Community Skilled Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Ohio.
- Location
- 1320 Mahoning Ave Nw, Warren, Ohio 44483
- CMS Provider Number
- 365412
- Inspections on file
- 24
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Community Skilled Healthcare during CMS and state inspections, most recent first.
A cognitively intact resident with a known history of sexually inappropriate behavior, including entering female residents’ rooms, was observed by a CNA standing in front of a severely cognitively impaired resident in a hallway with his pants halfway down and genitals exposed, telling the other resident to look. The cognitively impaired resident, who required extensive assistance with ADLs and could not reliably report events, affirmed that the exposure occurred and was later overheard saying she was scared. Despite this and a prior note of public indecency involving the same resident, the facility’s internal investigation concluded there was no inappropriate conduct, did not obtain witness statements from all involved staff, and documented findings that were inconsistent with what the Administrator reported, resulting in an unsubstantiated allegation of sexual abuse contrary to the facility’s abuse policy.
Multiple incidents showed that residents were not protected from misappropriation of medications. In one case, an LPN took Haldol from one resident’s stock supply and administered it by IM injection to another cognitively impaired resident without a physician’s order, instructing CNAs not to report it. In a second case, narcotic count sheets for a cognitively intact resident on Adderall showed repeated two‑tablet decreases at times when only one tablet was ordered and documented as given, all associated with the same LPN, with the DON later noting the LPN’s inconsistent explanations and refusal or delay in drug testing despite a policy requiring compliance. In a third case, an agency LPN documented removal of two Oxycodone tablets at multiple administration times for a resident ordered only one tablet q4h PRN, while the MAR reflected single‑tablet doses, revealing discrepancies between the narcotic count and the ordered and documented administration. These events demonstrate wrongful use and removal of resident medications contrary to physician orders and facility policies on medication administration, drug‑free safety, and prevention of misappropriation.
A resident with ADHD and other psychiatric and neurologic conditions was ordered Adderall 20 mg twice daily, but narcotic count sheets showed multiple instances where the count decreased by two pills when only one was ordered, all signed out by an LPN. The DON identified inaccurate counts tied to this LPN, who later stated she did not know why the count was wrong and claimed to have wasted a pill without a witness. The LPN refused an in-facility urine drug screen and did not appear for the initially scheduled independent test, yet was allowed to return to work despite a written Drug Free Safety Policy stating that refusal or failure to comply with required testing constitutes a refusal to test and results in termination.
Two residents were involved in an alleged incident of sexual abuse when a cognitively intact male resident with a known history of sexually inappropriate behavior was observed by a CNA standing in front of a severely cognitively impaired female resident in a hallway with his pants halfway down and his genitals exposed, telling her to look. The female resident affirmed that he had shown his genitals and was later overheard saying she was scared. A police report documented that staff reported the male resident exposing himself, although he denied the behavior. Despite this, the facility’s internal SRI concluded the allegation was unsubstantiated, stating there was no behavior suggesting concerning interaction and that the cognitively impaired resident could not provide a statement. The Administrator later acknowledged that his recollection of the event (pants down and genitals exposed) conflicted with the SRI, that not all involved staff provided witness statements, and that sexual abuse could not be ruled inconclusive, indicating the investigation was not complete or thorough as required by facility policy.
A resident with multiple complex medical conditions and cognitive impairment was discharged home with family present, but the LPN responsible did not complete the nursing section of the discharge paperwork. There was no documented review of discharge medications and no indication that prescriptions or a three-day supply of medications were offered, despite facility policy requiring a complete discharge summary and medication reconciliation. The Ombudsman and DON both confirmed the discharge documentation was incomplete and that medications were not reviewed or offered.
The facility did not provide enough nursing staff to meet residents' needs, resulting in missed showers and hygiene care for several residents who required assistance with ADLs. Staff reported inadequate staffing levels, inability to complete showers, and incomplete documentation, while residents dependent on staff did not receive bathing according to their preferences. The DON confirmed the facility failed to meet minimum daily staffing requirements on multiple days, and the facility assessment was outdated.
The facility did not ensure an RN was present for at least eight consecutive hours each day, as required. On two occasions, there was either no RN scheduled or the RN worked less than the required hours, as confirmed by the DON. This affected all residents in the facility.
The facility did not update its facility-wide assessment as required, with documentation showing the last update occurred over two years ago. The Administrator confirmed no evidence of an updated assessment, potentially affecting all residents.
The facility did not notify responsible parties or emergency contacts when two residents were transferred to the hospital—one for a urinary tract infection and another after a fall resulting in a head injury. Despite facility policy requiring prompt notification, documentation and staff interviews confirmed that notifications were not made in these cases.
The facility did not send required health status documentation to the hospital for two residents who were transferred, despite policy and staff statements indicating that transfer forms with key information should accompany residents. Both residents had significant medical needs and required substantial assistance with daily care.
Three residents who were dependent on staff for ADL care did not consistently receive baths or showers according to their documented preferences, with both paper and electronic records showing missed or undocumented bathing events. Interviews with residents and CNAs confirmed that showers were not provided as requested, primarily due to insufficient staffing, and the DON was aware of these ongoing issues. Facility policies required bathing to be consistent with resident choices, but this was not achieved.
A resident with severe cognitive impairment and total dependence on staff was not provided with prescribed interventions to prevent skin breakdown. Despite orders for daily foam dressing application and repositioning every two hours with a wedge pillow, the resident was repeatedly observed without the dressing and not repositioned as ordered, with the wedge pillow left unused on a chair. Nursing staff confirmed these interventions were not followed, contrary to facility policy.
The facility did not thoroughly investigate falls involving two residents, both identified as fall risks with significant medical histories. In both cases, the fall investigations lacked required witness statements, root cause analyses, documentation of toileting or call light use, and evidence of new interventions, despite facility policy mandating these steps. The DON confirmed these omissions during interviews.
Daily nurse staffing information was not updated to reflect the current day and did not include the required census number. A CNA confirmed the posting was outdated and incomplete, noting that the scheduler responsible for updates was on vacation. This issue was identified during a complaint investigation and had the potential to affect all residents.
The facility failed to thoroughly investigate incidents involving narcotic diversion and a resident altercation. In the first case, missing oxycodone tablets were not properly investigated, lacking witness statements, a police report, and resident assessments. In the second case, a resident altercation was inadequately investigated, with insufficient witness statements and no preventative measures. The facility did not adhere to its policy on abuse and misappropriation, resulting in these deficiencies.
The facility did not have an RN on duty for the required eight consecutive hours, affecting all 80 residents. On a specific day, no RN was scheduled for any shift, and only one RN punched in late at night. The DON was not informed of the absence, and the scheduled RN had called off. The facility's policy allowed for shift adjustments and emergency staffing, but these were not utilized.
