Buckeye Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Ohio.
- Location
- 1900 East Main Street, Lancaster, Ohio 43130
- CMS Provider Number
- 365250
- Inspections on file
- 30
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Buckeye Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that two residents who required staff assistance with ADLs and personal grooming did not receive timely facial hair removal despite care plan directives and facility policy. One resident with multiple chronic conditions and intact cognition was observed in a common area with long, noticeable chin hairs after stating that staff usually shaved them but had not done so that day, a fact confirmed by an LPN. Another resident with moderate cognitive impairment and multiple medical diagnoses was observed with prominent upper and lower lip hair resembling a mustache, reported that it was bothersome, and had a blank shower documentation sheet despite requiring assistance with showering and shaving. An LPN stated that CNAs are expected to shave female residents when facial hair is noticeable, even on non-shower days, but acknowledged that both residents’ requests for shaving had not been carried out, contrary to facility ADL and hygiene policies.
A resident with multiple chronic conditions and intact cognition reported lower abdominal pain, leading a physician to order a UA with culture and sensitivity and encourage fluids. The UA was ordered twice but not collected on either occasion, and there was no documented explanation for the missed collections. An antibiotic (Ciprofloxacin) was started for infection without a completed UA or documentation of ongoing symptoms, and the UA order was later discontinued after the resident had already been on antibiotics for two days. The DON confirmed the UA was not completed as ordered and that documentation regarding the reason for the antibiotic and the resident’s symptoms was lacking, contrary to the facility’s Antibiotic Stewardship policy.
A deficiency was identified when a resident’s wheelchair was not maintained in a clean and sanitary condition. The resident had multiple chronic conditions, including Parkinson’s disease, Type II DM, progressive multiple sclerosis, mild cognitive impairment, legal blindness, dementia, and major depressive disorder, and was documented as cognitively intact on a recent MDS. On two separate observations, the wheelchair was noted to have a large buildup of dirt, food, stains, and splatters along the sides and edges. During an interview, the DON acknowledged that the wheelchair needed cleaning and stated it was scheduled to be cleaned by night shift.
A resident with multiple medical conditions sustained a fractured humerus following a transfer with a sit-to-stand machine. The injury was not immediately recognized, and facility staff delayed documentation of the incident. Despite policy requiring prompt reporting of serious injuries, the DON did not file a Facility Reported Incident (FRI) with the state agency after learning of the fracture, and the aides involved had not been interviewed at the time of the survey.
A resident with impaired cognition and multiple diagnoses developed a blister with drainage on the right thigh. Although a physician was notified and orders for labs and antibiotics were given, no wound care treatment orders were implemented, and no wound assessments were documented for several months. Nursing staff changed bandages informally, but the facility's wound care policy requiring physician orders and documentation was not followed.
A resident with impaired cognition and multiple diagnoses sustained a second-degree burn after spilling hot coffee on himself during lunch, despite using a two-handled cup with a spouted lid as recommended by OT. All safety interventions and the plan of care were in place and functional at the time of the incident.
A resident receiving IV Vancomycin for osteomyelitis did not have required peak and trough lab levels ordered or drawn for three weeks, despite standard care expectations. Staff interviews confirmed the omission, and the facility lacked a policy for antibiotic lab monitoring.
Multiple residents were not provided adequate privacy and dignity during incontinence care and post-shower assistance, resulting in exposure of their bodies to others in the facility and, in one case, to the outside through an open window. Staff confirmed that privacy measures such as closing doors, drawing curtains, and covering residents were not consistently followed, contrary to facility policy.
Surveyors found that the facility did not properly safeguard or document controlled substances, with unlabeled medications stored inappropriately, discrepancies in medication counts, and missed documentation of opioid administration by nursing staff. Additionally, antibiotics were not administered as ordered to a resident, and staff failed to follow physician orders for pain management, leading to multiple deficiencies in medication management.
A resident with complex medical needs was affected when their controlled medication was misappropriated after being delivered and registered in the narcotic count, but later found missing. Additional observations revealed that nurses failed to consistently document administration of controlled substances, and discrepancies existed between medication cards and count sheets, which were not identified during shift change reconciliations. Staff interviews confirmed ongoing issues with documentation and awareness of proper controlled substance storage.
The facility failed to timely assess and monitor an indwelling catheter, delayed sending a urine sample for lab analysis, and initiated antibiotics before urine test results were available, resulting in delayed and inadequate treatment of a UTI for a resident. Additionally, another resident received inadequate incontinence care, as a CNA did not fully clean the resident after a bowel movement and left stool on the skin and in the clean incontinence product. These actions were not in accordance with facility policy and were confirmed by staff interviews and observations.
