Concord Care Center Of Toledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 3121 Glanzman Rd, Toledo, Ohio 43614
- CMS Provider Number
- 365030
- Inspections on file
- 41
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Concord Care Center Of Toledo during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and well-maintained environment for multiple residents. One shared room had a large, visibly substandard ceiling repair from a prior water leak directly over a bed, along with additional wall damage, while the resident who used that bed typically remained there most of the day. A shared bathroom for four residents had water-stained doors, a broken light switch plate, a baseboard heater pulling away from the wall, and an unknown hardened material around the heater. In the same room and at two nurse stations, baseboard heaters and ceiling vents had heavy dust buildup, including dust drooping from a ceiling vent. The administrator and CNAs confirmed these conditions, which did not align with the facility’s policy for a safe, clean, and homelike environment.
Surveyors found that the facility did not maintain a pest-free environment, with cockroaches, unidentified bugs, fruit flies, and house flies observed in resident shower and bathroom areas. Staff confirmed ongoing pest issues, water leaks, and water damage that contributed to the infestation, and a resident reported being bothered by the bugs.
The facility failed to notify a physician about two residents not receiving their prescribed antipsychotic medication, Clozapine, as ordered. Both residents had complex medical histories, including schizophrenia and bipolar disorder, and missed several doses over a three-month period. The lack of medication administration was due to an incomplete Patient Services Form, and there was no documentation of physician notification regarding these missed doses.
Two residents in the facility did not receive their prescribed doses of Clozapine, an antipsychotic medication, due to issues such as medication being on back order and a mix-up in the REMS system. This led to one resident experiencing altered mental status and requiring emergency room evaluation. The facility failed to notify the physician about the missed doses, violating their medication administration policies.
Two residents in the facility did not receive their physician-ordered doses of Clozapine due to issues with the REMS system, pharmacy delays, and disorganization within the facility. Despite recorded deliveries, the medication was not administered as prescribed, affecting residents with complex medical histories.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 8.11%. Errors included administering an expired multivitamin, incorrect dosage of Lamictal, and omission of dorzolamide eye drops due to unavailability. The resident involved had intact cognition and was diagnosed with major depressive disorder and alcohol-induced dementia. The errors were observed during a medication administration session by an RN, who confirmed the mistakes and reordered the missing medication.
The facility failed to provide adequate behavioral health training for staff, necessary for caring for residents with mental and psychosocial disorders, including trauma and PTSD. Only one in-service session on de-escalation tips was conducted in the past year, which did not meet regulatory requirements. Several staff members did not receive any behavioral health training during orientation, and there were four self-reported incidents involving staff-to-resident interactions in the past six months. Staff expressed concerns about safety due to insufficient training.
A resident was subjected to physical and verbal abuse by CNAs in an LTC facility. The resident, who was cognitively intact, was pushed by a CNA, resulting in a fall and injuries. Another CNA verbally threatened the resident after a confrontation. The facility's policy on abuse was not upheld, and the incidents were not immediately reported.
A facility failed to timely report a verbal abuse incident where a CNA threatened a resident. The incident was not reported until three days later when a housekeeper discovered an audio recording. The resident was cognitively intact and had a complex medical history. The facility's policy requires immediate reporting of abuse, which was not followed.
The facility failed to maintain a safe and sanitary environment, affecting 30 residents on the first floor. Observations included mold-like substances, broken fixtures, and unsanitary conditions in various rooms and restrooms. Staff interviews confirmed awareness of these issues, which persisted despite the facility's policy for a homelike environment.
The facility failed to maintain a pest-free environment on the first floor, affecting 30 residents. Surveyors observed gnats and ants in various areas, confirmed by a CNA. Pest control documentation showed no evidence of addressing these issues, despite the facility's policy emphasizing the importance of pest control for resident safety.
The facility failed to maintain a clean and safe smoking area, affecting 40 residents who smoke. Observations revealed flammable booths with cigarette butts, improperly disposed cigarette waste, and trash around the area. A CNA confirmed these findings, indicating non-compliance with the facility's smoking policy, which requires staff supervision and safety measures. This issue represents continued non-compliance from a previous survey.
