Continuing Healthcare Of Shadyside
Inspection history, citations, penalties and survey trends for this long-term care facility in Shadyside, Ohio.
- Location
- 60583 State Route 7, Shadyside, Ohio 43947
- CMS Provider Number
- 366285
- Inspections on file
- 36
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Continuing Healthcare Of Shadyside during CMS and state inspections, most recent first.
The facility failed to issue timely refunds to two residents or their estate after discharge and death, respectively. One resident with multiple sclerosis and osteoporosis was discharged to another setting, but a refund of private pay funds was not issued until more than 90 days later, exceeding both regulatory and facility policy timeframes. Another resident with dementia died in the facility, and a substantial refund owed to the estate was also delayed beyond 90 days, with the responsible party reporting repeated, unanswered contacts to corporate staff. The receptionist, who handled petty cash and communicated with the off‑site business office, and the administrator both confirmed that the refunds were not processed within the required time limits.
The facility’s written assessment of its staffing needs did not accurately reflect the number of staff required to meet resident care needs. The assessment, based on an average daily census of 83 residents including a locked memory care unit, listed estimated numbers of licensed nurses and nurse aides needed for direct care. However, the Regional Administrator later confirmed that administrative nurses (such as the DON, ADON, and MDS nurse) had been incorrectly counted as direct-care licensed staff, and administrative personnel (such as admissions and medical records staff) had been counted as nurse aides. This resulted in an inaccurate facility-wide assessment of the staffing resources necessary to meet residents’ assessed needs and care plans.
A severely cognitively impaired resident, fully dependent for ADLs and with multiple medical conditions, was observed seated alone in the dining room wearing only a hospital gown that left the back and legs exposed, with a full breakfast tray in front of him that he was not feeding himself. A CNA acknowledged bringing the resident to the dining room in the gown due to time and staffing constraints and recognized this was not appropriate but did not further cover the resident. An LPN stated it was acceptable for residents to be in the dining area in hospital gowns, despite the resident’s inability to choose his attire. This situation conflicted with the facility’s written policy requiring that residents be treated with dignity, respect, and privacy.
Staff failed to protect resident health information privacy by discussing medical conditions and treatment plans in public areas. A nurse practitioner and an RN discussed one resident’s medications in a hallway and assessed another resident’s ankle pain and new medication orders at a table in an activities room while other residents were present, without seeking the resident’s preference or moving to a private area. During a meal, a speech therapist questioned a resident with cognitive issues about a recent doctor’s appointment in a crowded dining room and then loudly asked an LPN across the room for details, prompting the LPN to describe the appointment within earshot of other residents and visitors, contrary to the facility’s privacy policy.
A resident with severe cognitive impairment, dysphagia, and total dependence for ADLs was brought to the dining room in an open-back hospital gown, leaving the resident exposed, and left sitting alone with a full breakfast tray and no staff assistance for an extended period. Breakfast had been delivered earlier, but no staff were present in the dining area, and the resident, who required full assistance with eating, was not fed until a CNA arrived from another unit and provided feeding without reheating the food. Staff interviews indicated there were not enough personnel or time to dress the resident appropriately before breakfast and that morning medication pass limited nurses’ ability to assist with feeding, despite a facility policy requiring care that maintains resident dignity and privacy.
Surveyors observed two residents in a memory care dining area eating lunch while a visitor held a small dog at the table, allowing the dog to lay its head on the table surface. The visitor, who had been holding the dog prior to the meal, did not perform hand hygiene and continued to hold the dog while feeding a resident. An LPN confirmed the sequence of events, and the DON acknowledged that having a dog at the table during meals and feeding a resident without hand hygiene violated the facility’s infection control policy, which is intended to reduce the risk of acquiring infections.
A resident with dementia and a history of falls experienced an unwitnessed fall and was found on the floor by a CNA, who notified an RN. The RN did not assess the resident or provide treatment, and the incident was not documented. The resident later complained of hip pain and showed decreased mobility, but was not transferred to the hospital until two days later, when an x-ray revealed a hip fracture.