A resident with a gastrostomy tube did not receive proper medication administration when an LPN failed to check tube placement, did not flush the tube before giving medications, and did not provide the prescribed water bolus, instead flushing with a lesser amount after administering multiple crushed medications. These actions did not follow physician orders or facility policy.
A resident with a gastrostomy tube was administered multiple crushed medications via the tube by an LPN without a physician's order for this route, resulting in a 48% medication error rate. The LPN did not check tube placement or flush the tube prior to administration, and facility policy requiring verification of orders and correct administration route was not followed.
A resident's controlled medication was found stored in pill-crusher pouches inside a cup labeled only with the resident's name and medication name in marker, lacking proper pharmacy labeling or identification. Staff could not verify the contents or quantity of the medication, and the DON confirmed the medication was not properly labeled or identifiable, contrary to facility policy.
The facility did not properly log or monitor infections, missing documentation of a resident's sepsis and UTI, and failed to identify infection trends despite multiple E. coli UTIs. Additionally, a CNA was observed providing incontinence care and handling personal items without performing required hand hygiene before or after glove changes, in violation of facility policy.
A resident with a history of UTI and recent catheter use was started on antibiotics before urinalysis and culture results were available, contrary to facility policy. The initial antibiotic was not effective against all identified organisms, and a second antibiotic was started after culture results. An LPN confirmed that antibiotics are often ordered prophylactically without confirming appropriateness, indicating a failure to follow antibiotic stewardship protocols.
A resident with hemiplegia and hemiparalysis was assessed to smoke independently without supervision, leading to a severe incident where her clothing caught fire. The facility failed to provide adequate fire safety measures, resulting in the resident sustaining third-degree burns and requiring hospitalization. The smoking area lacked accessible fire safety equipment, and the resident's care plan did not account for her physical limitations.
The facility failed to date multi-use vials of tuberculin PPD when opened, as observed in the medication room refrigerator. An LPN confirmed the vial was opened the previous day but was not dated, contrary to the facility's policy.
The facility failed to ensure food was not expired and was stored appropriately, and staff did not practice proper hand hygiene when handling food. Expired and improperly stored food items were found in the kitchen, and Cook #211 repeatedly handled food without washing hands or changing gloves, violating the facility's policies on food storage and preparation.
The facility failed to follow the dietary menu and portion control for residents on dysphagia advanced, mechanical soft, or pureed diets. Cook #211 served sloppy joes instead of cheeseburgers and did not use portion control utensils for shredded lettuce, affecting 23 residents.
A resident with multiple diagnoses, including dementia and schizophrenia, was improperly restrained by an LPN who sat on her in the smoking area after she went outside during non-smoking hours. The LPN's actions were deemed unnecessary and violated the facility's abuse prevention policy.
Failure to Provide Timely Facial Hair Grooming for Dependent Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide timely hygiene care, specifically shaving and removal of facial hair, for residents who required assistance with activities of daily living (ADLs). One resident with Parkinson’s disease, right shoulder pain, impaired mobility, COPD, bipolar disorder, obesity, osteoarthritis, heart failure, seizures, and other conditions was cognitively intact and required touching assistance for personal grooming, including shaving, per the MDS and care plan. The care plan documented an actual risk for ADL decline and the need for staff assistance with hygiene. During observation, this resident was seen in a common area with multiple long, white chin hairs that were noticeable. The resident reported being unable to find tweezers and stated that staff usually shaved the chin whiskers but had not done so that day. An LPN confirmed the presence of multiple long white chin hairs and that the resident had requested their removal, which had not been done. Another resident with atrial fibrillation, hypertension, osteoarthritis, anxiety disorder, hypothyroidism, major depressive disorder, ischemic heart disease, anemia, and electrolyte imbalance had moderate cognitive impairment and required moderate assistance for showering and personal hygiene, including shaving, as documented on the MDS and care plan. The care plan indicated an ADL self-care performance deficit related to impaired mobility and required staff assistance for showering and personal hygiene, including shaving. Review of a shower sheet for this resident showed a blank space where shower documentation should have been. Observation revealed multiple black hairs on the resident’s upper and lower lips with the appearance of a mustache, and the resident stated the facial hair bothered her because it did not look good. An LPN stated that female residents’ facial hair is to be shaved on shower days and when noticeable, and that CNAs are expected to shave female residents with facial hair even if it is not their shower day. The LPN confirmed the facial hair on this resident and that the resident had asked for it to be shaved but it remained. Facility policy required that residents unable to carry out ADLs independently receive services necessary to maintain grooming and personal hygiene, including support and assistance with hygiene in accordance with the plan of care.
