Continuing Healthcare At Forest Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in St Clairsville, Ohio.
- Location
- 100 Reservoir Road, St Clairsville, Ohio 43950
- CMS Provider Number
- 365696
- Inspections on file
- 24
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Continuing Healthcare At Forest Hill during CMS and state inspections, most recent first.
Staff failed to follow required infection control protocols for residents on airborne/contact/droplet precautions during meal service. An activity assistant entered multiple rooms posted for these precautions without donning an N95 mask, eye protection, gloves, or, in one case, a gown, despite signage directing staff to use full PPE and perform hand hygiene. The assistant did not perform hand hygiene after exiting two rooms and continued handling meal trays and fluids while wearing the same surgical mask. In a subsequent interview, the assistant confirmed not using eye protection in any of the identified COVID rooms, not wearing a gown in one room, and not performing hand hygiene when leaving two rooms, and stated a belief that a surgical mask was sufficient instead of an N95.
Two residents received unnecessary medications due to transcription and antibiotic stewardship failures. One resident with multiple neurologic and psychiatric conditions returned from a neurology visit with written orders to start Elavil at bedtime, but two nurses misread the order and transcribed it as Vistaril on the MAR, resulting in administration of Vistaril for several days even though it was not ordered by the neurologist. Another resident with vascular dementia, severe malnutrition, and CHF was prescribed cephalexin for a UTI after an ER visit; an internal antibiotic assessment documented that the resident did not meet criteria for antibiotic use and that the primary physician advised waiting for urine culture results, yet the antibiotic was continued by an NP, and no urine culture results or ER records were found in the chart. The facility’s Antibiotic Stewardship policy lacked language requiring that antibiotics meet defined criteria for use.
A resident with a history of heart issues was given multiple cardiovascular medications without proper blood pressure monitoring, despite care plan requirements. After receiving the medications, the resident became unresponsive and was found to have low blood pressure and pulse, requiring emergency treatment. The facility lacked protocols for routine vital sign monitoring before administering antihypertensive medications, contributing to the incident.
A resident with cognitive impairment was given another resident's medications, including cardiac and anti-anxiety drugs, after an LPN failed to verify the correct identity before administration. The error led to hypotension, bradycardia, and required hospital admission for observation and IV fluids. The facility's policy requiring verification of the '5 rights' of medication administration was not followed.
A nurse crushed and administered extended release potassium chloride and verapamil tablets to a resident with swallowing difficulties, despite guidelines stating these medications should not be crushed. The nurse also failed to provide a prescribed multivitamin due to its unavailability. These actions resulted in a medication error rate of 10.7% during the observed medication pass.
The facility failed to maintain adequate staffing levels, impacting care for residents, particularly those with dementia. Staff interviews revealed challenges in managing resident behaviors, long wait times, and difficulties in completing rounds. The facility administrator acknowledged the issue and sought approval to increase staffing levels.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies in medical records. A resident's contractures were not documented, another's fall with a major injury was omitted, a third resident's pain management regimen was inaccurately reported, and a fourth resident's UTI was not recorded. Interviews confirmed these inaccuracies, indicating a pattern of incomplete documentation.
The facility failed to follow physician orders for medication administration for a resident with hypertension, leading to inappropriate medication administration despite low blood pressure and pulse readings. Additionally, the facility did not adequately monitor or document skin conditions for two residents, resulting in untreated skin impairments. Another resident experienced significant weight gain without timely intervention or documentation of a cardiology referral. These deficiencies were confirmed through staff interviews and policy reviews.
The facility failed to provide timely care for UTIs and incontinence management. A resident experienced a delay in UTI treatment due to a weekend delay in obtaining a urinalysis. Another resident did not receive all prescribed IV antibiotics, with no documentation or provider notification. A third resident's care plan lacked a toileting program despite incontinence episodes. Additionally, a resident's urinary catheter was improperly managed, and antibiotics were administered without meeting treatment criteria.
The facility failed to ensure appropriate antibiotic use and assessments, affecting several residents. A resident received Keflex and Cefepime without meeting treatment criteria, while another was treated with Macrobid without a conclusive urine culture. Additionally, a resident was prescribed antibiotics for pneumonia without assessment, and another received Cefdinir for a UTI despite not meeting criteria. Lastly, a resident received antibiotics for urosepsis without surveillance upon admission.
The facility failed to ensure that call lights were accessible for several residents, including those with Huntington's disease, cerebral infarction, pneumonia, Alzheimer's dementia, and Creutzfeldt-Jakob disease. Observations revealed call lights on the floor or out of reach, contrary to the facility's policy requiring accessibility. This affected residents' ability to request assistance.
A resident with a preference for bed baths was not provided with the choice, receiving showers instead. Despite being cognitively intact and able to communicate her preferences, the resident was scheduled for showers and not offered the preferred bed baths. Documentation confirmed the lack of bathing on scheduled days, and the DON acknowledged the resident's right to choose the type of bath.
A facility failed to ensure accurate documentation of a resident's advanced directives, resulting in a discrepancy between the resident's code status as a Full Code and a DNR-CCA. Despite the family's request to change the status, the necessary paperwork was not signed, leading to confusion about the resident's actual wishes.
A facility failed to document and convey comprehensive information during multiple hospital transfers of a resident with a complex medical history. Despite having an assessment tool for transfers, staff did not complete it, and there was no policy or procedure in place for such transfers.
A resident with multiple health conditions was discharged to an assisted living facility without a complete discharge summary from the nursing and dietary departments. This deficiency was confirmed by the DON during an interview.
