Aventura At Walton Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Walton Hills, Ohio.
- Location
- 19859 Alexander Rd, Walton Hills, Ohio 44146
- CMS Provider Number
- 365705
- Inspections on file
- 28
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Aventura At Walton Hills during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including CKD, DM2, Parkinson’s disease, and dementia, exited through an emergency exit door, triggering an alarm and resulting in an unwitnessed fall outside. Staff responded, assessed the resident, and returned him to the unit, and a subsequent investigation confirmed he had been outside briefly and that door alarms functioned properly. However, the resident’s legal guardian reported being informed only of the fall and not that the resident had eloped, and the medical record lacked documentation that the guardian was notified of the elopement, despite facility policy requiring notification of the resident’s representative after accidents or significant incidents.
A resident with multiple chronic conditions, including dementia and Parkinson’s disease, was initially assessed as low risk for wandering but later scored as moderate and then high risk on wander-risk evaluations. Despite these increasing risk scores, the sections of the wander-risk tools designated for care plan interventions were left blank, and no elopement-risk care plan was initiated. The resident began self-propelling in a wheelchair and ultimately exited through an emergency exit door, triggering an alarm and sustaining an unwitnessed fall outside before being promptly found and assessed by staff. Interviews showed that an LPN completing the assessments had never filled out the intervention section, the MDS/RN relied on IDT judgment and did not care plan solely for wandering behavior, and leadership acknowledged that a care plan should have been implemented earlier in accordance with facility policy requiring care plan revisions when resident conditions change.
Multiple residents and staff reported that rooms and common areas were not cleaned daily, with observations confirming dirt, grime, damaged furniture, and poor floor conditions throughout the facility. Staff interviews revealed that environmental concerns had been known for months but not addressed, and improper floor maintenance practices contributed to the buildup. Facility policies for cleaning and disinfection were not followed, resulting in unsanitary conditions affecting residents, including those with significant physical limitations.
A resident at risk for pressure ulcers developed an unstageable ulcer due to the facility's failure to implement and document appropriate interventions. Despite having a care plan, the facility did not consistently perform skin assessments or provide necessary treatments, leading to the deterioration of the resident's condition. Interviews with staff confirmed inaccuracies in weekly skin observations and a lack of investigation into the ulcer's progression.
An LPN failed to perform hand hygiene during medication administration for three residents, despite facility policies requiring handwashing before and after resident contact and glove use. The residents had various medical conditions, and the deficiency was identified during a complaint investigation.
A facility failed to individualize a care plan for a resident with complex medical needs, including paraplegia and a recent unstageable pressure ulcer. The care plan did not address the pressure ulcer acquired in-house, and this was confirmed by the Regional Director of Clinical Operations. The facility's policy requires comprehensive, person-centered care plans, which was not followed in this instance.
The facility failed to conduct weekly skin observations as ordered for two residents, leading to incomplete documentation and lack of interventions for pressure ulcers. One resident had a history of paraplegia and pressure ulcers, while another was at moderate risk for skin breakdown. The facility's policy required weekly skin audits, but these were not consistently performed, as confirmed by staff interviews.
A facility failed to ensure staff followed enhanced barrier precautions during catheter care for a resident with paraplegia and neuromuscular dysfunction of the bladder. An LPN provided care without wearing a gown, contrary to the facility's policy and the sign on the resident's door, which required gloves and a gown for such procedures.
The facility failed to treat residents with dignity, affecting three individuals. A resident with developmental disorder and another with dementia had their urinary drainage bags visible without privacy covers, contrary to physician orders. Additionally, a resident with stroke and dementia was treated rudely by a CNA who blocked his wheelchair and spoke in an intimidating manner.
A facility failed to include a resident and their POA in the development and implementation of the resident's care plan. Despite the resident having intact cognition and the POA's attempts to arrange a care planning conference, no such conference was scheduled or documented. The facility's policy required resident involvement in care planning, but this was not adhered to, and no explanation was documented.
