Bella Terrace Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 1520 Hawthorne Avenue, Columbus, Ohio 43203
- CMS Provider Number
- 366207
- Inspections on file
- 54
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 45 (1 serious)
Citation history
Health deficiencies cited at Bella Terrace Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The deficiency centers on inadequate supervision and environmental safety, where a cognitively impaired, high‑elopement‑risk resident ordered to reside on a secured memory care unit was taken off that unit for smoking and then left unattended at an elevator on an unsecured floor, allowing the resident to exit through the front door and later be found over a mile away and hospitalized for NSTEMI, acute kidney injury, and dehydration. Another cognitively and communicatively impaired resident, assessed as high risk for elopement and lacking an elopement care plan, left the building alone during the night, was not promptly missed, and law enforcement was not notified until more than seven hours after her departure, despite prior orders to monitor wandering. Additionally, an RN brought a firearm into the building in a coat pocket, hung the coat in the medication room, and during a break the weapon discharged in a common area near resident rooms, causing damage to the floor and wall, while the RN did not immediately disclose the presence or discharge of the firearm, contrary to the facility’s written prohibition on weapons.
Surveyors identified widespread failure to maintain a safe, sanitary, and homelike environment, including a dining cart held together with duct tape, meals served on disposable plates with plastic utensils that residents found difficult to use, and multiple missing or damaged ceiling tiles following leaks and collapses. Common areas and hallways had extensive scuffing, grime buildup, water-stained or crumbling ceilings, and out-of-order public bathrooms and an elevator over an extended period. Numerous resident rooms contained rusted sinks, crumbling or missing drywall, exposed wiring and cable, loose or falling wall bars and grab bars, damaged or inadequate furniture, non-draining or leaking sinks, and very dim lighting, with several residents reporting difficulty opening swollen doors, inability to use call lights, and dissatisfaction with room conditions. Shower rooms had piles of wet towels left on the floor and dusty fans, and staff, including maintenance leadership, repeatedly confirmed that these areas and fixtures had not been maintained.
Surveyors identified a persistent cockroach and insect infestation throughout the facility, with dead insects observed in dining and common areas and a live cockroach seen in a shower room. Multiple residents reported seeing cockroaches in their rooms, hallways, and near the kitchen, with some killing several roaches daily and describing the building as heavily infested. Staff, including maintenance and dietary leadership, acknowledged ongoing cockroach problems, and a severe infestation was found in the room of a hoarding resident, requiring targeted extermination, while pest control records showed repeated treatments focused on cockroach eradication.
Two residents were affected when staff failed to follow physician orders and facility medication administration policy. One resident with chronic pain and recent shoulder surgery continued to receive Percocet after the NP had discontinued the order, and the DON confirmed the opioid was administered without a valid physician order. Another cognitively impaired resident with multiple neurological and psychiatric diagnoses was sent to the ED after a nurse accidentally administered approximately 22 mg of melatonin, despite there being no physician order for melatonin. These events occurred despite a facility policy requiring medications to be administered only as ordered and verified for the correct resident, medication, dose, time, and route.
Multiple deficiencies were identified, including persistent high temperatures due to HVAC failures, damaged and missing fixtures in resident rooms and bathrooms, non-functional hand hygiene equipment, and prolonged disrepair of essential care areas such as shower and therapy rooms. Residents and staff reported discomfort and limited access to necessary facilities, with maintenance issues confirmed through direct observation and staff interviews.
The facility did not maintain required indoor temperatures, with multiple rooms and common areas exceeding 81 degrees due to ongoing HVAC failures. Several residents reported discomfort from the heat, and staff confirmed that therapy was moved out of overheated areas. Despite the use of fans and portable AC units, the facility failed to keep temperatures within policy limits.
A resident with multiple medical conditions, including hemiplegia and depression, had not received a haircut since admission and expressed a desire for one. The facility had not maintained a beauty shop license for several years, preventing residents from accessing barber or beauty salon services on-site.
Two residents who required assistance with activities of daily living did not receive proper nail care, resulting in long, jagged, and unclean nails. One resident reported having to rip off his own fingernails, while another had not received podiatry services since admission. Staff interviews and record reviews confirmed that nail care was not provided as required by facility policy, and care plan interventions for nail care were not implemented.
