Avenue At Broadview Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Broadview Heights, Ohio.
- Location
- 1201 Akins Road, Broadview Heights, Ohio 44147
- CMS Provider Number
- 366471
- Inspections on file
- 29
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Avenue At Broadview Heights during CMS and state inspections, most recent first.
Surveyors found that a resident with diabetes, urologic issues, and skin‑breakdown risk reported hematuria, had a UA and culture ordered, but then received no documented monitoring of VS, temperature, mental status, or urinary status for several days, despite care plan and policy requirements. During this period, the resident’s urine culture later grew ESBL Proteus mirabilis, and an antibiotic was ordered to which the organism was resistant. The same resident, care planned for weekly skin checks and wound documentation, had undocumented or incompletely documented skin issues, and was later admitted to the hospital with sepsis, hypothermia, hypotension, altered mental status, and multiple wounds (including an unstageable buttock pressure injury and bilateral foot ulcers) that were present on admission but not reflected in recent facility assessments or the transfer form. In a separate case, another resident with newly identified type 2 DM refused metformin and had a Libre CGM ordered to allow ac TID glucose checks, yet the record over several months showed no blood glucose monitoring completed and repeated MAR entries indicating the Libre order was not carried out, while the resident reported receiving no diabetes education and no BG checks.
A cognitively intact resident with mobility limitations and multiple medical conditions had a care plan and posted schedule indicating showers on specific evenings and as requested, with sponge baths only when a full bath or shower could not be tolerated. Review of shower sheets, aide charting, and progress notes over a one‑month period showed missing documentation on some scheduled days and no evidence the resident received a shower or bed bath on those dates, nor that the resident refused showers or requested bed baths instead. During observation, the resident reported not having a shower for three weeks and only receiving bed baths, while an LPN and a CNA stated the resident was scheduled for evening showers on shifts they did not work and suggested staffing limitations related to the need for a mechanical lift and two‑person assist as a possible reason showers were not provided. This occurred despite facility policy stating residents have the right to make their own schedule and participate in decisions affecting their care.
A resident with spastic quadriplegic cerebral palsy, quadriplegia, and adult failure to thrive, who was cognitively intact and fully dependent on staff for ADLs, was care planned to receive assisted oral care every shift. Observations and interviews showed the resident had significant yellowish-brown buildup and apparent tartar at the gum line on all teeth and matted hair, while the resident reported that some aides did not take care of him and that he wanted his teeth brushed. A CNA new to the unit confirmed the poor oral condition and matted hair, indicating that oral hygiene and personal care interventions in the care plan and resident rights policy were not implemented as required.
A resident with diabetes, dysphagia, and multiple comorbidities had a care plan requiring monitoring and documentation of meal intake percentages to prevent unplanned weight changes and ensure consumption of more than 75% of two meals daily. For an extended period before the resident’s transfer to the hospital, aide charting and progress notes contained no evidence that the resident was eating, no recorded meal intake percentages, and no documentation of meal refusals. The DON, RDCO, and social services staff confirmed the absence of any such documentation in the record, despite the expectation that meal intakes would be monitored and recorded.
A resident with significant respiratory history and cognitive impairment had a care plan requiring close monitoring for respiratory distress and appropriate use of oxygen therapy. Facility staff discontinued the resident’s oxygen due to refusals and did not document ongoing monitoring of respiratory status or vital signs afterward. On a later date, the resident experienced shortness of breath and altered level of consciousness, EMS found audible crackles and an SpO2 of 90% on room air, and the nurse reported the resident was normally on continuous oxygen but had been without oxygen since the prior night. The resident was transported to the ED and later returned on oxygen, yet there were no corresponding physician orders for oxygen, even though staff continued to document the resident receiving oxygen at various liter flows. A subsequent observation found an oxygen concentrator running at 3 L/min with the nasal cannula on the floor, and an LPN and the DON confirmed that oxygen had been administered without physician orders and that the resident had not been monitored for respiratory distress as required.
A resident with multiple comorbidities, including Candida auris, was placed on Enhanced Barrier Precautions and later Contact Precautions, but the facility failed to consistently track this infection in its infection control program and could not produce infection control logs for several months. The care plan called for education of the resident, family, and staff about Enhanced Barrier Precautions, yet the medical record showed no evidence of education on Candida auris, its treatment, or required precautions until very late in the stay, despite the resident being cognitively intact. A care conference summary lacked any documentation of discussion about Candida auris, and there was no documented explanation for changes between Enhanced Barrier and Contact Precautions. Interviews with the DON, NP, PA, Medical Director, regional clinical leadership, and nursing staff revealed confusion about when Candida auris was first identified, whether it was infection or colonization, and who was responsible for infection control oversight, while infection control reports did not list the resident’s Candida auris status during the review period.
The facility failed to complete timely and appropriate routine skin assessments for two residents with altered skin integrity. One resident had a red area on the buttock identified at admission, but there was no detailed assessment, physician notification, or ongoing documentation, despite continued topical treatments. Another resident developed an unstageable pressure injury, with only two weekly skin assessments documented over several months and no follow-up after re-entry, despite physician orders. Staff interviews confirmed required assessments were not completed or communicated as per facility policy.
A resident with multiple complex diagnoses and a physician order for daily weights did not have actual weights recorded in the medical record after the initial days of admission. Staff signed off on the MAR as if daily weights were completed, but no weight values were documented, and this was confirmed by both the RD and DON. The facility's policy required weights to be recorded in the medical record, and this failure had the potential to affect all residents.
A resident with multiple complex medical conditions was repeatedly administered oxycodone without consistent pain assessments or documentation of non-pharmacological interventions, despite facility policy requiring such measures. Interviews revealed the resident’s discomfort was typically related to personal care and resolved without medication when staff followed her preferences, and the DON confirmed documentation failures regarding pain assessment and intervention prior to opioid use.
Two residents experienced medication errors when an LPN omitted a scheduled dose of fish oil and delayed administration of Senna, while another nurse substituted a chewable aspirin tablet for a prescribed capsule and allowed it to be swallowed whole. These actions resulted in a medication error rate above the required threshold, with failures to follow facility policy on medication administration timing, verification, and method.
A resident who was not approved to self-administer or store medications was left with a cup containing eight pills to take independently after an LPN handed over the medications and left the unit. The resident's records indicated only two medications could be self-administered, and facility policy required regular reassessment, which was not completed. The facility's approved self-administration list did not include this resident, and the medications were ordered for clinician administration.
The facility did not complete timely admission assessments, failed to enter all physician orders promptly, and did not conduct required fall risk assessments on admission, quarterly, or upon re-entry for several residents. In one case, a resident was sent to the hospital without necessary paperwork, and staff could not locate the initial assessment. These actions resulted in incomplete and inaccurate medical records, contrary to facility policy and professional standards.