The facility failed to provide adequate hygiene and grooming assistance to three residents, leading to deficiencies in their care. A resident with metabolic encephalopathy and Parkinson's disease was observed unshaven over several days, with no documented evidence of showers offered. Another resident with anxiety disorder and diabetes mellitus did not receive scheduled showers due to a lack of charged batteries for the mechanical lift, resulting in oily hair. A third resident with Creutzfeldt-Jakob disease and dementia had disheveled hair and dirty fingernails, with scheduled showers not completed. Staff confirmed the lack of completed hygiene tasks.
A resident with cognitive and heart conditions experienced a decline in a pressure ulcer on the right heel, which was not timely reported by staff. Initially a stage I ulcer, it deteriorated into a suspected deep tissue injury. The facility's policy required monitoring and reporting changes, but this was not followed, resulting in a deficiency.
The facility failed to implement necessary interventions for two residents to prevent foot drop, contractures, and limited range of motion. Despite therapy recommendations, one resident was observed with a contracted hand and no intervention, while another had a left foot drop and clenched hand without the recommended hand roll. Staff interviews and medical records confirmed the lack of restorative programs and failure to provide range of motion services.
The facility failed to implement fall prevention measures and conduct comprehensive fall investigations for two residents at high risk for falls. One resident experienced multiple falls without proper interventions or assessments, and observations revealed that fall prevention measures were not consistently in place. Another resident was found on the floor with the call light out of reach, despite care plan interventions. The facility did not adhere to its fall policy, contributing to these deficiencies.
A facility failed to monitor weekly weights for a resident with significant weight loss, diagnosed with conditions like Parkinson's and muscle wasting. The resident's weight dropped from 189.4 to 179.2 pounds over a month, with a note indicating a 5% loss due to fluid shifts. Despite being added to a weekly weight list, no weights were recorded until a nurse documented a weight on a later date. The dietary technician could not explain the oversight.
The facility failed to administer oxygen per physician orders and improperly stored CPAP equipment, affecting two residents. One resident received oxygen at a higher rate than prescribed, while another's CPAP mask was found on the floor, contrary to storage guidelines.
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in care. A resident with osteoarthritis did not receive scheduled Tylenol doses, despite reporting constant pain. Another resident with a hip fracture received pain medication without clear guidelines for severe pain, and non-pharmacological interventions were not documented. Nurses confirmed the lack of valid reasons for missed doses and insufficient documentation.
A facility failed to create individualized dementia care plans for a resident with Alzheimer's and dementia, who was receiving antipsychotic medications without documented target behaviors or interventions. Despite staff training, the care plan lacked specific target behaviors, and there was no comprehensive dementia care policy in place.
A pharmacist failed to identify medication irregularities for two residents. One resident had abnormal lab results and was prescribed risperidone without recommendations from the pharmacist. Another resident had multiple PRN morphine orders without clear parameters, which were not addressed by the pharmacist. Interviews confirmed these oversights.
A resident with Alzheimer's and urosepsis had abnormal lab results indicating anemia and vitamin D deficiency. Despite a physician's order for repeat lab work, there was no evidence that the physician or dietitian was notified of these results, nor was the resident receiving a vitamin D supplement. The DON confirmed the physician was not informed.
A resident with Alzheimer's and dementia was administered risperidone without proper consent or documented evaluation of its necessity. The facility failed to provide evidence of a psychologist's assessment or pharmacy recommendations, and the care plan lacked specific target behaviors. Interviews confirmed the absence of an appropriate diagnosis for the medication use, contrary to the facility's policy on antipsychotic medication evaluation.
A resident with a pressure ulcer was not placed in contact isolation despite wound culture results indicating MRSA. The resident, admitted for respite care with multiple health issues, was seen in the ER where cultures revealed Escherichia Coli and MRSA. The facility's IP was unaware of these results, leading to a failure in implementing necessary infection control measures.
A resident with CHF and edema did not receive comprehensive care, as their care plan lacked interventions for leg elevation despite medical recommendations. Observations showed the resident's legs were not elevated, and significant weight gain was not communicated to the provider. The family expressed concerns about the lack of effective interventions, and the facility's weight policy did not address CHF-specific needs.
A resident at high risk for pressure ulcers did not receive a comprehensive prevention program, leading to the development and deterioration of a pressure ulcer. The facility failed to implement timely interventions, and the care plan was not updated promptly, resulting in the ulcer progressing to Stage IV.
A resident with a pressure ulcer was inappropriately treated with antibiotics Clindamycin and Keflex, which were ineffective against the identified organisms Escherichia Coli and MRSA. The facility's infection control log and McGeer Criteria indicated a wound infection, but there was no documented evidence of infection symptoms. The Infection Preventionist was unaware of the culture results, and the facility's antibiotic stewardship policy was not effectively implemented.
Failure to Follow Airborne/Contact/Droplet Precaution Protocols During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to implement required infection control protocols for residents on Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP), specifically airborne/contact/droplet precautions. During lunch delivery, an activity assistant entered a resident’s room that had signage for airborne/contact/droplet precautions wearing only a gown and a surgical mask, without donning an N95 mask, eye protection, or gloves as required by the posted instructions. The signage indicated that before entering the room, staff should cleanse their hands and don a gown, N95 mask, eye protection, and gloves. Upon exiting this room, the activity assistant did not perform hand hygiene and kept the same surgical mask on, then immediately handled meal trays and fluids from the carts. The same activity assistant then entered another resident’s room, also posted for airborne/contact/droplet precautions, without donning any eye protection, gown, or N95 mask, and again did not perform hand hygiene upon exiting while continuing to use the same surgical mask. Later, after being instructed by another staff member, the assistant donned a gown before entering a third room with airborne/contact/droplet precautions signage but still did not wear an N95 mask or eye protection. After leaving this third room, the assistant performed hand hygiene. In an interview, the activity assistant confirmed that eye protection had not been worn in any of the identified COVID rooms, stated that an N95 mask was not used because a surgical mask was believed to be sufficient, and acknowledged not wearing a gown in one room and not performing hand hygiene when exiting two of the rooms.
