Continuing Healthcare At Willow Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in Zanesville, Ohio.
- Location
- 1020 Taylor Street, Zanesville, Ohio 43701
- CMS Provider Number
- 366244
- Inspections on file
- 41
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 52
Citation history
Health deficiencies cited at Continuing Healthcare At Willow Haven during CMS and state inspections, most recent first.
Multiple shower rooms had malfunctioning equipment and inappropriate water temperatures, with some rooms lacking hot water and others having leaking pipes and missing fixtures. A CNA confirmed that residents requested to use other halls due to these issues, and the Maintenance Director acknowledged that repairs were delayed and water temperatures were not routinely checked. These deficiencies had the potential to affect a significant number of residents.
A resident with intact cognition and multiple chronic conditions reported a missing Apple watch, but the facility did not complete a thorough investigation as required by policy. Key investigative steps were missed, including contacting hospital staff, following up with off-site laundry, using the locator app, and interviewing other residents or documenting police involvement.
Two residents experienced discrepancies in the documentation of controlled substance administration, including missing entries on the MAR and incomplete narcotic count sheets. Staff confirmed that records for opioid medications did not consistently reflect administration times, amounts received, or required signatures, resulting in incomplete and inaccurate medical records.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
The facility did not provide eight consecutive hours of RN coverage per day on multiple occasions, as confirmed by payroll records, staffing schedules, and interviews with the DON and ADON. The shortage of RNs, especially on weekends, limited the facility's ability to accept residents with higher acuity needs such as central lines or frequent IV therapy. Staffing decisions were based on budget rather than a formal policy, and recruitment efforts had not filled the necessary RN positions.
Multiple lapses in kitchen sanitation and food safety were observed, including improper use of hairnets by staff, a malfunctioning and leaking refrigerator contaminating beverages, heavy grease and dust buildup on kitchen equipment, and inadequate sanitizer concentration. Exposed electrical wires were also found under the dishwashing station. These deficiencies had the potential to impact all residents receiving food from the kitchen.
The facility did not maintain a clean and homelike environment, with observations of unclean rooms, sticky floors, overflowing trash, and stained curtains. During a meal, a pest control worker sprayed chemicals and handled traps in the dining area while residents ate, and entered the kitchen without a hairnet. Several rooms had maintenance issues such as leaking, moldy air conditioners and broken furniture. Staff and residents reported frequent shortages of essential supplies and linens, with staff confirming that rooms often lacked gloves, towels, and other necessary items, especially after a laundry fire disrupted operations.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Surveyors found that staff failed to consistently implement enhanced barrier precautions and proper infection control practices, including missing PPE signage, lack of EBP orders, and improper use of PPE during care for residents with indwelling devices and wounds. In addition, perineal care was not performed according to best practices due to insufficient policy detail and staff training, and infection control lapses were observed during wound care and handling of soiled linens.
A resident with multiple medical conditions, including dementia and muscle weakness, did not receive required therapy or restorative services for range of motion and ambulation after being discharged from hospice. Despite care plan interventions and the resident's expressed desire to walk, there was no evidence of therapy screening or maintenance programs, and staff confirmed the absence of regular therapy assessments, leading to a decline in the resident's ability to perform ADLs.
Two residents reported their mail was opened by facility staff without consent, violating their right to receive unopened mail. Despite having consent agreements on file, both residents denied giving permission. The facility's corporate office instructed staff to open mail from insurance companies or ODJFS, leading to this breach of privacy.
A resident with Alzheimer's and other conditions had their rollator walker, dentures, and glasses go missing after a hospital transfer. The facility's administrator attempted to contact the hospital but received no response, and no further follow-up was conducted. This failure to resolve the concern violated the facility's policy on resident rights, as noted during a complaint investigation.
A facility failed to provide comprehensive transfer information for a resident who had Alzheimer's, diabetes, and other conditions. The Transfer Form omitted the resident's son as the power-of-attorney, which was confirmed by the Administrator.
