Aventura At West Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 2950 West Park Drive, Cincinnati, Ohio 45238
- CMS Provider Number
- 365603
- Inspections on file
- 25
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aventura At West Park during CMS and state inspections, most recent first.
A resident with severe protein-calorie malnutrition, dysphagia, COPD, and other comorbidities was care planned as being at risk for altered nutrition and hydration, and a physician ordered monitoring of meal intake. A nutritional assessment and dietary notes documented that the resident consumed 25–50% of three daily meals, and RDs reported that these conclusions were based on NA meal-tracking sheets. However, review of the record showed no NA documentation of meal intake for two consecutive months, and the DON confirmed the facility could not provide any such records, despite a facility policy requiring complete and accurate charting of resident care and responses.
The facility failed to secure medications in a locked storage area, affecting 12 mobile residents. An LPN retrieved medication from an unlocked storage room, which had been left unsecured since the removal of the electronic keypad lock. Observations confirmed the door was often left ajar, and an employee noted it was usually unlocked.
The facility failed to ensure timely signing of physician progress notes for three residents, with delays ranging from several days to weeks. The DON confirmed these delays during a complaint investigation.
A facility failed to ensure a resident was seen by a physician every 60 days, as required. The resident, with diagnoses including stage 3 chronic kidney disease and rheumatoid arthritis, had not been seen since December 2024. This was confirmed by both the physician and the DON during interviews, highlighting a deficiency in compliance with required physician visit schedules.
A resident with Alzheimer's and dementia experienced verbal abuse during a transfer by an STNA who used inappropriate language. The resident, who required assistance, became resistive, leading to the STNA's inappropriate response. The facility's investigation confirmed the verbal abuse, which violated the resident's rights.
A former Business Office Manager misappropriated funds from deceased residents' accounts by writing unauthorized checks to herself and others. The deficiency affected three residents, with checks being cashed improperly instead of following the correct procedures for account closure. The issue was discovered during a resident trust audit after concerns were raised by a receptionist.
The facility failed to provide written Admission Agreements to new residents upon admission, affecting four residents with various medical conditions. The Business Office Manager could not provide evidence of these agreements, and the Administrator confirmed their absence. This deficiency was investigated under a specific complaint number.
The facility failed to maintain clean and sanitary carpeting on the third floor, affecting all residents residing there. Observations noted multiple stains in the main corridors and sitting area. Interviews with staff confirmed the condition, and while the Administrator mentioned plans to replace the flooring, no specific timeline was provided.
The facility failed to ensure medications were available to administer as ordered, affecting a resident with multiple diagnoses. The resident did not receive Morphine Sulfate as prescribed due to unavailability, and the medication was documented as given when it was not available. The DON confirmed the discrepancy, and the facility's policy on timely medication administration was not followed.
A resident with multiple diagnoses, including unspecified neoplasm of digestive organ and chronic ulcerative pancreatitis, was given double the prescribed dose of Morphine Sulfate over several days. The error was confirmed by an LPN and was due to the facility not following its medication administration policy.
A resident with a complex medical history, including severe cognitive impairment, was found unresponsive and without vital signs. Despite being designated as a full code in the physician orders and care plan, staff did not initiate CPR. Interviews with RNs, LPNs, and a PA confirmed awareness of the resident's full code status but revealed that CPR was not performed. This incident highlighted a critical gap in the facility's emergency response protocols, resulting in the resident being pronounced dead.
The facility failed to ensure all food temperatures were checked prior to meal service, with a dietary cook only checking one item and assuming the rest were hot. The chicken was initially below the required temperature and was reheated, but no other food temperatures were taken or logged.
The facility failed to maintain kitchen equipment in a sanitary manner and ensure staff wore appropriate hair restraints while preparing food. The kitchen hood was overdue for cleaning, and multiple staff members were observed preparing food without proper facial hair restraints, contrary to facility policy.
The facility failed to implement its Legionella Water Management Program by not completing water temperature checks for the entire year of 2023, as confirmed by records and the Maintenance Director. This lapse had the potential to affect all 78 residents.
