Cityview Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 6606 Carnegie Ave, Cleveland, Ohio 44103
- CMS Provider Number
- 365879
- Inspections on file
- 42
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Cityview Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Two residents with psychiatric histories were physically abused by another resident known to have aggressive behaviors related to mental illness. In one incident, a cognitively impaired resident was struck in the face in the dining area, sustaining a chin skin tear and facial bruising that required hospital treatment, with later information indicating the assailant used an object believed taken from a maintenance cart. In a separate hallway incident, another resident with intact cognition was hit in the back of the head after an argument over a notebook, resulting in a head laceration requiring staples and hospital evaluation. The aggressive resident had an existing care plan identifying potential for physical aggression and interventions such as counseling, conflict management, and seeking staff assistance, yet these measures did not prevent the two episodes of resident-on-resident physical abuse.
A resident with cognitive impairment and a history of wandering accessed a malfunctioning locked utility room and fell through a laundry chute to the basement, sustaining multiple traumatic injuries. Staff had been aware of the faulty lock prior to the incident, and the resident was able to leave the secured unit undetected. Documentation and investigation of the incident were incomplete, and the resident was not comprehensively assessed before being moved.
Multiple residents experienced unsanitary and unsafe room conditions, including water leaks, damaged fixtures, missing dispensers, and unclean bathrooms, while staff failed to answer facility phone calls promptly, as confirmed by direct observation and staff interviews.
The facility did not provide scheduled activities or implement care planned interventions for multiple residents, resulting in unmet psychosocial and recreational needs. Observations and interviews showed that activities listed on calendars were not conducted, activity staff were often absent, and documentation of participation was inconsistent. Several residents with cognitive and physical impairments reported boredom and lack of engagement, while staff confirmed that activities were not provided as scheduled and that outings were canceled due to transportation issues.
Two residents dependent on staff for ADLs did not receive timely or appropriate incontinence care, as observed by surveyors. One resident was found wearing two soiled briefs with evidence of prolonged exposure to urine and feces, and staff failed to follow proper glove and hand hygiene protocols. Another resident was left in a heavily soiled brief with makeshift protective bedding, and was left uncovered during care. These actions were not consistent with the facility's incontinence care policy.
Staff did not follow Enhanced Barrier Precautions for a resident with a feeding tube, as required by physician orders and facility policy. During high-contact care activities, including incontinence care and tube feeding management, two CNAs and an LPN failed to don isolation gowns, despite clear signage and policy directives. The staff's clothing came into contact with the resident and their environment, and interviews confirmed the required PPE was not used.
A resident with significant psychiatric history, including schizoaffective disorder and a history of suicide attempts, was found unresponsive due to a self-inflicted injury after an LPN provided scissors without reviewing the care plan or providing supervision. The resident's care plan required supervision while shaving and noted a history of self-harm. The facility lacked a policy on suicidal behavior or sharp object safety, contributing to the incident.
A resident with a history of mental health issues and self-harm was given scissors by an LPN without supervision, leading to a critical incident. The facility failed to report this potential neglect to the State Agency, as required by policy.
A facility failed to prevent resident-to-resident physical abuse, involving a cognitively impaired resident who exhibited aggressive behavior towards others. The incidents included kicking, hitting, and causing a fall, affecting multiple residents. Despite immediate interventions, the facility did not initially prevent these occurrences, highlighting a deficiency in protecting residents from abuse.
The facility failed to secure smoking materials, leading to unsafe smoking practices in resident rooms. A resident requiring supervision and a smoking apron was found alone with cigarette smoke present, while another resident with impaired cognition had been previously observed smoking unsupervised. The facility's policy required smoking only in designated areas, but effective systems to ensure compliance were lacking, posing a significant safety risk.
The facility failed to serve meals at an appropriate temperature and ensure they were palatable, affecting nearly all residents. An LPN observed a lunch tray with unappetizing food and melted ice cream, while two residents complained about the food quality and portion sizes. A meal test tray was also found to be cold and lacking flavor. Resident Council meeting minutes documented ongoing food concerns.
