Columbus Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 4301 Clime Road North, Columbus, Ohio 43228
- CMS Provider Number
- 365686
- Inspections on file
- 29
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Columbus Healthcare Center during CMS and state inspections, most recent first.
The deficiency involves multiple failures to implement ordered or care-planned fall-prevention measures and to conduct a complete post-fall investigation. Several residents with significant medical and functional impairments experienced falls or were identified as at risk, yet interventions such as non-skid floor strips, fall mats at bedside, Dycem on a wheelchair seat, and proper wheelchair foot pedals were not in place as ordered or documented by the IDT. In one case, a dependent resident was lowered to the floor during ADL care and sustained a skin tear, but the facility’s investigation did not clearly determine why the resident was lowered, who did so, or how the injury occurred, and staff accounts were contradictory. These events occurred despite a facility policy requiring prompt, detailed fall investigations and the identification and implementation of appropriate fall-prevention interventions.
A resident with multiple chronic conditions and documented intact cognition had a bed curtain with visible dark red splatter stains and linear black marks that remained uncleaned despite the resident’s request for cleaning. A CNA confirmed the stains, and Risk Management acknowledged there was no specific environmental policy, indicating such concerns were covered under a general resident rights policy that referenced safe and secure housing. This resulted in a deficiency related to failing to provide a safe, clean, and homelike environment.
Two residents who were dependent on staff for ADLs did not receive appropriate nail care. One cognitively intact resident with multiple chronic conditions had long, jagged toenails and reported that staff did not provide toenail care, while a CNA confirmed the condition and was unsure if CNAs were allowed to trim toenails, despite facility documents assigning personal care duties to CNAs. Another resident with anoxic brain damage, severe cognitive impairment, and bilateral hand contractures had long, dirty fingernails with no documentation of nail care, and staff interviews revealed confusion over whether nail care was the responsibility of CNAs, hospice, or an outside service.
A resident with a midline catheter in the upper arm had a transparent dressing that remained dated from the day of insertion, despite documentation on the TAR that weekly dressing and needleless connector changes were performed as ordered. Observation later showed the original dressing still in place, and an RN confirmed it should have been changed according to provider orders and the facility’s IV access line maintenance protocol.
The facility failed to ensure timely follow-up on a guardianship process for a cognitively impaired resident with multiple chronic conditions, despite an expert evaluation recommending guardianship and prior agreement to initiate it. The social worker submitted a referral to the county probate investigator and later sent correspondence to inquire about services, but no further documentation of progress or outcome was recorded for many months. The Director of Social Services reported believing the process was delayed due to the resident owning a house and acknowledged she had not followed up after her last note, while the Regional Business Office Manager was unaware of any housing barrier and had asked the social worker to follow up. This inaction did not align with the Social Service Director’s job description, which required coordinating services and performing resident advocacy, including applications for supplementary services.
A resident with diabetes experienced a significant acute change in condition, including extremely high blood glucose levels and symptoms of hyperglycemia, which were observed and reported by CNAs but not adequately assessed or communicated to the medical provider by nursing staff. Despite physician orders to notify the provider for blood sugars over 400 mg/dL, critical values were not reported, and interventions were delayed. The resident was eventually hospitalized with DKA, acute metabolic encephalopathy, and acute kidney injury after continued deterioration and family intervention.
A facility failed to notify a resident's court-appointed guardian about changes in care, including the discontinuation of pain medication and alcohol consumption. Despite the resident's medical conditions, the facility did not inform the guardian, as required by policy. This deficiency was confirmed through interviews and record reviews.
The facility failed to ensure consistent continuity of care for two residents, leading to deficiencies in medication administration and wound care management. A resident experienced delayed administration of dasatinib due to poor communication with the hematology oncology department, resulting in concurrent use with imatinib and a subsequent hospital transfer. Another resident received inconsistent wound care due to outdated and incomplete physician orders, with new recommendations not implemented promptly. Interviews with staff confirmed communication breakdowns and lack of follow-up with outside providers.
The facility failed to maintain a medication error rate below five percent, resulting in a 13.7% error rate. Two residents were affected: one received medications orally instead of via PEG tube, and another was nearly given an incorrect dosage of Vitamin D. Errors included crushing medications that should not be crushed and preparing incorrect dosages.
A resident with severe cognitive impairment developed a new pressure ulcer due to the facility's failure to implement an effective pressure ulcer prevention program. Despite being at high risk, the resident was not consistently repositioned every two hours, and staff were unaware of the resident's pain when laying on her right side. The facility's care plan and pressure ulcer prevention policy were not adequately revised to address the resident's specific needs.
A resident with severe cognitive impairment and mobility issues was observed with long, dirty fingernails, indicating a failure to provide necessary personal hygiene assistance. Despite requiring substantial assistance, the resident's hygiene needs were unmet, as confirmed by the DON.
A facility failed to follow dietician recommendations for a resident with cancer and malnutrition, resulting in unverified significant weight loss. Despite the dietician's request for a reweight, it was not conducted, and the resident was observed to have not eaten his meal. The DON did not receive the reweight request, leading to non-compliance with the care plan.
The facility failed to implement effective infection control policies during wound care for two residents. A resident with multiple sclerosis and quadriplegia received wound care without proper hand hygiene or barriers, leading to contamination. Similarly, another resident with dementia and malnutrition received care with contaminated supplies and inadequate hand hygiene. The ADON acknowledged these lapses, and the Regional Clinical Director confirmed the absence of a specific dressing change policy.
The facility failed to monitor the nutritional status and weight of several residents, leading to significant unplanned weight loss. A resident experienced severe weight loss due to inadequate monitoring during a tube feed discontinuation trial. Another resident's weights were not monitored weekly as recommended, and two other residents were not weighed as required, resulting in a lack of proper nutritional assessment and management.
The facility failed to ensure STNAs received annual performance reviews and completed 12 hours of continuing education annually, affecting all residents. Employee files for three STNAs lacked documentation of these requirements, confirmed by the HR Director.
The facility failed to properly store and label medications, with loose pills found in medication carts and an undated open vial of tuberculin PPD solution in the refrigerator. This was confirmed by the ADON, who acknowledged the non-compliance with facility policies and manufacturer's guidelines.
The facility failed to maintain safe and sanitary food storage, affecting all 96 residents. Observations revealed undated and unlabeled food items in the refrigerator, including shredded cheese, lettuce, and juice. A kitchen worker confirmed these items should be labeled and stored properly. Additionally, dented cans of tomatoes and fruit salad were found in dry storage, which another kitchen worker confirmed should have been discarded.
