Avenue At North Ridgeville
Inspection history, citations, penalties and survey trends for this long-term care facility in North Ridgeville, Ohio.
- Location
- 6200 Lear Nagle Road, North Ridgeville, Ohio 44039
- CMS Provider Number
- 366477
- Inspections on file
- 19
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Avenue At North Ridgeville during CMS and state inspections, most recent first.
Mechanical lifts used for resident transfers were not properly maintained, resulting in malfunctioning equipment that required staff to manually force the device to operate. Multiple CNAs and a resident reported issues with the lifts, and the Maintenance Director confirmed that necessary repairs had not been completed. Manufacturer instructions requiring regular inspection and maintenance were not followed, affecting numerous residents dependent on these devices for safe transfers.
Multiple residents experienced late administration of scheduled medications by an LPN, resulting in a medication error rate of 14 percent, well above the acceptable 5 percent threshold. Errors included late dosing of medications such as levetiracetam, memantine, gabapentin, Depakote, Apixaban, and Dulera, with morning medications often given after the facility's established administration window. The LPN acknowledged the late administration, and the DON confirmed ongoing issues with timely medication passes.
Two residents experienced changes in their prescribed medications, but their representatives were not notified as required by facility policy. One resident with impaired cognition was started on a new diabetes medication, and another with intact cognition had a therapeutic interchange for GERD treatment. In both cases, the DON confirmed that notification should have occurred, but there was no documentation of such communication.
The facility did not update care plans for two residents to reflect a change in a resident's morning routine requested by family and to include all known medication allergies. One resident's care plan was not revised after a family request to allow the resident to stay in bed longer, and another resident's care plan did not list all documented allergies, despite facility policy requiring regular review and updates.
A resident with multiple medical conditions and incontinence was not provided an external urinary catheter system as ordered by a physician. Despite recommendations from a urology consult and requests from the resident and her representative, the facility did not implement the intervention, citing an undocumented policy. The care plan lacked interventions for the external catheter, and the resident agreed to alternative care only because the device was not permitted.
A resident with multiple chronic conditions and a documented allergy to metformin was prescribed and administered metformin for 24 days without proper identification or intervention by nursing staff or the consulting pharmacist. The allergy was inconsistently documented in the care plan, and neither the resident's representative nor the physician was notified of the new order or the allergy. The pharmacy's monthly review failed to note the irregularity, and staff interviews revealed gaps in communication and adherence to facility policy regarding allergy checks and reporting.
A resident with a documented allergy to metformin was prescribed and administered metformin for several weeks without proper physician clarification or notification to the resident's representative. The allergy was noted in the medical record but not included in the care plan, and multiple nurses administered the medication without addressing the allergy alert. Pharmacy staff and the consulting pharmacist did not effectively communicate or act on the allergy information, resulting in the resident receiving a medication to which they were allergic.
The facility did not post daily staffing information on a specific date, affecting all 92 residents. Observations revealed outdated staffing information at the front desk, with the most recent data missing. The Administrator confirmed the absence of current staffing information.
The facility failed to provide surgical wound and wound drainage care as ordered for a resident re-admitted after hospitalization for a scrotal abscess. The resident's re-admission assessment did not indicate the presence of a scrotal surgical wound or Penrose drain, and staff were unaware of the required care. Observations confirmed the lack of proper dressing, and documentation did not show evidence of dressing changes.
A facility failed to ensure accurate re-admission and skin assessments for a resident with multiple medical conditions, including a scrotal surgical wound and Penrose drain. Observations revealed the resident had a Penrose drain without covering, a large dressing on the neck, and a dressing around a suprapubic catheter with dried red drainage. An LPN confirmed the assessments did not document these conditions.
A resident experienced a fall resulting in a major injury, and the facility failed to provide timely and adequate care. Despite the resident's complaints of pain and visible signs of distress, the facility delayed obtaining necessary x-rays and did not send the resident to the hospital immediately. This resulted in actual harm to the resident, who was later diagnosed with a markedly displaced fracture.