Two residents with indwelling catheters were not properly monitored for urine output, changes in urine characteristics, or signs of infection, despite care plans and facility policy requiring such actions. Staff failed to document and report abnormal findings, leading to delayed identification and treatment of UTIs. One resident developed septic shock and acute kidney injury due to a catheter-associated UTI, while another experienced delayed antibiotic therapy after a positive urine culture was not promptly communicated or acted upon.
A resident with COPD and chronic respiratory failure did not receive physician-ordered BIPAP therapy overnight after hospital discharge, and staff failed to monitor vital signs or oxygen saturation as required. The BIPAP machine was present but not used, and there was no documentation of refusal or appropriate assessment. The resident was later found in respiratory distress and required hospital transfer for acute hypoxic hypercapnic respiratory failure.
A resident with cognitive deficits and multiple medical conditions was discharged to the ER for a psychiatric evaluation without a proper care plan or necessary paperwork. The resident was transported by a CNA/Van Driver instead of a nonemergent transport service, and was left at the ER without documentation. Communication issues between the facility staff and the resident's daughter contributed to the unsafe discharge process.
A facility failed to initiate a baseline care plan within 48 hours for a resident with multiple medical conditions, including cognitive deficits, after admission. The absence of the care plan was confirmed by the facility's Administrator and MDS nurse, who noted that care plans were behind schedule.
A resident with multiple health conditions did not receive showers as per the facility's schedule and her preferences. Despite being scheduled for showers twice a week, documentation showed only one shower on an unscheduled day. Interviews and observations confirmed the resident had not received proper hygiene care, as evidenced by greasy hair and body odor. The facility's policy to provide personal care according to the resident's care plan was not followed.
A resident with type II diabetes mellitus was affected by improper insulin administration when an RN failed to cleanse the insulin pen with alcohol and did not prime the needle as per the manufacturer's instructions. The resident was dependent on nursing staff for medication administration, and the oversight was confirmed during an interview with the RN.
The facility failed to ensure proper infection control practices during medication administration, affecting three residents requiring Enhanced Barrier Precautions. Staff did not perform hand hygiene or use appropriate PPE, such as gowns, when administering medications through gastrostomy tubes. These lapses were observed during a complaint investigation, revealing non-compliance with the facility's infection control policies.
An LPN failed to follow standard nursing practices for safe medication administration, affecting two residents. The LPN did not use the MAR during administration, signing off medications before actually administering them. This led to an incorrect dose being given to one resident, violating the facility's policy.
A facility failed to provide an anchoring device for a resident's suprapubic catheter, leading to pain when the resident repositioned in bed. The resident had intact cognition and was admitted with a urinary tract infection and obstructive and reflux uropathy. Both a CNA and an LPN confirmed that an anchoring device should have been used.
A facility failed to maintain a resident's head of the bed at the required 30-degree elevation during continuous enteral feeding, as per the physician's order. The resident, with a history of chronic respiratory failure and other conditions, was observed with the bed almost flat, and the LPN confirmed the lack of a degree measure device, leading staff to estimate the bed's angle.
A resident with multiple diagnoses, including Alzheimer's and bipolar disorder, did not have a recommended General Dose Reduction (GDR) for Lamictal 100 mg addressed in a timely manner. The consultant pharmacist's recommendation was not acted upon, despite being marked as positive, and the facility's policy requiring timely action on such recommendations was not followed.
The facility failed to monitor behaviors and side effects of psychotropic medications for three residents, leading to overdue AIMS assessments and incomplete behavior documentation. Despite care plans requiring monitoring, there was no system in place for documenting these observations, as confirmed by the DON.
A facility failed to properly store and secure medications, affecting a resident with depression, anxiety, and respiratory failure. The resident had an order for Guaifenesin, but there was no indication they could self-administer it. An LPN documented administering the medication, but it was later found on the resident's tray table, as the resident was sleeping. The LPN confirmed not observing the resident take the medication. Facility policy requires medications to be stored securely and only accessible to licensed personnel.
A resident with a history of stroke and mobility issues was not assisted out of bed in a timely manner, despite expressing his desire to do so. The resident's call light was activated, but staff were delayed in responding due to being occupied with other duties. The facility's policy to provide care based on resident choices was not followed, leading to a deficiency finding.
A resident with mobility issues and incontinence was not assisted with toileting needs, despite being unable to get up on her own. The resident reported not receiving help since the previous day, and her call light was found to be non-functional. This resulted in the resident being found in saturated clothing, indicating a lack of incontinence care.
A resident's bedside commode was not emptied for two days, despite the resident informing staff of the need. The resident, who required assistance for toileting due to medical conditions, experienced a lapse in care as the facility failed to adhere to its policy on toileting assistance. This deficiency was confirmed by the ADON during a complaint investigation.
A resident developed a stage three pressure ulcer due to the facility's failure to implement a comprehensive pressure ulcer prevention program. The resident, who was high risk and dependent on staff, had inconsistent documentation and delayed treatment orders. The facility did not ensure timely identification and treatment of the ulcer, leading to its deterioration.
A resident with multiple sclerosis and incontinence issues did not receive timely care due to staff assignment confusion. The resident's call light was not answered for over two hours, resulting in a soaked incontinence brief. Staff interviews revealed a lack of awareness about the resident's assignment, leading to the deficiency.
A resident with multiple medical conditions was found with medications left at their bedside, despite being assessed as unsafe to self-administer. The resident discarded some pills and ingested one tablet, contrary to facility policy requiring observation post-administration. The DON confirmed the oversight.
A facility failed to investigate and implement interventions to prevent further skin impairment for a resident with multiple diagnoses, including dementia and anxiety. The resident experienced several skin tears and an abrasion, with no documentation on how these injuries occurred. Despite notifying the physician and family, the facility did not update the care plan with new interventions. Interviews confirmed no investigations were conducted, and no interventions were put in place to address the resident's behaviors contributing to the skin tears.
