Continuing Healthcare Of Cuyahoga Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Cuyahoga Falls, Ohio.
- Location
- 300 East Bath Road, Cuyahoga Falls, Ohio 44223
- CMS Provider Number
- 365826
- Inspections on file
- 56
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Continuing Healthcare Of Cuyahoga Falls during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its posted lunch menu for all residents receiving meals in the dining room. Instead of the planned corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake, staff served corn dogs, plain mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and omitted bread entirely. The cook reported there was no specific reason for not preparing cheesy potatoes, acknowledged forgetting to serve bread, and stated that pudding was substituted because cake had not been baked, even though cake mix was in stock. The Corporate Dietary Manager was unaware of some of these deviations, despite facility policy requiring that menus be followed and that any substitutions be nutritionally similar and documented.
Surveyors found that the facility failed to maintain sanitary kitchen conditions and safe food handling practices affecting all 63 residents who received meals. Observations included uncovered trash cans, dirty utensil drawers with scoops and ladles lying in a sticky substance, soiled shelves and food carts, and dry storage floors littered with cardboard and paper. Multiple food items in refrigerators and storage, including cereal tubs, prepared foods, lettuce, bacon bits, and red liquids, were unlabeled or undated. Additionally, two five-pound tubes of hamburger were improperly thawed in standing water and later left on the sink, with temperatures measured at 57.8°F and 49.8°F, which the dietary leadership acknowledged were unsafe. These conditions did not align with the facility’s own policies requiring proper labeling, storage, and sanitation in food service.
An LPN failed to maintain a resident’s privacy by entering the resident’s room during medication administration without knocking or waiting for permission. The resident had multiple behavioral health and medical diagnoses, including schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, substance dependence, major depressive disorder, adult failure to thrive, and PTSD. Observation showed the LPN prepared the medication at the hallway cart and then walked directly into the room, and the LPN acknowledged not knocking, contrary to the facility’s written privacy policy requiring staff to knock before entering resident rooms.
A resident with Alzheimer’s disease, severe protein calorie malnutrition, PVD, HTN, depression, CKD, and left eye blindness, who required setup or clean-up assistance for toileting, was found to have a bathroom with two softball-sized holes in the wall under the sink where the baseboard was missing, exposing the interior of the wall. Surveyors observed this damage on multiple occasions, and interviews revealed that the Director of Support Services did not conduct environmental rounds and was unaware of the issue, while the Administrator reported that regular environmental rounds were not performed and that staff relied on informal daily walk-throughs to identify needed repairs.
A resident with intact cognition and multiple comorbidities underwent cataract surgery and was prescribed several ophthalmic drops for post-operative care. The prescriptions were initially sent to the wrong pharmacy, then filled at a hospital pharmacy and personally delivered to the facility. The medications were placed in the wrong med cart, and the nurse on duty was unaware they had arrived. As a result, the ordered eye drops were not started as scheduled, and the resident did not receive any of the prescribed ophthalmic medications until the following day.
Surveyors identified infection control failures when two LPNs handled oral medications with bare hands during medication passes for two residents with multiple chronic conditions, including schizoaffective disorder, CKD, atrial fibrillation, heart failure, and depression, and intended to administer those medications. In a separate incident, a CNA was observed providing care to a resident with COPD, a pulmonary nodule, anxiety, and respiratory failure while a feces-soiled towel and disposable pad lay directly on the floor, contrary to facility policy requiring soiled linens to be bagged or placed in carts at the point of care.
The facility failed to timely notify responsible parties and the county health department of a COVID-19 outbreak and did not implement or document facility-wide outbreak communication and testing. Several cognitively impaired residents on a memory care unit tested positive, but their families were not informed until days later. Staff reported that only two of three nursing units underwent COVID-19 testing, and residents and responsible parties on one unit were not notified of the outbreak. No signage was posted at the main entrance to alert residents or visitors, and interviewed residents were unaware of the outbreak and were not offered masks or other PPE, despite facility policy and CDC guidance requiring prompt outbreak reporting and broad-based testing.
Multiple residents did not receive meals as specified by the dietitian-approved menu, with omissions such as milk and cereal, and some meals not matching the prescribed menu due to staff practices and budget constraints. Staff and dietary management confirmed that unless meal tickets specifically listed certain items, these were not provided, even when required by the menu. Residents affected included those with dementia, malnutrition risk, and other chronic conditions.
A resident with cognitive impairment eloped from a secured unit by escaping through a window that was not properly secured, despite care plans and monitoring protocols. Another resident with dementia was roughly transferred from a wheelchair to bed by a CNA, as captured on video and reported by family, with the transfer not following safe procedures. Additionally, five residents were observed smoking without proper ashtrays or safety equipment, resulting in cigarette butts scattered in the courtyard and unsafe disposal practices, with staff lacking training on smoking safety protocols.
Surveyors identified that the facility did not maintain a medication error rate below 5%, with two errors observed among 28 medications administered. One resident received an incorrect dose of an antidepressant, while another did not receive a prescribed supplement, despite documentation stating otherwise. These errors were confirmed through observation, record review, and staff interviews.
Surveyors found that multiple residents' rooms were not maintained in a safe or sanitary condition, with observations including stained carpets and chairs, dirty toilets, sticky floors, moldy food, and significant dust and debris. Staff confirmed these conditions, and one resident reported not having clean clothes for several days due to a blocked closet. The unsanitary environment was observed in both living and kitchen areas, with infrequent cleaning and improper storage of personal and medical items.
The facility did not provide scheduled therapeutic activities for all residents in the secured memory care unit, resulting in residents spending extended periods with minimal engagement, such as watching television or listening to music. Staff interviews confirmed that the activity calendar was often not followed, and some planned activities were either delayed, substituted, or not conducted. The physical setup of the common area limited social interaction, and some previously used engagement items had been removed. Despite having adequate supplies, the activity program did not meet the physical, mental, and psychosocial needs of the residents.
Surveyors found expired medications, opened wound care supplies, and improperly stored medical items in multiple medication storage rooms and carts. These deficiencies were confirmed with the ADON and DON, and were not in compliance with facility policy requiring removal and destruction of expired or unsecured items.
The facility did not ensure that food was served at safe and appetizing temperatures, as confirmed by a test tray and resident interviews. Multiple residents reported receiving meals that were not warm, and staff interviews revealed delays in tray delivery and a lack of urgency in serving food, resulting in food sitting for extended periods before reaching residents.
Surveyors observed that staff did not consistently follow infection control procedures during care for three residents, including not wearing required PPE during high-contact activities, failing to clean or use barriers on bedside tables before placing supplies, and not performing hand hygiene between glove changes. These actions were not in accordance with the facility’s infection control policies.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent assistance with eating and communication, as required by their care plan. Observations showed the resident struggled to use adaptive utensils, ate with her hands, and lacked access to communication tools, with staff only intervening after surveyor involvement. Staff interviews confirmed the absence of communication aids and inconsistent support with meals.
A resident with multiple diagnoses, including type 2 diabetes, did not receive prescribed blood sugar monitoring using a Dexcom G7 Sensor as ordered. The sensor was not administered on several scheduled dates, and documentation was incomplete or missing in the MAR, with no evidence of further attempts to provide the monitoring. The DON confirmed these findings, which were not in accordance with facility policy.
A resident with severe vision impairment and multiple comorbidities was recommended for cataract evaluation by an eye care consultant. Although staff attempted to find an ophthalmologist who accepted the resident's insurance and could accommodate bariatric needs, no appointment was scheduled, leaving the resident without necessary follow-up for vision care.
A resident with a seizure disorder did not receive their prescribed emergency seizure medication due to a lapse in reordering after a pharmacy change. During a seizure event, the medication was unavailable, and the resident required EMS intervention and hospitalization. Staff confirmed the medication was not on site for an extended period, resulting in a significant medication error.
An LPN administered Novolog insulin to a resident with diabetes, chronic kidney disease, and heart failure, despite a physician order to hold the dose for blood glucose levels below 110. The resident's blood glucose was 93 at the time, but the LPN proceeded with the injection, failing to follow the specific order and facility policy requiring review of physician instructions before medication administration.
A resident with severe cognitive impairment and a history of falls experienced multiple falls due to the facility's failure to thoroughly investigate the causes and implement effective, individualized fall prevention interventions. Incomplete fall investigations and inadequate updates to the care plan led to repeated incidents, culminating in a fall that resulted in a fracture and hospitalization.
Surveyors found that two residents had deficiencies related to medication storage and labeling. One resident kept an opened bottle of antacid and a tube of hemorrhoid cream at bedside and in the bathroom without a physician order permitting bedside storage, despite having active orders for these medications. An LPN confirmed the antacid should not be at bedside, and there was uncertainty about the hemorrhoid cream. Another resident's multi-use insulin vial was not dated when opened, and the LPN could not verify the opening date. These issues were observed during a review of medication storage practices.
Multiple residents reported and were observed to experience unclean living conditions, including overflowing trash, foul odors, and soiled items left in rooms. Environmental issues such as damaged walls, stained furniture, and lack of clean linens led to missed showers and bed baths, with staff confirming ongoing shortages and inadequate cleaning practices.