The facility failed to address grievances in a timely manner, affecting two residents. One resident with a suprapubic catheter had concerns about leakage and lack of catheter flushes, which were not documented or addressed despite attempts by the resident's POA to contact the DON. Another resident reported being left in the bathroom for a long time, but the DON was unaware of the issue. The facility's grievance log showed no entries for two months, indicating a failure to document and address grievances as per policy.
A facility failed to timely report an allegation of staff-to-resident verbal abuse involving a resident with Alzheimer's. The incident was observed by a receptionist who reported it a day later to the Admissions Director. The Administrator and DON were informed two days after the incident, and the self-reported incident was initiated on the same day, contrary to the facility's policy requiring immediate reporting and investigation.
A resident with a chronic indwelling suprapubic catheter did not receive appropriate catheter care, as the facility failed to document necessary catheter flushes and did not secure the catheter tubing properly. The resident reported that the catheter was not flushed despite a physician's order, leading to sediment buildup and leakage. Observation revealed the catheter insertion site was uncovered and not properly anchored, with thick mucus-like drainage and sediment in the tubing.
A resident with intact cognition was exploited by a kitchen aide who engaged in an inappropriate relationship, exchanging flirtatious texts and nude pictures, and soliciting money for sexual activity. The incident was reported after the aide claimed the resident assaulted her, leading to an investigation that confirmed the exploitation. The aide was fired for violating the facility's abuse policy.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive ordered wound care for newly identified open areas on the buttocks. Despite hospice orders for specific wound care, the facility's records lacked evidence of completion on two occasions. The resident's condition was later identified as Kennedy ulcers, and interviews confirmed the deficiency in documentation and care.
A resident with epilepsy and cognitive impairments did not return from a leave of absence as expected, and the facility failed to ensure her safety. The resident left without taking necessary medications, and staff did not follow procedures to sign her out or verify her whereabouts. Despite attempts to locate her, the resident was not found until she was hospitalized two days later.
Failure to Notify Legal Guardian of Resident Elopement Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal guardian of an elopement incident as required by facility policy. The resident, admitted with diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, had a daughter listed as his legal guardian. A discharge, return-anticipated MDS assessment indicated his memory was intact, he did not wander, and he required partial to moderate assistance for ambulation using a wheelchair. On the date of the incident, a progress note by an RN documented that the resident pushed on an exit door, triggering the alarm, and was found on his right side on the ground with his wheelchair beside him after an unwitnessed fall. A head-to-toe and neurological assessment were completed, vital signs were obtained, and the resident was assisted back into his wheelchair and brought to the nursing station for closer monitoring. A facility investigation documented that the resident had exited through an emergency exit door off a hall under construction and not occupied, had been outside less than five minutes, and had last been seen at the nurses’ station five minutes prior. The investigation noted that the alarm and egress doors functioned properly and staff responded immediately, finding the resident on the ground outside. However, the resident’s medical record did not contain evidence that the legal guardian was notified of the elopement. During a telephone interview, the guardian stated she had only been notified of the fall and was not aware the resident had gotten outside until speaking with the surveyor. The DON reported that an incident report in risk documentation (not part of the medical record) showed the family had been notified of an incident and transfer to the hospital, but it was unclear whether this referred to the elopement or the fall. The facility’s policy required nursing staff to notify the resident’s representative when the resident was involved in any accident or incident resulting in injury or a significant change in condition, and this notification specific to the elopement was not documented.