The facility failed to conduct required care conferences for four residents, including those with severe cognitive impairments and multiple health conditions. The Social Services Director and residents or their representatives confirmed the lapses, which violated the facility's policy for quarterly care plan meetings.
The facility failed to properly prepare pureed food, affecting five residents on a pureed diet. A dietary cook used an incorrect ratio of water to vegetables, resulting in a runny mixture. The cook confirmed he made the food watery to prevent choking, but a dietetic technician stated this compromised the food's nutritive value. The facility's recipe specified a lower amount of water for a mashed potato consistency, which was not followed.
A resident with multiple health conditions alleged that two STNAs ignored her requests to stop lifting her, causing her to pass out from pain and fall. Despite the facility's policy requiring immediate suspension of accused staff, the STNAs continued to work for several hours after the incident was reported.
The facility failed to properly transfer a resident using an appropriate assistive lift device, leading to the resident sliding out of a sit-to-stand lift and landing on the floor. Despite recommendations for a Hoyer lift, staff continued to use the incorrect device, violating the facility's policy on safe lifting procedures.
The facility failed to implement nutritional recommendations for a resident with weight loss. Despite a dietitian's recommendation to increase the house supplement to twice daily, the physician's orders were not updated, resulting in the resident not receiving the necessary nutritional support. The resident's weight showed a significant downward trend, and the Director of Nursing confirmed the oversight.
The facility failed to implement physician orders following pharmacy recommendations for three residents. Delays and failures in discontinuing or adjusting medications as recommended by the pharmacist were confirmed by the DON and ADON, contrary to the facility's Medication Therapy policy.
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate during a medication administration observation. An LPN omitted two prescribed medications for a resident but signed them off as administered. The LPN admitted to being nervous and unfamiliar with the residents, contributing to the error.
The facility failed to ensure that insulin pens were properly labeled and stored, affecting two residents. Insulin pens for two residents were found opened without an open date, contrary to the facility's medication administration policy. This was confirmed by an LPN and observed during a review of the medication cart.
The facility failed to provide timely pneumococcal vaccinations to three residents. One resident did not receive the required follow-up vaccine after PPSV23, another resident also missed the follow-up vaccine, and a third resident was not offered the vaccine at all since admission. The ADON confirmed these deficiencies, which were against the facility's policy.
Failure to Accurately Document Nutritional Intake for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete documentation of a resident’s meal intake in accordance with professional standards and its own documentation policy. A resident admitted with metabolic encephalopathy, kidney calculi, severe protein-calorie malnutrition, bipolar disorder, oropharyngeal dysphagia, and COPD had a care plan identifying risk for altered nutrition and hydration due to severe malnutrition, altered mental status, dysphagia, low BMI, and recent significant weight loss. An MDS assessment documented the resident as cognitively intact, and a nutritional assessment by an RD indicated the resident was consuming 25–50% of three daily meals. A physician’s order directed staff to monitor the resident’s meal intake. Despite this order and the resident’s identified nutritional risks, review of NA tracking sheets for November and December showed no recorded meal intake for the resident. Dietary progress notes and the RD’s nutritional assessment, which both stated the resident consumed 25–50% of three daily meals, were confirmed by the RDs to have been based on these NA tracking sheets, even though the facility could not produce any such documentation. The DON confirmed the facility was unable to provide documentation of meal intake tracking for the resident for those two months. The facility’s policy on documentation stated that charting should provide a complete account of care, treatment, responses, signs and symptoms, guidance for prescribers, a tool for measuring quality of care and developing care plans, and serve as a legal record, underscoring the discrepancy between policy and practice in this case.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to secure all medications in a locked storage area and to limit access to authorized personnel, which had the potential to affect 12 independently mobile residents on the 400 floor. During an observation of medication administration, an LPN was seen retrieving medication from an unlocked medication storage room on level 4. The LPN confirmed that the room had not been locked since the electronic keypad lock was removed. Further observation revealed that the door to the medication storage room was ajar, and an employee restocking a wound supplies cart mentioned that the door was usually left unlocked. This deficiency was confirmed through interviews and observations, indicating a lapse in securing medications properly.