Failure to Timely Obtain Ordered UA and Document UTI Management
Penalty
Summary
The deficiency involves the facility’s failure to timely obtain an ordered urinalysis (UA) with culture and sensitivity and to appropriately document and address a suspected urinary tract infection (UTI) for one resident. The resident was admitted with multiple diagnoses including Parkinson’s disease, Type II diabetes mellitus, progressive multiple sclerosis, malnutrition, dysphagia, legal blindness, and dementia, and had intact cognition per a recent MDS assessment. On 11/10/25, the physician documented the resident’s complaint of lower abdominal pain and ordered a UA with culture and sensitivity, along with encouragement of fluids while results were pending. A physician order for the UA with culture and sensitivity was entered on 11/11/25, but a progress note on 11/12/25 documented that the UA was not collected. On 11/18/25, another physician order was entered for a UA with culture and sensitivity, along with an order for Ciprofloxacin 250 mg by mouth every 12 hours for three days for infection, without documentation explaining the resident’s ongoing symptoms or the rationale for starting the antibiotic at that time. A progress note on 11/19/25 again documented that the UA was not collected. On 11/20/25, documentation showed the resident appeared in the lab system for a UA, but she had already been on antibiotics for two days; the physician was then asked if the UA was still needed, and on 11/21/25 the physician reported the order could be discontinued. Review of the medical record from 11/10/25 to 11/20/25 revealed no further documentation related to the UTI, and the DON confirmed the UA was not completed timely as ordered, that there was no documentation on 11/18/25 to indicate why the antibiotic was ordered or what symptoms persisted, and that the antibiotic was ordered without a UA. The facility’s Antibiotic Stewardship policy required that culture and sensitivity results and the current clinical situation be communicated to the prescriber to determine if antibiotic therapy should be continued or modified, but the UA was never obtained.
Unclean Wheelchair Environment for a Cognitively Intact Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident’s wheelchair in a clean and sanitary condition, as required to keep the environment safe, easy to use, clean, and comfortable for residents, staff, and the public. The resident, identified as Resident #52, had been admitted on 05/28/21 with multiple diagnoses including Parkinson’s disease, Type II DM, progressive multiple sclerosis, mild cognitive impairment, unspecified protein-calorie malnutrition, legal blindness, dementia, and major depressive disorder. A quarterly MDS assessment dated 10/16/25 documented that the resident had intact cognition. On 01/06/26 at 2:50 p.m. and again on 01/08/26 at 10:05 a.m., surveyor observations showed that the resident’s wheelchair had a large buildup of dirt, food, stains, and splatters along the sides and edges. During an interview on 01/08/26 at 10:05 a.m., the DON confirmed that the wheelchair needed to be cleaned and stated it was on the schedule for the night shift. This deficiency affected one resident out of three reviewed for environment and was investigated under Complaint Number 2706168, with a total facility census of 88.
Failure to Timely Report Resident Injury to State Authorities
Penalty
Summary
The facility failed to report an alleged violation involving a resident's injury to the state department of health in a timely manner. A resident with multiple complex medical diagnoses, including Parkinson's disease, dementia, and muscle weakness, experienced an incident during a transfer using a sit-to-stand machine. Initial nurse's notes indicated the resident felt weakness in her legs and was unable to hold on to the machine, leading staff to return her to bed. At the time, no injuries were noted, and the incident was not documented until approximately nine hours later. Later that evening, the resident reported pain and swelling in her right shoulder and arm, prompting the nurse to contact the physician, who ordered a stat X-ray. The following day, the X-ray revealed a fractured neck of the humerus, and the resident was sent to the emergency room for further evaluation. Despite being made aware of the fracture, facility leadership did not file a Facility Reported Incident (FRI) as required by policy, which mandates immediate reporting to the state agency within two hours for serious bodily injury. Interviews with the DON confirmed awareness of the injury and the connection to the previous day's incident with the sit-to-stand machine. However, the DON had not yet interviewed the two aides involved in the transfer, and the nurse's notes and incident report were not completed by those present at the time of the event. Facility records showed no FRI was filed for the incident, and the internal investigation was incomplete at the time of the survey.
