Bellbrook Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellbrook, Ohio.
- Location
- 1957 North Lakeman Drive, Bellbrook, Ohio 45305
- CMS Provider Number
- 365626
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Bellbrook Health And Rehab during CMS and state inspections, most recent first.
A cognitively intact resident with multiple psychiatric and medical diagnoses reported to a provider that an LPN became angry, yelled, and used profanity toward them. This allegation of verbal abuse was documented in the medical record but was not entered into the facility’s SRI system, and the Administrator was not informed, so no timely reporting or investigation occurred as required by the facility’s abuse policy and federal timeframes.
Two residents experienced significant medication errors when staff administered drugs not in accordance with prescriber orders. One resident with multiple cardiovascular and neurologic conditions and moderate cognitive impairment reported severe chest pain; a CNA observed an LPN place a medication under the resident’s tongue, and hospital documentation reflected that the resident reported receiving sublingual nitroglycerin, despite no order for nitroglycerin on the MAR and the NP confirming no such order was given. Another resident with a history of cerebral infarction, hemiplegia, traumatic brain injury, and sepsis due to MRSA was documented in the incident log as having received the wrong IV antibiotic when a trainee nurse retrieved IV ceftriaxone from the medication refrigerator and started the infusion, after verification with a training nurse, instead of the ordered IV cefepime; the MAR showed an order only for cefepime, and the DON confirmed the wrong antibiotic had been administered.
A resident with multiple medical conditions and moderately impaired cognition refused a prepared dose of pregabalin, a controlled substance, after an LPN had removed the capsule from the narcotic drawer, signed it out, and emptied the contents into a medication cup. When the medication was refused, staff were unable to locate any designated waste solution for controlled substances, and the DON instructed the LPN to flush the pregabalin and other refused medications down the toilet. The LPN disposed of the controlled substance alone in an empty room without a second licensed nurse to witness the destruction, contrary to facility policy and Ohio regulatory requirements for controlled substance disposal and witnessing.
A resident with multiple cardiovascular and neurologic diagnoses, including cerebral infarction, paroxysmal atrial fibrillation, and hypertension, experienced chest pain and was given a sublingual nitroglycerin tablet before being sent to the hospital. An incident report, hospital H&P, SBAR note, and a CNA interview all confirmed that a sublingual medication was administered for chest pain, but there was no corresponding documentation in the resident’s progress notes or MAR. The DON confirmed that, apart from the incident report notation about medication given without an order, the facility lacked any medical record entry showing that sublingual nitroglycerin had been administered.
Surveyors found that the facility did not maintain its courtyard in good repair, despite residents having access to the area. A raised planter box was broken with exposed rusty nails, an inoperable portable heater was left on the concrete nearby, the surrounding wooden fence was loose and leaning into the courtyard and held up by a bag of sand, and a wooden picnic table had peeling paint and deteriorating wood. These conditions were confirmed with the Administrator and were inconsistent with the facility’s Homelike Environment policy requiring a clean, sanitary, and orderly environment.
A resident with epilepsy and moderately impaired cognition experienced a seizure lasting several minutes, during which the resident had difficulty breathing and was given scheduled Keppra and oxygen by an LPN, despite no existing oxygen order and the resident not typically requiring oxygen. The event was not documented in the medical record, and neither the provider nor the resident’s representative was notified at the time, even though the care plan and the facility’s acute condition change protocol required reporting seizure activity and contacting the physician. Another LPN involved confirmed that no provider notification occurred, and the NP later stated she was not informed of the seizure until days afterward.