A facility failed to coordinate care for a resident by not scheduling a gynecology appointment as ordered for post-menopausal bleeding. Despite having intact cognition and multiple health diagnoses, the resident's referral was not made between the order date and a subsequent review. An interview confirmed the oversight, affecting one of three residents reviewed for appointments.
A resident's grievance about missing upper dentures was not addressed promptly by the facility, leading to a deficiency. The resident, admitted with both upper and lower dentures, reported the upper dentures missing, but the facility delayed scheduling a dental appointment and resolving the issue. The corporate office eventually agreed to cover half the replacement cost, but the resident was not informed, leading to frustration. The facility's policy on handling resident concerns was not effectively followed, resulting in a prolonged resolution process.
A resident with a history of abdominal wall infections experienced complications due to inadequate wound vac management and failure to implement a physician's order for a CT scan and surgical referral. The resident's wound vac leaked, leading to increased drainage and infection signs, resulting in hospitalization and surgical intervention. Staff interviews revealed a lack of training in wound vac management, and the facility's policy to notify physicians of wound changes was not followed.
The facility failed to maintain a safe and comfortable environment during a heat advisory, affecting several residents. The main AC units were non-functional, leading to discomfort in common areas despite the use of portable AC units and fans. Additionally, mold was found in shower rooms on two halls, with inadequate signage and cleaning efforts. Maintenance logs lacked documentation of these issues, indicating a failure in reporting and compliance with facility policies.
The facility failed to maintain a safe environment for 14 cognitively impaired residents who were independently mobile. Large portable air conditioning units and various fans were used in hallways due to non-functional main AC units. The fans posed hazards as their blades were accessible, cords were unsecured, and equipment blocked handrails. The facility lacked a policy on accident hazards.
Deficient Shower Room Maintenance and Inadequate Water Temperatures
Penalty
Summary
The facility failed to maintain safe and functional shower room environments, resulting in inappropriate water temperatures and malfunctioning equipment across multiple units. Observations and interviews revealed that the 200-hall shower room had a faulty valve and leaking pipes, with water dripping into a glove placed over the pipes. The shower room was not operational, leading residents to request showers in other halls. The 400-hall shower room had no hot water at the sink, and the water temperature in both the 400 and 500-hall shower rooms was consistently cold, measured at 101°F and 102°F, which was verified as not appropriate for resident bathing. Additionally, the 200-hall shower room had a missing exhaust fan cover and water-stained ceiling light cover. Maintenance records showed that parts had been ordered to address the issues, but repairs had not been completed due to competing maintenance demands. The Maintenance Director confirmed that water temperatures were not being routinely checked in the shower rooms. These deficiencies had the potential to affect 56 residents residing on Units 200, 300, 400, and 500, out of a total facility census of 76.
Failure to Thoroughly Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation involving a resident who reported a missing Apple watch. The resident, who had intact cognition and multiple medical diagnoses including COPD, anxiety disorder, and chronic respiratory failure, reported the watch missing after returning from a hospital stay. The resident's personal inventory at admission did not list the Apple watch, and staff acknowledged that inventories were not always updated when residents received new items. Multiple employees confirmed seeing the watch in the resident's room prior to the report, and the resident had a locator app on her phone to track the device. However, there was no documentation that the locator app was effectively used, and the missing item was not recorded in the facility's missing items log. The facility's investigation lacked several critical steps as outlined in their abuse policy. There was no evidence of communication with hospital staff to determine if the watch was left there, nor was there documentation of contact with the off-site laundry service beyond an initial message, with no follow-up recorded. Additionally, there was no documentation of interviews with other residents on the same unit to determine if they had knowledge of the missing watch or had experienced similar issues. The facility also did not document any police involvement or statements from other potentially affected residents, as required by their own investigative protocols.
