Belpre Landing Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Belpre, Ohio.
- Location
- 1915 Hill Street, Belpre, Ohio 45714
- CMS Provider Number
- 366443
- Inspections on file
- 28
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Belpre Landing Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple sclerosis, ventilator dependence, and a known history of hypothermia was re‑admitted after a prior hospitalization for hypothermia and infection. Although care plans required monitoring vital signs and reporting abnormalities, staff documented multiple low temperature readings over several days that triggered electronic alerts without corresponding nursing assessments, re‑checks, or provider notification, and one day with no temperature taken at all. The resident later exhibited confusion with a markedly low temperature and was sent to the hospital, where she was admitted to the ICU with hypothermia, ventilator‑associated pneumonia, septic shock, and a complicated UTI.
Surveyors found that the facility’s written assessment of its capabilities and resources was inaccurate, particularly regarding respiratory services and staffing. The assessment listed specific numbers for oxygen therapy, suctioning, tracheostomy care, and ventilator care but did not include staffing needs for residents receiving respiratory services and indicated no tracheostomy care and capacity for only two ventilator residents. An RT reported that there were actually two residents with tracheostomies and two on ventilators, and the Administrator acknowledged that the assessment reflected average resident numbers rather than the number of residents the facility could care for, stating the facility could admit up to ten ventilator residents and that no specific staffing requirements were documented for ventilator or trach care.
Two residents requiring tracheostomy and ventilator support did not consistently receive respiratory care as ordered, including daily changes of a heat moisture exchange (HME) device and tracheostomy care using sterile technique. For one resident, the HME was ordered to be changed daily and PRN but was entered and documented only as PRN, with changes recorded on a few isolated days and no evidence of daily changes, despite staff acknowledging the order and the importance of HME function. For another resident, an RT performed trach site cleansing and inner cannula changes using non-sterile gloves, without a mask or a barrier/sterile field, and handled sterile supplies with non-sterile gloves, even though facility policy required sterile technique, sterile gloves, appropriate PPE, and a sterile field for all tracheostomy care.
The facility failed to ensure adequate RN or RT coverage for two ventilator-dependent residents whose care plans and orders required frequent ventilator checks, trach care, suctioning, HME and circuit changes, and close monitoring of respiratory status. On at least one night shift, only LPNs were on duty with no RN or RT present, despite these residents’ dependence on mechanical ventilation and tracheostomies. The DON acknowledged there was no RN or RT on that shift, believed prior daytime RN presence met requirements, allowed LPNs to perform ventilator care without certification or documented competency, and was unsure whether such care was within LPN scope of practice. Cited literature from the National Library of Medicine noted that mechanical ventilators are complex, require specific training, and are best managed by RTs, with improper management linked to poor outcomes.
Two residents experienced misappropriation of controlled narcotic medications, including Morphine Sulfate and Oxycodone, which were accessed or tampered with without proper documentation or administration. An LPN discovered discrepancies in medication counts and evidence of tampering, such as punctured seals and replaced tablets. The DON did not promptly report these incidents to the state survey agency, despite facility policy requiring immediate reporting of suspected misappropriation. The Ohio Board of Pharmacy confirmed the tampering and removed the affected medications for further investigation.
Two residents' controlled medications were found to be tampered with or missing, including liquid Morphine Sulfate and Oxycodone tablets, with evidence of punctured seals, dilution, and replacement of tablets. Despite these findings, the DON did not report the suspicions of misappropriation to the state survey agency within the required timeframe, as facility policy and regulations mandate.
The facility did not consistently perform required reconciliation of controlled medications during shift changes and key exchanges, resulting in undetected tampering of liquid Morphine Sulfate bottles for two residents. Documentation and staff interviews revealed that the mandated process of having two nurses conduct and sign off on controlled substance counts was not followed, leading to discrepancies and missing medication.
The facility did not hold the required quarterly Quality Assessment and Assurance (QAA) committee meetings as part of their QAPI program, lacking documentation such as meeting minutes or sign-in sheets. The Administrator confirmed the absence of formal meetings, although quality improvement activities were conducted weekly. This deficiency had the potential to affect all 52 residents.
The facility failed to involve residents and their representatives in care planning, affecting four residents with various medical conditions. Care conferences lacked a multi-disciplinary approach, and documentation was incomplete, with residents confirming they were not invited to participate. Staff interviews revealed non-compliance with facility policies on care conferences.
A facility failed to accurately update a resident's MDS assessment to reflect their admission to hospice care. Despite a physician's order and a plan of care indicating hospice services, the MDS did not show the resident's life expectancy of less than six months or their receipt of hospice care. The MDS Nurse confirmed this oversight, highlighting a deficiency in the facility's assessment process.
The facility failed to update a PASARR assessment for a resident with a new diagnosis and did not ensure the accuracy of another resident's PASARR, which incorrectly omitted a dementia diagnosis. The facility's policy did not require verification of PASARR accuracy, contributing to these deficiencies.
A facility failed to notify the mental health authority by not completing a PASARR Level II assessment for a resident with a new diagnosis of dissociative conversion disorder. The resident, with existing diagnoses of traumatic brain injury and schizoaffective disorder, had a care plan addressing behavior issues. Despite these interventions, the facility did not update the PASARR, as confirmed by the DON.