A resident with stroke, dementia, type 2 DM, depression, anxiety, and polyneuropathy, who was cognitively impaired and dependent on staff for ADLs, did not receive adequate nail care as outlined in the care plan and facility ADL policy. Surveyors observed that the resident’s fingernails were overgrown and encrusted with a dark brown substance, and the resident reported staff had not offered to clean or trim them. A CNA acknowledged the nails were long and dirty and cited limitations on CNAs cutting the nails of diabetic residents, while an LPN stated CNAs were expected to clean and trim nails during bathing and that nurses or a podiatrist were responsible for trimming nails of residents with diabetes. Later observation showed the nails had been cleaned but remained uncut, demonstrating a failure to ensure complete nail care for this dependent resident.
A resident with acute respiratory failure, tracheostomy status, and multiple peripheral IV lines did not receive ordered wound vac dressing changes or documented IV site care during a short stay. The abdominal wound vac was applied once, but no subsequent dressing changes were recorded on the ordered schedule, and no skin or wound assessments were documented from admission through discharge. Despite IV pump alarms, painful IV access, and erythema under a transparent dressing that led to removal of one line and continuation of IV therapy through another site, there was no documentation of IV site care or monitoring. The DON confirmed the absence of skin/wound assessments, wound vac changes, and IV site care for this resident throughout the stay.
A resident with impaired cognition, hemiplegia, and dependence on staff for ADLs had a care plan and fall investigation specifying bilateral fall mats at the bedside and a call light within reach while in bed. Surveyors repeatedly observed the resident in bed without required fall mats in place—sometimes with no mats on the floor, sometimes with only one mat, and at times with a mat leaning against the wall. The resident also reported needing help with briefs while the call light lay on the floor out of reach, which staff confirmed. These observations showed that the facility did not consistently implement the resident’s fall-prevention interventions or ensure access to the call system as required by facility policy.
A resident with multiple medical conditions was discharged without a proper discharge plan, summary, or physician orders, and was sent home without insulin or a primary care physician in place. The facility also failed to notify the local ombudsman office of the discharge, as required, due to sending information to an incorrect fax number.
A resident with stage four pressure ulcers was not repositioned as required by their care plan, leading to a deficiency finding. Despite being at high risk for pressure ulcers, the resident was left on their left side for over two hours without repositioning. Staff interviews revealed lapses in care provision, with some staff not present or not providing care during their shifts. The facility's policy on pressure injury prevention was not followed, resulting in non-compliance.
A facility failed to follow enhanced barrier precautions for a resident with anoxic brain damage and stage four pressure ulcers. Staff entered the resident's room with a treatment cart and only wore gloves, neglecting additional PPE. A nurse aide, after touching soiled items, retrieved supplies from the cart without changing gloves, contaminating the supplies. Interviews confirmed the cart should not have been in the room and proper PPE was not used.
The facility failed to maintain exterior windows in resident rooms, affecting seven residents. Observations revealed plastic covering windows in two rooms to prevent cold air, and five rooms had missing screens. Interviews confirmed these issues, with one resident reporting a squirrel entering her room due to the lack of a screen. The Maintenance Director acknowledged the problems and lack of documentation for repairs.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse and initiate an investigation in accordance with its abuse reporting policy and federal requirements. Resident #23, admitted on 02/02/26 with diagnoses including bipolar disorder (current episode manic without psychotic features, moderate), anxiety disorder, hypothyroidism, mixed hyperlipidemia, major depressive disorder (single episode, severe, without psychotic features), and hypertension, was documented as cognitively intact on the admission MDS. The MDS also showed the resident required supervision for toileting, bathing, dressing, and transfers, setup assistance for oral and personal hygiene, and was independent with eating and bed mobility. On 02/16/26, a provider visit note signed by Former Nurse Practitioner #175 documented that Resident #23 reported an incident in which a staff member, identified as LPN #94, became angry, yelled, and used profanity toward the resident. Review of the facility’s electronic Self-Reported Incidents (SRI) system from 02/16/26 to 03/11/26 showed no alleged incidents involving this resident had been entered. During an interview on 03/11/26, the Administrator stated she had not been informed of any abuse allegation involving LPN #94 and Resident #23 and indicated she would have reported and investigated the allegation if she had been made aware. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised 04/2021, showed the facility was required to investigate and report any allegations within federally required timeframes; this did not occur for the allegation involving Resident #23.
