Canal Winchester Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canal Winchester, Ohio.
- Location
- 6800 Gender Road, Canal Winchester, Ohio 43110
- CMS Provider Number
- 366462
- Inspections on file
- 39
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Canal Winchester Care Center during CMS and state inspections, most recent first.
The facility failed to follow pre-op dental instructions and to implement and document physician orders for TED hose. One resident with heart failure and intact cognition had documented care plans for coordinated dental services, but the record lacked evidence of a key dental consult and scheduled surgery, and the dental office reported that pre-op fasting and medication instructions were not followed, causing cancellation of the planned procedure. Two other residents with edema and complex cardiac/vascular conditions had orders for bilateral TED hose or compression hose, yet surveyors repeatedly observed them without the ordered hose in place. In both cases, LPNs acknowledged that the ordered hose were not being used, while the treatment administration records showed the treatments as completed, contrary to observations and interviews.
Surveyors found that staff did not consistently follow transmission-based precautions, enhanced barrier precautions, or hand hygiene requirements. A resident on contact and droplet isolation for COVID-19 was cared for by a CNA who entered the room without required PPE and with a mask pulled down, despite clear isolation signage and available PPE. Another resident on enhanced barrier precautions was served a meal by a housekeeping manager who wore only a gown, touched room surfaces, then walked into the hallway still gowned and discarded the gown in regular trash, while a lab technician drew blood from a different resident on enhanced barrier precautions without donning a gown as indicated. An LPN providing medications and wound care to two residents failed to change soiled gloves or perform hand hygiene between contaminated and clean tasks, and handled personal items and room surfaces with contaminated gloves, contrary to the facility’s hand hygiene and PPE policies.
Two residents at risk for falls were not provided with the required two-person assistance during transfers, as specified in their care plans and facility policy. In one case, a resident was transferred with a mechanical lift by only one CNA, resulting in a fall when the lift strap broke. In another case, a resident with impaired cognition and mobility was assisted by only one LPN during a transfer and fell while being weighed. Both incidents occurred due to staff not following established protocols, though no major injuries were reported.
A resident with severe cognitive impairment and a history of falls was left unattended with the bed in a high position and the fall mat not in place when a CNA left the room to get supplies. The resident rolled out of bed and sustained a hip fracture requiring hospitalization and surgery. Staff interviews and records confirmed that required fall interventions were not in place at the time of the incident.
The facility did not provide timely surgical staple removal for two residents following surgery and failed to implement a physician's order for daily weights for another resident. In both wound care cases, there was a lack of documentation and follow-up regarding staple removal, and for the resident requiring daily weights, the order was not entered or carried out by staff.
A resident with significant mobility limitations and a history of pressure ulcer risk was not provided with prescribed off-loading interventions, such as heel boots, despite having a care plan and physician orders in place. Observations and interviews confirmed that staff did not apply the available heel boots, resulting in the resident developing a stage II pressure ulcer that was being treated but not adequately prevented.
A resident with multiple diagnoses and intact cognition experienced lower back pain, prompting an x-ray that revealed compression deformities. The resident was not informed of the x-ray results or new treatment orders until several days later, and documentation of this notification was delayed. There was also no timely documentation that the nurse practitioner was made aware of the x-ray findings, as confirmed by an LPN.
A resident with multiple medical conditions and moderate cognitive impairment, identified as being at risk for pressure ulcers, did not have a care plan in place for pressure ulcer prevention. Staff confirmed the absence of such a care plan and were unaware of any skin issues beyond a surgical incision. This deficiency was found during a complaint investigation.
A facility failed to follow proper infection control and isolation precautions for residents with influenza. PPE carts lacked eye protection, and signs indicating isolation precautions were missing. Staff entered isolation rooms without full PPE, contrary to facility policies.
A resident with multiple medical conditions, including COPD, experienced a lack of dignity and respect during a transfer when a CNA made an inappropriate comment as the resident became short of breath. The facility's investigation confirmed the incident, leading to the CNA's termination.
A facility failed to implement a comprehensive pressure ulcer prevention program for a resident, resulting in the development and deterioration of a pressure ulcer on the resident's foot. Despite hospice staff identifying the ulcer in February, the facility did not address it until August, leading to its classification as a Stage IV ulcer by September. The resident had severe cognitive impairment and multiple health conditions, and the facility's lack of monitoring and treatment contributed to the deficiency.
A resident's call light was left unanswered for over 10 minutes, despite being activated by a family member who needed assistance with the resident's incontinence brief and preparation for an appointment. Staff, including an STNA and an LPN, failed to respond promptly, leading to a delay in care. The incident was investigated under a complaint.
A resident with severe cognitive impairment and multiple medical conditions was found with facial bruising, which was not reported to the state agency as required. The bruising was likely caused by someone holding the resident's mouth to encourage eating. The facility's investigation was delayed, and the deficiency was identified during a complaint investigation.
A resident with severe cognitive impairment and multiple health issues was found with facial bruising, which was not promptly investigated by the LTC facility. Staff members noticed the bruising but failed to report or document it immediately. The facility's investigation was delayed, and it was later determined that the bruising likely occurred due to someone holding the resident's mouth to encourage eating.
A facility failed to implement fall interventions for a resident with a known fall history. Despite a care plan that included keeping the call light within reach, an observation revealed it was out of reach, verified by an LPN. This oversight represents a failure to follow the care plan, crucial for preventing falls in residents with multiple medical conditions.