The facility inaccurately coded MDS assessments for several residents receiving hospice care, failing to indicate their life expectancy of less than six months. Despite being on hospice, the assessments for residents with serious conditions like end-stage Alzheimer's, Parkinson's, and malignant neoplasm were incorrectly marked. An inexperienced LPN, following corporate instructions, contributed to this deficiency.
A resident experienced a persistent strong urine odor in their room, despite frequent incontinence care and being on a diuretic. Interviews with an LPN and an STNA confirmed the odor, and an observation further verified the issue. The facility's policy on resident rights was not upheld, affecting the resident's right to a dignified existence.
A resident with a history of falls and cognitive impairments fell due to inadequate assistance during ambulation. The STNA let go of the resident to move a chair, resulting in a fall. Additionally, the facility failed to conduct quarterly fall risk assessments as required, with the last assessment done over a year prior to the incident.
The facility failed to implement a comprehensive pressure ulcer prevention and care program, resulting in Immediate Jeopardy and actual harm to three residents. A resident developed a Stage III pressure ulcer due to inadequate interventions, leading to hospitalization for sepsis. Two other residents experienced worsening of their pressure ulcers due to insufficient care, including lack of timely repositioning and incontinence care.
The facility failed to provide sufficient nursing staff to meet residents' care needs, affecting six residents and potentially all 78 residents. Staffing levels fell short of the required 3.28 to 4.78 hours of care per resident per day, leading to missed showers, inadequate incontinence care, and insufficient repositioning. Staff interviews confirmed the facility was short-staffed, and the elimination of shower aides added to the burden on STNAs. Specific cases highlighted the impact, with residents not receiving care as per their schedules or preferences.
The facility administration failed to manage resources effectively, impacting the wellbeing of all 78 residents. The interim Administrator and new DON were recently appointed, and the facility was understaffed, leading to inadequate resident care. Persistent bed bug infestations were not properly addressed, and the physical environment was poorly maintained, with unrepaired holes in residents' rooms.
The facility failed to provide showers according to schedules or preferences for six residents, as revealed through observations, record reviews, and interviews. Residents with varying levels of cognitive impairment and assistance needs did not receive adequate bathing, with insufficient documentation of showers. Staff interviews indicated that the removal of shower aides contributed to this deficiency.
Two residents in the facility experienced a deficiency in their living environment due to holes in the walls behind their bed headboards. Despite being aware of the issue, the Environmental and Maintenance Directors had not addressed the problem. Both residents reported the holes, which were not documented in the maintenance log, indicating a lack of action to resolve the issue.
A facility failed to maintain an effective pest control program for bed bugs, affecting a resident and potentially impacting all residents. Despite multiple chemical treatments, bed bugs persisted in several rooms. Interviews confirmed the presence of bed bugs and insufficient pest control measures. The facility opted for chemical treatments instead of recommended heat treatments, contributing to the ongoing infestation.
The facility failed to maintain a sanitary kitchen environment, with observations of built-up dirt, unlabeled food items, expired test strips, and staff not following dress code policies, potentially affecting 80 residents.
The facility failed to ensure proper infection control practices for residents requiring enhanced barrier precautions and blood glucose monitoring. Observations revealed the absence of necessary signage and PPE for residents with indwelling catheters and wounds, and improper cleaning of blood glucose meters. Staff members were unsure of specific precautions, and the infection preventionist and DON confirmed the lapses in protocol.
The facility failed to prevent the misappropriation of medications by an RN, affecting multiple residents. The RN frequently documented wasting controlled substances without proper witnessing and forged signatures on logs. Despite these discrepancies, there was no evidence that residents went without their pain medications.
The facility failed to file required Self-Reported Incident (SRI) reports for medication misappropriation affecting four residents. Despite internal investigations revealing drug diversion by an RN, the facility did not report the incidents to the Ohio Department of Health as mandated by their policy.
A resident with asthma was found to self-administer an albuterol inhaler without informing nursing staff, and without a proper assessment or documentation. Interviews and observations confirmed the resident's actions and the facility's failure to follow its policy on medication self-administration.
The facility failed to change the nasal cannula oxygen tubing for a resident with chronic obstructive pulmonary disease and heart failure in a timely manner. The resident was observed using oxygen with tubing dated over a month old, contrary to the facility's policy requiring weekly changes. An LPN confirmed the oversight.
The facility failed to honor a resident's advanced directives, despite the resident's clear instructions to change his code status from full code to Do Not Resuscitate Comfort Care (DNRCC). The discrepancy was confirmed through multiple interviews and a review of the facility's records, which continued to list the resident as a full code.
The facility failed to conduct reference checks for three new hires, including two LPNs and one SSD, as required by their policy on Screening/Background Investigations. The absence of reference checks was verified by the Payroll Coordinator.
The facility failed to provide copies of medical records to a resident's representative, citing HIPAA concerns for third-party services. Despite the facility's policy indicating that various medical records could be requested, the Administrator denied access to dental records, leading to a deficiency.
The facility failed to thoroughly investigate an allegation of sexual abuse involving a cognitively impaired resident. No skin assessment was conducted, and no interviews with other residents or staff were performed. The resident was not sent to the hospital for further examination, contrary to the facility's policy.
Failure to Prevent and Properly Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident sexual abuse between two residents, one of whom had known sexually inappropriate behaviors and one who was severely cognitively impaired. One resident had diagnoses including autistic disorder, developmental disorder, anxiety, hypertension, and scoliosis, and was assessed as severely cognitively impaired, requiring extensive assistance or total dependence for most ADLs and unable to provide a reliable statement. The other resident had diagnoses including diabetes, depression, high cholesterol, and respiratory disorders, was cognitively intact, and was independent in ADLs. This cognitively intact resident had a care plan documenting sexually inappropriate behaviors, including entering female residents’ rooms, with interventions such as anticipating needs and discussing inappropriate behavior. On the date of the incident, a CNA reported witnessing the cognitively intact resident standing in front of the cognitively impaired resident in the hallway with his pants halfway down and his genitals exposed, telling the cognitively impaired resident to look. When the exposing resident saw the CNA, he returned to his bedroom. The CNA stated she asked the cognitively impaired resident if the other resident had shown his genitals, and the resident responded yes. The CNA also reported overhearing the cognitively impaired resident later tell another CNA that she was scared. A prior nursing note documented that the same resident had indecently exposed himself to another resident in the hallway on a different date. The facility’s self-reported incident and internal investigation documented that the exposing resident’s pants appeared to be positioned below his waist but concluded there was no evidence of inappropriate conduct, unintentional harm, or adverse outcome, and the allegation of sexual abuse was unsubstantiated. The investigation did not include a witness statement from a nurse, and witness statements were not obtained from all staff involved. The Administrator later confirmed that he had reported that the resident’s pants were down and his genitals were exposed to the cognitively impaired resident, which was inconsistent with the conclusion in the submitted self-report, and acknowledged that sexual abuse could not be ruled inconclusive based on the investigation results. Facility policy defined abuse to include resident-to-resident altercations and identified sexual abuse as non-consensual sexual contact, with an expectation that residents’ capacity to consent would be determined and recorded.