The facility failed to provide three residents with a copy of their baseline care plan within 48 hours of admission. Despite having intact cognition, these residents did not have timely care conferences, and there was no documented evidence of their involvement or receipt of care plans. The care conferences were either incomplete or lacked full interdisciplinary team attendance.
The facility failed to provide scheduled bathing assistance to three residents who were dependent on staff for personal care. One resident, with multiple health conditions, was scheduled for showers three times a week but only received three out of nine scheduled baths. Another resident, with orthopedic and mobility issues, was scheduled for showers three times a week but only received two. A third resident reported only receiving showers when a specific aide was working, with records confirming missed showers. The facility's policy required offering showers or baths twice a week, but this was not consistently followed.
The facility failed to invite two residents to participate in activities, despite their care plans indicating preferences for independent activities. Both residents reported not being invited to activities and spending most of their time in their rooms. The activity logs showed missing documentation for several days, and the Activity Director cited staffing struggles as a reason for the oversight. An LPN confirmed gaps in activity documentation.
A resident with a Foley catheter and occasional bladder incontinence experienced a delay in addressing UTI symptoms. Despite reporting symptoms for two weeks, the facility staff did not act promptly. An orthopedic consult recommended a urinalysis, which was delayed, and antibiotics were not administered until days after the UTI was confirmed. Interviews revealed that the resident's complaints were not addressed by the nursing staff, and the facility's policy on notifying changes in condition was not followed.
A facility failed to change a resident's oxygen tubing weekly as ordered by the physician. The resident, with diagnoses including venous insufficiency and hypertension, had orders for oxygen at two liters per minute via nasal cannula, with instructions to change the tubing weekly. Observations revealed the tubing had not been changed since a specific date, and interviews with staff confirmed it should have been changed. The facility's policy also recommended weekly changes.
A resident with a femur fracture experienced delays in receiving pain medication, despite a care plan indicating the need for timely pain management. The MAR showed inconsistencies in administering acetaminophen and Norco, with no clear parameters for use. The DON confirmed the resident experienced pain without receiving prescribed Norco, and the narcotic log showed discrepancies. Interviews revealed the resident's daughter had to intervene for timely medication, and a CNA reported delays even after notifying the nurse.
A facility failed to conduct an AIMS assessment for a resident receiving Olanzapine, despite the resident's severely impaired cognition and ongoing antipsychotic treatment. The Director of Nursing confirmed the absence of the assessment, which should have been conducted per facility policy. This affected one of five residents reviewed for unnecessary medications.
A facility failed to store stock medications in their original packaging, affecting three residents who received Tylenol Extra Strength from a medication cart. An LPN administered Acetaminophen 500 mg tablets stored in a bottle meant for 325 mg tablets, with no visible expiration date. The DON confirmed the improper storage, which violated the facility's medication storage policy.
The facility failed to document meal intake for two residents and pre/post dialysis evaluations for another. One resident had incomplete meal records and expressed dissatisfaction with food quality, while another had missing meal documentation and reported feeling sick from the food. Additionally, a resident with end-stage renal disease had missing dialysis evaluations, which were confirmed by an LPN Unit Manager.
The facility failed to implement enhanced barrier precautions for a resident with a history of ESBL and multi-drug resistant organism E-coli. Staff members were observed not following EBP protocols, including not using gloves or gowns and not washing hands after handling soiled items. This deficiency was verified by the Housekeeping Supervisor and represents non-compliance with the facility's infection prevention and control program.
The facility failed to assist two residents with activities of daily living (ADL) and grooming. One resident with chronic respiratory failure and ventilator dependence had not received help with hair washing or facial hair removal for at least three weeks. Another resident with severe dementia had broken and jagged fingernails for three days without assistance. These deficiencies were confirmed through observations and interviews.
The facility failed to ensure competent IV medication administration, affecting a resident with sepsis and other conditions. An LPN administered Meropenem IV late and without proper certification, and the facility could not provide evidence that the IV training met state requirements.
The facility failed to ensure medications were stored appropriately and administered when dispensed. An RN was found to have pre-poured medications for the morning administration, labeling them only with numbers and without any resident names or date/time. This affected two residents, one with asthma and atrial fibrillation, and another with arteriosclerotic heart disease.
The facility failed to ensure medications were administered without error, resulting in a 16% medication administration error rate. Two residents received incorrect medications or dosages, and the facility's medication administration policy was not followed.