The facility failed to maintain a clean and safe environment, affecting eight residents and potentially all 77 residents. Observations included missing ceiling light covers, stained tiles, pulled carpeting, and dust accumulation. Exposed wires and holes in walls and ceilings were noted, along with missing bathroom fixtures. Shower rooms had foul odors and cracked tiles. The facility's policies emphasized the need for a clean environment, but these standards were not met.
A facility failed to maintain smoking safety when an STNA left seven residents unsupervised in a courtyard while they smoked. The STNA facilitated the smoking session but returned inside due to cold weather, leaving the residents unattended for about ten minutes. The facility's policy requires supervision during smoking, which was not adhered to, leading to a deficiency under Complaint Number OH00158800.
The facility failed to maintain a medication error rate below five percent, resulting in a 7.41 percent error rate. An LPN administered incorrect dosages of guaifenesin and fluticasone propionate to a resident, contrary to the physician's orders. Both the LPN and the resident were unaware of the correct dosages.
The facility failed to convey funds timely upon a resident's death and did not notify several residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. This affected six residents, with balances ranging from $1,830.36 to $3,772.96, and was confirmed by the Business Office Manager.
The facility failed to obtain written authorizations from residents or their representatives to open Resident Trust accounts, affecting three residents. The Business Office Manager confirmed the absence of written consents, despite the facility's policy requiring such authorization.
A resident with type II diabetes mellitus received the wrong type of insulin and at the wrong time. The LPN administered Novolog insulin instead of the prescribed Lispro insulin after the resident had already eaten breakfast. The facility's policy on safe and timely medication administration was not followed.
The facility failed to ensure medications were stored, labeled, and kept secure, affecting five residents. One resident accessed the medication storage room to assist an LPN, and an RN prepared medications for multiple residents simultaneously, violating facility policies.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, and adequately maintained environment for multiple residents. In one shared room, the ceiling above a resident’s bed had an approximately four-by-three-foot area of visibly substandard plaster repair from an apparent prior water leak, with unsanded spackling and partially painted areas, and additional water damage repairs on the outside wall. The administrator confirmed the poor-quality ceiling repair, and a CNA reported that one of the residents preferred to remain in bed under this area most of the day except for meals. In another shared bathroom used by four residents, surveyors observed water stains six to eight inches from the bottom of the door, a broken light switch plate, a baseboard heater detaching from the wall, and an unknown hardened sand-like material around and under the heater. A CNA confirmed that this bathroom was in disrepair. Further observations showed that the facility did not ensure a clean environment in resident rooms and common areas. In the same room with the ceiling repair, the baseboard heating vent had visible buildup of what appeared to be dust. At two nurse stations, ceiling vents had a thick layer of dust, with dust at one station drooping off the vent, and the baseboard heating vent at that station was coated inside and out with a thick layer of dust. The administrator verified these environmental and cleanliness issues. Review of the facility’s “Homelike Environment” policy, dated February 2021, showed that residents were to be provided a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting; however, the observed conditions did not meet these policy expectations.
Failure to Maintain Pest-Free Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of cockroaches, unidentified bugs, fruit flies, and house flies in resident areas. Observations and staff interviews confirmed that the 100-hall shower room had a leaking toilet with towels placed around its base to contain water, which attracted bugs that were seen crawling from under the towel. The Housekeeping Supervisor acknowledged awareness of the pest issue, particularly in the 100-hall, and confirmed the presence of cockroaches and other pests. Additionally, a bathroom shared by four residents was found to have several fruit flies around the unsealed base of the toilet, on the ceiling, and near water pipes, with water damage to the ceiling contributing to the problem. Housekeeping staff confirmed the ongoing presence of these pests, and a resident reported being bothered by bugs in the bathroom. Further observations revealed that the water-damaged ceiling in the shared bathroom had hanging drywall paper and discoloration, and house flies were seen on a resident's clothing. The facility's pest control policy recognized the importance of pest and vermin control for resident health and safety, but the observed conditions demonstrated a failure to implement effective pest control measures. The deficiency had the potential to affect multiple residents who used the affected shower room and shared bathroom.