Misappropriation of Resident Medications and Failure to Safeguard Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of medications and to ensure medications were administered only as ordered. For one resident with Alzheimer’s disease, malnutrition, anxiety, and other conditions, the quarterly MDS showed cognitive impairment and a need for supervision with eating and staff assistance for all ADLs, including medication administration. On an evening in August, an LPN obtained a vial of Haldol 5 mg IM from another resident’s stock supply without a physician’s order for this resident and administered an injection in the resident’s room. Multiple CNAs reported being asked to assist the resident to the room, witnessed the LPN pull down the resident’s pants and give the injection, and stated the LPN told them not to say anything because the medication was not prescribed for the resident and had been taken from another resident’s supply. The DON confirmed there was no Haldol order for this resident on that date, that a vial was missing from the other resident’s Haldol supply, and that the LPN denied giving the dose. A second deficiency involved misappropriation and inaccurate handling of a controlled substance prescribed for another resident with ADHD, bipolar disorder, seizures, Tourette’s disorder, and other diagnoses. This resident was cognitively intact and independent with ADLs, and had an order for Adderall 20 mg twice daily at specific times. Review of the narcotic count sheets showed that on multiple occasions over two days, the Adderall pill count decreased by two tablets at times when only one tablet was ordered to be administered, all associated with the same LPN’s signatures. These discrepancies indicated that two pills were removed from the count when only one was ordered for the resident at each administration time. The DON later described that the LPN could not explain the discrepancies, claimed to have wasted a capsule without a witness, initially refused an in‑facility urine drug screen, delayed completion of an independent drug test, and that the facility’s policy stated refusal or failure to comply with drug testing requirements would be considered a refusal to test and subject to immediate termination. A third deficiency involved another resident with intact cognition and independence in ADLs who had multiple medical diagnoses and an order for Oxycodone 5 mg, one tablet by mouth every four hours as needed for pain. The MAR documented that this resident received single 5 mg doses at several times over two days, all administered by an agency LPN. However, the narcotic count sheet for the same period showed that the agency LPN repeatedly signed out two tablets at each administration time, including multiple entries for the same early‑morning time, despite the order being for only one tablet as needed. A subsequent review of the narcotic count by another LPN revealed discrepancies between the MAR and the narcotic sheet, with repeated documentation of two tablets being removed when only one tablet was ordered and documented as given. The DON stated that misappropriation occurred in all three incidents and that the facility’s abuse, neglect, and exploitation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and that the facility had unsubstantiated these incidents despite the misappropriation having occurred. The facility’s own policies and job descriptions further framed the deficiencies. The LPN job description required accurate preparation and administration of medications according to physician orders and accurate recording of medications administered. The Drug Free Safety Policy specified that refusal to comply with testing requirements, failure to provide valid specimens, or refusal to submit to reasonable suspicion or follow‑up tests would be considered a refusal to test and subject to immediate termination. The Abuse, Neglect, and Exploitation policy stated that the facility would implement policies and procedures to prevent and prohibit misappropriation of resident property. Despite these written expectations, the events described show that medications belonging to or prescribed for specific residents were wrongfully used or removed, and that in one case an LPN’s conduct around drug testing did not align with the facility’s stated policy, contributing to the overall deficiency in protecting residents from misappropriation.
Failure to Enforce Misappropriation and Drug-Free Workplace Policies for Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies related to misappropriation and drug-free workplace requirements in connection with a resident’s controlled medication. One resident, admitted with multiple diagnoses including ADHD, bipolar disorder, seizure disorder, and Tourette’s Disorder, had an order for Adderall 20 mg twice daily at 8:00 A.M. and 3:00 P.M. The resident’s MDS showed the resident was cognitively intact and independent with ADLs. Review of the resident’s Adderall narcotic count sheets showed that on specific dates, the pill count decreased by two tablets at times when only one tablet was ordered to be administered, indicating that two pills were signed out instead of one on multiple occasions. The facility’s SRI documented that the DON became aware that the Adderall count for this resident was inaccurate and identified that an LPN had signed out the medication at the times when the count decreased by two instead of one. During an interview, the LPN stated she did not know why the count was incorrect and claimed there was a day she punched out two capsules and wasted one but could not find another nurse to witness the waste. The DON reported that the LPN refused to complete an in-facility urine drug screen and did not appear for the initially scheduled independent drug test, despite facility policy stating that refusal or failure to comply with testing requirements constitutes a refusal to test and is subject to immediate termination. The DON acknowledged that, contrary to the written Drug Free Safety Policy, the LPN was allowed to return to work after refusing and missing the drug test, even though the policy specified that refusal to submit to required testing would result in termination.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident sexual abuse involving two residents. Resident #40, admitted on 04/07/16, had diagnoses including autistic disorder, developmental disorder, anxiety, hypertension, and scoliosis, and was documented as severely cognitively impaired, requiring extensive assistance with activities of daily living. Resident #52, admitted on 03/20/25, had diagnoses including diabetes, depression, high cholesterol, and respiratory disorders, was cognitively intact, and was independent in all ADLs. His care plan, initiated on 03/24/25, identified sexually inappropriate behaviors, including entering female residents’ rooms, with interventions focused on anticipating needs and addressing inappropriate behavior. On 01/11/26 at 9:32 P.M., a nursing note documented that Resident #52 indecently exposed himself to another resident in the hallway. The facility’s self-reported incident (SRI) and investigation dated 01/12/26 stated that Resident #52 was observed standing to the left of Resident #40 in the hallway with his pants appearing to be positioned below his waist, but asserted there were no movements, physical contact, or behaviors suggesting concerning interactions, and concluded the allegation of sexual abuse was unsubstantiated. The SRI noted that Resident #40 lacked the cognitive ability to provide a statement and that other resident interviews revealed no findings of abuse. However, a witness statement from CNA #213 documented that she saw Resident #52 standing in front of Resident #40, exposing his genital area and saying, "There you go, look at it," after which he rushed back to his bedroom when he saw her. CNA #213 reported that Resident #40 answered "yes" when asked if Resident #52 had shown his genitals and that Resident #40 was overheard telling another CNA she was scared. A police report recorded that staff reported Resident #52 exposing his genitals to Resident #40, though Resident #52 denied it. LPN #214 confirmed being told that Resident #52 exposed himself and acknowledged knowledge of his history of inappropriate sexual behaviors. The Administrator later confirmed he recalled reporting that Resident #52’s pants were down and his genitals were exposed to Resident #40, which was inconsistent with the SRI’s conclusion, and acknowledged that witness statements were not obtained from all involved staff and that sexual abuse could not be ruled inconclusive, contrary to the facility’s abuse policy requiring immediate, complete, and thorough investigation and documentation.