The facility failed to remove surgical staples as ordered and did not administer prescribed antibiotics or notify the physician about missed doses for two residents. The DON was unaware of the staple removal order, and there was no documentation of physician notification regarding missed antibiotic doses or order clarification.
Two residents with significant vision and hearing impairments did not receive timely optometry care. One resident had not seen an eye doctor since admission and could not locate her glasses, despite requests from her guardian to access ancillary services. Another resident, admitted with broken glasses and severe hearing loss, was not scheduled for a vision appointment and staff were unaware of the condition of the glasses.
A resident with multiple complex diagnoses, including a stage III sacral pressure ulcer, did not receive a comprehensive, individualized treatment plan for pressure ulcer prevention and management. Upon admission, there was no documentation of wound size or description, no immediate treatment orders, and delayed wound assessment and documentation. The air mattress was set above the resident's current weight, and only the sacral ulcer was identified and documented, contrary to facility policy requiring prompt and detailed wound care.
Two residents identified as high fall risk did not receive timely or appropriate fall prevention interventions, and post-fall assessments were inadequately documented. In one case, a mattress was used instead of a mat as ordered, and in another, interventions like a low bed and grab bars were not in place until after a fall resulted in a hematoma. Documentation of injuries and interventions was inconsistent, and communication gaps were noted between staff and family members.
An LPN failed to perform hand hygiene during medication administration for three residents, violating the facility's infection control procedures. The LPN did not wash or sanitize hands before and after administering medications, except after the third resident, despite Enhanced Barrier Precautions being in place.
The facility failed to timely notify resident representatives during an emergency evacuation due to a power outage, affecting 61 residents. The evacuation occurred without prior notification to all representatives, as the facility lacked electricity to charge communication devices. Notifications were completed the following day, with some representatives reached directly and others via voicemail or not at all due to disconnected phones or incorrect numbers. Facility policies lacked specific guidance on notifying representatives during evacuations.
The facility's kitchen was found to be unsanitary, with significant cockroach infestation and structural issues affecting food safety. Inspection reports noted dirty food contact surfaces, damaged physical facilities, and inadequate pest control. Interviews confirmed the kitchen's closure for deep cleaning, but ongoing issues persisted, highlighting a failure to adhere to sanitation policies.
The facility failed to control a cockroach infestation affecting the kitchen and resident areas, leading to a temporary kitchen closure and ongoing pest sightings. Despite pest control efforts, live cockroaches were found in the kitchen and Resident #63's bathroom, where a large hole and stagnant water were present. Staff confirmed widespread pest sightings and reported maintenance issues, but the infestation persisted, indicating deficiencies in pest control and maintenance practices.
The facility failed to ensure that two residents who were dependent on staff assistance received baths/showers as scheduled or requested. One resident received only 10 out of 28 scheduled baths/showers, and another received only six out of 22 scheduled baths/showers. Documentation and interviews confirmed the deficiency.
Elopements of High-Risk Residents and Firearm Discharge Due to Inadequate Supervision and Safety Controls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment, resulting in multiple elopements and the presence and discharge of a firearm inside the building. One cognitively impaired resident with vascular dementia, severe cognitive impairment, and a documented high risk for elopement was ordered to reside on a secured memory care unit. His care plan and secured unit screener specified that he was an elopement risk, wandered or would wander out of the facility, required a secure unit per physician order, and needed a structured environment with specialized activities. Despite these assessments and orders, a CNA took him off the secured unit to smoke with other memory care residents, then left him unattended at the elevator in the first‑floor lobby, pressing the elevator button and walking away. Video review later showed the resident leaving through the front door a few minutes later, while the front desk receptionist was at lunch, and staff did not realize he was missing from the secured unit until over an hour later. The same resident’s elopement was reconstructed through staff witness statements, facility investigation, and external records. Staff statements indicated that