Failure to Timely Care Plan for Resident Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, measurable care plan addressing elopement risk for a resident identified as being at risk for wandering and elopement. The resident was admitted with multiple diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, and had a legal guardian. An initial wander-risk evaluation in late 2025 identified the resident as low risk for wandering, and an annual MDS assessment documented that the resident was cognitively intact, did not wander, and required partial to moderate assistance with ambulation using a wheelchair. A subsequent wander-risk evaluation in early 2026, completed by an LPN, showed the resident had progressed to a moderate risk for wandering, but the section of the form asking what interventions would be care planned was left blank. A discharge, return-anticipated MDS again documented that the resident did not wander and required partial to moderate assistance with ambulation. A later wander-risk evaluation in mid-February 2026, completed by an MDS/RN, identified the resident as high risk for wandering, and again the section for care plan interventions was left blank. On the same date, a progress note documented that the resident pushed on an exit door, activated the door alarm, and was found on his right side outside the emergency exit door with his wheelchair beside him after an unwitnessed fall; he was assessed and brought back to the nursing station for closer monitoring. A facility investigation confirmed that the resident had exited through an emergency exit door on a hall under construction and had been outside for less than five minutes, with alarms and egress doors functioning and staff responding immediately. Interviews with the LPN and MDS/RN revealed that nurses completed wander-risk assessments and the MDS/RN handled care planning, that the LPN had never completed the care plan intervention section of the wander-risk tool, and that the MDS/RN did not initiate an elopement risk care plan when the resident’s risk level increased from low to moderate because the IDT believed the resident was not an elopement risk. The Administrator and DON confirmed that a care plan should have been initiated when the resident began self-propelling around the facility and that this was not done until after the elopement event, despite facility policy stating that assessments are ongoing and care plans are revised as resident conditions change.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for its residents, as evidenced by multiple observations, interviews, and record reviews. Several residents reported that their rooms and common areas were not cleaned daily, and that furniture was worn and damaged, with chipped wood and food debris present. Observations confirmed that hallways and resident rooms had a buildup of dirt, yellowed wax, stains, dried liquids, scuffed and dull floors, cracked or missing tiles, and holes in the walls. Specific rooms were noted to have significant grime, sticky and dirty floors, and furniture in poor condition. The main lobby and handrails were also found to be in disrepair, with chipped paint and worn surfaces. Interviews with facility staff, including the Regional Director of Operations, the Administrator, an LPN, and the Housekeeping Manager, confirmed that the facility had been aware of these environmental concerns for several months but had not addressed them in a timely manner. The Housekeeping Manager revealed that improper floor maintenance practices, such as applying multiple layers of wax without proper stripping, had led to significant dirt and grime buildup. Staff agreed that the facility was in need of deep cleaning, floor stripping, and repairs to maintain a sanitary environment. A review of facility policies indicated that floors and environmental surfaces were to be cleaned and disinfected regularly, with specific procedures for cleaning, disinfection, and maintenance. However, these policies were not followed, as evidenced by the observed conditions and staff admissions. One resident with significant physical limitations and dependence on staff for all activities of daily living was found to have dirt and debris on the floor of their room, further highlighting the facility's failure to provide a clean and safe environment for vulnerable individuals.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of an in-house pressure ulcer for Resident #58, who was at risk due to conditions such as type II diabetes mellitus, schizophrenia, and secondary Parkinsonism. Despite having a care plan in place since 2018 that included interventions like turning and repositioning, pressure-reducing mattresses, and skin assessments, there was no documented evidence that these interventions were consistently implemented. The resident's medical record showed a lack of timely identification and treatment of a pressure ulcer that developed on the left buttock, which eventually became unstageable. The facility's records revealed inconsistencies in weekly skin assessments, with several instances where no skin issues were documented despite the presence of a pressure ulcer. The Braden Scale, which assesses the risk of pressure ulcer development, was not completed until after the ulcer was identified. Furthermore, there was a lack of documentation regarding the administration of pain medication and the specific treatments applied to the wound, indicating a failure in comprehensive care and record-keeping. Interviews with facility staff, including the Regional Director of Clinical Operations and the Wound Nurse/Assistant Director of Nursing, confirmed that weekly skin observations were not completed accurately. The facility did not conduct an investigation to determine how the abrasion deteriorated into an unstageable pressure ulcer without staff knowledge. This deficiency represents a significant lapse in the facility's responsibility to provide necessary treatment and services to prevent and manage pressure ulcers, as outlined in their policies.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control measures during medication administration, specifically regarding hand hygiene. An LPN was observed preparing and administering medications to three residents without performing hand hygiene before or after the process. This included not washing hands before entering residents' rooms, after administering medications, and after removing gloves used for administering eye drops. The residents involved had various medical conditions, including hemiplegia, diabetes, vascular dementia, hypertensive heart disease, chronic kidney disease, Alzheimer's disease, and dementia. The facility's policies on infection prevention and control, hand hygiene, and medication administration clearly outlined the requirement for handwashing before and after resident contact and glove use. However, these protocols were not followed by the LPN, as confirmed by interviews with the LPN and the Regional Director of Clinical Operations. This deficiency was identified during a complaint investigation and was a repeat finding from a previous complaint survey.