Failure to Monitor and Respond to Hypothermia in High‑Risk Ventilator‑Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively monitor and assess a ventilator‑dependent resident with multiple sclerosis and a known history of hypothermia, and to ensure timely provider notification when low temperatures were recorded. The resident had previously been transferred to the hospital on 12/04/25 with a documented temperature of 93°F, after complaining of feeling very hot, and was treated for hypothermia related to multiple sclerosis and infection. She was re‑admitted to the facility on 12/24/25 following that hospitalization. Her care plans addressed risks related to respiratory failure, tracheostomy and ventilator dependence, infection risk, and musculoskeletal impairment, with interventions that included monitoring vital signs as ordered, reporting abnormalities to the provider, and assessing for signs and symptoms of infection such as elevated temperature and changes in respiratory status. Following re‑admission, the facility’s records show multiple low temperature readings and gaps in monitoring without corresponding assessments or provider notification. On 01/14/26, the resident’s temperature was documented as 98°F in the morning and 97.3°F in the afternoon; the electronic system flagged the 97.3°F as a low value, but there was no nursing note, no evidence of a comprehensive assessment, no re‑check of the temperature, and no documentation that the physician was notified. On 01/15/26, the temperature log shows no temperature taken for the resident, and there is no evidence that her condition was thoroughly assessed or monitored that day. On 01/16/26, her temperature was recorded as 96.4°F and again triggered a low‑temperature alert in the electronic system, yet there was no corresponding nursing note, no documented comprehensive assessment, no re‑check of the temperature, and no evidence of physician notification. On 01/17/26 at 1:16 P.M., the resident’s temperature was documented as 95.7°F, which again triggered a low‑temperature alert. A nursing note at 1:46 P.M. recorded that the resident was showing increased confusion and repeating herself, and her temperature was then documented as 85.7°F, after which verbal orders were received to send her to the emergency room. Hospital records show she was admitted with ventilator‑associated pneumonia, septic shock, a complicated urinary tract infection, and hypothermia with a temperature of 91°F on arrival, requiring intensive care and antibiotic therapy. Interviews with staff indicated there was no formal increased monitoring protocol in place for hypothermia despite the resident’s prior episodes; the NP reported not being aware of increased monitoring related to hypothermia and suggested that vital signs might be checked more frequently, while a CNA stated she noticed the resident’s skin was very cold but that there was no official increased monitoring, and the DON confirmed that the care plan focused on elevated temperature even though the resident’s temperature dropped with infection and that multiple low temperatures had been triggered in the electronic system without documented follow‑up or physician notification.
Inaccurate Facility Assessment of Respiratory Care Capacity and Staffing
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate facility-wide assessment of the resources needed to care for residents, including during day-to-day operations and emergencies. The written facility assessment stated that the facility treats a wide range of patients transitioning from hospital to home and that, prior to admission, the DON and interdisciplinary team assess residents’ physical and psychosocial needs to determine appropriate placement. The assessment also indicated that special treatments available in the facility included respiratory services such as oxygen therapy, suctioning, tracheostomy care, and ventilator or respirator care, and it listed specific numbers for these services (oxygen therapy 15, suctioning 5, tracheostomy care 0, ventilator/respirator care 2). However, the assessment did not include information on staffing needs for residents receiving respiratory services. During an interview, an RT reported that there were two residents with a tracheostomy and two residents with ventilators in the facility, which did not match the facility assessment’s indication of zero tracheostomy care and capacity for only two ventilator/respirator residents. In a separate interview, the Administrator stated that, in the facility assessment, they had entered the average number of residents usually present with certain care needs rather than the number of residents the facility was able to care for based on those needs. The Administrator further stated that the facility was able to admit ten residents with ventilators, confirming that the assessment was not based on the services the facility could provide and that there was no specific number or types of staffing requirements listed to address the needs of residents on ventilators or receiving tracheostomy services. This inaccuracy had the potential to affect all 49 residents in the facility.
Failure to Follow Respiratory and Tracheostomy Care Orders and Sterile Technique
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care as ordered for two residents who required complex airway management. One resident was admitted with sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia, and had care plans addressing alterations in respiratory function, dependence on a tracheostomy and ventilator, and the need for oxygen therapy and respiratory treatments. The resident had a physician order dated 01/12/26 for the heat moisture exchange (HME) device to be changed daily and as needed. Review of the treatment administration record (TAR) for January 2026 showed the HME was documented as changed only on 01/12/26, 01/15/26, and 01/21/26, with no additional evidence that the HME was changed daily as ordered. Further review of respiratory progress notes documented that respiratory therapists performed trach care, oral care, suctioning, inner cannula changes, and HME changes on specific dates, but these entries did not establish that the HME was changed every day as required by the order. The nurse practitioner confirmed that the TAR reflected only as-needed HME replacement and that she was not familiar with HMEs until she researched them and learned they humidify air so the lungs do not get dry. She also stated she did not give orders for tracheostomy or ventilator care and was unsure where those orders originated. The DON acknowledged that the HME order stated it should be changed daily but had been entered into the system as an as-needed order, and reported being told by an RT that HME changes were considered part of standard ventilator care and therefore did not require a separate order. An RT later explained that HMEs are used for humidification, are good for 24 hours, and are changed every time care is completed, and stated that the HME must have its own separate order because ventilator care documentation alone does not confirm that the HME was changed. This RT described the HME order entry as a clerical error and expressed confidence that daily care was being completed based on his checks of HME dates, but there was no documentation to support daily changes as ordered. The nurse practitioner also identified concerns related to not changing the HME, including pneumonia related to bacteria or aspiration due to increased airway resistance, mucus plugging, hypothermia, pneumonia, and potential respiratory distress. The second resident was admitted with multiple sclerosis, chronic respiratory failure with hypoxia, a tracheostomy, ventilator dependence, and a history of ventilator-associated pneumonia and sepsis. The care plan for alteration in respiratory function and tracheostomy/ventilator use included interventions to change the size 6 disposable tracheostomy inner cannula and cleanse the tracheostomy site as ordered. Physician orders directed staff to cleanse the tracheostomy site with sterile water, pat dry, apply a drain sponge, and change every shift and as needed, and to change the size 6 Shiley tracheostomy inner cannula every shift and as needed. During an observed tracheostomy inner cannula and site care procedure for this resident, the RT donned a gown, performed hand hygiene, and used non-sterile gloves but did not wear a mask. Treatment supplies were placed on a bedside table that also contained personal items, and no barrier or sterile field was used. The RT discarded the sterile gloves from the tracheostomy kit because they were the wrong size, then handled sterile items from the kit with non-sterile gloves, prepared cleaning solutions, and cleansed the tracheostomy stoma using split gauze held with non-sterile gloves. After changing gloves and performing hand hygiene, the RT placed a split gauze around the stoma and then, again using non-sterile gloves, removed the used inner cannula and inserted a new sterile disposable inner cannula before reconnecting the ventilator tubing. The DON verified that tracheostomy care was supposed to be completed using sterile technique, including sterile gloves, a barrier for supplies, and appropriate personal protective equipment such as a mask. The RT confirmed he did not use a barrier or mask and used non-sterile gloves because the sterile gloves in the kit did not fit, despite acknowledging that sterile gloves were available in the facility. He stated that he performed the procedure using a non-sterile technique and asserted that the facility policy, which required sterile technique at all times for tracheostomy and trach tube care, was wrong. The written policy specified that meticulous tracheostomy care was mandatory to prevent complications, that the tracheostomy stoma should be cleansed regularly using sterile technique at all times, and that the inner cannula should be cleaned regularly using sterile technique at all times, underscoring that the observed practice did not follow the established standard. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702282.