A resident with COPD and respiratory failure had their oxygen nasal cannula improperly stored, wrapped around the oxygen holder without a protective bag. Observations also noted a nebulizer machine with its delivery system left on the counter outside of a plastic bag. An LPN confirmed the inappropriate storage, which did not comply with the physician's orders for equipment maintenance.
A resident with a complex medical history, including COPD and anxiety disorder, experienced a delay in receiving prescribed Cepacol sore throat lozenges. The lozenges, ordered for administration every two hours as needed, were not delivered until two days after the order was placed. An LPN confirmed the delay in initiation of the medication.
A facility failed to timely obtain a physician-ordered urinalysis and culture for a resident with a complex medical history, due to unavailable lab services over the weekend. The delay led to the resident being treated for a UTI during an ER visit before the test was conducted. An LPN confirmed the untimely collection of the urine sample, resulting in a deficiency finding.
A resident's family member discovered soiled linen and a ripped mattress stained with urine and feces, emitting a strong odor. The facility failed to maintain the mattress in a clean and sanitary manner, as confirmed by the Administrator.
The facility failed to maintain a clean environment in one of its units, affecting several rooms with stained carpeting. A resident reported the stains were present upon admission and even offered to pay for cleaning. An LPN confirmed the issue, which was investigated under multiple complaints.
A facility failed to ensure proper infection control practices, as observed when an STNA delivered meal trays to residents, including those with COVID-19, without changing masks or performing hand hygiene. The STNA wore only a surgical mask, contrary to the facility's policy requiring an N-95 mask, gown, gloves, and face shield for COVID-19 precautions. This noncompliance potentially affected multiple residents and was confirmed by interviews with the STNA and an LPN.
A resident with multiple diagnoses, including diffuse large B-Cell lymphoma and atrial fibrillation, hit her head on the side rail while being assisted with bed mobility. The facility failed to notify the physician, initiate neurological checks, or conduct follow-up assessments. The resident was later hospitalized with a scalp hematoma. Interviews confirmed the lack of incident reporting and follow-up care, contrary to facility policy.
The facility failed to ensure proper date labeling, cleanliness of dishware, and appropriate hot holding temperatures for food, potentially affecting all residents except two who were NPO. Observations revealed expired food items, soiled storage containers, and food temperatures below the required 135 degrees Fahrenheit.
The facility failed to serve food at a palatable and warm temperature, affecting four residents and potentially impacting all residents receiving meals from the kitchen. Observations and interviews confirmed that food temperatures were below the required 135 degrees Fahrenheit, contrary to the facility's policy.
A resident with multiple diagnoses and a moderate cognitive deficit was observed with long, jagged, and dirty fingernails on two occasions, despite the care plan and facility policy requiring staff to provide nail care. The resident expressed her inability to clean her nails and desire for assistance, highlighting the staff's failure to adhere to care guidelines.
A facility failed to identify and document a resident's left great toe injury. Observations showed a bandaged toe with dark red drainage and an untrimmed toenail. The resident's medical record lacked treatment orders, and staff interviews confirmed the absence of documentation. The injury occurred when the resident's toe got caught in bed covers, and the facility's policy on skin and wound care was not followed.
The facility failed to ensure that pressure reducing devices were in place for a resident with multiple medical conditions, including a surgical wound to the left achilles. Despite the care plan's directive to use a heel protector, observations revealed the device was not consistently in place, leaving the resident's left achilles directly on the bed. This deficiency was confirmed through multiple observations and staff interviews.
The facility failed to have a physician's order for the use of oxygen for a resident with COPD and other serious conditions. The resident was observed receiving oxygen without the necessary documentation or care plan interventions, as confirmed by an LPN.
The facility failed to maintain a medication error rate below five percent, resulting in a 10.34 percent error rate. Errors included incorrect dosages of Potassium Chloride and Famotidine for one resident and improper administration of eye drops for another. The errors were confirmed through observation and interviews with the LPN involved.
The facility failed to notify the PCP of elevated blood glucose levels for a resident with diabetes, despite multiple readings exceeding the physician-ordered parameters. An LPN confirmed the lack of notification, which was against the facility's policy on Change in Condition Notification.
The facility failed to ensure individualized fall preventative interventions were in place for two residents. One resident's fall mat was not in place, and another resident's wheelchair lacked the required Dycem for safety. These deficiencies were confirmed by staff and were against the facility's Fall Management Guidelines policy.