The facility failed to maintain functioning and accessible call lights for 14 residents. An Activities Aide and a CNA observed that some rooms had short call light cords, making them unreachable for residents in bed, and several rooms had non-functioning call lights without an alternative system. The Maintenance Director was aware of the issue for weeks and had only recently received parts for repairs.
The facility failed to ensure a clean and sanitary environment, affecting two residents. One resident experienced a persistent water leak in their room, leading to water accumulation and unchanged, stained linens. Another resident's room had a strong odor of waste, with a toilet containing unflushed stool and urine. Staff were aware of these issues but did not take timely action to resolve them.
Failure to Prevent Repeated Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident with a known history of physical aggression related to mental illness. One resident had severely impaired cognition, bipolar disorder with psychotic features, a history of traumatic brain injury, and exhibited verbal behaviors directed at others. Another resident had intact cognition but carried diagnoses including schizophrenia, borderline personality disorder, obsessive compulsive disorder, and bipolar disorder. The aggressive resident had a care plan in place since admission identifying potential for physical aggression and interventions such as counseling on conflict management, walking away from peers, and seeking staff assistance when conflicts arose. On one occasion, staff witnessed the aggressive resident strike a cognitively impaired resident in the dining room. The injured resident reported being hit in the face by the aggressor. A general note documented a skin tear to the left chin, and the resident was sent to the hospital, where a thick layer of dermal glue was applied and bruising to the left eye was noted. Although the self-reported incident and investigation confirmed that the aggressor hit the resident, the written witness statements and investigation did not document what object was used. In a later interview, the DON stated that the resident had been hit with a [NAME] that had a wooden handle and rubber head, and staff believed the object was obtained from a maintenance cart. On a separate occasion, the same aggressive resident struck another resident in the back of the head in a hallway following an argument over a composition notebook, which was later found in the aggressor’s room. A housekeeper reported seeing the argument that resulted in the aggressor hitting the other resident, and a CNA described the aggressor as very aggressive that morning. The injured resident sustained a laceration to the back of the head, was sent to the hospital, and returned with two staples in the crown of the head and a CT scan showing no additional anomalies. In an interview, this resident confirmed being hit in the head with a rock by the same aggressor and expressed relief that the aggressor was no longer present. These events demonstrate that the facility did not prevent physical abuse between residents despite prior knowledge of the aggressor’s behavioral risks and existing care plan interventions.
Resident Falls Through Laundry Chute Due to Inadequate Supervision and Faulty Door Lock
Penalty
Summary
A resident with diagnoses including schizophrenia, dementia, muscle weakness, and difficulty walking, who resided on a secured unit due to aggressive behaviors and risk for wandering, was able to access a locked soiled utility room containing a laundry chute on the third floor. The resident subsequently fell through the laundry chute to the facility's basement, where he was found inside a laundry bin by the Maintenance Director. The only points of entry to the basement laundry chute room were the chute itself and a locked door, confirming the resident's path of entry. At the time of discovery, the resident had visible injuries including bleeding around the mouth and eye, and a large bump on the hand. Staff interviews and record reviews revealed that the lock on the third-floor soiled utility room had been malfunctioning for approximately a week prior to the incident, and staff, including the former administrator, had been made aware of the issue. Despite the resident's known risk for wandering and the requirement for supervision, the resident was able to leave the secured unit undetected during lunch service. Documentation and investigation into the incident were incomplete and inconsistent, with discrepancies in staff accounts and a lack of comprehensive assessment or immediate summoning of emergency services prior to moving the resident from the scene. The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent the accident. The resident sustained multiple traumatic injuries, including a C6 compression fracture, an acute T4 anterior fracture, and multiple rib fractures, requiring hospitalization and subsequent transfer to a long-term acute care hospital. The incident affected one of three residents reviewed for accidents, and the facility census at the time was 88.