Unnecessary Medication and Antibiotic Use Due to Transcription Error and Lack of Stewardship Criteria
Penalty
Summary
The deficiency involves failures in medication management that resulted in residents receiving unnecessary or incorrect medications. For one resident with anoxic brain damage, epilepsy, depression, anxiety, insomnia, hypertension, history of methadone poisoning, and migraines, neurology orders from an outside appointment directed an increase in Baclofen, continuation of Keppra, Prozac, and Topamax, and initiation of Elavil at bedtime. Nursing staff transcribed these orders onto the MAR as Vistaril 25 mg at bedtime instead of Elavil, and the resident received Vistaril from mid-December through late December despite the neurologist’s written order specifying Elavil. The DON reported that two nurses reviewed the neurology orders and believed the medication name was Vistaril, leading to the incorrect transcription and administration of a medication not ordered by the neurologist. A second deficiency involved antibiotic use for another resident with vascular dementia, severe protein-calorie malnutrition, and congestive heart failure. After a fall and transfer to the ER for shoulder pain, the resident returned with a diagnosis of UTI and a new prescription for cephalexin 500 mg every eight hours for five days. An antibiotic assessment completed the next day documented that the resident did not meet criteria for antibiotic use and that the primary physician advised waiting for urine culture results. Despite this, the resident was seen by a nurse practitioner two days later and the antibiotic was continued. The facility’s records contained no urine culture results or ER records from the visit, and the facility’s Antibiotic Stewardship policy did not include requirements that antibiotics meet specific criteria for use.
Failure to Monitor Vital Signs Before Administering Cardiovascular Medications Resulted in Harm
Penalty
Summary
A deficiency occurred when a resident with a history of cardiovascular issues, including a prior non-ST elevation myocardial infarction and essential hypertension, was not adequately monitored before administration of multiple cardiovascular medications. The resident's care plan required monitoring of vital signs and holding medications if certain parameters, such as a low pulse, were met. On the evening prior to the incident, the resident's pulse was recorded as 57 beats per minute, leading to the appropriate withholding of Metoprolol as per the medication order. However, blood pressure was not assessed at that time. The following morning, the resident's pulse was 70 beats per minute, but again, blood pressure was not measured prior to administering four cardiovascular medications, including Metoprolol, Isosorbide Mononitrate ER, Amlodipine Besylate, and Lisinopril. The medication order for Metoprolol specified to hold the medication if the pulse was less than 60, but there were no parameters for blood pressure, and no blood pressure reading was taken before administration. Shortly after receiving the medications, the resident became unresponsive, with a significant drop in both pulse and blood pressure. The resident was transported to the emergency room, where she was treated for hypotension with intravenous fluids. Documentation and interviews revealed that the facility did not have protocols in place for routine blood pressure or pulse monitoring for residents receiving blood pressure medications, unless specific parameters were listed in the medication orders. This lack of monitoring and protocol contributed to the adverse event, as the resident experienced actual harm due to the administration of medications without adequate assessment of vital signs.
Significant Medication Error Due to Failure to Identify Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dependent on staff for medication administration, was given medications prescribed for another resident. The medications administered in error included cardiac medications that lower heart rate and blood pressure, an anti-platelet agent, a medication for gout, and an anti-anxiety medication. The error was due to the nurse's failure to properly identify the resident before administering the medications, as confirmed by both the nurse and the facility administrator. The facility's policy required verification of the '5 rights' of medication administration, including ensuring the medication is given to the correct person, but this was not followed. Following the administration of the incorrect medications, the resident experienced a change in condition, including hypotension (low blood pressure), bradycardia (low pulse), and lethargy. The resident was transported to the emergency room, where she was admitted for overnight observation and treated with intravenous fluids. Hospital records confirmed the resident had received multiple medications not prescribed to her, resulting in hypotension and bradycardia throughout her ER stay, which improved with treatment. Medical record review showed that none of the medications given in error were ordered for the resident. The incident was identified before the nurse administered the resident's own medications to another individual. The error was documented in the facility's medication error report, and the nurse involved acknowledged the failure to verify the resident's identity prior to administration. The event affected one of two residents reviewed for medication errors during the survey.
Plan Of Correction
Resident #10 was sent to the ER by the physician on 6/6/25. She returned to the facility on 6/7/25 with no lasting effects of medication error. She was assessed on 6/23/25, 6/30/25, and 7/8/25 by NP since readmit with no ill effects identified. A care conference was held with the family on 6/17/25 with no concerns identified. All residents have the ability to be affected. Therefore, an initial audit was conducted by the DON or designee on 6/6/25 to ensure all residents have appropriate photo identification in the medical record. Any negative findings were addressed immediately. LPN responsible for the error was educated on medication rights to include how to identify a resident on 6/6/25 by the DON. Per policy, a discipline was also issued to the LPN responsible by the DON on 6/6/25 to prevent recurrence. Audits for medication errors were completed by RCS weekly between 6/6/25 and 6/25/25 with no identified errors. All nurses were reeducated by 7/14/25 by the DON or designee on medication pass policy and procedure to include when a nurse is unable to verify resident identification with the medical record picture, they must ask the resident their name and get a response prior to administering the medication. If the resident does not respond, they are to get assistance from other staff members. Medication pass observations of 5 nurses per week for 4 weeks will be conducted by the DON or designee to ensure no significant medication errors occur. Any negative findings will be addressed immediately. The DON is responsible for ongoing compliance. Results of audits will be reviewed at QAPI for adjustments as needed.