Staff failed to follow infection prevention protocols, including hand hygiene and proper glove use, during medication administration for three residents and did not disinfect a glucometer between uses. Additionally, a nurse did not wear a gown as required during wound care for a resident on enhanced barrier precautions. These actions were inconsistent with facility policy and CDC guidelines.
A resident with chronic incontinence and multiple health conditions was left without timely incontinence care after requesting assistance from a CNA, who was unable to help due to staffing shortages. The resident waited several hours before receiving care from an LPN and another CNA. Despite facility policy requiring thorough investigation of neglect allegations, administrative staff did not conduct a proper investigation or collect statements from those involved.
A resident with incontinence and multiple health issues was left without timely incontinence care after requesting assistance from a CNA, leading to a confrontation. The incident was reported internally to an LPN and ADON, but no formal investigation was conducted and the required notifications to the administrator and state agency were not made, in violation of facility policy.
A resident with chronic incontinence and multiple health issues was left without timely incontinence care after requesting assistance from a CNA, leading to a confrontation. Due to staffing shortages, the resident waited several hours before receiving care from other staff. Despite reports to the LPN, ADON, and DON, the incident was not documented, investigated, or reported to the state agency as required by facility policy.
A resident with multiple wounds, including a stage three pressure ulcer, did not receive the physician-ordered wound care treatments. An LPN substituted wound dressings due to unavailable supplies, using calcium alginate with silver and covering wounds with abdominal pads and gauze instead of the specified products. This action did not follow the facility's policy or the physician's orders.
Three medication errors were observed during medication administration, resulting in a 12.5% error rate. Two residents received either incorrect dosages or missed doses of prescribed medications, and the nurse involved confirmed the errors during interviews. These incidents reflect non-compliance with the facility's medication administration policy.
Three residents were served food that was burnt, watery, and unappetizing in both taste and appearance. Staff confirmed the poor quality and presentation of the meal, and residents reported dissatisfaction, with some refusing to eat. The Certified Dietary Manager identified improper cooking methods as a cause, and the facility lacked a policy on food palatability.
The facility failed to serve meals at an appetizing temperature, affecting all 59 residents. A test tray with lemon pepper chicken, rice, and peas and carrots was served at room temperature, with the rice being hard. It took 20 minutes from plating to serving in the secured memory care unit. A resident confirmed that hot food was served cold. This deficiency was investigated under Complaint Number OH00161747.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 59 residents. Observations revealed improper food storage, including undated and unlabeled items, and a failure to maintain required food temperatures. Staff were seen preparing food without proper hair restraints and handling food with bare hands. The facility's food safety policies were not followed, leading to these deficiencies.
The facility did not offer the 2024-2025 COVID-19 vaccinations to residents, as required by CDC guidelines and facility policy. Five residents, all over 65 with various medical conditions, were not offered the updated vaccine. Medical records and interviews confirmed this deficiency, which was investigated under a specific complaint number.
The facility failed to provide sufficient nursing staff on the secured memory care unit, affecting 19 residents. On several occasions, the unit was left with inadequate supervision, leading to incidents such as falls and inadequate incontinence care. Interviews and observations confirmed the staffing issues, with reports of only one CNA being present at times, leaving residents unsupervised and at risk.
The facility failed to provide appropriate dementia care and services in the memory care unit, affecting multiple residents. A resident was found lying on the floor without staff intervention, another was in a room with a strong urine odor and no memory aids, and a third was wandering aimlessly without guidance. The unit was understaffed, leaving residents unsupervised and without meaningful activities, contributing to the deficiencies observed.
The facility did not follow the prescribed menu for residents on mechanical soft and pureed diets, resulting in inadequate portion sizes and missing items like pureed dinner rolls. Observations and interviews confirmed these discrepancies, affecting 12 residents. The Registered Dietitian verified the use of incorrect serving scoops and the absence of certain menu items.
The facility failed to provide adequate nursing staff to meet residents' needs, leading to incidents such as a CNA sleeping during her shift, residents left unattended, and insufficient assistance during meals. Observations and interviews confirmed the lack of staff, impacting personal care and meal services. The facility's staffing did not meet the required nurse-to-resident ratio, as acknowledged by the Administrator.
The facility failed to provide adequate dietary staff, resulting in consistent meal delays for residents. Observations and interviews revealed that meals were late, with staff attributing delays to insufficient kitchen staffing. Non-dietary staff, including maintenance and laundry aides, were assisting in the kitchen without formal training, highlighting the staffing inadequacies.
The facility failed to maintain a clean kitchen and safe food storage in resident refrigerators. Observations revealed unsanitary conditions in the kitchen, including dusty fixtures and stained surfaces. A resident's refrigerator contained spills, a foul odor, and unsafe food, while another resident's refrigerator had expired items and improper temperature. Staff confirmed these deficiencies, which violated the facility's sanitation policies.
The facility failed to maintain a clean and functional environment, affecting all 59 residents. Observations revealed non-functional lighting, unclean rooms, and common areas with foul odors. Maintenance staff reported corporate cost concerns, and housekeeping was inadequate, with rooms not cleaned regularly. Specific incidents included non-functional lights, stained bathrooms, and a lack of hand soap. The facility's policy required daily cleaning, but this was not followed, indicating systemic issues.
The facility failed to address residents' concerns about care, treatment, and environmental issues, affecting multiple residents. Complaints included call light response times, dietary issues, missing laundry, and staff turnover. Specific incidents involved a non-functioning light, inadequate shower room temperature, and missing clothing after a hospital visit. The facility's records showed unresolved complaints and a lack of inventory documentation, with no evidence of action taken to address these issues.
The facility failed to secure hazardous chemicals and medicated treatments in the Memory Care Unit, allowing residents unrestricted access. Additionally, a resident with a history of choking was left unsupervised during meals, despite having a care plan requiring monitoring. Staff confirmed the lack of security and supervision, and the DON acknowledged the expectation for staff to monitor the resident during meals.
The facility failed to securely store medications, affecting several residents. Observations showed unattended medication cups and pills scattered on the floor. Interviews confirmed that medications were not administered per physician orders, and the facility's policy requiring staff to remain with residents until medications are swallowed was not followed.
The facility did not maintain food at appropriate temperatures, affecting residents on pureed and mechanical soft diets. Observations showed food items like baked ziti and beets were served below the required 140°F, and residents reported the food was cold. The Dietary Manager confirmed these findings, indicating non-compliance with the facility's policy on safe food temperatures.
A facility failed to discontinue an as-needed psychotropic medication, Ativan, after 14 days for a resident with Alzheimer's, anxiety, insomnia, and dementia. The resident's medical record showed an active order for Ativan without a stop date, which should have been discontinued after 14 days. The DON confirmed the oversight and that the medication was not needed outside of the routine order.
The facility failed to follow physician orders for two residents. One resident with edema was not consistently encouraged to elevate her feet, leading to observed swelling. Another resident with a PICC line did not have his dressing changed as ordered, despite records indicating otherwise. Staff admitted to signing off on treatments before completion due to being busy.
A resident with a history of femur fracture and limited mobility was observed without physician-ordered heel protectors, intended to prevent pressure ulcers. Despite being dependent on staff for daily activities, the resident remained in bed without the necessary protective devices, as confirmed by staff interviews and observations during the survey period.
The facility failed to provide adequate foot care for two residents with diabetes, resulting in untreated wounds and dry, cracked skin. One resident had a month-old dressing with no treatment documentation, while another had a physician's order for foot care that was not followed, despite being signed off as completed. Staff admitted to not performing the care, highlighting a significant lapse in adherence to care protocols.
A resident with a fractured hip and limited mobility was not provided with a required pillow between the legs, as per the care plan and physician orders, to prevent dislocation. Despite staff awareness of the need for this precaution, observations during the survey period consistently found the resident without the necessary positioning device.
The facility had a medication error rate of 12%, affecting two residents. An LPN administered an incorrect dose of Miralax to a resident due to improper measurement, and another LPN failed to prime an insulin Kwikpen before use, risking incorrect insulin dosage. Both actions were contrary to the prescribed orders and manufacturer's guidelines.
Failure to Follow Posted Lunch Menu and Provide Planned Food Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned lunch menu for all 63 residents receiving meals from the dining room. The written menu for a specific date listed corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake for lunch. During observation of the meal service, staff were instead serving corn dogs, regular mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and no bread was provided. The yellow cake specified on the menu was not served. In an interview, the cook serving the meal acknowledged that the mashed potatoes were not prepared as cheesy potatoes and stated there was no particular reason for this change. The cook also stated that yellow cake was not available because it had not been made, so pudding was served instead, and confirmed that bread had been forgotten entirely. Later, the Corporate Dietary Manager reported she was not aware that cheesy potatoes and bread were not served, but she did know that pudding was substituted for yellow cake because the cake had not been prepared the night before, despite the facility having yellow cake in stock. Facility policy on menus required that menus meet residents’ nutritional needs, that appropriate substitutions be made and recorded when items were not available, and that substitutions be similar in nutritional value to the planned items.