The facility failed to implement proper pest control in the kitchen, affecting all residents. Observations revealed dozens of gnats in the dry storage area and around food preparation. A kitchen worker confirmed the gnat problem was untreated by professionals, and the Maintenance Director was unaware of the issue. The kitchen sink was frequently clogged, contributing to the problem, and pest control logs showed no treatment for gnats despite policy requirements.
The facility did not have an RN on duty for at least eight consecutive hours on several weekends, as required. This was confirmed through staff schedules, facility assessment, and an interview with the Administrator. The facility's policy stated that sufficient staff would be provided, but this was not met on specific dates.
The facility failed to address resident concerns regarding laundry services, aide assistance, and call light response, as documented in Resident Council meetings over several months. Despite repeated complaints from residents, there was no evidence of corrective actions taken by the facility. Interviews confirmed the lack of follow-up, and the Administrator admitted that planned staff education was not conducted.
The facility failed to update a resident's care plan to address behavioral changes, specifically physical aggression, and did not conduct required care conferences for several residents. A resident with cognitive impairments was involved in incidents of aggression, but their care plan lacked interventions to prevent such behaviors. Additionally, care conferences were not held as required, with some residents having only one or two meetings documented over a year. The facility's policy mandates regular care conferences and resident participation, which were not adhered to.
The facility failed to follow infection control practices for residents with PICC lines, medication administration, and wound care. A resident's PICC line dressing was not intact or dated, and staff did not change it after administering antibiotics. A nurse did not perform hand hygiene before or during medication administration for two residents, handling pills directly with ungloved hands. Additionally, staff did not wear gowns or maintain hand hygiene during wound care for three residents, increasing the risk of infection.
The facility failed to provide routine nail care and bathing assistance to residents dependent on staff for ADLs. Observations revealed long, dirty nails and missed scheduled showers for several residents, despite facility policies requiring such care. Interviews confirmed the lack of consistent hygiene assistance, affecting residents with significant medical conditions.
The facility failed to provide appropriate care for residents to maintain or improve range of motion, affecting four residents. A resident with diabetes was not fitted for diabetic shoes despite orders, leading to instability. Another resident with a hand contracture was not wearing a splint due to it being lost, and staff were unaware of the requirement. Two other residents with contractures were not wearing prescribed splints, and staff confirmed non-compliance with care plans.
A resident with a complex medical history was observed wearing a hospital gown instead of regular clothing due to the facility losing his clothes. Interviews revealed that staff did not make efforts to provide appropriate clothing, and the administrator confirmed the oversight, compromising the resident's dignity.
The facility failed to ensure accurate documentation of advanced directives and code status for two residents. One resident's record showed a signed directive for DNRCC-A, but a physician's order changed it to DNRCC, leading to a discrepancy. Similarly, another resident's directive indicated DNRCC-A, but a later order changed it to DNRCC. Both residents were cognitively intact, yet inconsistencies remained, violating the facility's policy on accurate communication of advanced directives.
The facility failed to notify a physician about a resident's blood glucose levels outside ordered parameters and did not inform a resident's representative about the discontinuation of enteral tube feeding. The facility's policy requires notification of significant changes, but this was not followed, leading to deficiencies in communication and care management.
A resident with multiple mental health diagnoses, including bipolar disorder and PTSD, was not provided with the specialized services recommended by the PASARR screening. The resident required ongoing case management and substance abuse treatment, but the care plan lacked these recommendations. Interviews confirmed the resident was not offered these services, and the Social Services Director was unaware of the resident's qualifications for specialized services.
The facility failed to comprehensively assess pressure ulcers for three residents upon admission or readmission, leading to a deficiency in pressure ulcer care. One resident was readmitted with a stage IV pressure ulcer, but the initial assessment lacked staging and measurements. Another resident was admitted with multiple pressure ulcers, but the nursing evaluation did not include necessary details. A third resident's skin condition was not reassessed upon admission, contrary to facility policy.
The facility failed to properly store and maintain respiratory equipment for two residents. A resident with obstructive sleep apnea had a BiPap mask improperly stored, confirmed by the DON. Another resident with COPD had undated oxygen tubing, found on the floor, indicating it was not changed as ordered. The facility's policy requires nasal cannula tubing to be labeled and changed weekly, which was not followed.
A facility failed to ensure a resident's call light was within reach, despite the resident's cognitive and physical impairments. Observations showed the call light was often on the floor, inaccessible to the resident. Additionally, a cognitively intact resident was not allowed to go outside, despite no clinical rationale for the restriction. Interviews confirmed the facility's rule against residents needing assistance going outside, except for smoke breaks.
A resident's privacy curtain was repeatedly observed to be dirty with brown splatter and food crumbs. Despite confirmation from the resident's representative and a State tested Nursing Aide (STNA), the issue was not addressed, as the STNA indicated it was not their responsibility to clean the curtain. The resident had multiple medical conditions, including cognitive impairment, and required assistance with ADLs.
The facility failed to timely evaluate and treat a rectal fistula for a resident, did not reschedule a necessary GI consult for another resident, and neglected to update hospice documentation for a third resident. These deficiencies involved inadequate wound care, failure to secure timely medical appointments, and lapses in hospice service coordination.
A resident with cognitive impairment and multiple diagnoses was referred for ophthalmology services but was not seen by a vision provider. The resident's representative was unaware of any arrangements, and the Social Services Director, responsible for organizing such services, was not informed of the referral, leading to a lapse in care.
A resident with multiple health issues, including incontinence, did not receive timely incontinence care despite using the call light to request assistance. Staff delayed care, leaving the resident soiled and the room with a strong odor. An LPN confirmed that care should be provided promptly, but was unaware of the resident's requests. The facility's policy on resident-centered care and skin integrity was not followed.