Physician Note Signing Delays
Penalty
Summary
The facility failed to ensure that physicians signed progress notes at the time of service for three residents. Resident #51, who had multiple diagnoses including emphysema and dementia, had a physician visit on 01/27/25, but the progress note was not signed until 02/09/25. The physician claimed to sign notes immediately after completion, but this was contradicted by the Director of Nursing (DON) who confirmed the delay. Similarly, Resident #52, with diagnoses such as chronic kidney disease and rheumatoid arthritis, had two physician visits on 09/10/24 and 10/07/24, with both progress notes signed only on 10/19/24. Resident #60, diagnosed with conditions including pulmonary embolism and chronic pain syndrome, had a physician visit on 10/21/24, with the note signed on 11/16/24. The DON verified these delays, which were discovered during a complaint investigation.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at least every 60 days, as required. This deficiency was identified during a review of the medical records, physician interviews, and staff interviews, specifically affecting one resident out of three reviewed for physician visits. The resident in question, who was admitted with diagnoses including stage 3 chronic kidney disease, depression, and rheumatoid arthritis, had intact cognition and required varying levels of assistance for daily activities. The last documented physician visit for this resident was on December 23, 2024, which was confirmed by both the physician and the Director of Nursing during interviews conducted on March 27, 2025. This oversight was part of a complaint investigation under Complaint Number OH00162751.
Verbal Abuse Incident During Resident Transfer
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, specifically affecting one resident who had a history of Alzheimer's disease, anxiety disorder, dementia with behavioral disturbance, and other medical conditions. The resident, who had severely impaired cognition, was involved in an incident where a State Tested Nursing Assistant (STNA) was verbally inappropriate during a transfer. The resident, who required assistance with transfers, experienced a behavioral episode and became resistive to care, leading to a situation where the STNA attempted to move the resident without proper assistance. During the incident, the STNA was reported to have used inappropriate language, telling the resident to "get your ass up" after the resident had gone limp and was lowered to the ground. The facility's investigation, which included reviewing video footage provided by the resident's family, confirmed that the STNA's actions constituted verbal abuse. The STNA admitted to making the inappropriate comment, which was against the facility's policy on resident rights to freedom from abuse. The facility's policy clearly states that residents have the right to be free from abuse, including verbally aggressive behavior. The investigation revealed that the STNA did not follow the proper protocol by attempting to assist the resident without notifying a nurse, and the language used was deemed unacceptable. The incident was reported to the police, and the facility took immediate action to address the situation.
Misappropriation of Deceased Residents' Funds by Former BOM
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money, specifically involving the misappropriation of funds from deceased residents' accounts. This deficiency affected three residents who had passed away in the facility. The former Business Office Manager (BOM) was found to have written checks to herself and others from the accounts of these deceased residents, which was discovered during a resident trust audit initiated by the facility. Resident #21, who was cognitively intact, had a check written from their account for $567.49 by the former BOM, which was then cashed. Similarly, Resident #22, who had mild to moderate cognitive deficits, had a check for $1,548.58 made out to a receptionist, allegedly to be handed over to the resident's daughter, which never occurred. Resident #23, with moderate to severe cognitive deficits, had a check for $300 made out to petty cash by the former BOM. These actions were unauthorized and against the facility's policy for handling deceased residents' accounts. The misappropriation was brought to light when a receptionist raised concerns about the accuracy of the resident trust accounts. The facility's Administrator conducted a comprehensive investigation, which confirmed the illegal activities of the former BOM. The investigation revealed that the former BOM had not followed the proper procedures for closing accounts, which should have involved sending funds to the funeral home or the Attorney General's Office, rather than cashing checks for personal use.