Removal Plan
- Instructed Licensed Practical Nurses (LPN) #283, #291, #303, and #342 to conduct head counts of their units to ensure all residents were accounted for and had not wandered off their units.
- Checked the soiled utility room containing the laundry chute on the 200 unit to determine if the door was locking properly.
- Checked the soiled utility room containing the laundry chute on the 400 unit to determine if the door was locking properly.
- Checked the soiled utility room containing the laundry chute on the 300 unit to determine if the door was locking properly.
- Coordinated an ad hoc Quality Assurance (QA) meeting to discuss the incident with Resident #51. A root cause analysis was performed, and the team discussed a plan to prevent the incident of a resident wandering into secured places and/or off the unit.
- Decided to re-educate staff on the importance of ensuring the utility room doors were latched and always locked, after each entry and exit, as well as installing an extra lock on each (laundry) chute access on each unit.
- Additional staff training would include ensuring residents on secured units were always supervised and present on their units, ensuring maintenance work orders and all work orders would be placed into TELS (an electronic method for placing, tracking, and communicating work orders that are needed) and emergency orders would be additionally communicated to the Administrator.
- RCSRN #401 and Unit Manager (UM) LPN #287 conducted wandering assessments on 87 current residents.
- Identified 15 residents who triggered as high risk for wandering; the remaining 72 in-house residents were identified as low risk for wandering.
- Installed padlocks on the laundry chute access doors on all three resident care units.
- The DON, ADON #279, UM LPN #253, UM LPN #287, and RCSRN #401 educated all staff on the importance of ensuring utility room doors where the laundry chutes were contained were latched and always locked after each entry and exit.
- Staff were educated that an extra lock had been applied to the chute access doors on each unit and ensuring the padlocks were in a position after each use.
- Staff were additionally educated on ensuring residents on secured units were supervised and ensuring maintenance work orders were placed into TELS and emergency orders communicated to the Administrator.
- All staff education was completed.
- Implemented a plan that all new hires would be educated during orientation by the Administrator or designee on ensuring utility room doors were secured when not in use, the process for submitting maintenance work orders, and ensuring emergency orders were communicated to the Administrator.
- Additional new hire training would ensure laundry chute doors would be always locked when not in use.
- The DON or designee began ongoing audits for all three soiled utility rooms in which the laundry chute access was contained, five days per week, for a duration of four weeks to ensure all doors and chutes were locked and secured appropriately. The results of the audits would be reviewed in the facility's QA meetings.
- The DON or designee implemented ongoing, every shift head counts at the end of each nursing shift to ensure all residents were accounted for. The DON or designee would complete these head counts every shift, seven days per week, for a duration of four weeks. The results of the audits would be reviewed in the facility's QA meetings.
Failure to Maintain Clean, Safe Environment and Timely Communication
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents on the third floor nursing unit, as evidenced by direct observations, interviews, and record reviews. In one resident's room, there was a persistent puddle of water on the floor due to a leaking ceiling and a disconnected sink drain, which had been ongoing for two to three months. The sink and counter were partially pulled away from the wall, and both the soap and paper towel dispensers were missing, with visible wall damage where they had been ripped off. The room also lacked a cover for the light bulbs above the sink and the thermostat, and the bathroom door would not stay closed, requiring a trash can to keep it shut. These issues were confirmed by housekeeping staff, the DON, and the maintenance supervisor, who indicated that some of the problems had not been reported or addressed in a timely manner. Additional observations on the same unit revealed widespread stained ceiling tiles in several residents' rooms and a broken light cover in another room. In one resident's room, the shared bathroom was found to be dirty, with urine stains and a strong odor, which was confirmed by both the resident and an LPN. The facility's housekeeping policy required rooms and bathrooms to be clean, free of odors, and for dispensers to be checked and replaced as needed, but these standards were not met in the observed areas. The facility also failed to ensure that phone calls were answered in a timely manner, which had the potential to affect all residents. There were documented instances where phone calls to the facility went unanswered for extended periods, including one call that rang 28 times without being answered and another that rang 18 times before being picked up. Staff interviews revealed that there was no receptionist on night shift, and nursing staff were sometimes too busy to answer the phone, despite the expectation that calls should be answered within three rings. This issue was further highlighted by a fire department incident report noting a delay in entering the building due to no one being at the front desk.
