Avenue At Lyndhurst
Inspection history, citations, penalties and survey trends for this long-term care facility in Lyndhurst, Ohio.
- Location
- 5442 Rae Road, Lyndhurst, Ohio 44124
- CMS Provider Number
- 366488
- Inspections on file
- 16
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Avenue At Lyndhurst during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure clean food service areas and failed to label or date opened food items in storage, preparation, and refrigeration areas. Observations included undated dry goods, food residue on equipment, and unlabeled items in both the refrigerator and freezer, all of which were verified by the Administrator. Facility policies required labeling, dating, and regular sanitation, but these were not followed.
Several dependent residents with cognitive and mobility impairments did not receive timely incontinence care or assistance with activities of daily living after activating their call lights. Staff were observed turning off call lights without providing care, and some residents' needs went unmet for extended periods. Facility policy required prompt response and completion of requested tasks before turning off call lights, but this was not consistently followed, as confirmed by resident interviews, staff statements, and electronic call light audits.
The facility did not implement required fall prevention interventions, failed to respond promptly to call lights, and did not provide the necessary level of staff assistance during transfers and care for several residents with cognitive and physical impairments. In multiple instances, residents were left unattended or transferred without the required two-person assistance, resulting in falls and injuries. Required post-fall assessments were also not completed for a resident who sustained minor injuries.
Staff served smaller portions of chicken and wild rice casserole than required by the facility's menu spreadsheet, using a four-ounce scoop instead of the specified eight-ounce serving. This resulted in at least one resident reporting hunger and requesting more food, and the issue was confirmed by dietary staff and management.
The facility did not serve meals in accordance with posted mealtimes and resident preferences, resulting in delayed meal delivery to multiple residents. Staff confirmed the delays and residents reported frequent late meal service, with observations showing trays delivered well after scheduled times. The deficiency affected several residents and had the potential to impact all who received meals from the kitchen.
The facility did not provide required behavioral health training to all staff, including contract housekeeping, dietary, maintenance, and several CNAs, as outlined in its facility assessment. Training records and interviews confirmed that behavioral health education was not included in new hire orientation or annual in-services for non-nursing staff, potentially affecting all residents.
A resident's personal representative, through a law firm, made multiple requests for the resident's complete medical records, including a signed authorization and court order, but the facility did not provide access to the records until several months later. Staff interviews confirmed the delay was due to a former medical records employee not fulfilling the requests, resulting in noncompliance with timely record release requirements.
The facility did not notify the Ombudsman of transfers for two residents with complex medical needs and failed to issue required transfer notices for another resident with severe cognitive impairment and multiple diagnoses. These deficiencies were confirmed through record review and staff interviews.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and lack of timely follow-up by nursing staff. One resident experienced a delay in starting an antibiotic for a UTI, while another missed several doses of an antianxiety medication, with insufficient documentation and delayed action to resolve the issue.
A CNA failed to change gloves and perform hand hygiene after providing incontinence care to a resident with multiple comorbidities and impaired cognition, instead continuing to reposition the resident and adjust the bed with the same gloves, contrary to facility policy.
A resident admitted with acute pain and a vascular wound did not receive prescribed Tramadol for three days, leading to severe unrelieved pain. Despite multiple complaints, staff failed to adequately assess and manage the resident's pain, and the facility's pain management policy was not followed.
The facility failed to secure residents' medical records, as observed during a tour with the DON, where three out of four chart room doors had tape over the locks, leaving them unsecured. Additionally, a chart room door was found propped open with a wheelchair leg. An LPN confirmed the door was open upon her arrival for her shift. The DON acknowledged the issue and removed the tape during the tour.
The facility failed to maintain adequate staffing levels, impacting all 100 residents. On a surveyed day, a CNA responsible for 14 residents arrived 2.5 hours late, delaying care. Residents reported long call light response times and insufficient staff assistance. Staff confirmed the need for more personnel, and records showed frequent understaffing. The facility's policy on timely call light response was not followed, leading to unmet resident needs.
The facility failed to provide hot, palatable meals to all 100 residents, as confirmed by resident interviews and observations. Residents reported dissatisfaction with cold food, and a test tray demonstrated significant temperature drops from kitchen preparation to delivery. The Dietary Manager confirmed the meals were not served at a hot temperature.
The facility failed to serve meals in a timely manner, affecting all residents. Observations and interviews revealed that meals were consistently late and cold, with some residents not receiving breakfast by the scheduled time. The Dietary Manager confirmed that meal carts were delivered late, and floor staff were responsible for distributing meals to residents.
The facility failed to provide adequate supplies for resident care, affecting all residents. Observations revealed a lack of towels, washcloths, and incontinence briefs, confirmed by CNAs who reported frequent shortages. A resident's daughter reported a lack of briefs and received no response from the DON, though the AD located one package. The Administrator and DON did not confirm or deny the shortage.
The facility failed to submit complete and accurate staffing information to CMS, as the schedule did not specify which staff were assigned to the Assisted Living (AL) area. The SNF and AL used the same schedule, and the Administrator confirmed that the same staff cared for both areas, but this was not reflected in the schedule. One resident in the AL required minimal care, and the staff hours for the SNF did not include hours for this resident.
The facility failed to ensure adequate staff training, affecting all 100 residents. Two CNAs had incomplete orientation checklists, missing critical areas like infection control and dementia care. An LPN reported insufficient orientation due to staffing shortages. This deficiency was investigated under Master Complaint Number OH00162102.
The facility failed to treat residents with dignity and respect, affecting four individuals. Residents with urinary catheters were observed without privacy bags, contrary to care plans. A resident with dementia and mobility issues was left without meal assistance, despite needing help. Facility policies on resident rights and catheter care were not adhered to.
The facility failed to maintain a clean and sanitary environment, with observations of unsanitary conditions in resident rooms and bathrooms. Residents reported not receiving assistance for toileting or cleaning, and staff failed to remove old meal trays. Additionally, the facility did not ensure comfortable water temperatures, affecting several residents who were unable to receive showers or bed baths. The facility's policies for cleanliness and water temperature monitoring were not effectively implemented, leading to discomfort and inadequate care for residents.
The facility failed to address grievances effectively, impacting several residents. Family members reported care concerns, such as inadequate care and lack of cleanliness, to the DON, but these issues persisted. Staff were observed neglecting duties, and no disciplinary actions were recorded. The facility's grievance log showed no recorded grievances since September 2024, indicating a lack of documentation and follow-up.
The facility failed to maintain up-to-date care plans for four residents, including one with COVID-19, as required by policy. Care plans were not reviewed quarterly, affecting residents with various medical conditions. The DON and MDS Nurse confirmed the deficiencies during interviews.
The facility failed to implement a physician-ordered treatment for a resident's vascular wound upon admission, resulting in the resident experiencing significant pain. Additionally, the facility did not ensure timely response to call lights, affecting multiple residents who were left without necessary assistance. Staff frequently turned off call lights without providing care, contrary to facility policy.
