Aventura At Shiloh Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Trotwood, Ohio.
- Location
- 3500 Shiloh Springs Road, Trotwood, Ohio 45426
- CMS Provider Number
- 366302
- Inspections on file
- 39
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Aventura At Shiloh Springs during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes and osteomyelitis, was receiving scheduled oxycodone, a narcotic analgesic associated with constipation risk. The medical record contained no documentation of bowel movement monitoring or of the resident’s last bowel movement, despite this risk. The resident reported not having a bowel movement for 10 days and felt that any treatment provided was not effective. The Administrator confirmed the absence of bowel movement documentation, leading surveyors to cite a deficiency for failure to provide appropriate monitoring and care related to constipation.
A resident with multiple medical conditions, including bacteremia and diabetes, had a physician order for a Foley catheter to be clamped over a 24-hour period and then discontinued, with specific instructions for straight catheterization and possible Foley replacement based on post-void residuals. Record review showed no documentation that staff removed or attempted to remove the Foley as ordered, and the catheter remained in place. The resident later presented with abnormal vital signs and was sent to the ER, and interviews with the Administrator and DON confirmed there was no documentation of Foley removal or attempts, despite the DON believing it had been removed and reinserted.
Two residents were observed smoking outside of designated areas, with one smoking unsupervised near the main entrance despite requiring supervision, and another smoking in the parking lot instead of off facility property as required. Staff confirmed that smoking materials were provided and stored by nursing staff, but supervision and adherence to designated smoking areas were not maintained. Additionally, cigarette butts were found discarded in multiple inappropriate locations, despite the availability of non-combustible containers.
A facility failed to notify the physician or family of a newly identified pressure ulcer in a resident with intact cognition and multiple diagnoses, including diabetes and hypertension. Upon admission, no pressure ulcers were documented, but a later assessment revealed a significant unstageable sacral pressure wound. The facility's policy required notification of such changes, but this was not done, as confirmed by the DON.
A facility failed to provide adequate assistance with personal hygiene and ADLs for a resident requiring moderate assistance. Despite having a care plan for toileting and incontinence care, the resident received only one bed bath during her stay. A physical therapist noted multiple instances where the resident was found saturated and unable to receive timely assistance from CNAs, impacting therapy sessions. The DON confirmed the lack of documentation for additional showers or baths.
The facility failed to provide appropriate care for pressure ulcers for two residents. One resident developed an unstageable sacral pressure wound that was not treated promptly, and the wound physician's orders were not followed correctly. Another resident had unstageable pressure wounds on both heels, but there was a lack of documentation and delayed treatment. The facility's policy for pressure sore assessment was not adhered to.
A resident admitted with orders for PT and OT services did not receive timely evaluations, with PT delayed and OT never conducted. The facility's expectation for therapy screening within 48 to 72 hours was not met, as confirmed by staff interviews.
A facility failed to follow proper infection control procedures during the care of a resident with significant impaired cognition and multiple health conditions. An LPN was observed applying multiple layers of gloves and not performing hand hygiene between glove changes, contrary to the facility's policy. This incident was noted during a complaint investigation.
Two residents' rooms were found in unsanitary conditions, with dirty floors, black dirt around wall edges, and a leaking bathroom sink. One resident, with severe cognitive impairment, had a room with stained floors and circular marks, while another cognitively intact resident had a very dirty floor and a dripping sink. The facility's policy on maintaining a clean and homelike environment was not followed.
A resident with multiple health conditions experienced a delay in assistance due to a call light being obscured by an unlatched fire door. The CNA took 20 minutes to respond, exceeding the facility's 15-minute response policy. The DON confirmed the expected response time, while the Regional Administrator was unaware of the door issue.
A resident with multiple diagnoses, including cellulitis and acute kidney failure, did not receive timely pain medication as ordered. Despite the resident's request and reporting a high pain level, an LPN failed to administer oxycodone IR 5 mg due to lack of access to the emergency drug kit. The medication was available, but the LPN did not have the necessary key, leading to a delay in pain management.
A resident with type two diabetes was not adequately monitored for blood glucose levels, affecting the administration of sliding scale insulin. The resident had a continuous glucose monitoring device, but an LPN failed to check the glucose levels or administer insulin as prescribed. The LPN documented refusals without verifying the resident's glucose levels, and the DON was unaware of this non-compliance.