the resident was last seen on the secured unit around breakfast and morning rounds, then taken out to smoke around late morning. After the smoke break, the CNA who escorted him did not remain with him, and he was left in an unsecured area. Nursing staff and activities staff later searched the unit and building after he was reported missing, and the DON notified police and the resident’s responsible parties. A police report and hospital records documented that bystanders found the resident on a sidewalk approximately 1.2 miles from the facility, in hot weather conditions, after he had walked away from the building and crossed a high‑traffic multi‑lane street. Hospital documentation showed he was brought to the ED by EMS after a witnessed fall and was treated for a non‑ST elevation myocardial infarction, acute kidney injury, and slight dehydration. A second cognitively impaired resident with aphasia following a stroke, communication deficits, impaired insight and memory, and documented lack of medical decision‑making capacity was assessed by the facility as high risk for elopement shortly after admission. The interim care plan noted cognitive and visual impairment and that the resident would not be able to easily communicate with staff, and physician orders directed staff to monitor behaviors including wandering. However, the resident did not have a care plan addressing her identified high elopement risk. She left the facility unattended in the early morning hours, as later confirmed by facility video reviewed by police, and was seen by another resident packing her bags and crossing streets near the parking lot. Nursing notes showed that staff initially searched the building and grounds without finding her, notified the physician and on‑call nurse, and contacted family members hours after she had left. Family interviews and the police missing persons detective confirmed there was a delay of more than seven hours between the time she exited the building and when law enforcement was notified, during which time she remained away from the facility until returning later that day. The facility also failed to maintain a safe environment when an RN brought a firearm into the building and it discharged in a common area near resident rooms on the second floor. According to the regional director of operations and the police preliminary investigation report, the RN stated he had a firearm in his coat pocket, forgot it was there when he came to work, and hung the coat in the locked medication room. During a break, he put the coat on, placed his hand in the pocket, and the firearm discharged, creating a bullet hole in the floor and a ricochet into the wall of a resident room. Staff and residents on the unit heard a loud bang and saw dust and damage to the floor and wall, and one CNA reported finding bullet casings on the floor. The RN did not immediately inform other staff about the firearm or the cause of the loud noise and smoke, and management only learned of the incident later during their investigation. This occurred despite a written facility policy prohibiting employees, residents, visitors, vendors, or others from possessing firearms or other weapons on the premises. In addition, review of the facility’s elopement policy revealed it required staff to investigate and report all cases of missing residents but did not contain safety measures or protocols to identify residents at risk for potential elopement. This lack of detailed procedural guidance existed alongside the documented cases in which one resident at high risk for elopement on a secured unit was taken off that unit and left unsupervised in an unsecured area, and another high‑risk resident with significant communication and cognitive deficits had no elopement care plan and was able to leave the building unaccompanied during the night. These combined findings formed the basis of the cited deficiency for failure to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents.
Removal Plan
- Completed a Root Cause Analysis by the Administrator with input from the management team.
- Created a list of residents on the secured unit who are smokers and distributed it to staff.
- Completed whole house elopement risk assessments and updated care plans accordingly by the DON and Unit Manager LPN #262.
- Held an ad-hoc QAPI meeting to discuss elopement policy best practices and supervision of secured unit residents while off the secured unit.
- Updated the bed board to include leave of absence status after review of current resident room locations and new elopement risk assessment.
- Educated all staff on the elopement policy best practices and supervision of residents off the secured unit.
- Updated staff smoking assignments.
- Updated the facility's elopement binders to include resident's name and picture, current smokers list, elopement policy and missing resident best practices.
- Conduct audits three times a week for four weeks to ensure any resident taken off the secured unit is supervised at all times while off the unit.
- Conduct elopement drills once a week on day shift and once a week on night shift for four weeks.