The facility failed to monitor resident weights as ordered, affecting four residents with conditions requiring regular weight checks. Weights were missing or not documented, and staffing issues were cited as a reason for non-compliance. The facility's policy for weekly weights upon admission was not followed, as confirmed by interviews with staff.
The facility failed to ensure timely medication administration, resulting in significant medication errors for five residents. Medications scheduled for 8:00 A.M. were consistently administered several hours late throughout January 2025. Interviews with staff and family members confirmed the issue, with an LPN admitting to occasional late administration and a family member providing evidence of late medication delivery. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, which was not adhered to, leading to these errors.
The facility failed to honor dietary preferences for several residents, leading to declined meals and unmet nutritional needs. A resident who preferred bacon for breakfast consistently received meals without it, while another resident's lunch preferences were not followed. The absence of a kitchen manager and inability to individualize meal requests contributed to the deficiency.
The facility failed to maintain accurate medical records for several residents, including inconsistencies in care plans and physician orders, and errors in medication administration. A resident received multiple doses of a one-time medication, and another lacked an admission assessment. Additionally, residents did not receive showers due to cold water, despite documentation indicating otherwise.
The facility failed to maintain a clean and sanitary environment, with dirty dinner trays left in common areas and staff drinks at nurses' stations despite posted prohibitions. Observations confirmed by staff revealed a lack of awareness and enforcement of cleanliness policies, affecting all residents.
A resident with self-care deficits and chronic conditions was affected when an aide turned off and placed the call light on the floor, making it inaccessible. The facility's policy requires call lights to be within reach, but this was not adhered to, as confirmed by video footage reviewed by the resident's wife and the DON.
A resident with dementia and a history of falls reported ankle pain from a fall in December, which was not communicated until much later. An x-ray revealed an ankle fracture, and the resident was sent to the hospital. The facility failed to report the injury of unknown origin to the State Agency within the required timeframe, as per their policy.
The facility failed to provide necessary meal assistance to two residents, leading to a deficiency in care. One resident with dementia and heart disease was observed trying to eat without required help, despite orders for feeding assistance. Another resident with hemiplegia and dyskinesia required meal supervision, but staff were unaware of this need, leading to inadequate assistance. The facility's policy on Activities of Daily Living was not followed, resulting in non-compliance with care standards.
A resident with a history of stroke and aphasia was found to have an untreated pressure ulcer on the left buttock, which was not timely assessed or treated by the facility. The wound was reported to an LPN but was not assessed until the Wound Nurse Practitioner was informed days later. The facility's policy for immediate action on new skin areas was not followed.
A facility failed to re-order a hand splint for a resident with hemiplegia and hemiparesis, affecting their range of motion. The resident, who was cognitively intact, had an order for a left-hand resting splint that was discontinued after a hospital stay and not re-ordered upon return. Despite the resident's requests and a sign in the room indicating the need for the splint, staff confirmed it had not been seen for a long time. The Therapy Director admitted the oversight, and an order was placed only after the surveyor's intervention.
The facility failed to conduct thorough fall investigations and implement individualized fall prevention interventions for two residents. One resident experienced a fall shortly after admission, with inadequate documentation and follow-up care, leading to a later-discovered fracture. Another resident's fall was not properly documented or followed up with necessary assessments. Additionally, a non-clinical staff member assisted a resident with a transfer, contrary to facility policy.
The facility failed to provide timely incontinence care for three residents, leading to prolonged periods without necessary hygiene assistance. A resident with a history of stroke was left unchanged from the previous evening until late morning, found saturated with urine and wearing two briefs. Another resident with muscle weakness was similarly neglected, and a third resident with COPD experienced a significant delay in care, despite activating the call light. These incidents highlight a breach in the facility's policy on activities of daily living.
The facility failed to ensure medications were not left unattended in residents' rooms, affecting three residents. A resident's daughter found two cups of medications left in the room, while another resident's wife observed a cup of medications on the bedside table. Additionally, unknown medications were found in a resident's oatmeal, which was reported to the DON. The facility's policy requires residents to be observed after medication administration to ensure ingestion.
A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
A resident with dementia, type 2 diabetes, and hypertension did not receive the appropriate mechanical soft diet as prescribed. During a meal observation, the resident was served a hard hashbrown, unsuitable for her dietary needs. An LPN confirmed the meal did not meet the resident's therapeutic diet requirements.
A resident with severe cognitive impairments and dependent on staff for ADLs was not provided with the required red divided plate during a meal, as specified in her care plan and physician orders. An LPN confirmed the oversight, which was identified during a complaint investigation.
The facility failed to follow infection control protocols for two residents. One resident with COVID-19 had no care plan, and staff entered the room without PPE. Another resident with scabies was kept on isolation longer than necessary, and staff were unclear about treatment protocols. The facility's non-compliance with infection control policies led to these deficiencies.
The facility failed to regularly screen residents for fall risk, affecting three residents. A resident with diabetes and muscle weakness was last assessed in January and identified as not at risk, while two other residents with Alzheimer's and chronic conditions were last assessed in November and March, respectively, and identified as at risk. The facility's policy required assessments on admission, quarterly, and with significant change, but these were not conducted as required. The DON confirmed these findings.
A facility failed to document and schedule wound care for a resident with a stage III pressure ulcer. The resident had an as-needed order for wound care without specified times, and the treatment administration record showed no documentation of wound care in July. Interviews confirmed daily wound care was supposed to occur, but it was not documented. The DON acknowledged the lack of documentation, noting the wound's location led to frequent dressing changes despite no scheduled orders. An observation showed the dressing was changed per orders, with no signs of negligence.
The facility failed to provide syrup or alternatives for breakfast, affecting residents who requested syrup for their waffles. Despite having jelly and sugar-free syrup available, these alternatives were not communicated to staff. The deficiency was identified during a complaint investigation.
Failure to Maintain Food Service Sanitation and Labeling Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain clean food service areas and did not properly label or date opened food items. During a kitchen tour, potato chips and white cake mix in the dry storage area were found without dates, and in the prep area, the slicer had dried food on the blade while the mixer had dried batter on the backsplash. In the reach-in refrigerator, bacon, chicken noodle soup, and lima beans were not labeled or dated, and in the reach-in freezer, breaded chicken patties, chicken fingers, unbreaded chicken breasts, onion rings, and French fries were also not labeled or dated. These findings were confirmed by the Administrator at the time of observation. Facility policies reviewed indicated that open packages and leftovers should be labeled and dated, and that kitchen sanitation should be maintained through compliance with a written cleaning schedule. Four residents were identified as receiving nothing by mouth (NPO), and the facility census was 86 at the time of the survey.