Failure to Follow Dental Pre-Op Instructions and Apply Ordered TED Hose
Penalty
Summary
The deficiency involves the facility’s failure to follow pre- and post-appointment instructions and to implement physician orders for compression (TED) hose. One resident with chronic obstructive sleep apnea, heart failure, and intact cognition had care plans indicating the need for coordinated dental services, including arranging dental care and following pre- and post-operative treatment changes. The resident’s record contained no evidence of a dental appointment on a specified November date or any pre- or post-operative orders for a dental surgery scheduled for a specified December date. A dental office staff member reported that the resident had a consult in early November where preoperative instructions were given to the resident’s daughter, but when the resident arrived for surgery in mid-December, she reported she had eaten and taken medications that morning contrary to the preoperative instructions, resulting in cancellation of the surgery. The DON confirmed the surgery was later completed in late December and acknowledged there was no documentation of the earlier appointment or scheduled surgery in the resident’s record, and that appointment information should be entered on the TAR and after-visit information obtained and followed. The deficiency also includes failure to apply TED hose as ordered for a resident with multiple cardiovascular and circulatory diagnoses, including acute on chronic combined systolic and diastolic heart failure, pulmonary hypertension, chronic venous hypertension with bilateral lower extremity ulcers, localized edema, and other conditions. This resident was cognitively intact and required assistance with several ADLs. A physician order directed that TED hose be applied to both legs every day shift for swelling and circulation. On multiple observations over two days, the resident was seen in bed and in a wheelchair without TED hose in place. During wound care, an LPN applied an ace wrap to the resident’s left shin instead of TED hose, and later confirmed that ace wraps, not TED hose, were being used and that the resident had never worn TED hose, despite the existing physician order. The February treatment administration record showed TED hose as signed off as applied on one of the observation dates by the same LPN. A third resident, admitted with diagnoses including localized edema, major depression, hypertension, and acute respiratory failure, and with intact cognition, also had a physician order for compression hose to both lower extremities to be applied in the morning and removed in the evening each day for edema. Observations on two consecutive days at multiple times showed that the ordered hose were not in place. During a concurrent interview, an LPN verified that the hose were not on as ordered. Review of the February treatment record revealed that on one of the observation dates, the hose had been documented as applied, despite repeated observations that they were not on the resident. The facility’s policy on physician and practitioner orders, last issued and reviewed on specified dates, states that a licensed nurse is responsible for completing care per physician orders. This deficiency was investigated under a specific complaint number.
Failure to Follow Transmission-Based Precautions, Enhanced Barrier Precautions, and Hand Hygiene Requirements
Penalty
Summary
The deficiency involves multiple failures in implementing transmission-based precautions, enhanced barrier precautions, and proper hand hygiene. In one instance, a CNA entered the room of a cognitively intact resident who was on contact and droplet isolation for a newly identified positive COVID-19 test without wearing required PPE, with their mask pulled down to the chin. The resident’s door displayed signs for droplet and contact isolation, and a PPE cart was properly stocked outside the room. The CNA stated they did not think the resident was on isolation precautions, and the resident reported not knowing if she was on contact isolation. A nurse later confirmed the resident was on contact and droplet isolation and that staff should be wearing PPE when entering the room. Another set of deficiencies involved improper use of enhanced barrier precautions and PPE by non-nursing staff. A housekeeping and laundry manager entered the room of a resident on enhanced barrier precautions wearing only a gown and no gloves to deliver a meal tray. While in the room, she touched the bedside table to move items and then exited the room, walked across the hallway still wearing the gown, and discarded it in a regular trash can at the nurse’s station before using hand sanitizer. She acknowledged seeing the enhanced barrier precautions sign and admitted she donned a gown but not gloves because she was unsure of the rules. In a separate incident, a laboratory technician entered the room of another resident on enhanced barrier precautions, who had a PICC line and a JP drain, and drew blood without wearing a gown as required by the posted signage and facility policy. The technician stated she did not see the signage or the PPE available on the back of the door, but indicated she would normally wear a gown and gloves for a blood draw under enhanced barrier precautions. Additional deficiencies were identified in hand hygiene and glove use during medication administration and wound care. During medication administration to a resident with COVID-19 and weeping edema of the lower extremities, an LPN performed hand hygiene and donned PPE before entering the room, then touched the resident’s weeping lower extremities and soiled bed linens with gloved hands, and subsequently handled a blood pressure cuff and administered medications without changing gloves or performing hand hygiene. The LPN later verified that soiled gloves were not removed and hand hygiene was not performed before touching the blood pressure cuff and medications, contrary to the facility’s hand hygiene policy. In another observation, the same LPN performed wound care on a cognitively intact resident with multiple lower extremity wounds. During the procedure, the LPN intermittently performed hand hygiene and changed gloves but also touched her cell phone and the back pocket of her scrubs with gloved hands, then continued wound care, handled dressings, wiped the floor, and moved the resident’s wheelchair before finally removing PPE and performing hand hygiene. The LPN acknowledged that hand hygiene was not consistently performed after handling soiled dressings and linens and before moving from contaminated to clean body sites, and the unit manager confirmed that facility policy required hand hygiene in these situations. Facility policies reviewed by surveyors specified that contact precautions require hand hygiene, gloves, and gown; droplet precautions require gloves, gown, mask, and eye protection; and enhanced barrier precautions require gown and glove use during high-contact resident care activities for residents colonized with MDROs or at increased risk due to indwelling devices. The hand hygiene policy required hand hygiene before moving from a contaminated body site to a clean body site, after handling contaminated objects or equipment, and before and after handling clean or soiled dressings or linens, as well as before handling medications. The observed practices by the CNA, housekeeping and laundry manager, laboratory technician, and LPN did not conform to these written policies, resulting in the cited infection prevention and control deficiency affecting multiple residents. This deficiency represents noncompliance investigated under Complaint Number #2713145.
Failure to Provide Adequate Supervision and Follow Transfer Protocols Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate care and services to prevent falls for two residents who were identified as being at risk. One resident, with diagnoses including pulmonary hypertension, dementia, and spondylosis, was assessed as needing two-person assistance for bed mobility and touch assistance for transfers. Despite this, the resident was transferred using a mechanical lift by only one CNA, contrary to both the resident's care plan and facility policy, which required two trained staff for such transfers. During the transfer, the mechanical lift strap broke, causing the resident to fall backwards onto the bed, though no injuries were noted. Another resident, with a history of heart failure, hypertension, multiple cancers, muscle weakness, and impaired cognition, was care planned for two-person physical assistance with transfers and did not ambulate at baseline. This resident experienced a fall while being re-weighed at the weight station. The resident was being assisted by only one LPN, who was using a gait belt, when the resident lost balance and was eased to the floor. The care plan specified two-person assistance for transfers, but only one staff member was present at the time of the incident. In both cases, staff actions did not align with the residents' care plans or facility policies regarding the required number of staff for transfers and use of mechanical lifts. These failures resulted in falls, though neither resident sustained major injuries. The facility's policies and care plans were not followed, leading to deficiencies in accident prevention and supervision.