Failure to Notify Physician of Missed Antipsychotic Medication Doses
Penalty
Summary
The facility failed to notify a physician about residents not receiving their prescribed antipsychotic medication, Clozapine, as ordered. This deficiency affected two residents, both of whom had complex medical histories including schizophrenia and bipolar disorder. Resident #36 was admitted with multiple diagnoses and had a physician's order for Clozapine 100 mg to be administered twice daily. However, the resident did not receive the medication on several occasions in November 2024, December 2024, and January 2025. The lack of medication administration was linked to an incomplete Patient Services Form in the Clozapine Risk Evaluation and Mitigation system, which prevented the pharmacy from dispensing the medication. Despite this, there was no documentation indicating that the physician was notified of these missed doses. Similarly, Resident #53, who also had a complex medical history including paranoid schizophrenia and psychosis, did not receive the prescribed doses of Clozapine on multiple occasions across November 2024, December 2024, and January 2025. The facility's records showed no evidence of physician notification regarding these missed doses. Interviews with the Regional Director of Clinical Services confirmed the medication was not administered as ordered and that there was no documentation of physician notification for either resident.
Failure to Administer Antipsychotic Medications as Prescribed
Penalty
Summary
The facility failed to ensure the mental health needs of two residents were met due to the improper administration of antipsychotic medications. Resident #36, diagnosed with schizophrenia and other conditions, did not receive her prescribed doses of Clozapine on multiple occasions across November 2024, December 2024, and January 2025. The lack of administration was due to issues such as the medication being on back order, not being available, or due to a mix-up in the Clozapine Risk Evaluation and Mitigation Strategy (REMS) system. This resulted in Resident #36 experiencing altered mental status and being sent to the emergency room for evaluation, where it was determined that her condition was due to not receiving her medications. Resident #53, with a diagnosis including paranoid schizophrenia and other conditions, also did not receive his prescribed doses of Clozapine on several occasions in November 2024, December 2024, and January 2025. The reasons for the missed doses included the medication not being available or on order. There was no documentation indicating that the facility notified the physician about the missed doses for both residents, which is a critical oversight in managing their care. The facility's policies on administering medications and handling medication errors were not adhered to, as evidenced by the lack of timely administration and physician notification. Interviews with staff, including the Regional Director of Nursing Compliance and the Director of Nursing, confirmed the deficiencies in medication administration and communication. The failure to administer medications as prescribed and to notify the physician of missed doses contributed to the deterioration of the residents' mental health conditions.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed, affecting two residents. Resident #36, who had multiple diagnoses including schizophrenia and bipolar disorder, did not receive her prescribed doses of Clozapine 100 mg on several occasions across November 2024, December 2024, and January 2025. The issues stemmed from a mix-up in the Clozapine Risk Evaluation and Mitigation Strategy (REMS) system, which prevented the pharmacy from dispensing the medication. Additionally, there were delays and back orders from the pharmacy, leading to missed doses. Resident #53, with a history of cognitive and emotional deficits, also experienced missed doses of Clozapine 100 mg and 200 mg during the same period. The facility's records indicated that the medication was not available on multiple occasions, and there were delays in receiving the medication from the pharmacy. Despite deliveries being recorded, the resident did not receive the medication as ordered, leading to further missed doses. Interviews with the Regional Director of Clinical Services confirmed the missed doses for both residents and highlighted disorganization within the facility due to changes in key staff positions, including the Director of Nursing and psychiatry provider. The facility's policy on administering medications, which mandates timely and safe administration, was not adhered to, resulting in this deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 8.11% during the observation period. This deficiency was identified through the observation of medication administration for three residents, with three errors specifically affecting one resident. The errors included the administration of an expired multivitamin, the failure to administer the correct dosage of Lamictal, and the omission of dorzolamide hydrochloride eye drops due to unavailability. The resident involved had intact cognition and was diagnosed with major depressive disorder and alcohol-induced dementia. The errors were observed during a medication administration session conducted by a registered nurse. The nurse confirmed the administration of an expired multivitamin and acknowledged the failure to administer the correct dosage of Lamictal, as only one tablet was given instead of the prescribed two. Additionally, the dorzolamide eye drops were not administered because they had not been reordered, which the nurse addressed by placing a refill order after the observation. The facility's policy on administering medications, which requires checking expiration dates and adhering to physician orders, was not followed, contributing to the identified deficiencies.