Widespread Environmental Disrepair and Unsanitary Conditions Throughout Facility
Penalty
Summary
The facility failed to ensure a safe, sanitary, and homelike environment for all 85 residents, as evidenced by multiple observations of disrepair, unclean conditions, and inadequate equipment throughout the building. On the third floor, the dining cart was held together with duct tape, and residents were served meals in polystyrene foam containers with plastic utensils. One resident reported difficulty cutting food with a plastic fork on the disposable containers, and another resident stated being tired of eating on disposable plates. The Dietary Supervisor confirmed that disposable plates were being used because the boiler was under repair. In the memory care unit, a large section of ceiling tiles was missing after a ceiling collapse, and the Maintenance Director acknowledged the damage but stated he had to prioritize heater repairs. Additional observations showed widespread physical deterioration and non-functioning equipment in common areas and resident rooms. The main elevator had extensive scratches and gouges on the walls and dust on the ceiling grid, hallways and lobby walls were heavily scuffed, and ceiling tiles were missing or water-stained in several locations, including near a vending machine and in a second-floor shower room where a ceiling tile was crumbling. Multiple public bathrooms on all three floors were marked out of order, and a back elevator remained out of order over an extended period. There were active and recurrent water leaks, including wet blankets and caution signs in a second-floor hallway and chapel, and a burst pipe with an active leak managed with buckets and towels. The President of Plant Operations stated the building had very old cast iron pipes that could only be repaired as they broke and confirmed the crumbling ceiling and repeated pipe breaks. Within resident rooms, numerous deficiencies were documented, including rusted sinks and drains, missing laminate, crumbling or missing drywall, exposed cable and wiring, loose or falling wall bars, loose grab bars by toilets, and damaged or old furniture such as bedside tables and wardrobes in disrepair. Several residents reported issues directly: one resident had only a desk and no dresser and a slow-draining sink; another had a swollen door that was difficult to open, a non-draining sink, and loose sink lamination; another demonstrated that the foot of his bed would not raise and the headboard was detached, with a telephone outlet dangling from the wall with exposed wires. In one room, a resident’s call light was pulled out from the wall, and the resident stated she had to yell out for assistance. Other residents reported dissatisfaction with marred walls, damaged areas around sinks, and missing or inadequate furniture such as chairs and dressers. Lighting and cleanliness issues were also prevalent. Several rooms were described as very dim even with all lights on, and some light fixtures were missing covers, leaving exposed bulbs. In multiple rooms, there were stains on ceilings, apparent water damage, and what was described as dark staining potentially resembling mold. In the front lobby and adjacent hallways, there was approximately two inches of dark grime along the edge of the flooring by the walls, which remained present over multiple days until a housekeeper was observed scraping it. In shower rooms, there were piles of wet towels left on the floor on more than one occasion, and an overhead fan in a memory care shower room was covered in dust; a CNA stated she did not know who was responsible for cleaning the fan. Throughout the building, staff including the Maintenance Director, Regional Maintenance Director, and President of Plant Operations toured the cited areas and verified that the described areas had not been maintained. Handrails and safety fixtures in resident bathrooms and rooms were also compromised. One resident had a very loose handrail by the toilet with rust near the pipe and a sink with missing enamel and a sharp edge, along with exposed drywall and ripped wall areas. Another resident’s sink lacked hot water, and the wall around the sink was partially unpainted; this resident also noted the absence of a chair they wanted in the room. In common areas, chunks of wall were missing, hallway railings were marred along their length, and paint was missing in multiple locations. Across various rooms and hallways, there were chips in floor tiles, missing baseboards, missing trim, and marred or gashed doors. These conditions, confirmed by multiple staff interviews and walk-throughs, demonstrate a pattern of failure to maintain the building, equipment, and environment in a safe, sanitary, and homelike condition for residents, staff, and the public. In several instances, residents explicitly described how these environmental deficiencies affected their daily experience. Residents reported difficulty using plastic utensils on disposable plates, frustration with long-standing door and furniture problems, and concern about stains on ceilings above their beds. One resident confirmed that when turning on the sink, water came out onto the floor, and the entire sink and cabinet were not attached to the wall and could be tilted forward with a light touch. Another resident stated that the condition of the wall and area under the sink bothered him, and others expressed dissatisfaction with dim lighting and damaged surroundings. Staff interviews repeatedly confirmed awareness of many of these conditions, including broken fixtures, out-of-order bathrooms and elevators, water damage, and structural deterioration, without evidence in the report of timely correction prior to the survey observations.