Failure to Monitor Acute Change in Condition, Skin Integrity, and Diabetes Management
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and care plan interventions for monitoring and treating acute changes in condition and skin integrity, as well as failure to timely treat a new diagnosis of type 2 diabetes. One resident with a history of type 2 diabetes mellitus with neuropathy, obstructive and reflux uropathy, prior osteomyelitis, and documented risk for bladder incontinence and skin breakdown reported blood in his urine in the evening. A nurse practitioner was contacted and ordered a urinalysis and urine culture and sensitivity, but there was no documentation that the resident’s urine was assessed or described, and no evidence that vital signs, temperature, or mental status were monitored from the time of the complaint through several subsequent days. The medical record showed no evaluation by the resident’s NP or PA after the report of hematuria, and no documented monitoring for urinary status or change in condition during this period, despite facility policy requiring assessment and documentation of changes such as altered urination, confusion, or lethargy. The same resident had multiple risk factors for skin breakdown and was care planned for weekly head‑to‑toe skin assessments and treatment documentation for any skin issues. A Braden assessment identified mild risk, and a prior diabetic heel ulcer had been documented as healed and discharged from wound care. A skin tear on the right middle knuckle was documented and ordered to be monitored every shift, and a weekly skin check on one date showed no new problems. However, a wound culture for Candida auris was later obtained from an open area on the resident’s arm due to scratching and picking, without clear documentation of the wound’s location or ongoing treatment. A weekly skin check was marked as completed on the treatment record, but there was no corresponding assessment form in the record. When the resident was transferred to the hospital after an acute decline, hospital documentation identified an unstageable pressure injury on the right lower buttock and non‑pressure ulcers on both feet that were present on admission, as well as multiple skin tears on the bilateral upper extremities, none of which had been documented on the transfer form or in the facility’s recent assessments. On the morning of the acute event, staff found the resident in bed, humming, with involuntary right arm shaking, confusion, and repeated inappropriate responses. Vital signs showed hypotension and bradycardia, and a blood glucose of 59, but no temperature or oxygen saturation was recorded. A subsequent note described the resident as pale, cool, clammy, stuporous, and unable to make eye contact or answer questions appropriately, and EMS was called. EMS documented a blood glucose of 47, hypotension, bradycardia, and altered mental status, and the resident was transported to the emergency department. In the ED, the resident was found to be hypothermic with a core temperature of 86.4°F, hypotensive, and bradycardic, and was diagnosed with altered mental status, UTI, sepsis, hypothermia, and hypotension. A urine culture collected at the facility showed Proteus mirabilis >100,000 CFU/mL with ESBL production and resistance to ciprofloxacin; an order for oral ciprofloxacin had been started based on lab results, but the organism was resistant. The resident was admitted to the MICU with sepsis and septic shock, and multiple wounds were documented as present on admission. A second deficiency involved another resident with type 2 diabetes mellitus without complications and other neurologic and muscular diagnoses. This resident’s hemoglobin A1c was elevated, and a NP was notified that the resident refused metformin, stating a preference to try diet control first. The dietitian recommended use of a FreeStyle Libre 2 continuous glucose monitoring sensor because the resident did not want finger sticks, and the NP ordered the Libre sensor to assist with pre‑meal glucose checks three times daily. Review of the medical record from the time of the order through several months later showed no evidence that blood sugars were checked, and the MAR repeatedly showed the Libre sensor order not completed, with notations such as the sensor being on order or not available, and in some instances no reason documented at all. The resident later reported being told she was diabetic but receiving no diabetes education and having no blood sugar checks performed, and she stated she did not know what she was supposed to do about her diabetes.
Failure to Honor Resident’s Shower Preferences and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing in accordance with a cognitively intact resident’s stated preferences and care-planned interventions. The resident, admitted with diagnoses including cellulitis of the left lower limb, peripheral vascular disease, and major depressive disorder, had a care plan dated 03/06/25 indicating an ADL self-care performance deficit related to impaired mobility and muscle weakness. Interventions included providing bathing and showering per the shower schedule and as requested, and offering a sponge bath when a full bath or shower could not be tolerated. Physician orders dated 03/20/25 documented that the resident required a two-person assist with a mechanical lift. A Quarterly MDS assessment showed the resident required substantial to maximal assistance with toileting hygiene and bathing, was dependent for transfers and getting in and out of a tub or shower, and did not reject care during the seven-day look-back period. Record review of shower sheets and aide charting from 12/08/25 through 01/08/26 showed missing documentation for 12/08/25 and 12/18/25, with no evidence the resident received either a shower or a bed bath on those dates. During this period, the resident received a mix of bed baths and showers, but not consistently per the posted shower schedule, which indicated showers on Monday and Thursday evenings. Progress notes from 12/08/25 through 01/08/26 did not show that the resident refused showers or requested bed baths instead. On observation, the resident reported she had not had a shower for three weeks and had only been given bed baths, and stated she wanted showers and did not care about the time of day. When questioned, an LPN and a CNA stated the resident was scheduled for evening showers on days that were not their shift and suggested she might not be getting showers because she required a mechanical lift and two staff, and there might not have been enough staff available. The facility’s resident rights policy stated that residents have the right to make their own schedule, participate in care planning, and participate in decisions affecting their care.
Failure to Provide Adequate Oral Hygiene and Personal Care
Penalty
Summary
The facility failed to ensure adequate oral care for Resident #21, who was care planned to receive oral care every shift and as needed, with one staff member assisting with personal hygiene and oral care. Resident #21 had spastic quadriplegic cerebral palsy, quadriplegia, adult failure to thrive, was cognitively intact, and was dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and bed mobility. He was always incontinent of bowel and bladder and did not reject care during the assessment look-back period. His care plan identified an ADL self-care performance deficit related to his diagnoses, with the goal to improve his current level of function in ADLs. During observations, Resident #21 was found in bed with his head tilted to the left, reporting that some aides did not take care of him and specifically stating he would like someone to brush his teeth. Surveyor observation revealed a large buildup of yellowish-brown food material and apparent tartar at the base of all his teeth where they met the gums, and his hair was matted at the back of his head. A CNA, who was new to the hall and had not previously cared for this resident, confirmed that his teeth had a large amount of yellowish-brown buildup and appeared not to have been brushed for a long time, and also confirmed his hair was matted. The facility’s policy on resident rights stated that residents have the right to be treated with dignity and respect and to receive needed care and services. This deficiency was cited under a complaint investigation.
Failure to Implement and Document Nutritional Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document nutritional care plan interventions for a resident with multiple medical conditions. The resident was admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, obstructive and reflux uropathy, acute osteomyelitis of the left ankle and foot, and Candida auris. The resident’s care plan, initiated shortly after admission and revised later, identified a potential for altered nutrition and hydration related to diabetes, altered mental status, tremors, anxiety, dysphagia, a mechanically altered diet, and other diagnoses. The care plan specified goals that the resident would avoid unplanned significant weight changes and would consume more than 75% of two meals daily, with interventions that included monitoring meal intakes and recording them on the STNA/CNA flow record. Record review for the period immediately prior to the resident’s transfer to the hospital showed that these interventions were not carried out as planned. Aide charting from 02/07/25 through 02/22/25 contained no evidence that the resident was eating and no documentation of meal intake percentages. Progress notes for the same period also lacked any information about whether the resident was eating, what his meal intake was, or whether he refused meals. During interviews, the DON, the Regional Director of Clinical Operations, and the Social Services Designee confirmed there was no documentation in the medical record, including aide charting, to show that the resident was eating or that meal percentage intakes were recorded. The RDCO stated that the resident’s stable weights and frequent eating in the facility café were viewed as indicators that he was eating, but this was not supported by documented meal intake records as required by the care plan.