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide adequate behavioral health training to its staff, which is necessary for caring for residents with mental and psychosocial disorders, including those with a history of trauma and PTSD. The facility's assessment indicated a need for staff competency in these areas, yet the only training provided in the past year was a single in-service session on de-escalation tips, which did not meet regulatory requirements. This session was attended by 25 employees, seven of whom are no longer employed at the facility. Additionally, a review of employee files revealed that several staff members, including CNAs, LPNs, and administrative personnel, did not receive any behavioral health training during their orientation. The deficiency was further highlighted by the fact that in the past six months, there were four self-reported incidents involving staff-to-resident interactions. Interviews with staff members, including CNAs and the Director of Nursing, confirmed the lack of adequate training, with some staff expressing concerns about their safety due to insufficient behavioral health training. The facility is currently working on establishing a crisis prevention and de-escalation/intervention training program, but as of the time of the report, no such program was in place.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by staff members. Resident #39, who was cognitively intact with a BIMS score of 15, was involved in an incident where a Certified Nursing Assistant (CNA) pushed him, causing him to fall. This incident occurred after Resident #39 was banging on the door of an employee restroom occupied by the CNA. Upon exiting the restroom, the CNA pushed the resident when he forcibly approached her, resulting in the resident falling and sustaining a skin tear on his left shin and a reddened face. The cause of these injuries was inconclusive, but it was suggested that they might have occurred when the resident was rolling on the floor or hitting the sink in his room. In addition to the physical abuse, verbal abuse was also reported. Another CNA threatened Resident #39 by stating, "if you spit on me, I will kick your [explicit term] teeth in," after the resident threatened to spit on her. This statement was verified by the CNA in a written statement. The facility's policy on resident abuse, neglect, and mistreatment emphasizes the right of residents to be free from verbal, sexual, physical, or mental abuse, yet this policy was not upheld in these instances. The incidents were not immediately reported to the facility, and the facility only became aware of the verbal abuse on November 4, 2024, and the physical abuse thereafter. The CNAs involved had participated in the facility's abuse, neglect, and exploitation training, yet the incidents still occurred. The facility's failure to prevent these incidents represents non-compliance with the standards for protecting residents from abuse.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged verbal abuse incident involving a resident. The incident occurred when a Certified Nursing Assistant (CNA) threatened a resident by stating, "if you spit on me, I will kick your [expletive] teeth in." This incident was not reported immediately as required by the facility's policy. The resident involved was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, and had a complex medical history including schizophrenia, bipolar disorder, and other mental health conditions. The verbal abuse was not reported to the facility until three days after the incident, when a housekeeper discovered an audio recording of the event on her phone. The housekeeper had overheard the incident but did not report it immediately. The facility's policy mandates that any alleged abuse must be reported immediately, but not later than two hours if it involves abuse or results in serious bodily injury. The delay in reporting the incident represents a failure to comply with this policy, affecting the resident involved and potentially impacting other residents in the unit.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff, affecting 30 residents on the first floor. During an environmental tour, several deficiencies were observed, including a blanket used as a curtain in multiple rooms, black mold-like substances in the shower room and resident restrooms, broken radiator covers, peeling paint, missing baseboards, and holes in walls and ceilings. Additionally, there were issues with exposed wires, broken outlet covers, missing soap dispensers, and toilet paper holders, as well as dried feces and unidentified brown substances in restrooms. Interviews with staff revealed that the foul odor in the first-floor shower room was persistent and emitted from the drain, and dried feces had been present in a shared restroom since November. The Regional Director of Operations acknowledged awareness of these environmental issues. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by the continued non-compliance from a previous survey and a complaint investigation.