The facility failed to ensure resident dignity and privacy, including an incident where a nurse used profanity towards a resident, a resident left exposed while toileting, and two residents with uncovered urinary catheter drainage bags in common areas.
The facility failed to complete a Minimum Data Set (MDS) 3.0 significant change assessment for a resident who experienced a significant decline in functional abilities following a fall that resulted in an upper extremity fracture. The resident also had an indwelling urinary catheter that was not removed as ordered and continued to be used without proper documentation or justification. The MDS 3.0 Medicare 5-day assessment showed a decline in functional abilities and mobility, but a significant change MDS was not completed as required.
The facility failed to ensure baseline care plans were developed and summaries provided to two residents and/or their representatives. One resident with multiple health issues had no baseline care plan or care conference, and the family reported communication difficulties. Another resident had a baseline care plan initiated, but no summary was provided to the resident or family.
The facility failed to update care plans for two residents, one with a left arm fracture and an indwelling urinary catheter, and another with a neck fracture requiring a neck brace. The care plans did not reflect these critical care needs, leading to inconsistencies in care.
The facility failed to remove an indwelling urinary catheter for a resident as ordered and did not provide justification for its continued use. The resident returned from the hospital with the catheter, which was supposed to be removed on a specific night shift, but it remained in place throughout March. Staff interviews and observations confirmed the catheter was never removed, and there was no documentation explaining the need for its continued use.
Mechanical Lift Maintenance Deficiency Affects Resident Transfers
Penalty
Summary
The facility failed to ensure that mechanical lift (Hoyer) devices were properly maintained, resulting in equipment that did not function as intended for safe resident transfers. Observations and interviews revealed that at least one Hoyer lift had a right wheel that would not move due to strings being caught in it, preventing the legs from opening fully. Certified Nursing Assistants reported that the lifts were not working properly, with one stating that the spotter had to kick the wheels to separate the legs and move the device. The Maintenance Director confirmed that the Hoyer lift with the scale had not been serviced and required immediate attention. The Administrator indicated that replacement wheels had been ordered by a previous Maintenance Director but were not installed. A review of the manufacturer's instructions for the Hoyer lifts indicated that casters and axle bolts require regular inspection and that the legs must be fully opened for optimal stability and safety. The Director of Nursing identified 31 residents who required the use of a mechanical lift for transfers, including a resident with quadriplegia, anxiety disorder, and hypothyroidism, who was cognitively intact and dependent for activities of daily living. The deficiency was substantiated through observation, record review, and staff and resident interviews, and was investigated under two complaint numbers.
Medication Administration Errors Exceed Acceptable Rate Due to Late Dosing
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate of 14 percent, which exceeds the acceptable threshold of 5 percent. During observation, 41 opportunities for medication administration were reviewed, and six errors were identified, affecting four residents. The errors primarily involved the late administration of scheduled medications, with morning medications being given well past the facility's established administration window of 7:00 A.M. to 11:00 A.M. For one resident with chronic obstructive pulmonary disease, hypertension, dementia, and adjustment disorder, morning medications including levetiracetam and memantine, both scheduled twice daily, were administered late at 11:23 A.M. instead of within the scheduled window. The LPN responsible confirmed the late administration, and the resident also reported that medications were usually given earlier. Another resident with neurogenic bowel, anxiety disorder, and iron deficiency anemia did not receive morning medications until 12:01 P.M., resulting in a late dose of gabapentin, which was scheduled three times daily. The LPN again verified the late administration. Additional residents were affected by similar issues. One resident with diabetes, congestive heart failure, hypertension, atrial fibrillation, and depressive disorder received Depakote, scheduled twice daily, late at 12:15 P.M. Another resident with chronic obstructive pulmonary disease, asthma, atrial fibrillation, hyperlipidemia, and depression received Apixaban and Dulera, both scheduled twice daily, late at 12:42 P.M., and Furosemide was not administered until 2:51 P.M. The LPN acknowledged the late administration and indicated that this had been an ongoing problem. The Director of Nursing confirmed the late medication passes and noted that the LPN had previously reported difficulties completing medication passes on time.