Incomplete Discharge Documentation and Medication Review for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and complete discharge process for one resident. The resident had multiple complex diagnoses, including rhabdomyolysis, moderate protein-calorie malnutrition, hypertensive chronic kidney disease stage V, seizures, hypothyroidism, anemia, hyperfunction of the pituitary gland, urinary retention, hyperlipidemia, diabetes insipidus, and hypopituitarism. A discharge MDS assessment showed the resident had cognitive impairment and required setup or cleanup assistance for ADLs. On the day of discharge to home via private car, progress notes documented that family was present, gathered belongings, and discharge paperwork was given. However, the nursing section of the discharge documents completed by the LPN responsible for the discharge was not filled out. Review of the medical record and interviews revealed there was no evidence that discharge medications were reviewed or offered to the resident or family, and the discharge paperwork was incomplete. The Ombudsman reported that the resident was discharged without medication prescriptions and that the discharge paperwork was not filled out completely. The DON confirmed that the discharge documentation was incomplete and that there was no evidence discharge medications were reviewed or offered. The LPN who discharged the resident acknowledged she did not complete the discharge paperwork and did not document reviewing discharge medications or offering a three-day supply, despite this being required by facility policy. The facility’s Transfer and Discharge policy specified that the nurse caring for the resident at the time of discharge must ensure the Discharge Summary is complete, including a recap of the stay, final status, and reconciliation of pre- and post-discharge medications, which was not done in this case.
Insufficient Staffing Leads to Missed Resident Showers and Hygiene Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple interviews, record reviews, and policy review. Certified nurse aides reported that there were not enough staff to complete essential activities of daily living (ADL) care, including showers and hygiene tasks. Staff described working without breaks, working overtime to complete charting, and being unable to provide showers or baths according to residents' preferences due to inadequate staffing levels. The Director of Nursing confirmed that the facility did not meet the minimum direct care daily average of 2.5 hours per resident per day on several dates, and the facility assessment had not been updated since April 2022. Three residents were specifically affected by the staffing deficiency. One resident, with severe cognitive impairment and total dependence on staff, preferred tub baths three times a week but often received bed baths instead, and there was no documented evidence of regular bathing or showers in the electronic medical record. Another resident, fully dependent for transfers and requiring a mechanical lift, preferred a weekly bath but had incomplete or missing documentation for showers and baths, with only two days marked as completed in the electronic record. A third resident, also fully dependent on staff for bathing and with a history of depression, had inconsistent documentation of showers and bed baths, and some shower sheets were not filled out. The facility's policy required assisting residents with bathing and maintaining proper hygiene according to their preferences, but this was not consistently followed. The lack of sufficient staffing directly impacted the ability to provide care as planned and documented, affecting residents' ability to receive showers or baths as preferred and required. The deficiency was identified through interviews with staff and residents, review of staffing schedules, and examination of care documentation.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present in the facility for at least eight consecutive hours each day, seven days a week, as required. Review of staffing schedules and tools for specific weeks in May 2025 showed that no RN was scheduled to work on one day, and on another day, an RN worked only 7.25 hours. During an interview, the Director of Nursing (DON) confirmed there was no additional evidence to show that an RN had worked the required hours on those days. This deficiency was identified incidentally during a complaint investigation and had the potential to affect all 75 residents in the facility.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to update its facility-wide assessment annually as required. Review of the assessment showed it was last dated over two years prior to the survey, and the Administrator confirmed during interview that the date had not been changed and could not provide evidence of any updates since that time. This lapse had the potential to affect all 75 residents in the facility. The deficiency was identified during a complaint investigation and was based on both document review and staff interview.
Failure to Notify Responsible Parties of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the responsible party, Power of Attorney (POA), or emergency contact when residents were transferred to the hospital. In the case of one resident with quadriplegia, kidney disease, and anemia, there was no documented evidence that his emergency contact, who is his sister, was informed of his hospital admission for a urinary tract infection. The resident was cognitively intact and required significant assistance with daily activities. The Director of Nursing confirmed that there was no evidence of notification to the responsible party regarding this transfer. Another resident, who had Alzheimer's disease, kidney disease, anemia, depression, and high cholesterol, was found to be severely cognitively impaired and dependent on staff for most activities. After sustaining a laceration on her forehead from a fall, she was transferred to the emergency department and treated for a closed head injury. Although the DON and physician were notified, there was no documentation that her responsible party, POA, or emergency contact was informed of the transfer. Staff interviews confirmed the lack of evidence for notification in both cases. Facility policy requires prompt notification of the resident's representative in such events, regardless of the resident's cognitive status.
Failure to Send Required Resident Information During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation regarding resident health status to the hospital upon transfer for two of three residents reviewed for hospitalizations. For one resident with quadriplegia, kidney disease, and anemia, who was cognitively intact and dependent on staff for most activities of daily living, there was no evidence that any information was sent to the hospital when he was admitted due to a urinary tract infection. For another resident with Alzheimer's disease, kidney disease, anemia, depression, and high cholesterol, who was severely cognitively impaired and dependent on staff for care, there was also no documentation that information was sent to the hospital following a transfer after a fall resulting in a laceration. Interviews with facility staff, including an RN and the DON, confirmed that the process for hospital transfers should include sending a transfer form with resident demographics, physician's orders, and a list of medications. However, review of the records and facility policy revealed that this information was not sent for the two residents in question, despite the policy stating that such documentation should accompany residents for continuity of care during hospital transfers.
Failure to Provide Bathing Services per Resident Preference Due to Staffing Issues
Penalty
Summary
The facility failed to provide bathing and showering services according to resident preferences for three residents who were dependent on staff for activities of daily living (ADL) care. Documentation and interviews revealed that residents did not consistently receive their preferred method or frequency of bathing, despite their preferences being documented in care plans and assessments. For example, one resident with severe cognitive impairment and total dependence on staff preferred a tub bath three times a week, but records showed they often received bed baths or showers instead, and there was no consistent documentation of bathing in the electronic medical record. Another resident, who was cognitively intact but fully dependent for transfers and required a mechanical lift, reported not receiving baths according to their preference of once a week. Paper shower sheets were frequently left unfilled, and electronic records only sporadically documented completed bathing tasks. A third resident, also fully dependent on staff for bathing and with a history of depression, reported not being bathed as frequently as preferred, with gaps in both paper and electronic documentation. This resident had also voiced concerns to staff about the issue. Interviews with multiple CNAs confirmed that resident showers were not regularly provided according to resident preferences, citing insufficient staffing as a primary reason. The Director of Nursing acknowledged awareness of staffing issues affecting the provision of care. Facility policies reviewed indicated that bathing should be consistent with resident choices and requests, but these were not followed in practice, resulting in the deficiency.