Widespread Cockroach and Insect Infestation Throughout Facility
Penalty
Summary
The facility failed to maintain an environment free from pest infestation, specifically cockroaches and other insects, affecting resident rooms, hallways, dining, shower, and common areas. Surveyors observed multiple dead insects, including those resembling spiders and cockroaches, along the walls near windows in the first-floor dining room and on a second-floor windowsill near the memory care entrance. A live cockroach was observed crawling up the wall in the third-floor shower room, and German cockroaches were identified in at least one resident room and by the Regional Maintenance Director. Pest control work orders over several months documented repeated treatments of individual rooms and common areas, with the primary focus on cockroach eradication. Multiple residents reported ongoing cockroach activity throughout the building. One resident stated that roaches were so prevalent that it felt like the residents were living with them, describing roaches coming out when housekeeping mopped and climbing walls, causing fear they would fall on her. Another resident reported seeing cockroaches in her room, hallways, and coming from the kitchen, killing about half a dozen per day and wishing the entire building had been fumigated. Other residents described seeing one or two cockroaches in their rooms but more in hallways, feeling the insect issues were bad, or saying the place was “roached out” with roaches everywhere, especially at night. A resident reported seeing roaches come from under her bed, and another called the cockroaches his biggest complaint because they were repulsive. The Maintenance Director and Dietary Supervisor acknowledged cockroach issues, though they felt the situation was improving, and the Regional Maintenance Director reported finding a cockroach infestation in the room of a hoarding resident, requiring exterminator intervention.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders for two residents. One resident with vertebral fractures, neuropathy, chronic low back and shoulder pain, and a recent right rotator cuff repair had care plan interventions that included administering medications as ordered. Physician orders in December included a daily topical lidocaine patch and Percocet 7.5-325 mg PO every six hours as needed for pain, with the Percocet order starting on 12/23/25 and ending on 12/29/25. The resident’s prescription from an orthopedic surgeon also specified Percocet 7.5-325 mg every six hours as needed with a 10-day supply. The MAR showed Percocet was administered daily from 12/24/25 to 12/29/25, and progress notes documented that the DON received an order from an NP on 12/29/25 to discontinue Percocet due to the resident’s drug-seeking history. However, the controlled substance administration record showed Percocet was administered at least daily from 12/24/25 through 12/30/25, and the DON verified the resident continued to receive Percocet on 12/30/25 without a physician order. The second resident, admitted with diagnoses including insomnia, epilepsy, schizophrenia, anxiety, and senile degeneration of the brain, was cognitively impaired and required staff assistance with hygiene, dressing, and transfers. Progress notes documented that this resident was sent to a hospital for evaluation after receiving an excessive dose of melatonin. The hospital ED note stated the resident was evaluated for drug overdose after being accidentally administered approximately 22 mg of melatonin at the facility, and that the MD, after consulting the poison center, noted melatonin was not expected to cause concern and the resident was asymptomatic. The resident returned to the facility the same day with no new orders. Review of physician orders for the relevant period showed no orders for melatonin, and the DON confirmed that a nurse had administered approximately seven melatonin 3 mg tablets to the resident. Facility policy on administering medications required that medications be given in accordance with orders, that staff initial the MAR after each medication, and that the individual administering medications verify the right resident, medication, dose, time, and route by checking the label three times before administration.
Widespread Environmental and Maintenance Deficiencies Impact Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, staff, and the public, as evidenced by multiple deficiencies in temperature control, maintenance of resident rooms and common areas, and the functionality of essential equipment. Observations and documentation revealed that the HVAC system was not consistently operational, resulting in room and common area temperatures frequently exceeding the required range of 71 to 81 degrees. Residents and staff reported discomfort due to excessive heat, with temperatures in some areas reaching as high as 85 degrees. Work orders and interviews confirmed ongoing issues with the air conditioning system, including a malfunctioning cooling tower and improperly wired components, which led to repeated failures and inadequate cooling throughout the facility. In addition to temperature control issues, the facility exhibited widespread maintenance problems affecting resident safety and comfort. Multiple resident rooms and bathrooms lacked functional toilet paper holders, had damaged or missing vanities, delaminated furniture, and broken or chipped fixtures. Several hand sanitizer dispensers were non-functional, and some sinks were out of order without alternative hand hygiene options provided. Observations also noted significant wear and damage to furniture, flooring, walls, ceilings, and window seals, including leaking ceilings, missing floor tiles, and stained or unpainted surfaces. In one case, a resident's mattress did not fit the bed frame, creating a large gap and potential safety concern, which persisted over several days without resolution. Essential resident care areas, such as shower rooms and therapy rooms, were also found to be in disrepair or unusable. A large shower room was out of order for an extended period due to a ruptured water pipe, with exposed wall material and visible dark substances in the corners. The therapy room was excessively hot, limiting its use for resident therapy sessions. Interviews with staff confirmed the ongoing nature of these issues and the lack of timely maintenance or alternative accommodations for affected residents. These deficiencies were substantiated through direct observation, review of work orders, facility policies, and staff and resident interviews.