Failure to Provide Admission Agreements to New Residents
Penalty
Summary
The facility failed to provide written Admission Agreements to new residents at the time of their admission, affecting four out of five residents reviewed for admission procedures. This deficiency was identified through a review of medical records and staff interviews. The residents involved had various medical conditions, including diabetes mellitus type II, lumbar disc degeneration, congestive heart failure, acute myocardial infarction, adult failure to thrive, non-pressure chronic ulcer, morbid obesity, acute kidney failure, depression, acute osteomyelitis, partial traumatic amputation, polyneuropathy, bilateral osteoarthritis, and edema. Despite these conditions, the facility did not have evidence of providing the necessary Admission Agreements to these residents. The Business Office Manager was unable to provide the requested evidence of written Admission Agreements for the residents in question. Subsequent interviews with the Administrator confirmed that the facility had no evidence of signed Admission Agreements for the affected residents. This deficiency was investigated under Complaint Number OH00154443, highlighting a lapse in the facility's admission procedures and documentation practices.
Carpeting Maintenance Deficiency on Third Floor
Penalty
Summary
The facility failed to maintain the carpeting on the third floor in a clean and sanitary manner, affecting all 10 residents residing on that floor. Observations revealed multiple stains throughout the main corridors and sitting area. Interviews with the Maintenance Aid and the Administrator confirmed the stained condition of the carpeting. Although the Administrator indicated that steps were being taken to replace the flooring, no specific timeline for completion was provided. This deficiency was investigated under Master Complaint Number OH00155422 and Complaint Number OH00154443.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were available to administer as ordered, affecting one resident. Resident #80, who had multiple diagnoses including unspecified neoplasm of the digestive organ, essential hypertension, and chronic ulcerative pancreatitis, was admitted to the facility and later expired there. The resident had physician orders for Morphine Sulfate to be administered for pain and shortness of breath, which were not consistently followed due to the unavailability of the medication. The Medication Reconciliation Sheet and Medication Administration Record (MAR) revealed discrepancies in the administration of Morphine Sulfate, with doses documented as given even when the medication was not available. The Director of Nursing (DON) confirmed that the resident did not receive the Morphine Sulfate as ordered from a specific time period, and the medication was documented as administered when it was not available. The facility's policy on administering medications stated that medications should be administered as prescribed in a safe and timely manner, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00154174.
Significant Medication Error: Double Dose of Morphine Administered
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when they administered double the dose of Morphine to a resident. Resident #80, who had multiple diagnoses including unspecified neoplasm of digestive organ, essential hypertension, and chronic ulcerative pancreatitis, was admitted to the facility and later expired there. The resident was receiving Hospice services and had a physician's order for Morphine Sulfate 20 mg per 5 ml solution, to be given 0.5 ml (2 mg) every hour for pain or shortness of breath. However, the facility administered multiple 0.5 ml (10 mg) doses of Morphine Sulfate 100 mg/5 ml from [DATE] to [DATE], which was double the prescribed dose. The error was confirmed during an interview with an LPN who verified that the resident had been given the incorrect dosage. The facility's policy on administering medications, which requires the person administering medications to check three times to ensure the correct medication and dose, was not followed. This deficiency was identified during a complaint investigation and represents noncompliance under Complaint Number OH00154174.