Failure to Follow Physician Orders for Pressure Injury Prevention
Penalty
Summary
The facility failed to follow physician orders for the prevention of skin breakdown for one resident who was at risk for pressure ulcers. The resident, who was severely cognitively impaired, totally dependent on staff for care, and always incontinent of urine and bowel, had a care plan and physician orders in place to address their risk for pressure injuries. These included daily application of a foam dressing with protective cream to the coccyx area and repositioning every two hours using a wedge pillow. However, during observations, the resident was repeatedly found lying on their back without the prescribed foam dressing in place, and the wedge pillow intended for repositioning was consistently found on a bedside chair rather than being used for the resident. Interviews with nursing staff confirmed that the foam dressing was not applied as ordered and that the wedge pillow was not being used for repositioning, despite the presence of a physician's order and facility policy requiring evidence-based interventions for pressure injury prevention. The resident was observed to have a significant reddened area on the coccyx, and staff acknowledged the lack of adherence to the prescribed interventions. Facility policy review further supported that such interventions should have been implemented for residents at risk for pressure injuries.
Failure to Thoroughly Investigate Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate falls for two residents, resulting in incomplete fall investigations. For one resident with diabetes, heart disease, and other chronic conditions, a fall occurred when her incontinence brief slid down during a transfer, causing her to trip. Although she was assessed and found to have no injuries, the facility's fall investigation lacked witness statements, a root cause analysis, documentation of when she was last toileted, evidence of call light use, and implementation of new interventions. The care plan had identified her as a fall risk, but the investigation did not meet the facility's policy requirements. Another resident with Alzheimer's disease and multiple comorbidities experienced a fall resulting in a head laceration and required emergency treatment. The investigation for this incident also lacked staff witness statements, a root cause analysis, documentation of toileting or call light use, and evidence of new interventions. The DON confirmed that these elements were missing from both investigations, and the facility's policy required such steps to be completed for all falls, especially unwitnessed ones. These deficiencies were confirmed through record review, interviews, and policy review.
Failure to Timely and Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted both timely and accurately. On the morning of 06/10/25, the posted staffing information was observed to be for the previous day, 06/09/25, and did not include the facility census as required. During an interview at the time of observation, a CNA confirmed that the information had not been updated for the current day and that the scheduler, who was responsible for updating the posting, was on vacation. The CNA also verified that the census number was missing from the displayed information. This deficiency was identified incidentally during a complaint investigation and had the potential to affect all 75 residents in the facility.
Inadequate Investigation of Narcotic Diversion and Resident Altercation
Penalty
Summary
The facility failed to conduct thorough investigations regarding the diversion of narcotics and a resident-to-resident altercation, affecting three residents. In the first incident, two oxycodone tablets were missing from a resident's narcotic count. The investigation lacked essential components such as witness statements, a police report, and assessments of the resident involved or other residents on narcotic pain medication. Additionally, there was no evidence of staff education on narcotic counts or misappropriation, and no preventative measures were implemented. In the second incident, a resident-to-resident altercation occurred, where one resident pulled a chair from under another, causing the latter to fall. The investigation into this incident was incomplete, with only one resident witness statement and no assessment of the resident who caused the altercation. There were no interviews or assessments of other residents regarding potential abuse, and no staff education or preventative interventions were documented. The facility's policy on abuse, mistreatment, neglect, and misappropriation of resident property was not followed. The policy requires interviews with all involved parties, obtaining written statements, and documenting evidence of the investigation. It also mandates that the facility's interdisciplinary team determine appropriate interventions and that the quality assurance committee reviews the investigative materials to prevent future incidents. These steps were not adequately executed, leading to the identified deficiencies.
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, seven days a week, as required by regulations. This deficiency had the potential to affect all 80 residents of the facility. On 08/04/24, the staff schedule and the facility's Daily Staffing Sheet revealed that no RN was scheduled for any shift, and only one RN punched in late at night, well after the required hours. Interviews with the Staffing Coordinator and the Director of Nursing (DON) confirmed that no RN was scheduled for the required hours on that day. The DON was not notified of the absence of an RN, and the scheduled RN had called off, resulting in the lack of RN coverage. The facility's policy indicated that staff might be required to work different shifts to maximize staffing, and administrative or third-party agency staff would be used in emergencies, but these measures were not implemented on the day in question.
Inaccurate MDS Coding for Hospice Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for five residents, leading to deficiencies in the documentation of their health conditions. These residents were admitted with various serious diagnoses, including end-stage diseases, and were receiving hospice services. However, their MDS assessments incorrectly indicated that they did not have a life expectancy of less than six months, despite being on hospice care. Resident #5 was admitted with cerebral atherosclerosis and other conditions and was on hospice care from admission. Similarly, Resident #11, with chronic kidney disease and congestive heart failure, was also on hospice care. Both residents' MDS assessments failed to reflect their life expectancy accurately. Resident #51, with Alzheimer's disease, and Resident #71, with Parkinson's disease, were also on hospice care, yet their assessments were incorrectly coded. Resident #73, with a malignant neoplasm, was similarly affected. The MDS Licensed Practical Nurse (LPN) responsible for these assessments was inexperienced and had been instructed by corporate not to code residents as having a life expectancy of less than six months. This instruction led to the incorrect coding of the MDS assessments, as confirmed by the review of the MDS 3.0 Resident Assessment Instrument (RAI) manual, which states that residents receiving hospice services should be coded as having a life expectancy of less than six months.
Failure to Maintain Resident Dignity Due to Persistent Urine Odor
Penalty
Summary
The facility failed to maintain a dignified existence for Resident #36, as evidenced by the persistent strong odor of urine in the resident's room. Resident #36, who was admitted with diagnoses including memory deficit, morbid obesity, hypertensive congestive heart failure, and major depression, was frequently incontinent of urine and bowel. Despite being on a diuretic, Lasix, and receiving incontinence care every two hours, the resident's room continued to have a strong urine odor. This was confirmed through interviews with a Licensed Practical Nurse and a State Tested Nurse Aid, both of whom acknowledged the persistent odor. An observation conducted in Resident #36's room further confirmed the strong urine odor, which was also acknowledged by the resident during an interview. The facility's policy on Resident Rights, revised in June 2015, states that residents have a right to a dignified existence, which was not upheld in this case. This deficiency was investigated under Complaint Number OH00156094, affecting one of the three residents reviewed for dignity in a facility with a census of 80.