A resident with multiple chronic conditions sustained a laceration to her foot requiring sutures after contacting a torn and rough footboard while attempting to sit up in bed. The unsafe condition of the footboard was not addressed prior to the incident, and there was no evidence of a system for ongoing maintenance and timely repair of resident equipment to prevent injuries.
A resident with multiple respiratory conditions experienced a decline in respiratory status, including labored breathing and low oxygen saturation. Staff administered oxygen above the ordered range for several days without additional interventions or updates to the care plan, and there was a lack of documented assessment or monitoring during a critical period. The resident was eventually transferred to the hospital and admitted for acute respiratory failure, COPD exacerbation, and pneumonia.
Four residents received antibiotics without meeting established infection criteria or proper documentation. In each case, antibiotics were administered for suspected infections such as pneumonia or UTI, but required surveillance checklists were incomplete or missing, and appropriate diagnostic tests were not always performed or communicated to the provider. Facility policy requiring infection prevention oversight and documentation was not consistently followed.
The facility did not follow dietary recommendations for two residents with complex medical needs, including not providing a prescribed nighttime protein snack for a resident on dialysis and failing to consistently document meal intake for another resident with malnutrition and dementia. Staff interviews and record reviews confirmed that dietary orders were not implemented and meal intake documentation was incomplete.
A resident with end stage renal disease and multiple comorbidities had all morning medications withheld on dialysis days over several months without a current physician order. Staff followed an outdated order from a previous admission, and the facility did not coordinate with the dialysis center or provider to clarify medication administration times, leading to improper medication management.
A resident admitted under hospice care with multiple diagnoses did not have medications properly reconciled on admission, resulting in an incorrect Lorazepam order and inconsistent documentation of Morphine administration. The MAR and narcotic count sheet contained discrepancies, and staff confirmed the errors in medication entry and record-keeping.
A resident with dementia and a history of falls experienced an unwitnessed fall that was not documented in the medical record, and neither the resident's representative nor the physician was notified until several days later, after the resident was hospitalized. This failure to follow notification protocols was confirmed by facility staff and was not in accordance with the facility's fall policy.
A resident with multiple comorbidities and a history of pressure ulcers was found to have a pressure relieving air mattress set incorrectly for their weight, contrary to the manufacturer's guidelines. Staff were unaware of the correct setting and did not address the service light, which indicated the mattress required maintenance. Documentation showed the mattress was checked regularly, but the improper setting and lack of response to the service alert persisted.
Failure to Timely Issue Resident Refunds After Discharge and Death
Penalty
Summary
The facility failed to ensure residents received refunds due within the regulatory timeframe of 30 days, and also failed to meet its own 90‑day refund policy. One resident with multiple sclerosis and osteoporosis was admitted and later discharged to an assisted living facility, with nursing documentation confirming the discharge. An invoice showed that this resident’s refund check for $1,565 was not issued until more than 90 days after discharge, exceeding both the facility’s policy and regulatory requirements. Another resident with dementia was admitted and later expired in the facility, with nursing notes documenting the death and notification of the physician, family, and hospice. An invoice indicated that a refund check for $6,440 to this resident’s estate was issued more than 90 days after the resident’s death. The responsible party reported not having received the refund despite multiple contacts with corporate staff. The receptionist, who managed petty cash and communicated with the corporate office, believed refunds should be issued within 90 days and acknowledged that the time elapsed for this refund exceeded that period. The administrator confirmed that refunds are processed by the corporate office, not on-site, and acknowledged that both residents’ refunds were issued later than 90 days after discharge or death and beyond the 30‑day regulatory requirement.