Failure to Maintain Safe and Comfortable Indoor Temperatures
Penalty
Summary
The facility failed to maintain a comfortable temperature range for residents, as required by policy, resulting in room and common area temperatures consistently exceeding the upper limit of 81 degrees. Temperature logs and direct observations showed that several resident rooms and common areas reached temperatures between 81 and 85 degrees, with some air conditioning units not functioning and windows left open. Multiple residents reported feeling hot, and staff confirmed that therapy was moved to resident rooms due to excessive heat in the therapy room. The issue was compounded by a malfunctioning cooling tower, which had previously required significant repairs and temporary equipment, and by a wiring error that caused the cooling system to fail again after repairs were completed. Work orders and interviews indicated ongoing problems with the air conditioning system, including specific reports of non-functioning units in resident rooms and common areas. The facility attempted to mitigate the heat by providing fans and portable air conditioning units, encouraging fluid intake, and relocating residents to cooler areas when possible. Despite these efforts, the facility did not maintain the required temperature range, and residents continued to experience discomfort due to elevated indoor temperatures during a period of high outdoor heat.
Failure to Provide Barber Services for Resident
Penalty
Summary
The facility failed to provide barber services for a resident who was admitted with diagnoses including hemiplegia, hemiparesis, depression, and adjustment disorder with anxiety. The resident was found to be cognitively intact and reported not having received a haircut since admission, expressing a desire for one. Observation confirmed that the resident's hair was below shoulder length. The Licensed Nursing Home Administrator confirmed that the facility had not maintained a beauty shop license since 2021, and as a result, residents were unable to receive haircuts or beauty salon services within the facility.
Failure to Provide Nail Care to Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care to dependent residents, as evidenced by observations, interviews, and record reviews. One resident with multiple medical conditions, including vertebral fractures, malnutrition, and cognitive communication deficits, reported not receiving nail care since admission. He stated he had to rip off his own fingernails, which were observed to be jagged, with sharp edges and dark debris underneath, and his toenails were also long. Staff interviews confirmed that nail care had not been provided, and the LPN indicated that nail care was only performed in the activity room and not in individual rooms unless residents were on a locked unit. The facility's policy required daily cleaning and regular trimming of nails, with documentation of care provided, but this was not followed for the resident. Another resident with a history of dementia, diabetes, and psychiatric disorders was observed to have very long toenails and reported not having seen a podiatrist for nail care since admission. Review of facility records confirmed the resident was not on the podiatry list, and the DON verified that no ancillary services had been provided since admission. The resident's care plan included interventions for nail care on bath days and as necessary, but these interventions were not implemented. These findings demonstrate a failure to provide necessary assistance with activities of daily living, specifically nail care, for residents who were dependent on staff for this aspect of personal hygiene.
Failure to Follow Physician Orders for Surgical Staple Removal and Antibiotic Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and professional standards for two residents. For one resident admitted with multiple diagnoses including staphylococcal arthritis, osteomyelitis, and diabetes, the after visit summary from the hospital specified that surgical staples were to be removed by facility staff two weeks post-operation. However, the Director of Nursing (DON) was unaware of this order and initially believed the resident would not allow staff to remove the staples. The DON later confirmed the order and that the resident permitted removal, but this occurred after the scheduled date. For another resident admitted with osteomyelitis, CHF, and diabetes, there were multiple physician orders for intravenous Daptomycin to treat a staph infection. The medication was not administered on two occasions, with one instance lacking a documented reason and another citing the pharmacy's care. Additionally, there was no documentation that the physician was notified about the need for order clarification or the missed antibiotic doses, as required by facility policy. The DON confirmed these lapses in medication administration and communication.
Failure to Provide Timely Vision Care to Residents
Penalty
Summary
The facility failed to provide adequate and timely vision care to two residents. One resident, admitted with multiple diagnoses including dementia and psychiatric disorders, reported wearing glasses for distance vision prior to admission but had not seen an eye doctor since entering the facility. The resident was unable to locate her glasses and there was no evidence in her record of an optometry consult during her stay. Her guardian confirmed the resident was eligible for veteran's benefits and had previously requested staff assistance in accessing ancillary services, but no such services had been arranged. The Director of Nursing verified that the resident had not received optometry care since admission. Another resident, admitted with complex medical conditions including encephalopathy, HIV, malnutrition, and sensorineural hearing loss, was documented as having impaired vision and hearing. The resident was observed wearing broken glasses with only one lens and tape holding the frame together. Despite these issues, the resident was not included on the list for vision appointments, and staff interviews confirmed the resident had not seen an eye doctor since admission. Staff were also unaware of the condition of the resident's glasses. These findings were based on observation, record review, and interviews, and affected two of three residents reviewed for vision care.
