The Medical Director later expressed confidence that the injury did not occur during the incident on the mechanical lift, as there was calcification around the fracture, indicating it happened earlier.
Failure to Obtain Ordered Laboratory Test
Penalty
Summary
The facility failed to obtain a laboratory test as ordered by a physician for one of the residents. The resident, who had diagnoses including heart failure, chronic kidney disease, hypertension, type two diabetes mellitus, and peripheral vascular disease, was admitted with intact cognition and occasional urinary incontinence. A physician's order was placed for a urinalysis (UA) with reflex culture to be collected on a specific date. However, the medical record review revealed that the UA with reflex culture was not collected as ordered, and no laboratory results were documented. The Director of Nursing (DON) confirmed during an interview that the UA with reflex culture was not obtained because it was not picked up in time and was subsequently discarded. The test was not re-collected, leading to a lapse in the resident's care. The resident was later treated for a urinary tract infection (UTI) in the hospital. The facility's policy required staff to process test requisitions and arrange for tests, but this was not followed in this instance, resulting in non-compliance as investigated under a specific complaint number.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents. Resident #4, who was admitted with dementia and other mental health diagnoses, was reported to have engaged in aggressive behavior, including swatting at staff and exit-seeking. On a specific date, a nurse's note initially documented that Resident #4 grabbed another resident by the throat, but this was later corrected by the Director of Nursing (DON) to indicate that Resident #4 merely touched the other resident's neck without force. However, a witness statement from a staffing coordinator described Resident #4 as having pushed Resident #21 around the throat, causing her head to move back. Despite these accounts, the incident was not documented in the facility's incident log, nor was a Self-Reported Incident (SRI) completed, indicating that no formal investigation was conducted. Interviews with staff confirmed the occurrence of the incident and the lack of documentation or investigation. The DON acknowledged the incident but did not believe it warranted an investigation, despite the witness's statement confirming the physical interaction. This oversight led to a deficiency being cited under Complaint Number OH00158828.
Failure to Communicate Family Concerns About Medication Change
Penalty
Summary
The facility failed to communicate with the physician regarding family concerns about the discontinuation of a medication for a resident diagnosed with dementia, anxiety, and other mental health issues. The resident, who was cognitively impaired and required various levels of assistance with daily activities, had their medication Brexpiprazole (Rexulti) discontinued due to cost. The family expressed concerns that the resident might no longer be in a stable mindset after the medication change, but these concerns were not communicated to the Nurse Practitioner (NP) responsible for the resident's psychiatric care. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the family’s concerns were not relayed to the NP, who was available for consultation. The resident's spouse reported a decline in the resident's condition following the medication change, which was not addressed due to the lack of communication. This deficiency was identified during an investigation under a specific complaint number.
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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