Failure to Individualize Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that care plans were individualized for a resident, specifically Resident #33, who was affected by this deficiency. The resident had a medical history that included paraplegia, neuromuscular dysfunction of the bladder, neurogenic bowel, a history of COVID-19, a colostomy, and cannabis dependence. Despite these complex medical needs, the care plan for Resident #33, dated 10/23/24, did not include a plan for a recent unstageable pressure ulcer acquired in-house on 12/05/24. This omission was confirmed during an interview with the Regional Director of Clinical Operations, who acknowledged the absence of a care plan for the pressure ulcer and the lack of updated interventions. The facility's policy, revised in December 2016, requires comprehensive, person-centered care plans that include identified problem areas, measurable objectives, and timeframes, which were not adhered to in this case.
Failure to Conduct Weekly Skin Observations
Penalty
Summary
The facility failed to ensure that weekly skin observations were accurately completed as ordered for two residents, Resident #33 and Resident #72. Resident #33, who had a history of paraplegia and other medical conditions, had orders for wound care on a Stage 3 pressure ulcer on the right lateral ankle and a deep tissue injury on the right heel. However, the care plan did not include these pressure ulcers, and there were no interventions or revisions noted for them. Weekly skin observations were not consistently documented, with missing entries and lack of measurements for the pressure ulcers. Interviews with the Regional Director of Clinical Operations and the Wound Nurse confirmed these deficiencies. Resident #72, who had diagnoses including acute duodenal ulcer and morbid obesity, was at moderate risk for skin breakdown. Despite this, only one weekly skin assessment was completed during her stay, which did not identify any skin issues. The facility's policy required weekly skin audits for all residents, but this was not adhered to for Resident #72, as confirmed by interviews with facility staff. The lack of consistent weekly skin observations for both residents represents a failure to comply with the facility's policy and physician orders. The deficiency was identified during a survey, and it was noted that the facility's policy on Pressure Ulcer/Injury Care and Management, revised in August 2022, required weekly skin audits for all residents. The failure to conduct these audits as required led to the non-compliance finding, which was investigated under a specific complaint number. The report highlights the facility's inability to maintain accurate and timely documentation of skin observations, which is crucial for the management and treatment of pressure ulcers and other skin conditions.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to ensure that staff adhered to enhanced barrier precautions during catheter care for a resident. The resident, who was admitted with paraplegia and neuromuscular dysfunction of the bladder, had physician's orders for catheter care every shift and enhanced barrier precautions. During an observation of catheter care, an LPN provided care to the resident without donning a gown, despite a sign on the door indicating that gloves and a gown were required for such procedures. The facility's policy on enhanced barrier precautions, updated in March, specifies that personal protective equipment, including gloves and a gown, must be used when performing care such as hygiene, changing briefs, assisting with toileting, and urinary catheter care. The LPN acknowledged not wearing a gown as instructed by the sign, which was a requirement under the enhanced barrier precautions. This deficiency was identified during an investigation under Complaint Number OH00161853.
