Continuing Healthcare Of Toledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 4420 South Avenue, Toledo, Ohio 43615
- CMS Provider Number
- 365488
- Inspections on file
- 30
- Latest survey
- September 30, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Continuing Healthcare Of Toledo during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for toileting did not receive timely incontinence care, resulting in saturated and soiled bed sheets, strong odors, and improper use of multiple incontinence products. Staff confirmed that care was not provided during the night, and facility policy requiring regular perineal care was not followed.
A resident with severe cognitive impairment and incontinence was found with a moldy water cup and soiled bed linens, while strong odors of urine and stool were present in the hallway. Staff confirmed lapses in cleaning and linen changes, and there was no documentation of water cup cleaning by dietary staff.
A resident with a suprapubic catheter did not receive consistent monitoring and care as required by physician orders and facility policy. Documentation was missing for daily cleansing and dressing changes at the catheter site, and urinary output was not consistently recorded. Observation confirmed the absence of a required dressing, and the DON acknowledged the lack of documentation for catheter site condition, treatment, and output.
The facility did not ensure that food and drink were served at safe and appetizing temperatures, resulting in multiple residents receiving cold and unpalatable meals. Staff and residents reported ongoing issues with food temperature and palatability, and direct observation confirmed that both hot and cold foods were served outside of safe temperature ranges. The Dietary Manager acknowledged these deficiencies, which affected several residents and had the potential to impact most individuals receiving meals from the kitchen.
Surveyors observed multiple areas of the facility that were not clean or well-maintained, including resident rooms with floor spots and wall scuffs, common areas with dirt and debris, hallways with cracked tiles and soiled walls, and a dining room with food spots, a cigarette butt, and debris. These conditions were confirmed by staff and did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with epilepsy, who was cognitively intact, refused three consecutive doses of their prescribed anti-seizure medication. The facility did not notify the physician as required by policy, and this was confirmed through medical record review and staff interview.
The facility failed to prevent skin breakdown in three residents with severe cognitive impairment and dependency on staff for daily activities. Observations revealed residents with double incontinence briefs, inadequate incontinence checks, and repositioning, contrary to facility policy. Care plans lacked specific frequency for these interventions, leading to potential risks for pressure ulcers.
The facility failed to provide timely incontinence care for three residents, all with severe cognitive impairment and always incontinent. Observations revealed residents with double briefs, contrary to facility policy, and a lack of documentation and communication between shifts. The DON confirmed that double briefing increases the risk of skin breakdown and infections.
A resident at risk for pressure ulcers experienced deterioration of an existing stage four ulcer and developed additional stage three ulcers due to the facility's failure to replace a broken ROHO cushion and implement alternative pressure-relieving interventions. Despite recommendations from a wound specialist, the resident remained in a wheelchair without necessary pressure relief, and staff were unaware of required wound care treatments, leading to untreated wounds and further skin breakdown.
The facility failed to maintain an effective quality assurance program, resulting in repeated deficiencies in providing ADL care to residents. Observations during the survey revealed a resident with dirty fingernails and another with long, jagged nails and heavy facial hair, indicating inadequate personal hygiene care. These issues were confirmed by staff interviews, highlighting a systemic problem in the facility's quality assurance processes.
The facility failed to maintain a safe and sanitary environment for its residents. A resident's room had a strong urine odor and exposed drywall, while another's room had soiled incontinence briefs and a dirty bathroom. A resident was observed in a wheelchair without an armrest pad, and two residents reported dirty air conditioning units and dusty window blinds. These conditions were confirmed by staff and violated the facility's policy on providing a safe, clean, and homelike environment.
The facility failed to ensure proper hand hygiene during meal service, affecting six residents. An LPN and an STNA were observed not performing hand hygiene between resident contacts while delivering meal trays. The STNA misunderstood the facility's policy, which requires hand hygiene between resident interactions.
The facility failed to accurately complete MDS assessments for two residents. One resident had a documented intact range of motion despite having a limited range in the left shoulder, confirmed by therapy reports and staff. Another resident's MDS assessment inaccurately documented a pressure ulcer instead of a trauma injury to the forearm. The DON confirmed these inaccuracies.