A facility failed to accurately document medication administration records for a resident with diabetes, affecting their blood glucose monitoring and insulin administration. An LPN did not check the resident's blood glucose levels or verify the need for insulin, despite having a continuous glucose monitoring device. The resident confirmed the LPN did not visit them for insulin administration, and their blood glucose reading was 279 mg/dL. This deficiency was found during a complaint investigation.
The facility failed to document the administration of as-needed medication and care services for three residents, leading to deficiencies in medical record accuracy. A resident's incontinent care was not documented as per the care plan, another resident's BiPap device application was not recorded despite physician orders, and a third resident's Tylenol administration for pain was not reflected in the MAR, despite LPNs confirming its administration. The DON verified these documentation lapses.
A resident was physically abused by two other residents in a LTC facility. The incident involved one resident being struck in the face with a cane and then hit in the head from behind. The facility's investigation confirmed the abuse, with admissions from the involved residents. The affected resident had moderate cognitive impairment and required assistance for daily activities. The facility's failure to prevent this abuse was noted as non-compliance.
A resident with cognitive impairment and a history of wandering eloped from the facility in a wheelchair, despite being identified as at risk and requiring one-on-one monitoring. The facility's care plan and elopement policy were not effectively implemented, leading to the resident's unsupervised exit.
A facility failed to administer medications timely, affecting a resident's scheduled doses. An LPN was observed administering medications late, including gabapentin, which was supposed to be given three times daily at specific times. The delay was acknowledged by the LPN, impacting the timing of subsequent doses. This action was contrary to the facility's policy requiring timely medication administration.
Failure to Monitor Bowel Movements for Resident on Narcotic Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to monitor bowel movements for a resident at risk of constipation while receiving narcotic pain medication. The resident was admitted with diagnoses including bacteremia, hypertension, cellulitis, type 2 diabetes mellitus, and osteomyelitis, and a quarterly MDS documented that the resident was cognitively intact. Physician orders included oxycodone hydrochloride 5 mg by mouth four times a day for pain, a medication known to potentially cause constipation. Despite this risk, review of the medical record showed no documentation that the resident’s bowel movements were being monitored and no record of the date of the last bowel movement. During an interview, the resident reported it had been 10 days since having a bowel movement and stated they believed they had been given something to help but did not think it was effective. The Administrator confirmed there was no documentation of bowel movement monitoring for this resident. Reference materials reviewed by surveyors, including Medscape and MedlinePlus, indicated that oxycodone may cause constipation and that a medical provider should be contacted if a person has not had a bowel movement in three days. This lack of monitoring and documentation for a resident at risk of constipation formed the basis of the cited deficiency.
Failure to Follow Foley Catheter Discontinuation Order
Penalty
Summary
The facility failed to follow a physician’s order to attempt removal of an indwelling Foley catheter for a resident. The resident was admitted with diagnoses including bacteremia, hypertension, cellulitis, type 2 diabetes mellitus, and osteomyelitis, and a quarterly MDS indicated the resident was cognitively intact. A physician’s order dated 12/30/25 directed staff to clamp the Foley catheter for four hours, release for 15 minutes, repeat for 24 hours, then discontinue the Foley. The order further specified that if the resident did not void, staff could perform straight catheterization every four to six hours and as needed, and if the post-void residual exceeded 500 milliliters twice, the Foley should be replaced. Review of the medical record showed no documentation that the Foley catheter was removed or that removal was attempted as ordered on 12/20/26. Progress notes instead showed that the Foley was removed on 01/06/25 per order, and the resident was sent to the ER for elevated temperature, elevated pulse, and decreased blood pressure. During an observation and interview, the resident was noted to have an indwelling Foley in place and reported that a nurse had told him the Foley “didn’t look right.” In an interview, the Administrator and DON confirmed there was no documentation of the Foley being removed or of any attempt to remove it, and the DON stated she thought the Foley had been removed and reinserted but acknowledged there was no documentation. This constituted a failure to ensure appropriate Foley catheter care as ordered.