Inaccurate Facility Assessment of Staffing Needs
Penalty
Summary
The facility failed to accurately complete its facility-wide assessment regarding the number of staff needed to provide competent care to all residents during routine operations and emergencies. The written Facility Assessment Tool, updated 02/13/26, documented an average daily census of 83 residents, including a locked memory care unit with a 32-bed capacity and an average daily census of 28. The assessment identified a wide range of care needs for the memory care unit, including ADLs, mobility and fall risk, bowel and bladder care, skin integrity, mental health and behavioral needs, medications, pain management, infection prevention and control, management of medical conditions, therapy, nutrition, and person-centered psycho/social/spiritual support. The facility’s assessment stated it estimated needing 12–14 licensed nursing staff to provide direct care, 20–25 nurse aides, and three nursing personnel with administrative duties to care for the resident population. During an interview, the Regional Administrator confirmed that the staffing estimates documented on the Facility Assessment were incorrect. She explained that, when determining the number of licensed nurses providing direct care, she had inappropriately included administrative nurses such as the DON, ADON, and MDS nurse. Similarly, when calculating the number of nurse aides, she had included individuals in administrative roles, such as admissions and medical records staff. As a result, the facility assessment did not accurately reflect the overall number of facility staff actually needed to ensure a sufficient number of qualified staff were available to meet each resident’s needs as identified through resident assessments and care plans. This deficiency was identified as an incidental finding during the investigation of Master Complaint Number 2746972.
Resident Dignity Not Maintained When Brought to Dining Room in Exposing Hospital Gown
Penalty
Summary
Surveyors identified a failure to protect a resident’s dignity when a severely cognitively impaired memory care resident was observed seated alone in the dining room wearing only a hospital gown, with his back and legs exposed. The resident had multiple medical diagnoses including unspecified dementia, psychosis, delusional disorder, TIA, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. His most recent MDS showed a BIMS score of 0, highly impaired vision, unclear speech, and dependence on staff for all ADLs, including dressing, toileting, and eating. At the time of observation, he had a full breakfast tray in front of him but was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown and stated there was not enough time or staff to get him dressed before breakfast, acknowledging that this was not appropriate attire for the dining room but leaving him uncovered. An LPN reported she believed it was appropriate for residents, particularly skilled residents, to be in the dining area in hospital gowns, while also acknowledging that this resident could not choose how he was dressed due to his cognitive impairment. The resident’s spouse stated she believed staff did everything they could given staffing ratios and that responses could be delayed because staff were busy. The facility’s Dignity, Respect, and Privacy Policy stated that residents were to be treated with respect and cared for in a manner that protected their privacy, but this was not followed in this incident.
Failure to Protect Resident Health Information Privacy in Public Areas
Penalty
Summary
The deficiency involves failures to maintain the privacy and confidentiality of residents’ personal health information during clinical interactions in public areas. A nurse practitioner and an RN discussed medications with Resident #7 in a hallway near a resident room after the resident approached the NP with questions about medications prescribed the prior day; there was no evidence the NP directed the resident to a private location for this discussion. The same NP and RN then went to the activities room, where six residents were seated at a table playing a dice game, and the NP discussed Resident #42’s ankle pain and the plan to prescribe new medication at the table without asking if the resident was comfortable being assessed there or making any accommodations to move her away from the other residents. Resident #42’s record contained a progress note documenting that she was seen by the NP and that new orders were received related to complaints of leg pain. A separate incident occurred in the dining area during lunch, where a speech therapist spoke with Resident #79 about a recent doctor’s appointment in the presence of two visitors, 11 residents, and two LPNs. When the resident, who had cognitive issues, could not provide the information, the therapist loudly called across the room to an LPN to ask about the appointment, and the LPN responded by describing the physician visit loudly enough to be heard from the other side of the room. The LPN later confirmed that private medical information had been requested and shared in the full dining area and acknowledged that this information should not have been disclosed in that public setting. These actions were inconsistent with the facility’s Dignity, Respect, and Privacy Policy, which requires that unnecessary individuals be asked to leave while care is provided and that residents’ privacy and dignity be maintained.