Failure to Monitor Respiratory Status and Administer Oxygen per Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care and monitoring for a resident with significant respiratory risk factors. The resident had diagnoses including nontraumatic subarachnoid and intracerebral hemorrhage, vascular dementia, aphasia, morbid obesity, history of pulmonary embolism, respiratory failure, and a history of tracheostomy. The care plan identified altered respiratory status and required monitoring for signs and symptoms of respiratory distress, including changes in orientation, restlessness, anxiety, air hunger, increased respirations, decreased pulse oximetry, increased heart rate, diaphoresis, headaches, lethargy, confusion, and skin color changes, as well as administration of ordered respiratory medications and treatments. On one date in November, progress notes documented new orders to discontinue the resident’s oxygen due to continued refusals, with oxygen saturations reportedly remaining in the 90s and the POA notified. However, from the following day through later in November, there was no documentation that the resident was monitored for respiratory distress or that vital signs and oxygen saturation were checked as outlined in the care plan. On a later November morning, a chest X-ray was ordered to rule out pneumonia, with findings of pneumothorax or pleural effusion and improved depth of inspiration compared to a prior exam, but there were no new orders and no evidence that vital signs, including oxygen saturation, were obtained at that time. Later that same morning, EMS records show the facility called for altered level of consciousness and shortness of breath. EMS found the resident conscious, alert and oriented, with audible crackles and an oxygen saturation of 90% on room air, which improved after oxygen and a DuoNeb treatment. The nurse told EMS the resident was normally on continuous oxygen at 2–4 L/min via nasal cannula and that she had noticed there was no oxygen in the room, and the resident stated she had been off oxygen since the previous night. Facility progress notes documented that the resident was sent to the ED for shortness of breath and later returned with diagnoses of chronic bronchitis and respiratory tract infection, receiving oxygen at 2 L/min, but there were no corresponding physician orders for oxygen from that date through early January. Subsequent documentation of oxygen saturations in late November and December repeatedly showed the resident on oxygen via nasal cannula, often without specifying the liter flow, and on one January observation the oxygen concentrator was running at 3 L/min with the nasal cannula and tubing lying on the floor, while the LPN confirmed there were no current physician orders for oxygen and that oxygen had been administered without orders. The DON and Administrator confirmed the lack of monitoring after oxygen discontinuation and the absence of vital signs when EMS was called.
Failure to Track Candida auris and Educate Resident and Family Within Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and control program for a resident with Candida auris, including failure to track the infection and failure to provide timely education to the resident and family. The resident was admitted with multiple diagnoses including type 2 diabetes with neuropathy, osteomyelitis of the left ankle and foot, and Candida auris, and had an order for Enhanced Barrier Precautions related to Candida auris that remained active until the resident was transferred to the hospital. The care plan documented that Enhanced Barrier Precautions would be maintained and included an intervention to educate the resident, family, and staff regarding these precautions. However, the medical record contained no evidence that the resident or resident representative received education on the infection, its treatment, or necessary precautions until a late entry close to the end of the resident’s stay. The resident was cognitively intact and required extensive assistance with mobility, ADLs, and use of a wheelchair, but there was no documentation that the resident refused family involvement in care or treatment. A care plan conference summary showed that the resident’s diagnoses and plan of care were reviewed, but the narrative section was blank and did not document any discussion of Candida auris, and there was no evidence that family members attended. Infection control logs for several months could not be produced, and an Infection Control Detail Report for a period in which the resident was on Enhanced Barrier Precautions did not list Candida auris for this resident. The facility was unable to demonstrate that the resident’s Candida auris status was tracked in the infection control program from late in the year through early the following year. Physician orders initially placed the resident on Enhanced Barrier Precautions for Candida auris and later changed to Contact Precautions, then back to Enhanced Barrier Precautions after a negative culture, but the record did not explain why the level of precautions changed or document a clear determination of infection versus colonization. Progress notes showed that the resident’s POA was contacted about Contact isolation and retesting for Candida auris, but the notes described the POA as verbally aggressive and did not document that the POA received clear education about the infection or precautions. Interviews with the DON, NP, PA, Medical Director, Regional Director of Clinical Operations, and former RN staff revealed confusion and lack of awareness about when Candida auris was first identified, why the resident was on lifelong precautions, and who was responsible for infection control oversight. The former RN reported discovering Candida auris in the chart, initiating Contact Precautions after consulting corporate, and notifying the family, who questioned why precautions were only then being implemented. The facility’s own resident rights policy and CDC guidance referenced the need for residents and representatives to be fully informed about medical conditions and for facilities to use consistent infection prevention and control measures for Candida auris, but the documentation and interviews showed that the facility did not consistently track the infection or ensure timely, documented education for the resident and family. Additional interviews further highlighted gaps in communication and documentation related to Candida auris. The DON and Administrator could not locate infection control logs for several months and could not confirm whether the resident’s Candida auris was tracked during that time. The Social Services Designee stated that the resident did not want his family involved in care conferences but acknowledged that this was not documented in the medical record. The PA who assumed care after a change in primary provider reported he was not informed of the resident’s Candida auris and saw no documentation about it when he took over care. The Medical Director stated he did not recall the Candida auris issue and did not believe a meeting was needed to discuss it. Collectively, the lack of infection control tracking, missing logs, absence of clear documentation of infection status and precaution rationale, and failure to document timely education to the resident and family led to the cited deficiency in the facility’s infection prevention and control program.
Failure to Complete Timely and Appropriate Skin Assessments
Penalty
Summary
The facility failed to ensure appropriate and timely routine skin assessments for two residents with altered skin integrity. For one resident, the medical record showed an admission with multiple complex diagnoses, including diabetes, kidney failure, and schizoaffective disorder. Upon admission, a red area was noted on the right buttock, but the assessment lacked details such as size, etiology, drainage, or surrounding tissue condition. There was no evidence that the physician was notified or that interventions were initiated at the time the skin issue was identified. Although physician orders required a Braden skin assessment on admission and weekly for three weeks, only the initial assessment was completed, and it did not reflect the resident's actual mobility status or the presence of the skin issue. No ongoing skin assessments or documentation of the skin condition's resolution were found during the resident's stay, despite continued use of topical treatments and a care plan indicating actual skin impairment. For the second resident, who had diagnoses including multiple sclerosis, COPD, and chronic kidney disease, the care plan addressed an actual skin impairment of the coccyx but did not address the risk for impaired skin integrity due to mobility and incontinence issues. The resident developed an unstageable pressure injury that was not present on admission. Documentation showed that only two weekly skin assessments were completed over several months, and there were no nursing progress notes related to the new skin issue when it was identified. After a re-entry to the facility, physician orders for Braden skin assessments were not followed, and no such assessments were documented. Interviews with facility staff, including the DON, RN, and LPN Unit Manager, confirmed that weekly skin assessments were required and should be documented in the electronic medical record. Staff interviews also revealed uncertainty about the process for notifying the wound nurse of new skin concerns and inconsistent communication regarding skin integrity issues. Review of facility policy indicated that all residents should have routine skin assessments, with documentation at least weekly, but this was not followed for the residents in question.