Failure to Implement and Document Wound Care and Assessments
Penalty
Summary
The facility failed to ensure that wound care treatment and assessments were appropriately implemented and completed for a resident with a history of Parkinsonism, dementia, and dysphagia, who was assessed to have impaired cognition. Despite the identification of a new blister with green and yellow drainage on the resident's right thigh, and subsequent notification of the physician with orders for laboratory testing and antibiotic therapy, no wound care treatment orders were implemented, and no wound assessments were documented from the time the blister was identified through several months. The care plan indicated the resident was at risk for impaired skin integrity, but there was no evidence of wound care or assessment for the blister during the specified period. Observations revealed the presence of a bandage on the resident's right thigh, and interviews with nursing staff confirmed that although the wound was known and bandages were being changed, formal wound care orders were not followed, and required assessments were not completed or documented. The facility's own policy required physician orders for wound care and thorough documentation of wound care and assessments, but these procedures were not adhered to in this case. The Assistant Director of Nursing confirmed that wound care treatment orders and assessments were not implemented or documented as required.
Resident Burn from Hot Coffee Despite Safety Interventions
Penalty
Summary
A resident with diagnoses including Parkinsonism, dementia, and dysphagia, and assessed to have impaired cognition, sustained a burn after spilling hot coffee on himself during lunch. At the time of the incident, the resident was using a two-handled cup with a spouted lid as recommended by Occupational Therapy to prevent spillage and burns. Despite these interventions, the resident spilled coffee, resulting in a blister and redness on the right outer leg, later assessed as a second-degree burn measuring 10.5 cm by 6.6 cm. Record review and staff interview confirmed that all safety interventions and the plan of care were in place and functional at the time of the occurrence. The incident was documented in nursing progress notes, and the burn was assessed and measured by the facility. The event affected one resident out of three reviewed for accidents, and the facility census was 93 at the time.
Failure to Obtain and Monitor Vancomycin Lab Levels
Penalty
Summary
The facility failed to ensure that blood draw orders for Vancomycin peak and trough levels were obtained and completed for a resident who was receiving intravenous Vancomycin for osteomyelitis. The resident, who had multiple diagnoses including acute osteomyelitis, peripheral vascular disease, diabetes mellitus type two, and abscess of the right ankle and foot, was admitted and received Vancomycin without any corresponding lab orders for monitoring drug levels. Review of the medical record and nursing notes confirmed that no Vancomycin peak or trough levels were ordered or documented during a three-week period of administration. Interviews with facility staff, including an LPN, a physician assistant, the consulting pharmacist, and the Director of Nursing, confirmed that the standard of care for Vancomycin administration was not followed, as regular lab monitoring was expected but not performed. The pharmacist noted that hospital discharge instructions included weekly trough levels, but these were not implemented upon admission. The facility also lacked a policy regarding lab draws and monitoring for antibiotics, contributing to the oversight.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during personal care activities, as evidenced by multiple observations involving incontinence care and post-shower assistance. In several instances, residents with cognitive intactness and various medical conditions, including multiple sclerosis, Parkinson's disease, dementia, and heart failure, were exposed during care. One resident was observed receiving incontinence care with the room door open and privacy curtain not drawn, resulting in exposure of the resident's buttocks and legs. Another resident was seen sitting naked on the toilet with her head lowered, and staff confirmed that dignity was not maintained during these activities. Additionally, an incontinence product containing stool was left on the floor without a barrier during care. In a separate incident, a resident was observed self-propelling in a wheelchair in the hallway after a shower, covered only by a towel that left her shoulders, upper thighs, and feet exposed. Staff accompanying the resident acknowledged that the resident was not fully covered. Another resident received incontinence care next to a large window with open blinds, exposing her to view from an adjacent parking lot and sidewalk. The staff member providing care confirmed that the blinds were not closed during the procedure. Facility policy required staff to promote and maintain resident privacy and dignity during personal care, which was not followed in these instances.
Failure to Safeguard and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain a comprehensive pharmaceutical program to safeguard controlled substances and ensure medications were administered as ordered. During a reconciliation of controlled drugs, surveyors observed that controlled medications were not properly labeled or stored. Specifically, two pill-crusher pouches containing an unknown quantity of blue, round, scored tablets were found in a disposable cup labeled only with a resident's name and drug name, but without a pharmacy label or other required identification. The Director of Nursing (DON) was unable to confirm the contents or how long the pouches had been present, and the count of oxycodone tablets did not match the controlled drug record, with missing documentation and discrepancies in the number of tablets available versus what was recorded. Further observations revealed that staff failed to accurately document the administration of controlled medications. In two instances, a registered nurse admitted to administering opioid medications to residents but forgot to sign out the doses on the controlled drug record. Additionally, the number of controlled medication count sheets did not match the number of medication cards, and this discrepancy was not identified during shift change reconciliations. Review of medication administration records and controlled drug records for several residents showed inconsistencies, with some doses recorded as administered on one record but not the other, and in one case, a nurse withheld scheduled pain medication based on personal judgment rather than physician orders. The facility also failed to ensure that antibiotics were administered as ordered. One resident, who had been prescribed a course of Augmentin for pneumonia, did not receive the full number of ordered doses, as confirmed by both the medication administration record and staff interview. Review of facility policies indicated that medications were to be administered as prescribed and that controlled substances were to be properly documented and reconciled, but these procedures were not consistently followed, resulting in multiple deficiencies affecting several residents.