Medication Administration Errors: Crushing ER Tablets and Missed Dose
Penalty
Summary
A medication administration deficiency occurred when a nurse crushed and administered extended release (ER) tablets of potassium chloride and verapamil to a resident, contrary to manufacturer guidelines and accepted standards of practice, which specify that ER tablets should not be crushed. The nurse stated that the resident was unable to swallow whole pills and believed the resident also crushed pills at home. However, there was no evidence that the physician had been consulted regarding alternative formulations or the appropriateness of crushing these medications. Additionally, the nurse failed to administer a prescribed multivitamin (PreserVision AREDS) in the morning as ordered, citing unavailability on the medication cart. The facility's medication error rate was calculated at 10.7%, with three errors identified out of 28 opportunities during observation. The errors affected one resident who had a history of swallowing difficulties, as documented in a hospital discharge summary, which recommended crushing pills only if they were crushable. The nurse and another staff member later confirmed that ER tablets are generally not to be crushed, and medication information sources suggested considering liquid alternatives for residents with swallowing difficulties.
Plan Of Correction
Resident #5 was assessed by RCS on 6/26/25 with no ill effects related to medications being crushed or missed vitamin administration. MD was notified with orders to change medications to crushable form and to discontinue the PreserVision AREDS as she was on a multivitamin with minerals on 6/26/25 by the floor nurse. By 7/14/25, all residents with a need for medications to be crushed will be audited by RCS to ensure medications ordered were able to be crushed. Any negative findings will be addressed. An initial audit of all residents' medication administration records will be completed by RCS to ensure medications are administered as ordered. Any negative findings will be addressed. By 7/14/25, LPN #100 was educated by RCS related to crushing medications, forms that cannot be crushed, and administering all medications as ordered. All nurses will be educated by 7/14/25 by the DON or designee on medication administration to include crushing medications, medications that are not crushable, and administering all medications as ordered. Audit of 5 residents per week who require medications to be crushed will be completed weekly for 4 weeks by the DON or designee to ensure medications ordered are allowed to be crushed. Medication pass observations will be conducted by the DON or designee for 5 nurses per week for 4 weeks to ensure proper medication administration. Any negative findings will be addressed immediately. The DON or designee will complete medication pass audits for 5 nurses per week for 4 weeks to ensure all medications are appropriately ordered and administered. The DON will be responsible for ongoing compliance. Results of audits will be reviewed at QAPI for adjustments as needed.
Insufficient Staffing Levels Affect Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels to provide adequate care and services to its residents, as evidenced by a review of the Payroll Based Journal (PBJ) data and staffing schedules. The facility had a one-star staffing rating and low weekend staffing levels during the third quarter of 2024. The facility assessment indicated a minimum staffing level plan of five to ten direct care nurses and seven to fourteen State Tested Nurse Aides (STNA) per day, with a daily average resident census of 71 to 78. However, on several dates, the facility did not meet these minimum staffing levels, with specific instances of low staffing on weekends and weekdays, affecting the care provided to residents. Interviews with staff members, including LPNs and CNAs, revealed that the insufficient staffing levels made it challenging to provide necessary care, especially for residents with dementia who required increased supervision and assistance. Staff reported difficulties in managing resident behaviors, long wait times for residents, and challenges in completing rounds and responding to call lights. The facility administrator acknowledged the insufficient staffing levels and indicated that the facility had requested approval to increase minimum staffing levels to better meet resident needs.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their medical records. Resident #30 was admitted with multiple diagnoses but lacked documentation of contractures, despite physical therapy notes indicating functional limitations due to contractures. Observations and interviews revealed inaccuracies in the MDS regarding the resident's range of motion, which did not reflect the actual condition of the lower extremities. Similarly, Resident #52's MDS did not document a fall with a major injury, despite hospital records confirming a hip fracture following a fall. Interviews confirmed the MDS was inaccurate and required modification. Resident #53's MDS inaccurately reported the absence of a scheduled pain medication regimen, despite the resident receiving a Lidoderm patch daily for pain management. Additionally, Resident #11's MDS assessments failed to document a urinary tract infection (UTI) despite laboratory reports and medication records indicating treatment for a UTI. Interviews with nursing staff confirmed these inaccuracies in the MDS assessments, highlighting a pattern of incomplete and inaccurate documentation for these residents.
Deficiencies in Medication Administration and Skin Condition Monitoring
Penalty
Summary
The facility failed to adhere to physician orders and monitor vital signs appropriately for Resident #3, who was admitted with conditions including hypertension and myocardial infarction. Despite specific physician parameters to withhold certain medications if the resident's systolic blood pressure (SBP) or pulse fell below a set threshold, these medications were administered when the resident's SBP and pulse were below the specified limits. Additionally, the facility did not consistently check the resident's blood pressure before administering the P.M. dose of hydralazine, contrary to the care plan's directives. Resident #43, admitted with pneumonia and hyperlipidemia, experienced a failure in the facility's monitoring and documentation of skin conditions. Despite a baseline care plan indicating a risk for skin alterations, a skin tear with active bleeding was observed, and subsequent skin impairments were noted without any documented treatment or assessment in the medical record. The facility's policy required documentation of wound care, which was not adhered to, as confirmed by interviews with nursing staff. Resident #35 experienced a significant weight gain that went unnoticed by the facility until highlighted by surveyors. The resident, with a history of diabetes and chronic respiratory failure, had a weight increase from 225.9 pounds to 256.2 pounds without any documented intervention or notification to the physician until later. Additionally, there was a lack of documentation and follow-up regarding a cardiology referral, with staff failing to secure an appointment in a timely manner. Resident #15 also suffered from unmonitored skin alterations, with no evidence of assessments or treatment orders for skin conditions on the nose and foot until surveyor intervention. The facility's failure to document and address these issues was confirmed through staff interviews and policy reviews.