Failure to Document and Record Physician-Ordered Daily Weights
Penalty
Summary
The facility failed to ensure that physician orders for daily weights were completed and properly documented for a resident with multiple complex medical conditions, including acute respiratory failure, severe persistent asthma, type II diabetes, congestive heart failure, and a history of bariatric surgery. The resident had a physician order for daily weights due to their medical status and use of diuretics, and the care plan included monitoring and recording weights as ordered. However, review of the medical record showed that after the initial days following admission, no actual daily weights were recorded in the electronic medical record, and the last documented weight was several weeks prior to discharge. Staff were signing off on the Medication Administration Record (MAR) indicating that daily weights were completed, but no actual weight values were entered, except for one day marked as refused and one day left blank. Interviews with the Registered Dietitian and the DON confirmed that daily weights were not recorded as required by the physician's order, and that the facility's policy required weights to be documented in the resident's medical record. This failure had the potential to affect all residents in the facility.
Failure to Ensure Drug Regimen Free from Unnecessary Opioids
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of opioids. The resident in question had multiple complex diagnoses, including nontraumatic subarachnoid hemorrhage, intracerebral hemorrhage, dysphagia, aphasia, epilepsy, COPD, chronic respiratory failure, and diabetes. Despite these conditions, documentation showed that the resident was regularly administered oxycodone, an opioid, without consistent evidence of pain assessments or attempts at non-pharmacological interventions prior to administration, as required by facility policy and the resident’s care plan. Review of the Medication Administration Record (MAR) over several months revealed that oxycodone was given on numerous occasions when pain assessments were either not documented or marked as 'NA' (not applicable), and non-pharmacological interventions were not attempted or recorded before opioid administration. In many instances, the overall pain rating for the shift was documented as zero, and there was no indication that the resident experienced moderate to severe pain or requested the opioid. Additionally, acetaminophen, a non-opioid analgesic, was not administered prior to oxycodone, and documentation of non-pharmacological interventions was largely absent. Interviews with the resident and multiple CNAs indicated that the resident’s discomfort was typically related to personal care activities and subsided once care was completed, with the resident preferring non-pharmacological interventions such as staff taking their time and following her instructions. The DON confirmed that 'NA' was not an approved method for documenting pain assessments and acknowledged the lack of consistent pain assessments and intervention documentation prior to opioid administration. Facility policy required exploration and documentation of both pharmacological and non-pharmacological interventions for pain, which was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold Due to Omission and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 8.33% during medication administration for two out of five residents. For one resident with multiple chronic conditions, including diabetes, hypertension, and macular degeneration, the morning medication pass was observed to be incomplete. The resident did not receive a scheduled dose of fish oil, and there was uncertainty regarding the application of a prescribed topical lotion. The LPN responsible for medication administration also delayed giving a dose of Senna due to its absence from the medication cart, retrieving it later and adding it to the same medication cup as the other pills. Documentation on the Medication Administration Audit Report did not reflect the administration of fish oil, and the timing of other medications was inconsistent with observed administration times. Another resident, with a history of paraplegia, chronic pain, and musculoskeletal issues, was prescribed aspirin in capsule form for pain management. During the observed medication pass, the nurse dispensed a chewable aspirin tablet instead of the ordered capsule and placed it with the other oral medications. The resident swallowed the chewable tablet whole, rather than chewing it as intended. The nurse confirmed that the facility did not have the prescribed capsule form available and substituted with a chewable tablet without adjusting the administration method or order. Facility policy required medications to be administered as prescribed, within 60 minutes of the scheduled time, and for staff to verify medication orders against labels, ensuring the right medication, dose, route, and time. The observed incidents demonstrated non-compliance with these policies, as medications were omitted, substituted without proper adjustment, and not administered according to the prescribed method or schedule.
Medications Left Unattended with Non-Approved Resident
Penalty
Summary
A deficiency occurred when a resident, who was not approved to self-administer or safely store medications, was left with a cup containing eight pills to take independently. The resident's medical record indicated multiple diagnoses, including spinal stenosis, depression, diabetes, repeated falls, and other chronic conditions. An assessment had determined that the resident could only safely self-administer two specific medications, but there was no indication that the resident could safely store medications at the bedside, and no follow-up evaluations were completed with quarterly assessments. During a medication pass, an LPN prepared and placed eight different medications in a cup and handed it to the resident in their room, verified the resident had water, and then left the room while the resident began taking the pills. The LPN then returned to the medication cart, prepared medications for another resident, and subsequently left the unit, leaving the resident to finish taking the medications unsupervised. The resident confirmed that medications were sometimes left in the room for independent consumption and stated that some nurses allowed this because they trusted the resident to take them. The facility's list of residents approved for self-administration did not include this resident, and facility policy required quarterly reassessment of self-administration ability, which was not documented. The medications in question were ordered to be administered by clinical staff, not self-administered, and included high-risk medications such as antibiotics. The LPN confirmed the process of handing the medication cup to the resident and leaving the unit, despite the resident not being approved for self-administration.
Failure to Complete Timely Admission and Fall Risk Assessments, and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to ensure timely and accurate completion of admission assessments and routine risk assessments, as well as proper maintenance of medical records for multiple residents. For one resident, the admission assessment was not completed upon entry, and the information present was outdated, having been carried over from a previous admission. Physician orders for medications were not entered until at least ten hours after admission, and not all ordered medications were entered into the system. Additionally, when the resident experienced a medical emergency and was sent to the hospital, no paperwork accompanied the transfer, and staff were unable to locate the initial nursing assessment at the time of transfer. Another resident was readmitted to the facility but did not have a fall risk assessment completed upon re-entry or on a quarterly basis, as required. The only fall risk assessment documented during the current stay was completed after the resident experienced an unwitnessed fall. The quarterly Minimum Data Set (MDS) assessment for this resident also failed to reflect the fall history accurately. The DON confirmed that no admission or quarterly fall risk assessments had been completed since the resident's re-entry, except for the one conducted after the fall. A third resident also did not receive a fall risk assessment upon readmission or on a quarterly basis. The only assessments documented were at initial admission and after the resident sustained an unwitnessed fall. The facility's policy required fall risk assessments to be completed on admission, quarterly, and with significant changes, but this was not followed. The DON confirmed the lack of required assessments for this resident as well. These findings demonstrate a pattern of non-compliance with accepted professional standards for safeguarding resident-identifiable information and maintaining accurate, up-to-date medical records.