Failure to Maintain Fall Interventions Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that fall risk and safety interventions were in place for a resident with a known history of falls from bed. The resident had severe cognitive impairment, required extensive assistance from two staff for bed mobility, and was identified as being at high risk for falls due to multiple medical conditions, including a cerebrovascular accident with left-sided hemiplegia, muscle contractures, and confusion. The resident's care plan included specific interventions such as keeping the bed in the lowest position and ensuring a fall mat was in place. On the day of the incident, a CNA left the resident's room to retrieve personal care supplies, leaving the bed in a high position and the fall mat leaned against the wall instead of being properly placed. During this time, the resident rolled out of bed and sustained a fall, resulting in a nondisplaced intertrochanteric fracture of the left femur. The resident was found on the floor by her bed, complained of hip pain, and was subsequently hospitalized for surgical repair of the fracture. The investigation confirmed that the required fall interventions were not in place at the time of the fall. Prior to this incident, the resident had a documented history of falls, including a recent fall from bed without injury. The care plan and fall risk assessments had identified the need for consistent implementation of fall prevention measures. However, staff failed to follow these interventions, directly leading to the resident's injury. Interviews with staff confirmed that the fall precautions were not maintained when the CNA left the room, and the incident was immediately reported to management.
Failure to Provide Timely Wound Care and Implement Physician Orders
Penalty
Summary
The facility failed to provide timely care for surgical incision staple removal for two residents and did not obtain physician-ordered daily weights for another resident. For one resident with a history of fractured femur, mood disorder, and other significant medical conditions, staples from a surgical incision were not removed in a timely manner. The resident's follow-up appointment for staple removal was canceled by the trauma clinic, and although the spouse, who is the POA, requested that the removal be done in the facility to avoid confusion for the resident, there was no documentation of any plan or action to remove the staples until two weeks later. During this period, the resident continued to have the staples in place, and the spouse reported ongoing concerns to the facility. Another resident, admitted with diagnoses including diverticulitis, acute respiratory failure, and recent abdominal surgery, had a surgical incision with staples present on admission. The medical record indicated that the staples remained in place throughout the resident's stay, and there was no documentation of any discussion or order regarding staple removal during the entire admission. Wound assessments noted the presence of the staples, but no further action was documented regarding their removal. A third resident, with a history of myocardial infarction, acute respiratory failure, and pressure ulcers, had a physician's order for daily weights following a cardiology appointment. Although medication changes from the after-visit summary were implemented, the order for daily weights was not entered into the system, and the resident was not weighed daily as ordered. Interviews with staff confirmed that the process for entering new orders from after-visit summaries was not followed, resulting in the omission of the daily weight order.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with multiple comorbidities, including a history of cerebrovascular accident with hemiplegia, contractures, and decreased mobility, was not provided with appropriate pressure ulcer prevention interventions. The resident was assessed as being at risk for pressure ulcer formation and had a care plan in place that included interventions such as floating heels, use of heel boots, frequent turning and repositioning, and daily skin monitoring. Despite these documented interventions and physician orders, observations revealed that the resident was lying in bed with a dressing on her right ankle/foot and no off-loading devices, such as heel boots, in use. Further investigation through interviews confirmed that heel boots were available but not being applied by staff, as noted by a family member who found the boots in the resident's closet. An LPN also verified that no off-loading was provided to the pressure ulcer on the resident's right ankle. The lack of implementation of prescribed interventions for pressure ulcer prevention and care led to the deficiency, as the resident developed a stage II pressure ulcer that was being monitored and treated, but preventive measures were not consistently followed.
Failure to Timely Notify Resident and Practitioner of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to both a resident and the medical practitioner regarding a change in the resident's condition and the need to alter the treatment plan. The resident, who had diagnoses including cerebral infarction, neuropathy, anxiety, and major depression, was cognitively intact at the time of the incident. On one occasion, the resident experienced lower back pain, and staff notified the nurse practitioner, who ordered an x-ray and Tylenol for pain management. The x-ray, completed and reported on the same day, revealed L2 and L3 compression deformities of undetermined age. Despite these findings, the resident was not informed of the x-ray results or subsequent new orders for lab work and Prednisone until several days later. Documentation showed that the resident was only notified of these results and new orders days after the x-ray was performed, and this notification was entered as a late entry in the medical record. Additionally, there was no documentation that the nurse practitioner was made aware of the x-ray results until several days after the test, as confirmed by the unit manager LPN, who could not provide a reason for the delay.
Failure to Develop Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for the prevention of pressure ulcers for one resident who was identified as being at risk. Medical record review showed that the resident had multiple diagnoses, including diverticulitis with perforation and abscess, influenza, colostomy status, bladder disorder, rheumatoid arthritis, anxiety, and intellectual disabilities. The resident's admission MDS indicated moderate cognitive impairment and a risk for pressure ulcers, as well as the use of a pressure-reducing mattress and receipt of surgical wound care. Despite these risk factors, there was no care plan in place to address pressure ulcer prevention. This was confirmed by the MDS Coordinator RN, who acknowledged the absence of a care plan, and by a CNA who was unaware of any skin impairments other than the resident's surgical incision. This deficiency was identified during a complaint investigation and was based on both interview and medical record review.