Deficiencies in UTI Management and Incontinence Care
Penalty
Summary
The facility failed to provide timely care and services to restore bladder function and treat urinary tract infections (UTIs) for several residents. Resident #3 experienced a delay in obtaining a urinalysis and culture over the weekend, resulting in a delay in treatment for a symptomatic UTI. The urine culture indicated an infection with Escherichia Coli, and treatment was initiated only after the results were received. The Assistant Director of Nursing (ADON) confirmed the delay and was unable to provide a reason for not obtaining the urinalysis over the weekend. Resident #11 did not receive all doses of prescribed intravenous antibiotics for a UTI, as documented in the Medication Administration Record (MAR). The ADON verified that the nursing staff failed to document the administration of the IV antibiotics, and there was no evidence that the provider was notified of the missed doses. This lack of documentation and communication resulted in incomplete treatment for the resident's UTI. Resident #44's care plan lacked a toileting program despite episodes of incontinence, and there was no assessment to identify the type of bladder incontinence or interventions to restore continence. Interviews with staff revealed a lack of awareness and documentation regarding the resident's incontinence and the absence of restorative programs for toileting. Additionally, Resident #52 experienced multiple instances of missed antibiotic doses for UTIs, with no evidence that the provider was notified or that the medication was extended to cover the missed doses. Resident #57's urinary catheter was improperly managed, and the resident was treated with antibiotics without meeting the criteria for treatment, as the urine culture was not recollected.
Inappropriate Antibiotic Use and Assessment Failures
Penalty
Summary
The facility failed to ensure appropriate use of antibiotics and accurate assessments for several residents, leading to unnecessary medication administration. Resident #52 was administered Keflex as a preventative measure after a Foley catheter replacement, despite not meeting the criteria for treatment. Additionally, the resident was given Cefepime for a wound infection, although the culture report indicated it was not effective against the MRSA bacteria present. The Infection Preventionist confirmed that the resident did not meet the criteria for treatment of a UTI, and the antibiotic prescribed was inappropriate for the MRSA infection. Resident #57 was treated with Macrobid for a UTI without a conclusive urine culture, as the initial culture suggested recollection due to multiple bacterial isolates. Despite not meeting the criteria for treatment, the resident was administered antibiotics following a fall, as discussed with the provider. Similarly, Resident #41 was prescribed Flagyl and Cefpodoxime for pneumonia without any antibiotic assessment to determine the appropriateness of these medications. Resident #12 was prescribed Cefdinir for a UTI, although the culture results did not meet the criteria for antibiotic use, as the colony count was below the threshold. Lastly, Resident #48 received Cipro and Metronidazole for urosepsis without any antibiotic surveillance upon admission, as the facility lacked culture information to review. These instances highlight the facility's failure to adhere to its antibiotic stewardship policy, which emphasizes the importance of appropriate antibiotic use and culture review before ordering antibiotics.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were readily accessible, affecting five residents during the initial tour. Resident #47, diagnosed with Huntington's disease, scoliosis, epilepsy, anxiety, and depression, was observed with both call lights on the floor under the bed, despite care plans emphasizing the importance of keeping the call light within reach. Similarly, Resident #3, with cerebral infarction and anxiety disorder, was found with the call light on the floor, out of reach, and was unable to locate it when asked. Resident #43, diagnosed with pneumonia, had the call light looped around a siderail, making it inaccessible while sitting in a recliner chair. Resident #48, with Alzheimer's dementia, was observed with the call light on the floor under a chair, and the resident was unaware of its location. Resident #54, diagnosed with Creutzfeldt-Jakob disease, was also found with the call light on the floor, not within reach. The facility's policy, dated April 2018, requires that call lights be within easy reach of residents when they are in bed or a chair, highlighting a failure to adhere to this policy across multiple instances.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, leading to a deficiency in promoting and facilitating resident self-determination. The resident, who had diagnoses including a left hip fracture, depression, and type two diabetes mellitus, expressed a preference for bed baths over showers. Despite being cognitively intact and able to communicate her preferences, the resident was scheduled for showers on specific days and was not offered the choice of a bed bath as per her preference. Documentation revealed that the resident received a shower on one occasion and was not offered bathing on two other scheduled days. The Director of Nursing confirmed the lack of evidence for bathing being offered on those days and acknowledged the resident's right to choose the type of bath. The resident reported dissatisfaction with the frequency and type of bathing provided, indicating she was bathed less frequently than requested and not according to her preference.
Failure to Ensure Accurate Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurately documented for a resident, leading to a discrepancy in the resident's code status. The medical record review revealed that the resident was admitted with a diagnosis of cerebral infarction, but there was no Advanced Directive form available for review. The Baseline Care Plan and the Nurse Practitioner's History and Physical indicated that the resident was a Full Code, while the electronic medical record and physician orders listed the resident as a DNR-CCA. This inconsistency in documentation created confusion regarding the resident's actual code status. Interviews with the Assistant Director of Nursing (ADON) confirmed that the resident's family had requested a change in the code status to DNR-CCA, but the necessary Ohio Advanced Directive paperwork had not been signed by the physician or family. The ADON stated that until the signed paperwork was in the resident's chart, the resident would be treated as a Full Code. The facility's policy required that all residents without advanced directives be treated as Full Codes, and the advanced directive physician's order in the electronic health record should be the primary source for nurses during a code blue situation. However, the lack of a signed advanced directive form in the resident's medical record led to a failure in accurately reflecting the resident's wishes.