Failure to Maintain Sanitary Kitchen Conditions and Safe Food Handling Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe and sanitary kitchen environment for all 63 residents who received meals from the kitchen. During a kitchen tour with the Corporate Dietary Manager, surveyors observed two large trash cans without lids, a utensil drawer containing scoops and ladles lying in a red, sticky substance, and a stainless-steel shelf under the steam table soiled with food and a yellow liquid. Three three-tiered red food carts were observed soiled with food debris and dried white liquid. In dry storage, several pieces of cardboard and paper littered the floor. In the refrigerator, surveyors found an unlabeled small stainless-steel pan with a white, hard substance, an open bag of lettuce with no date, a bag of bacon bits without an open date, and in a reach-in refrigerator, a large round container and three pitchers of red liquid with no dates or identifying labels. Two large tubs of rice crispy cereal were also not labeled with an open date. The Corporate Dietary Manager confirmed these observations during the tour. Surveyors also observed improper thawing and temperature control of ground beef. Two five-pound semi-frozen tubes of hamburger were initially seen soaking in warm water in a stainless-steel sink and later, at midday, still defrosting in stagnant cool water. Later in the afternoon, the same hamburger tubes were observed out of the water, sitting on the sink and cool to the touch. When a staff member took the temperatures in the presence of the Corporate Dietary Manager and Dietary Manager, one tube measured 57.8°F and the other 49.8°F. The Corporate Dietary Manager verified that these temperatures were not safe. Review of facility policies showed that food was to be received and stored to minimize contamination and bacterial growth, with repackaged food placed in appropriate containers labeled with contents and date, and that the Nutrition/Culinary Service Director was responsible for food safety, sanitation, and implementation and monitoring of a cleaning schedule. These observed conditions and practices were inconsistent with the facility’s written food safety and sanitation policies.
Failure to Knock Before Entering Resident Room During Medication Pass
Penalty
Summary
Facility staff failed to maintain resident privacy when an LPN entered the room of Resident #26 without knocking or waiting for permission during medication administration. Resident #26 had been admitted on an unspecified date with multiple diagnoses, including schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder. On 02/25/26 at 9:00 A.M., observation showed LPN #133 prepared medications for Resident #26 at the medication cart in the hallway and then walked directly into the resident’s room without knocking on the door. In an interview at that time, LPN #133 confirmed she had not knocked or waited for a response before entering, despite the facility’s written privacy policy stating that staff would provide residents with their right to privacy and security and would knock on doors for permission to enter. This deficiency affected one of five residents observed during medication administration and was identified through observation, medical record review, staff interview, and review of the facility’s privacy policy dated 06/19.
Failure to Maintain Safe and Well-Maintained Resident Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable bathroom environment for Resident #10, whose bathroom had two softball-sized holes in the wall where the baseboard was missing under the sink, exposing the interior of the wall. Resident #10 had been admitted with diagnoses including Alzheimer's disease, severe protein calorie malnutrition, peripheral vascular disease, hypertension, depression, chronic kidney disease, and left eye blindness, and the admission MDS documented moderately impaired cognition, no psychosis or behaviors, a need for setup or clean-up assistance with toileting, occasional urinary incontinence, and full bowel continence. On two separate observations, surveyors noted the same unrepaired holes in the bathroom wall. During interviews, the Director of Support Services stated he was unaware of the damage and acknowledged he did not conduct environmental rounds, and the Administrator confirmed the facility did not perform regular environmental rounds, instead relying on informal daily walk-throughs to notice needed repairs. This deficiency was cited under the resident’s right to a safe, clean, comfortable, and homelike environment, specifically related to maintaining the bathroom in a safe and comfortable manner, and was investigated under Complaint Number 2743199.
Failure to Timely Administer Post-Operative Ophthalmic Medications
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administering of prescribed ophthalmic medications for Resident #32 following cataract surgery. Resident #32, who had intact cognition and multiple medical diagnoses including macular degeneration and cataracts, underwent cataract surgery and received post-operative orders for Prednisone 1% ophthalmic drops once daily, Ketorolac Tromethamine 0.5% drops four times daily, and Moxifloxacin 0.5% drops three times daily to the left eye for specified durations. The resident reported he was to start eye drops two hours after surgery and had given the paperwork to staff. Review of the medication administration record showed that none of the ordered eye drops were administered on the afternoon and evening of the surgery date or the following morning. Interviews revealed multiple breakdowns in the medication process. The surgery office initially sent the prescriptions to the resident’s old pharmacy and later had them filled at the hospital pharmacy, with the lead nurse personally delivering the medications to the facility in the late afternoon. The DON stated the facility did not have the eye drops the night before and that the pharmacy was called to drop ship them the next morning. The resident later stated he had been told the drops were delivered around 4:00 p.m. the previous day but were not placed in the medication cart and could not be located. An LPN confirmed she had not administered the drops and was only going to do so once they were found. Another LPN verified the drops had been delivered the previous afternoon by the hospital pharmacy, but the staff member who received them placed them in the wrong medication cart, and the nurse on duty was unaware they had been delivered, resulting in the medications not being started as ordered until the following morning.
Infection Control Failures During Medication Administration and Handling of Soiled Linens
Penalty
Summary
The deficiency involves failures in infection prevention and control during medication administration and handling of feces-soiled linens. For one resident with schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder, an agency LPN was observed during a morning medication pass popping an Amlodipine 5 mg tablet directly from the medication card into her bare hand before placing it into a medication cup. When stopped and interviewed by the surveyor, the LPN confirmed she had touched the tablet with her bare hands and intended to administer it to the resident. In a separate observation, another resident with chronic kidney disease, atrial fibrillation, heart failure, depression, and cerebral infarction was receiving medications when an LPN poured an Aspirin 81 mg tablet from a bottle into her bare hand and then popped Carvedilol 25 mg and Eliquis 5 mg tablets from medication cards into her bare hand before placing all tablets into a medication cup. This LPN also verified during interview that she had handled the tablets with bare hands and planned to administer them. The deficiency also includes improper handling of feces-soiled linens for a resident admitted with chronic obstructive pulmonary disease, a solitary pulmonary nodule, anxiety disease, and respiratory failure. During the initial tour, the resident’s room door was open and a CNA was brushing the resident’s hair while a hand towel and a blue disposable pad, both heavily soiled with feces, were lying directly on the floor. During interview at that time, the CNA acknowledged that feces-soiled items should not have been placed directly on the floor without a barrier or in a plastic bag. Review of the facility’s Laundry Services policy dated 02/2022 stated that soiled linens should be handled as little as possible, with minimal agitation, and that all soiled linen would be bagged or placed in carts at the location where the resident was cared for, with linens saturated in blood or body fluids placed in a biohazard bag.
Failure to Timely Report and Communicate COVID-19 Outbreak and Implement Facility-Wide Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and accurate documentation and reporting of a COVID-19 outbreak, including delayed notification to residents’ responsible parties and the county health department, and incomplete facility-wide outbreak communication and testing. Three residents residing on the memory care unit, all with dementia or significant cognitive impairment and poor memory, tested positive for COVID-19. One resident tested positive on 01/02/26, and two additional residents tested positive on 01/03/26. Documentation showed that their responsible parties or families were not notified of the COVID-19 outbreak until 01/06/26 by the Social Service Designee, despite the earlier positive test results. Record review for 24 residents on the Buckeye Trail unit showed no documented evidence that facility-wide COVID-19 testing was implemented following identification of the outbreak, and no documentation that these residents or their responsible parties were notified of the outbreak. The Social Service Designee reported she was informed on 01/06/26 that the facility had determined there was a COVID-19 outbreak and that she notified residents and responsible parties on the Cascade and memory care units, but did not notify residents, responsible parties, or visitors for those on the Buckeye Trail unit. The Infection Control Preventionist stated that after learning of the first positive case, the facility tested residents on the memory care unit and identified two additional positive residents and one LPN, and that testing was conducted on two of the three nursing units, but not on the Buckeye Trail unit. The Infection Control Preventionist also stated she called the county health department to report the outbreak, while the county health department RN reported that the facility notified her of the outbreak on 01/07/26. The receptionist stated she had not placed any signage at the main entrance and had not been instructed by administrative or supervisory staff to do so, confirming there was no sign on the main entrance door during the outbreak. Two residents interviewed reported they were unaware of a COVID-19 outbreak in the facility and were not offered masks or other PPE, and one resident who frequently used the main entrance stated there were no signs posted to alert visitors or residents of the outbreak. Facility policy required outbreaks of COVID-19 to be reported to the county health department and state LTC bureau by the end of the next business day, and CDC guidance cited in the report called for broad-based testing in nursing homes during outbreaks, rather than limiting testing to close contacts.