Failure to Safeguard and Accurately Document Controlled Substances
Penalty
Summary
The facility failed to safeguard controlled substances, resulting in the misappropriation of a resident's medication. A resident with multiple medical conditions, including diabetes, fractures, heart failure, and a urinary tract infection, was prescribed oxycodone. When staff attempted to reorder the medication, the pharmacy reported it was too soon for a refill, revealing that 60 tablets had already been delivered and registered in the facility's narcotic count. Despite a comprehensive search, the medication and its control sheet could not be located, and the facility was unable to determine who or when the medication was misappropriated. The incident was identified when the pharmacy denied the refill request, and the attending physician was notified immediately. Further observations during the survey revealed ongoing issues with the documentation and reconciliation of controlled substances. During medication reconciliation, discrepancies were found between the number of tablets recorded on the Controlled Drug Administration Record (CDR) and the actual number of tablets present for two residents. In both cases, a nurse admitted to administering the medication but forgetting to sign it out on the CDR. Additionally, inconsistencies were found between the number of controlled medication cards and the corresponding count sheets, which were not identified during shift change reconciliations. Interviews with nursing staff confirmed a lack of awareness regarding unidentified controlled drugs being stored in the medication lock box and acknowledged continued concerns with documentation and reconciliation of controlled substances. The facility's policy prohibits misappropriation of resident property, but the failure to maintain accurate records and perform thorough shift change counts contributed to the deficiency.
Failure to Provide Timely Catheter Assessment, UTI Treatment, and Adequate Incontinence Care
Penalty
Summary
The facility failed to provide timely and appropriate care for residents with indwelling catheters, urinary tract infections (UTIs), and incontinence. One resident was admitted with multiple diagnoses, including a fracture, heart failure, chronic kidney disease, benign prostatic hyperplasia, and a UTI. The resident had an indwelling catheter for pain control and mobility, which required comprehensive evaluation upon admission, weekly for four weeks, and then quarterly. However, there was no evidence of ongoing comprehensive evaluation of the catheter between late February and the end of April. The resident's catheter was eventually discontinued at his request, but the urinalysis sample obtained at that time was not sent to the lab promptly, resulting in delayed diagnosis and treatment. The resident was started on antibiotics before urine test results were available, and ultimately required two different antibiotics due to resistance patterns identified later. Additionally, the facility failed to provide adequate incontinence care for another resident who was frequently incontinent of bowel and bladder. During observed care, a CNA performed incontinence care with the blinds open, exposing the resident to potential lack of privacy. The CNA did not fully clean the resident, leaving stool on the resident's skin and on the clean incontinence product that was applied. The CNA acknowledged that the resident was not fully cleaned and stated that staff would check and clean the resident again in about 20 minutes. The Assistant Director of Nursing confirmed that the care provided was not appropriate and that the resident should not have been left soiled. Policy review indicated that indwelling catheters should be used sparingly and only for appropriate indications, with ongoing evaluation and documentation of need. The policy also required prompt identification and management of UTIs and appropriate incontinence care. The facility's failure to follow these policies resulted in delayed assessment and treatment of a UTI, inadequate catheter care, and insufficient incontinence care for the residents involved.
Failure to Follow Protocol for G-Tube Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube did not receive proper care during medication administration. The resident, who had diagnoses including dysphagia, intracranial hemorrhage, congestive heart failure, gastrostomy, and dementia, was observed receiving multiple crushed medications mixed in water through the g-tube. The LPN administering the medications failed to check the tube for placement and did not flush the tube prior to medication administration, contrary to facility policy. Additionally, the LPN did not provide the ordered 200 mL of water bolus as prescribed, instead flushing the tube with only 60 mL of water after medication administration. Medical record review confirmed the resident was ordered a regular diet with pureed texture, thin liquids, and a specific water bolus twice daily. Facility policy required verification of tube placement, flushing before and between medications, and use of the prescribed amount of water. The LPN acknowledged during interview that these steps were omitted due to forgetting the cup and not wanting to set it down, resulting in failure to follow both physician orders and facility policy for enteral tube medication administration.