Failure to Document and Convey Required Information During Hospital Transfers
Penalty
Summary
The facility failed to ensure comprehensive information was conveyed to the receiving health care provider and documented in the medical record for a resident who was transferred to the hospital multiple times. The resident, who had a complex medical history including metabolic encephalopathy, urinary tract infection, Parkinson's disease, cognitive communication deficit, attention and concentration deficit, dementia, major depression, anxiety, and benign prostatic hyperplasia, was transferred to the hospital on several occasions. However, there was no documented evidence that all required information, such as physician contact information, resident representative contact information, advanced directives, special instructions, and precautions for ongoing care, was conveyed to the hospital during these transfers. Interviews with a registered nurse confirmed that the facility did not document or convey the necessary information for the hospital transfers. The nurse reported that the facility had an assessment tool or form that staff were supposed to complete with each transfer, but this was not done for the transfers in question. Additionally, it was confirmed that the facility did not have a policy or procedure for transfers, although they claimed to follow the regulation.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident following their discharge. The medical record review and staff interview revealed that a resident, who had been admitted with diagnoses including congestive heart failure, atherosclerotic heart disease, hypertension, and hyperlipidemia, was discharged to an assisted living facility. However, the discharge summary lacked completion by the nursing and dietary departments. This deficiency was confirmed during an interview with the Director of Nursing, who verified that the discharge summary for the resident was not thoroughly completed.
Failure to Provide Adequate Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide adequate hygiene and grooming assistance to three residents, leading to deficiencies in their care. Resident #73, diagnosed with metabolic encephalopathy, Parkinson's disease, and a neurocognitive disorder, required substantial assistance with bathing and personal hygiene. Despite being compliant with care, observations over several days revealed that Resident #73 was unshaven, and there was no documented evidence of showers or baths being offered on specific dates. The Director of Nursing confirmed the lack of documentation for these dates. Resident #29, with diagnoses including anxiety disorder, asthma, and type two diabetes mellitus, was scheduled for showers twice a week. However, records showed no evidence of showers being offered on several dates, and the resident reported not receiving a shower due to a lack of charged batteries for the mechanical lift. Despite being willing to take a shower, the resident's hair appeared oily, and a bed bath was offered but refused. The Director of Nursing could not provide additional information to confirm that showers were given as scheduled. Resident #54, suffering from Creutzfeldt-Jakob disease, diabetes mellitus type-2, and dementia, required substantial assistance with daily living activities. Observations and interviews revealed that Resident #54's scheduled showers were not completed on multiple occasions, resulting in disheveled and oily hair, dirty fingernails, and facial hair. The facility's policy required showers twice a week, with bed baths offered on other days, but there was no evidence of compliance with this policy. Interviews with staff confirmed the lack of completed hygiene tasks as scheduled.
Failure to Timely Identify and Treat Pressure Ulcer Decline
Penalty
Summary
The facility failed to ensure timely identification and adequate treatment of a decline in a pressure ulcer for a resident with cognitive communication deficit, heart failure, and vascular dementia. The resident was admitted with pressure ulcers on both heels, and the care plan included monitoring and reporting any changes in skin status. However, the staff did not report a decline in the condition of the right heel, which was initially a stage I ulcer and later suspected to be a deep tissue injury. Observations revealed that the right heel ulcer had deteriorated, with a scabbed area noted by a CNA and later confirmed by an RN and a wound NP. The facility's policy required documentation of changes in the resident's condition and reporting in accordance with professional standards, but this was not adhered to, leading to the deficiency.
Failure to Implement ROM Interventions for Residents
Penalty
Summary
The facility failed to implement necessary interventions to prevent foot drop, contractures, and limited range of motion for two residents. Resident #30, who was admitted with multiple diagnoses including hemiplegia and hemiparesis, was observed to have a contracted right hand without any intervention in place. Despite therapy recommendations for a foam roll to prevent skin breakdown and contractures, there was no evidence of a range of motion program or use of the recommended device. Interviews with staff confirmed the lack of awareness and implementation of necessary interventions, and documentation showed several instances where passive range of motion was not provided. Resident #59, admitted with a history of cerebral vascular accident and contractures, also did not receive the recommended interventions. Therapy had suggested a hand roll for the left hand, but there was no evidence of its use, and the resident was observed with a left foot drop and a clenched left hand without any intervention. Interviews with staff revealed a lack of restorative programs and failure to notify therapy of the resident's condition, resulting in no range of motion services being provided. Both residents were affected by the facility's failure to implement and document necessary interventions to maintain or improve their range of motion. The lack of communication and follow-through on therapy recommendations contributed to the residents' decline in mobility and positioning, as observed and confirmed by staff interviews and medical record reviews.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention interventions were in place as ordered and did not complete comprehensive fall investigations for two residents. Resident #3, who was admitted with multiple diagnoses including coronary artery disease and cerebral infarction, experienced a fall on 07/03/23, resulting in a bruise to her left eye. Despite being at high risk for falls, there was no evidence of a comprehensive fall investigation following this incident. Additionally, on 10/14/24, Resident #3 fell in the bathroom while attempting to self-transfer, and again, no fall risk assessment was completed post-fall. Observations on 10/21/24 and 10/22/24 revealed that the resident's call light was not within reach, and fall prevention measures such as a floor mat and bathroom door sign were not in place. Resident #54, diagnosed with Creutzfeldt-Jakob disease and dementia, was found on the floor on 01/25/24 with the call bell not within reach. Despite a care plan intervention to ensure the call light was accessible, observations on 10/21/24 showed the call light on the floor, out of the resident's reach. The facility's fall policy, revised in April 2023, mandates proper review of fall risks and implementation of interventions, which were not adhered to in these cases. The facility's failure to implement and maintain fall prevention interventions as ordered, and to conduct thorough fall investigations, directly contributed to the deficiencies observed. Both residents were at high risk for falls, yet the necessary precautions and assessments were not consistently applied, leading to repeated incidents and inadequate supervision to prevent accidents.