Failure to Provide Scheduled Activities and Implement Care Planned Interventions
Penalty
Summary
The facility failed to provide scheduled activities and did not implement care planned interventions for several residents, resulting in unmet psychosocial and recreational needs. Multiple observations and interviews revealed that activities listed on the facility's activity calendars, such as manicures, cards, hydration carts, bingo, and group discussions, were not conducted as scheduled across various nursing units. Staff and residents consistently reported that activity staff were often absent, and scheduled activities were not provided, with some staff attributing this to activity aides being off work or reassigned to supervise smoke breaks. Additionally, documentation of resident participation in activities was inconsistent or missing, with activity aides lacking access to the electronic system and resorting to informal paper records, which were not always maintained or transferred to the official record. Several residents with cognitive and physical impairments, including those with hemiplegia, schizoaffective disorder, dementia, and paraplegia, expressed feelings of boredom, isolation, and disappointment due to the lack of activities and outings. Residents reported that they were not encouraged or assisted to attend activities, were not taken outside except for smoke breaks, and had not participated in planned community outings such as zoo trips, which were canceled due to lack of transportation. Some residents noted that broken recreational equipment, such as video games and air hockey tables, further limited their options for engagement. Interviews with staff confirmed that activities were not provided as scheduled, and that there were no activities on weekends or during certain shifts, leading to increased resident boredom and behavioral issues. Review of care plans and medical records for affected residents showed that interventions to encourage participation in activities, socialization, and outings were not implemented. Residents' preferences for specific activities, outdoor time, and pet therapy were not honored, and there was little evidence of one-to-one or self-directed activity participation. The facility's own policy required the provision of meaningful experiences and a variety of activities, but observations and documentation revealed that these standards were not met. The lack of consistent activity programming and failure to follow care plans had the potential to affect all residents in the facility.
Failure to Provide Timely and Appropriate Incontinence Care
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for two residents who were dependent on staff for all activities of daily living. For one resident with diagnoses including senile degeneration of the brain, Parkinson's Disease, and paranoid schizophrenia, observations revealed the resident was wearing two incontinence briefs, both soaked with dark yellow urine and containing a moderate amount of hard brown feces. Staff noted the resident had not been changed in a while, and the resident cried out in pain during care, with visible redness on the inner buttocks. Additionally, one CNA failed to change soiled gloves or perform hand hygiene before applying a clean brief, contrary to facility policy. For another resident with dementia, anxiety disorder, and adult failure to thrive, staff observed a large amount of dark yellow urine in the incontinence brief, which appeared to have been present for some time. The resident was also found with a folded blanket and a reusable chux pad under the buttocks, with the blanket showing dried urine. Staff indicated these items were likely used for added protection against incontinence, but this was not in line with standard practice. During care, the resident was left uncovered from the waist down while a CNA left the room to gather supplies. Both incidents were observed to be inconsistent with the facility's incontinence care policy, which requires cleansing with perineal wash, proper glove use, hand hygiene, and changing linens and clothing as needed. The deficiencies were identified through observation, interview, and record review, and affected two out of three residents reviewed for incontinence care.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow physician orders and care plan interventions for Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. The resident, who had diagnoses including unspecified dementia, anxiety disorder, and adult failure to thrive, was dependent for activities of daily living, frequently incontinent of urine, always incontinent of bowel, and received the majority of nutrition via a PEG tube. Physician orders and the care plan required the use of EBP, including donning gowns and gloves during high-contact care activities such as incontinence care and tube feeding management. During observation, two CNAs and an LPN provided incontinence care and managed the resident's tube feeding without donning isolation gowns, despite clear signage and facility policy requiring this PPE for such activities. The staff's clothing came into contact with the resident, bed, and linens during care. Interviews confirmed that the staff did not wear the required gowns, and the LPN was unaware that a gown was necessary for tube feeding care. The facility's policy, updated in 01/2025, specified that EBP must be used for residents with indwelling medical devices, including feeding tubes, during high-contact care activities.