Insufficient Qualified Nursing and Respiratory Staff for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient qualified RNs or RTs were available to care for residents requiring ventilator support. Resident #1 was admitted with sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia and had physician orders for ventilator checks every four hours and as needed, tracheostomy care every shift and as needed, suctioning via trach as needed, and daily HME changes. Care plans for Resident #1 documented dependence on a ventilator and tracheostomy, with goals to maintain adequate oxygenation and be free from respiratory distress, and interventions including monitoring lung sounds and oxygen levels, providing respiratory treatments and oxygen as ordered, and ensuring ventilator settings were correct. Resident #2 was admitted with anemia, ventilator dependence, and functional quadriplegia, and had care plans indicating alteration in respiratory function related to respiratory failure, tracheostomy, ventilator use, and a history of aspiration pneumonia and mucus plugging. The care plans for Resident #2 included goals to remain free from respiratory distress and maintain oxygen levels at provider-set targets. Interventions required included ventilator checks every four hours, AVAP per physician order, tracheostomy tube changes every 30–45 days by an RT, regular changes of ventilator circuits, HMEs, inner cannulas, trach ties, and nebulizer setups, as well as suctioning, CPT, aerosol treatments, and close monitoring of lung sounds, oxygen levels, and signs of dyspnea. Review of staffing schedules for a specified week showed that on one night shift there were three LPNs on duty and no RTs or RNs present, despite the presence of two ventilator-dependent residents. In an interview, the DON confirmed that there was no RN or RT on that night shift and stated he believed that having an RN in the building earlier in the day met requirements and that LPNs could care for ventilator residents based on education and observation, even though they had no certification or documented return demonstration. The DON also stated he was unsure whether ventilator care was within the LPN scope of practice. Literature from the National Library of Medicine cited in the report emphasized that mechanical ventilators are sophisticated devices requiring specific training, that inappropriate management can result in poor patient outcomes, and that RTs are best suited to manage and adjust ventilators, underscoring the need for appropriately trained personnel.
Failure to Prevent and Report Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of controlled narcotic medications for two residents. One resident, with diagnoses including dementia, dysphagia, amputation, and osteoarthritis, had a physician's order for liquid Morphine Sulfate as needed for pain or shortness of breath. Despite the medication being present in the facility for several months, there was no documentation of any doses being administered, and a discrepancy was discovered when a nurse noted that the Morphine bottle contained less medication than expected. The bottle was found to have a puncture hole in the seal, and the syringe packaging was unused, indicating the medication had been accessed without proper documentation. A similar puncture was found in another resident's Morphine bottle, which appeared full but was later determined to have a diluted concentration of the drug, suggesting tampering and replacement of the medication with another solution. Further investigation into the second resident revealed that a standing order for Morphine Sulfate was not properly carried over into active physician's orders, resulting in the medication not being included on the medication administration record. The controlled drug record for this medication was blank, showing no evidence of administration. Additionally, the same resident had an order for Oxycodone, and an internal investigation found that multiple Oxycodone tablets had been removed from blister packs and replaced with Loratadine tablets. The tampering was confirmed by the facility's contracted pharmacist, who identified slits in the blister pack backing and mismatched tablets. The investigation could not determine who was responsible for the tampering, but it was clear that the resident did not receive the intended medication. The Director of Nursing (DON) did not initially report these incidents to the state survey agency, believing that reporting was only required if misappropriation was proven. However, the facility's own policy required immediate reporting of any allegations or suspicions of misappropriation. The DON later acknowledged that the incidents should have been reported in a timely manner, as required by policy and regulation. The findings were confirmed by the Ohio Board of Pharmacy, which conducted on-site investigations and confiscated the tampered medication bottles and blister packs.