Insufficient Staffing Led to Delayed Feeding and Inappropriate Attire in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to maintain the highest practicable psychosocial well-being of a resident who was dependent for all ADLs and required full assistance with eating. The resident had severe cognitive impairment (BIMS score of 0), highly impaired vision, unclear speech, and multiple medical diagnoses including dementia, dysphagia, psychosis, delusional disorder, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. The MDS documented that the resident was dependent for eating and all ADLs, required a mechanically altered diet, and needed to be up in a chair for meals with assistance for intake per speech therapy. On the morning of the survey observation, breakfast trays arrived to the memory care unit shortly before 8:00 A.M. At 8:55 A.M., the resident was observed sitting alone in the dining room in a wheelchair, wearing a hospital gown that was open in the back, leaving his back and legs exposed, with a full breakfast tray in front of him. No staff were present in the dining area, and the resident was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown because there was not enough time or enough staff to get him dressed before breakfast, despite knowing this attire was not appropriate for the dining room. The care plan included interventions for fall risk and having the resident eat meals in the all-purpose room for closer monitoring when awake. The resident remained without feeding assistance until 9:23 A.M., when another CNA arrived from a different unit and began feeding him, giving a few bites without reheating the food and then completing the meal. This CNA believed the resident sometimes fed himself and was unsure why he had not been fed earlier, estimating that breakfast trays arrived around 8:00 A.M. An LPN stated that nurses helped feed residents when they could but that mornings were very busy with medication pass, and she believed it was acceptable for a resident to be in the dining area in a hospital gown, even though the resident could not choose his clothing due to cognitive impairment. The resident’s spouse reported that he had required assistance with eating since a recent hospitalization for pneumonia and that she came daily to feed him lunch, noting that staff response could be delayed because they were very busy. The facility’s Dignity, Respect, and Privacy Policy required that residents be treated with respect and cared for in a manner that protected their privacy.
Dog at Dining Table and Lack of Hand Hygiene Breach Infection Control Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when a visitor’s dog was allowed at a dining table while residents were eating. During observation of the memory care unit dining area at lunchtime, two residents were seated together at a small table, each accompanied by a visitor. The visitor for Resident #77 was holding a small dog that repeatedly laid its head on the dining table. When Resident #77’s lunch tray arrived, the visitor continued to hold the dog and began feeding the resident without performing hand hygiene. An interview with LPN #384 confirmed that the visitor had been present prior to lunch, had continuously held the dog, and had not washed her hands or put the dog down at any point before feeding the resident. In a separate interview, the DON confirmed that having a dog at the table while residents were eating, and holding a dog while feeding a resident without hand hygiene, constituted an infection control issue and was against the facility’s infection control policy. Review of the facility’s Infection Control Prevention Policy, updated 01/11/25, showed that the facility’s policy was to provide care in a safe environment that promoted health and reduced the risk of acquiring infections. This incident was cited as an incidental finding of non-compliance during investigation of a master complaint.
Failure to Timely Assess and Treat Resident After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident experienced an unwitnessed fall with injury, and the facility failed to provide a timely assessment and necessary treatment. The incident began when a CNA observed the resident on the floor in front of her wheelchair and notified an RN. However, the RN did not assess the resident or provide needed treatment at that time. The CNA, after waiting for the nurse, assisted the resident back into her wheelchair without a nursing assessment, and there was no documentation of the fall or any assessment in the medical record for that date. Following the fall, the resident, who had a history of dementia, Alzheimer's disease, repeated falls, and was receiving hospice care, complained of hip pain and exhibited decreased mobility. Despite these symptoms, the resident was not transferred to the emergency room until two days later, after further assessment revealed significant pain and physical changes, including a leg length discrepancy. X-rays subsequently confirmed an acute right hip fracture, and the resident was then transferred to the hospital for treatment. Interviews and record reviews confirmed that the facility's fall policy, which required immediate assessment and notification of the physician and family, was not followed. The RN did not assess the resident after being notified of the fall, and the incident was not documented in the medical record. The lack of timely assessment and intervention resulted in a delay in necessary treatment for the resident's injury.
Failure to Maintain Safe Resident Equipment Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident's bedroom furniture in a safe condition, resulting in an injury. The resident, who had a history of respiratory failure, COPD, and type II diabetes, sustained a laceration to the top of her right foot after her foot came into contact with a torn and rough footboard while she was attempting to sit up in bed. The incident happened in the early morning hours, and the wound required hospital treatment, including the placement of seven sutures. Documentation and interviews confirmed that the footboard was in a state of disrepair at the time of the incident. Further review and staff interviews revealed that the rough patch on the footboard had not been addressed prior to the injury. There was no evidence provided to show that the facility had an effective system in place for the ongoing maintenance and timely repair of resident equipment to prevent such injuries. The resident's medical condition, including significant leg swelling and fragile skin, increased her vulnerability to injury, but the unsafe condition of the footboard was the direct cause of harm.