Failure to Provide Timely Incontinence Care and Call Light Response
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for several dependent residents, as evidenced by record reviews, direct observations, interviews, and policy review. Multiple residents with significant medical conditions, including chronic kidney disease, cognitive impairment, limited mobility, and incontinence, were observed not receiving prompt care after activating their call lights. In one instance, a resident repeatedly called for help to be changed, but staff either turned off the call light without providing care or failed to respond for an extended period, despite the resident's continued requests and visible distress. Facility policy required that call lights not be turned off until the resident's needs were met, but this was not followed, and electronic call light audits showed a significant number of delayed responses. Additional observations revealed that other residents requiring moderate assistance for toileting and mobility also experienced delays in care. Staff were seen turning off call lights and leaving rooms without addressing residents' needs, and some staff were unaware of the specific requests made by residents. Interviews with residents confirmed that their needs were not met in a timely manner, and that staff often left after turning off the call light, sometimes not returning to provide the requested assistance. Staff interviews indicated a lack of awareness or adherence to the facility's call light response procedures. Further review of records showed that a resident's power of attorney had to contact the facility to report that the resident had not been checked or changed for several hours, contrary to the facility's policy of checking and changing every two hours. The incident was documented, and staff were reminded of the policy, but the deficiency was confirmed through interviews and documentation. Facility policies clearly outlined the expectation for timely response to call lights and incontinence care, but these were not consistently followed, resulting in unmet care needs for multiple residents.
Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to ensure the safety of residents at risk for falls by not implementing care plan interventions, responding to call lights in a timely manner, and conducting timely intermittent observations. One resident with dementia and a history of repeated falls was not provided with required fall prevention measures such as Dycem under the mattress, and was left unattended for extended periods despite activating the call light and exhibiting restless behaviors. Video evidence showed the resident was not repositioned or checked on for several hours, resulting in multiple falls from bed. Staff also failed to use the mechanical lift with the required two-person assistance, as a hospice aide transferred the resident alone, contrary to physician orders and facility policy. Two other residents with quadriplegia and significant ADL needs were not provided with the required level of assistance during care. In both cases, a single CNA left the resident unattended while turned on their side during care, resulting in falls from bed. The care plans and Kardex for these residents specified the need for two-person assistance for mobility and toileting, but this was not followed. Staff interviews confirmed that only one aide was present during the incidents, and that the residents were dependent on staff for care due to their conditions. Additionally, the facility failed to complete required post-fall assessments for a resident who sustained minor injuries after a fall outside the building. Although the fall was witnessed and the resident was assessed for injuries, the pain assessment and fall assessment forms were not completed as required. These deficiencies were verified through record review, staff interviews, and facility policy review, affecting multiple residents with varying degrees of cognitive and physical impairment.
Failure to Serve Accurate Meal Portions According to Menu Requirements
Penalty
Summary
The facility failed to ensure that accurate portions were served according to the menu diet spreadsheet during meal service. Observations revealed that residents in the main dining room who were not on a pureed diet received less than the required portion of chicken and wild rice casserole. Specifically, the serving utensil used was a #8 scoop, which provided only four ounces, while the facility's spreadsheet indicated that the serving size should be one cup, or eight ounces, using either an eight-ounce spoodle or two four-ounce scoops. This discrepancy was confirmed by both dietary staff and the Mobile Dietary Manager during the observation. As a result of the insufficient portions, at least one resident reported feeling hungry and requested additional food. The deficiency affected 22 residents who were not on a pureed diet and had the potential to impact all residents receiving meals from the facility. The facility census at the time was 86, with additional residents identified as receiving pureed diets or being NPO. The findings were based on direct observation, interviews with residents and staff, and review of facility documentation.
Failure to Serve Meals Timely According to Resident Needs and Posted Mealtimes
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner according to posted mealtimes and resident preferences. Observations revealed that lunch trays were delivered late to certain halls, with one food cart leaving the kitchen 24 minutes after the scheduled time and meal trays being delivered to residents well past the posted mealtime. Staff interviews confirmed the delay, with one staff member stating they were unsure of the reason for the late meal service and had been asked to assist with passing trays. Residents also voiced concerns during a Resident Council meeting that meals were often served late. The deficiency affected at least three residents and had the potential to impact all residents receiving food from the kitchen. The facility census was 86, with four residents identified as NPO (nothing by mouth). Review of posted mealtimes indicated that the Middle Hall and Back Hall received their meal trays later than scheduled. The findings were based on observation, interview, and record review, and were investigated under two complaint numbers.
Failure to Provide Behavioral Health Training to All Staff
Penalty
Summary
The facility failed to provide behavioral health training to all staff as required by its own facility assessment and regulatory standards. Review of training records and personnel files showed that behavioral health training was not provided upon hire or annually to several categories of staff, including contract housekeeping, dietary, maintenance, and multiple certified nursing assistants. The facility assessment indicated that all staff would receive education and competency training related to caring for residents with mental and psychosocial disorders, as well as those with trauma histories, but documentation did not support that this training was completed for all employees. Interviews with the Corporate Human Resource Manager and the contracted Regional Housekeeping Director confirmed that behavioral health training was not included in new hire orientation or in the annual in-service requirements for staff. Additionally, a review of a nursing in-service on behaviors revealed that only nursing staff were included, excluding other departments. This deficiency had the potential to affect all 86 residents in the facility, as staff across multiple departments were not adequately trained to address behavioral health needs as outlined in the facility's own assessment.
Failure to Timely Provide Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a former resident whose personal representative, through a law firm, submitted a request for a complete copy of all records. The initial request, accompanied by a signed medical authorization and a court order, was made on 03/31/25, with a follow-up request on 05/12/25. Despite these requests, the records were not made available until 08/20/25, when a secure link was finally provided to the law firm. Review of the uploads confirmed that the resident's medical records were uploaded on 08/13/25, but access was not granted until a week later. Interviews with staff revealed that the delay was due to the former medical records employee's failure to fulfill the requests, which was later confirmed by the Licensed Nursing Home Administrator. The facility's policy required approval from the Corporate Clinical Director and written consent for record release, but these procedures did not result in timely fulfillment of the requests. The deficiency was identified during a review of medical record requests, emails, staff interviews, and facility policy, and affected one resident out of three reviewed for such requests.