Failure to Administer CPR to Full Code Resident
Penalty
Summary
The facility failed to ensure that CPR was provided to a resident, identified as Resident #76, who was a full code and found unresponsive and without vital signs on a specific date and time. Despite the resident being designated as a full code, staff members did not immediately initiate CPR upon discovering the resident's condition. The failure to provide CPR to Resident #76, who was in need of immediate life-saving intervention, resulted in the resident being pronounced dead. This incident led to an Immediate Jeopardy situation, posing a serious risk of harm or death to the resident due to the lack of timely CPR administration. Review of the medical records and documentation revealed that Resident #76 had a complex medical history, including diagnoses such as left hip fracture, essential hypertension, paralytic ileus, pancytopenia, and various other conditions. The resident was noted to have severe cognitive impairment as per the comprehensive Minimum Data Set (MDS) assessment. Despite being identified as a full code in the physician orders and care plan, CPR was not promptly initiated when the resident was found unresponsive and without vital signs. The facility's failure to adhere to established protocols for residents designated as full code directly contributed to the deficiency in providing timely life-saving measures to Resident #76. Interviews with staff members, including RNs, LPNs, and the Physician Assistant (PA), confirmed that CPR was not initiated for Resident #76 despite the resident's full code status. Staff members acknowledged that they were aware of the resident's code status but did not take immediate action to perform CPR. The lack of timely response and failure to initiate CPR for a resident in need of such intervention highlighted a critical gap in the facility's emergency response protocols. The deficiency in providing CPR to Resident #76, as required by the facility's policies and guidelines, resulted in a serious incident that required immediate corrective actions to address the identified Immediate Jeopardy situation.
Failure to Check Food Temperatures Prior to Meal Service
Penalty
Summary
The facility failed to ensure all food temperatures were checked prior to the start of meal service, potentially affecting all 78 residents. During an interview, a dietary cook confirmed that he only checked the temperature of one food item on the steam table at the beginning of each meal, assuming that if one item was hot, the rest would be as well. On the observed date, the cook tested the temperature of the chicken, which initially read 140 degrees Fahrenheit, below the required 165 degrees Fahrenheit. The chicken was then reheated and rechecked, reaching 179 degrees Fahrenheit, but no other food temperatures were taken or logged for that meal. A review of the food temperature log revealed that only the temperature of the chicken was documented for the observed date, with no other entries made since a previous date. The facility's policy mandates that all hot food items must be held and served at a temperature of at least 135 degrees Fahrenheit, and temperatures should be taken often to ensure safe food holding temperatures. An interview with a registered dietetic technician confirmed that the temperature of all foods should be checked prior to meal service.
Failure to Maintain Sanitary Kitchen Conditions and Proper Hair Restraints
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary manner and ensure staff wore appropriate hair restraints while preparing food. During an observation, the hood in the kitchen, which covered the fryer, stove, grill, and steamers, was found to be covered with a black and grey fuzzy substance. The last cleaning of the hood was recorded in June 2023, which was confirmed by the Food Service Manager to be past due. The facility policy indicated that stove hoods and filters should be cleaned at least monthly and professionally cleaned at least yearly, which was not adhered to in this instance. Additionally, multiple staff members were observed preparing food without proper hair restraints. Dietary Cook #430 and Dietary Cook #445 were both seen with uncovered facial hair while preparing food. Even after bringing facial hair covers into the kitchen, DC #445 did not fully contain his facial hair. Dietary Aide #338 was also observed assisting with meal service and food preparation without any facial hair restraint. The facility policy required all employees to wear hair restraints to prevent hair from contacting exposed food, which was not followed by the staff members involved.