Significant Medication Errors Involving Unauthorized Nitroglycerin and Wrong IV Antibiotic
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically involving two residents who received medications not in accordance with prescriber orders. One resident with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension, and who had moderately impaired cognition, reported severe chest pain rated 9/10 one morning. Documentation in the resident’s progress and SBAR note showed the resident was sent to the emergency department after the onset of chest pain and that the primary care clinician (a nurse practitioner) was notified, but there was no documentation of any medication administered in response to the chest pain in the medical record. An incident report prepared by the DON documented that the resident complained of chest pain, vital signs were taken, the NP was called, and that medication was given to the resident without an order before the resident was sent to the ER. A hospital history and physical note recorded that the patient stated they had been given a dose of sublingual nitroglycerin prior to coming to the emergency department. The NP later stated that, to their knowledge, the resident was given sublingual nitroglycerin without an order and that facility staff called after the medication had already been administered, asking for an order to be placed retroactively, which the NP did not do. The DON reported being aware that sublingual nitroglycerin had been administered without an order and that no nurse on duty would admit to giving the medication, while a CNA reported witnessing an LPN place a medication under the resident’s tongue in response to the chest pain. Review of the resident’s physician orders and MAR for the month showed no order for sublingual nitroglycerin. The second resident involved had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, diffuse traumatic brain injury with loss of consciousness, essential hypertension, anxiety, and a more recent diagnosis of sepsis due to MRSA. The facility’s Incident and Accident Log documented a medication error for this resident on one date, indicating that the wrong antibiotic had been administered. An incident report showed that the resident was given IV ceftriaxone instead of the ordered IV cefepime, and that the incorrect antibiotic infusion ran for approximately five to ten minutes before being stopped. The report indicated that a trainee nurse obtained the wrong antibiotic from the medication refrigerator and started the infusion after verifying the resident’s name, medication, and dose with another nurse who was training them. Review of the MAR confirmed an active order for IV cefepime and no order for IV ceftriaxone. The DON confirmed that a medication error occurred when the wrong antibiotic was administered. The facility’s policy on administering medications required that medications be administered in accordance with prescriber orders, which was not followed in these instances.
Improper Disposal and Lack of Witnessing for Controlled Substance Waste
Penalty
Summary
Surveyors identified a deficiency related to improper disposal of a controlled substance for one resident with moderately impaired cognition and multiple medical diagnoses, including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension. During a morning medication pass, an LPN removed a 150 mg pregabalin capsule from a locked medication cart drawer, signed it out in the narcotic tracking binder, opened the capsule, and poured the contents into a medication cup for administration. The resident subsequently refused the pregabalin along with all other morning medications offered. After the refusal, surveyors observed that the facility had no waste/disposal solution available to safely discard pregabalin powder or other controlled substances, and staff were unable to locate any such solution. The DON stated that a regional director would need to obtain a disposal solution from another facility and, in the meantime, instructed the LPN to dispose of the pregabalin and other refused medications by flushing them down the toilet. The LPN then entered an empty, unassigned room and flushed the controlled substance without another staff member present to witness the disposal. The DON later confirmed that disposal of controlled substances should be witnessed by another licensed nurse, and facility policy and the cited Ohio Administrative Code require controlled substances to be disposed of in accordance with applicable regulations and with appropriate witnessing by licensed nursing staff.