Failure to Notify Ombudsman and Issue Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and hospitalizations for three residents. For two residents with complex medical conditions, including acute kidney failure, multiple sclerosis, diabetes mellitus, general anxiety disorder, and acute respiratory failure, there was no documented evidence that the Ombudsman was notified of their transfers to the hospital, as required. This was confirmed through both record review and staff interview, which revealed that the Social Service Designee did not notify the Ombudsman of these hospitalizations. Additionally, for a third resident with diagnoses such as cerebral infarction, pneumonia, hemiplegia, sepsis, gastrostomy status, and dementia, there were no transfer notices issued for two separate hospitalizations. The resident was noted to have severely impaired cognition and required maximum assistance with daily activities. The absence of required transfer notices was verified by the Corporate Director of Operations. These deficiencies affected all three residents reviewed for hospitalization.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available for administration to two residents, as evidenced by record reviews and staff interviews. One resident, admitted with multiple diagnoses including acute respiratory failure, dementia, and a recent urinary tract infection (UTI), experienced a delay in receiving a prescribed antibiotic (Cefdinir) for the UTI. Although the physician ordered the medication after reviewing laboratory results, documentation showed that the medication was not available from the pharmacy on the evening it was ordered, resulting in a delay until the following morning. There was no nursing note explaining the missed dose, and the delay was confirmed by the Regional Director of Clinical Service. Another resident, admitted with conditions such as pneumonia, esophageal cancer, and anxiety disorder, did not receive a prescribed antianxiety medication (Alprazolam) on several occasions. The medication was marked as pending delivery, and nursing notes indicated that the provider and pharmacy were contacted only after multiple missed doses. There was a lack of documentation regarding the missed doses on some days, and no evidence of timely action to obtain the medication. These findings were verified by facility leadership, confirming delays in medication administration for both residents.
Failure to Follow Infection Control Protocol During Incontinence Care
Penalty
Summary
During an observation of incontinence care for Resident #69, a CNA gathered supplies, performed hand hygiene, and donned gloves before removing the resident's brief and providing care. After cleaning the resident and applying a clean brief, the CNA continued to reposition the resident and adjust the bed by touching the remote control with the same gloves that had been used during incontinence care. The CNA then removed her gloves, performed hand hygiene, and exited the room. An interview with the CNA revealed that she did not believe it was necessary to change gloves while repositioning the resident or adjusting the bed, as the gloves were not visibly soiled. Review of the facility's incontinence care policy indicated that gloves should be disposed of and hand hygiene performed after cleaning and drying the resident, before continuing with other tasks. This practice was not followed, resulting in a failure to adhere to proper infection control procedures for a resident who was dependent on staff for all activities of daily living and had multiple diagnoses, including impaired cognition and incontinence.
Failure in Pain Management for Resident with Acute Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident admitted with acute pain and a vascular wound on the left foot. The resident was admitted with a physician's order for Tramadol, an opioid pain reliever, to be administered every 12 hours as needed for pain. However, the medication was not administered until three days after admission, during which time the resident experienced severe and unrelieved pain. The delay in administering the prescribed medication was due to a failure in obtaining the necessary prescription from the pharmacy, despite multiple notifications to the nurse practitioner. Observations and interviews revealed that the resident frequently complained of severe pain, which was not adequately addressed by the nursing staff. On several occasions, the resident was heard yelling out in pain, and staff members, including LPNs and the RN, failed to respond appropriately to the resident's complaints. The resident's pain was not consistently assessed, and there was a lack of documentation regarding pain ratings and the administration of pain medication. The facility's pain management policy, which requires a comprehensive assessment and timely intervention for pain, was not followed. The resident's care plan included interventions for pain management, but these were not effectively implemented. The Director of Nursing and other staff members were unaware of the resident's ongoing pain issues, indicating a breakdown in communication and care coordination within the facility.
Failure to Secure Residents' Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and security of residents' personal and medical records. During a tour with the Director of Nursing (DON), it was observed that three out of four doors to the facility's chart rooms had tape over the locks, leaving the rooms unsecured. These chart rooms contained residents' hard charts with access to various components of their medical records. The DON confirmed the presence of tape and acknowledged that the chart rooms were supposed to be locked at all times, subsequently removing the tape during the tour. Further observation revealed a chart room on the 300 hall with a wheelchair leg propping the door open. An interview with an LPN confirmed that the door was already propped open when she arrived for her shift. The LPN stated that the chart room doors were required to remain secured at all times. This deficiency was investigated under Complaint Numbers OH00161142 and OH00161136.
Inadequate Staffing Levels Affect Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of its residents, affecting all 100 residents residing in the facility. On the day of the survey, the facility had scheduled seven CNAs for the first shift, but one CNA, who was responsible for 14 residents, arrived approximately 2.5 hours late. This delay resulted in residents not receiving timely care, including incontinence care and assistance with getting out of bed. Observations and interviews with residents and staff revealed that call lights were not being answered promptly, and some residents had to wait for extended periods for assistance. Interviews with residents and staff highlighted ongoing issues with staffing levels. Residents reported that there were not enough staff to assist with their needs, and call light response times were over 30 minutes. Staff members, including CNAs and LPNs, confirmed that the facility could use more staff and that the current staffing levels were insufficient to meet the needs of the residents. The facility's staffing records showed a pattern of understaffing, with CNAs frequently arriving late for their shifts, further exacerbating the issue. The facility's assessment indicated that staffing was based on resident population and acuity, requiring seven full-time CNAs and one part-time CNA for the first shift. However, the facility's staffing schedules and time-punch records revealed that the facility was often staffed below these planned ratios. The facility's policy on responding to call lights in a timely manner was not being implemented, as evidenced by residents' reports of call lights being turned off without their needs being met. This deficiency was investigated under multiple complaint numbers, indicating a systemic issue with staffing and care delivery at the facility.
Facility Fails to Serve Hot Meals
Penalty
Summary
The facility failed to serve hot, palatable meals to its residents, affecting all 100 residents who were not identified as NPO (not receiving food by mouth). Multiple resident interviews revealed dissatisfaction with the temperature and quality of the food. Residents reported that meals were often cold and unappetizing, with some expressing reluctance to eat due to the temperature of the food. Specific instances included a resident needing to rewarm breakfast and another describing the food as a joke. Observations during meal preparation and delivery further confirmed the deficiency. The kitchen's steam table showed appropriate temperatures for breakfast items, but by the time the meal cart reached the 200-Hall Unit, the food temperatures had significantly dropped. A test tray demonstrated that scrambled eggs and a bagel were well below the initial temperatures, and some items were missing entirely. The Dietary Manager verified these findings, confirming the meals were not served at a hot temperature, contributing to the residents' complaints.
Delayed Meal Service for Residents
Penalty
Summary
The facility failed to ensure meals were served in a timely manner, affecting all 100 residents. Observations and interviews revealed that residents frequently received their meals late and cold. For instance, Resident #52 and Resident #54 reported that their meals were consistently served late and cold, with Resident #54 not having received breakfast by 9:07 A.M. on the day of the interview. Observations confirmed that the breakfast cart arrived late to the 200-Hall unit, and Resident #77 and Resident #115 were without breakfast trays well past the scheduled meal service time. The facility's meal service schedule indicated breakfast should be served between 7:00 A.M. and 8:45 A.M. However, observations showed that the first unit did not receive its last tray until 8:46 A.M., and other units had not been served by that time. The Dietary Manager confirmed that the kitchen staff delivered meal carts to the units, but the floor staff were responsible for distributing them to residents. This delay in meal service was identified during an investigation of multiple complaints, highlighting a systemic issue in the facility's meal delivery process.