Failure to Serve Dietitian-Approved Menus to Residents
Penalty
Summary
The facility failed to ensure that meals were served according to the dietitian-approved menu, affecting multiple residents and potentially all residents who consumed meals at the facility. Observations and interviews revealed that several residents did not receive all components of the prescribed meals, such as milk and cereal, despite these items being listed on the approved menus and required by the meal tickets. Staff confirmed that unless the meal tickets specifically indicated certain items, such as milk or cereal, these were not provided, even though the menu required them. This practice was confirmed by both the Dietary Manager and the Administrator. Several residents with significant medical histories, including dementia, malnutrition risk, and other chronic conditions, were directly impacted. For example, one resident at risk for malnutrition and with recent weight loss did not receive milk or cereal as required by the menu. Another resident, who was malnourished and required finger foods and health shakes, did not receive all menu items, including cereal and milk, during observed meals. Similar deficiencies were observed for other residents, including those with Alzheimer's disease, multiple sclerosis, and other serious diagnoses, who did not receive the full menu as approved by the dietitian. Additionally, there were instances where the meals served did not match the menu due to substitutions or omissions, such as serving a taco instead of a cheeseburger or omitting buttered carrots from a lunch meal. Staff interviews indicated that some menu items were not provided due to budget constraints or lack of clarity on meal tickets. The dietitian and dietary staff confirmed that the approved menus were not consistently followed, and some residents did not have completed nutritional assessments or care plans at the time of the survey.
Failure to Prevent Accidents, Unsafe Transfers, and Inadequate Smoking Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with a history of alcohol abuse, depression, anxiety, and moderate cognitive impairment, residing on a secured memory care unit, was assessed as a moderate elopement risk and had care plans and physician orders in place for frequent monitoring and a wander guard. Despite these interventions, the resident was able to elope by dislodging screws from a window, climbing out, and leaving the premises undetected. The resident was missing for several hours before being located at a family property four miles away. Observations after the incident revealed that the window in the resident's room could still be fully opened, and screws intended to prevent this were not in place. Another deficiency involved the unsafe and undignified transfer of a resident with Alzheimer's disease and severe cognitive impairment. A CNA was observed on video roughly transferring the resident from a wheelchair to a bed, lifting the resident under the arms and throwing the resident's legs onto the bed, resulting in an audible thump and a verbal expression of discomfort from the resident. The incident was reported by the resident's family, who had video evidence from a camera in the room. Although no injuries were found on assessment, the transfer was confirmed by the DON to be inappropriate and not in accordance with facility policy, which requires cooperative and safe transfer techniques. Additionally, the facility failed to implement proper smoking procedures for five residents. During a supervised smoking break, residents were observed without access to appropriate ashtrays, flicking ashes onto the ground, and handing lit cigarettes to staff for disposal. Cigarette butts were found scattered throughout the courtyard, including in non-combustible trash cans and among dried leaves. One resident with severe visual impairment and motor/dexterity concerns was not provided with a clothing protector during smoking, and the smoking safety assessment did not accurately reflect the resident's needs. Staff supervising the smoking break reported a lack of formal training on safe smoking protocols, and the facility's policy requiring fire blankets and approved ashtrays was not followed.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.14% during the survey period. Specifically, two medication errors were observed among 28 medications administered to residents. In one instance, a resident with a history of alcohol abuse, depression, and anxiety, and exhibiting moderate cognitive impairment, was prescribed 75 mg of Sertraline (Zoloft) to be administered in the morning. However, the LPN administered only 25 mg, which was confirmed by both observation and subsequent interview with the nurse involved. In another case, a resident with diagnoses including alcohol abuse, muscle weakness, and difficulty walking, and also exhibiting moderate cognitive impairment, was prescribed Thiamine 100 mg daily. During medication administration, the LPN failed to administer the ordered Thiamine, despite documentation indicating it had been given. The DON later confirmed that the Thiamine was not administered as ordered and was located on another medication cart. These events were verified through record review, direct observation, and staff interviews, demonstrating non-compliance with the facility's medication management policy.
Failure to Maintain Safe and Sanitary Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain resident rooms in a safe and sanitary condition, affecting six residents. Specific findings included numerous stains on carpets and chairs, strong odors, dirty toilets, and the presence of brown stains and debris in multiple rooms. In some cases, bedpans with brown stains were found on the floor, and residents' personal items, such as wheelchairs and medical equipment, were improperly stored. Sticky floors, dirty and dusty floorboards and walls, holes and dents in walls, and missing drawers and cabinet handles were also noted. Moldy food, dirty dishes, and evidence of flies were present in some rooms, and in one instance, a resident reported not having clean clothes for several days, with their closet blocked and containing dirty clothing. These observations were confirmed through interviews with facility staff, including the Administrator, CNAs, and the DON. The unsanitary conditions extended to kitchen areas, where dried liquid stains, food debris, and black dirt were found around sinks and refrigerators. In several cases, moldy food was discovered and removed only after being pointed out by surveyors. Residents reported infrequent cleaning, and staff confirmed the presence of dirt, dust, and debris. The findings were substantiated under a specific complaint investigation, indicating a pattern of inadequate environmental maintenance and failure to provide a clean, safe, and homelike environment for residents.
Failure to Provide Therapeutic Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide therapeutic activities in the secured memory care unit to meet the physical, mental, and psychosocial well-being of all 18 residents in that unit. Observations over several weeks revealed that scheduled activities were not consistently implemented, with residents often sitting in common areas with minimal engagement, such as a single television being on or music playing. The activity calendar was frequently not followed, and some planned activities, such as crafts, manicures, and basketball trivia, were either delayed, substituted, or not conducted at all. Staff interviews confirmed uncertainty about why activities were not occurring as scheduled and acknowledged that there were not enough activities, especially for residents unable to leave the secured unit. The physical environment in the common area was not conducive to social interaction, with chairs arranged in a way that limited conversation among residents. Some residents were taken off the unit for activities like bingo, but those who could not leave had no alternative activities provided. Staff also reported that items previously used for engagement, such as sofas, baby dolls, and cribs, had been removed. Despite having adequate supplies, the activity program did not meet the needs of the residents, and hydration or bathroom assistance was sometimes listed as an activity. The facility's own policy required meaningful, person-centered activities, but this was not being met according to observations and staff interviews.
Expired and Improperly Stored Medications and Supplies Found in Facility
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were properly labeled, unexpired, and stored according to policy and professional standards. During inspection of two medication storage rooms, two treatment carts, and two medication carts, multiple expired medications and medical supplies were found, including a bottle of Children's Flonase, Zyno Medical administration sets, Monject filter needles, ICU Medical sterile caps, and Assure blood glucose control solutions. Additionally, opened and unsecured wound care supplies such as DermaRite xeroform gauze, hydrogel gauze, and DermaGinate/AG dressings were present in the treatment carts. These findings were verified with the Assistant Director of Nursing and the Director of Nursing at the time of observation. Review of the facility's policy confirmed that expired or unsecured medications and supplies are to be removed and destroyed according to procedure. However, the presence of expired and opened items in medication storage areas and carts indicated non-compliance with these policies. The deficiency had the potential to affect all residents served from the affected storage rooms and carts, as these areas are used for medication and treatment supply storage throughout the facility.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at appetizing and safe temperatures, as required by their Nutrition Services Policy. Observations and interviews revealed that residents who typically eat meals in their rooms often received food that was not warm. A test tray plated and delivered to a hall was found to have food items below appropriate temperatures, with pasta measured at 122.4°F and raspberry applesauce at 61°F. The pasta was described as lukewarm, though both items tasted appetizing. These findings were confirmed by the Dietary Manager, who acknowledged awareness of issues with cold food. Resident Council minutes documented complaints that CNAs only passed trays to their assigned residents, resulting in food sitting for extended periods before being served. There was no evidence of resolution to these complaints in subsequent council minutes. The Dietary Manager and Administrator confirmed that it took over 20 minutes to pass out 13 trays, and despite efforts to expedite the process, there was a lack of urgency among staff. The facility's policy required food temperatures to be maintained at acceptable levels during all stages of food handling, but this was not achieved, affecting nearly all residents except one who was not receiving food by mouth.
Failure to Follow Infection Control Procedures During Resident Care
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices affecting three residents. For one resident with dementia, dysphagia, and an ostomy, Enhanced Barrier Precautions (EBP) were ordered, requiring the use of gloves and gowns during high-contact care. Despite an EBP sign on the door, staff were observed changing the resident’s leaking ostomy bag while only wearing gloves, not gowns as required. The resident’s hospital gown was stained and wet from the leak, and the call light was out of reach, with the resident reporting not being changed in two days. The unit manager acknowledged not wearing a gown during the procedure, contrary to facility policy. In another instance, two CNAs provided incontinence care to a resident with diabetes and myelitis without cleaning the bedside table or placing a barrier before setting down supplies. During care, a pack of wipes was placed directly on the resident’s bed, and one CNA changed gloves without performing hand hygiene. For a third resident with a history of sepsis and multiple comorbidities, an LPN performed wound care without cleaning the bedside table or using a barrier before placing supplies, which was confirmed in interview. These actions were inconsistent with the facility’s infection control policies, which require hand hygiene, proper glove use, and clean surfaces or barriers for supplies during resident care.