Failure to Accurately Document Administration of Sublingual Nitroglycerin
Penalty
Summary
The facility failed to maintain an accurate and adequately comprehensive medical record for one resident when documentation did not reflect the administration of sublingual nitroglycerin given for chest pain. The resident, who had diagnoses including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension, was assessed as having moderately impaired cognition on the most recent MDS. On the date in question, an incident report, an outside hospital history and physical, and an SBAR nursing communication note all indicated that the resident was administered a sublingual nitroglycerin tablet at the facility in response to complaints of chest pain prior to transfer by ambulance. Despite these records and a CNA’s interview confirming they witnessed a medication being placed under the resident’s tongue for chest pain, the resident’s facility medical record did not contain any progress note documenting the administration of a sublingual medication or nitroglycerin on that date. Additionally, the resident’s MAR for the month showed no entry indicating that sublingual nitroglycerin had been administered. The DON confirmed that, aside from the notation on the incident report referencing medication given without an order, there was no facility-produced documentation identifying that the resident received sublingual nitroglycerin.
Failure to Maintain Courtyard Area in Safe and Sanitary Condition
Penalty
Summary
The facility failed to ensure that outdoor areas were maintained in good repair and in a clean, sanitary, and orderly condition, as required by its Homelike Environment policy. Observation of the outdoor courtyard showed a square raised planter box filled with soil that had a broken corner coming apart, exposing rusty nails. A small inoperable portable heater was left on the concrete next to the planter box, and the wooden fence enclosing the courtyard was loose, falling toward the courtyard, and propped up by a bag of sand. Additionally, a wooden picnic table in the courtyard was covered in peeling paint and the wood appeared to be deteriorating. During an interview and observation with the Administrator, these conditions in the courtyard were confirmed, including the broken planter box with exposed rusty nails, the portable heater in the courtyard, and the loose, leaning wooden fence. The Administrator also confirmed that residents have access to this courtyard area. The deficiency was cited as non-compliance under Complaint Numbers 2566940 and 2581568 and had the potential to affect all 34 residents residing in the facility.
Failure to Notify Provider and Representative After Seizure and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider and resident representative of a resident’s change in condition following a seizure event, and failure to document the event and related care. Resident #9, admitted on 10/19/22 with diagnoses including epilepsy and moderately impaired cognition per the MDS, had a care plan revised on 10/17/25 that directed staff to monitor and report any seizure activity and to report abnormal vital signs to the physician. Despite this, review of progress notes from 01/07/25 to 01/14/25 showed no documentation of a seizure or any notification to the provider or resident representative. The DON confirmed there was no documentation of the seizure that occurred on 01/12/26 and no documentation of notification to the provider or resident representative, and also confirmed there was no order for oxygen in the resident’s record. Staff interviews further detailed the unreported and undocumented change in condition. One LPN stated that Resident #9 had a seizure on the night of 01/12/26 lasting about five minutes, during which the resident had difficulty breathing while lying on his back; the LPN administered scheduled Keppra and applied oxygen at 2.5 liters, even though the resident did not have an oxygen order and did not normally require oxygen. The LPN reported believing another LPN had obtained an oxygen order from the provider while he was in the room, but the second LPN later confirmed he did not notify the provider and did not speak to the provider about oxygen. The NP confirmed she was not notified of the seizure until 01/14/26 and stated that, had she been informed at the time, labs would have been ordered. Review of the facility’s “Acute Condition Changes Clinical Protocol” dated 03/2018 showed that nursing staff are required to contact the physician based on the urgency of the situation and discuss possible causes and needed diagnostic tests, which did not occur in this case.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with personal hygiene and nail care to a resident who was dependent on staff for activities of daily living. The resident was admitted with multiple diagnoses including stroke, dementia without behaviors, type 2 diabetes mellitus, depression, anxiety, and polyneuropathy, and was documented on a quarterly MDS as cognitively impaired and dependent on staff for personal hygiene and toileting. The resident’s care plan identified a physical functioning deficit and included an intervention for nail care as needed. During an observation and interview, the resident’s fingernails were noted to extend approximately one eighth of an inch beyond the fingertips and were encrusted with a dark brown substance. The resident reported that staff had not offered to clean or trim his nails and stated he would like assistance with nail care. Further observations and staff interviews confirmed the lack of appropriate nail care. A CNA acknowledged that the resident’s fingernails were long and dirty and stated that another CNA had said she would take care of the nails. The CNA indicated she would clean the nails and notify a nurse that the resident’s nails needed to be cut, explaining that CNAs were not permitted to cut the nails of residents with diabetes. An LPN stated that the expectation was for CNAs to clean and trim residents’ nails during showers or bed baths, and that for residents with diabetes, it was the responsibility of a nurse or podiatrist to ensure nails were trimmed. A subsequent observation showed the resident’s fingernails were clean but still uncut. The facility’s ADL policy stated that residents unable to carry out ADLs independently would receive appropriate support and assistance with hygiene, including grooming, but this was not followed for this resident’s nail care.