Failure to Notify Resident Representatives of Medication Changes
Penalty
Summary
The facility failed to notify resident representatives of medication changes for two residents. For one resident with diagnoses including type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia, there was no documentation that the resident's representative was informed when a new order for metformin was initiated. The resident had impaired cognition, and the lack of notification was confirmed by the Director of Nursing (DON) during an interview. For another resident with chronic obstructive pulmonary disease, hypertension, dementia, osteoarthritis, and GERD, there was no documentation that the resident's representative was notified when a therapeutic interchange was made from lansoprazole to omeprazole for GERD management. The resident had intact cognition, and the DON confirmed that the representative should have been notified of the medication change. Review of the facility's policy indicated that responsible parties should be notified of changes in the resident's condition or status.
Failure to Update Care Plans for Resident Allergies and Preferences
Penalty
Summary
The facility failed to ensure that care plans were revised to accurately reflect changes in residents' needs and conditions. For one resident with Alzheimer's disease, atrial fibrillation, and major depressive disorder, the care plan was not updated after the resident's daughter requested a change in the resident's morning routine to allow the resident to stay in bed longer. Despite documentation of this request and a conversation with the administrator, the care plan continued to state that the resident was to get up early in the morning for safety, and no revision was made to address the family's concern. In another case, a resident with multiple diagnoses including type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia had allergies to several medications. The care plan failed to include two of the resident's known allergies, specifically to metformin and Ativan, even though these were documented in the allergy alert profile. The MDS Coordinator confirmed that all allergies should be reviewed quarterly and acknowledged that the care plan had not been updated to reflect these additional allergies. These deficiencies were identified through interviews and record reviews, and were not in accordance with the facility's policy requiring regular review and updating of care plans.
Failure to Provide Physician-Ordered External Urinary Catheter System
Penalty
Summary
The facility failed to provide an external urinary catheter system for a resident with a physician order for its use. The resident, who had diagnoses including chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, and dementia, was frequently incontinent of bladder and always incontinent of bowel, and required substantial assistance for transfers and toileting. Despite a physician order for an external urinary catheter to be applied nightly, the resident's care plan did not include this intervention, and the system was not implemented during the resident's stay. Documentation showed that the resident and her representative had requested the external catheter, and a urology consult recommended its use to reduce skin breakdown and infection. However, facility staff, including the DON and Administrator, stated that the external catheter system was not allowed, citing facility policy, although no such policy was documented or provided to the resident or her representative. Interviews with the resident confirmed that she had previously used an external urinary catheter at home and would have preferred to continue its use in the facility, but agreed to regular check and change care only because the external catheter was not permitted. The facility's admission agreement and information packet did not inform residents that external urinary catheters were not allowed. The lack of implementation of the physician-ordered external urinary catheter system, absence of related interventions in the care plan, and lack of clear facility policy or communication regarding the prohibition of the device led to the deficiency.
Failure to Identify and Address Resident Allergy During Medication Review
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's allergy to metformin was properly identified and addressed during the monthly medication regimen review by the consulting pharmacist. The resident, who had multiple diagnoses including type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia, had a documented allergy to metformin in the allergy alert profile. However, this allergy was not consistently reflected in the resident's care plan, and a physician order for metformin was entered and administered despite the known allergy. The medication administration record showed that metformin was given daily for 24 days by four different nurses, even though the allergy was documented in the resident's profile and flagged in the electronic physician order system. There was no documentation that the resident's representative or the physician was notified about the new order for metformin or the resident's allergy to the medication. Additionally, the pharmacy's monthly review did not document the irregularity of the metformin order in the presence of the allergy, and the consulting pharmacist assumed the allergy had been previously addressed without further investigation. Interviews with facility staff and pharmacy representatives revealed a lack of communication and follow-up regarding the allergy and the medication order. The Director of Nursing confirmed that nurses should check for allergies before administering medications and that the resident's representative should have been notified. The consulting pharmacist acknowledged that the allergy should have been investigated further during the monthly review. Facility policies required pharmacists to review medication regimens and report irregularities, as well as evaluate new medication orders for allergies, but these procedures were not followed in this case.