Incomplete and Inaccurate Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete regarding the administration of controlled substances for two residents. For one resident with multiple diagnoses including diabetes, COPD, and chronic kidney disease, there was a discrepancy between the Individual Patient Controlled Substance Administration Record and the Medication Administration Record (MAR) for Hydrocodone-Acetaminophen. The controlled drug record indicated the medication was administered at a specific time, but the MAR did not reflect this administration. This discrepancy was confirmed during an observation of the medication cart and through interviews with facility staff. For another resident with a history of hemiplegia, diabetes, and chronic pain, the MAR showed that Oxycodone was administered at bedtime, but the narcotic count sheet marked this dose as an error, suggesting it was not given. Additionally, two narcotic sheets for this resident lacked critical information such as the date and amount of narcotic received, amount sent, and the signature of the person receiving the medication. These omissions were verified by staff interviews and were not in accordance with the facility's policy for controlled medication storage and accountability.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of registered nurse (RN) coverage per day, as required, which had the potential to affect all 68 residents. Payroll-Based Journal records for the second quarter of 2025, along with staffing schedules from January through July 2025, showed multiple dates where there was no RN coverage for the required consecutive hours. The facility assessment tool indicated an average daily census of 69 to 78 residents, and the staffing plan was based on resident needs, but the facility did not meet the RN coverage requirement on numerous specific dates. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the lack of RN coverage on these dates and verified ongoing shortages, particularly on weekends. The DON stated that the facility had only one RN on nights, two PRN RNs, and a wound nurse who was on medical leave. The facility was unable to accept residents with central lines, TPN, or orders for IV therapy more than twice a day due to the lack of available RNs or IV-trained LPNs. The DON and Administrator confirmed that there was no staffing policy in place and that staffing decisions were based on the facility's budget. Efforts to recruit RNs included job postings and participation in job fairs, but these had not resulted in sufficient hires to meet the required RN coverage.
Failure to Maintain Safe and Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, as evidenced by multiple observations during meal preparation and service. Staff were observed not following proper food safety and hygiene protocols, including a dietary staff member whose hairnet did not fully cover her hair while serving food, and a pest control employee entering the kitchen without a hat or hairnet. The reach-in refrigerator was found to be malfunctioning, with water leaking onto beverages prepared for meal service, and the thermometer inside was not working. Staff confirmed that the refrigerator had been leaking for several weeks and that the thermometer was not functional. Additionally, the stove and kitchen hood had heavy grease and dust buildup, with food debris present along gas pipes, outlets, and serving carts, all of which were verified by staff at the time of observation. Further deficiencies included improper sanitizer concentration in a red bucket used for cleaning, which tested below the required level according to posted guidelines. Exposed electrical wires with only wire nuts for protection were found under the dishwashing station, though staff stated these wires were not in use. Facility policies required food contact and non-food contact surfaces, equipment, and utensils to be kept clean and sanitized, and for thermometers to be maintained in working order, but these standards were not met. These failures had the potential to affect all 68 residents who received food from the kitchen.