Failure to Provide Timely and Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate and timely respiratory care and treatment for a resident with a complex medical history, including COPD, asthma, and recent pneumonia. The resident experienced a decline in respiratory status, exhibiting symptoms such as shortness of breath, abnormal lung sounds, and decreased oxygen saturation. Despite an order for oxygen at 1-5 liters per minute, staff increased the oxygen to seven liters without additional interventions or new orders, and there was no documented evidence of further assessment or monitoring of the resident's respiratory or neurological status for a two-day period. The resident's care plan included interventions for COPD, such as monitoring for signs of respiratory insufficiency and infection, but there was no documentation reflecting the use of oxygen or updates to the plan of care after the resident's respiratory decline. Progress notes indicated that the resident had labored breathing and low oxygen saturation, yet no new treatments or orders were implemented by the nurse practitioner after these findings. The medication administration record showed that oxygen was administered above the ordered range for five days, with no corresponding documentation of physician notification or adjustment of the care plan. Ultimately, the resident developed new onset shortness of breath and chest pain, with abnormal lung sounds and pitting edema, leading to a transfer to the hospital where the resident was admitted for acute respiratory failure with hypoxia, acute exacerbation of COPD, and pneumonia. Interviews with staff confirmed concerns about the resident's status and a lack of timely intervention or escalation of care prior to the hospital transfer.
Failure to Ensure Antibiotic Use Met Established Criteria
Penalty
Summary
The facility failed to ensure that antibiotic usage met established criteria, as evidenced by the administration of antibiotics to four residents without proper documentation or justification according to McGeer's criteria. In one case, a resident with chronic respiratory failure, heart failure, and liver disease was given Omnicef for pneumonia despite not meeting the criteria for antibiotic treatment, with no documented explanation from the physician. The infection preventionist confirmed that the x-ray did not show pneumonia and there was no evidence supporting the need for antibiotics. Another resident with heart failure, diabetes, and benign prostatic hyperplasia received Bactrim for a urinary tract infection after returning from the hospital, but was not listed on the infection control log and did not have McGeer criteria completed. The DON and RN confirmed that the resident did not meet the criteria for antibiotic treatment, and the infection preventionist was not notified until several days after the antibiotics were started. Similarly, a resident with dementia and diabetes was started on Keflex for a suspected urinary tract infection without a completed culture or McGeer criteria form, and there was no evidence that the physician was informed about the lack of culture results. A fourth resident with dementia, ileus, and dysphagia was treated with Keflex for a urinary tract infection after returning from the emergency room, despite a urinalysis showing no significant growth and not meeting McGeer's criteria. The DON documented that the resident was started on antibiotics in the emergency room, but the medical provider ordered the medication to be continued based on a change in condition, agitation, and increased confusion, rather than established infection criteria. Facility policy required the infection preventionist to ensure appropriate testing and documentation before antibiotics were ordered, but this was not consistently followed.
Failure to Implement Dietary Recommendations and Monitor Nutrition
Penalty
Summary
The facility failed to implement dietary recommendations and adequately monitor and document meal intake for two residents with significant nutritional needs. For one resident with end stage renal disease, protein-calorie malnutrition, heart failure, diabetes, and liver disease, the dialysis dietician had recommended high-protein snacks at night to address low albumin levels. Despite this recommendation being faxed to the facility, there was no evidence of a corresponding order, documentation, or provision of a nighttime protein snack. Interviews confirmed that the facility's dietician had misplaced the recommendation, and the resident did not routinely receive a protein snack at night unless specifically requested. For another resident with dementia, anemia, malnutrition, and other chronic conditions, the care plan included multiple interventions to address nutritional risk, such as monitoring meal intake and providing assistance as needed. However, review of documentation revealed several instances where meal intake was not recorded, and analysis of the available records showed variable and often low meal consumption. Staff interviews confirmed that meal intake was expected to be documented for every meal, but gaps in documentation were present. Observations and interviews further supported that the facility did not consistently follow through on dietary recommendations or maintain accurate records of residents' nutritional intake. The lack of implementation of specific dietary orders and incomplete documentation of meal consumption contributed to the deficiency in ensuring adequate food and fluid provision to maintain residents' health.