Failure to Prevent Administration of Medication Despite Documented Allergy
Penalty
Summary
A deficiency occurred when a resident with multiple documented medication allergies, including an allergy to metformin, was prescribed and administered metformin without proper clarification from the physician. The resident had a history of type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia, and was noted to have impaired cognition. The allergy to metformin was recorded in the resident's allergy alert profile, but was not included in the care plan, and subsequent physician orders for metformin were entered despite the allergy being flagged in the electronic medical record. The medication administration record showed that metformin was administered daily for 24 days by four different nurses, with no documentation that the resident's representative or the physician was notified about the allergy or the new medication order. The pharmacy's documentation acknowledged the allergy, but there was no evidence that the pharmacy communicated this to the facility or that the consultant pharmacist addressed the issue during monthly reviews. The facility's policies required evaluation of medication allergies with new orders, but this process was not followed in this case. Interviews with the DON and pharmacy staff revealed a lack of awareness and communication regarding the allergy and the medication order. The DON confirmed that nurses should check for allergies before administering medications and that the resident's representative should have been notified. The consulting pharmacist admitted to assuming the allergy had been previously addressed and did not investigate further. This series of actions and omissions resulted in the resident receiving a medication to which they had a documented allergy, without appropriate review or notification.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted on 08/29/24, which had the potential to affect all 92 residents. During an observation at 11:38 A.M. on 08/29/24, it was noted that the staffing information displayed at the front desk was dated 08/27/24. Additionally, the staffing information for 08/28/24 was found tucked behind the sheet for 08/27/24, and there was no staffing information available for 08/29/24. An interview with the Administrator at the time of observation confirmed that the posted staffing information was outdated and that the information for 08/29/24 was missing.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide surgical wound and wound drainage care as ordered by a physician for a resident following re-admission. The resident, who had a history of bipolar disorder, urine retention, multiple sclerosis, Alzheimer's disease, and neoplasm of the genital organs, was re-admitted to the facility after hospitalization for a scrotal abscess that required incision and drainage surgery. The hospital discharge documentation specified that the resident needed a nurse to change the Kerlix dressing twice a day and maintain a Penrose drain. However, the re-admission nursing assessment did not indicate the presence of a scrotal surgical wound or Penrose drain. Upon observation, the resident was found with a Penrose drain in the scrotal area without any covering or dressing. The treatment administration record and current physician orders did not show any evidence of dressing changes for the Penrose drain. Interviews with staff revealed a lack of awareness and proper documentation regarding the resident's condition and required care. The Director of Nursing and the Administrator confirmed the presence of the scrotal incision site with a Penrose drain and no dressing in place. This deficiency is an example of continued noncompliance from a previous survey.