Failure to Timely Report Suspected Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure that all allegations or suspicions of misappropriation of resident property, specifically medications, were reported to the State Survey Agency as required. In two separate cases, controlled medications prescribed to residents were found to be tampered with or missing, but the incidents were not reported in the required timeframe. In the first case, a resident with dementia, dysphagia, and a recent amputation had a prn order for liquid Morphine Sulfate, which was never documented as administered. A discrepancy was discovered when a nurse noticed the Morphine bottle contained less medication than expected, and a puncture hole was found in the seal. The DON was notified, and the Ohio Board of Pharmacy was involved, confirming that medication had been removed from the bottle. However, the DON did not submit a self-reporting incident (SRI) to the state survey agency until after the Board of Pharmacy's determination, acknowledging the report was not made within the required timeframe. A similar issue was identified with another resident who had a history of stroke, prostate cancer, and dementia, and was under hospice care. This resident's Morphine Sulfate bottle also had a puncture hole in the seal, and although the bottle appeared full, testing revealed the concentration of Morphine was significantly diluted, indicating that some medication had been removed and replaced with another solution. Again, there was no documentation of administration, and the DON did not report the suspicion of misappropriation to the state survey agency until after confirmation from the Board of Pharmacy, which was not within the required reporting period. Additionally, an investigation into this same resident's Oxycodone tablets revealed that several tablets had been removed from blister packs and replaced with Loratadine tablets. The tampering was discovered by a nurse and confirmed by the facility's contracted pharmacist, who identified slits in the packaging and mismatched tablets. Despite clear evidence that the resident's medication had been tampered with and replaced, the DON did not submit a self-reporting incident to the state survey agency, believing that proof of who took the medication was required. The facility's policy required immediate reporting of all allegations or suspicions of misappropriation, but this was not followed in these cases.
Failure to Properly Reconcile Controlled Medications During Shift Changes
Penalty
Summary
The facility failed to ensure proper pharmacy procedures were followed regarding the reconciliation of controlled medications during shift changes and when medication cart keys were exchanged between nurses. Specifically, the required process of conducting a physical inventory of all controlled substances with two licensed nurses at each shift change or key exchange was not consistently performed. Documentation revealed that on several occasions, only one nurse signed off on the reconciliation, and in some instances, the count was not performed at all when keys were handed over. This lapse in procedure was confirmed through review of shift-to-shift controlled medication reconciliation sheets, staff witness statements, and interviews. The deficiency was identified following an investigation into suspected tampering of liquid Morphine Sulfate bottles for two residents. One nurse discovered that a resident's Morphine Sulfate bottle was missing approximately 3.5 ml, and both this bottle and another resident's bottle had puncture holes in their seals, despite appearing otherwise unopened. The syringes for these bottles were still in their original packaging, indicating they had not been used for administration. Staff interviews revealed that several nurses who had access to the medication cart did not properly inspect the bottles or perform the required reconciliation counts, and some were unaware of the need to remove the lid and inspect the seal of liquid Morphine bottles. Further review of facility policy and state regulations confirmed that the facility was required to conduct a physical inventory of all controlled substances at each shift change or key exchange, with documentation by two licensed nurses. The investigation found that this policy was not followed, as evidenced by incomplete or missing signatures on reconciliation forms and staff statements admitting to not performing or witnessing the required counts. The failure to follow these procedures contributed to the inability to promptly detect and address the tampering and discrepancies in the controlled medication inventory.
Failure to Hold Quarterly QAA Meetings
Penalty
Summary
The facility failed to meet the requirement of holding at least quarterly meetings for the Quality Assessment and Assurance (QAA) committee as part of their Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through a review of the facility's QAPI program, which revealed no documented evidence, such as meeting minutes or sign-in sheets, indicating that these quarterly meetings were held. During an interview, the Administrator confirmed the absence of such documentation, although she mentioned that quality improvement activities were conducted weekly without formal meetings or minutes. The facility's policy mandates that the Medical Director attend these quarterly QAPI committee meetings, and the committee is responsible for analyzing system changes made over the quarter that could affect outcomes. The lack of documented meetings had the potential to impact all 52 residents residing in the facility.
Failure to Include Residents in Care Planning
Penalty
Summary
The facility failed to ensure a multi-disciplinary approach was taken in the development of care plans and did not include residents or their representatives in the process. This deficiency affected four residents, each with varying medical conditions and needs. For instance, one resident with orthopedic aftercare and other health issues was not included in her care conference, and the documentation did not reflect her participation or that of any other relevant disciplines. The resident confirmed she was not invited to any care conference, and the Social Service Director acknowledged the lack of proper documentation and involvement of necessary team members. Another resident with a traumatic brain injury and other mental health diagnoses also did not have a care conference that included her input or that of a full interdisciplinary team. The resident confirmed she was not informed or invited to any meetings regarding her care, and the facility's social services staff admitted to not sending formal invitations or documenting attendance. The facility's policy required a comprehensive team approach, but this was not followed, leading to incomplete care planning. Additional residents with complex medical conditions, such as end-stage renal disease and malignant neoplasms, were similarly affected. These residents were not invited to participate in their care conferences, and the documentation did not reflect a multi-disciplinary approach. Interviews with staff confirmed the absence of key team members in these meetings, and the facility's policy on care conferences was not adhered to, resulting in a lack of comprehensive care planning for these residents.
Failure to Reflect Hospice Care in Resident Assessment
Penalty
Summary
The facility failed to accurately reflect a significant change in condition for a resident who was admitted to hospice care. The resident, who had multiple diagnoses including chronic kidney disease, cerebral infarction, and dementia, was admitted to hospice care as per a physician's order. However, the significant change Minimum Data Set (MDS) assessment did not indicate that the resident had a life expectancy of less than six months or that they were receiving hospice services. Additionally, the nursing progress notes did not document the resident's admission to hospice services. The MDS Nurse confirmed that the assessment did not address hospice care, which was a significant oversight. The resident's plan of care did include hospice services and interventions for comfort care, but this was not reflected in the MDS assessment. This discrepancy indicates a failure in the facility's assessment process, as the MDS should have been updated to reflect the resident's hospice care status.