Failure to Clarify and Implement Dialysis Medication Orders
Penalty
Summary
The facility failed to ensure that dialysis orders regarding the holding of medications were clarified and properly implemented for a resident with end stage renal disease and multiple comorbidities, including heart failure, diabetes, and liver disease. Medical record review showed that after the resident's readmission, there was no evidence of physician orders to hold medications on dialysis days, yet staff continued to withhold all morning medications on those days. This practice occurred repeatedly over several months, as documented in the medication administration records, without any supporting physician order. Interviews with the DON confirmed that staff were following an outdated order from a previous admission and had not obtained clarification or new orders from the physician or dialysis center. The DON acknowledged that staff held all morning medications on dialysis days in February, March, and April without a current physician order. The facility's policy required coordination with the dialysis center and provider regarding medication administration times, but this was not followed, resulting in the deficiency.
Failure to Reconcile and Accurately Document Medications on Admission
Penalty
Summary
The facility failed to ensure proper reconciliation of medications upon admission for a resident who was admitted under hospice care and had multiple complex diagnoses, including dementia, Alzheimer's disease, COPD, and a malignant neoplasm. The hospice medication list specified Lorazepam 0.5 mg to be given every four hours for anxiety and/or restlessness, and Morphine Sulfate Oral Solution to be administered in varying doses based on pain level or shortness of breath. However, the physician order entered at admission incorrectly listed Lorazepam to be given four times a day instead of every four hours as per the hospice order. This discrepancy was confirmed by the Regional Clinical RN during an interview. Additionally, there were inconsistencies in the documentation and administration of Morphine Sulfate. The Medication Administration Record (MAR) and the narcotic count sheet did not match regarding the times and amounts of Morphine administered. For example, the MAR showed doses of 0.75 ml and 1.0 ml administered at specific times, while the narcotic count sheet recorded a 0.5 ml dose at different times, indicating inaccurate documentation. These failures in medication reconciliation and documentation were identified through medical record review and staff interviews.
Failure to Notify Resident Representative and Physician After Unwitnessed Fall
Penalty
Summary
A resident with multiple diagnoses, including dementia, Alzheimer's disease, chronic obstructive pulmonary disease, malignant neoplasm of the bronchus or lung, and a history of repeated falls, was admitted to the facility on hospice services. The resident's baseline care plan identified them as being at risk for elopement, wandering, and falls, with interventions in place such as keeping commonly used articles within reach, maintaining clear pathways, monitoring for side effects of psychotropic medications, and assigning a room close to the nurses' station. On a specified date, the resident experienced an unwitnessed fall, as documented in the facility's investigation. Despite the fall, there was no documentation in the resident's medical record indicating that the fall occurred, nor was there evidence that the resident's representative or physician was notified at the time of the incident. Notification to the responsible party and physician did not occur until several days later, after the resident was hospitalized. The facility's fall policy required prompt notification of the physician and resident representative following a fall, but this protocol was not followed in this instance.
Failure to Set and Maintain Pressure Relieving Mattress per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure that a pressure relieving air mattress was set according to the resident's weight and maintained per the manufacturer's guidelines for a resident with a history of pressure ulcers and multiple comorbidities, including suspected deep tissue injury, peripheral vascular disease, anemia, chronic kidney disease, vascular dementia, hemiplegia, protein-calorie malnutrition, and diabetes. The resident's care plan and medical records indicated the use of an air mattress as an intervention for impaired skin integrity, with the resident weighing 174.5 pounds. However, observations revealed that the mattress was set at a level intended for residents weighing 441-500 pounds, rather than the correct setting for the resident's weight range of 163-244 pounds as specified by the manufacturer's label and manual. Despite staff documenting that the mattress was checked every shift and no issues were noted, the incorrect setting persisted, and the service light on the mattress was illuminated, indicating the need for service after a certain number of hours of use. Interviews with staff, including the ADON and CNA, confirmed a lack of awareness regarding the correct weight-based setting and the significance of the service light. The facility was not tracking the service light or notifying the rental company when it was activated, as required by the manufacturer's guidelines. These actions and inactions resulted in the failure to provide appropriate pressure ulcer care and prevention for the resident.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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