Failure to Implement Fall-Prevention Interventions and Complete Thorough Post-Fall Investigation
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions and to conduct a thorough post-fall investigation for multiple residents. For one resident with COPD, severe protein-calorie malnutrition, dysphagia, wheelchair use, and severe cognitive impairment, orders and care plan interventions for non-skid floor strips near the bed and fall mats on both sides of the bed were in place following recurrent falls. However, during observation of the resident’s room, there were no non-skid strips or fall mats at the bedside, and the LPN confirmed these items were not present. Another resident, cognitively intact and largely independent in ADLs except for needing substantial assistance with bathing, experienced a fall and had a post-fall intervention of nonskid strips to the floor documented in an IDT follow-up note. The resident’s fall risk care plan did not include nonskid strips as an intervention, and a separate care plan intervention for a visual reminder to ask for assistance when getting out of bed was not observed in the room on multiple occasions. Nursing staff confirmed that nonskid strips were not on the floor and that the visual reminder, which should have been posted near the bed and in the bathroom, was not in place. A third resident, cognitively intact with a history of cerebral infarction, hemiplegia, traumatic cerebral hemorrhage, heart disease, and alcohol abuse, had an unwitnessed fall after sliding from a wheelchair post-therapy. The IDT determined Dycem should be added to the wheelchair seat as a preventive intervention, but subsequent observation in the therapy department showed no Dycem on the wheelchair, and therapists confirmed its absence despite one therapist stating she had previously placed it. For a resident with anoxic brain damage, COPD, dysphagia, bilateral hand contractures, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and severely impaired cognition, the plan of care identified fall risk and dependence for rolling and other ADLs. A progress note documented that the resident was lowered to the floor during ADL care by a CNA and sustained a skin tear to the right side of the back. The fall investigation concluded that a hospice aide was providing care when the resident fell out of bed and that the suspected root cause was the air mattress and turning the resident, but the investigation did not identify why the resident needed to be lowered to the floor, who lowered the resident, or how the skin tear occurred. The DON later stated that both a hospice aide and a facility CNA were present, that staff accounts were contradictory, that only one witness statement from a unit manager was available, and verified that it remained unclear what happened and how the skin tear was obtained, confirming that a thorough investigation was not completed. Another resident with intact cognition, major depressive disorder, borderline personality disorder, seizure history, and other psychiatric and pain-related diagnoses was care planned as being at risk for falls due to new admission status, potential medication side effects, and seizure history. After the resident fell from bed during a seizure and was found on the floor at bedside, the IDT added fall mats to both sides of the bed as an intervention. On two separate observations, the resident was in bed without fall mats in place, and the DON confirmed that the fall mat intervention ordered after the first fall was not in place. A further resident, cognitively intact with an above-knee amputation, polyneuropathy, muscle weakness, and muscle wasting, fell forward out of a wheelchair while being transported by a company driver to a van for dialysis, with the right leg caught in the wheelchair wheel. The IDT follow-up identified the cause as the absence of the right foot pedal and initiated an intervention that the right foot pedal be in place when the resident was transported. The therapy manager stated that residents with wheelchairs are always given foot pedals, that this resident always used foot pedals, could not remove the pedal independently, and could not self-propel, and the DON confirmed the fall occurred when the resident did not have the right foot pedal on the wheelchair when leaving for dialysis. The facility’s fall prevention and management policy stated that the facility would identify risk factors to minimize falls, obtain information from assessments, diagnoses, and current ADL status, and begin a fall investigation once the resident was safely transferred following a fall. The policy required asking the resident what they were doing when they fell, identifying witnesses and obtaining written statements immediately, attempting to identify why the resident fell before implementing post-fall interventions, and conducting an interdisciplinary review with discussion of the fall, potential causes, existing interventions, and a deep root cause investigation. The findings show that for multiple residents, ordered or care-planned fall-prevention interventions such as non-skid strips, fall mats, Dycem, and wheelchair foot pedals were not in place at the time of observation or transport, and for one resident, the post-fall investigation did not meet the facility’s own policy requirements for a thorough and clearly documented investigation.
Failure to Maintain Clean and Sanitary Bed Curtain for a Resident
Penalty
Summary
The facility failed to maintain a clean and sanitary bed curtain for one resident, compromising the resident’s right to a safe, clean, comfortable, and homelike environment. The resident had multiple medical diagnoses, including type 2 diabetes mellitus with hyperglycemia, long-term insulin use, COPD, moderate protein-calorie malnutrition, epilepsy, a right artificial shoulder joint, an above-knee right leg amputation, polyneuropathy, anemia, and generalized anxiety disorder, and was documented as cognitively intact on the MDS. During observation, surveyors noted three dark red splatter stains on the resident’s bed curtain, with the largest measuring approximately 1 cm and two others approximately 0.5 cm, along with additional linear black stains on the curtain. The resident reported having requested that the bed curtain be cleaned, but stated the facility never cleaned it. A CNA confirmed the presence of stains on the bed curtain during interview. When interviewed, the facility’s Risk Management staff member stated that the facility did not have an environment policy and indicated that environmental concerns would fall under the facility’s undated “Resident Rights” policy, which stated that residents will be treated with dignity and respect and that dignity includes providing safe and secure housing. This lack of a specific environmental policy and the failure to clean the stained bed curtain led to the cited deficiency under the resident’s right to a safe, clean, and homelike environment.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. One resident, admitted with multiple diagnoses including COPD, dysphagia following cerebral infarction, malnutrition, hypertension, anxiety, and depression, was cognitively intact and dependent on staff for putting on and taking off footwear. Observation showed this resident had long, jagged toenails, and the resident reported that staff did not provide toenail care. A CNA confirmed the poor condition of the toenails and expressed uncertainty about whether CNAs were permitted to trim toenails. The resident had previously declined podiatry care, and facility documents indicated that CNAs were responsible for personal care and that routine daily care was to be provided. The second resident had an admission diagnosis that included anoxic brain damage, COPD, dysphagia, bilateral hand contractures, ADHD, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and cognitive communication deficit, with severely impaired cognition and dependence on staff for personal hygiene and bathing. The care plan identified self-care deficits related to anoxic brain injury and contractures, and noted the resident was dependent for personal hygiene. There was no documentation in the medical record indicating when this resident’s nails were cleaned or cut. Observations on multiple occasions revealed long fingernails on both hands, with a dark brown substance underneath, and the resident declined to open his contracted hand or accept assistance. Staff interviews showed confusion about responsibility for nail care, with a CNA and an RN suggesting an outside service or hospice might be responsible, while the DON stated that CNAs were responsible for nail care.