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to properly implement its Legionella Water Management Program, which had the potential to affect all 78 residents. Specifically, the facility did not complete water temperature checks for the entire year of 2023, a key control measure for monitoring Legionella. This was confirmed through a review of the facility's water management records and temperature logs, which showed that water temperatures were only recorded from January 2024 through March 2024. An interview with the Maintenance Director confirmed the lapse in monitoring. The facility's policy, dated July 2017, emphasized the importance of taking water temperatures to prevent, detect, and control water-borne contaminants, including Legionella.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct care conferences as required, affecting four residents. Resident #16, admitted with multiple diagnoses including necrotizing fasciitis and type two diabetes mellitus, had only one documented care conference on 10/27/23. The Social Services Director confirmed no further care conferences were held for this resident. Resident #23, with severe cognitive impairment and multiple diagnoses including congestive heart failure and Alzheimer's disease, had a care conference on 08/14/23, but no further conferences were documented. The Social Services Director confirmed this lapse in care planning. Resident #19, with severe cognitive impairment and other significant health issues, did not have care conferences for the second and third quarters of 2023 or the first quarter of 2024, despite being continuously in the facility. The resident's representative confirmed this deficiency. Resident #41, with intact cognition and multiple health conditions, did not have a care conference in the first quarter of 2024. Both the resident and the Social Services Director confirmed this lapse. The facility's policy requires quarterly care plan meetings, which were not adhered to in these cases.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to properly prepare pureed food, affecting five residents on a pureed diet. During an observation, a dietary cook was seen using an incorrect ratio of water to vegetables, resulting in a runny and liquified mixture. The cook confirmed that he intentionally made the food watery to prevent choking. However, a registered dietetic technician later confirmed that this ratio was excessive and compromised the nutritive value of the food. The facility's recipe for pureed vegetables specified a much lower amount of water to achieve a mashed potato consistency, which was not followed.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to ensure residents were protected during abuse investigations, affecting one resident. Resident #14, who had diagnoses including acute and respiratory failure, CHF, bipolar disorder, chronic kidney disease stage three, and type two diabetes mellitus, alleged that on 03/11/24, two STNAs raised her too high in a stand lift despite her requests to stop, causing her to pass out from pain and fall to the ground. The incident was reported to an RN, who assessed the resident and found no injuries besides shoulder pain. The STNAs were supposed to be suspended immediately during the investigation, as per facility policy. However, the daily staffing sheet and time clock records revealed that the STNAs continued to work for several hours after the Self-Reported Incident (SRI) was initiated. The Administrator confirmed that the STNAs were not suspended immediately, allowing them to work until late in the afternoon on the day the SRI was initiated. This failure to suspend the accused staff members immediately during the investigation was a direct violation of the facility's abuse policy, which mandates immediate suspension of employees accused of resident abuse.
Improper Use of Assistive Lift Device for Resident Transfer
Penalty
Summary
The facility failed to properly transfer Resident #14 using an appropriate assistive lift device, which led to the resident sliding out of a sit-to-stand lift and landing on the floor. Resident #14, who had diagnoses including acute and respiratory failure with hypercapnia, congestive heart failure, bipolar disorder, chronic kidney disease stage three, and type two diabetes mellitus, was assessed to require a Hoyer lift for transfers. Despite this, staff used a sit-to-stand lift, contrary to the care plan and physical therapy recommendations, resulting in the fall incident on 03/11/24. The resident was assessed for injuries and none were found, and the resident was subsequently transferred to bed using a Hoyer lift. The interdisciplinary team later confirmed the need for a Hoyer lift for all transfers to prevent further falls. Observation on 04/04/24 revealed that staff continued to use the sit-to-stand lift for transferring Resident #14, despite the established requirement for a Hoyer lift. Interviews with staff and review of the facility policy confirmed that the correct procedure was not followed. The facility policy on using mechanical lifts emphasized assessing the resident's condition to determine the appropriate transfer method, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00152118.