Failure to Ensure Dignified Treatment of Residents
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, affecting three residents. Resident #31, who had developmental disorder, bladder dysfunction, and Parkinson's, required maximum assistance with personal care and had a urinary catheter. Observations revealed that Resident #31's urinary drainage bag was visible from the doorway without a privacy cover, contrary to physician orders. CNA #317 confirmed the lack of privacy bags and was unaware of their availability in the facility. Similarly, Resident #68, diagnosed with dementia and requiring assistance with personal care, also had a urinary catheter. Observations showed that Resident #68's urinary drainage bag was visible without a privacy cover, and CNA #317 confirmed the absence of privacy bags. Additionally, Resident #70, who had a stroke, aphasia, and dementia, was observed being treated rudely by CNA #313, who blocked the resident's wheelchair and spoke in an intimidating manner. CNA #313 admitted to being instructed to prevent Resident #70 from entering his room but was unsure if the situation had been explained to the resident.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their responsible parties were included in the development and implementation of the plan of care, affecting one resident out of three reviewed for care planning. The resident in question, who had intact cognition, was admitted with diagnoses including paraplegia and bladder dysfunction. Despite multiple attempts by the resident's Power of Attorney (POA) to arrange a care planning conference, no such conference was scheduled or documented in the resident's medical records. Interviews with the Social Services Designee (SSD) revealed that care planning conferences were supposed to occur upon admission and quarterly thereafter, with documentation in the resident's electronic medical records. However, there was no documented evidence of a care planning conference for the resident, and the SSD could not recall specific details of any discussions with the POA. The facility's policy required that a comprehensive, person-centered care plan be developed with the involvement of the resident and their family or legal representative, and any impracticality in involving them should be documented, which was not done in this case.
Failure to Address Resident Grievances Timely
Penalty
Summary
The facility failed to address grievances in a timely manner, affecting two residents. Resident #11, who has paraplegia and bladder dysfunction, had a chronic indwelling suprapubic catheter upon admission. Despite physician orders to flush the catheter with normal saline as needed, there were no documented flushes in December 2024 and January 2025. Resident #11 expressed concerns about his catheter to the nursing staff, but was unaware of who the Director of Nursing (DON) was. His Power of Attorney (POA) attempted to contact the DON multiple times regarding the catheter leaking issue, but received no response. The DON and Administrator later acknowledged the concerns but had not addressed them promptly. Resident #67, who has a right below-knee amputation and vision loss, reported being left in the bathroom for an extended period. A Licensed Practical Nurse (LPN) informed the DON about the incident via text, but the DON claimed to be unaware of the issue. The facility's grievance log showed no entries for December 2024 or January 2025, indicating a failure to document and address grievances as per the facility's policy. The policy requires grievances to be logged and addressed within 72 hours, but this was not adhered to in these cases.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident verbal abuse to the State Agency as required. This incident involved a resident with Alzheimer's and impaired cognition, who required maximum assistance with daily tasks. The incident occurred when a receptionist observed a CNA yelling at the resident near the nurse's station. The receptionist, unsure of the proper procedure, reported the incident the following day to the Admissions Director. The Administrator and Director of Nursing were informed two days after the incident, and the self-reported incident was initiated on the same day, which was not in compliance with the facility's policy. The facility's policy mandates that any supervisor who receives information about potential abuse must notify the Administrator or Director of Nursing immediately and begin an investigation within 24 hours. However, in this case, the report to the State Agency was delayed, as the incident was not reported until two days after it occurred. This deficiency was identified during an investigation of a master complaint and another complaint, highlighting a lapse in the facility's adherence to its abuse reporting policy.