Infection Control and Isolation Precaution Deficiency
Penalty
Summary
The facility failed to adhere to proper infection control and isolation precaution procedures, affecting four residents diagnosed with influenza. Observations revealed that personal protective equipment (PPE) carts were placed outside the rooms of two residents, but there were no signs indicating the type of isolation precautions in place. Interviews with licensed practical nurses confirmed that these residents were on contact/droplet isolation precautions, and signs should have been posted as a safety measure for staff and visitors. Further observations showed that six resident rooms had PPE carts, but none contained eye protection, which is required for droplet isolation precautions. Interviews with two licensed practical nurses confirmed the absence of eye protection in the PPE carts for four residents on droplet isolation precautions. Additionally, a certified nursing aide was observed entering a resident's room on droplet/contact isolation precautions wearing only a mask, without the required gown, gloves, and eye/face protection. The residents involved had various medical conditions, including influenza, respiratory failure, and chronic diseases. Their care plans indicated that they were to be in contact/droplet isolation in single-occupant rooms, with all services provided in-room and staff observing all PPE precautions. The facility's policies on influenza management and infection control outlined the necessary precautions, including the use of PPE and proper signage, which were not followed in these instances.
Resident Dignity Compromised During Transfer
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, affecting a resident who was cognitively intact and had multiple medical conditions, including chronic respiratory failure and COPD. During a transfer involving a mechanical lift, the resident became short of breath after her oxygen was removed for safety reasons. At this time, a Certified Nursing Aide (CNA) made an inappropriate comment, suggesting that the resident should go to her 'happy place' if she couldn't hold on. This comment was reported by the resident, who felt upset and discouraged by the interaction. The facility conducted an investigation into the incident, which confirmed the inappropriate comment was made by the CNA. The CNA involved admitted to joking around with residents but did not recall making the specific comment. Another CNA present during the incident corroborated the resident's account of the event. The investigation findings supported the resident's allegation, leading to the termination of the CNA involved. The deficiency was identified during the course of a complaint investigation.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident, leading to the development and deterioration of a pressure ulcer on the resident's left lateral foot. The resident, who was cognitively impaired and dependent on staff for daily living activities, was first identified by hospice staff to have an unstageable pressure ulcer in February 2024. However, the facility did not identify or address this pressure ulcer until August 2024, despite having a care plan in place that included interventions for pressure injury prevention. The resident's medical history included severe cognitive impairment, cerebrovascular accident with left-sided hemiplegia, severe protein-calorie malnutrition, and Parkinson's disease, among other conditions. The facility had physician orders for weekly skin evaluations, but there was no documented evidence of assessments or interventions for the pressure ulcer from February to August 2024. The facility's failure to monitor and treat the ulcer resulted in its deterioration, with the ulcer being classified as a Stage IV pressure ulcer by September 2024. Interviews with hospice staff revealed communication issues with the facility's management, and the facility's documentation did not reflect the ongoing assessments and treatments provided by hospice. The facility's policy required weekly evaluations of skin alterations, but this was not adhered to, contributing to the deficiency. The facility's inaction and lack of comprehensive assessments and monitoring led to actual harm to the resident, as the pressure ulcer worsened over several months.
Failure to Respond to Resident's Call Light in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident's call light was answered in a timely manner, affecting one resident out of seven sampled. The resident, who had a moderate cognitive deficit and required substantial assistance with daily activities, had a call light activated for over 10 minutes without any staff response. The resident's family member had activated the call light at 9:25 A.M. due to difficulty in applying the resident's incontinence brief and the need to prepare the resident for a scheduled appointment. Despite the call light being activated, staff members, including a State Tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN), did not respond promptly. The STNA left the unit after finishing with another resident, and the LPN, when informed of the situation, did not take action to assist. It was only after more than 10 minutes that another LPN acknowledged the need to address the call light and mentioned the need to educate staff on timely responses. This incident was investigated under Complaint Number OH00158259.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with facial bruising to the required state agency. The resident, who had a severe cognitive impairment and was dependent on staff for assistance, was found with bruising on both sides of the jaw. The bruising was first noticed by an LPN and later confirmed by other staff members, but it was not reported to the state agency as required by the facility's policy. The facility's investigation determined that the bruising likely occurred when someone was holding the resident's mouth to encourage eating, as the resident had a history of pocketing food and being difficult to feed. The resident's medical history included multiple diagnoses such as cerebrovascular accident with left-sided hemiplegia, severe protein-calorie malnutrition, and major depressive disorder, among others. Despite the facility's policy requiring immediate reporting of injuries of unknown origin, the incident was not reported to the state agency. The facility's investigation into the incident was delayed, with skin sweeps not conducted until several days after the bruising was first observed. The deficiency was identified during a complaint investigation.