Pest Control Deficiency on First Floor
Penalty
Summary
The facility failed to maintain a pest-free environment on the first floor, which had the potential to affect 30 residents. During a facility tour, surveyors observed approximately 15-20 gnats in the hallway, kitchen, and resident rooms, as well as ants in the resident restrooms. A Certified Nursing Assistant confirmed these findings. A review of the facility's pest control documentation from August to November revealed no evidence of addressing the issues with gnats and ants. The facility's Pest Control Policy emphasizes the importance of pest control in ensuring a safe living environment for residents.
Smoking Area Safety and Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain the smoking area in a clean and safe manner, potentially affecting 40 residents who smoke. During an observation tour, surveyors noted several safety and cleanliness issues in the smoking area, including four flammable restaurant-style booths with cigarette butts underneath, two metal ashtrays lined with aluminum foil, and a cigarette butt found in the seat of one booth. Additionally, a trash can containing cigarette butts and other trash was located next to the exterior wall of the facility, with more cigarette butts found under the edge of the wall. Leaves and trash were observed around containers holding trash and cigarette butts, and a towel on the ground was found with two cigarette butts nearby. A Certified Nursing Assistant (CNA) present in the smoking area with residents confirmed these findings. The facility's smoking policy, dated July 2023, states that smoking is only permitted during listed times with staff supervision, emphasizing safety. However, the observed conditions indicate non-compliance with this policy, as smoking without staff supervision is prohibited. This deficiency represents continued non-compliance from a previous survey conducted in October 2024.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, directly affecting eight residents and potentially impacting all 77 residents. Observations revealed several issues, including a missing ceiling light cover, stained and bowing ceiling tiles, and carpeting pulled away from the wall. There were dark brown streaks and black discoloration on furniture, stained carpeting, and spider webs and dust hanging from the ceiling. Additionally, a thick layer of dust was found on hallway vents, handrails, and fire alarm boxes. Missing ceiling tiles exposed wires and metal framing, and there were holes in the ceiling and walls in residents' rooms, with exposed and capped wires. Further issues included a missing toilet bowl tank cover, a bathroom door missing, and broken wall plates exposing wires. Three shower rooms had a foul musty urine odor, missing and cracked tiles, and a black substance on the tile and grout. The Housekeeping Supervisor and Maintenance Director verified these findings. The facility's policy on Resident Rights emphasized the right to a safe and clean environment, and the Facility Assessment stated that physical resources should meet residents' health and safety needs. The Daily Housekeeping Checklist required daily cleaning of resident rooms, bathrooms, and hallways, with specific attention to spots, stains, and dust removal.
Unsupervised Smoking Session in Courtyard
Penalty
Summary
The facility failed to ensure smoking safety was maintained for seven residents who were observed smoking in a fenced courtyard without supervision. On the morning of 10/28/24, a State tested Nursing Assistant (STNA) facilitated the smoking session by opening an exterior door, allowing the residents to enter the courtyard, handing each a cigarette, and lighting them. The STNA then returned inside the building, leaving the residents unsupervised while they smoked. This unsupervised smoking session lasted approximately ten minutes. Interviews conducted with the STNA and the Administrator confirmed that the residents were left unattended during the smoking session. The STNA admitted to leaving the residents unsupervised due to the cold weather. The facility's smoking policy, dated July 2023, mandates that residents must be supervised at all times during smoking, with no independent smokers allowed. The policy also specifies that smoking is only permitted during designated times and under direct staff observation. This incident represents a violation of the facility's smoking policy and was investigated under Complaint Number OH00158800.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 7.41 percent error rate. This was based on the observation of medication administration, staff interviews, record reviews, and policy reviews. Specifically, during an observation, an LPN administered 800 mg of guaifenesin to a resident instead of the prescribed 1,200 mg. Additionally, the same resident self-administered two sprays of fluticasone propionate in each nostril under the supervision of the LPN, contrary to the physician's order of one spray per nostril. Both the LPN and the resident were unaware of the correct dosage as per the prescriber's order. The deficiency was identified during a survey, which included a review of the facility's policy on administering medications. The policy, last revised in April 2019, stated that medications should be administered in accordance with prescriber orders. The facility census at the time was 76, and the error affected one of the three residents observed for medication administration. The deficiency was investigated under Complaint Number OH00153921.