Inadequate Urinary Catheter Care for Resident
Penalty
Summary
The facility failed to ensure appropriate urinary catheter care for Resident #11, who had a chronic indwelling suprapubic catheter. The resident, diagnosed with paraplegia and bladder dysfunction, was dependent on staff for toileting and required maximum assistance with personal hygiene tasks. Despite having a physician's order to flush the urinary catheter with 60 mL of normal saline every 24 hours as needed for possible blockages, there was no documented evidence of catheter flushes in the Treatment Administration Record for December 2024 and January 2025. The resident reported that the evening shift nurse did not flush the catheter or perform any care of the catheter site, only emptying the urinary drainage bag. On observation, the resident's catheter insertion site was uncovered, with a soiled dressing hanging from the catheter tubing. Thick, white mucus-like drainage with a slight foul odor was noted around the insertion site, and large amounts of thick sediment were observed in the catheter tubing and collection bag. The catheter tubing was not properly anchored to the resident's leg, which was confirmed by LPN #237 during an interview. The LPN acknowledged the physician's order for catheter flushing and confirmed that the catheter should have been anchored to prevent movement. The facility's policy on urinary catheter care, revised in September 2014, emphasized the importance of securing the catheter to reduce friction and movement at the insertion site.
Exploitation of Resident by Employee
Penalty
Summary
The facility failed to prevent the exploitation of a resident by an employee, which was substantiated through a self-reported incident, police report, and interviews. The resident, who had intact cognition and was independent in certain activities, was involved in an inappropriate relationship with a kitchen aide. The resident had exchanged personal text messages with the aide, which included flirtatious content and requests for money via a cash app. The aide sent the resident nude pictures and suggested that for a sum of money, they could engage in sexual activity. The incident came to light when the kitchen aide reported that the resident had assaulted her with his wheelchair. Upon investigation, it was discovered that the resident had the aide's phone number and had received nude pictures from her. The resident admitted to giving the aide money and stated that they were planning to have sex after he moved to an assisted living facility. The facility's Director of Nursing (DON) was informed, and an investigation was initiated, which included contacting the police. The police report confirmed the resident's account of the events, including the exchange of money and the solicitation for sexual activity. The facility's policy on abuse, which prohibits taking advantage of residents for personal gain, was violated. The kitchen aide was subsequently fired, although she did not attend a scheduled meeting to discuss disciplinary action. The deficiency was investigated under a specific control number, indicating non-compliance with regulatory standards.
Failure to Complete Ordered Wound Care for Resident
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer wound care was completed as ordered, affecting one of the three residents reviewed for pressure ulcers. The resident, who was admitted with severe cognitive impairment and other medical conditions, was identified as high risk for developing pressure ulcers. Upon admission, the resident had bruising and later developed bilateral buttocks dermatitis. On a subsequent date, three open areas on the buttocks were observed by a nursing assistant and the resident's daughter, leading to new orders for wound care from hospice services. Despite these orders, the facility's records did not show evidence that the wound care was ordered or completed on two specific dates. The resident's condition was later documented as having Kennedy ulcers, with specific treatment instructions provided. Interviews with the DON and ADON confirmed the lack of documentation and completion of the ordered wound care. The facility's Wound Care Management policy was intended to ensure assessments and interventions for skin integrity, but this was not adhered to in this case.
Failure to Ensure Resident Safety During Leave of Absence
Penalty
Summary
The facility failed to ensure the safety of a resident who did not return from a leave of absence (LOA). The resident, who had a history of epilepsy, diabetes mellitus, and cognitive impairments, was allowed to leave the facility with the expectation of returning the same day. However, the resident did not return as planned, and there was no evidence that the resident had taken a supply of her medications during the LOA. The facility's policy required residents to be signed out when leaving the premises, but this procedure was not followed. The Director of Nursing (DON) and other staff members were aware of the resident's absence but did not take immediate action to locate the resident or ensure her safety. The DON was notified late in the evening when the resident did not return, but attempts to contact the resident's mother were unsuccessful. The following day, the DON and other staff members made efforts to locate the resident, including contacting the police for a welfare check. Despite these efforts, the resident was not found until she was transported to a hospital two days later, after being reported missing. Interviews with facility staff revealed a lack of communication and adherence to procedures regarding the resident's LOA. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) involved did not ensure the resident was signed out or verify her whereabouts. The facility's failure to follow its own policies and ensure the resident's safety during the LOA resulted in the resident being without necessary medications and medical supervision for an extended period.
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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