Failure to Supervise Resident Smoking and Enforce Designated Smoking Areas
Penalty
Summary
The facility failed to ensure that residents who smoked were properly supervised and that smoking occurred only in designated areas, as required by facility policy. Observations revealed that one resident, who was assessed as requiring supervision while smoking, was seen smoking unsupervised near the facility's main entrance, despite a posted no smoking sign. Staff interviews confirmed that this resident was supposed to be supervised and to smoke only in the designated area, with smoking materials stored by staff. The resident confirmed that staff provided him with his smoking supplies that morning, but he proceeded to smoke unsupervised outside the main entrance. Another resident, who was assessed as safe to smoke without direct supervision, was observed smoking in the facility's parking lot rather than in the designated smoking area or off facility property, as required by policy. This resident acknowledged awareness of the rule to smoke off facility property and confirmed that staff kept his smoking supplies at the nurses' station. Staff interviews corroborated that residents not requiring supervision were expected to smoke off facility property, but this was not being followed. Additionally, multiple cigarette butts were observed discarded on the ground along the sidewalk, in the parking lot, and in the mulch at the facility's entrance and in the designated smoking area. Although a non-combustible container was available for disposal, cigarette butts were found in inappropriate locations, indicating that residents were not consistently using the proper containers to extinguish smoking materials. These findings demonstrate a failure to maintain safe smoking practices and adequate supervision as outlined in the facility's smoking policy.
Failure to Notify Physician and Family of Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician or family of a newly identified pressure ulcer for a resident. The resident, who had intact cognition and required moderate assistance for certain activities, was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus, and hypertension. Upon admission, there were no pressure ulcers documented. However, a skin assessment conducted on 02/06/25 revealed a nine by eleven centimeter unstageable sacral pressure wound. The notification section of the assessment document lacked any indication that the physician or family had been informed of this significant change in the resident's condition. An interview with the Director of Nursing confirmed that neither the physician nor the family had been notified of the pressure ulcer upon its discovery. The facility's policy required notification of the physician and resident representative in the event of changes in a resident's medical condition, which was not adhered to in this case.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene and Activities of Daily Living (ADL) for a resident, identified as Resident #10, who required moderate assistance with these tasks. The resident, who had intact cognition and was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus, and hypertension, was found to have received only one bed bath during her stay from early February until her hospitalization later that month. The care plan for the resident included interventions for assistance with toileting needs and incontinence care, but these were not adequately implemented. The deficiency was further highlighted by a physical therapy note indicating that on multiple occasions, the resident was found saturated and in need of cleaning, but nursing aides were not available to assist in a timely manner. The Director of Nursing confirmed the lack of documentation for additional showers or baths, and a physical therapist reported difficulty in locating CNAs to assist the resident, which impacted the therapy sessions. This lack of timely assistance and documentation represents a failure in providing necessary care for the resident's hygiene and ADL needs.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and services for pressure ulcers for two residents. Resident #10 was admitted with no pressure ulcers but developed an unstageable sacral pressure wound measuring 9 cm by 11 cm, which was not treated until three days after it was discovered. The wound physician's orders for daily dressing changes were not followed correctly, as the facility implemented a different dressing and frequency than prescribed. The Director of Nursing (DON) confirmed these discrepancies and acknowledged that the wound physician's orders were not followed as written. Resident #11, who had impaired cognition, was found to have unstageable pressure wounds on both heels during a readmission skin assessment. However, there were no measurements or detailed assessments documented for these wounds. Treatment orders were delayed by two days, and subsequent skin assessments failed to document the presence of these wounds. The DON verified the lack of documentation and measurements for Resident #11's wounds and acknowledged that the issue would be addressed. The facility's policy required a full assessment of pressure sores, including location, stage, and measurements, which was not adhered to in these cases.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility failed to provide timely therapy services to a resident, which was identified during a review of medical records, hospital referrals, and staff interviews. The resident, who was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus, and hypertension, had orders for both Physical Therapy (PT) and Occupational Therapy (OT) services to continue after discharge from the hospital. Despite these orders, the resident was not evaluated by PT until several days after admission, and OT services were never provided. Interviews with the Therapy Manager and the Administrator revealed that the facility's expectation was for residents to be screened for therapy services within the first 48 to 72 hours of admission. However, due to an oversight, the resident did not receive the necessary evaluations in a timely manner. The Therapy Manager could not recall the specifics of the resident's needs, and the Administrator confirmed the delay in PT evaluation and the absence of OT evaluation. This deficiency was investigated under specific complaint numbers.