Inadequate Assistance and Lapse in Fall Risk Assessment
Penalty
Summary
The facility failed to provide adequate assistance to Resident #37 during ambulation, resulting in a fall. Resident #37, who had a history of falls and was diagnosed with dementia, major depression, and anxiety, required maximum assistance for walking and transfers. Despite this, on the day of the incident, a State Tested Nursing Assistant (STNA) let go of the resident to move a chair obstructing the path to the bathroom, leading to the resident losing balance and falling. The resident was subsequently sent to the emergency room for evaluation, although no fractures were found. Additionally, the facility did not complete fall risk evaluations and assessments quarterly as required. The last fall risk assessment for Resident #37 was conducted over a year before the fall incident, despite the facility's policy mandating such assessments quarterly and after any fall. The Director of Nursing confirmed the lapse in conducting timely fall risk assessments, which contributed to the deficiency in ensuring the resident's safety.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer program, resulting in Immediate Jeopardy and actual harm to Resident #44. This resident, who was at risk for pressure ulcer development and dependent on staff for all activities of daily living, developed a Stage III pressure ulcer on the sacrum. The ulcer progressed from moisture-associated dermatitis to a Stage III pressure ulcer due to inadequate interventions, including poor incontinence care, lack of timely turning and repositioning, and insufficient offloading of pressure. The resident's condition deteriorated, leading to hospitalization for sepsis secondary to the pressure ulcer. Resident #10, who was also at risk for pressure ulcer development, experienced actual harm when the facility failed to provide necessary care and services, resulting in the development and worsening of a Stage III pressure ulcer. The ulcer increased in size and drainage due to the resident not being repositioned timely and per facility policy. There was no documentation of timely incontinence care, turning, repositioning, or showers being completed as per the resident's care plan and preference. Similarly, Resident #72 developed an in-house acquired Stage III pressure ulcer to the sacrum, which worsened due to new damaged skin around the wound. The facility failed to provide timely incontinence care, turning, repositioning, and showers as per the resident's care plan. The lack of proper care and interventions led to the deterioration of the pressure ulcer, affecting the resident's overall condition.
Removal Plan
- Director of Nursing (DON) #804 began staff education for licensed nurses and State tested Nursing Assistants (STNAs) on the need to ensure that all pressure relieving interventions were in place in accordance with the plans of care and that incontinence care, turning and repositioning, and showers/bed baths were implemented timely and in accordance with the plan of care for all residents, including those with wounds.
- All nursing staff were also in-serviced on the need to inform the nurse if wound dressings become soiled with urine or stool so they can be changed.
- Any staff not In-serviced would be in-serviced prior to their next working shift.
- Licensed Practical Nurse/Wound Nurse (LPN/WN) #800 re-assessed the resident's sacral wound and a new order to cleanse with normal saline, apply Santyl nickel thick and cover with bordered gauze was obtained.
- The resident's care plan was reviewed and included interventions of turn and reposition side to side, lay down after meals, and Chamosyn to buttocks after incontinence episodes was initiated.
- All necessary physician orders including medication orders and wound care orders were reviewed to ensure accurately reflected in the care plan.
- LPN/WN #800 initiated review of care plans for all residents who had existing wound, Resident #7, #10, #44, #45, #46, #49, #58, #61, #65 and #72.
- LPN/WN #800 again reviewed all necessary physician orders for Resident #44 and the facility implemented a plan to review these orders daily to ensure they were accurately reflected in the resident's care plan.
- The resident was also scheduled to see the wound care physician.
- Director of Nursing (DON) #804 began in-service with all licensed nurses on the need to ensure the physician was timely notified of all wound changes, treatments were implemented in accordance with orders, and all orders for cultures and labs were obtained timely and orders for antibiotics were implemented timely.
- Any staff not educated would be educated prior to their next working shift.
- Licensed Practical Nurse/Wound Nurse (LPN/WN) #800, LPN #801, LPN #802, and LPN #803 completed skin sweeps and new Braden Scales on all facility residents. No new pressure ulcers or infections were identified.
- All resident care plans would be reviewed to ensure appropriate preventative interventions were in place and appropriate treatments were in place if appropriate.
- DON #804 posted the STAT phone number for the lab at all nurse's stations to ensure staff had access and were calling the correct number when STAT labs need to be drawn, and in-serviced all nurses on the number as well as the need to contact the DON or Administrator if the lab cannot be reached.
- LPN/WN #800 checked all culture containers (urine and swabs) and discarded all expired items and contacted the lab to request non-expired culture containers be provided.
- LPN/WN #800 would then check culture containers monthly and discard expired containers.
- DON #804 in-serviced all licensed nurses on the process for monthly checking of culture containers for expired containers and on the need to check all containers, including swabs for expiration prior to use.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON #804, LPN/WN #800, and Medical Director (MD) #900 to review the plan.
- The meeting included a discussion of skin issues identified with the skin/wound CQI report.
- The facility implemented a plan for LPN/WN or designee to complete observations of at least five random residents per day for four weeks to ensure pressure relieving interventions were being implemented in accordance with the plan of care, including offloading, incontinence care provided timely, and showers completed in accordance with the plan of care and shower schedule.
- The observation/audits would include residents with and without wounds. All audits would be reviewed by the QAPI committee.
- The facility implemented a plan for LPN/WN or designee to complete observations/audits of at least three residents with wounds per day to ensure wound treatments were being implemented as ordered, dressings were changed if soiled, and new orders for labs or cultures are implemented timely.
- The audits/observations would be completed for four weeks, and all audits would be reviewed by the QAPI committee.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to maintain sufficient nursing services staff to meet the total care needs of residents according to their plan of care. This deficiency affected six residents and had the potential to affect all 78 residents residing in the facility. The facility's staffing plan indicated that licensed nurses and State tested Nursing Assistants (STNA) should provide a range of 3.28 to 4.78 hours of direct resident care per resident per day. However, during the periods reviewed, the facility did not meet these minimum staffing requirements, providing only 2.95 to 3.65 hours of care per resident per day. Interviews with staff revealed that the facility was short-staffed, leading to inadequate care for residents. STNAs reported being unable to complete showers, provide timely incontinence care, or reposition residents as needed. The facility had eliminated the shower aide position, further burdening the STNAs with additional responsibilities. The Director of Nursing (DON) acknowledged the staffing concerns and had begun some staff education, but more training was needed. Specific resident cases highlighted the impact of insufficient staffing. For example, a resident with cerebral palsy and a pressure ulcer did not receive timely incontinence care or showers, contributing to the development of a pressure ulcer. Another resident, who preferred bed baths, reported that staff did not assist him unless he attempted to wash himself. Several residents confirmed they did not receive showers according to their schedules or preferences, and documentation of care was lacking, with missing shower sheets for multiple residents.