Facility Fails to Provide Adequate Supplies for Resident Care
Penalty
Summary
The facility failed to ensure adequate supplies were available for resident care, affecting all residents. On 01/21/25, an observation of the clean linen closet on the 200 hall revealed a lack of towels, washcloths, and only one package of disposable incontinence briefs. This was confirmed by a CNA who reported frequently needing to search other units for supplies and experiencing delays in receiving linens. Another CNA reported multiple instances of insufficient supplies for incontinence care. A resident's daughter reported a lack of incontinence briefs for her parent on 01/26/25, and despite notifying the DON via text, she received no response. She informed the AD, who found one package of briefs, and she shared these with other residents out of concern for their care. The facility's Administrator and DON did not confirm or deny the supply shortage during an interview on 02/05/25. This deficiency was investigated under Complaint Number OH00161142.
Incomplete Staffing Information Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified during a review of the State Tested Nursing Assistant (STNA) assignments from January 7, 2025, through February 5, 2025. The review revealed that the schedule did not specify which nurse and aide were assigned to care for residents in the attached Assisted Living (AL) area, as the Skilled Nursing Facility (SNF) and AL used the same schedule. The Administrator confirmed that the nurse and aides assigned to the SNF premium nursing unit were also responsible for residents in the AL area, but the schedule did not reflect this dual assignment. During an interview, the Administrator stated that there was one resident residing in the AL area who required minimal care and was independent, with no need for dressing changes. The Administrator also mentioned contacting the corporate office regarding the lack of a separate schedule for the SNF and AL. The corporate auditor indicated that the AL was not a separate building but part of someone's unit, and the staff hours calculated for the SNF did not include the hours needed to care for the resident in the AL. This deficiency was identified incidentally while investigating several complaint numbers.
Incomplete Staff Training and Orientation
Penalty
Summary
The facility failed to ensure that staff were adequately trained as required, which had the potential to affect all 100 residents residing at the facility. During a review of employee files, it was found that the orientation checklists for two Certified Nursing Assistants (CNAs) were incomplete. CNA #823, who started on 10/10/24, had numerous sections of the general orientation checklist not checked off, including critical areas such as infection control, dementia and memory care training, wound care, and incident/accident reporting. Similarly, CNA #885, who started on 07/03/24, also had an incomplete orientation checklist with missing sections in infection control, dementia training, and other essential areas. Interviews conducted with the Human Resource Director confirmed that the orientation checklists for the CNAs were partially filled out and not complete as required. Additionally, an interview with an LPN revealed that they did not feel they received proper orientation upon hire, as they were only given an orientation packet to read without any staff going over the information. The LPN was supposed to have a two-day orientation but only received one day due to staffing shortages. This deficiency was investigated under Master Complaint Number OH00162102 and related Complaint Numbers.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting four residents. Resident #50, diagnosed with paraplegia and bladder dysfunction, was observed in a wheelchair with an uncovered urinary catheter drainage bag, despite the care plan requiring a privacy bag. Similarly, Resident #70, with urinary retention and bladder dysfunction, was observed in bed with an uncovered catheter. Resident #59, diagnosed with falls, muscle weakness, and dementia, was seen in a common dining area with an uncovered catheter, and the LPN was unsure if privacy bags were available. Resident #71, with polyosteoarthritis, dementia, and hypertensive heart disease, was observed without a breakfast tray while seated in the dining room, despite being dependent on staff for activities of daily living and having a physician's order for meal assistance. Later, Resident #71 was seen attempting to eat breakfast in bed without staff assistance, and when a CNA arrived, they fed her while holding another resident's tray. The CNA incorrectly stated that Resident #71 could feed herself, despite her documented need for assistance. The facility's policies on resident rights and catheter care were not followed, leading to these deficiencies.
Facility Fails to Maintain Sanitary Environment and Adequate Water Temperatures
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident rooms and bathrooms. Resident #82's bathroom was found with a soiled brief and clothing on the floor, and the toilet was filled with urine, feces, and toilet paper. The resident reported not receiving assistance from staff for toileting or cleaning. Similarly, Resident #42's room contained old meal trays from previous meals, and staff failed to remove them before delivering new trays. Resident #29 also reported that staff consistently left used dishes and trays in his room despite his requests for their removal. Additionally, the facility failed to ensure that water temperatures were maintained at a comfortable and safe level, affecting several residents. Residents reported a lack of hot water, which prevented them from receiving showers or bed baths. The Maintenance Supervisor confirmed that water temperatures were below regulation standards, and the facility's water temperature logs were incomplete, with no records for a significant period. The Administrator acknowledged the issue but was unable to provide documentation of timely actions taken to address the problem. The facility's policies for maintaining a clean environment and monitoring water temperatures were not effectively implemented. The failure to adhere to these policies resulted in unsanitary conditions and discomfort for residents, as well as a lack of appropriate care for activities of daily living. The facility's inaction and delayed response to the water temperature issue further contributed to the deficiency, as residents were left without adequate hot water for an extended period.
Failure to Address Resident Grievances and Care Concerns
Penalty
Summary
The facility failed to address resident grievances effectively, impacting four residents and potentially affecting all 100 residents in the facility. Family members of the residents reported various concerns, including inadequate care, lack of cleanliness, and insufficient response to grievances. For instance, a family member of one resident installed a camera in the resident's room due to care concerns and observed that the resident did not receive care for several hours. Despite communicating these issues to the Administrator and the Director of Nursing (DON), the problems persisted. Another family member reported concerns about the cleanliness of a resident's room and care issues to the DON, but these concerns were not addressed. Additionally, there were reports of staff neglecting their duties, such as CNAs being observed watching TV and using their phones during shifts. Despite these observations being reported to the DON, there were no disciplinary actions recorded in the personnel files of the CNAs involved. The facility's grievance log showed no recorded grievances since September 2024, indicating a lack of documentation and follow-up on resident concerns. The facility's grievance policy requires prompt resolution of grievances, but the facility failed to adhere to this policy, as evidenced by the unresolved issues and lack of communication with the residents' families.
Failure to Maintain Up-to-Date Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were up-to-date and reviewed on a quarterly basis as required, affecting four residents. Resident #44, who was admitted with diagnoses including bilateral primary osteoarthritis of the knee and major depressive disorder, tested positive for COVID-19. Despite being placed on droplet isolation, her care plan lacked documentation for infection control, droplet precautions, or COVID-19. The Director of Nursing confirmed the absence of these care plan elements during an interview. Resident #9, re-admitted with conditions such as epilepsy and type II diabetes mellitus, had a care plan that had not been fully reviewed since May 2023, despite the requirement for quarterly reviews. This was confirmed by MDS Nurse #848, who acknowledged the lapse in the care plan review process. Similarly, Resident #26, admitted with hemiplegia and morbid obesity, had a care plan that had not been updated since November 2024, with no quarterly reviews completed as required. Resident #54, with diagnoses including chronic respiratory failure and bipolar disorder, had a care plan initiated in October 2023, with the last revisions made in May 2024. MDS Nurse #848 confirmed that no quarterly care plan reviews had been completed since then. The facility's policy mandates that the Interdisciplinary Team coordinate with residents to review care plans upon admission, quarterly, and annually, which was not adhered to in these cases.