Infection Control Deficiency During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during the care of a resident, which was observed during a complaint investigation. The resident, who was admitted with conditions including hemiplegia, diabetes mellitus, depression, and a gastronomy tube, was also on hospice care and had significant impaired cognition. The resident was dependent on staff for various activities, including eating, bed mobility, transfers, and toileting hygiene, and was always incontinent of urine and bowel. During an observation of wound care, the resident was found to be incontinent, and the LPN left the room to gather supplies. Upon returning, the LPN washed her hands and applied multiple layers of gloves before proceeding with the care. During the wound care process, the LPN removed the top layer of gloves after cleansing the resident's buttocks and continued to remove additional layers of gloves without performing hand hygiene between glove changes. The facility's policy required staff to remove disposable gloves, discard them, and wash and dry hands thoroughly, which was not followed in this instance. The LPN acknowledged that hand hygiene was not performed during the observation or after removing multiple layers of gloves, which was against the facility's infection control policy.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting two residents' rooms. Resident #34, who has chronic diastolic heart failure, cognitive communication deficit, atrial flutter, and hypertension, was observed to have a room with a dirty and stained floor. The floor had 25 circular brownish-black marks, and the wall edges were covered with black, hard dirt extending two to three inches into the room. Housekeeping Aide #236 confirmed the difficulty in cleaning the floor, suggesting the presence of old floor wax. Resident #34, assessed with severely impaired cognition, verified the floor's condition. Resident #13, diagnosed with type two diabetes, alcohol dependence, bipolar disorder, major depressive disorder, acute kidney failure, and hypertension, was found to have a very dirty floor with large circular wear patterns and black, hard dirt around the wall edges. The Housekeeping Director confirmed these observations and noted a continuous drip from the bathroom sink onto brown paper towels. Resident #13 was assessed as cognitively intact. The facility's policy on providing a safe, clean, and homelike environment was not adhered to, as evidenced by the conditions in these residents' rooms.
Delayed Response to Call Light Due to Obstructed View
Penalty
Summary
The facility failed to provide timely care and services in response to call lights, specifically affecting Resident #29. The resident, who has diagnoses including bipolar disorder, type two diabetes, morbid obesity, anxiety, and major depression, was assessed with intact cognition and required assistance with various activities of daily living (ADLs). On the morning of January 22, 2025, Resident #29 activated the call light while in the bathroom needing assistance. However, the call light was not answered until 20 minutes later by CNA #278. The delay was attributed to the call light being obscured by an opened fire door, which was unlatched and blocked the view of the call light. Interviews with staff and the resident confirmed the delay in response. CNA #278 acknowledged the delay and attributed it to the obscured call light. The Director of Nursing stated that call lights should be answered within 15 minutes, while the Regional Administrator was unaware of the fire door's malfunction. The facility's policy on answering call lights requires staff to respond promptly and indicate the time it will take to assist the resident. This deficiency was investigated under Complaint Number OH00161139.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide timely pain medication to Resident #3, who was admitted with diagnoses including cellulitis, acute kidney failure, major depressive disorder, and hypertension. The resident had a physician's order for oxycodone IR 5 mg to be taken every eight hours as needed for pain. On the morning of January 22, 2025, the resident requested the medication from LPN #292, who informed the resident that she needed to contact the pharmacy regarding the delivery status of the medication. However, the medication was not administered, and the resident reported a pain level of seven out of ten later that afternoon, stating he had not received the medication for two days. Further investigation revealed that the oxycodone IR 5 mg was available in the facility's emergency drug kit, but LPN #292 did not have access to the narcotic locked cart. The Director of Nursing later confirmed the availability of the medication in the emergency supply and facilitated its administration. LPN #228 acknowledged that LPN #292 should have accessed the emergency supply earlier in the day when the resident requested the medication. This deficiency was identified during a complaint investigation under Complaint Number OH00161139.
Failure to Monitor Blood Glucose Levels for Insulin Administration
Penalty
Summary
The facility failed to ensure that blood glucose levels were adequately monitored for a resident with type two diabetes, which affected the administration of sliding scale insulin. Resident #13, who was cognitively intact, had a continuous glucose monitoring device, the FreeStyle Libre 2 Sensor, to monitor blood glucose levels. The resident was prescribed Humalog insulin to be administered based on specific blood glucose readings. However, the medical administration record (MAR) showed that the resident refused insulin doses on multiple occasions without documented evidence of blood glucose levels being checked. Licensed Practical Nurse (LPN) #292 admitted to not checking the resident's blood glucose levels or knowing the location of the resident's glucose monitor. The LPN documented that the resident refused insulin without verifying the blood glucose levels, which was confirmed by the resident who stated that the LPN did not visit him for insulin administration or glucose level checks. The Director of Nursing (DON) was unaware of the staff's failure to monitor the resident's blood glucose levels as ordered, acknowledging that this was not acceptable practice.