The facility failed to provide adequate nail care for two residents dependent on staff for ADLs. One resident with diabetes and anxiety had long nails with debris, despite being scheduled for nail care on bath days. Another resident with multiple disorders was observed with long, jagged nails and heavy facial hair. Staff interviews confirmed the lack of consistent nail care, indicating a deficiency in meeting personal hygiene needs.
The facility failed to follow physician orders for wound care and did not implement the bowel protocol for three residents. A resident with a forearm wound did not receive the prescribed daily dressing change, while two residents on pain medication did not receive necessary interventions for constipation despite prolonged periods without bowel movements. Staff interviews confirmed the lack of adherence to protocols, indicating systemic issues in care delivery.
The facility failed to supervise two residents while smoking and did not maintain smoking materials safely. One resident, with impaired cognition, was observed smoking unsupervised, while another resident had a half-smoked cigarette in his room despite being out at a doctor's appointment. Staff confirmed the lack of supervision and improper handling of smoking materials.
A resident with a history of incontinence was found heavily soiled with urine during a night shift, and the responsible STNA failed to provide necessary perineal care. The DON confirmed the resident required assistance with incontinence needs, but the facility lacked a specific policy for assessing bowel and bladder needs, despite having a perineal care policy.
A facility failed to follow enhanced barrier precautions for a resident with MRSA and a stage four pressure ulcer. An STNA did not wear a gown while providing incontinence care and carried an unbagged soiled brief through the facility. The resident's care plan required gown and glove use during high-contact activities, which was not adhered to, violating the facility's infection control policy.
The facility did not offer COVID-19 booster vaccines to three residents, as indicated by their medical records, which showed no education or consent for booster vaccines since their last administration in 2022. The DON confirmed the oversight, despite facility policy requiring vaccine offers and education when supplies are available, aligning with CDC guidelines for those aged 65 and older.
A facility failed to maintain an effective pest control program, resulting in gnats and house flies in a resident's room. The resident, with multiple health issues and impaired cognition, was observed with pests on bed linen and in the restroom. Staff confirmed the infestation, and the Maintenance Director was unaware and lacked documentation of pest prevention treatments.
The facility failed to ensure STNAs completed required training on dementia care and 12 hours of continuing education annually, potentially affecting all 61 residents. Personnel files for several STNAs lacked documentation of dementia care training, and interviews confirmed the absence of such training due to the facility not having a designated dementia unit.
Failure to Provide Timely Incontinence Care and Maintain Cleanliness
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and total dependence for toileting and showers did not receive timely incontinence care. The resident, who was always incontinent of bowel and bladder, was observed to have a strong odor of urine and stool coming from their room. Upon further observation, the resident's bed sheets were found to be saturated with urine and soiled with stool, and the resident was wearing an incontinence brief with an additional brief used as a pad inside. Staff interviews confirmed that the resident's incontinence care products were saturated from the overnight shift and that care had not been provided during the night. The certified nurse aide reported that the stool was stuck to the resident's skin and that the bed sheets had not been changed during the morning care. The facility's policy required perineal care to be provided as needed to promote cleanliness, comfort, and prevent infection and skin breakdown. However, the care plan for the resident specified peri-care with each incontinence episode, and the Director of Nursing stated that briefs should be checked and changed every two hours. Despite these requirements, the resident did not receive timely incontinence care, and multiple incontinence products were used in a manner not consistent with standard practice. This failure affected one resident directly and had the potential to impact other residents identified as incontinent.
Failure to Maintain Cleanliness and Sanitation in Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by unclean water cups and persistent strong odors of urine and stool. One resident with severe cognitive impairment, functional bladder incontinence, and total dependence for toileting and showers was found to have a water cup on her dresser containing a black substance identified as mold, along with floating debris and film in the water. The resident was unaware of the location of her water cup, and staff confirmed the presence of mold. Dietary staff were responsible for cleaning water cups, but there was no documentation of cleaning practices. Additionally, a strong odor of urine and stool was observed in the hallway outside the same resident's room. The resident reported her incontinence brief had not been changed during the night, and staff confirmed that while her brief was changed in the morning, her bed sheets, which were saturated with urine and soiled with stool, had not been changed. Facility policy required a clean, sanitary, and comfortable environment, including clean bed linens and pleasant scents, but these standards were not met.