Failure to Provide Adequate Nutritional and Communication Assistance
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, dysphagia, and severe cognitive impairment, did not receive adequate assistance with activities of daily living (ADLs), specifically related to nutrition and communication. The resident's care plan indicated a risk for malnutrition and required staff to provide assistance with all meals, snacks, and supplements, as well as to use communication tools and gestures the resident could understand. However, observations revealed the resident struggled to open a milk carton, was unable to use adaptive utensils, and resorted to eating with her hands. Staff only became aware of the need for assistance after surveyor intervention, and no communication tools were present in the resident's room or at bedside during multiple observations. Interviews with staff confirmed that the resident was sometimes unable to feed herself and was difficult to understand, yet no communication aids were available to facilitate interaction. The facility's policy required necessary care to be provided to residents unable to perform ADLs independently to ensure proper nutrition, but this was not consistently implemented for the resident in question. The deficiency was substantiated through record review, direct observation, and staff interviews, demonstrating a failure to provide the required nutritional and communication assistance.
Failure to Administer and Document Blood Sugar Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that blood sugar monitoring was performed as ordered for Resident #55, who had diagnoses including heart failure, type 2 diabetes, atrial fibrillation, and low back pain. The resident had a physician's order for a Dexcom G7 Sensor to monitor blood sugars every ten days. Review of the Medication Administration Record (MAR) showed that the sensor was not administered on several occasions, including a period from 08/20/25 to 09/18/25, and there were blank entries and missed documentation regarding administration. Additionally, there was no documentation in the progress notes indicating any further attempts to administer the sensor during this time. The Director of Nursing confirmed these findings. Facility policy required medications to be administered as ordered, recorded on the MAR, and for explanatory notes to be entered if a medication was not given, which was not followed in this case.
Failure to Ensure Timely Ophthalmology Follow-Up for Severely Impaired Vision
Penalty
Summary
A resident with multiple diagnoses, including chronic diastolic heart failure, type 2 diabetes mellitus, morbid obesity, asthma, insomnia, major depressive disorder, dry eyes syndrome, and bilateral age-related cataracts, was admitted to the facility and assessed as having severely impaired vision. The resident was alert, oriented, and cognitively intact. Medical records showed that the resident was seen by an eye care consultant, who recommended a follow-up with an ophthalmologist for cataract evaluation. Despite this recommendation, the resident reported being unable to see due to cataracts and stated that cataract surgery had been recommended but no appointment had been scheduled. Facility staff documented attempts to contact eight ophthalmologist offices, noting difficulties in finding a provider who accepted the resident's insurance and could accommodate bariatric patients, but there was no evidence that an appointment was ultimately scheduled.
Failure to Provide Prescribed Emergency Seizure Medication
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including epilepsy and a history of seizures, was not provided with their prescribed emergency seizure medication, Valtoco, as ordered by the physician. The resident was admitted with several diagnoses requiring anticonvulsant therapy and had a standing order for Valtoco to be administered intranasally as needed for seizures. Despite this, the medication was not available or administered during a seizure event, as documented in the medical record and confirmed by staff interviews. The medication was not reordered after a pharmacy change, and the resident did not receive the prescribed seizure medication during a documented seizure, resulting in the need for emergency medical intervention and hospitalization. The facility's records and staff interviews revealed that the medication was unavailable from the time of the pharmacy change until it was reordered and delivered over a month later. During this period, the resident experienced a seizure, and staff confirmed that the emergency medication was not on hand, leading to the resident being sent to the hospital where alternative seizure medications were administered. The facility's policy required medications to be administered as ordered, but this was not followed, resulting in a significant medication error affecting the resident.
Insulin Administered Despite Order to Hold for Low Blood Glucose
Penalty
Summary
A significant medication error occurred when a licensed practical nurse (LPN) administered insulin to a resident despite a physician's order to hold the dose for blood glucose levels less than 110. The resident, who had diagnoses including chronic kidney disease, heart failure, type 2 diabetes mellitus, and protein calorie malnutrition, had a care plan that included monitoring blood sugar and administering insulin as ordered. On the day of the incident, the LPN checked the resident's blood glucose, which was 93, and proceeded to draw up and administer four units of Novolog insulin, contrary to the order to hold the dose for blood sugar below 110. The error was identified during observation and confirmed through interviews and record review. The LPN followed standard procedures for blood glucose testing and insulin administration but failed to adhere to the specific physician order regarding when to withhold insulin. The facility's policy required staff to review physician orders and follow the eight rights of medication administration, which was not done in this instance, resulting in the resident receiving insulin when it should have been withheld.
Failure to Investigate and Prevent Repeated Resident Falls Resulting in Injury
Penalty
Summary
The facility failed to thoroughly investigate the root cause of repeated falls experienced by a resident and did not implement appropriate fall prevention interventions. The resident, who had a history of falls, severe cognitive impairment, and required extensive assistance with activities of daily living, experienced falls on three separate occasions. After each fall, the facility's investigations were incomplete, lacking critical information such as whether the resident was incontinent, attempting to use the bathroom, the timing of last toileting, use of call light, type of footwear, and whether previously implemented interventions were in place at the time of the falls. Despite the resident being identified as high risk for falls and having a care plan that included interventions such as maintaining a clear pathway, monitoring for side effects of psychotropic medications, encouraging the use of briefs, and use of a tilt-in-space wheelchair, the facility did not update or individualize interventions based on the circumstances of each fall. For example, after the first fall, the only intervention added was to ensure the resident wore briefs at all times, which was later confirmed by staff as not being an appropriate intervention for a resident who was falling while attempting to transfer to the bathroom. Additionally, after subsequent falls, interventions such as non-slip strips were implemented, but these were not consistently updated in the care plan or verified as being in place at the time of later incidents. Actual harm occurred when the resident fell while attempting to transfer herself to the bathroom unsupervised, resulting in a distal left tibia fracture that required hospitalization. The facility's failure to conduct thorough root cause analyses and to implement and document effective, individualized fall prevention interventions contributed to the recurrence of falls and the resulting injury.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified deficiencies related to medication storage and labeling for two residents. For one resident with diagnoses including weakness, GERD, vitamin D deficiency, and osteoporosis, observations revealed an opened bottle of store brand antacid and a tube of hemorrhoid cream kept at the bedside and in the bathroom, respectively. The resident stated these items were brought in by a friend and used as needed, and that staff were too busy to provide them. Review of physician orders confirmed active orders for both medications, but there was no order permitting the resident to keep these medications at bedside. Staff interviews confirmed awareness that antacids should not be kept at bedside without a physician order, and there was uncertainty regarding the hemorrhoid cream. For another resident with chronic obstructive pulmonary disease, type 2 diabetes, and asthma, surveyors observed a multi-use vial of NovoLog insulin on the medication cart that was not dated when opened. The LPN present confirmed the vial was not dated and could not verify when it had been opened. Facility policy and professional standards require multi-use vials to be dated upon opening to ensure safe use. These findings affected two out of sixteen residents reviewed for medication storage and had the potential to affect all residents in the facility.
Failure to Maintain Clean, Safe, and Homelike Environment Due to Poor Housekeeping and Linen Shortages
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident complaints. Resident council meeting minutes documented concerns about staff not making beds, changing sheets, emptying trash cans, or sweeping rooms frequently enough. During interviews and observations, one resident was found with an overflowing trash can in her room, which she stated was bothersome. Further inspection revealed her room smelled of urine and feces, with a soiled brief in an unlined trash can and spilled liquids with disintegrated tissues and a toilet paper roll under the bed. Additional environmental issues included a large hole in a wall, ripped wallpaper, a handrail pulled away from the wall, a comb with hair on the floor in a common area, and a stained lounge chair. There were also significant shortages of clean linens, with linen closets lacking washcloths and having limited towels, which staff and residents confirmed led to missed showers and bed baths. The last order for washcloths had been placed weeks prior, with no pending orders for more, and staff interviews confirmed the ongoing shortage. The facility's own cleaning policy required daily cleaning tasks that were not being met. These findings were verified by the Housekeeping and Maintenance Supervisor and corroborated by multiple staff and resident interviews.
Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during medication administration and wound care for several residents. Specifically, a registered nurse did not perform hand hygiene after administering medications to one resident and before donning gloves to check another resident's blood sugar. The same nurse also failed to clean and disinfect the glucometer after use and did not don gloves or perform hand hygiene prior to administering insulin injections to two residents. These lapses occurred despite the facility's policy requiring hand hygiene before and after resident contact, after glove removal, and after contact with potentially contaminated equipment. Additionally, a licensed practical nurse did not perform hand hygiene before administering medications to a resident, immediately after completing medication administration for another resident. This was confirmed during an interview with the nurse, who acknowledged the failure to follow hand hygiene protocols as outlined in facility policy. During wound care for a resident with severe edema, multiple sores, and a physician order for enhanced barrier isolation precautions, another licensed practical nurse failed to don a gown as required. The nurse confirmed during an interview that a gown should have been worn for the procedure. Facility policies and CDC guidelines reviewed by surveyors emphasized the importance of cleaning and disinfecting shared medical equipment and using appropriate personal protective equipment (PPE) during high-contact care activities, especially for residents with wounds or indwelling devices.