Delayed Investigation of Resident's Facial Bruising
Penalty
Summary
The facility failed to timely investigate an injury of unknown origin for a resident with facial bruising who was dependent on staff. The resident, who had a severe cognitive impairment and required extensive assistance for eating, was found with discoloration on the jaw by an LPN. Despite the observation, the incident was not immediately reported or investigated. Several staff members, including an STNA and an RN, noticed the bruising but did not take immediate action to report or document the incident properly. The facility's investigation into the bruising was delayed, with skin sweeps not conducted until several days after the bruising was first observed. The investigation determined that the probable cause of the bruising was related to someone holding the resident's mouth to encourage eating, as the resident had a history of pocketing food. The facility's policy on abuse requires a timely and thorough investigation of any allegations, which was not adhered to in this case, leading to a deficiency being cited.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident with a known history of falls. The resident, identified as having multiple medical conditions including aphasia, chronic kidney disease, and dementia, was at risk for falls due to factors such as deconditioning, incontinence, and muscle weakness. The care plan for the resident included various interventions to mitigate fall risks, such as keeping the bed in the lowest position, using non-skid footwear, and ensuring the call light was within reach. However, during an observation, it was noted that the resident's call light was out of reach, which was verified by an LPN. This oversight represents a failure to implement the planned interventions, specifically the accessibility of the call light, which is crucial for the resident's ability to request assistance and prevent falls. This deficiency was investigated under multiple complaint numbers, indicating a pattern of non-compliance in ensuring a safe environment for residents at risk of falls.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of a resident's oxygen nasal cannula, affecting one resident out of a sample of seven. The resident, who was dependent on supplemental oxygen due to chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypoxia, had a care plan that included providing oxygen at six liters per nasal cannula. Observations on multiple occasions revealed that the nasal cannula was wrapped around the oxygen holder and not stored in a protective bag. Additionally, a nebulizer machine was observed with its medication delivery system laying on the counter outside of a plastic bag. The resident's medical record indicated a moderate cognitive deficit and a range of diagnoses, including anxiety disorder, major depressive disorder, and peripheral vascular disease, among others. The physician's orders required the change of oxygen tubing and related equipment weekly and as needed, and to check the placement and positioning of the nasal cannula every shift. However, the observations made on consecutive days showed non-compliance with these orders, as confirmed by an interview with an LPN who verified the inappropriate storage of the oxygen nasal cannula and nebulizer delivery system.
Medication Availability Delay for Resident
Penalty
Summary
The facility failed to ensure the timely availability of medication for a resident, identified as Resident #31, who was affected by this deficiency. The resident had a complex medical history, including chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, and several other conditions. The resident was admitted with a moderate cognitive deficit, as noted in their comprehensive Minimum Data Set (MDS) assessment. A physician's order dated September 21, 2024, prescribed Cepacol sore throat lozenges to be administered every two hours as needed for a sore throat. However, the review of the resident's Medication Administration Record (MAR) for September 2024 showed that the lozenges were not administered until September 23, 2024, at 6:04 A.M. The pharmacy delivery invoice confirmed that the lozenges were not delivered until September 23, 2024. An interview with an LPN on October 3, 2024, verified that the Cepacol throat lozenge was not initiated in a timely manner. This deficiency was investigated under Complaint Number OH00158259.
Failure to Timely Obtain Physician-Ordered Lab Test
Penalty
Summary
The facility failed to timely obtain a physician-ordered laboratory test for a resident, which was identified as a deficiency. The resident, who had a complex medical history including chronic obstructive pulmonary disease, anxiety disorder, and other conditions, was admitted with a moderate cognitive deficit. The resident's care plan included monitoring for changes in elimination and obtaining a urinalysis and culture and sensitivity (UA/C&S) as ordered by the physician. However, the laboratory test was not conducted in a timely manner due to the unavailability of laboratory services over the weekend. The delay in obtaining the UA/C&S resulted in the resident being placed on an antibiotic for a urinary tract infection during an emergency room visit before the test could be conducted. The resident's daughter was informed of the delay, and the deficiency was confirmed through an interview with an LPN, who acknowledged that the urine sample was not collected as required. This incident was investigated under a specific complaint number, indicating noncompliance with the facility's obligation to provide timely laboratory services.
Unsanitary Mattress and Linen Found in Resident's Bed
Penalty
Summary
The facility failed to maintain resident equipment in a clean and sanitary manner, specifically affecting a resident with multiple medical conditions including COPD, anxiety disorder, and dependence on supplemental oxygen. The resident's family member discovered that the bed was made with soiled linen, and upon further inspection, found a rip in the mattress. The foam mattress underneath was stained yellow and brown with dried urine and feces, emitting a strong odor of urine. This indicates that the mattress had not been properly cleaned or maintained, posing a potential health risk to the resident. Interviews with the resident and her family member confirmed the unsanitary condition of the mattress. The family member reported assisting the resident back into bed and noticing the strong odor of urine from the cloth incontinence pad and the mattress. Photographs taken by the family member showed the stained mattress, corroborating the unsanitary conditions. The facility's Administrator verified that the mattress was not maintained in good repair or a clean and sanitary manner, confirming the deficiency.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, specifically affecting one of its four units, the 500 unit, with a census of 72 residents. Observations on September 30, 2024, revealed that the carpeting in Resident #31's room was stained with black and white spots, which had been present since her admission. The resident had even offered to pay for the carpet to be shampooed. Further observations of unoccupied and occupied rooms in the same unit showed similar black stains on the carpeting. On October 3, 2024, an LPN confirmed the presence of stained carpeting in multiple rooms, including rooms 506, 511, and Resident #31's room. This deficiency was investigated under several complaint numbers, indicating ongoing issues with maintaining cleanliness in the facility.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed, specifically regarding hand hygiene and the use of personal protective equipment (PPE) to prevent the spread of COVID-19. This deficiency was observed during the delivery of meal trays by a State tested Nursing Assistant (STNA) who did not adhere to the required protocols. The STNA was seen delivering meal trays to residents, including those with active COVID-19 infections, without changing masks or performing hand hygiene between rooms. The STNA wore only a surgical mask and no additional PPE, despite the facility's policy requiring an N-95 respirator mask, gown, gloves, and face shield for staff entering rooms of residents with COVID-19. The report highlights that two residents were identified with active COVID-19 infections and were under contact and droplet precautions. Despite this, the STNA continued to enter multiple residents' rooms without changing PPE or performing hand hygiene, potentially affecting 16 residents in the hall. Interviews with the STNA and a Licensed Practical Nurse (LPN) confirmed the lack of adherence to the facility's infection control policy, which was revised to include specific PPE requirements for COVID-19 precautions. This deficiency was investigated under multiple complaint numbers, indicating a pattern of noncompliance.