Failure to Maintain and Monitor Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to maintain and monitor a resident's urinary catheter system, specifically for a resident with a suprapubic catheter. The resident, who was admitted with multiple diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and a history of urinary tract infection, was dependent on staff for all activities of daily living and had a care plan that addressed some aspects of catheter care. However, the care plan did not include interventions to monitor the suprapubic stoma or to record the amount of urine collected in the catheter drainage bag. Physician orders required daily cleansing of the suprapubic catheter site and application of a dry dressing, but there was no documentation that this was performed on several specified dates. Additionally, there was a lack of assessment of the catheter stoma site in the medical record. Observation revealed that the resident did not have a dressing in place at the suprapubic insertion site as ordered. Electronic documentation also showed inconsistent recording of urinary output, with several shifts and days lacking any documentation of output. The facility's catheter care policy required catheter care every shift, regular changing of privacy bags, and emptying of drainage bags at specified intervals, but these practices were not consistently documented or observed. The Director of Nursing confirmed the lack of documentation regarding the catheter stoma condition, site treatment, and urinary output.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe, appetizing temperatures and were palatable, as required by both FDA guidelines and facility policy. Multiple residents who received meals in their rooms reported that their food was consistently cold and, in some cases, not palatable. Staff interviews confirmed that food delivered to resident rooms was typically at room temperature. During observation, a test tray revealed that hot foods, such as a fish sandwich, carrots, and green beans, were served below the recommended temperature of 140°F, with readings of 123°F, 110°F, and 108°F, respectively. The milk was also served above the safe cold temperature, at 53°F, and Jell-O was observed to be in a liquid state rather than properly set. The fish sandwich was described as cold, mushy, and overwhelmingly salty, making it unpalatable. Residents and staff consistently reported complaints regarding both the temperature and palatability of the food. The Dietary Manager acknowledged these concerns and verified the issues with the food's temperature and quality during the survey. The facility's own policy requires that residents receive nourishing, palatable, and well-balanced diets that meet their needs and preferences, but this standard was not met for several residents, with the potential to affect nearly all residents receiving meals from the kitchen.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, well-maintained, and homelike environment, as evidenced by multiple observations throughout the building. In one resident's room, there were large spots on the floor by the bed, scuff marks on the walls, and two gouges on the floor, each approximately three inches in diameter. The administrator confirmed these findings. In the common area of the 200-hall, dirt and debris were observed coating the floor by the nurse's station, which was also verified by the administrator. Additional observations included a hallway with eight cracked tiles, a wall soiled with an unidentified black substance near a resident's room, and another wall splattered with an unidentified brown substance next to a different resident's room. An LPN confirmed the presence of these issues. In the dining room of the 200-hall, there were 14 spots of unidentified food on the floor, a cigarette butt by the scale, and the floor under the air filter was coated with an unidentified black substance and debris. These findings were verified by staff interviews and were not in accordance with the facility's policy to provide a safe, clean, comfortable, and homelike environment.
Failure to Notify Physician After Multiple Medication Refusals
Penalty
Summary
The facility failed to notify the physician when a resident, who was cognitively intact and had a diagnosis of epilepsy, refused their prescribed anti-seizure medication, Keppra, for three consecutive doses. Medical record review showed that the resident refused both morning and bedtime doses on one day and the morning dose the following day, with no documentation indicating that the physician was informed of these refusals. Staff interview with the DON confirmed the lack of physician notification, and review of facility policy revealed that the nurse is required to notify the physician after two or more consecutive refusals of medication or treatment. This deficiency was identified during a complaint investigation.