Medication Administration Errors via Gastrostomy Tube
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a gastrostomy tube, resulting in a medication error rate of 48% (12 errors out of 25 opportunities) during medication administration. The resident, who had diagnoses including dysphagia, nontraumatic intracranial hemorrhage, congestive heart failure, gastrostomy, and dementia, was observed receiving multiple medications crushed and administered via a gastrostomy tube by an LPN. There was no physician order to administer these medications through the enteral tube, and the medications were ordered to be given orally, with instructions that they could be crushed and given with food if appropriate. During the observed medication pass, the LPN did not check the gastrostomy tube for placement or flush it prior to administration, and only flushed the tube after administering the medications. The LPN confirmed that all medications, including those not intended for enteral administration, were crushed and given via the tube without a proper order. Facility policy required verification of a physician's order for enteral tube medication administration and adherence to the prescribed route, which was not followed in this instance.
Improper Labeling and Storage of Controlled Medication
Penalty
Summary
The facility failed to ensure that medications were properly labeled in accordance with professional standards and facility policy. During a reconciliation of controlled substances, surveyors observed that a resident's oxycodone tablets were stored in pill-crusher pouches inside a disposable water cup, with the cup labeled only with the resident's name and medication name written in marker. The pouches themselves lacked any pharmacy label or proper identification, containing only handwritten initials and the number '30'. The staff were unable to verify the exact contents or quantity of the medication in the pouches, and the Director of Nursing confirmed that there was no way to know what the tablets actually were or how many were present, aside from the five tablets remaining in the original prescription bottle. The resident involved had a history of osteoporosis, spinal stenosis, chronic pain, osteoarthritis, and joint pain, and had been prescribed oxycodone 5 mg as needed for pain. The medication policy required that drugs be stored in their original packaging with complete pharmacy labeling, and only the dispensing pharmacy was authorized to transfer or relabel medications. The observed practice of storing and labeling the medication did not comply with these requirements, as the medication was not in its original container and lacked the necessary identifying information.
Failure to Monitor Infections and Ensure Hand Hygiene
Penalty
Summary
The facility failed to properly monitor and log infections, as well as identify possible infection trends, as evidenced by the omission of a resident's sepsis and urinary tract infection (UTI) from the Infection Control Log. Medical record review showed that a resident with multiple diagnoses, including respiratory failure and heart failure, was admitted and later diagnosed and treated for sepsis and UTI in the hospital. However, the infection preventionist confirmed that these infections were not recorded in the facility's infection control log, and no trends or patterns were identified, despite multiple residents being diagnosed with UTIs caused by E. coli. Additionally, the facility failed to ensure proper hand hygiene practices during incontinence care. Observation revealed that a certified nurse assistant (CNA) provided incontinence care to a resident, disposed of soiled materials, and changed gloves without performing hand hygiene before or after glove changes, contrary to facility policy. The CNA also handled personal items and applied ChapStick to the resident without washing hands. Policy review confirmed that hand hygiene is required after glove removal and after contact with body fluids or contaminated surfaces, but these procedures were not followed during the observed care.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement appropriate antibiotic stewardship for one resident who was admitted with multiple diagnoses, including a urinary tract infection (UTI). Medical record review showed that the resident was cognitively intact, frequently incontinent of urine, and had a recent history of UTI. The resident had an indwelling urinary catheter for a period prior to the incident. On a specific date, the resident complained of back pain and dysuria, and cloudy urine was observed. A urinalysis was sent for analysis, but a prophylactic antibiotic (Bactrim) was started before the urinalysis and urine culture results were available. The resident continued to receive Bactrim pending the results, and fluids were encouraged. The urine culture later revealed the presence of Escherichia coli (sensitive to Bactrim) and enterococcus faecalis (not sensitive to Bactrim). The resident was then started on a different antibiotic (Cipro) after the culture results were received. An interview with an LPN confirmed that antibiotics were started prior to receiving test results, and that the physician assistant routinely orders antibiotics prophylactically without confirming appropriateness. Facility policy required assessment and diagnostic testing to guide antibiotic use, but this protocol was not followed in this case. This deficiency was identified during a complaint investigation.