Failure to Provide Comprehensive Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide a comprehensive, resident-centered treatment plan for the prevention and management of pressure ulcers for a resident admitted with multiple complex medical conditions, including a stage III sacral pressure ulcer. Upon admission, the care plan noted the presence of pressure ulcers but did not document the size or provide a description of the wounds, and there were no treatment orders in place for the wounds to the right buttock or sacrum. The initial wound assessment and documentation were delayed until an outside wound doctor evaluated the resident several days after admission, at which point the stage III sacral ulcer was measured and described. Treatment orders for the sacral wound were not documented on the treatment administration record until several days after admission. Further review revealed that the care plan interventions included the use of an air mattress and regular repositioning, but the air mattress was set to a weight higher than the resident's current weight, as verified by staff and the DON. There was also a lack of documentation regarding the pressure ulcer to the right buttock, and only the sacral ulcer was identified by the wound doctor. The facility's wound and skin care policy required prompt initiation of a wound program, weekly measurements, and detailed documentation, which were not followed in this case.
Failure to Implement and Document Comprehensive Fall Prevention and Post-Fall Assessment
Penalty
Summary
The facility failed to provide a comprehensive, resident-centered fall prevention plan and did not adequately assess residents after a fall, affecting two of three residents reviewed. For one resident with multiple diagnoses including epilepsy, schizophrenia, repeated falls, and agitation, the physician ordered a low bed with a mat beside the bed. However, observations revealed a mattress, not a mat, was placed on the floor, and the Director of Nursing confirmed this discrepancy between the physician's order and what was implemented. Another resident, admitted with a history of falls and multiple medical conditions such as a pubic fracture, diabetes, and seizures, was identified as high risk for falls. The care plan included interventions like a low bed, mat, and grab bars, but these were not implemented until after the resident experienced a fall from bed, resulting in a hematoma above the left eye. Documentation of the fall and injury was inconsistent and incomplete, with delayed and conflicting entries regarding the size and description of the hematoma. The initial fall documentation was not part of the official medical record, and there was no clear record of whether fall prevention interventions were in place at the time of the incident. Interviews with the DON and the resident's family revealed further gaps in communication and documentation. The family had informed staff of the resident's fall risk upon admission and requested bed rails, but staff indicated a physician order was required. The DON confirmed that documentation did not verify if the bed was in a low position or if nonskid socks were used as intended. The facility's fall policy required follow-up on any fall with injury, but there was no evidence that this was consistently followed, as documentation of injury assessment and intervention implementation was lacking.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration, affecting three residents. During an observation, an LPN was seen preparing and administering medications to residents without washing or sanitizing their hands before and after the process. Specifically, the LPN did not perform hand hygiene before preparing medications for the first resident and continued this practice with the second resident, even after donning and removing personal protective equipment due to Enhanced Barrier Precautions. The LPN only sanitized their hands after administering medications to the third resident. This was confirmed during an interview with the LPN, who acknowledged the failure to follow the facility's infection control procedures, which require handwashing or sanitizing before and after administering medications to each resident. The facility's policy on administering medications emphasizes the importance of following established infection control procedures, including hand hygiene.
Failure to Timely Notify Resident Representatives During Emergency Evacuation
Penalty
Summary
The facility failed to provide timely notification to resident representatives and guardians regarding a temporary discharge due to an emergency evacuation. This affected 61 out of 91 residents at the facility. The evacuation was necessitated by a power outage that began on July 22, 2024, at approximately 12:30 P.M., which led to the temporary relocation of all residents by 11:30 P.M. the same day. However, due to the lack of electricity, the facility was unable to contact all family members and representatives until the following day, July 23, 2024. Interviews with the Administrator revealed that while some family members were contacted during the evacuation, the facility could not reach all representatives until staff members went home to charge their devices. The facility's records showed that the notifications to the residents' representatives were made on July 23, 2024, with varying success. Some representatives were reached directly, while others received voicemail messages or could not be contacted due to disconnected phones or incorrect numbers. The facility's policies, including the Emergency Procedure-Immediate Evacuation policy and the Change in a Resident's Condition or Status policy, were reviewed. The Emergency Procedure policy, dated January 2011, lacked documentation on notifying family members during evacuations. The Change in a Resident's Condition or Status policy, dated May 2017, stated that the facility should promptly notify representatives of changes in a resident's status, but it did not specifically address evacuation scenarios. This deficiency was investigated under Complaint Number OH00156156.