Failure to Provide Appropriate Care After Resident Accident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident following an accident with injury. Resident #99, who had diagnoses including diffuse large B-Cell lymphoma, muscle weakness, viral hepatitis B, and atrial fibrillation, was admitted to the facility with mildly impaired cognition and required partial/moderate assistance with bed mobility. On a specific date, while being assisted with bed mobility, the resident hit her head on the side rail. Despite this incident, the facility did not notify the physician, initiate neurological checks, or conduct follow-up assessments. The resident was later transferred to the hospital due to concerns from the resident's representative about changes in the resident's behavior. Hospital records revealed a mid-left parietal scalp hematoma without skull fracture. Interviews with the resident's representative and a Licensed Practical Nurse confirmed that the facility staff did not complete an incident report, initiate neurological checks, notify the physician, or conduct follow-up assessments after the incident. The facility's policy required reporting, investigating, and reviewing any accidents or incidents involving residents, including initiating neurological checks in the event of head trauma.
Deficiencies in Food Handling and Sanitation
Penalty
Summary
The facility failed to ensure proper date labeling, cleanliness of dishware, and appropriate hot holding temperatures for food, potentially affecting all residents except two who were NPO. Observations revealed that iced tea, lemonade, and punch were incorrectly dated, and a tub of chocolate pudding had an extended date. Hard-boiled eggs and wedge tomatoes were also found with expired dates. The Dietary Manager and Corporate Nutrition Services Coordinator confirmed the discrepancies and discarded the expired items. The facility's policy stated a seven-day use-by date for refrigerated items, but the staff did not adhere to this guideline. Additionally, clear plastic food storage containers on the air-dry rack were found soiled with sticky residue and food debris. The Dietary Manager confirmed the contamination and rewashed the containers. During a tray line observation, the temperatures of carrots, mashed potatoes, and a fish sandwich were below the required 135 degrees Fahrenheit, while French fries were at 172 degrees Fahrenheit. The Dietary Manager and Corporate Nutrition Services Coordinator acknowledged the issue, noting that hot foods should be held at 140 degrees Fahrenheit or above. The facility's policy required TCS foods to be maintained at 135 degrees Fahrenheit or above, which was not followed in this instance.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure food was served at a palatable and warm temperature, affecting four residents and potentially impacting all residents receiving meals from the kitchen. Resident #9, diagnosed with diverticulosis, dysphagia, and irritable bowel syndrome, reported that the food was served cold. Resident #10, with congestive heart failure, type II diabetes, and morbid obesity, also reported that the food was cold and lukewarm. Resident #29, diagnosed with type II diabetes, acute kidney failure, and morbid obesity, stated that the food was sometimes undercooked, overcooked, and cold. Resident #49, with legal blindness, cerebral infarction, and heart failure, described the food as terrible, too cold, and too salty to eat. These observations were confirmed through interviews and medical record reviews for each resident involved. The facility census was 80, with two residents identified as NPO and not affected by the food temperature issue. Observation of the tray line and test tray on 04/17/24 revealed that the food temperatures were below the required 135 degrees Fahrenheit. The Dietary Manager confirmed that the carrots were 124 degrees F, mashed potatoes were 121 degrees F, the fish sandwich was 124 degrees F, and the French fries were 172 degrees F when placed on the test tray. Upon arrival at the 200 Hall and subsequent serving, the food temperatures had further decreased to 113 degrees F for the carrots, 111 degrees F for the mashed potatoes, and 118 degrees F for the French fries. The facility's Food Temperature Monitoring and Recording Policy mandates that all TCS hot food items must be served at a temperature of at least 135 degrees F, which was not adhered to in this instance. The Dietary Manager acknowledged the issue and noted that test trays had not been conducted since her tenure at the facility.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure nail care was provided for a resident who was dependent on staff. Resident #22, who had multiple diagnoses including cerebral infarction, chronic kidney disease, and diabetes mellitus, was observed on two separate occasions with long, jagged, and dirty fingernails containing a brown substance. The resident's care plan indicated that staff should check nail length and trim and clean nails on bath day and as necessary. However, these interventions were not followed, as evidenced by the observations and the resident's own admission that she was unable to clean her nails herself and desired assistance. The deficiency was confirmed through medical record review, observations, and interviews. The resident's quarterly Minimum Data Set (MDS) assessment indicated a moderate cognitive deficit, further emphasizing her dependence on staff for personal hygiene. Despite the facility's policy on nail care, which mandates that RNs, LPNs, and STNAs provide appropriate nail care to prevent infections, the staff failed to adhere to these guidelines, resulting in the resident's neglected nail care.