Failure to Monitor and Manage Catheter Care Resulting in Delayed UTI Identification and Harm
Penalty
Summary
The facility failed to properly assess, monitor, and document the urinary condition of two residents with indwelling catheters, resulting in delayed identification and treatment of urinary tract infections (UTIs). For one resident, who had multiple comorbidities including chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive uropathy, the care plan required monitoring of intake and output, catheter care, and observation for UTI symptoms. However, there was no evidence that urine outputs were monitored or recorded for several months, and staff did not consistently observe or document changes in urine color, consistency, or output. The resident experienced episodes of catheter obstruction, pain, and distention, leading to emergency department transfers. On one occasion, the resident developed septic shock secondary to a catheter-associated UTI, with positive urine and blood cultures for multiple organisms, and required intensive hospital treatment. Another resident with an indwelling catheter due to neurogenic bladder also experienced inadequate monitoring and documentation. The care plan required observation and documentation of intake and output, as well as reporting of UTI symptoms. Despite this, there was no evidence that urine was consistently monitored for color or consistency, and changes in urine appearance were not always reported to a physician. The resident experienced catheter occlusions and thick, milky urine, and laboratory results indicating infection were not promptly communicated to the physician. There was a significant delay in reporting positive urine culture results and initiating antibiotic therapy, despite the medication being available in the facility's automated dispensing system. Interviews with staff, including the DON, LPNs, and medical providers, confirmed lapses in monitoring, documentation, and timely communication of abnormal findings. Facility policy required staff to observe and report signs of infection, but these procedures were not followed. The lack of consistent monitoring, documentation, and timely intervention contributed to actual harm for at least one resident, who developed septic shock and acute kidney injury as a result of a catheter-associated UTI.
Failure to Implement and Monitor Physician-Ordered Oxygen and BIPAP Therapy
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia, and a left pneumonectomy was admitted to the facility and required oxygen therapy and BIPAP at night per physician orders. The resident's care plan included specific interventions such as administering oxygen as ordered, using BIPAP with prescribed settings at bedtime and as needed, and monitoring for signs of respiratory distress. Upon return from a hospital stay, the resident's discharge instructions reiterated the need for 3L oxygen via nasal cannula during the day and BIPAP overnight, with encouragement for nightly BIPAP use. Despite these orders, facility records did not show evidence that the BIPAP was administered as prescribed during the night following the resident's return from the hospital. Nursing documentation failed to indicate that the resident refused BIPAP, and interviews with the resident and family contradicted any claims of refusal. The BIPAP machine was reportedly present in the room, but staff did not attempt to place it on the resident, nor did they ask the resident about its location or encourage its use. Additionally, vital signs and oxygen saturation were not monitored throughout the night, and there was no assessment for symptoms such as fever, shortness of breath, or lethargy, despite the resident's high risk for respiratory complications. The following morning, the resident was found in a deteriorated state with low oxygen saturation and was subsequently sent to the emergency department, where she was diagnosed with acute hypoxic hypercapnic respiratory failure. Interviews with staff revealed confusion about the location and use of the BIPAP machine, lack of follow-up on highlighted physician orders, and failure to notify the nurse practitioner when the BIPAP was not available. Facility policy required timely and appropriate care for changes in condition and adherence to physician orders for oxygen therapy, but these were not followed, resulting in a failure to provide safe and appropriate respiratory care as needed.
Failure to Ensure Safe and Orderly Discharge of Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #73, who was discharged to the emergency room (ER) for a psychiatric evaluation. The resident had a history of multiple medical conditions, including a urinary tract infection, altered mental status, and cognitive deficits. Upon admission, the resident exhibited aggressive behavior, was exit-seeking, and was considered a fall risk while on anticoagulation therapy. The Director of Nursing (DON) decided to send the resident to the ER for evaluation due to the risk of harm to herself and others. The discharge process was not handled appropriately, as there was no 48-hour care plan initiated for the resident. The facility's staff, including RN #805 and LPN #807, failed to ensure that the necessary discharge paperwork was printed and sent with the resident. Additionally, the resident was transported to the ER by a CNA/Van Driver instead of a nonemergent transport service, as the latter would have required a long wait. The CNA/Van Driver left the resident at the ER with a security guard without any paperwork, and the resident's daughter, who was supposed to meet them at the ER, was not present at the time of arrival. Interviews with the resident's daughter and facility staff revealed discrepancies in communication regarding the discharge process. The daughter claimed she informed the facility that she needed to stop at home before going to the hospital, but this was not acknowledged by the staff. The CNA/Van Driver and RN #805 both stated that the daughter was aware of the plan to send the resident to the ER, but there was no clear communication or documentation to ensure a safe and orderly discharge. This deficiency was investigated under Complaint Number OH00160463.
Failure to Initiate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to ensure a baseline care plan was put in place for a resident within 48 hours of admission, affecting one resident out of five reviewed for care plans. The resident, who had a history of multiple medical conditions including urinary tract infection, altered mental status, pulmonary embolism, anxiety, major depressive disorder, type II diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and aortic valve stenosis, was admitted after a hospital stay. The resident's hospital paperwork indicated some cognitive deficits. Upon review, it was found that no 48-hour care plan was initiated for the resident. Interviews with the facility's Administrator and the MDS nurse confirmed the absence of a baseline care plan, with the MDS nurse noting that care plans were behind schedule since November 2024.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident received showers according to the facility's schedule and the resident's preferences. The resident, who had intact cognition, was admitted with multiple diagnoses including a sacrum fracture, spinal stenosis, diabetes mellitus type II, hypertension, atrial fibrillation, and chronic kidney disease. The resident required partial to moderate assistance for activities such as transferring, showering, dressing, and toileting. According to the facility's shower schedule, the resident was supposed to receive showers on Tuesdays and Fridays. However, documentation showed that the resident only received a shower on a Monday, which was not a scheduled shower day. Interviews with the resident revealed that she had not received a shower since her admission and had only had a bed bath while in the hospital. The resident expressed awareness of the facility's schedule and confirmed that she did not receive showers on the designated days. Observations of the resident noted greasy hair and body odor, indicating a lack of personal hygiene care. The Director of Nursing confirmed the lack of proper documentation for the resident's showers. The facility's policy stated that residents should receive personal care according to their care plan to promote dignity, cleanliness, and general well-being, which was not adhered to in this case.