Failure to Maintain Safe Smoking Area Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a safe outdoor smoking area for residents, particularly for a resident with significant physical impairments. This resident, who had hemiplegia and hemiparalysis affecting her left side, was assessed to smoke independently without supervision. However, she was not accurately assessed for her ability to extinguish herself in the event of a fire, nor was she provided with reasonable access to fire safety equipment or a means to obtain assistance in case of an emergency. On the day of the incident, the resident was smoking in the designated smoking area when an ash from her cigarette ignited her clothing, resulting in severe third-degree burns to her upper body and face. A visitor observed the resident on fire and attempted to extinguish the flames using her own clothing, as there was no fire blanket readily accessible in the smoking area. The resident was subsequently hospitalized and required surgical intervention for her injuries. The facility's smoking policy at the time did not ensure that fire safety equipment was adequately accessible to residents in the smoking area. The resident's care plan and smoking assessment failed to account for her physical limitations and the need for supervision or assistance in the event of a fire, contributing to the severity of the incident.
Removal Plan
- Licensed Practical Nurse (LPN) #242 responded to Resident #100 after being notified the resident had caught fire. LPN #242 assessed Resident #100 for pain which the resident initially denied and refused a transfer to the emergency room. Later Resident #100 agreed to the hospital transfer, the transfer was facilitated, and the resident's representative was notified of the incident.
- The Administrator called Resident #100's representative and discussed the incident.
- The Administrator visited Resident #100 in the hospital. The Administrator stated the resident voiced concerns about losing her smoking privileges and also stated the wind blew amber out of her cigarette and caught her clothes on fire.
- Licensed Practical Nurse (LPN) #242 reviewed the current smoking residents in the facility with no injuries noted. All smoking evaluations were reviewed for accuracy and the plans of care was updated if needed for the residents reviewed. LPN #242 also instructed the residents on the location of the fire safety equipment, fire blanket, and ensured they understood how to use it.
- The Director of Nursing (DON) reviewed skin evaluations on all current residents and there were no signs of any injuries of unknown origin or injuries consistent with a smoking injury.
- LPN #242 observed independent smokers' clothing and no signs of damaged clothing consistent with a smoking incident were noted.
- LPN #242 re-educated current smoking residents on the importance of informing staff of any potential fire hazards immediately to prevent similar incidents from occurring.
- LPN #242 re-educated the current staff on the updated facility smoking policy.
- The Administrator met with the resident council to review the smoking policy, and to receive feedback from the residents related to the possibility of transitioning the facility to supervised smoking in the future.
- Regional Nurse Consultant (RNC) #800 incorporated fire safety equipment checks immediately, daily for four days, then monthly and as needed thereafter to ensure appropriate fire safety equipment was present and in functional order.
- Activities Director (AD)#294 started random audits on a minimum of five residents per week for four weeks then as needed to ensure residents were appropriately assessed and were smoking safely independently, avoiding loose and flammable clothing, and were taking appropriate precautions related to weather conditions. Any issues identified within the audits were to be forwarded to the Quality Assurance (QA) committee for immediate follow-up.
- Registered Nurse (RN) #319 provided staff, residents, and visitors with education regarding placement of the fire extinguisher and fire blanket.
- The Administrator obtained a quote for a gazebo to be placed in the smoking courtyard.
- Regional Nurse Consultant (RNC) #800 updated the smoking policy to include additional fire safety measures, such as having fire extinguisher in the smoking area, training residents on basic fire safety, and inspection and maintenance of fire safety equipment.
- AD#294 educated current smokers on the updated smoking policy, the current smokers were provided with a copy of the policy and signed an attestation of understanding.
- AD#294 placed signage on the facility doors informing and reminding residents and staff of the smoking rules and fire safety practices.
- The Administrator held a meeting with the Ombudsman and all independent smoking residents regarding the smoking policy, placement of the fire extinguisher, placement of the fire blanket, and the importance of verbalizing the need for assistance.
- A gazebo was placed within the courtyard by Maintenance Director (MD) #281.
- MD #281 placed a fire blanket on the gazebo.
- MD #281 moved the fire extinguisher to the designated smoking area.
- Occupational Therapist (OT) #318 assessed all independent smokers to ensure they were able to follow safety precautions related to fire safety and ensured residents were able to remove the fire blanket and understood how to use a fire extinguisher.
- The facility implemented a plan that the DON would educate all licensed nurses on how to complete a smoking assessment to ensure consistency. Licensed nurses would be responsible for completing smoking assessments moving forward. The education would include the new location of the smoking blanket in the designated smoking area. No agency staff were being utilized and no licensed nurses were on leave at the time of the training.
- AD #294 hung signs on the two handicapped accessible doors leading to the smoking area to ensure staff, residents, and visitors had knowledge of where the smoking blanket and fire extinguisher were located.
- The Administrator fastened a walkie talkie to the smoking gazebo for communication in the event of an emergency. The walkie talkie would be changed out daily to ensure it was charged.