Failure to Provide Timely Incontinence Care and Inadequate Investigation of Neglect Allegation
Penalty
Summary
Facility staff failed to provide timely incontinence care to a resident with multiple medical conditions, including heart failure, atrial fibrillation, and chronic incontinence. The resident, who was always incontinent of bowel and bladder, requested assistance from a CNA after a bowel movement but was told to wait due to staffing shortages. The resident waited for several hours before receiving assistance, during which time she blocked the CNA from leaving her room in an attempt to get help. Interviews revealed that the CNA felt unable to assist the resident promptly because she needed to attend to other residents and the nurse assigned to the area was on break. The resident eventually received incontinence care from an LPN and another CNA several hours after her initial request. The incident was reported to the ADON and DON, but neither conducted a thorough investigation or collected statements from involved staff or the resident. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress. The policy requires all allegations of neglect to be thoroughly investigated and reported. In this case, the facility did not follow its own policy, as the incident was not properly investigated or documented, and the resident's care needs were not met in a timely manner.
Failure to Report and Investigate Alleged Neglect
Penalty
Summary
An allegation of neglect involving a resident with multiple medical conditions, including heart failure, diabetes, and incontinence, was not reported to the state agency or the facility administrator as required by policy. The resident, who was always incontinent of bowel and bladder, requested incontinence care from a CNA after a bowel movement. The CNA informed the resident that assistance would be delayed due to staffing shortages. The resident subsequently blocked the CNA in the room, demanding immediate care, and an argument ensued. The resident was eventually assisted by an LPN and another CNA several hours later. Interviews revealed that the CNA reported the incident to the LPN, who in turn notified the ADON. The ADON did not investigate further or notify the administrator, and the DON was only partially aware of the situation. No formal investigation was conducted, and the incident was not reported to the state agency as required by the facility's abuse and neglect policy. The policy mandates immediate reporting and investigation of all alleged violations involving abuse or neglect, including notification of the administrator and state agency, and removal of the accused staff member pending investigation. The facility's failure to follow its own policy resulted in the lack of a timely and thorough investigation into the alleged neglect. Documentation of the incident was absent from the resident's clinical record, and no statements were collected from involved staff. The administrator confirmed that the required notifications and investigation did not occur.
Failure to Investigate and Report Alleged Neglect
Penalty
Summary
A deficiency was identified when the facility failed to thoroughly investigate and take corrective action regarding an allegation of neglect involving a resident with multiple medical conditions, including heart failure, diabetes, and chronic incontinence. The resident, who was always incontinent of bowel and bladder, reported that after requesting incontinence care from a CNA, she was told to wait due to staffing shortages. The resident subsequently blocked the CNA in her room, demanding assistance, and ultimately received care from other staff members several hours later. Interviews with staff revealed that the facility was short-staffed on the day of the incident, and the CNA involved reported the altercation to both an LPN and the ADON. The LPN, after being informed of the situation, contacted the ADON for guidance but was told to handle the situation without further instruction. The CNA also reported the incident to the DON and the ADON, but was not asked to provide a written statement, and was later not permitted to care for the resident. There was no documentation in the resident's clinical record regarding the incident or the alleged neglect. Further interviews with facility leadership, including the DON, ADON, and Administrator, confirmed that the incident was not thoroughly investigated, statements were not collected, and the event was not reported to the state agency as required by facility policy. The facility's policy mandates immediate and thorough investigation of all alleged violations, including interviews, documentation, and reporting to the appropriate authorities, none of which were completed in this case.
Failure to Follow Physician-Ordered Wound Care Treatments
Penalty
Summary
Staff failed to provide physician-ordered wound care treatments for a resident with multiple wounds, including a stage three pressure ulcer and other sores on the thighs, abdominal fold, buttocks, and back. The resident had a complex medical history, including bullous pemphigoid, morbid obesity, lymphedema, and other chronic conditions. Physician orders specified the use of particular wound care products and dressings, such as betadine, calcium alginate, silicone super absorbent dressings, and foam dressings, to be applied to specific wound sites following cleansing with normal saline. During an observed wound care procedure, an LPN did not follow the physician's orders and instead used calcium alginate with silver and covered all wounds with abdominal pads and gauze, securing them with paper tape. The LPN stated that the required silicone super absorbent and foam dressings were not available in the facility, leading to the substitution of materials. The facility's policy required staff to follow physician orders and manufacturer guidelines for wound care products, but these were not adhered to during the observed treatment.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that staff administered medications with an error rate below five percent, as required. During observation, three medication errors were identified out of 24 opportunities, resulting in a 12.5 percent error rate. Specifically, a registered nurse administered two tablets of metoprolol tartrate 25 mg instead of the prescribed one tablet to a resident with chronic respiratory and cardiac conditions. The nurse later confirmed the error during an interview. Additionally, another resident with multiple chronic conditions, including hypertensive heart failure, bipolar disorder, and diabetes, received an incorrect dosage of cyanobalamin (500 mcg instead of the ordered 1000 mcg) and did not receive the prescribed vitamin D2 50 mcg tablet. The nurse responsible acknowledged both the incorrect dosage and the omission of the vitamin D2 medication. These incidents were observed and verified through record review and staff interviews, demonstrating non-compliance with the facility's medication administration policy.
Unpalatable and Unattractive Food Served to Residents
Penalty
Summary
The facility failed to ensure that food served to three residents was palatable, attractive, and prepared to an appropriate consistency. Observations during a lunch meal revealed that the meatloaf had burnt edges and required scraping to serve, the mashed potatoes were runny and watery, and the rice was clumped together. These issues were confirmed by staff present on the tray line, who acknowledged the poor quality and presentation of the food. A test tray further demonstrated that the food was unappetizing in appearance, with burnt meatloaf pieces and watery mashed potatoes that had spilled over the plate, affecting the overall presentation. Taste testing confirmed the meatloaf was hard and burnt, and the mashed potatoes lacked flavor and proper consistency. Interviews with the affected residents revealed dissatisfaction with the food, with one resident stating she did not like the taste, another refusing to eat lunch due to the unappetizing appearance of the meat, and a third reporting that the meat was burnt and the rice overcooked. The Certified Dietary Manager confirmed the issues with the food and attributed the burnt meatloaf to the use of an incorrect pan size. Additionally, the facility administrator acknowledged that there was no policy or procedure in place regarding food palatability.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing taste and temperature, affecting all 59 residents who received meals from the kitchen. During an observation, a test tray consisting of lemon pepper chicken breast, white rice, and cooked peas and carrots was served from the kitchen tray line and placed within a meal cart. The meal cart was delivered to the secured memory care unit, and the nursing staff began serving residents their meals. It took approximately 20 minutes from the time the meals were plated until they were served. When the test tray was tested, the Registered Dietitian confirmed that the food temperatures were 93.5 degrees Fahrenheit for the chicken breast, 84 degrees Fahrenheit for the white rice, and 94 degrees Fahrenheit for the peas and carrots, indicating that the food was at room temperature. The rice was also noted to be hard. An interview with a resident revealed that hot food was served cold. All 59 residents had a diet order, and this deficiency was investigated under Complaint Number OH00161747.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner, affecting all 59 residents who received meals from the kitchen. During an initial tour, the kitchen's tiled floor was found to be black and sticky, and there were no paper towels at the handwashing sink in the dish machine room. Observations revealed improper food storage, including milk cartons on the floor, an opened bag of hot dogs without a date, and undated pie slices in the walk-in refrigerator. The outside walk-in freezer door could not be closed due to ice buildup, and the freezer was found unlocked. The food temperature log showed that eggs served for breakfast on two consecutive days did not reach the required minimum internal temperature of 160 degrees Fahrenheit. Further observations noted unlabeled and undated food items in the kitchen's refrigerators, including cornbread pieces and gelled peaches. Ice buildup was also observed on the ceiling of the walk-in freezer. Staff members were seen preparing food without proper hair restraints, and one staff member handled food with bare hands, including a hand with a band-aid. The facility's policies on food safety and storage were not adhered to, as evidenced by the improper labeling, dating, and storage of food items, as well as the lack of adherence to safe food preparation practices.