Failure to Implement Effective Behavioral Health Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized, and effective interventions to meet the behavioral health care needs of a resident with significant psychiatric history. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, dementia, anxiety, antisocial personality disorder, hallucinations, body dysmorphic disorder, and a history of suicide attempts, was found unresponsive in a communal shower room due to a self-inflicted injury. This incident occurred after an LPN provided the resident with a pair of scissors to cut his hair, without reviewing the resident's care plan or providing supervision. The resident's care plan included supervision while shaving and noted a history of self-harm and suicidal ideations. Despite this, the LPN did not check the resident's care plan or Kardex before giving the scissors, which were described as safety scissors with a rounded blunted end. The resident was left unsupervised with the scissors, leading to a self-inflicted injury that resulted in significant blood loss and ultimately, the resident's death. Interviews with staff revealed that there was no indication or concern that the resident was suicidal at the time, and no behaviors or statements suggested self-harm intentions. However, the facility lacked a policy addressing suicidal behavior, residents at risk for self-harm, or sharp object safety, which contributed to the incident. The root cause analysis concluded that the incident was due to the LPN providing the resident with a sharp object, which should not have occurred.
Removal Plan
- Resident #93 was noted with acute blood loss, Emergency Medical Services (EMS) was notified, and Resident #93 was transported to a local emergency room (ER) by local EMS providers.
- LPN #500 was immediately provided 1:1 verbal education by the DON on not providing sharp objects to residents.
- LPN #500 was suspended by the Administrator following the incident, pending a thorough investigation. LPN #500 was permitted to return to work.
- The Director of Nursing (DON), ADON #270, Unit Manager #267, Housekeeping Supervisor #283, Human Resource Manager #262, Licensed Social Worker (LSW) #246, Central Supply #317 and Admissions Director #216 completed a whole house sweep for sharp objects with no sharp objects noted.
- All residents were assessed, and medical records were reviewed (including psychiatric/provider notes) to identify those residents who had self-harm and/or suicidal ideation history. In addition, those who could be, were interviewed, related to suicidal ideation/self-harm. Eleven residents (#100, #15, #16, #28, #33, #38, #40, #101, #57, #61, and #102) were identified as at risk for self-harming behaviors. Care plans and associated Kardex's were reviewed by Regional Clinical Support Nurse #244.
- All staff were interviewed regarding any knowledge of residents exhibiting any signs, symptoms, or behaviors which could be indicative of suicidal ideations. This was completed by the Administrator.
- Regional Clinical Support Nurse #244 educated all facility interdisciplinary team members (IDT) on updating care plans for resident(s) who have suicide ideations/self-harm and pulling them to the Kardex.
- All staff were educated by the DON/Designee on reviewing residents' Kardex, ensuring residents were free and safe from self-harm, and assisting and providing supervision to residents as deemed necessary.
- The Administrator completed a quality assessment and performance improvement (QAPI) and a root cause analysis with the Medical Director, DON, ADON #270, Regional Clinical Support Nurse #244, Medical Records #317, Human Resources Manager #262 and LSW# 246. The facility root cause analysis identified the nurse (LPN #500) gave Resident #93 a sharp object and should not have. The facility corrective action plan involved mitigating the risk and availability of sharp objects and identifying those residents at risk for self-harm or suicidal ideations.