Midline Dressing Not Changed as Ordered and per Policy
Penalty
Summary
Failure to provide appropriate treatment and care occurred when nursing staff did not change a midline catheter dressing as ordered and per facility policy for one resident. The resident, who was cognitively intact, had diagnoses including cellulitis of the left lower limb, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and obesity. A midline catheter was inserted into the left cephalic vein on 02/27/26, and a transparent dressing was applied at that time. Physician orders dated 03/03/26 directed that the external catheter length be measured with each dressing change every day shift on Fridays and that the needleless connector be changed with the site change weekly on Fridays. The Treatment Administration Record for March 2026 showed that on 03/06/26 and 03/13/26, staff documented measuring the external catheter length with each dressing change and changing the needleless connector with each site change. Despite these documented dressing and connector changes, observation of the midline insertion site on 03/16/26 at 9:08 A.M. revealed the dressing in place was still dated 02/27/26. During an interview at 9:21 A.M. the same day, an RN confirmed that the dressing was dated 02/27/26 and acknowledged it should have been changed. Review of the facility’s “PSG Infusion Intravenous (IV) Access Line Maintenance Protocol” effective 04/15/23 showed that transparent dressings for midline catheters were to be changed 24 hours after insertion, then weekly and as needed. The discrepancy between the dressing date, the documented TAR entries, the physician orders, and the facility policy demonstrated that the midline dressing had not been changed as required.
Failure to Follow Up on Guardianship Process for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services by not timely arranging and following up on guardianship for Resident #78 as recommended by an expert evaluation. Resident #78 was admitted on 03/22/23 with multiple diagnoses including chronic myeloid leukemia, COPD, chronic heart failure, aphasia, dementia, epilepsy, spondylosis, gout, and depression, and had moderately impaired cognition per the comprehensive MDS 3.0 assessment. A hospital social work discharge summary documented that the hospital social worker had spoken with the facility about starting guardianship and the facility agreed. An expert evaluation completed on 03/05/25 concluded that guardianship should be established or continued for this resident. Progress notes showed that on 04/24/25 the facility social worker submitted a referral to the county probate investigator following the expert evaluation, and on 07/08/25 the social worker sent correspondence to the county probate office to inquire about services and the prior referral, noting she was waiting on a response and would update the facility team and discuss next steps. However, from 07/09/25 to 03/23/26 there was no additional documentation in the medical record regarding the resident obtaining a guardian. In interviews, the Director of Social Services stated she believed the guardianship process had been delayed due to the resident having a house that had not been previously known, acknowledged she did not know if this had been followed up since her 07/08/25 note, and later confirmed she had no further information and had not followed up after submitting information for guardianship. The Regional Business Office Manager reported being unaware of any housing situation that would prevent guardianship and stated she had asked the social worker to follow up. The facility’s Social Service Director job description required planning, assessing, coordinating, and implementing services to enhance residents’ social and psychosocial well-being and performing all duties involved in resident advocacy and applications for supplementary services, which was not met in this case.
Failure to Timely Assess and Communicate Acute Change in Condition for Diabetic Resident
Penalty
Summary
The facility failed to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with type 2 diabetes, resulting in actual harm and subsequent hospitalization. The resident had a history of heart disease, heart failure, muscle weakness, cognitive communication deficit, muscle wasting, hemiplegia, hemiparesis, vascular disease, and diabetes. Physician orders required monitoring for signs and symptoms of hypo/hyperglycemia, with instructions to notify the provider if blood sugar was under 60 or over 400 mg/dL. Despite these orders, a blood glucose reading of 471 mg/dL was recorded and not communicated to the medical provider, and there was no documentation of assessment or intervention for this critical value. Over several days, the resident exhibited symptoms of hyperglycemia, including changes in mental status, drowsiness, incontinence, and dietary changes, which were reported by CNAs to nursing staff. However, there was a lack of comprehensive assessment and timely communication with the medical provider regarding these changes. On the day of hospital transfer, the resident was found to have extremely high blood glucose readings (over 500 mg/dL), and only after this point did staff begin to treat the hyperglycemia with insulin. Multiple doses of insulin were administered with no significant improvement, and the resident's condition continued to deteriorate until the family demanded hospital transfer. Upon hospital admission, the resident was diagnosed with diabetic ketoacidosis (DKA), acute metabolic encephalopathy, and acute kidney injury, with a blood glucose reading of 1157 mg/dL. Interviews with staff revealed that changes in the resident's condition were observed and reported by CNAs, but nursing staff did not consistently assess or document these changes, nor did they notify the medical provider as required by policy and physician orders. The facility's policies on notification of change in condition and blood glucose monitoring emphasized prompt provider notification and documentation, but these were not followed. The DON confirmed that the medical team should have been notified of the high blood sugar readings and that more frequent monitoring and interventions should have been implemented given the resident's trending lab results and dietary issues.
Failure to Notify Guardian of Resident's Care Changes
Penalty
Summary
The facility failed to notify the court-appointed guardian of a resident's change in care, specifically regarding the discontinuation of pain medication and the resident's alcohol consumption. The resident, who has a history of dementia, traumatic brain injury, and cognitive communication deficit, was found with a beer given by another resident. Despite the risks associated with the resident's medical conditions, including liver cirrhosis and diabetes, the facility did not inform the guardian about the alcohol consumption or the subsequent change in the resident's medication plan. The facility's policy requires notifying the resident's representative or legal guardian of any changes in condition or treatment. However, interviews with the guardian and the Director of Nursing confirmed that no attempts were made to contact the guardian regarding these significant changes. This oversight was identified during a complaint investigation, highlighting a deficiency in the facility's compliance with its notification policy.
Communication and Follow-Up Failures in Resident Care
Penalty
Summary
The facility failed to ensure consistent continuity of care between outside providers, affecting two residents. For Resident #55, there was a lack of timely communication and follow-up with the hematology oncology department regarding critical lab results and medication orders. The resident had a critical platelet level, and a new order for dasatinib was delayed in being communicated and administered. The facility did not clarify whether to continue or discontinue the use of imatinib alongside dasatinib, leading to both medications being administered concurrently. This lack of communication and follow-up resulted in the resident being transferred to the hospital due to abnormal lab results. For Resident #46, the facility did not implement the hospital's after-visit summary instructions for surgical wound care. The physician orders were missing Adaptic, and there were inconsistencies in the wound treatment orders. The facility continued with outdated orders and did not implement new wound care recommendations until much later. This resulted in the resident receiving inconsistent wound care, with duplicate orders and incorrect documentation not being addressed in a timely manner. Interviews with facility staff, including the DON, LPNs, and contracted pharmacist, confirmed the communication breakdowns and lack of follow-up with outside providers. The facility's failure to ensure proper communication and implementation of physician orders led to deficiencies in the quality of care provided to the residents, as evidenced by the delayed administration of critical medications and inconsistent wound care management.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 13.7%. This deficiency affected two residents during medication administration. For Resident #64, who has multiple diagnoses including anoxic brain damage and dysphagia, the Certified Medication Aide (CMA) administered medications incorrectly. Despite physician orders specifying administration via a percutaneous endoscopic gastrostomy (PEG) tube, the CMA crushed and administered the medications orally. Additionally, the CMA crushed medications that should not have been crushed due to their extended-release and enteric-coated formulations. For Resident #80, who is cognitively intact and has conditions such as vitamin D deficiency and type two diabetes mellitus, a Licensed Practical Nurse (LPN) prepared an incorrect dosage of Vitamin D. The LPN intended to administer 50,000 units instead of the prescribed 5,000 units. This error was identified and corrected before administration. The facility's medication administration policy, which includes observing the five rights of medication administration and following manufacturer recommendations, was not adhered to in these instances.