Failure to Offer 2024-2025 COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to offer the 2024-2025 COVID-19 vaccinations to its residents, as required by the CDC guidelines and the facility's own policy. This deficiency was identified through a review of medical records, CDC guidelines, and interviews. The CDC's guidelines recommend that individuals aged 65 and older receive two doses of the 2024-2025 COVID-19 vaccine, with specific instructions for those who began vaccination with the Novavax vaccine. Despite these guidelines, the facility did not offer the updated COVID-19 vaccinations to five residents, all of whom were over the age of 65 and had various medical conditions such as Alzheimer's disease, schizophrenia, COPD, and diabetes. The medical records of the affected residents showed that they either had not been offered the 2024-2025 COVID-19 vaccine or had not received it. For instance, one resident had received a Pfizer booster in 2022 but had not been offered the new vaccine. Another resident had refused a Pfizer vaccine in 2023 but was not offered the 2024-2025 vaccine. Interviews with the President of Operations confirmed the lack of evidence that these residents were offered the updated vaccinations. This deficiency was investigated under Complaint Number OH00162019.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide appropriate supervision to residents residing on the secured memory care unit, affecting 19 residents. The deficiency was identified through observations, interviews, and reviews of staff assignment sheets and education in-service attendance records. On multiple occasions, the facility did not have enough staff to cover the [NAME] Hills unit, leaving residents unsupervised. For instance, on 01/23/25, RN #9, CNA #21, and CNA #8 attended an all-staff meeting, leaving the unit unattended. Similarly, on 01/25/25, two nurses called off, and the Director of Nursing (DON) had to cover both the [NAME] Hills and Buckeye Trail units, leaving only one CNA on the [NAME] Hills unit. The lack of adequate staffing led to several incidents involving residents. Resident #17, #34, #38, and #53 experienced falls, with some resulting in injuries. Resident #9 was observed wandering aimlessly and later found lying on the floor, while Resident #58 was found on the floor fiddling with bed parts. Resident #12's room had a strong odor of urine, and her bed linens were found to be wet and stained, indicating a lack of timely incontinence care. Interviews with family members and staff confirmed the insufficient staffing levels, with reports of only one nurse aide being present on the unit at times. The deficiency was further corroborated by interviews with the Director of Nursing and the Vice President of Operations, who acknowledged the staffing issues. The Ombudsman also expressed concerns about the lack of staff presence on the unit during visits. The facility's failure to maintain adequate staffing levels resulted in residents being left unsupervised, increasing the risk of falls and inadequate care for those with Alzheimer's disease and dementia.
Inadequate Dementia Care and Staffing in Memory Care Unit
Penalty
Summary
The facility failed to provide appropriate dementia care and services to residents in the memory care unit, affecting multiple residents. Resident #58, who was cognitively intact according to his MDS assessment, was observed lying on the floor and fiddling with bed parts without staff intervention. He expressed a desire to leave the facility and was not engaged in any activities, despite his care plan indicating the need for structured activities and supervision. The lack of organized activities and staff presence contributed to his restlessness and attempts to exit the unit. Resident #12, who was severely cognitively impaired, was found in a room with a strong odor of urine and a cold temperature due to an open window. She was observed picking up food from the floor and speaking unintelligibly, with her care plan indicating the need for structured activities and reorientation strategies. However, there were no memory aids or activity calendars in her room, and her incontinence issues were not adequately addressed, as evidenced by the wet bed linens and persistent urine odor. Resident #9, diagnosed with early onset Alzheimer's disease, was observed wandering aimlessly and lying on the floor without staff intervention. His care plan included interventions for falls and behavior problems, but there was no guidance on how to redirect or prevent these behaviors. The memory care unit was understaffed, with reports of only one CNA present at times, leaving residents unsupervised. The facility's failure to provide adequate staffing and engage residents in meaningful activities contributed to the deficiencies observed in the care of these residents.
Failure to Follow Prescribed Menus for Residents on Special Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu to ensure nutritional adequacy for residents on mechanical soft and pureed diets. Specifically, residents ordered a pureed diet were supposed to receive pureed scrambled eggs, pureed toast, and six ounces of pureed hot or cold cereal for breakfast, but observations revealed they only received pureed eggs and pureed toast. Additionally, during lunch, residents on a mechanical soft diet were supposed to receive three ounces of ground lemon pepper chicken, while those on a pureed diet were to receive three ounces of pureed lemon pepper chicken, four ounces of pureed fluffy steamed rice, four ounces of peas and carrots, and two ounces of pureed dinner roll. However, the facility used incorrect serving scoops, resulting in smaller portion sizes, and failed to prepare or serve pureed dinner rolls. Interviews with residents confirmed that portion sizes were perceived as small, and the Registered Dietitian verified the discrepancies in serving sizes and the absence of pureed dinner rolls. The facility's menu policy mandates that menus meet the nutritional requirements and be followed as written unless specific exceptions apply, which were not the case here. This deficiency affected 12 residents who were ordered mechanical soft or pureed diets, as documented in the diet order report, and was investigated under Complaint Number OH00161747.
Inadequate Staffing and Care in Memory Care Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the total care needs of the residents and did not ensure adequate nursing coverage on each shift. This deficiency was observed through various incidents, including a Certified Nursing Assistant (CNA) found sleeping in a resident's bed and consuming snacks during her shift, which led to her termination. The Director of Nursing confirmed that there was only one nurse on duty during that incident. Additionally, observations revealed that residents in the Memory Care Unit were left unattended due to insufficient staffing, with call lights going unanswered for extended periods and residents not receiving timely assistance with personal care. Further observations highlighted the lack of staff during meal services, where non-nursing staff were observed serving meals without providing necessary assistance, such as opening milk cartons for residents. This resulted in residents being unable to consume their meals properly. Interviews with staff members, including a Registered Nurse and a CNA, confirmed the challenges faced due to inadequate staffing, which hindered their ability to provide necessary care, such as incontinence care and assistance with meals. The facility's staffing issues were further corroborated by resident council minutes and complaint logs, which documented ongoing concerns about insufficient staffing and unmet personal care needs. The facility's assessment indicated a required nurse-to-resident ratio that was not met according to the reviewed nursing schedules. The Administrator acknowledged that the staffing levels did not align with the facility's assessment, confirming the deficiency in meeting the required staffing standards.
Inadequate Dietary Staffing Leads to Meal Delays
Penalty
Summary
The facility failed to provide adequate and appropriate dietary staff to meet the dietary needs of its residents, affecting all residents except one who was on a nothing by mouth order. Observations and interviews revealed that meals were consistently late, with residents reporting delays in receiving breakfast, lunch, and dinner. For instance, one resident reported that their lunch always arrived after 2:30 P.M., and dinner after 6:30 P.M. Observations in the dining room confirmed that lunch trays were not served on time, with residents waiting for meals well past the scheduled serving times. Staff interviews corroborated the issue, with CNAs and LPNs acknowledging the consistent delays in meal service. They attributed the delays to insufficient kitchen staffing, which was further confirmed by the Dietary Manager. The Dietary Manager, who had recently started, noted that staffing was low, and on the day of observation, a cook had called off, and a dietary aide was involved in a car accident. As a result, non-dietary staff, including maintenance and laundry aides, were assisting in the kitchen, despite lacking formal training in food service. The facility's reliance on untrained staff to fill in for dietary roles highlighted the staffing inadequacies. The Director of Maintenance and a Maintenance Assistant, both without formal food service training, were involved in kitchen duties during emergencies. The Dietary Manager also had to step in to prepare meals when the cook walked out. These staffing challenges led to significant delays in meal service, impacting the residents' dining experience and potentially their nutritional intake.
Sanitation and Food Safety Deficiencies in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a tour with the Administrator. The walk-in cooler had heavily dusty light fixtures and a black substance on the ceiling and fan parts. The area around the walk-in freezer door also had black spots. A clean rack contained a black bucket with cloudy plastic cups and a silverware container with water spots and crumbs. The dry storage room floor was heavily soiled, and the steam table and coffee urn area were dusty and stained. Additionally, the area under the sink with the juice machine had a large white dried stain and a sticky brown substance, while the ice machine had a tannish substance inside. These observations were verified by the Administrator and the Dietary Manager. Resident #55's medical record indicated a diagnosis of type two diabetes mellitus, among other conditions. The resident had a personal refrigerator in their room, which contained multiple food items and was found to be in an unsanitary condition. The refrigerator had spills, a foul odor, and no thermometer. The resident attempted to clean it but lacked cleaning supplies. The Director of Nursing confirmed the unsafe condition of the food and the resident's report of needing cleaning assistance. Resident #1, diagnosed with vascular dementia and Alzheimer's disease, had a refrigerator in their room on the Memory Care Unit. The refrigerator's temperature was above the acceptable range, and it contained expired food items. There was no temperature tracking log, and the resident confirmed consuming the food items. The Director of Admissions verified the expired food and stated that CNAs and housekeeping should clean the refrigerator and dispose of expired items. The facility's policy required safe maintenance and sanitation of refrigerators, with temperature tracking and disposal of expired food items.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to maintain a clean, functional, and sanitary environment, affecting all 59 residents. Observations revealed multiple issues, including non-functional lighting, unclean resident rooms, and common areas. Resident interviews confirmed that housekeeping was inadequate, with rooms not being cleaned regularly, resulting in foul odors and visible dirt. Maintenance staff reported that corporate was unwilling to replace flickering lights due to cost concerns, and the maintenance assistant lacked access to the electronic system used to monitor facility needs. Specific incidents included a resident's over-the-bed light being non-functional for eight weeks, and another resident's bathroom having brown stains and a foul odor. The Memory Care Unit had a floor strip that was lifting and peeling, and a pervasive odor of urine was noted. Housekeeping staff admitted to not cleaning rooms if residents were present and not addressing shower curtains or privacy curtains. Additionally, several residents reported a lack of hand soap in their bathrooms, and one resident had a shower curtain stained with blood that had not been replaced for two weeks. The facility's maintenance director, who also served as the housekeeping supervisor, confirmed the poor condition of resident rooms and common areas. Observations included sticky floors, mold in showers, and clogged sinks. The facility's policy required daily cleaning of high-touch areas and resident restrooms, but this was not being followed. The deficiency was investigated under multiple complaint numbers, indicating a systemic issue with the facility's cleanliness and maintenance practices.