- The DON/Designee began random, ongoing resident audits on care plans for residents with a history of suicidal ideations and/or self-harm. The ongoing audits were completed four times weekly for a total of six weeks.
- The DON/Designee began random, ongoing audits of staff competencies regarding staff utilization of the resident Kardex's. The audit reviewed five random staff members four times weekly for a total of four weeks.
- The Administrator held a QAPI meeting with the DON, ADON, Medical Director, Activities Director #201, Medical Records Coordinator #317, Human Resource Manager #262, Regional Clinical Support Nurse #244 and LSW# 246 to discuss the findings of the facility audits.
Failure to Report Potential Neglect Incident
Penalty
Summary
The facility failed to report an incident of potential neglect involving a resident to the State Agency as required. The resident, who had a history of schizoaffective disorder, bipolar disorder, dementia, and other mental health conditions, was found in a critical state with significant blood loss from the groin area. The resident was transported to a hospital where he was pronounced deceased. The facility's investigation revealed that the incident was caused by a Charge Nurse providing the resident with a sharp object, specifically a pair of safety scissors, without supervision, despite the resident's care plan indicating the need for supervision during activities like shaving. The resident's care plan highlighted several mental health issues, including a history of self-harm and suicidal ideations, and required supervision for certain activities due to these conditions. Despite this, the LPN provided the resident with scissors without consulting the care plan or providing supervision. The LPN believed the resident was independent in activities of daily living and did not exhibit aggressive behaviors, which led to the decision to give the scissors. The facility's administrator confirmed that the incident was not reported to the State Agency, believing it to be an accident and not reportable. The facility's policy required the investigation of all alleged violations involving abuse, neglect, and injuries of unknown source, but the administrator did not consider the incident as such. This oversight represents a deficiency in the facility's compliance with reporting requirements for incidents of potential neglect.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, affecting five residents. Resident #2, who was severely cognitively impaired, was involved in multiple incidents of aggression towards other residents. On one occasion, Resident #2 kicked Resident #23 in the leg, and on another, hit Resident #21 in the face over a dispute involving a television remote. Additionally, Resident #2 hit Resident #20 in the head, causing him to fall to the floor. These incidents highlight a pattern of aggressive behavior by Resident #2 towards other residents. Resident #22, who was cognitively intact, was involved in an incident where he scratched Resident #2 in the face. This occurred as Resident #2 attempted to punch Resident #22, and Resident #22 acted in self-defense. The facility's records indicate that Resident #2's aggressive behavior was a recurring issue, necessitating intervention to prevent further incidents. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property emphasizes the right of residents to be free from abuse. However, the incidents involving Resident #2 demonstrate a failure to uphold this policy, as multiple residents were subjected to physical aggression. The facility's response to these incidents included immediate interventions, but the deficiency lies in the initial failure to prevent the abuse from occurring.
Unsafe Smoking Practices in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe environment free from potential accident hazards when smoking materials were not secured, leading to unsafe smoking practices in resident rooms. This deficiency was observed when Resident #38, who required staff supervision and a smoking apron, was found alone in his room with a strong cigarette odor and visible smoke. The room, shared with Resident #37, had cigarette ashes on the bathroom floor, burn marks on the toilet seat and toilet paper holder, and cigarette butts in a trash can. Resident #37, who was away from the facility at the time, had been previously observed smoking in the room. Resident #37 had impaired cognition and was assessed to require supervision while smoking, as documented in his care plan and a Last Chance Agreement. Despite these measures, the facility did not prevent him from smoking unsupervised in the room. Resident #38, with intact cognition, also required supervision and a smoking apron while smoking, yet was found in a room with evidence of smoking. The presence of oxygen in a nearby room further heightened the risk of potential harm. The facility's policy stated that smoking was only permitted in designated areas and that smoking materials should be kept locked. However, the facility did not have effective systems in place to ensure compliance with these policies, as evidenced by the presence of smoking materials in the residents' room and the lack of adherence to supervision requirements. This oversight posed a significant risk to the safety of the residents and the facility.