Failure to Monitor Weekly Weights for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure that weekly weights were monitored for a resident who experienced significant weight loss. The resident, diagnosed with Parkinson's disease, muscle wasting, neurocognitive disorder, and gastroesophageal reflux disease, had a recorded weight of 189.4 pounds on September 20, 2024, which decreased to 179.2 pounds by October 9 and 10, 2024. A weight change note on October 10, 2024, indicated a significant weight loss of 5% in one month, likely due to fluid shifts from resolving edema, and stated that the resident would be added to the weekly weight list. However, no additional weights were recorded until October 23, 2024, when a registered nurse provided a list of weekly weights showing a weight of 180.4 pounds, which was obtained on that day. The registered dietary technician stated that residents on weekly weights were reviewed every Thursday but could not explain why the resident's lack of weekly weights was not identified or addressed.
Improper Oxygen Administration and CPAP Storage
Penalty
Summary
The facility failed to administer oxygen therapy according to physician orders and did not properly store respiratory equipment, affecting two residents. Resident #15, who was admitted with diagnoses including heart failure and asthma, had an order for oxygen at three liters per minute via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen was set at five liters per minute, contrary to the physician's order. The facility's policy required a physician's order for oxygen use and oversight by licensed nurses, which was not adhered to in this case. Resident #229, admitted with conditions such as sleep apnea and congestive heart failure, had a physician's order for CPAP therapy with two liters of oxygen at bedtime. On one occasion, the CPAP mask was found on the floor under the resident's bed, with no documentation of its use on that day. The mask was not stored properly, as it should have been kept in a bag after use. The facility's staff confirmed the improper storage and handling of the CPAP equipment, which was against the manufacturer's guidelines for cleaning and storage.
Deficiency in Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in care. Resident #29, diagnosed with osteoarthritis and type two diabetes mellitus, had a care plan indicating a risk for pain and an order for Tylenol 650 mg four times a day. However, the medication was not administered at scheduled times on multiple occasions in September 2024, with the rationale being that the resident was sleeping. Despite being cognitively intact and reporting constant pain, the resident did not always receive the prescribed medication. A registered nurse confirmed there was no valid reason for the missed doses. Resident #178, with a left hip fracture and type two diabetes mellitus, had an order for acetaminophen 650 mg every six hours as needed for pain. The resident reported constant pain, frequently interfering with sleep and activities, and rated the worst pain as a ten on a scale of 0-10. An additional order for oxycodone-acetaminophen for severe pain lacked clear guidelines on what constituted severe pain. The October 2024 MAR showed administration of both Tylenol and Percocet for varying pain levels, but there was no documentation of non-pharmacological interventions being attempted before administering medication. A registered nurse verified the lack of parameters and documentation for non-pharmacological interventions.
Failure to Develop Comprehensive Dementia Care Plans
Penalty
Summary
The facility failed to develop individualized comprehensive dementia care plans and policies for a resident diagnosed with dementia. Resident #48, who was admitted with Alzheimer's disease, dementia, and urosepsis, was receiving antipsychotic medications without a documented comprehensive dementia care plan. The admission Minimum Data Set 3.0 assessment indicated moderate impairment in daily decision-making, and the resident was on routine antipsychotic medication. However, there was no documentation of target behaviors or interventions to justify the use of these medications. The care plan for psychotropic medication use related to dementia lacked specific target behavior symptoms and interventions. Despite the electronic Physician Orders indicating the use of risperidone for restlessness, yelling out, and impulsiveness, there were no documented episodes of these behaviors. Interviews with the Director of Nursing and a Registered Nurse confirmed the absence of a dementia care policy and the lack of specific target behaviors in the care plan. The facility did not have a specialized dementia care unit, and although staff received annual training, the care planning for Resident #48 was inadequate.
Pharmacist's Failure to Identify Medication Irregularities
Penalty
Summary
The pharmacist failed to identify irregularities in the medication management of two residents, leading to deficiencies in the drug regimen review process. Resident #48, who was admitted with Alzheimer's disease, dementia, and urosepsis, had abnormal lab results that were not addressed or communicated to the physician. Additionally, the pharmacist did not make any recommendations regarding the use of risperidone, an antipsychotic medication prescribed for dementia and later for restlessness, yelling out, and impulsiveness. These omissions indicate a lack of thorough review and communication by the pharmacist. Resident #3, admitted with coronary artery disease, cerebral infarction, hemiplegia, anxiety disorder, depression, and obsessive-compulsive disorder, had multiple PRN orders for morphine sulfate without clear parameters for administration. Despite the absence of morphine administration and low pain ratings, the pharmacist did not address the appropriateness of the morphine orders or the lack of specific guidelines for its use. Interviews with the Assistant Director of Nursing confirmed that the pharmacy had not identified these irregularities, highlighting a significant oversight in the medication review process.
Failure to Address Abnormal Lab Results
Penalty
Summary
The facility failed to address abnormal laboratory results for a resident, leading to a deficiency in managing the resident's drug regimen. The resident, who was admitted with Alzheimer's disease, dementia, and urosepsis, had abnormal lab values indicating anemia and vitamin D deficiency. Despite a physician's order to repeat lab work, the results showed low red blood cell count, hemoglobin, hematocrit, and vitamin D levels. There was no documented evidence that the physician or dietitian was notified of these abnormal results, nor was there any indication that the resident was receiving a vitamin D supplement. An interview with the Director of Nursing confirmed that the physician was not informed of the abnormal lab results.