Failure to Document Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration records for a resident with type two diabetes, affecting their blood glucose monitoring and insulin administration. The resident, who was cognitively intact, had a continuous glucose monitoring device, the FreeStyle Libre 2 Sensor, which was to be used to monitor blood glucose levels. Despite having a physician's order for sliding scale Humalog insulin based on specific blood glucose levels, the medication administration record showed that the resident was documented as refusing insulin doses on two consecutive days without any evidence of blood glucose levels being checked. An LPN admitted to not checking the resident's blood glucose levels or asking the resident for their blood glucose reading, despite the presence of the monitoring device. The LPN documented that the resident refused insulin without verifying the blood glucose level, which was necessary to determine the need for insulin administration. The resident confirmed that the LPN did not visit them to check their blood glucose level or administer insulin, and at the time of observation, the resident's blood glucose reading was 279 mg/dL. This deficiency was identified during an investigation of a complaint.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to document the administration of as-needed medication and care services for three residents, leading to deficiencies in medical record accuracy. For Resident #45, the facility did not document incontinent care as per the plan of care, which included assistance with toileting needs and incontinence care on routine rounds. The Director of Nursing (DON) confirmed that the task was not triggered for the State tested Nursing Assistant (STNA) to document, and no other documentation was found to indicate that the care was provided. Resident #18's medical records lacked documentation related to the application of a BiPap device at bedtime, despite having physician orders for its use. The DON verified that the treatment administration record was silent on this matter and acknowledged that the orders were not added to the electronic health record after the resident returned from the hospital. The facility's policy required documentation of the general assessment and specifics of the CPAP/BiPap use, which was not adhered to. For Resident #15, the Medication Administration Record (MAR) did not reflect the administration of Tylenol for pain management, despite interviews with two Licensed Practical Nurses (LPNs) confirming they had administered the medication. The DON verified the absence of documentation and noted that the nurses would make a late entry regarding the administration. Additionally, there was no independent order for pain monitoring every shift, which was later added to the resident's medication profile.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in an incident where a resident was struck by two other residents. Resident #19 reported being hit in the face with a cane by Resident #41 and then being struck in the head from behind by Resident #52. This incident was initially denied by the accused residents, but Resident #52 later admitted to the act, and Resident #41 confessed during a subsequent interview. The facility's self-reported incident and investigation revealed these events, which affected Resident #19, who had moderate cognitive impairment and required substantial assistance for daily activities. Resident #19, who had a history of behavior problems and was disruptive, was sent to the hospital following the incident with complaints of seeing black dots after the head trauma but returned with no new diagnosis. Resident #41, who had a history of major depressive disorder and behavioral issues, was also sent to the hospital after the incident. Resident #52, diagnosed with multiple sclerosis and depression, was involved in the altercation and was sent to the hospital as well. The facility's policy on preventing and addressing elder abuse was reviewed, highlighting the purpose of preventing and prosecuting elder abuse and neglect. The Director of Nursing confirmed the details of the incident, acknowledging that Resident #41 used a metal cane to hit Resident #19 and that Resident #52 struck Resident #19 from behind. The facility's failure to prevent this abuse represents non-compliance with regulations, as investigated under a specific complaint number. The report does not mention any corrective actions or follow-up measures taken by the facility to address the deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as Resident #24, who was at risk for wandering due to cognitive impairment. The resident had been admitted with diagnoses including Wernicke's encephalopathy and altered mental status, and was noted to be cognitively impaired, requiring maximal assistance with activities of daily living. A Wander Risk Evaluation conducted on 02/02/24 identified the resident as at risk for wandering, but no interventions were care planned at that time. The care plan later included interventions such as observing for signs of planning to leave and redirecting the resident, but these measures were not effectively implemented. On 05/27/24, Resident #24 eloped from the facility in a wheelchair through the 100 hallway door, shortly after receiving evening medications. The alarm alerted staff, and the resident was found outside the facility and returned to his room. The Director of Nursing confirmed that the resident should have been on one-on-one monitoring since 03/20/24, as per the care plan, but this was not adhered to. The facility's policy on elopement indicated that residents should be placed on one-on-one monitoring after an elopement until the interdisciplinary team meets, but this was not followed, leading to the deficiency.
Medication Administration Delay
Penalty
Summary
The facility failed to ensure timely administration of medications, affecting one resident out of four observed for medication administration. On the morning of July 2, 2024, an LPN was observed administering medications to a resident, including gabapentin, which was scheduled to be given three times daily at specific times. However, the administration was delayed, and the LPN acknowledged that the delay would affect the timing of subsequent doses. The facility's policy, dated August 2023, mandates that medications be administered in a safe and timely manner, which was not adhered to in this instance.
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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