Unsanitary Kitchen Conditions and Pest Infestation
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect all 95 residents who received food from the kitchen. The City of Columbus Inspection Report noted dirty food contact surfaces and dust hanging from vents in the dish area. A subsequent State of Ohio Food Inspection Report revealed a significant infestation of cockroaches throughout the kitchen, including under sinks, around cooking equipment, and inside the stand mixer cover. Additionally, there were issues with the plumbing system, damaged physical facilities, and dirty non-food contact surfaces, all contributing to the unsanitary conditions. The inspection reports highlighted several structural and maintenance issues, such as water-damaged ceiling tiles, cracked flooring, and holes along the walls. The baseboards throughout the kitchen and dishwashing areas were peeling off and not sealed, allowing for potential pest entry. Equipment was not maintained in good working order, with openings in the sink and stove areas needing sealing. The facility's policies on sanitation and infection control were not adhered to, as evidenced by the presence of food debris, grease, and dirt on various surfaces and equipment. Interviews with the Dietary Supervisor and the Administrator confirmed the kitchen's closure due to the cockroach infestation and the need for a deep cleaning. Despite efforts to clean and reopen the kitchen, observations revealed ongoing issues, such as live cockroaches under cup drying racks and food debris attracting pests. The facility's failure to routinely clean and maintain the kitchen environment according to their policies contributed to the unsanitary conditions and the subsequent health department interventions.
Cockroach Infestation and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant cockroach infestation that affected the entire facility, including the kitchen and resident areas. The State of Ohio Food Inspection Report noted the presence of 20 to 30 cockroaches in various stages of life throughout the kitchen, including under sinks, around cooking equipment, and inside the stand mixer cover. This led to an emergency notice and temporary closure of the kitchen due to imminent danger to public health. Despite efforts to clean and repair the kitchen, subsequent observations revealed ongoing issues with cockroaches, including live sightings and food debris attracting pests. In addition to the kitchen, the infestation extended to resident areas, as evidenced by the condition of Resident #63's bathroom. A large hole under the toilet, stagnant water, and live cockroaches were observed, with the resident confirming the issue had been present since their admission. Despite reports to nursing staff and maintenance, the problem persisted, indicating a lack of timely response to maintenance requests. Interviews with staff confirmed awareness of the pest issue, but there was a disconnect in addressing the maintenance needs effectively. Further interviews with housekeeping and nursing staff revealed widespread sightings of cockroaches along baseboards, walls, and throughout resident care areas. Staff reported using cleaner to spray pests upon identification and notifying maintenance, but the infestation continued. The facility's pest control work orders indicated treatment in various areas, but the ongoing presence of cockroaches highlighted deficiencies in the pest control program and maintenance practices, contributing to the non-compliance investigated under the complaint.
Failure to Provide Scheduled Baths/Showers
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff assistance received baths/showers as scheduled or requested. This deficiency affected two residents. Resident #68, who had multiple diagnoses including cerebral infarction and hemiplegia, was scheduled to receive baths or showers on Mondays and Thursdays. However, from January 1, 2024, to April 7, 2024, Resident #68 only received 10 out of the 28 scheduled baths/showers. The facility's documentation confirmed the lack of adherence to the bathing schedule, and the administrator acknowledged the absence of additional documentation to indicate that the resident was offered or received the baths/showers as scheduled or requested. Similarly, Resident #73, who had diagnoses including spinal stenosis and major depressive disorder, was scheduled to receive baths or showers on Wednesdays and Saturdays. From January 22, 2024, to April 7, 2024, Resident #73 only received six out of the 22 scheduled baths/showers. Interviews with State Tested Nursing Aides (STNAs) confirmed that if a shower form was not filled out, it likely meant the bath/shower was not offered or completed. Resident #73 also confirmed that she did not receive showers as scheduled or requested. The administrator confirmed the lack of additional documentation to indicate that the resident was offered or received the baths/showers as scheduled or requested.
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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