Improper Insulin Administration Procedure
Penalty
Summary
The facility failed to ensure proper administration of insulin for a resident, which was identified during a complaint investigation. The resident, who had intact cognition, was dependent on nursing staff for medication administration, including insulin. The resident's medical history included type II diabetes mellitus, cellulitis, MRSA infection, anxiety disorder, heart failure, diabetic retinopathy, and hypertension. According to the physician's orders, the resident was to receive Humalog insulin 15 units subcutaneously before meals and at bedtime, with additional units based on a sliding scale depending on blood sugar levels. During an observation of medication administration, a registered nurse (RN) did not follow the manufacturer's instructions for the Humalog insulin pen. The RN failed to cleanse the top of the insulin pen with alcohol before applying the needle and did not prime the needle with two units of insulin before administering the dose. The blood sugar check indicated the resident was to receive a total of 19 units of insulin, but the RN did not perform the necessary steps to ensure proper administration. This oversight was confirmed during an interview with the RN, who acknowledged the failure to follow the correct procedure.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to ensure staff adhered to infection control policies and procedures, specifically regarding hand hygiene and the use of Personal Protective Equipment (PPE) when administering medications. This deficiency was observed in three residents who required Enhanced Barrier Precautions (EBP) due to their medical conditions. For Resident #4, a registered nurse did not perform hand hygiene before applying gloves and failed to wear a gown while administering medications through a gastrostomy tube. Similarly, for Resident #33, a licensed practical nurse did not perform hand hygiene before applying gloves and did not wear a gown while administering medications through a gastrostomy tube. Additionally, the same nurse did not perform hand hygiene before handling medications for Resident #25. The medical records of the affected residents revealed significant health issues that necessitated strict adherence to infection control measures. Resident #4 had a history of infectious diseases and required EBP due to a gastrostomy tube and tracheostomy. Resident #33 also required EBP to prevent the transmission of multidrug-resistant organisms due to indwelling devices. Despite these requirements, staff failed to follow the facility's policy on hand hygiene and PPE use, as outlined in the facility's Medication Administration-General Guidelines. These observations were made during a complaint investigation, highlighting lapses in infection control practices.
Failure in Safe Medication Administration Practices
Penalty
Summary
The facility failed to ensure standard nursing practices were followed for safe medication administration, affecting two residents. For Resident #8, the Licensed Practical Nurse (LPN) #383 documented administering medications including Calcium with Vitamin D, Cranberry, Lexapro, and Lubiprostone at 7:48 A.M. However, during an observation at 8:10 A.M., it was revealed that LPN #383 was not using a computer or paper physician orders during the medication administration process. Instead, she stated that she reviewed the computer before starting her rounds and signed off on the medications before actually administering them. This practice was contrary to the facility's policy, which required the use of the Medication Administration Record (MAR) during administration to ensure the five rights of medication administration were followed. Similarly, for Resident #44, LPN #383 documented administering medications including Magnesium Oxide, a multivitamin, Vitamin D3, and Pregabalin at 7:43 A.M. An observation at 8:16 A.M. showed that LPN #383 was again not using the MAR during administration. She admitted to signing off the MAR before administering the medications and subsequently administered an incorrect dose of Vitamin D3, giving 10 micrograms instead of the prescribed 25 micrograms. This was a direct violation of the facility's medication administration policy, which mandates the use of the MAR to verify the correct medication, dose, and other critical factors during administration.
Failure to Implement Anchoring Device for Suprapubic Catheter
Penalty
Summary
The facility failed to ensure proper care for a resident with a suprapubic catheter by not implementing an anchoring device to prevent accidental pain or injury from excessive tension. The resident, who had intact cognition and an indwelling catheter, was admitted with diagnoses including a urinary tract infection and obstructive and reflux uropathy. During an observation, it was noted that the resident's catheter lacked an anchoring device, causing pain when the resident repositioned in bed. Both a CNA and an LPN verified that an anchoring device should have been in place for the resident's catheter.
Failure to Elevate Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident's head of the bed was elevated according to the physician's order during continuous enteral feedings. The resident, who had a medical history of chronic respiratory failure, heart failure, dysphagia, and gastrostomy status, was observed with the head of the bed almost completely flat while receiving enteral feeding at 50 milliliters. The physician's order required the head of the bed to be elevated at least 30 degrees during feeding. However, the bed lacked a degree measure device, making it difficult for staff to accurately determine the correct elevation. An LPN confirmed that the resident's head was below the required 30 degrees and acknowledged that staff had to estimate the bed's angle due to the absence of a measuring device.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely manner for a resident, leading to a deficiency in drug regimen management. Resident #22, who had diagnoses including Alzheimer's dementia, hemiplegia, hemiparesis, and bipolar disorder, was receiving multiple medications such as antipsychotics, antidepressants, anticonvulsants, and opioids. A review of the resident's medical records revealed that a General Dose Reduction (GDR) for Lamictal 100 mg was recommended by the consultant pharmacist on 07/24/24. However, there was no evidence that this recommendation was acted upon, despite the positive indication in the outcome/response column of the pharmacist's report. The facility's policy required that any irregularities identified by the consultant pharmacist be reported to the attending physician, medical director, and Director of Nursing (DON), and that these reports be acted upon in a timely manner. The attending physician was also required to document any actions taken or provide a rationale if no changes were made. In this case, the Director of Nursing confirmed that the recommended GDR was not completed as recommended, indicating a lapse in following the facility's policy and procedure for addressing pharmacy recommendations.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to provide routine monitoring for behaviors and side effects associated with psychotropic medications for three residents. Resident #38, who was cognitively intact, had multiple diagnoses including anxiety and depression, and was on several psychotropic medications. Despite having a care plan that required monitoring for side effects and effectiveness, there was no documentation of behavior or medication side effects for the past 30 days. The last Abnormal Involuntary Movement Scale (AIMS) assessment was overdue, and the Director of Nursing (DON) confirmed that there was no system in place for documenting these observations. Resident #51, also cognitively intact, was receiving hypnotic and antidepressant medications. The facility did not document behavior or medication side effects consistently, with gaps noted in the behavior monitoring records. The last AIMS assessment was also overdue, and the DON acknowledged the lack of a proper documentation system for monitoring behaviors and medication effects. Resident #22, with diagnoses including Alzheimer's dementia and bipolar disorder, was on psychotropic medications but lacked documented behavior monitoring and side effects assessment. The care plan required monitoring for adverse reactions, but there were no relevant nursing progress notes for the past three months. The AIMS assessments were not conducted as required, and the DON confirmed the inconsistency in behavior monitoring tasks. The facility's policy required monitoring for adverse effects every six months, which was not adhered to.