Failure to Implement Wound Care and Respond to Call Lights
Penalty
Summary
The facility failed to timely implement a physician-ordered treatment for a vascular wound upon admission for Resident #77. Upon review of the resident's medical records, it was found that there was no evidence of an admission nursing assessment, including a comprehensive skin assessment, to identify any areas of skin impairment present upon admission. The resident was admitted with a vascular wound on the left foot and ankle, which required specific dressing orders that were not followed. Observations revealed that the dressing was tattered, soiled, and unchanged, and the nursing staff were unaware of the wound's specifics, leading to the resident experiencing significant pain. Additionally, the facility failed to ensure that resident call lights were answered and care was provided in a timely manner. This affected four residents who were reviewed for call light response. For instance, Resident #17's call light was activated, but staff turned it off without providing the necessary assistance, leaving the resident in bed for an extended period. Similarly, Resident #26 required incontinence care and activated the call light multiple times, but staff turned it off without providing the needed care, resulting in the resident not being assisted since the previous night. The facility's policy required all staff to respond to call lights and not turn them off if the needs could not be met immediately. However, observations showed that staff frequently turned off call lights without providing care, leaving residents without the necessary assistance. This non-compliance was noted in resident council meeting minutes, where concerns about call light response were repeatedly voiced, indicating a systemic issue within the facility.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to adequately monitor the nutritional status of residents by not obtaining consistent weights as per physician orders. This deficiency affected four residents, each with specific medical conditions that necessitated regular weight monitoring. For instance, one resident with hemiplegia and morbid obesity had no active physician order for weight monitoring, and no weights were recorded for two months. Another resident with chronic respiratory failure and diabetes had physician orders for monthly weights, but weights were not recorded for two consecutive months due to staffing issues. Additionally, a resident with alcohol abuse and diabetes had an order for weekly weights upon admission, but only the admission weight was recorded, with no documentation of refusals or reattempts to obtain weights. Similarly, a resident with a malignant brain neoplasm had orders for weekly weights, but only two weights were recorded, and the Medication Administration Record indicated weights were completed without evidence in the medical record. Interviews with the Registered Dietitian and Assistant Director of Nursing confirmed these discrepancies and the lack of adherence to physician orders. The facility's policy required new admissions to be weighed weekly for the first four weeks, with documentation in the medical record. However, the facility failed to follow this policy, as evidenced by missing weights and lack of documentation for refusals or reasons for not obtaining weights. This deficiency was identified during an investigation of multiple complaints, highlighting a systemic issue in the facility's weight monitoring practices.
Significant Medication Errors Due to Late Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the late administration of medications to five residents. The review of medical records revealed that medications scheduled for 8:00 A.M. were consistently administered several hours late on multiple occasions throughout January 2025. For instance, Resident #26's medications were administered between three to nearly six hours late on various days, while Resident #27 experienced delays ranging from over three hours to more than seven hours. Similarly, Resident #61's medications were administered late by up to eight hours, and Resident #77's evening medications were delayed by up to nine hours. Resident #115 also experienced delays of over three hours on two occasions. Interviews with staff and family members corroborated the findings of late medication administration. An LPN admitted that medications were sometimes administered late and were occasionally unavailable. A family member of one resident reported witnessing late medication administration and provided photographic evidence of medication cups left in a resident's room. The Director of Nursing confirmed awareness of the issue and acknowledged resident complaints about late medications. The facility's policy on medication administration, revised in August 2014, mandates that medications be administered within 60 minutes of the scheduled time unless specified otherwise by the provider. The policy also emphasizes the importance of adhering to the five rights of medication administration. However, the facility's failure to comply with these guidelines resulted in significant medication errors, as evidenced by the late administration of medications to the affected residents.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that resident dietary preferences were maintained, affecting five residents. Resident #28, who was alert and oriented, had a care plan that included assessing food preferences and providing a prescribed diet. However, during multiple observations, Resident #28's breakfast preferences were not followed, as she consistently received meals that did not include her preferred bacon. The facility lacked a kitchen manager, and staff were unable to individualize meal requests, leading to Resident #28 declining her meals. Resident #82, with a care plan acknowledging changing food preferences, also experienced issues with meal preferences not being honored. During an observation, Resident #82's breakfast tray did not include his preferred bacon. Similar to Resident #28, the facility's lack of a kitchen manager and inability to individualize meal requests contributed to the deficiency. Other residents, including Resident #26, Resident #25, and Resident #33, also experienced issues with their meal preferences not being followed. Resident #26 did not receive eggs, which she preferred, while Resident #25 often did not receive breakfast meat. Resident #33's lunch meal did not include her preferred items, such as mashed potatoes and milk. The facility's policy on selective menus was not implemented, and the absence of a kitchen manager further exacerbated the issue, leading to the deficiency.