Inadequate Indications and Interventions for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving antipsychotic medication had adequate indications for its use and appropriate behavioral interventions. The resident, who was admitted with diagnoses including Alzheimer's disease, dementia, and urosepsis, was receiving risperidone without documented consent or a review of potential risks and benefits. The facility did not have evidence of a psychologist's evaluation since the resident's admission, and there were no pharmacy recommendations regarding the use of risperidone. Additionally, the care plan did not identify specific target behaviors or the appropriateness of the antipsychotic medication use. Interviews with the Director of Nursing and a Registered Nurse confirmed that the resident's care plans lacked specific target behaviors and that there was no appropriate diagnosis for the use of risperidone. The facility's policy on antipsychotic medication use required evaluation for appropriateness and indications for use, which was not adhered to in this case. The policy also mandated re-evaluation of antipsychotic medication at admission and within two weeks, which was not documented for this resident.
Failure to Implement Contact Isolation for Resident with MRSA
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer was placed in contact isolation precautions as indicated by the wound culture results. The resident, who was admitted for respite care with multiple diagnoses including malignant neoplasm of the brain and chronic obstructive pulmonary disease, was seen in the emergency room for hypokalemia and a decubitus ulcer. During the ER visit, cultures were obtained from the ulcer, revealing the presence of Escherichia Coli and Methicillin Resistant Staphylococcus Aureus (MRSA). The results, which indicated the need for contact precautions, were not communicated to the facility's Infection Preventionist (IP). The facility's infection control log and the resident's medical records did not reflect the MRSA diagnosis or the need for isolation precautions. The IP was unaware of the wound culture results from the ER visit and confirmed that the resident was not placed in isolation for MRSA. This oversight led to a failure in implementing necessary infection control measures for the resident, as the wound culture results were not reviewed or acted upon appropriately.
Failure to Provide Comprehensive Care for CHF and Edema
Penalty
Summary
The facility failed to provide comprehensive, resident-centered care for a resident with congestive heart failure (CHF) and edema. The resident, who was admitted with multiple diagnoses including cerebrovascular disease, vascular dementia, Parkinson's Disease, CHF, cardiomegaly, and a cardiac pacemaker, did not have a care plan that included interventions to encourage the elevation of lower extremities, despite physician and nurse practitioner notes recommending this. The resident's care plan only included monitoring and documenting signs of CHF, such as dependent edema and weight gain, but lacked specific instructions for leg elevation. Observations and interviews revealed that the resident's legs and feet were not elevated during multiple checks, and there was no evidence of non-compliance from the resident regarding this intervention. The facility's Director of Nursing (DON) confirmed that the care plan did not include leg elevation and that staff were not comprehensively assessing the resident's edema. Additionally, the facility did not have parameters for weight monitoring specific to CHF, and the resident's significant weight gain was not communicated to the provider. Interviews with the resident's family highlighted ongoing concerns about the resident's edema and the lack of effective interventions. The family had provided a recliner chair to help with leg elevation, but space constraints limited its use. The facility's weight policy did not address CHF-specific needs, and there was no documented evidence of notifying the provider about the resident's weight gain. The resident was eventually seen for a problem visit, where significant edema and weight gain were noted, leading to adjustments in the resident's treatment plan.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident within 30 days of admission. The resident, who was admitted for respite care, had a high risk for pressure ulcers as indicated by a Braden score of 11. Despite this, the baseline plan of care was incomplete, lacking specific interventions for skin integrity. The resident's condition included multiple diagnoses such as malignant neoplasm of the brain, anxiety, and cognitive impairments, which contributed to their vulnerability. Upon admission, the resident's skin was intact, but they were at risk for developing pressure ulcers. The facility did not implement adequate interventions such as a turning/repositioning program or nutritional and hydration interventions to manage skin problems. The resident developed a pressure ulcer on the left buttocks, initially documented as moisture-associated skin damage, which later deteriorated to a Stage IV pressure ulcer. The facility's records showed a lack of timely and appropriate interventions, with significant delays in updating the care plan and implementing necessary treatments. Interviews with facility staff revealed inconsistencies in the documentation and implementation of pressure-relieving interventions. The facility lacked a wound nurse at the time, and there was no documented evidence of pressure-relieving interventions being implemented upon admission. The facility's policy required a Braden Scale risk assessment and preventative measures based on assessed needs, but these were not adequately followed, leading to the resident's pressure ulcer development and deterioration.
Inappropriate Antibiotic Use for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure appropriate antibiotic use for a resident with a pressure ulcer, leading to a deficiency. The resident, who was admitted for respite care with multiple diagnoses including malignant neoplasm of the brain and chronic obstructive pulmonary disease, was seen in the emergency room for hypokalemia and a decubitus ulcer. Cultures taken during the ER visit revealed the presence of Escherichia Coli and Methicillin Resistant Staphylococcus Aureus (MRSA). Despite these results, the resident was discharged back to the facility on antibiotics Clindamycin and Keflex, which were not effective against the identified organisms. The facility's infection control log and McGeer Criteria for Infection Surveillance Checklist indicated the resident met criteria for a wound infection, but there was no documented evidence of heat, swelling, or tenderness in the resident's medical records. The Infection Preventionist was unaware of the culture results and confirmed the antibiotics prescribed were not appropriate for the organisms identified. The facility's policy on antibiotic stewardship was not effectively implemented, as evidenced by the inappropriate antibiotic use and lack of isolation precautions for MRSA.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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