Failure to Maintain Clean, Homelike Environment and Adequate Supplies
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several resident rooms were found to be unclean, with sticky floors, overflowing trash, stained privacy curtains, and bathrooms with stained caulking. Housekeeping logs indicated that some rooms had not been cleaned or had their floors mopped or trash emptied for several days, particularly over weekends when only one housekeeper was on duty. The Housekeeping Manager confirmed that staffing shortages on weekends prevented all rooms from being cleaned as required. During a lunch meal in the main dining room, a pest control employee was observed spraying chemicals and handling glue traps in the presence of residents eating their meals. The pest control employee also entered the kitchen without a hairnet during meal service. The chemical used, PT Fendona Pressurized Insecticide, has aspiration hazards and should be kept away from food and drink, according to its safety data sheet. The Regional Culinary Manager verified that it was inappropriate to spray pest chemicals during meal service and that the pest control employee was not following proper hygiene protocols. Multiple resident rooms had maintenance issues, such as leaking and moldy air conditioning units, broken headboards, scraped and dirty walls, and floors that were dull, dirty, or covered in debris. Residents and family members reported that maintenance requests, such as mounting a television or fixing air conditioning units, were not addressed in a timely manner. Additionally, the facility consistently lacked adequate supplies and linens, including gloves in appropriate sizes, wet wipes, tissues, towels, and washcloths. Staff interviews confirmed that they frequently ran out of these essential items, impacting their ability to provide proper care. The facility's laundry operations were disrupted due to a fire, resulting in further shortages of clean linens, and the par level for washcloths was insufficient to meet the needs of incontinent residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) and proper infection control practices during resident care, as evidenced by multiple observations and interviews. For several residents with indwelling medical devices such as gastrostomy tubes and urinary catheters, there was a lack of EBP signage, absence of personal protective equipment (PPE) outside rooms, and missing physician orders for EBP. Staff were observed providing care without appropriate PPE, and some were unaware of the requirements for EBP during high-contact activities, such as dressing changes and hygiene care. In one instance, a sign was incorrectly placed above the wrong bed, and a PPE basket was missing due to being broken and not replaced. During incontinence care, staff did not follow proper perineal cleansing techniques. One CNA was observed not cleansing the inner labia as required, and both the skills checklist and facility policy lacked specific instructions on how to perform perineal care. The Director of Nursing confirmed that the policy and competency documents did not provide detailed guidance, and staff training was insufficient in this area. This resulted in incomplete hygiene practices for residents requiring incontinence care. Additionally, improper infection control practices were observed during wound care for a resident with multiple wounds, including a Stage III pressure ulcer. Staff used the same gloves for different tasks, such as cleansing the perineal area and then handling the wound and clean supplies, which could lead to cross-contamination. Dirty linens were also left on the floor instead of being properly bagged. These lapses in infection prevention and control affected multiple residents and were confirmed through interviews, observations, and policy reviews.
Failure to Maintain Resident's ADL Abilities Due to Lack of Therapy and Restorative Services
Penalty
Summary
The facility failed to ensure that a resident maintained the ability to perform activities of daily living (ADLs), including range of motion (ROM) and ambulation, without a documented medical reason for decline. The resident, who had diagnoses including heart failure, unspecified dementia, muscle weakness, and cognitive communication deficit, was discharged from hospice but did not receive therapy or restorative services for ROM or ambulation in the months following discharge. Medical record review showed no evidence of therapy screens or restorative programs in 2024 or 2025, except for a single therapy screen after the resident slid out of her wheelchair. The resident's care plan noted impaired mobility and encouraged participation in ADLs, but there was no documentation of ongoing therapy or maintenance programs to support ambulation or ROM. Observations and interviews revealed that the resident expressed a desire to walk again and reported not receiving recent therapy or ROM services. Staff interviews confirmed that the resident had not been screened by therapy since hospice discharge, and that quarterly therapy screens, which were standard practice, had not been completed. The Rehab Manager acknowledged the lack of recent ROM assessment and services, and certified nurse aides reported only seeing the resident self-transfer or take steps during toileting, with no independent ambulation observed in the room or hallway. The lack of regular therapy screening and absence of restorative or maintenance programs contributed to the resident's decline in ADL performance.
Violation of Residents' Mail Privacy
Penalty
Summary
The facility failed to ensure residents had their mail delivered unopened, affecting two residents. Resident #19, who was cognitively intact and had no communication issues, reported that his mail from the Ohio Department of Jobs and Family Service (ODJFS) was opened by facility staff without his consent. Although the facility claimed he had signed a Mail and Package Consent Agreement, Resident #19 denied ever giving such consent and revoked any perceived consent after the incident. The facility's process for obtaining consent was unclear, and the resident was not aware of signing any electronic form. Resident #69, who was also cognitively intact, experienced similar issues with her mail being opened. She reported that her insurance card and another letter, mistaken for junk mail, were opened by the facility. Despite having a Mail and Package Consent Agreement on file, she denied giving consent for her mail to be opened and expressed dissatisfaction with the situation. The receptionist acknowledged the mistake and apologized, indicating the mail was opened accidentally. Interviews with facility staff revealed that the corporate office instructed them to open mail from insurance companies or ODJFS for Medicaid recipients. The facility's Administrator confirmed this practice and acknowledged the violation of residents' rights to receive unopened mail. The facility's Welcome Packet included a copy of the Resident's Rights, which stated that residents have the right to receive unopened mail, yet the facility's actions contradicted this policy.