Inaccurate Medical Records and Care Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, affecting seven individuals. For instance, Resident #6's care plan and physician orders were inconsistent regarding the level of assistance required for transfers and bathing. Similarly, discrepancies were noted in the care plans and physician orders for other residents, such as Resident #49 and Resident #82, where the documented interventions did not align with the actual care provided. Additionally, interviews revealed that residents did not receive showers due to cold water issues, despite documentation indicating otherwise. Resident #9's medical records showed a significant error in medication administration. The resident was prescribed a one-time dose of Permethrin cream for scabies, but the Medication Administration Report (MAR) indicated multiple doses were administered over several days. Interviews with the LPN and the pharmacy confirmed that only one tube of the cream was sent, and the DON acknowledged that the extra doses should not have been documented as administered. Furthermore, Resident #77's records lacked an admission assessment, which is a critical component of the resident's medical documentation. The DON was aware of this omission and had previously educated the staff on the importance of completing and recording admission assessments. These deficiencies were confirmed by the facility's Administrator and were part of a complaint investigation, highlighting the facility's non-compliance with maintaining accurate and complete medical records.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by multiple observations of dirty dinner trays and dishes left in common areas and adjacent to residents' rooms on the 200-Hall Unit. On several occasions, old and dirty dinner trays were observed on the ledge of the common area near residents' rooms, and staff members were either unaware of who placed them there or confirmed that they should have been removed after meals. These observations were confirmed by various staff members, including a Certified Nurse Assistant and a Licensed Practical Nurse, who acknowledged the presence of the dirty dishes. Additionally, the facility did not enforce its policy regarding staff drinks at the nurses' station. Multiple open and used staff drinks were observed at the nurses' station on both the 200-Hall and 300-Hall Units, despite a posted sign prohibiting drinks in these areas. Interviews with staff, including a Business Office Manager and an LPN, revealed a lack of awareness or enforcement of this policy, as they confirmed the presence of drinks at the nurses' station. These deficiencies were investigated under several complaint numbers, indicating a pattern of non-compliance with maintaining a clean and sanitary environment.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents, specifically affecting one resident. This resident, who had been admitted with diagnoses including falls, chronic heart failure, and chronic obstructive pulmonary disease, was noted to have self-care deficits and required maximum assistance with toileting, bathing, and personal hygiene. The care plan for this resident included an intervention to encourage the use of the call bell for assistance. However, an incident was observed where an aide turned off the resident's call light and placed it on the floor, rendering it inaccessible to the resident. The incident was captured on video footage, which was reviewed by the resident's wife and later shown to the Director of Nursing. The footage confirmed that the aide had turned off the call light and allowed it to fall to the floor while the resident was sleeping. The facility's policy on the resident call system, revised in March 2023, requires staff to ensure that call lights are placed within the resident's reach when leaving the room. This deficiency was identified during the investigation of multiple complaints.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the State Agency as required, affecting one resident. The resident, who had diagnoses including muscle weakness, difficulty walking, and dementia, was at risk for falls. The resident reported ankle pain related to a fall in December while living at a group home, which was not communicated until much later. An x-ray revealed an ankle fracture, and the resident was subsequently sent to the hospital. The facility's policy required that injuries of unknown source be reported immediately, but no later than two hours after the allegation is made. However, the facility did not initiate a self-reported incident (SRI) until two days after the injury was identified. The Director of Nursing was unable to provide an explanation for the delay in reporting. This deficiency was investigated under Complaint Number OH00161859.
Failure to Provide Meal Assistance to Residents
Penalty
Summary
The facility failed to provide necessary assistance with meals to two residents, leading to a deficiency in care. Resident #71, who was admitted with diagnoses including dementia and heart disease, was observed multiple times attempting to eat without the required assistance. Despite having a physician's order for feeding assistance due to her self-care deficit and limited mobility, staff failed to consistently provide the necessary help. Observations revealed that staff either left her to eat alone or inadequately assisted her, which was confirmed by interviews with staff members who were unaware of her needs. Resident #26, diagnosed with conditions such as hemiplegia and morbid obesity, also required supervision during meals due to extrapyramidal symptoms and dyskinesia. However, the facility's staff were not aware of the active orders for meal supervision and assistance. Observations and interviews indicated that staff believed Resident #26 only needed meal setup, not supervision, leading to a lack of proper assistance during meals. This misunderstanding persisted despite the resident's care plan and physician orders indicating the need for supervision to prevent choking and ensure safe eating. The facility's policy on Activities of Daily Living, which mandates providing appropriate care and services to maintain or improve residents' abilities, was not adhered to in these cases. The deficiency was identified during an investigation under specific complaint numbers, highlighting the facility's non-compliance with ensuring residents received the necessary assistance with meals to maintain their health and safety.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a newly-identified pressure ulcer for Resident #17. The resident, who had a history of stroke with right-sided weakness and aphasia, was observed to have a quarter-sized red, open area on her left buttock that was bleeding during toileting assistance. This observation was made by the Director of Nursing, who was unaware of the wound prior to this. The resident's medical record indicated a treatment order for a wound on the right buttock, but no treatment was listed for the left buttock wound. The resident's care plan included interventions for skin integrity risks due to incontinence, but these were not effectively implemented. Interviews revealed that the wound on the left buttock was reported to an LPN on 01/20/25, but the LPN did not assess the area and was waiting for the weekly wound rounds. The Wound Nurse Practitioner was only informed of the wound on 01/23/25 and subsequently assessed it as a stage two pressure ulcer. The facility's policy required immediate initiation of a skin grid flow record and notification of the physician and responsible parties when a new skin area was identified, which was not followed in this case.
Failure to Re-Order Hand Splint for Resident
Penalty
Summary
The facility failed to ensure that a hand splint was re-ordered and applied for a resident, leading to a deficiency in maintaining the resident's range of motion. The resident, who was cognitively intact with a BIMS score of 13, had a history of hemiplegia, hemiparesis, morbid obesity, and unilateral osteoarthritis. The resident was dependent on staff for mobility and transfers and had an order for a left-hand resting splint to be worn daily for six hours as tolerated. This order was discontinued following a hospitalization in July 2024, and the splint was not re-ordered upon the resident's return to the facility. Observations and interviews revealed that the resident had requested a new splint from the therapist but had not received one. A sign in the resident's room indicated the need for the splint, but staff, including a CNA, confirmed they had not seen the splint for a long time. The Therapy Director acknowledged that the order for the splint was not re-activated after the resident's hospital discharge, which should have been done. An order for the splint was placed only after the surveyor brought the issue to the staff's attention, indicating a lapse in the facility's process for ensuring continuity of care for the resident's range of motion needs.
Deficiencies in Fall Management and Resident Care
Penalty
Summary
The facility failed to conduct accurate and thorough fall investigations and implement individualized fall prevention interventions for two residents. Resident #110 experienced a fall shortly after admission, but the incident was not properly documented in the facility's incident log. The fall investigation checklist lacked essential assessments, such as fall risk, pain, and 72-hour post-fall assessments. Additionally, there was no evidence of a completed nursing admission assessment or care plan within 48 hours of admission. Interviews with staff revealed confusion and miscommunication regarding the incident report and follow-up care, and the resident was later found to have a fracture after being transferred to another facility. Resident #97 also experienced a fall, but the facility failed to complete a nursing admission care plan and did not conduct a pain assessment or 72-hour post-fall documentation. The fall investigation checklist lacked details about the fall, including whether the resident hit his head. The resident's care plan was not updated with immediate fall interventions, and the family was only informed via voicemail without detailed information about the fall. Additionally, the facility allowed non-clinical staff to assist with resident transfers, as observed with Resident #115. The Admissions Director, who was not trained to provide hands-on transfer assistance, helped the resident transfer from bed to wheelchair. This action was against the facility's policy, which requires only clinical and trained staff to assist with transfers. The facility's failure to adhere to its fall management policy and ensure proper documentation and follow-up care contributed to these deficiencies.