Removal Plan
- Conduct room sweeps on all resident rooms for the presence of smoking materials.
- Search Resident #37's room and secure any smoking materials identified.
- Search Resident #38's room and person and secure any smoking materials identified.
- Assess Resident #32, Resident #37, and Resident #38 for injuries.
- Re-educate all staff on the facility smoking policy and procedure related to supervision of residents who smoke.
- Re-educate all 64 residents who smoke on the smoking policy, which includes residents smoking only in designated areas, securing smoking materials, and other applicable policies.
- Perform a root cause analysis to determine residents may have purchased and brought back smoking materials without staff knowledge and policies and procedures for securing smoking materials had not been adhered to.
- Complete an audit of the smoking assessments for all 64 residents who smoke to ensure accuracy and update care plans as needed.
- Complete a skin assessment on all residents who smoke.
- Provide all staff two questionnaires to ensure education is effective.
- Update the procedure for securing smoking materials when a resident leaves and returns to the facility, to include signing out smoking materials and signing them back in.
- Educate all staff and residents on the updated procedure.
- Audit smoking material sign out/sign in sheets to ensure smoking materials are returned.
- Complete room audits on all residents who smoke, and throughout the facility, to ensure residents have no smoking materials in their rooms and are adhering to the facility's smoking policy.
- Hold an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee meeting to review the root cause analysis and corrective action plan.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals were served at an appropriate temperature and were palatable, affecting all residents except one who did not receive food from the kitchen. During a lunch meal service observation, an LPN noted that the meal tray contained a red watery substance, a mixture of meat and beans, and a bag of chips, which she described as 'slop.' The ice cream on the tray was melted, and residents complained about the food quality and portion sizes. Interviews with two residents confirmed that the food was often awful and insufficient. Further observations included a meal test tray that left the kitchen and was received cold and lacking flavor. The meal consisted of scrambled eggs, bacon, toast, and grits. The Assistant Director of Nursing verified these findings. Resident Council meeting minutes from August and September 2024 also documented concerns about the food, including meat being too hard and food not being properly cooked. This deficiency was investigated under Complaint Number OH00158177.
Non-Functioning and Inaccessible Call Lights
Penalty
Summary
The facility failed to ensure that resident call lights were in working order and accessible to residents, affecting 14 residents. During an interview, an Activities Aide observed that some resident rooms had call light cords that were only two to three inches long, making them unreachable for residents in bed. Additionally, several rooms had non-functioning call lights, and no alternative call light system was implemented. The Activities Aide confirmed that the call lights had been non-functional for several weeks. Further interviews revealed that a Certified Nursing Assistant was aware of the non-functioning call lights in several rooms, and this was verified through observation. The Maintenance Director acknowledged that the call light system had not been functioning properly for two to three weeks and had only recently received parts to begin repairs. The Maintenance Director also confirmed the issue with the short call light cords, which would prevent residents from reaching them while in bed. This deficiency was investigated under Complaint Number OH00158177.
Failure to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting two residents. Resident #39 reported a persistent water leak in his room, which had been ongoing for several weeks. Despite informing the Administrator and maintenance, the issue remained unresolved, leading to water accumulation on the floor. Observations confirmed the presence of a large puddle and stained, odorous bed linens, which had not been changed for an extended period. Housekeeping staff acknowledged the water issue, and a CNA confirmed the condition of the linens but did not change them until prompted. The Maintenance Director later identified the leak's source after several weeks of investigation. Resident #46's room was found to have a strong odor of stool and urine, with the toilet containing a large amount of waste and dried stool on the seat. A CNA verified these findings and expressed reluctance to flush the toilet due to concerns about potential overflow, indicating a lack of immediate action to address the unsanitary condition. This deficiency was investigated under Complaint Number OH00158177.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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