Failure to Complete and Verify PASARR Assessments
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) assessment for Resident #6 after a new diagnosis of dissociative conversion disorder was added on 09/30/24. The resident, who was admitted with diagnoses including traumatic brain injury, schizoaffective disorder, and dissociative conversion disorder, had a care plan addressing behavior problems and mood alterations. Despite these significant mental health concerns, the most recent PASARR dated 01/16/24 did not reflect the new diagnosis, as confirmed by the Director of Nursing. Additionally, the facility did not ensure the accuracy of the admission PASARR for Resident #37, who was admitted with a diagnosis of unspecified dementia. The PASARR Identification Screen completed on 11/19/24 by a hospital social worker incorrectly indicated that the resident did not have dementia. This error was not caught by the Admissions Director, who acknowledged the oversight and the absence of any additional PASARRs completed since the resident's admission. The facility's policy on PASARRs, updated on 01/01/19, requires the Admission Director to verify the completion of Level I screens but does not specify ensuring their accuracy. This lack of specificity contributed to the failure to identify and correct the inaccuracies in Resident #37's PASARR, as well as the failure to update Resident #6's PASARR with the new diagnosis.
Failure to Update PASARR for Resident with New Diagnosis
Penalty
Summary
The facility failed to notify the mental health authority by completing a Pre-Admission Screening and Resident Review (PASARR) Level II assessment for a resident with a new diagnosis. The resident, who was admitted with diagnoses including traumatic brain injury, schizoaffective disorder, and dissociative conversion disorder, had a care plan addressing behavior problems related to delusions, hallucinations, and emergency calls. Despite these issues, the facility did not update the PASARR after a new diagnosis of dissociative conversion disorder was added. The Director of Nursing confirmed that the most recent PASARR was dated earlier in the year and did not reflect the new diagnosis. The resident was prescribed antipsychotic, antidepressant, and antianxiety medications, and the care plan included interventions such as medication administration, behavior monitoring, and referrals to psychiatric services. However, the failure to complete a new PASARR with the updated diagnosis represents a deficiency in the facility's compliance with notification requirements for residents with mental health needs.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to ensure that three residents or their representatives were provided with a copy of their baseline care plan within 48 hours of admission. Resident #4 was admitted with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease. Despite having intact cognition, there was no documented evidence of a new admission care conference being completed within 48 hours of admission, nor was there a sign-in sheet or list of attendees at the care conferences. Similarly, Resident #19, who was admitted with malignant neoplasm of the stomach and esophagus, muscle wasting and atrophy, and hypertension, was not invited to a care conference, and there was no evidence that he received a copy of his baseline care plan. His cognition was also intact, and the care conference only included his family, a social worker, and a physical therapist. Resident #36, admitted with a displaced intertrochanteric fracture of the left femur, muscle wasting and atrophy, chronic kidney disease stage three, and hypertension, also did not have an initial care conference completed within 48 hours. The assessment for the care conference was blank, and there was no documented evidence that she or her representative received a copy of her baseline care plan. The care conference assessment was not completed until over a month after her admission, and only social services and physical therapy were present for the care conference. All three residents had intact cognition and no behaviors, yet the facility failed to provide them with the necessary documentation and involvement in their care planning process.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for personal care received the assistance needed to shower or bathe according to their scheduled times. This deficiency affected three residents who were reviewed for activities of daily living (ADL). The facility's policy required that residents receive personal care according to their plan of care, which included offering a shower, bath, or tub twice a week, and as often as the resident would like per their request. Resident #147, who was admitted with multiple diagnoses including orthopedic aftercare and diabetes, was scheduled to receive showers or baths every Tuesday, Thursday, and Saturday. However, documentation revealed that out of nine opportunities, the resident only received three bathing activities. The resident expressed a preference for at least two showers a week, but the facility failed to meet this preference. The Director of Nursing provided additional documentation showing that bed baths were given on two of the missed dates, but there was no documentation for the remaining missed dates. Resident #149, admitted with conditions such as orthopedic aftercare and morbid obesity, was scheduled for showers or baths every Monday, Wednesday, and Friday. The resident was documented as having received a shower or bath only twice during the review period. The resident expressed a preference for showers over bed baths, but the facility did not consistently offer showers, and there was confusion over whether the resident had refused care. Additionally, Resident #19, who had diagnoses including malignant neoplasm and muscle wasting, reported that he only received showers when a specific aide was working. The facility's records confirmed that three scheduled showers were missed for this resident.
Failure to Invite Residents to Activities
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #4 and Resident #19, were invited to participate in activities, which is a deficiency in meeting all residents' needs. Resident #4, who was admitted with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease, had a care plan indicating a preference for independent activities such as music and word puzzles. Despite having intact cognition and no behaviors, Resident #4 reported not participating in any activities and spending most of her time in bed. A CNA confirmed that Resident #4 had not been out of bed for six to seven months due to discomfort from the Hoyer lift and chair, and in-room activities were not offered. The activity participation log showed no activities for several days in December 2024, and the Activity Director acknowledged missing documentation due to staffing struggles. Similarly, Resident #19, with diagnoses including malignant neoplasm of the stomach and esophagus, muscle wasting, and hypertension, also reported not being invited to activities and spending time sitting in his room. His care plan noted a preference for independent activities, and his cognition was intact with no behaviors. The activity log for Resident #19 also showed no documented activities for multiple days in December 2024. The Activity Director confirmed the lack of documentation and attributed it to being busy with providing activities and completing documentation. An LPN confirmed the gaps in activity documentation, indicating a systemic issue in ensuring residents' participation in activities.