Failure to Identify and Document Toe Injury
Penalty
Summary
The facility failed to identify and appropriately document an injury to a resident's left great toe and toenail. Observations revealed the resident's toe was covered with a gauze bandage that lacked proper labeling. Further examination showed dark red drainage on the bandage and a thick, long toenail with dried dark red drainage, indicating it had not been trimmed or filed recently. The resident's medical record did not contain any treatment orders for the toe injury, and weekly skin assessments and progress notes did not document the injury or the need for a bandage. Interviews with the resident's spouse and facility staff confirmed the presence of the bandage and the lack of documentation or treatment orders. The resident had refused podiatry services earlier in the month, and the Director of Nursing revealed that the injury occurred when the resident's toe got caught in the bed covers, causing the toenail to bleed. The facility's policy on skin and wound care requires evaluation and documentation of skin alterations by a licensed nurse, which was not followed in this case.
Failure to Ensure Pressure Reducing Devices for Resident
Penalty
Summary
The facility failed to ensure that pressure reducing devices were in place for Resident #17, who had a history of multiple medical conditions including osteomyelitis, dementia, diabetes mellitus, and chronic kidney disease. The resident's care plan included specific interventions to prevent skin injury and manage existing wounds, such as the use of a heel protector to reduce pressure on the left heel. However, observations on multiple occasions revealed that the heel protector was not in place, leaving the resident's left achilles directly on the bed, contrary to the care plan requirements. The resident's medical record indicated a history of a surgical wound to the left achilles, which was present on admission and required ongoing treatment. Weekly skin and wound evaluations documented the wound's measurements and condition, noting moderate amounts of drainage and the presence of slough. Despite the documented need for pressure relief and the care plan's directive to use a heel protector, staff failed to ensure the device was consistently in place, as observed on 04/16/24 and verified by a State tested Nursing Assistant (STNA). Further observations on 04/17/24 during a wound treatment procedure confirmed the absence of the heel protector, with the resident's left achilles laying directly on the bed. The facility's policy on skin and wound care emphasized the importance of individualized care plans to address specific risk factors and prevent skin injury. The failure to adhere to the care plan and ensure the use of pressure reducing devices contributed to the deficiency identified in the report.
Lack of Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to have a physician's order for the use of oxygen for Resident #35. An observation revealed that Resident #35 was receiving oxygen via nasal cannula with the oxygen concentrator set at four liters. However, a review of Resident #35's medical record showed no physician orders for oxygen use. Additionally, the resident's care plan for COPD did not include any interventions for oxygen use, and there was no documentation of oxygen use in the progress notes from 04/01/24 to 04/16/24. Resident #35 was admitted to the facility with diagnoses including Lewy Bodies disorder, Alzheimer's disease, high blood pressure, and COPD. The resident was also admitted to hospice services for neurocognitive disorder with Lewy Bodies disease. Despite these conditions, the facility did not have the necessary physician orders for oxygen use, which was confirmed by the LPN Unit Manager. The facility's policy requires managing residents utilizing oxygen per physician orders, which was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 10.34 percent error rate. This was observed during medication administration for two residents. For Resident #19, the LPN administered 40 mEq of Potassium Chloride instead of the physician-ordered 20 mEq and 10 mg of Famotidine instead of the prescribed 20 mg. The resident had multiple diagnoses, including cerebrovascular accident, dysphagia, and chronic kidney disease, and was noted to have a moderate cognitive deficit. The errors were confirmed through interviews with the LPN involved in the administration. For Resident #17, the LPN administered Cyclosporine Ophthalmic Emulsion 0.05% in both eyes, despite the physician's order specifying administration only in the right eye. The resident had a history of osteomyelitis, asthma, dementia, and other conditions, and also had a moderate cognitive deficit. The LPN's actions were observed and verified through an interview. The facility's policies on medication administration and eye drop administration were reviewed, revealing that the procedures were not followed as required.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to ensure the primary care physician (PCP) was notified of elevated blood glucose levels outside of the physician-ordered parameters for Resident #16. The resident, who had multiple diagnoses including diabetes mellitus, had a care plan that required blood glucose monitoring and physician notification for levels less than 60 or greater than 200. Despite this, the resident's medical record showed multiple instances in April 2024 where blood glucose levels exceeded 200, with no documented evidence that the PCP was notified. Specifically, blood glucose levels of 218, 225, 237, 248, 208, and 215 were recorded without corresponding notifications to the physician. An interview with an LPN confirmed that the physician was not notified of these elevated blood glucose levels. The facility's policy on Change in Condition Notification, dated 08/09/23, mandates notifying the resident, their attending physician, and the resident's designated representative of changes in the resident's medical or mental condition. This deficiency was identified during an investigation under Complaint Number OH00152459.
Failure to Implement Individualized Fall Preventative Interventions
Penalty
Summary
The facility failed to ensure individualized fall preventative interventions were in place for two residents. Resident #16, who had multiple diagnoses including osteomyelitis, dysphagia, and chronic obstructive pulmonary disease, was identified as being at risk for falls. Despite having a care plan that included interventions such as keeping the bed in a low position and using a fall mat, an observation revealed that the fall mat was folded up and not in place. This was verified by a State tested Nursing Assistant (STNA) and was contrary to the facility's Fall Management Guidelines policy, which emphasizes individualized interventions to minimize fall risks. Similarly, Resident #68, who had a history of breast cancer, dementia, and chronic obstructive pulmonary disease, was also at risk for falls. The care plan for this resident included the use of Dycem on the wheelchair seat for safety. However, an observation revealed that the Dycem was not in place, and instead, the wheelchair seat had a waffle air cushion and other items like playing cards and a magazine. The Director of Nursing (DON) confirmed the absence of Dycem, which should have been on top of the foam pressure-reducing cushion. This was also against the facility's Fall Management Guidelines policy.
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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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