Failure in Timely Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for three residents, resulting in significant lapses in care. Resident #26, who had a history of stroke and overactive bladder, was observed with an active call light and reported not receiving incontinence care since 10:00 P.M. the previous evening. Despite informing staff of her needs, she remained unchanged until 9:48 A.M. the following day, at which point she was found saturated with urine, wearing two incontinence briefs, and with stained sheets. Similarly, Resident #49, with diagnoses of muscle weakness and vision loss, was found heavily saturated with urine and wearing two briefs, with no recollection from staff of the last change, indicating neglect in care rounds. Resident #54, diagnosed with respiratory failure and COPD, also experienced a delay in incontinence care. Despite activating her call light and informing staff of her needs, she was not changed from 11:00 P.M. the previous night until 10:45 A.M. the next day. She was found soaked with urine, which had penetrated her sheets and mattress. The facility's policy on activities of daily living, which mandates necessary services for personal hygiene, was not adhered to, leading to these deficiencies. These incidents were part of a broader investigation under multiple complaint numbers.
Medications Left Unattended in Residents' Rooms
Penalty
Summary
The facility failed to ensure medications were not left unattended in residents' rooms, affecting three residents. Resident #27's daughter reported that her mother's morning medications were administered in the afternoon, and she found two cups of medications left in the room. She provided a photograph of the medication cups as evidence. Similarly, Resident #61's wife observed a cup of medications left on the bedside table after 2:00 P.M., and she also took a photograph showing a single pill in a medication cup. Additionally, RN #874 was informed by Resident #115's daughter that unknown medications were found in the resident's oatmeal. Upon investigation, RN #874 confirmed the presence of three unknown pills in the oatmeal and reported the incident to the Director of Nursing. The facility's policy on medication administration, revised in August 2014, requires that residents be observed after administration to ensure the dose is completely ingested. This deficiency was investigated under Complaint Number OH00161136.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
Failure to Provide Appropriate Therapeutic Diet
Penalty
Summary
The facility failed to ensure that meals were served in the proper, safe form for a resident requiring a therapeutic diet. Resident #60, who was admitted with diagnoses including dementia, type 2 diabetes, and hypertension, was observed to have a meal that did not comply with her prescribed dietary needs. The resident's care plan indicated a potential for altered nutrition, with interventions to provide and serve the prescribed diet as ordered by the physician. However, during an observation, it was noted that the resident's breakfast meal included a whole crunchy hard hashbrown, which was not suitable for her mechanical soft diet requirement. The deficiency was confirmed through an interview with LPN #832, who acknowledged that the hashbrown was too hard for the resident to eat and verified that the resident did not receive the appropriate mechanical soft diet for her breakfast meal. This incident was identified while investigating several complaint numbers, indicating a lapse in the facility's adherence to dietary orders for residents with specific dietary needs.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide the appropriate assistive devices for meals to a resident, identified as Resident #60, who was dependent on staff for Activities of Daily Living (ADLs) due to severe cognitive impairments. The resident's care plan specified the use of a red divided plate as an assistive device to aid in her nutrition, which was not provided during a breakfast observation. Instead, the resident was served her meal on a regular flat plate, contrary to the physician's order for a red plate with a lid. During an interview, an LPN confirmed that Resident #60 required a red divided plate and acknowledged that the meal was served without it. This deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's adherence to the resident's care plan and physician orders, which are crucial for ensuring the resident's nutritional needs are met effectively.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control policies and protocols, affecting two residents. Resident #44, who was admitted with multiple diagnoses including osteoarthritis and major depressive disorder, tested positive for COVID-19. Despite being placed on isolation precautions, there was no care plan in place for infection control. Staff interviews revealed a lack of awareness about the resident's COVID-19 status and isolation precautions. Observations showed that staff entered the resident's room without donning personal protective equipment (PPE), contrary to the facility's policy. Resident #9, diagnosed with scabies, was placed on contact precautions. The care plan included treatment with Permethrin cream, but there was confusion regarding the application and isolation duration. Staff interviews indicated uncertainty about the resident's shower schedule and the application of the cream. Observations showed that the resident remained on isolation longer than necessary, and staff entered the room without PPE. The Director of Nursing confirmed the resident should not have been on isolation after the initial treatment. The facility's failure to implement its infection control policies and update care plans for residents with infections led to non-compliance. The lack of communication and adherence to protocols resulted in staff being unaware of necessary precautions, potentially compromising resident safety. The deficiency was investigated under a complaint, highlighting the need for improved infection control practices.
Failure to Regularly Screen Residents for Fall Risk
Penalty
Summary
The facility failed to ensure that residents were regularly screened for fall risk, affecting three out of four residents reviewed for falls. Resident #15, admitted with diagnoses including diabetes, muscle weakness, and venous insufficiency, had her last fall risk assessment on 01/28/24, which identified her as not at risk for falls, with no documented falls in the last three months. Resident #57, with Alzheimer's dementia, diabetes, obesity, and unspecified difficulty walking, was last assessed for fall risk on 11/05/23 and identified as at risk for falls, also with no documented falls in the last three months. Resident #61, diagnosed with prostate cancer, asthma, and chronic kidney disease, had his last fall risk assessment on 03/19/24, identifying him as at risk for falls, with no documented falls in the last three months. The facility's fall management policy, dated 12/2022, required all residents to be assessed for fall risk on admission, quarterly, and with significant change. However, the records showed that these assessments were not conducted as per the policy, leading to noncompliance. The Director of Nursing confirmed these findings during an interview.
Failure to Document and Schedule Wound Care for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that wound care was ordered and documented according to the nurse practitioner's orders for a resident with a stage III pressure ulcer. The resident, who was admitted with a stage III pressure ulcer and diabetes, had an as-needed order for wound care without specified times or days. The treatment administration record for July 2024 showed no documentation of wound care procedures being completed, despite the resident having a daily order for calcium alginate and a clean dry dressing, later changed to a silver alginate dressing. Interviews with the resident, the wound nurse practitioner, and the Director of Nursing confirmed that the resident was supposed to receive daily wound care, which was not documented. The resident reported receiving daily wound care and had no concerns, while the wound nurse practitioner was unaware of any issues with the wound care not being done. The Director of Nursing acknowledged the lack of documentation and noted that the wound's location made it prone to becoming soiled, leading staff to change the dressing regularly despite the absence of scheduled orders. An observation of wound care showed the dressing was changed according to orders, with no signs of negligence or infection.
Facility Fails to Provide Syrup or Alternatives for Breakfast
Penalty
Summary
The facility failed to provide condiments or an alternative for breakfast on a specific date, affecting all residents who receive food from the kitchen, except for two residents identified as receiving nothing by mouth. Observations revealed that residents in the special care dining room requested syrup for their waffles, but the kitchen was out of syrup and offered no alternatives. Interviews with several residents confirmed their desire for syrup, which was not available, and they were only provided with butter for their waffles. One resident had syrup in his room, but others did not have any alternatives provided. The Dietary Manager confirmed receiving a call about the syrup shortage and mentioned that jelly and sugar-free syrup were available as alternatives, but these were not communicated to the staff. The Dietary Aide on tray line reported that only one request for sugar-free syrup was made, but no alternatives were communicated to the staff. A review of facility invoices showed that syrup had been delivered twice in the previous month. This deficiency was identified during a complaint investigation.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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