Failure to Provide Ordered Wound Vac Care and IV Site Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatment and adequate assessment for a resident with complex medical needs, including a wound vac and multiple IV lines. The resident was admitted with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, tracheostomy status, and depression, and had moderately impaired cognition and dependence on staff for toileting and bathing. From admission through discharge, there were no wound or skin assessments documented, despite the presence of an abdominal wound vac ordered at 100 mmHg suction with dressing changes scheduled for Monday, Wednesday, and Friday on dayshift. The record shows the wound vac was applied on one date, but there is no documentation of any subsequent wound vac dressing changes on the ordered days. The resident also had multiple peripheral IV lines, including sites in the left wrist, left shoulder, and right forearm. Progress notes describe IV pump alarms and attempts to use different peripheral lines, including removal of one access due to resident-reported pain and observed erythema beneath the transparent dressing, with notification of the NP and continuation of IV medications via another access. However, from admission through discharge, the progress notes and TAR contain no documentation of IV site care or monitoring of the access sites. In interviews, the DON confirmed that no skin or wound assessments were completed, no wound vac changes were performed after the initial application, and no IV site care was documented for this resident during the stay.
Failure to Implement Fall-Prevention Interventions and Ensure Call Light Access
Penalty
Summary
The facility failed to ensure that fall-prevention interventions and call light access were consistently in place for a resident with a known history of falls and significant functional impairments. The resident, admitted with diagnoses including epilepsy, cerebral infarction, and hemiplegia/hemiparesis of the left non-dominant side, had a Minimum Data Set showing moderately impaired cognition and dependence on staff for toileting, bathing, and personal hygiene. The care plan, initiated due to fall risk related to impaired mobility, required bilateral fall mats on each side of the bed, the call light within reach at all times when in bed, education and reminders to use the call light before transfers and for toileting needs, personal items within reach, and a sign at eye level reminding the resident to use the call light. A prior fall investigation also identified bilateral fall mats as an intervention. Despite these documented interventions and policies, multiple observations showed that the fall-prevention measures were not implemented as planned. On several occasions, the resident was observed lying in bed without fall mats on the floor, with the mat either leaning against the wall or present on only one side of the bed. At one point, the resident reported needing help with adult briefs while the call light was on the floor and not within reach, which was confirmed by a CNA. Subsequent observations continued to show inconsistent placement of fall mats, with only one mat on the right side or the mat again leaning against the wall instead of being on the floor beside the bed. These findings occurred in the context of facility policies requiring a resident-centered fall prevention plan and provision of a means for residents to call staff from bed and other locations.