Resource Mismanagement and Environmental Deficiencies in LTC Facility
Penalty
Summary
The facility administration failed to manage resources effectively, impacting the wellbeing of all 78 residents. The interim Administrator and the new Director of Nursing (DON) were both recently appointed, with the Administrator starting on 06/28/24 and the DON on 06/21/24. The facility was found to be understaffed, with State Tested Nursing Assistants (STNAs) and licensed nurses providing fewer hours of direct care per resident per day than outlined in the Facility Assessment. Interviews with staff revealed that the lack of staffing led to residents not receiving showers, timely incontinence care, or being turned and repositioned as needed. The facility also struggled with a persistent bed bug infestation. Despite multiple chemical treatments, bed bugs were still present in several rooms, and residents reported being bitten. The exterminator confirmed that the facility had not followed recommended procedures, such as heat treatment and treating adjacent rooms, which are necessary to eradicate bed bugs effectively. The facility's approach was limited to chemical treatments, which were insufficient to address the infestation. Additionally, the physical environment of the facility was not maintained adequately. Observations revealed holes in the walls of residents' rooms, which had not been repaired despite being known to the Environmental Director and Maintenance Director. Residents reported these issues, but they were not documented in the maintenance log, indicating a lack of attention to maintaining a safe and comfortable environment for residents.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents received showers according to their schedules or preferences, affecting six residents out of the six reviewed. The facility's census was 78. The deficiency was identified through observations, medical record reviews, shower schedule reviews, facility policy reviews, and interviews with staff and residents. The facility's policy, last revised in December 2013, stated that residents should receive baths or showers according to their preferences, which was not adhered to. Resident #4, who had intact cognition and required partial assistance for personal hygiene and showers, preferred bed baths over showers. However, the facility could only provide evidence of one bed bath over a two-month period. Resident #10, with impaired cognition and requiring substantial assistance for showers, reported not having had a shower in a long time, and no shower sheets were available for the requested period. Resident #32, who was severely cognitively impaired and dependent on staff for all ADLs, had only one shower sheet available for the two-month period. Resident #44, who was severely cognitively impaired and dependent on staff for all ADLs, had only four shower sheets available for the requested period. An observation revealed a strong odor of urine, indicating inadequate bathing. Resident #72, with severely impaired cognition and dependent on staff for all ADLs, had no shower sheets available for the requested period. Resident #79, with intact cognition and requiring partial assistance for showers, confirmed not receiving showers per schedule or preference, with only four shower sheets available. Interviews with staff revealed that the facility had eliminated shower aides, leading to inadequate showering for residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain the physical environment in a safe and homelike condition for two residents, as evidenced by the presence of holes in the walls of their rooms. Resident #1, who has a history of hypertensive urgency, chronic kidney disease, and other health issues, was admitted to the facility with slight cognitive impairment and required varying levels of assistance with daily activities. Resident #79, diagnosed with multiple sclerosis and other conditions, had intact cognition but required significant assistance with personal care. Observations revealed holes in the walls behind the headboards in both residents' rooms, which were confirmed by the Environmental Director and Maintenance Director, who acknowledged the issue but had not yet addressed it. Interviews with both residents confirmed their awareness and concern about the holes, with Resident #1 expressing that the holes were bothersome and had been reported to staff without resolution. Resident #79 also reported the issue to the administration team, but no action had been taken. A review of the maintenance log from May to July did not document any mention of the holes, indicating a lack of formal acknowledgment or action to repair the damage. This deficiency was investigated under Complaint Number OH00154346.
Ineffective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program for bed bugs, affecting one resident directly and potentially impacting the entire resident population. Resident #4, who had intact cognition and required partial assistance for some activities, was prescribed hydrocortisone cream for itching caused by bed bug bites. Despite multiple chemical treatments by an exterminator, bed bugs were observed in several rooms, including those previously occupied by Resident #4. Interviews with residents and staff confirmed the presence of bed bugs and indicated that the facility's pest control measures were insufficient. The exterminator noted that the facility opted for chemical treatments rather than the recommended heat treatments, which are necessary to eradicate bed bugs effectively. The facility's approach was limited to treating only the infested rooms, rather than adjacent areas, which contributed to the persistence of the infestation. The deficiency was investigated under multiple complaint numbers, highlighting the ongoing nature of the issue.
Sanitary Deficiencies in Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect 80 residents who receive food from the kitchen. During a tour of the kitchen, it was observed that the floor in the dry storage area had built-up dirt and debris underneath the shelves. Additionally, there were opened and unlabeled bags of macaroni and a container of cornstarch with a pan stored inside it for scooping. The three-sink sanitation station contained expired Hydrion test strips, and the standup refrigerator had opened and unlabeled food items, including a half brick of queso cheese and beverages belonging to staff. The Dietary Manager verified these findings during the tour. Further observations revealed that a dietary aide with a full beard was preparing coffee without a beard cover, which could lead to contamination. The facility's policies on food storage and uniform dress code were reviewed, indicating that scoops should not be stored in food containers and leftover food should be labeled and dated. The dress code policy also required staff to wear hair nets and beard covers. These deficiencies indicate a failure to adhere to professional standards for food storage, preparation, and sanitation.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices for several residents requiring enhanced barrier precautions (EBP) and one resident requiring blood glucose monitoring. Observations revealed that multiple residents with indwelling urinary catheters and wounds did not have EBP signage or personal protective equipment (PPE) available at their room entrances. Staff members, including an activity director, a state-tested nursing assistant (STNA), and a housekeeper, were unsure of the specific precautions needed and confirmed the absence of necessary signage and PPE. The infection preventionist also confirmed the lack of EBP implementation for any resident in the facility. Additionally, a licensed practical nurse (LPN) failed to follow proper procedures for blood glucose monitoring. The LPN was observed carrying a blood glucose meter (BGM) with a used test strip out of a resident's room and placing it on top of a medication cart without cleaning or disinfecting it. The LPN admitted to being unaware of specific cleaning processes for the BGM and confirmed that disinfecting wipes were not available on the medication cart. The Director of Nursing (DON) confirmed that BGMs should be cleaned between every resident use. The report highlights deficiencies in infection control practices, including the lack of EBP signage and PPE for residents with indwelling catheters and wounds, as well as improper cleaning and disinfection of BGMs. These deficiencies were observed and confirmed through interviews with various staff members, including the infection preventionist and the DON, who acknowledged the lapses in protocol and the need for proper infection control measures.
Medication Misappropriation by RN
Penalty
Summary
The facility failed to ensure that resident medications were not misappropriated, affecting two current residents and two former residents. The issue was primarily related to the actions of RN #438, who was suspected of diverting controlled substances, specifically oxycodone and morphine. The facility's investigation revealed that RN #438 frequently documented the wasting of oxycodone tablets without proper witnessing, and there were instances of forged signatures on controlled substance logs. Despite these discrepancies, the facility could not find evidence that residents went without their pain medications, although one resident reported receiving a pill that did not look like their usual medication. Resident #20, who had multiple diagnoses including heart failure and COPD, had orders for oxycodone to manage pain. The medication administration records showed that the resident received oxycodone daily, but RN #438 documented wasting the medication multiple times without proper witnessing. Similarly, Resident #33, who had chronic kidney disease and COPD, also had orders for oxycodone and lorazepam. The controlled drug records showed that RN #438 documented wasting these medications on several occasions without proper witnessing, and there were no progress notes indicating that the medications needed to be wasted. Former Residents #234 and #332 were also affected. FR #234 had orders for Percocet and was noted to have had the medication wasted by RN #438 without proper witnessing. FR #332 had orders for morphine sulfate, and a discrepancy was noted in the morphine count at the time of discharge. The facility's investigation revealed that the morphine was missing, and there was no follow-up by the previous Director of Nursing. The facility's policies on controlled substances and reporting abuse were not adequately followed, leading to these deficiencies.