Failure to Resolve Missing Resident Property
Penalty
Summary
The facility failed to ensure the timely resolution of a concern regarding missing resident property, specifically affecting a resident with moderately impaired cognition due to Alzheimer's disease and other medical conditions. The resident, who had been admitted with a rollator walker, dentures, and glasses, was transferred to a hospital and upon return, these items were missing. The resident's power-of-attorney filed a concern about the missing items, but the facility's efforts to resolve the issue were inadequate. The facility's administrator made an attempt to contact the inpatient psychiatric hospital where the resident had been transferred, but no response was received. Interviews with the Social Services Designee and the Administrator confirmed that the last attempt to resolve the concern was made shortly after the resident's return, with no further follow-up. The facility's policy on resident rights emphasizes the right to retain personal possessions, but this was not upheld in this instance, leading to the deficiency being noted during a complaint investigation.
Failure to Provide Accurate Transfer Information
Penalty
Summary
The facility failed to ensure comprehensive resident information was provided to the receiving facility during a transfer, affecting one resident reviewed for death. The resident, who had diagnoses including Alzheimer's disease, diabetes mellitus, anxiety disorder, depression, and a personal history of malignant neoplasm, was admitted to the facility and later expired there. A review of the resident's Transfer Form revealed that the facility did not include accurate information regarding the resident's representative, specifically omitting the resident's son, who was the power-of-attorney (POA)/resident representative. This omission was confirmed during an interview with the Administrator.
Failure to Schedule Gynecology Appointment for Resident
Penalty
Summary
The facility failed to ensure coordination of care for a resident related to a gynecology appointment to address medical symptoms in a timely manner. The resident, who had diagnoses including multiple sclerosis, anxiety disorder, chronic kidney disease stage four, and chronic diastolic heart failure, was noted to have intact cognition. A progress note dated 10/23/24 indicated a new order for a referral to gynecology for post-menopausal bleeding, and a physician order dated 10/24/24 confirmed the referral. However, a review of the resident's medical record from 10/23/24 to 11/11/24 revealed no evidence that the referral had been made. An interview with the Administrator on 12/17/24 confirmed that an appointment with gynecology had not been scheduled as ordered by the physician. This deficiency affected one resident out of three reviewed for appointments, with the facility census being 76 at the time. The incident was identified during a closed record review, facility investigation, and staff interview, highlighting a lapse in the coordination of care for the resident.
Delayed Resolution of Missing Dentures Grievance
Penalty
Summary
The facility failed to address a resident's grievance regarding missing upper dentures in a timely manner, leading to a deficiency. The resident, who was admitted with both upper and lower dentures, reported the upper dentures missing on October 1, 2024. Despite the resident being cognitively intact and able to communicate effectively, the facility did not resolve the issue promptly. The dentures were reportedly missing since the resident's move from the 400 hall to the 100 hall in August 2024, and the resident had repeatedly informed staff about the missing dentures. The facility's investigation into the missing dentures was delayed, with a dental appointment scheduled over a month after the initial report. The cost of replacement dentures was not covered by the resident's insurance, and the facility's corporate office was involved in discussions about covering the cost. The corporate office eventually agreed to pay half the cost, but this decision was not communicated to the resident, who was frustrated with the delay and lack of resolution. The resident's son, who was not initially aware of the missing dentures, believed the facility should cover the full cost of replacement since the dentures were lost while under the facility's care. Interviews with staff revealed that the resident's dentures were initially stored in an emesis basin rather than a denture cup, which may have contributed to their loss. The facility's policy on handling resident concerns was not followed effectively, as the investigation and resolution process took several months without a satisfactory outcome for the resident. The deficiency was identified during a complaint investigation, highlighting the facility's failure to ensure the resident's grievance was addressed promptly and appropriately.