Improper Medication Storage and Security
Penalty
Summary
The facility failed to ensure medications were properly stored and secured, affecting one resident. Resident #40, who was admitted with diagnoses including depression, anxiety, and respiratory failure, had an order for Guaifenesin 600 milligrams to be taken twice daily for a cough. There was no indication that the resident was permitted to self-administer or keep the medication at bedside. On the morning of November 5, 2024, it was documented that LPN #371 administered the medication to the resident. However, an observation and interview later that morning revealed that the medication was left in a cup on the resident's tray table because the resident was sleeping. LPN #371 confirmed that she did not observe the resident take the medication before leaving the room. The facility's policy on medication storage, revised in November 2018, requires medications to be stored safely and securely, accessible only to licensed nursing personnel.
Failure to Honor Resident's Choice for Morning Care
Penalty
Summary
The facility failed to honor Resident #19's choices regarding getting out of bed in the morning, which was a deficiency identified during a survey. Resident #19, who had a history of cerebral infarction and difficulty walking, required assistance from staff for daily activities, including getting out of bed. Despite having intact cognition and being able to communicate his needs, Resident #19 was left waiting in bed for assistance. On the morning of the survey, he expressed his desire to get out of bed, but staff were delayed in responding to his call light. The delay was observed when Resident #19 activated his call light at 10:02 A.M., and it remained on until 10:09 A.M. when RN #384 responded. However, the resident was still in bed at 10:37 A.M. due to the aide being busy with other residents. LPN #301, who was covering for an absent aide, was unaware of Resident #19's request to get out of bed. The facility's policy on Activities of Daily Living, which emphasizes providing care based on resident assessments and choices, was not adhered to in this instance.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to provide necessary assistance with toileting for Resident #169, who was admitted with multiple fractures of the pelvis, muscle weakness, and difficulty in walking. The resident was documented as being incontinent of bladder and required one-person assistance for toileting. Despite these needs, the resident reported not receiving assistance with toileting since the previous day around lunch, and the midnight shift staff did not check on her until 5:00 A.M. the following day. The resident was unable to get up on her own and was found to be incontinent of urine. Further observations revealed that the resident's call light was not functioning, preventing her from requesting help. At 12:05 P.M., the resident was found wearing saturated gray sweatpants, indicating a lack of incontinence care since the morning. The facility's policy on activities of daily living, which includes providing necessary care for hygiene and toileting, was not adhered to in this instance. This deficiency was identified during a complaint investigation under Complaint Number OH00159653.
Failure to Timely Empty Resident's Bedside Commode
Penalty
Summary
The facility failed to ensure that a resident's bedside commode was emptied in a timely manner, which compromised the resident's right to a safe, clean, and comfortable environment. The resident, who was alert and oriented, was admitted with diagnoses including heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. The care plan indicated that the resident required supervision or assistance for toileting and was at risk for bladder incontinence. Despite these needs, the resident's bedside commode was observed to contain urine and had not been emptied for two days, as confirmed by both the resident and the Assistant Director of Nursing. The resident reported that staff frequently forgot to empty the commode, and despite informing them of the need, the issue persisted. Observations confirmed the presence of a yellow liquid substance and an odor of urine in the commode. The facility's policy on Activities of Daily Living, which includes assistance with toileting and elimination, was not adhered to in this instance. This deficiency was identified during the investigation of a complaint, affecting the resident's living conditions and highlighting a lapse in the facility's adherence to its own policies.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in a stage three pressure ulcer on a resident's left buttock. The resident, who was dependent on staff for various activities of daily living and was incontinent of bowel and bladder, was admitted to the facility with multiple skin tears and abrasions but no documented pressure ulcers. Despite being identified as high risk for pressure ulcers, the facility did not have appropriate treatment orders in place until several days after admission. The resident's medical records revealed inconsistencies and errors in documentation regarding the presence and treatment of the pressure ulcer. Initially, there was no evidence of a pressure ulcer upon admission, but later assessments indicated a stage three ulcer. The facility's staff, including the RN Unit Manager and Nurse Practitioner, provided conflicting accounts of the ulcer's presence and staging, with some documentation being entered in error and later struck from the record. The facility's failure to timely identify and treat the pressure ulcer, as well as the lack of consistent documentation and adherence to pressure ulcer prevention policies, contributed to the resident's condition. The resident's care plan and treatment orders were not adequately implemented, and the facility did not ensure that wound care was completed as ordered, leading to the development and deterioration of the pressure ulcer.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, leading to a deficiency finding. The resident, who was admitted with diagnoses including multiple sclerosis, varicose veins, and difficulty in walking, was always incontinent of urine and frequently incontinent of bowel. On a specific observation, the resident was found with a soaked incontinence brief and pad, indicating a delay in care. The resident had activated the call light at approximately 3:15 A.M. for assistance, but the staff did not respond in a timely manner. Interviews with the staff revealed that the call light was not answered because the staff member responsible did not see it, and there was confusion regarding the assignment of the resident. The staff member who was supposed to attend to the resident was unaware of the assignment due to a mix-up, resulting in the resident not receiving timely incontinence care. The facility's incontinence care policy aims to prevent urinary tract infections and restore continence, but the failure to adhere to this policy led to the deficiency finding.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered safely, affecting one resident. Resident #58, who was cognitively intact, had significant medical diagnoses including osteomyelitis, sepsis, diabetes, paraplegia, hypertension, and gastroesophageal reflux disease. The resident had multiple medication orders, including oxybutynin, Topamax, zinc sulfate, melatonin, gabapentin, vitamin C, acidophilus, cholecalciferol, and cranberry capsules. Despite being assessed as unsafe to self-administer medications, an observation revealed medications left at the bedside of Resident #58, including a small white tablet and a small tan tablet in a plastic cup, a white tablet in the resident's hand, and a white capsule on the bed. Resident #58 stated that the medications in the cup were from the previous night and expressed a preference to take medications after breakfast. The resident then discarded the cup of pills and ingested the small white tablet in her hand. The Director of Nursing (DON) confirmed the observation and acknowledged that medications should not be left at the bedside. The facility's policy on medication administration, dated August 2014, requires that residents be observed after administration to ensure the dose is completely ingested. This deficiency was investigated under Complaint Number OH00155697.
Failure to Investigate and Prevent Skin Impairment
Penalty
Summary
The facility failed to conduct a thorough investigation and implement interventions to prevent further skin impairment for a resident with multiple diagnoses, including adult failure to thrive, altered mental status, congestive heart failure, dementia, anxiety, and depression. The resident experienced several skin tears and an abrasion over a period of time, with no documentation on how these injuries occurred. Despite notifying the physician and family and receiving treatment orders, the facility did not document the cause of the injuries or update the care plan with new interventions to prevent further skin breakdown. Interviews with registered nurses confirmed that no investigations were conducted for the incidents, and no interventions were put in place to address the resident's behaviors that contributed to the skin tears. The facility's policy on skin care, which includes implementing preventative measures based on assessed risk levels, was not followed. This deficiency was identified during a complaint investigation, indicating non-compliance with the facility's own policies and procedures.
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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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