Failure in Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to implement a comprehensive and individualized pressure ulcer prevention program, resulting in actual harm to a resident with severe cognitive impairment. The resident, who required substantial assistance for bed mobility, developed a new in-house pressure ulcer on the right ischium due to inadequate interventions, including turning and repositioning. The resident was already at high risk for pressure ulcers, as indicated by previous assessments, but the facility's care plan did not adequately address these risks. Observations and interviews revealed that the resident was not consistently repositioned every two hours as required. Despite physician orders to encourage frequent offloading and to have the resident sit up in a chair during meals, the resident was observed to remain on her left side for extended periods due to pain when laying on her right side. This lack of adherence to the care plan and physician orders contributed to the development of the new pressure ulcer. Interviews with staff, including nurse aides and the LPN, indicated a lack of awareness and communication regarding the resident's inability to lay on her right side due to pain. The Director of Nursing was also unaware of this issue, and the facility's pressure ulcer prevention policy was not revised to address the resident's specific needs. This deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with pressure ulcer prevention protocols.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, identified as having severe cognitive impairment due to dementia, required substantial to maximal assistance with personal hygiene. Despite this need, observations on multiple occasions revealed that the resident had long, dirty fingernails with a dark brown substance underneath, indicating a lack of proper hygiene care. The resident's medical record indicated a history of dementia, protein-calorie malnutrition, and dysphagia, with a care plan that required assistance with personal hygiene due to decreased mobility and contractures. However, during the survey, it was noted that the resident's hygiene needs were not met, as evidenced by the condition of her fingernails. The Director of Nursing confirmed the observation and acknowledged that the resident required a manicure, highlighting a deficiency in the facility's care provision.
Failure to Follow Dietician Recommendations for Nutritional Monitoring
Penalty
Summary
The facility failed to follow up on dietician recommendations to ensure a resident maintained acceptable parameters of nutritional status, including body weight. This deficiency affected a resident diagnosed with malignant neoplasm of the floor of the mouth and protein-calorie malnutrition, who was on a mechanically altered dysphagia diet. The resident experienced a significant weight loss of 11.2 pounds, or 8.9 percent, in one day, which was documented without a subsequent reweight to verify the accuracy of this measurement. Despite the dietician's recommendation for a reweight on 08/10/24, no evidence was found that the reweight was conducted by 08/22/24. Observations revealed the resident appeared thin and had not consumed his lunch meal, as noted on 08/21/24. The dietician confirmed she had requested a reweight via email, but the Director of Nursing stated she did not receive any such requests, and a reweight had not been completed. This deficiency was investigated under Complaint Number OH00156977, highlighting the facility's failure to monitor and address significant weight changes as outlined in the resident's care plan.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to implement effective infection control policies, resulting in unsanitary conditions during wound care for two residents. Resident #3, who has multiple sclerosis and quadriplegia, was observed receiving wound care for a Stage 4 pressure ulcer and an unstageable pressure ulcer. The Assistant Director of Nursing (ADON) placed wound care supplies directly on the resident's bed without a barrier, failed to perform hand hygiene between glove changes, and used contaminated supplies. These actions were contrary to the facility's infection control policy, which emphasizes hand hygiene and the use of barriers to prevent contamination. Similarly, Resident #57, diagnosed with dementia and protein-calorie malnutrition, was observed receiving wound care for deep tissue injury pressure ulcers. The ADON again placed supplies on the bedside table without a barrier and used a bottle of wound cleanser that had previously fallen on the floor. The ADON did not perform hand hygiene between glove changes and returned contaminated supplies to the treatment cart, which is used for other residents. These practices were inconsistent with the facility's standard precautions policy, which requires hand hygiene after glove removal and the use of barriers to prevent contamination. Interviews with the ADON and the Regional Clinical Director of Operations confirmed the lack of adherence to infection control protocols. The ADON acknowledged the failure to perform hand hygiene and use barriers, while the Regional Clinical Director revealed the absence of a specific policy for dressing changes. This deficiency was identified during an investigation under Complaint Number OH00156977.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to adequately monitor and manage the nutritional status of several residents, leading to significant unplanned weight loss. Resident #88 experienced a severe weight loss of 8.5% over less than three months due to inadequate monitoring during a tube feed discontinuation trial. The resident's nutritional intake was not properly assessed, and weights were not monitored weekly as recommended. The dietitian's recommendations for monitoring were not followed, resulting in the resident's nutritional needs not being met. Resident #14 also experienced issues with weight monitoring. Despite a recommendation for weekly weight checks due to declining intakes, the facility failed to obtain and monitor these weights consistently. This lack of monitoring occurred over a period of three and a half weeks, during which the resident's nutritional status was not adequately assessed or addressed. Similarly, Resident #20 and Resident #56 were not monitored as required. Resident #20 had significant weight loss and was supposed to receive fortified pudding as a nutritional intervention, but there was no documentation of the resident's acceptance of this intervention. Additionally, the facility did not obtain the required weekly weights. Resident #56, who had undergone bilateral leg amputations, was also not weighed weekly as ordered, leading to a lack of proper nutritional assessment and management.