Failure to Ensure Accurate Re-Admission and Skin Assessments
Penalty
Summary
The facility failed to ensure accurate re-admission and skin assessments for a resident, which was identified through observation, medical record review, hospital documentation review, and staff interviews. The resident, who had multiple medical diagnoses including bipolar disorder, urine retention, multiple sclerosis, Alzheimer's disease, and neoplasm of the genital organs, was re-admitted to the facility after hospitalization for a scrotal abscess that required incision and drainage surgery. The hospital discharge documentation specified that the resident required a nurse to change the Kerlix dressing twice a day and maintain a Penrose drain. However, the re-admission nursing assessment and subsequent skin assessment did not document the presence of the surgical wound, Penrose drain, suprapubic catheter, or skin impairment on the left side of the neck. During an observation, the resident was found in bed with a Penrose drain in place without any covering or dressing, a large dressing dated several days prior covering the left side of the neck down to the shoulder, and a dressing around the suprapubic catheter tubing with dried red drainage. An interview with an LPN confirmed that the re-admission and skin assessments failed to address these critical aspects of the resident's condition. This deficiency affected the quality of care provided to the resident and highlighted lapses in the facility's assessment and documentation processes.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to ensure Resident #100 received adequate and timely care and treatment following an unwitnessed fall with a major injury. On the evening of 03/03/24, Resident #100 fell and sustained a head injury. Despite the resident's medical history, including cerebrovascular accident with residual right-sided weakness and being on blood thinners, the facility did not send the resident to the hospital immediately. Instead, the resident was assisted back to her chair, and neurological checks were initiated. The resident's pain and injury were not adequately assessed or treated in the following days, despite verbal complaints of pain and visible signs of distress. On 03/05/24, the Nurse Practitioner was notified of the resident's bilateral arm pain and ordered x-rays, which were not obtained until 03/07/24. The x-ray results indicated a left arm fracture, and the resident was subsequently transferred to the hospital, where a markedly displaced fracture was diagnosed. The hospital questioned why the resident was not sent to the hospital immediately after the fall, given her medical condition and the severity of the injury. The facility's delay in obtaining the x-ray and providing appropriate care resulted in actual harm to the resident. Interviews with family members and staff revealed concerns about the resident's care and communication issues within the facility. The family reported that they had requested the resident be sent to the hospital immediately after the fall but were unsure why this did not happen. Staff interviews indicated a lack of familiarity with the resident's baseline condition and confusion about the process for ordering x-rays. The Director of Nursing acknowledged a delay in obtaining the x-ray due to a new nurse's unfamiliarity with the facility's procedures. Additionally, there were no post-fall assessments completed as required by the facility's policy, further contributing to the inadequate care provided to Resident #100.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure Resident #89 was treated with respect and dignity during care. Resident #89, who had intact cognition and required substantial assistance with activities of daily living, was involved in an incident where a Registered Nurse (RN) used profanity and engaged in a verbal altercation with the resident. The RN admitted to being frustrated and using inappropriate language, which was corroborated by a State tested Nurse Aide (STNA) and the resident himself. The facility's investigation into the incident, initiated after a family member's public review, concluded that no abuse occurred, but the RN's behavior was deemed disrespectful and not in line with the facility's customer service expectations. The facility also failed to provide privacy and dignity to Resident #02 while toileting. Resident #02, who had severely impaired cognition and required moderate assistance with toileting, was observed yelling for help while seated nude on the toilet with the door open, visible from the hallway. The call light was activated, but it took 10 minutes for a staff member to respond and provide privacy. The staff member admitted to leaving the doors open, and the Unit Manager confirmed that privacy should have been provided. Additionally, the facility did not ensure that indwelling urinary catheter drainage bags were covered in a dignified manner for Residents #39 and #56. Both residents, who had severely impaired cognition and used wheelchairs, were observed with uncovered urinary catheter drainage bags in common areas, exposing the contents to other residents, staff, and visitors. Staff members verified that the drainage bags should have been covered, and the Unit Manager confirmed that the facility typically used urinary drainage bags with built-in privacy covers.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) 3.0 significant change assessment for a resident who experienced a significant decline in functional abilities following a fall that resulted in an upper extremity fracture. The resident, who had medical diagnoses including Sjogren syndrome, lack of coordination, muscle weakness, and a displaced fracture of the surgical neck of the left humerus, sustained a fall on 02/22/24. The incident report indicated that the resident attempted to get up unassisted to walk to the bathroom, fell, and landed on her left shoulder. An x-ray confirmed the fracture, and the resident was transported to the local emergency department for further evaluation. The resident also had an unrelated hospitalization due to pneumonia from 02/27/24 to 03/03/24 and returned to the facility with an indwelling urinary catheter that was supposed to be removed on 03/04/24, but records indicated it was not removed as ordered and continued to be used without proper documentation or justification in the progress notes. The resident's MDS 3.0 Medicare 5-day assessment dated 03/10/24 showed a decline in functional abilities and mobility compared to the prior quarterly assessment dated 01/12/24, but a significant change MDS was not completed as required by the Resident Assessment Instrument (RAI) Manual guidelines. Interviews with MDS nurses revealed they were unaware of the resident's continued use of the urinary catheter and did not recognize the decline in functional abilities in more than two areas until prompted to review the assessments side by side. The RAI Manual specifies that a significant change in status assessment must be completed when there is a major decline or improvement that impacts more than one area of the resident's health and requires interdisciplinary review and/or revision of the care plan. The failure to complete the significant change assessment for the resident who had a decline in three areas of activities of daily living and six areas of mobility, as well as the continued use of an indwelling urinary catheter without proper documentation, represents a deficiency in the facility's assessment and care planning processes.