Failure in Wound Vac Management and Physician Order Implementation
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and knowledgeable in the use of Negative-Pressure Wound Therapy (NPWT) and did not implement a physician's order for a CT scan and surgical referral for a resident showing signs of an infected abdominal wound. This deficiency affected a resident with a history of abdominal wall infections, who displayed possible signs of infection in an abdominal wound. The wound physician ordered a CT scan and a referral to a surgeon, but the facility did not make these referrals as ordered. The resident experienced complications related to the use of a wound vac, and a nurse failed to adequately intervene or notify the wound physician of these complications. The resident's wound vac began to leak, and the drainage increased throughout the night, saturating the area around the abdominal wound. By morning, the wound area became red, hard, and warm to the touch, with the resident experiencing mild to severe abdominal pain. The resident was transferred to the hospital, where he was hospitalized and required two separate incisions and drainage procedures to debride the abdominal abscess and remove a foreign body. The hospital's CT scan revealed a retained foreign body, identified as a large white vac sponge, which was likely left from a previous wound vac dressing. Interviews with staff revealed that the facility's nurses were not adequately trained in wound vac management prior to the incident. The facility's policy required notifying the physician when a change in wound condition was noted, but this was not done. The resident's medical record lacked evidence of the CT scan being ordered or the surgeon being contacted for a re-consult. The facility's failure to act on the physician's orders and the lack of proper wound vac management led to the resident's hospitalization and the need for surgical intervention.
Facility Fails to Maintain Safe Environment During Heat Advisory and Mold Issues
Penalty
Summary
The facility failed to maintain a comfortable and safe living environment during an excessive heat advisory, affecting five residents. The main air conditioning units were not functioning properly, leading to the use of portable AC units and fans to cool the common areas. Despite these measures, residents reported discomfort due to high temperatures in the hallways and common areas. Maintenance staff confirmed that the AC units on certain halls had been non-functional for an extended period, and there was a lack of documented temperature monitoring during the heat advisory. Additionally, the facility had issues with mold in the shower rooms on the 100 and 200 halls. The 100 hall shower room had exposed water pipes and mold on broken drywall and tiles, which had not been addressed or tested for black mold. The shower room was supposed to be out of use, but there was no signage indicating this. The 200 hall shower room also had mold, and staff were instructed to clean it with bleach, but the mold persisted. The presence of mold was verified by multiple staff members, and it was noted that residents used the 200 hall shower room. The facility's maintenance logs did not document the AC unit failures or the mold issues in the shower rooms, indicating a lack of proper reporting and documentation. The facility's policy on temperature extremes required specific monitoring and safety measures in case of AC system failure, which were not adequately implemented. This deficiency was investigated under specific complaint numbers, highlighting the facility's non-compliance with maintaining a safe and comfortable environment for residents.
Facility Fails to Maintain Safe Environment Due to Improper Use of Fans
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment, affecting 14 residents identified as cognitively impaired and independent with mobility. During an observation, large portable air conditioning units with dual vent coils were noted in each hallway, along with various types of fans placed on the floor. These fans included three freestanding metal fans, a high-velocity fan, a box fan, and two stand-up cylinder fans. The Environmental Services Director confirmed that the main air conditioning units were not operational, and the fans were used to circulate air. However, the fan blades were accessible through the slats, posing a risk to residents. Further observations revealed that the fans' cords were unsecured, and the placement of air conditioning units and fans, along with other equipment, obstructed access to handrails. Additionally, some fan plugs were not securely inserted into outlets. The Administrator acknowledged these hazards, particularly for cognitively impaired residents who were independently mobile. The facility did not have a policy regarding accident hazards, contributing to the deficiency identified under Complaint Number OH00155031.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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