Deficiency in STNA Performance Reviews and Continuing Education
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) received annual performance reviews and completed 12 hours of continuing education annually, which had the potential to affect all residents residing in the facility. The employee file review revealed that STNA #43, hired on 10/25/22, and STNA #96, hired on 01/11/23, did not have documentation of annual performance appraisals or completion of the required continuing education. Additionally, STNA #94, hired on 01/30/23, also lacked an annual performance appraisal. An interview with the Human Resources Director confirmed these deficiencies, indicating a lapse in the facility's compliance with regulatory requirements for staff training and evaluation.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, which had the potential to affect all 96 residents. During an observation of the medication cart in the 300-hallway, eight loose pills were found in the drawer below the prepackaged medication cards. This was confirmed by an interview with the Assistant Director of Nursing (ADON) #77, who acknowledged that the loose pills should have been discarded. A similar observation was made in the 400-hallway, where three loose pills were found in the medication cart. The facility's policy on medication storage, dated August 2020, requires that medications without secure closures be immediately removed from inventory and disposed of according to procedures for medication disposal. Additionally, an observation of the medication room refrigerator revealed an open vial of tuberculin purified protein derivative (PPD) solution that was not dated upon opening. The ADON confirmed that the vial was opened but undated, making it unclear when it should be discarded. According to the manufacturer's guidelines, PPD solution vials should be discarded 30 days after opening. The facility's policy also mandates that a date opened sticker be placed on medications, with the open date and expiration date recorded.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in the kitchen, affecting all 96 residents. During an observation of the refrigerator, it was found to contain a bag of undated shredded cheese, a bag of lettuce that was undated and left open to air, and three pitchers of undated and unlabeled juice. A kitchen worker confirmed these findings and acknowledged that all foods should be labeled, dated upon opening, and stored in airtight packaging. Additionally, an observation of the dry storage area revealed three large, dented cans of tomatoes and two large, dented cans of fruit salad. Another kitchen worker confirmed that these dented cans should not be used and should have been discarded. The facility's policy on the storage of resident foods indicated that dietary staff should monitor the kitchen for food safety concerns and dispose of expired or unsafe food, as well as food exposed to incorrect temperatures or other environmental contaminants.
Failure to Implement Pest Control in Kitchen
Penalty
Summary
The facility failed to implement proper pest control interventions in the kitchen, affecting all 96 residents. During an observation, dozens of gnats were found in the dry storage area, with an uncovered bowl of vinegar placed nearby. A kitchen worker confirmed the presence of a gnat problem that had not been addressed by a professional pest control company. Additionally, the kitchen sink near the cooking area was clogged and slow to drain, which had not been treated by pest control professionals. Further observations during lunch preparation revealed gnats flying around the food preparation area. The Maintenance Director was unaware of any pest control issues in the kitchen and had not scheduled any pest control services for gnats. He confirmed that the kitchen sink frequently clogged due to staff putting food down the drain, which likely contributed to the gnat problem. A review of pest control logs from January to June 2024 showed no treatment for gnats in the kitchen, despite the facility's policy requiring pest control services to be contacted if a problem develops.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, as required. This deficiency was identified through a review of staff schedules, facility assessment, staff interviews, and facility policy. Specifically, on several weekends between October 1, 2023, and December 31, 2023, the facility did not have an RN on duty for the required duration on the dates of October 15, November 12, November 26, December 9, December 10, December 23, and December 24. The facility's assessment indicated that six to eight licensed nurses were expected to provide direct care per day for 12-hour shifts. The Administrator confirmed the absence of an RN for the required hours on the specified dates. The facility policy stated that a sufficient number of staff would be provided to care for the residents, but this was not adhered to on the mentioned dates.
Failure to Address Resident Concerns in a Timely Manner
Penalty
Summary
The facility failed to timely respond to resident concerns as documented in the Resident Council meeting minutes. Residents consistently voiced issues related to laundry services, inadequate assistance from aides, and delayed response to call lights. These concerns were raised in multiple meetings from August 2023 to May 2024, affecting 16 residents who attended these meetings. Despite the repeated nature of these complaints, there was no evidence of the facility providing a response or taking corrective actions to address these issues. Interviews with residents and the Administrator confirmed the lack of follow-up on the concerns discussed during the Resident Council meetings. The Administrator acknowledged that there was a plan to educate staff in December 2023, but it was not executed. The facility's policy on Resident Rights states that grievances should be resolved promptly, yet the facility did not adhere to this policy, resulting in unresolved resident grievances over an extended period.
Failure to Update Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to update the care plan for a resident who exhibited behavioral changes, specifically physical aggression towards other residents. The resident, who was admitted with diagnoses including altered mental status and cognitive communication deficit, was involved in two self-reported incidents where they physically slapped other residents. Despite these incidents, the care plan did not include interventions to address or prevent such behaviors. The Clinical Regional Nurse confirmed that the care plan had not been updated to reflect these changes in behavior. Additionally, the facility did not conduct care conferences for several residents as required. One resident, who was totally dependent on staff for activities of daily living and had impaired cognition, did not have documented care conferences from July 2023 to June 2024. The resident's representative confirmed they were not invited to any care conferences, and the Social Services Director acknowledged the facility's non-compliance in scheduling these meetings. The facility policy mandates care conferences upon admission, readmission, quarterly, and upon request, but these were not adhered to. The facility also failed to hold care conferences for other residents, with records showing only one or two conferences held over a year for each resident. The Director of Social Services confirmed the lack of care conferences upon admission or quarterly for these residents. The facility's policy emphasizes the importance of resident and representative participation in care planning, but this was not implemented effectively, as evidenced by the lack of scheduled meetings and documentation.
Infection Control Deficiencies in PICC Line, Medication, and Wound Care
Penalty
Summary
The facility failed to adhere to infection control practices for residents with PICC lines, medication administration, and wound care. For Resident #87, the PICC line dressing was not intact, dated, or initialed, and staff did not change the dressing after administering antibiotics. This was confirmed by both the resident and the Regional Clinical Manager. The facility's policy required PICC line dressings to be dated and replaced when loose or soiled, which was not followed. In the case of medication administration, a registered nurse did not perform hand hygiene before or during the preparation and administration of medications for Residents #5 and #47. The nurse popped pills directly into her ungloved, unwashed hands before placing them into medication cups. This practice was confirmed by the nurse and the facility administrator, who acknowledged that hand hygiene should be performed before and between residents, and medications should not be handled directly by hand. The facility also failed to ensure proper use of personal protective equipment and sanitary wound care practices. For Resident #24, staff did not wear gowns while performing wound care, and treatments for multiple wounds were done simultaneously, increasing the risk of infection. Similar issues were observed with Resident #27, where hand hygiene was not maintained during wound care and incontinence care, and multiple treatments were completed at once. For Resident #43, a nurse did not wear a gown while performing wound care, despite the resident being on enhanced barrier precautions. These actions were contrary to the facility's policy on enhanced barrier precautions, which required gowns and gloves for high-contact activities.