Facility Fails to Address Resident Concerns and Environmental Issues
Penalty
Summary
The facility failed to address residents' concerns regarding care, treatment, and environmental issues, affecting multiple residents. Residents expressed dissatisfaction with call light response times, dietary issues, missing laundry, and staff turnover. Specific incidents included a resident's complaint about a non-functioning light, another resident's concern about the shower room temperature, and missing clothing after a hospital visit. The facility's records showed a lack of inventory documentation and unresolved complaints, with no evidence of action taken to address these issues. Resident #62, who was cognitively intact, reported missing clothing after a hospital visit, but the facility did not conduct an inventory upon admission or when initially requested by the Ombudsman. The facility's investigation into the missing clothing was inconclusive, and no resolution or replacement of the clothing was provided. The Ombudsman confirmed the absence of an inventory list during her initial investigation, and the facility only created one after her return visit. The facility's concern logs from August to December revealed numerous unresolved complaints about dietary issues, maintenance problems, and staffing concerns. Residents reported issues such as flickering hallway lights, inadequate water temperatures in the shower room, and personal care concerns. Despite these complaints being documented in the concern logs and Resident Council minutes, there were no resolutions noted, and the facility's policy on addressing complaints was not followed.
Failure to Secure Hazardous Items and Supervise At-Risk Resident
Penalty
Summary
The facility failed to ensure that potentially hazardous chemicals and medicated treatments were kept in a secured area, posing a risk to residents in the Memory Care Unit. Observations revealed that the kitchenette area adjacent to the dining area had unsecured cabinets and drawers containing items such as COVID-19 tests, body cleansers, sprays, and cleaning chemicals. Residents were observed wandering freely in this area, with full access to these unsecured items. A Registered Nurse confirmed the lack of security for these items and acknowledged that residents frequently accessed the area. Additionally, the treatment cart in the Memory Care Unit was found unlocked and unsupervised, containing various medicated creams and ointments. A Registered Nurse admitted that the cart was left unsecured in a residential area where residents were actively wandering. The nurse also noted that there was insufficient staff presence in the unit at the time of the observation. The facility also failed to provide adequate supervision for a resident at risk of choking during meals. The resident, who had a history of dysphagia and a recent choking incident requiring the Heimlich maneuver, was observed eating breakfast unattended. The resident had multiple dental issues affecting her ability to chew, and staff were not present to assist or monitor her during the meal. Interviews with staff confirmed the lack of supervision, and the Director of Nursing acknowledged the expectation for staff to monitor the resident during meals, as outlined in her care plan.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely, affecting several residents and potentially impacting others who were cognitively impaired and independently mobile. Observations revealed multiple instances where medications were left unattended. For instance, 11 pills were found unattended in a medication cup at the bedside of one resident, and four pills were left on another resident's bedside table. Additionally, several pills were found scattered on the floor in a resident's room and in the hallway, indicating a lack of proper medication management and storage. Interviews with nursing staff confirmed these observations and revealed that the medications were not administered according to physician orders. The Director of Nursing confirmed that the residents involved did not have orders or assessments to self-administer medications, and acknowledged that medications should never be left unsecured. The facility's policy on medication administration and management, which requires staff to remain with residents until medications are swallowed, was not adhered to, leading to this deficiency.
Food Temperature Non-Compliance
Penalty
Summary
The facility failed to ensure that food was held and served at appropriate and palatable temperatures, affecting residents on pureed and mechanical soft diets. Observations and interviews revealed that food items such as ground baked ziti and pureed beets were served at temperatures below the facility's policy requirements. Specifically, the ground baked ziti and pureed baked ziti were recorded at 120 degrees Fahrenheit, and pureed beets at 130 degrees Fahrenheit, which are below the required holding temperature of 140 degrees Fahrenheit or higher. Residents expressed concerns about the food being served cold, which was corroborated by staff observations. The Dietary Manager confirmed the food temperatures during a test tray observation, noting that the baked ziti was 111 degrees Fahrenheit and the diced beets were 108.8 degrees Fahrenheit, both of which were flavorful but cold. The facility's policy on safe food temperatures mandates that hot foods be held at 140 degrees Fahrenheit or higher during meal service, and the steam table should not be used to reheat food. The deficiency was identified during an investigation of multiple complaints, indicating non-compliance with the facility's policy on maintaining safe food temperatures.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to discontinue an as-needed psychotropic medication, Ativan, after 14 days of ordering, as required. This deficiency affected one resident, who had been diagnosed with Alzheimer's disease with early onset, anxiety disorder, insomnia, and dementia. The resident's medical record showed an active order for Ativan, 0.5 mg by mouth every 4 hours as needed for anxiety, starting on November 11, 2024. However, there was no stop date for the medication, which should have been discontinued after 14 days. Interviews with the Director of Nursing confirmed the oversight and that the medication had not been needed outside of the routine order.
Failure to Implement Physician Orders for Residents
Penalty
Summary
The facility failed to follow and implement physician orders for two residents, leading to deficiencies in care. Resident #46, who has dementia, anxiety disorder, Alzheimer's disease, muscle weakness, and difficulty walking, was observed multiple times sitting in a wheelchair without her feet elevated, despite physician orders to encourage elevation due to bilateral edema. Interviews with staff revealed that while they encouraged foot elevation when the resident was in bed, they did not ensure her feet were elevated while in the wheelchair. Observations confirmed that the resident's left foot appeared swollen, and staff admitted to not consistently implementing the physician's orders. Resident #62, with diagnoses including cutaneous abscess, Crohn's disease, and a rectal fistula, was supposed to have his PICC line dressing changed every five days. However, observations and interviews revealed that the dressing had not been changed since 11/25/24, despite being signed off as completed on the medication administration record. The resident confirmed he never refused the dressing changes, and the LPN admitted to signing off on the treatment before performing it due to being busy, resulting in the dressing not being changed as required.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that physician-ordered pressure-relieving devices were in place for a resident, leading to a deficiency in pressure ulcer prevention. Resident #21, who had a history of a displaced fracture of the neck of the right femur and was dependent on staff for activities of daily living, was observed multiple times without the required heel protectors. The resident was admitted and re-admitted with diagnoses including muscle weakness and aftercare following joint replacement surgery. The care plan included interventions such as using positioning devices for proper body alignment and floating heels every shift as per physician orders. Despite these orders, observations during the survey period revealed that Resident #21 did not have heel protectors in place while in bed. Interviews with staff, including a CNA and two LPNs, confirmed the absence of heel protectors and a lack of awareness of the specific orders for heel protection. The resident remained in bed without the necessary protective devices throughout the survey period, indicating a failure to adhere to the prescribed care plan and physician orders aimed at preventing pressure ulcers.
Failure to Provide Adequate Foot Care for Residents
Penalty
Summary
The facility failed to provide appropriate foot care for two residents, both of whom had medical conditions that necessitated careful monitoring and treatment of their feet. Resident #41, who had type two diabetes mellitus and other related conditions, was found with a dressing on his right foot that was dated over a month prior, with no documentation or treatment orders for the wound. The facility's policy required regular evaluation and documentation of wounds, but there were no records of assessments or treatments for Resident #41's foot, indicating a lapse in care and monitoring. Resident #15, who also had type two diabetes mellitus and required assistance with personal hygiene, had a physician's order for foot care that was not being followed. Despite the treatment being signed off as completed in the medication and treatment administration records, staff admitted that the care was not being provided. Observations confirmed that Resident #15's feet were dry and flaky, with a large crack on the heel, further demonstrating the facility's failure to adhere to prescribed care protocols.
Failure to Provide Required Positioning Device for Resident with Hip Fracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion due to a fractured hip. The resident, who was alert but had cognitive impairment, was dependent on staff for activities of daily living. The care plan for the resident included the use of an abductor pillow to maintain hip precautions and a pillow between the legs to prevent dislocation. Despite these orders, observations revealed that the resident was consistently found in bed without a pillow between the legs, which was a necessary precaution to prevent further injury. Interviews with staff, including a CNA and LPNs, confirmed that the resident was supposed to have a pillow between the legs at all times due to pain and limited mobility. However, during multiple observations, the resident was found without the required positioning device. The deficiency was noted during the annual survey period, where the resident remained in bed without the necessary pillow, indicating a failure in adhering to the prescribed care plan and physician orders.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate. This deficiency affected two residents. For one resident, the LPN did not have the prescribed calcium tablet available and administered an incorrect dose of Miralax, as the LPN filled the cap only halfway to the fill line, contrary to the manufacturer's instructions. The resident was at risk for constipation due to decreased mobility and medication use, and the care plan required medications to be administered as ordered. For another resident with type two diabetes mellitus, the LPN failed to prime the insulin Kwikpen before administration, which is necessary to ensure the correct dose is delivered. The LPN was unaware of the need to prime the pen, as indicated by her questioning the surveyor about the requirement. The manufacturer's guidelines clearly state that priming is essential to remove air from the needle and cartridge, ensuring the pen functions correctly. This oversight could have led to an incorrect insulin dose being administered.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