Failure to Implement Nutritional Recommendations for Resident with Weight Loss
Penalty
Summary
The facility failed to implement nutritional recommendations made by the licensed dietitian for a resident with weight loss. Resident #11, who had multiple diagnoses including polyneuropathy, cellulitis, anxiety, depression, dementia, cervical disc degeneration, and peripheral vascular disease, was identified as being at risk for malnutrition. The resident's care plan included interventions such as administering medications, honoring food preferences, offering substitutes, and providing supplements as ordered. Despite a recommendation from the dietitian to increase the house supplement to twice daily due to significant weight loss, the physician's orders were not updated to reflect this change. The resident's weight records showed a downward trend, with weights recorded as 122 pounds, 117 pounds, 113 pounds, 109 pounds, and 113 pounds over a span of several months. The Director of Nursing confirmed that the order for the increased supplement had not been implemented as recommended by the dietitian. The facility's policy on Weight Assessment and Intervention, dated August 2023, stated that staff would implement interventions for undesirable weight loss based on resident choices, preferences, and nutritional needs. However, the failure to update the physician's orders to reflect the dietitian's recommendation resulted in the resident not receiving the necessary nutritional support. This deficiency was identified through medical record review, staff interviews, and policy review, highlighting a lapse in the facility's adherence to its own policies and the dietitian's recommendations for managing the resident's nutritional needs.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to implement physician orders following pharmacy recommendations for three residents. For Resident #5, the pharmacist recommended discontinuing Seroquel 25 mg, which the physician agreed to on 07/17/23. However, the medication was not discontinued until 11/03/23. Resident #23 had a recommendation to increase lisinopril to 30 mg daily, agreed upon by the physician on 07/17/23, but the order was not implemented until 10/03/23. Additionally, a recommendation to increase Novolog insulin to six units three times daily was agreed upon on 02/13/24, but the order was never implemented. Resident #16 had a recommendation to start Insulin Lispro at two units daily, agreed upon by the nurse practitioner on 02/23/24, but the order was never implemented. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the delays and failures in implementing these pharmacy recommendations. The facility's policy on Medication Therapy, revised in April 2007, states that the facility and practitioner, with the assistance of the Consultant Pharmacist, should review a resident's medication regimen periodically to ensure appropriate use, dosage, and administration. The facility did not adhere to this policy, resulting in the deficiencies noted in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below five percent during a medication administration observation, resulting in an eight percent error rate. This deficiency affected one resident, who had diagnoses including diabetes, atrial fibrillation, insomnia, hypertension, and Asperger's syndrome. The resident required staff assistance with activities of daily living and had physician orders for pantoprazole and Flonase to be administered each morning. However, during an observation, the LPN administering the medications omitted these two medications but signed them off in the electronic medical record as administered. The LPN admitted to being nervous and unfamiliar with the residents on that hall, which contributed to the error. The Regional Director of Clinical Operations confirmed the medication error rate was eight percent for the observed medication administration. The facility's policy on administering medications, dated August 2022, stated that medications should be administered in a safe and timely manner, as prescribed, which was not adhered to in this instance.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
The facility failed to ensure that insulin pens were properly labeled and stored, affecting two residents. Resident #23, who has diagnoses including congestive heart failure, type two diabetes mellitus, and acute kidney failure, had a Lantus insulin pen that was opened without an open date. Similarly, Resident #55, who has diagnoses including type one diabetes mellitus, atrial fibrillation, and Asperger's syndrome, had both Humalog and Lantus insulin pens that were opened without an open date. These deficiencies were observed during a review of the medication cart on the 700 hall and confirmed by an LPN who acknowledged that insulin pens should be dated upon opening to ensure proper discard timing. The facility's policy titled 'Administering Medications' dated August 2022, mandates that medications be administered safely and timely, as prescribed, and that the expiration or beyond use date on the medication label be checked prior to administration. The policy also requires that the date of opening be recorded on multi-dose containers. The failure to adhere to this policy was confirmed through staff interviews and observations, highlighting a lapse in the facility's medication management practices.
Failure to Provide Timely Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide the pneumococcal vaccine in a timely manner to three residents. Resident #10, who was admitted with diagnoses including type two diabetes mellitus, generalized anxiety, depression, and chronic kidney disease stage three, received the PPSV23 vaccine on 02/01/13 but did not receive the subsequent PCV15 or PCV20 vaccine at least one year later as required. Similarly, Resident #11, admitted with generalized anxiety disorder, major depressive disorder, and dementia, received the PPSV23 vaccine on 07/01/18 but was not given the PCV15 or PCV20 vaccine at least one year later. Resident #21, admitted with hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, and depression, was not offered the pneumococcal vaccine at all since admission to the facility. The Assistant Director of Nursing confirmed that these residents were not up to date on their pneumococcal vaccines. The facility's policy, dated November 2023, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections and assessed for eligibility prior to or upon admission. The policy also indicated that the vaccine series should be offered within thirty days of admission unless medically contraindicated or if the resident had already been vaccinated. However, the facility did not adhere to this policy for the three residents mentioned.
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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