Failure to Provide Proper Discharge Planning and Ombudsman Notification
Penalty
Summary
The facility failed to provide a proper discharge for a resident, as evidenced by the lack of a discharge plan, discharge summary, and appropriate physician orders for discharge. The resident, who had diagnoses including orthostatic hypotension, diabetes mellitus, dehydration, dysphagia, and anxiety disorder, was cognitively intact but dependent on staff for medication administration and required assistance with activities of daily living. Despite the resident expressing discomfort and uncertainty about self-administering insulin and not feeling ready to go home, the discharge proceeded without ensuring a primary care physician was in place or a follow-up appointment scheduled. The discharge documentation was incomplete, with only the social services section partially filled out and no signatures or summaries from nursing, dietary, activities, or rehabilitation services. The resident was discharged to an independent living apartment, not an assisted living facility as some staff believed. Upon discharge, the resident did not have insulin or a primary care physician, and home health staff had to intervene to secure necessary medication and assist in finding a physician. The facility's own policy required a discharge summary and post-discharge plan to be developed and filed in the resident's medical record, but this was not done. Interviews with staff confirmed the absence of a discharge summary, discharge plan, and proper coordination for the resident's ongoing care needs. Additionally, the facility failed to properly notify the local ombudsman office of the resident's discharge. Monthly discharge lists were faxed to an incorrect number, and there was no documented evidence that the ombudsman received any notifications of discharges over a six-month period. The ombudsman confirmed they had not received any such notifications, and the facility administrator acknowledged the error and lack of documentation.
Failure to Reposition High-Risk Resident
Penalty
Summary
The facility failed to provide timely repositioning and turning for a resident with existing stage four pressure ulcers on the left elbow and sacrum. The resident, who was at high risk for developing pressure ulcers due to impaired mobility, was observed lying on their left side for over two hours without being repositioned. The care plan for the resident included interventions such as turning and repositioning every one to two hours, using a low air loss mattress, and conducting weekly wound assessments. However, these interventions were not consistently followed, as evidenced by the lack of repositioning observed during the survey. Interviews with facility staff revealed that the resident was not repositioned from 5:00 A.M. until 11:42 A.M. on the day of the observation. The staff responsible for the resident's care during this period either did not provide care or were not present due to various reasons, such as being called in late or leaving early. The facility's policy on the prevention of pressure injuries emphasized the importance of following the care plan for repositioning, which was not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's pressure ulcer prevention protocols.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions for a resident who was re-admitted with anoxic brain damage and stage four pressure ulcers on the left elbow and sacrum. During an observation, a registered nurse and a state-tested nurse aide entered the resident's room to perform incontinence care, repositioning, wound care, and check the urinary catheter. The staff brought the wound treatment cart into the room and only wore gloves, neglecting to use additional personal protective equipment as required by the facility's enhanced barrier precautions policy. The state-tested nurse aide, after touching the resident's linens and incontinent brief, was instructed to retrieve a four-by-four dressing from the treatment cart. The aide did not remove her soiled gloves, perform hand hygiene, or don new gloves before searching through the treatment cart's drawers, thereby contaminating the supplies. Interviews with the Director of Nursing and the registered nurse confirmed that the treatment cart should not have been taken into the room and that the aide should not have reached into the cart with dirty gloves. The facility's policy mandates the use of gowns and gloves during high-contact care activities, which was not followed in this instance.
Failure to Maintain Exterior Windows in Resident Rooms
Penalty
Summary
The facility failed to ensure that exterior windows in resident rooms were properly maintained, affecting seven residents. Observations revealed that plastic was covering the windows and blinds in two residents' rooms, preventing the blinds from being opened without damaging the plastic. This plastic was applied to mitigate cold air entering the rooms due to old windows. Additionally, five other residents' rooms were found to have missing screens in their exterior windows, which had been an issue for a long time according to the Maintenance Director. Interviews with the affected residents confirmed the presence of plastic over the windows and the absence of screens, with one resident even reporting that a squirrel had entered her room due to the lack of a screen. The Maintenance Director confirmed the issues with the windows and the absence of screens, stating that there was no documentation of any window repairs, invoices, or assessments for the affected rooms. The plastic coverings were applied in December 2023 or January 2024 to address the cold air problem. The deficiency was identified during a survey conducted on 04/26/24, and it was noted that the facility had not taken adequate steps to maintain the windows, resulting in discomfort and potential safety hazards for the residents.
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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