Delayed Response to UTI Symptoms in Resident
Penalty
Summary
The facility failed to address signs and symptoms of a urinary tract infection (UTI) in a timely manner for Resident #36. The resident, who was admitted with diagnoses including a displaced intertrochanteric fracture of the left femur and hypertension, had an indwelling Foley catheter and was occasionally incontinent of bladder. Despite having a care plan in place to monitor for UTI symptoms, the resident reported symptoms such as dysuria and urinary incontinence for over a week without appropriate action from the facility staff. An orthopedic consult recommended a urinalysis, which was delayed, and the resident did not receive antibiotics until several days after the UTI was confirmed. Interviews revealed that the resident, a retired nurse, had been complaining of UTI symptoms for approximately two weeks, but her concerns were not addressed by the nursing staff. A CNA reported the resident's symptoms multiple times to the nurses, but no action was taken. The Director of Nursing confirmed the delay in obtaining the urinalysis and starting antibiotic treatment. The facility's policy on notifying changes in a resident's condition was not followed, as staff failed to promptly notify the provider and responsible parties of the resident's symptoms.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to ensure that a resident's oxygen tubing was changed weekly as ordered by the physician. Resident #4, who was admitted with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease, had a physician's order for oxygen at two liters per minute via nasal cannula, with instructions to change the oxygen tubing weekly on Wednesdays. Observations on December 30 and 31 revealed that the oxygen and nebulizer tubing had not been changed since December 18, despite the order. Interviews with a CNA and an LPN confirmed that the tubing should have been changed on December 25, but it was not. The facility's policy also recommended changing the nasal cannula weekly and as needed.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for Resident #36, who was admitted with a displaced intertrochanteric fracture of the left femur, among other conditions. The resident's care plan included interventions for managing pain, but the facility did not adhere to these interventions effectively. The Minimum Data Set (MDS) assessment indicated a pain rating of seven out of ten, yet the medication administration records (MAR) showed inconsistencies in administering prescribed pain medications, such as acetaminophen and Norco, without clear parameters for their use. The resident experienced significant delays in receiving pain medication, sometimes waiting up to six hours, which was corroborated by interviews with the resident and staff. The Director of Nursing (DON) confirmed that the MAR indicated Resident #36 experienced pain on multiple occasions without receiving the prescribed Norco. Additionally, the narcotic log showed discrepancies, with doses of Norco being signed out but not documented as administered. Interviews revealed that the resident's daughter had to intervene to ensure timely medication administration, and a Certified Nursing Assistant (CNA) reported delays in the resident receiving her medication even after notifying the nurse. The facility's pain management policy emphasized prompt response and documentation, which was not followed in this case, leading to the deficiency.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment for Resident #37, who was receiving the antipsychotic medication Olanzapine (Zyprexa). The resident was admitted with diagnoses including unspecified psychosis, unspecified dementia, and anxiety disorder. Despite the resident's severely impaired cognition and the administration of antipsychotic medication, there was no documented evidence of an AIMS assessment being completed since the resident's admission or after the medication was restarted following a hospital stay. The Director of Nursing confirmed the absence of the AIMS assessment for Resident #37, acknowledging that such assessments should be conducted for every resident receiving antipsychotic medication. The facility's policy indicated that AIMS testing should occur initially upon admission and then every six months for residents on psychotropic medications. This oversight affected one of the five residents reviewed for unnecessary medications, highlighting a lapse in monitoring for potential extrapyramidal side effects.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure that stock medications were stored in their original packaging, which led to the inability of staff to identify the expiration date of the medication. This issue affected three residents who were administered Tylenol Extra Strength from a medication cart on the 200 hall. During a medication administration observation, it was noted that Acetaminophen 500 mg tablets were stored in a bottle intended for Acetaminophen 325 mg tablets. The bottle was labeled with medical tape indicating the incorrect dosage, and there was no expiration date visible, as the tablets were not in their original packaging. An LPN confirmed the improper storage and acknowledged that the 500 mg tablets had been placed in a smaller bottle for easier access, which was not intended for that dosage. The Director of Nursing was informed of the situation and confirmed that the nursing staff should not have transferred the tablets into the incorrect bottle, as it prevented them from knowing the expiration date. The facility's policy on medication storage, which requires medications to remain in their original containers to maintain integrity and support safe administration, was not followed in this instance.