- The DON or designee would complete weekly audits for four weeks and as needed to ensure the completed smoking observation/assessments were accurate and reflected the medical record.
- The DON or designee would complete weekly audits for four weeks and as needed to ensure the fire blanket, fire extinguisher, and walkie talkie were in place.
- Results of the audits would be reviewed during monthly Quality Assurance (QA) meetings to determine if the current action plan was effective or if additional interventions would need to be added. Any issues identified within the audit would be forwarded to the QA committee for immediate follow-up.
Failure to Date Multi-Use Vials of Tuberculin PPD
Penalty
Summary
The facility failed to ensure that multi-use vials of tuberculin purified protein derivative (PPD) were dated when opened. This deficiency was observed during an inspection of the medication room refrigerator, where an opened vial of tuberculin PPD was found without a date indicating when it was opened. An LPN confirmed that the vial was opened the previous day for a new admission but acknowledged that it was not dated as required. The facility's policy, dated April 2019, mandates that the date of opening must be recorded on multi-dose containers, which was not adhered to in this instance.
Improper Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure food was not expired and was stored appropriately, as well as failed to ensure staff practiced proper hand hygiene when handling food. During an initial tour of the kitchen, several food items were found to be expired or improperly stored, including a half-used container of salsa, a bag of brown, soggy shredded lettuce, an opened and undated bag of fresh grapes, an unopened bag of pre-sliced potatoes, and a partially used bottle of hot sauce. Additionally, a large bag of premade peanut butter cookie dough cookies was found opened and undated in the freezer. The Dietary Manager confirmed these findings and discarded the items. The facility's policy on food receiving and storage was not adhered to, as it requires foods to be received and stored in a manner that complies with safe food handling practices. Furthermore, Cook #211 was observed not practicing proper hand hygiene while handling food. Cook #211 donned clean gloves without washing hands, handled food items, and then removed the gloves without performing hand hygiene. This process was repeated multiple times during the lunch meal service, including handling French fries, slices of cheese, hamburger buns, and other food items. The cook continued to handle food with the same gloves on, even after touching various surfaces and items. The facility's policy on food preparation and service, which requires proper hygiene and sanitary practices to prevent cross-contamination, was not followed. The Administrator, Dietary Manager, and Cook #211 confirmed these observations during an interview.
Failure to Follow Dietary Menu and Portion Control
Penalty
Summary
The facility failed to ensure the menu was followed for residents on dysphagia advanced, mechanical soft, or pureed diets. On the specified date, the lunch menu was supposed to include a cheeseburger on a bun, lettuce and tomato, French fries, creamy coleslaw, and a cookie. However, Cook #211 prepared and served sloppy joes instead of cheeseburgers, and did not include buns in the pureed version of the meal. Additionally, Cook #211 used gloved hands to scoop shredded lettuce onto plates instead of using a portion control utensil to ensure the correct amount was served, as indicated on the dietary spreadsheet. This affected 23 residents who required specific dietary modifications. Interviews with Cook #211, the Dietary Manager, and the Administrator confirmed that the dietary spreadsheet was not followed for the lunch meal. Cook #211 admitted to using a homemade recipe for sloppy joes and acknowledged the omission of buns in the pureed version, as well as the failure to use portion control utensils for the shredded lettuce. The facility's policy on food preparation and service, which mandates adherence to dietary spreadsheets and portion sizes, was not followed, leading to this deficiency.
Failure to Ensure Resident was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, which affected one resident. The incident involved a resident who was cognitively intact and had multiple diagnoses, including epilepsy, schizophrenia, and dementia. The resident alleged that an LPN sat on her in the smoking area after she went outside during non-smoking hours. The LPN was trying to get the resident back inside, and the resident became combative, resulting in a bruise on her shoulder from hitting a bench outside. The facility's Self-Reported Incident revealed that the LPN grabbed the resident's wrist, leading to a physical altercation. The LPN then restrained the resident by sitting on her while they were both on a bench outside. Witnesses confirmed that the LPN initiated the physical contact and restrained the resident, which was unnecessary as the resident did not physically engage with the LPN until he grabbed her wrist. The facility's abuse prevention policy prohibits any physical restraint not required to treat the patient's medical symptoms. Interviews with the resident and staff confirmed the details of the incident. The resident expressed frustration about not being allowed to smoke when she wanted, and the LPN's actions were deemed inappropriate and unnecessary. The facility's policy review and interviews indicated that the LPN's actions violated the facility's abuse prevention policy, leading to the deficiency being cited by the surveyors.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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