Failure to Convey Resident Funds and Notify of Account Balances
Penalty
Summary
The facility failed to ensure timely conveyance of funds upon the death of a resident and did not notify several residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. Specifically, Resident #100 expired in the facility and had a balance of ninety-three dollars and thirty-six cents in their personal funds account, which was not conveyed to social security within the required 30 days. This was confirmed by the Business Office Manager during an interview. Additionally, five other residents had balances nearing or exceeding the state-allowed limit, but there was no evidence that spend down notifications were issued to them or their representatives as required. These residents had balances ranging from $1,830.36 to $3,772.96, and the lack of notification was verified by the Business Office Manager during interviews. The deficiency affected six of ten residents reviewed for funds conveyance and notices, with the facility census being 80. The Business Office Manager confirmed during interviews that there was no evidence of spend down notifications being sent to the residents or their representatives. This non-compliance was investigated under Complaint Number OH00152252, highlighting the facility's failure to adhere to regulatory requirements regarding resident funds management and notification procedures.
Failure to Obtain Written Authorization for Resident Trust Accounts
Penalty
Summary
The facility failed to obtain written authorizations from residents or their representatives to open Resident Trust accounts. This deficiency affected three residents, who had trust accounts with transactions recorded but no written consent on file. Specifically, Resident #3 had a trust account with a balance of $0.34, Resident #37 had a trust account with a balance of $0.36, and Resident #74 had a trust account with a balance of $228.72. In each case, the Business Office Manager confirmed that no written authorizations were available to show that the residents had authorized the facility to manage their trust accounts. The facility's policy requires written authorization from the resident or their representative before managing personal funds. However, the review of the medical records and quarterly statements for the three residents revealed that this policy was not followed. The deficiency was identified during an interview with the Business Office Manager and a review of the facility's admission packet and Resident Funds Policy and Procedure, which clearly state the need for written authorization to manage residents' personal funds.
Medication Administration Error
Penalty
Summary
The facility failed to ensure medications were administered to residents without significant medication errors. Specifically, Resident #77, who has type II diabetes mellitus and moderate cognitive impairment, was observed receiving the wrong type of insulin. The physician's order specified that Resident #77 should receive insulin Lispro before meals and at bedtime, but the Licensed Practical Nurse (LPN) administered Novolog insulin instead. Additionally, the insulin was administered after the resident had already eaten breakfast, contrary to the prescribed timing of administration before meals. The LPN acknowledged the error during an interview, stating that she was behind schedule and could not administer the insulin before the resident ate. The Director of Nursing confirmed that Novolog insulin is not the same as Lispro insulin and verified that the resident should have received Lispro insulin as ordered. The facility's policy on administering medications emphasizes that medications must be administered safely, timely, and as prescribed, which was not followed in this instance.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored, labeled, and kept secure at all times, affecting five residents. One incident involved a resident who was cognitively intact and admitted with schizoaffective disorder and bipolar disease. This resident entered the medication storage room and removed an orange medication box at the request of an LPN, which was against facility policy. The Assistant Director of Nursing and the Director of Nursing both confirmed that residents should not have access to the medication storage room. Observations revealed that the orange medication tote was unlocked and contained various stock medications, violating the facility's policy that only authorized personnel should have access to the medication room and its keys. Another incident involved improper medication administration practices by an RN. The RN prepared medications for two residents simultaneously, placing labeled medication cups on top of the medication cart and then transferring them to a bin in the cart's top drawer. This practice was observed during medication administration to two unidentified residents in the dining room, where medications were prepared ahead of time. The Assistant Director of Nursing confirmed that medications should be prepared and administered one resident at a time to prevent potential medication errors. The facility's policy mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in these instances.
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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