Documentation Failures in Meal Intake and Dialysis Evaluations
Penalty
Summary
The facility failed to ensure proper documentation of meal intake for two residents and pre and post dialysis evaluations for another resident. Resident #4, who was admitted with diagnoses including venous insufficiency and hypertension, had incomplete meal intake records on several dates in December 2024. An interview with the resident revealed dissatisfaction with the food quality, and an LPN confirmed the missing documentation. Similarly, Resident #19, admitted with malignant neoplasms and hypertension, also had missing meal intake documentation on multiple dates. This resident also expressed dissatisfaction with the food, which reportedly made him sick. Additionally, the facility did not complete pre and post dialysis evaluations for Resident #11, who has end-stage renal disease and other significant health issues. The resident had orders for hemodialysis three times a week, but the evaluations were missing on numerous occasions from June to November 2024. An LPN Unit Manager confirmed the absence of these evaluations, which should have been completed with each dialysis visit. The facility's policy required vital signs and weight checks before and after dialysis, as well as monitoring for complications, but these were not documented as required.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to initiate enhanced barrier precautions (EBP) as required for Resident #37, who was admitted with diagnoses including Parkinson's disease, diabetes mellitus, and a history of Extended-spectrum beta-lactamases (ESBL). Despite physician orders dated 04/01/24 indicating the need for EBP due to a history of ESBL and multi-drug resistant organism E-coli, observations on 05/06/24 revealed no EBP sign posted outside Resident #37's room. By 05/08/24, although an EBP sign was posted, staff members were observed not following EBP protocols. Specifically, an LPN was seen removing soiled items without gloves or a gown, and an STNA entered the room without washing hands or applying personal protective equipment, handling soiled linens with bare hands and leaving the room without washing hands afterward. The Housekeeping Supervisor verified that EBP were not implemented as ordered for Resident #37. The facility's policy on Enhanced Barrier Precautions, revised in March 2024, aims to reduce the transmission of multidrug-resistant organisms during high-contact resident care activities. This deficiency was investigated under Complaint Number OH00152983 and represents non-compliance with the facility's infection prevention and control program.
Failure to Assist Residents with ADLs and Grooming
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living (ADL) and grooming as needed. Resident #7, who was admitted with chronic respiratory failure, end-stage renal disease, and ventilator dependence, was observed to have long black facial hairs and large white dandruff-like skin in her hair. Despite her care plan indicating the need for assistance with personal hygiene, it was revealed through interviews and observations that her hair had not been washed for at least three weeks, and she had not received help with removing her facial hair. This lack of assistance led Resident #7 to feel the need to cover her hair with a hat when out of her room or at the dialysis center to hide the dandruff-like flakes. The issue was confirmed by a State-tested Nurse Aide who acknowledged the observations and the resident's need for assistance with shaving and hair washing. The resident expressed appreciation once her facial hair was removed and her hair was washed after the observation was made. Resident #53, admitted with diagnoses including unspecified dementia and severe impairment in daily decision-making, was observed with broken and jagged fingernails on her right hand. The resident stated that her nails had been in that condition for three days and she did not have the means to trim them herself. Her care plan also indicated the need for assistance with personal hygiene to remain well-groomed and free of odors. The observation was verified by a therapy staff member who stated they would inform the aide responsible for the resident's nail care. This deficiency was investigated under Complaint Number OH00152983.
Failure to Ensure Competent IV Medication Administration
Penalty
Summary
The facility failed to ensure competent nursing staff administered intravenous medications, affecting one resident observed for medication administration. Resident #47, admitted with diagnoses including sepsis, diabetes mellitus, and a history of embolism, had an order for Meropenem 1000 mg IV every 12 hours. On the observed date, an LPN administered the medication late due to training new staff and being behind schedule. The LPN flushed the resident's PICC line with normal saline before administering the medication. The LPN's licensure was reviewed, revealing that while her license was active for medication administration, there was no evidence she was certified for IV administration. The Director of Nursing confirmed that the LPN received training from the company staff educator, but the facility could not provide evidence that the IV training met the Ohio Board of Nursing requirements. The DON referenced a legislative change indicating that LPNs no longer need specific IV education to perform IV skills, but this did not address the immediate competency issue observed.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure medications were stored appropriately and administered when dispensed. During an observation and interview on 05/06/24, a Registered Nurse (RN) was found to have pre-poured several resident medications for the morning medication administration. The medications were stored in the top drawer of the medication cart, labeled only with numbers and without any resident names or date/time to identify them. This practice was confirmed by RN #2, who admitted to pre-pouring medications depending on the day's circumstances. The medications in the cups were not identifiable, and there was no way to verify which resident they belonged to. Medical record reviews revealed that Resident #1 had diagnoses including asthma and atrial fibrillation, and Resident #3 had diagnoses including arteriosclerotic heart disease. The facility's policy on Medication Administration General Guidelines, dated December 2012, stated that medications were to be administered at the time they were prepared. The RN's actions were in direct violation of this policy, leading to the deficiency noted in the report. This incident affected two residents from one of the three medication carts observed during the survey.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered without error, resulting in a medication administration error rate of 16%. This affected two residents out of five observed during 25 medication opportunities. Resident #5, who was admitted with diagnoses including atrial fibrillation and constipation, was ordered to receive senna 8.6 mg for bowel management. However, on the morning of 05/06/24, RN #2 administered senna plus (a combination of a stool softener and laxative) instead of the prescribed senna. RN #2 confirmed the error during an interview. Resident #47, admitted with diagnoses including sepsis and diabetes mellitus, had scheduled orders for insulin, an IV antibiotic, and Lactobacillus. On the same day, LPN #4 administered the insulin after breakfast instead of before a meal, the IV antibiotic was given later than the scheduled time, and only 50 mg of Lactobacillus was administered instead of the prescribed 100 mg. LPN #4 verified these discrepancies during an interview. The facility's policy on medication administration, dated December 2012, was not followed, leading to these errors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