Deficiency in Routine Nail and Bathing Care
Penalty
Summary
The facility failed to provide routine nail care and bathing assistance to residents who were dependent on staff for activities of daily living (ADLs). This deficiency affected multiple residents, including those with significant medical conditions such as multiple sclerosis, quadriplegia, and dementia. Observations and interviews revealed that residents had long, jagged, and dirty fingernails and toenails, which were not addressed by the staff despite being part of the facility's policy for routine hygiene care. For instance, Resident #24 had long nails with a brown substance under them, which were causing discomfort, yet they were not trimmed despite the resident's request. Additionally, the facility failed to ensure that residents received scheduled bathing assistance. Resident #27, who had a self-care deficit due to conditions like COPD and morbid obesity, did not receive scheduled showers on multiple occasions. This was confirmed through interviews with the resident and staff, who acknowledged the inconsistency in providing bathing assistance. Similarly, Resident #92, who was totally dependent on staff for ADLs, missed several scheduled showers without any documented refusal or rationale for the omission. The facility's failure to adhere to its policies for routine resident care and nail hygiene services was evident in the lack of documentation and follow-up care for residents requiring podiatry services. For example, Resident #20, who was dependent on staff for ADLs, had long and discolored nails, and there was no record of a podiatry visit despite being scheduled. The Regional Clinical Manager confirmed that the facility did not schedule necessary follow-up visits for residents like Resident #50, who had a history of mycotic toenails requiring regular care to prevent complications.
Failure to Provide Appropriate ROM Care
Penalty
Summary
The facility failed to ensure that residents received appropriate care to maintain or improve their range of motion and mobility. This deficiency affected four residents who were reviewed for range of motion issues. The facility did not ensure that splints were placed appropriately and orders for fitting diabetic shoes were completed in a timely manner. Resident #47, who was admitted with diagnoses including diabetes mellitus and difficulty in walking, was not fitted for diabetic shoes despite multiple orders and recommendations from healthcare providers. Observations revealed that the resident was only wearing non-skid socks, and interviews confirmed that the resident had not received the necessary footwear, which contributed to instability during ambulation. Resident #14, who had a contracture and limited range of motion in the left hand, was not wearing a splint as per the care plan. The splint was reportedly lost, and staff were unaware of the requirement for the resident to wear it. Similarly, Resident #20, who had severe contractures, was not wearing the prescribed splints for the left hand and feet, and the splints were not documented in the treatment administration records. Resident #24, with multiple contractures, was also not wearing the required splints as per the care plan, and staff interviews confirmed the non-compliance with the care plan.
Resident Dignity Compromised Due to Lack of Appropriate Clothing
Penalty
Summary
The facility failed to ensure that Resident #43 was dressed in an appropriate and dignified manner, which is a violation of the resident's rights to dignity and self-determination. Resident #43, who has a complex medical history including acute kidney failure, spina bifida, and severe morbid obesity, was observed wearing a hospital gown instead of regular clothing. The resident confirmed that his clothing was lost by the facility, and he preferred to wear regular clothing rather than a hospital gown. Interviews and observations revealed that the facility did not maintain an inventory of the resident's belongings, and there was a lack of effort to provide the resident with appropriate clothing. An LPN confirmed that the resident had limited clothing and that staff did not retrieve clothes from the laundry or check donated clothing for suitable items. The administrator acknowledged the issue, confirming that the facility had not ensured the resident was dressed in a dignified manner when leaving his room.
Inaccurate Documentation of Advanced Directives and Code Status
Penalty
Summary
The facility failed to ensure that the advanced directives and code status of residents were accurately reflected in their medical records. This deficiency was identified through a review of records and staff interviews, affecting two residents. For the first resident, the medical record showed a signed advanced directive indicating a code status of 'do not resuscitate comfort care arrest' (DNRCC-A) dated July 13, 2020. However, a physician's order dated May 2, 2023, changed the code status to 'do not resuscitate comfort care' (DNRCC). Despite the resident being cognitively intact, the plan of care dated May 23, 2024, still reflected the DNRCC status, leading to a discrepancy between the signed form and the physician's order. Similarly, the second resident's medical record contained a signed advanced directive with a code status of DNRCC-A dated March 10, 2023. A subsequent physician's order dated March 14, 2023, altered the code status to DNRCC. The resident was also cognitively intact, yet the inconsistency between the signed form and the physician's order persisted. The facility's policy on advanced directives required that copies be made available and accurately communicated to staff, which was not adhered to in these cases.
Failure to Notify Physician and Family of Significant Changes
Penalty
Summary
The facility failed to notify the primary care physician of a resident's blood glucose levels that were outside the physician-ordered parameters. This deficiency affected a resident with multiple diagnoses, including diabetes mellitus, who was receiving insulin daily. The resident's blood sugar levels were recorded as being outside the specified range on several occasions in May and June 2024, yet there was no documentation of physician notification as required by the facility's policy. The Regional Clinical Nurse confirmed the lack of notification to the primary care physician. Additionally, the facility did not inform the resident's representative about the discontinuation of enteral tube feeding for another resident. This resident, who had cognitive impairments and relied on enteral nutrition to meet dietary needs, had their tube feeding discontinued without prior notification to their representative. The representative only became aware of the change during a visit when they inquired about the resident's care. Interviews with the dietician and registered nurse confirmed the absence of documentation regarding communication with the resident's family about the change in treatment. The facility's policy on Notification of Change in Condition, dated 2022, mandates that significant changes in a resident's condition or treatment should be communicated to the attending practitioner and resident representatives. However, in both cases, the facility failed to adhere to this policy, resulting in deficiencies related to communication and notification of significant changes in the residents' care plans.
Failure to Implement PASARR Level II Services
Penalty
Summary
The facility failed to educate, offer, or implement Level II services for a resident who was reviewed for PASARR screenings. The resident, who was admitted with diagnoses including bipolar disorder, depression, dementia, alcohol abuse, anxiety disorder, and PTSD, required ongoing case management from a mental health agency and emergency mental health services. The PASARR screening indicated the need for specialized services, including an initial psychiatric evaluation and ongoing medication review by a psychiatrist, as well as substance abuse treatment options. However, the care plan did not include these specialized service recommendations. Interviews revealed that the resident had not been offered any specialized services, such as substance abuse treatment options, and was unaware of any services being provided. The Social Services Director, who had been in the position for two months, was not aware that the resident qualified for specialized services and confirmed that the resident had not been educated or offered the recommended services. The facility's PASARR policy required the identification and evaluation of residents for severe mental illness to ensure their needs were met in the most appropriate setting, but this was not adhered to in this case.