Failure to Provide Baseline Care Plans and Summaries
Penalty
Summary
The facility failed to ensure a baseline care plan was developed and a summary provided to two residents and/or their representatives. Resident #100, who had a cerebrovascular accident with residual right-sided weakness, type II diabetes mellitus, and frequent falls, was admitted on [DATE] and transferred to a local hospital on 03/07/24. The medical record revealed no evidence of a baseline care plan or any care conference. The family of Resident #100 reported difficulty in contacting the facility and receiving updates on the resident's care. A falls plan of care was only initiated after the resident sustained a fall on 03/03/24. Resident #111, admitted on [DATE] with diagnoses including a wedge compression fracture, adult failure to thrive, iron deficiency anemia, and anxiety, was transferred to the hospital on 03/10/24. Although a baseline care plan was initiated, there was no indication that the resident or their family received a summary of the plan. Interviews with family members and the Unit Manager confirmed that the facility did not provide the necessary care plan summaries to the residents or their representatives, contrary to the facility's policy.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure resident care plans were updated to reflect individualized and necessary components of the residents' care. This deficiency affected two residents. Resident #20 had multiple medical diagnoses, including Sjogren syndrome, lack of coordination, muscle weakness, and a displaced fracture of the left humerus. After a fall and subsequent hospitalizations, the care plan did not include a notation that Resident #20 was non-weight bearing on the left upper extremity or that she had an indwelling urinary catheter. Despite observations and interviews confirming the presence of the catheter and sling, the care plan was not updated accordingly until much later. Resident #94, who had a displaced fracture of the first cervical vertebrae, dementia, muscle weakness, and a history of falls, also experienced a deficiency in care planning. After a fall that resulted in a neck fracture, the hospital provided explicit instructions to keep a neck collar on at all times. However, there was no order for the neck brace in the resident's record, and the care plan did not reflect the need for the neck brace until much later. Observations and interviews confirmed the resident wore the neck brace inconsistently, and staff were unsure if there was an order for it. The facility's policy on care planning, revised in December 2022, states that the interdisciplinary team will coordinate with the resident and their responsible party to create an appropriate plan of care based on assessments and reassessments. However, the facility failed to adhere to this policy, resulting in incomplete and outdated care plans for both residents. This deficiency was discovered during a complaint investigation.
Failure to Remove Indwelling Urinary Catheter as Ordered
Penalty
Summary
The facility failed to remove an indwelling urinary catheter for Resident #20 as ordered and did not provide justification for its continued use. Resident #20, who had medical diagnoses including Sjogren syndrome, lack of coordination, muscle weakness, and a displaced fracture of the surgical neck of the left humerus, was hospitalized for pneumonia and returned to the facility with an indwelling urinary catheter. The physician's order indicated the catheter was to be removed on the night shift of 03/04/24, but records show it was not removed and remained in place throughout March 2024. Observations and interviews confirmed that the catheter was never removed as ordered, and there was no documentation explaining the need for its continued use. The care plan for Resident #20, which was revised in June 2022, did not reflect the presence of an indwelling urinary catheter, instead noting the resident's frequent incontinence of bowel and bladder. Interviews with staff, including an STNA, LPN, and the Unit Manager, revealed a lack of awareness and documentation regarding the catheter's continued use. The Unit Manager admitted to transcribing the order for catheter removal but was unsure why it had not been discontinued. The MDS Nurse later confirmed that the physician ordered the catheter's removal on 04/02/24, with instructions to monitor the resident's ability to void and reinsert if necessary after 24 hours.
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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