Failure to Report Medication Misappropriation
Penalty
Summary
The facility failed to file a Self-Reported Incident (SRI) report related to allegations of misappropriation of medications affecting four residents. The facility's internal investigation revealed that a Registered Nurse (RN) was suspected of drug diversion, specifically wasting oxycodone tablets and morphine sulfate oral solution. Despite these findings, the facility did not report the incidents to the Ohio Department of Health (ODH) as required by their policy, which mandates immediate reporting within 24 hours and a final report within five working days. Resident #20 had multiple diagnoses, including heart failure and chronic obstructive pulmonary disease (COPD), and was prescribed oxycodone for pain management. The RN documented wasting oxycodone tablets on multiple occasions. The facility's Administrator confirmed that concerns about drug diversion were reported on 04/11/24, but no SRI was filed because they believed the resident did not go without needed doses of medication. Similar issues were found with Resident #33, who also had multiple diagnoses and was prescribed oxycodone. The RN documented wasting oxycodone tablets frequently, and the facility did not file an SRI despite internal concerns and an incident report filed with the local police and the Ohio Board of Nursing. Former Residents #234 and #332 also had issues with medication misappropriation. FR #234 was prescribed Percocet for pain, and the RN documented wasting tablets. The facility did not file an SRI, believing the resident did not go without needed medication. FR #332 had a discrepancy in the morphine sulfate oral solution count upon discharge, which was reported to the facility's Administrator. Despite these findings, no SRI was filed with ODH. The facility's policy on abuse investigations clearly states that an SRI should be submitted within 24 hours, but this was not followed in these cases.
Failure to Ensure Clinical Appropriateness of Self-Administered Medications
Penalty
Summary
The facility failed to ensure that a resident's right to self-administer medications was clinically appropriate. Resident #78, who had intact cognition and a history of asthma, was found to have an albuterol inhaler at his bedside, which he used without informing the nursing staff. The resident confirmed that he self-administered the inhaler as needed for shortness of breath but did not communicate this to the nurses. The medical record review revealed no documentation of albuterol administration, and there was no assessment titled Medication Self-Administration Safety Assessment for the resident. The facility's policy required an interdisciplinary team to determine the clinical appropriateness of self-administration and to secure the medication properly in the resident's room, which was not followed in this case. Interviews with the resident, an LPN, and the Director of Nursing (DON) confirmed that the resident self-administered the medication without proper assessment or documentation. The DON acknowledged that any resident wishing to self-administer medications should be assessed for safety and appropriateness, and this assessment should be documented in the resident's medical record. However, a facility-generated report indicated that no residents were currently approved to self-administer medications, highlighting a discrepancy between policy and practice. The facility's failure to conduct the necessary assessments and ensure proper documentation led to this deficiency.
Failure to Timely Change Nasal Cannula Oxygen Tubing
Penalty
Summary
The facility failed to change the nasal cannula oxygen tubing for Resident #39 in a timely manner. Resident #39, who has significant diagnoses including chronic obstructive pulmonary disease and heart failure, was observed using oxygen at two liters per minute via nasal cannula with tubing dated 04/13/24, despite the facility's policy requiring weekly changes. This deficiency was confirmed by an LPN who verified the date on the tubing and acknowledged that it should have been changed weekly. The facility's policy, dated 11/2015, mandates that oxygen masks, nasal cannulas, and aerosol setups be changed every week.
Failure to Honor Resident's Advanced Directives
Penalty
Summary
The facility failed to honor the advanced directives of Resident #78, who had intact cognition and was independent with personal care. Despite the resident's clear verbal and written instructions to change his code status from full code to Do Not Resuscitate Comfort Care (DNRCC), the facility's records and staff continued to list him as a full code. This discrepancy was confirmed through multiple interviews with the resident, a licensed practical nurse (LPN), the Social Services Designee (SSD), and the Administrator. The resident had signed a DNRCC form, but it was undated and not properly reflected in the electronic medical record or care plan. The facility's Advanced Care Planning Policy, dated 2013, mandates that residents' goals and advanced care planning preferences be documented and communicated with the care team. However, this policy was not followed in the case of Resident #78. The SSD and Administrator both verified that the DNRCC form was signed by the physician, yet the resident's orders still listed him as a full code. This failure to update and honor the resident's advanced directives represents a significant lapse in compliance with the facility's own policies and procedures.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to develop and implement policies and procedures to include checking references of three employees to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. This deficiency was identified during a review of personnel files for three staff members: two Licensed Practical Nurses (LPNs) and one Social Service Designee (SSD). The personnel files for these employees, hired between April and July 2024, contained no reference checks. The Payroll Coordinator verified the absence of reference checks for these employees. The facility's policy on Screening/Background Investigations, which was undated, stated that the Staff Development Coordinator or another designated person would conduct employment background checks, reference checks, and criminal conviction checks on applicants, but this was not followed in these cases.
Failure to Provide Medical Records to Resident's Representative
Penalty
Summary
The facility failed to provide copies of the medical record to Resident #8's representative. Resident #8 had medical diagnoses including cerebral atherosclerosis, chronic obstructive pulmonary disease, generalized anxiety disorder, and vascular dementia. The resident's daughter, listed as the only emergency contact, made a verbal request to the Administrator for dental records. The Administrator denied the request, citing HIPAA concerns due to the dental services being provided by a third party. Despite reading the results of the dental visit to the representative, the Administrator maintained that the facility does not provide third-party medical records such as lab work, imaging, or wound care. The facility's policy on medical records requests and the Authorization for Release of Specialized Privileged Information document indicated that various types of medical records, including lab work and imaging, could be requested. However, the Administrator was unable to explain why the facility's medical record copy prices chart included costs for imaging results if such records were not provided. This inconsistency and the failure to process the request for dental records led to the deficiency, affecting one resident out of the 89 in the facility census.
Failure to Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident with severe cognitive impairment and hallucinations. The resident alleged she had been raped, but the investigation was inconclusive. The facility did not conduct a skin assessment on the resident, did not interview other residents or staff members, and did not send the resident to the hospital for a rape test. The facility's policy required a thorough investigation, including interviews and record reviews, which were not fully completed in this case. The Administrator and Director of Nursing confirmed that no skin assessments were conducted and no like residents or staff members were interviewed. The Administrator also decided against sending the resident to the hospital for further examination, citing the resident's confusion and potential harm. The facility's policy mandates a comprehensive investigation for all allegations of abuse, which was not adhered to in this instance, leading to a deficiency in the facility's response to the alleged sexual abuse.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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