Failure to Comprehensively Assess Pressure Ulcers Upon Admission
Penalty
Summary
The facility failed to comprehensively assess pressure ulcers for three residents upon admission or readmission, leading to a deficiency in pressure ulcer care. Resident #24 was readmitted with multiple diagnoses, including a stage IV pressure ulcer to the left buttocks. The nursing admission evaluation did not include staging, measurements, or a description of the wounds. The plan of care indicated the resident was at risk for skin breakdown, but the initial assessment was incomplete. The wound NP's progress note later provided detailed measurements and descriptions of the ulcers. Resident #27 was admitted with several diagnoses and multiple pressure ulcers, including an unstageable ulcer to the left heel and stage II ulcers to various body parts. The nursing admission evaluation lacked staging, measurements, and descriptions of the wounds. The plan of care identified the resident's impaired skin integrity and included interventions for weekly skin checks. However, the initial comprehensive assessment was not conducted, as confirmed by the RCN. Resident #43, with a history of spina bifida and other conditions, was admitted with pressure injuries to both heels. The nursing admission evaluation did not reassess the resident's skin condition, and the initial assessment was incomplete. The wound NP's progress note later detailed the condition of the pressure injuries. The facility's policy required evaluations upon admission and weekly thereafter, but this was not adhered to, resulting in a deficiency under Complaint Number OH00154396.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and maintenance of respiratory equipment for two residents. Resident #27, who has a history of obstructive sleep apnea and other significant health issues, was observed with a BiPap delivery mask improperly stored outside of a plastic bag on two separate occasions. This was confirmed by the Director of Nursing (DON) during an interview, indicating a lapse in following the facility's protocol for storing respiratory equipment. Resident #152, diagnosed with COPD and chronic respiratory failure, was found to have oxygen tubing that was not dated, suggesting it had not been changed as per the physician's orders. Observations revealed the tubing was laying directly on the floor, which was confirmed by the DON as unsanitary. The facility's policy requires nasal cannula tubing to be labeled and changed weekly or when soiled, which was not adhered to in this case. These deficiencies highlight the facility's failure to comply with its own policies regarding respiratory care.
Deficiencies in Call Light Accessibility and Resident Autonomy
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident with cognitive impairment and physical limitations. The resident, who had diagnoses including hemiplegia, hemiparesis, and muscle weakness, required staff assistance with activities of daily living. Despite the care plan specifying that the call light should be within reach, observations on multiple occasions revealed the call light was left on the floor, out of the resident's reach. Interviews with the resident's representative and a State tested Nursing Aide confirmed the call light was frequently inaccessible to the resident. Additionally, the facility did not respect a resident's choice to go outside when it was not medically contraindicated. A cognitively intact resident, who required moderate assistance with activities of daily living, was not allowed to leave the facility to sit outside, despite not being assessed as a wandering or elopement risk. Interviews with the resident, the Ombudsman, and facility staff revealed that the facility had a rule preventing residents who needed assistance from going outside, except for smoke breaks. The Regional Clinical Manager confirmed there was no clinical rationale for restricting the resident's access to the outdoors.
Unclean Privacy Curtain in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident #88, as evidenced by the condition of the resident's privacy curtain. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphasia, aphasia, atrial fibrillation, muscle weakness, and cognitive communication impairment, was observed to have a dirty privacy curtain with brown splatter and food crumbs on multiple occasions. These observations were made on three separate days, and the resident's representative confirmed the curtain's unclean state. Additionally, a State tested Nursing Aide (STNA) acknowledged the dirty condition of the curtain but indicated that addressing it was not part of their responsibilities, suggesting that housekeeping should be informed instead. This deficiency was identified during an investigation under Complaint Number OH00153744.
Deficiencies in Resident Care and Coordination
Penalty
Summary
The facility failed to timely evaluate and treat a rectal fistula for Resident #11, who had diagnoses including paraplegia and anal fistula. Despite having a care plan for impaired skin integrity, there were no wound treatment orders for the rectal area, and the wound was not reported by the staff. The wound was observed to have light brown drainage and appeared to be tunneling. The facility only became aware of the wound when it was observed during incontinence care, leading to the decision to transfer the resident to the hospital for further evaluation. Resident #73, who had diagnoses including bipolar disorder and chronic obstructive pulmonary disease, was supposed to have a GI consult for blood in stool and diarrhea. Although an appointment was scheduled, it was not with a provider that accepted the resident's insurance, and the facility did not attempt to reschedule the appointment with a different provider as instructed by the nurse practitioner. Consequently, the resident did not receive the necessary GI evaluation in a timely manner. Resident #64, with a diagnosis of diffuse traumatic brain injury, was on hospice services. However, the facility failed to ensure that the hospice recertification, plan of care, and assessment were updated. The documentation for hospice services had expired, and the facility had not arranged for an updated certification, plan of care, or assessment, as confirmed by the Director of Nursing. This oversight was contrary to the facility's policy on coordination of care for hospice services.
Failure to Arrange Timely Ophthalmology Services
Penalty
Summary
The facility failed to ensure timely follow-up for ophthalmology services for a resident, which was identified during a review of medical records, interviews with the resident's representative, and staff. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphasia, aphasia, atrial fibrillation, muscle weakness, and cognitive communication impairment, was referred for ophthalmology services on 04/25/24 after a doctor's appointment. However, the facility's vision provider list from July 2023 to June 2024 showed that the resident was not seen by any vision service provider during this period. An interview with the resident's representative revealed that they were unaware if the ophthalmology appointment had been arranged, despite expressing concern about the resident's eye swelling. The Social Services Director, responsible for arranging vision services, confirmed that she was not aware of the referral made on 04/25/24, resulting in the resident not receiving the necessary ophthalmology services.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for Resident #14, who was cognitively intact and required moderate to dependent assistance for personal hygiene and bathing. The resident was admitted with multiple diagnoses, including aneurysm, hemiplegia, hemiparesis, convulsions, diabetes, polyneuropathy, muscle wasting, and atrophy. The care plan indicated that the resident was incontinent of bowel and bladder and required regular checks and toileting. However, observations and interviews revealed that the resident's requests for incontinence care were not addressed promptly, leading to a strong smell of urine and feces in the resident's room and hallway. On the morning of the observation, the resident used the call light to request assistance, but staff delayed providing care. An STNA turned off the call light and promised to return later, but continued with other tasks, leaving the resident soiled. Another STNA informed the resident that the first STNA was on break and also did not provide care. An LPN confirmed that incontinence care should be provided immediately or within five minutes of a request, but was unaware of the resident's ongoing requests. The facility's policy emphasized resident-centered care and maintaining skin integrity, but these standards were not met in this instance.
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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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