Failure to Prevent Skin Breakdown in Residents
Penalty
Summary
The facility failed to provide adequate interventions to prevent skin breakdown for three residents, as observed during a survey. Resident #1, who had severe cognitive impairment and was dependent on staff for daily activities, was found with two incontinence briefs applied, contrary to facility policy. The resident was also missing an offloading boot, which was part of the care plan to prevent pressure ulcers. Documentation showed a lack of consistent incontinence checks and repositioning, which are critical for preventing skin breakdown. Resident #2, also with severe cognitive impairment and dependent on staff, was similarly found with two incontinence briefs and was soiled with urine. The staff was unaware of the last incontinence care provided, and there was a lack of documentation for repositioning and incontinence checks. The care plan did not specify the frequency for these interventions, which are essential for maintaining skin integrity. Resident #3, with severe cognitive impairment and at high risk for pressure ulcers, was found in a similar situation with two incontinence briefs and inadequate documentation of incontinence checks and repositioning. The facility's policies on pressure injury prevention and management were not followed, as evidenced by the lack of systematic documentation and adherence to care plans designed to prevent skin breakdown.
Failure to Implement Timely Incontinence Care
Penalty
Summary
The facility failed to implement timely and appropriate incontinence care interventions for three residents, as observed during a survey. Resident #1, who has severe cognitive impairment and is always incontinent of bowel and bladder, was found in bed with two incontinence briefs applied. The resident was unable to indicate when they were last checked for incontinence, and there was no documentation of incontinence checks after 9:23 P.M. the previous day. The CNA responsible for the resident at the time of observation had not received a report from the previous shift, and the Director of Nursing (DON) confirmed that double briefing is against facility policy due to the risk of skin breakdown and infections. Resident #2, also with severe cognitive impairment and always incontinent, was similarly found with two briefs and soiled with urine. The CNA on duty was unaware of the last incontinence check, and there was no documentation of checks after 11:48 P.M. the previous night. Interviews with staff revealed a lack of communication between shifts, with CNAs not providing reports to incoming staff. The DON reiterated the policy against double briefing and the requirement for CNAs to document incontinence checks. Resident #3, who is dependent on staff for all activities of daily living and always incontinent, was found with two briefs and no documentation of incontinence checks after 8:22 A.M. the previous day. The CNA on duty had not received a report from the previous shift, and the DON confirmed the facility's policy against double briefing. The lack of documentation and communication between shifts contributed to the failure to provide timely and appropriate incontinence care for these residents.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in the deterioration of an existing stage four pressure ulcer and the development of additional stage three pressure ulcers. The resident, who was at risk for pressure ulcers due to conditions such as paraplegia and diabetes, had a specialized ROHO cushion removed from their wheelchair for repair, and no alternative pressure-relieving intervention was implemented. This lack of intervention led to the resident developing two new stage three pressure ulcers and worsening of the existing stage four ulcer. The resident's medical record indicated a history of chronic stage four pressure ulcer on the right ischium, which was not healing as expected. Despite recommendations from a wound specialist to off-load the wound and use a specialized cushion, the facility did not replace the broken cushion or provide alternative pressure relief. Observations revealed that the resident remained in the wheelchair for extended periods without the necessary pressure relief, contributing to the skin breakdown. Interviews with staff, including a State Tested Nurse Aide and a Licensed Practical Nurse, revealed a lack of awareness and implementation of the required wound care treatments. The resident was found without dressings on their wounds, and there was a delay in applying the prescribed treatments. The Director of Nursing confirmed the absence of a pressure-relieving cushion and acknowledged the resident's inability to reposition themselves, which further exacerbated the situation.
Failure in Quality Assurance Program and ADL Care
Penalty
Summary
The facility failed to maintain an effective quality assurance program to address repeated quality concerns, as evidenced by deficiencies identified during three consecutive annual surveys. The CASPER Report dated August 2, 2024, highlighted deficiencies in providing activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022. This issue affected all 61 residents in the facility, indicating a systemic problem in the facility's quality assurance processes. Specific observations during the current annual survey revealed that Resident #24, who had intact cognition and was dependent on staff for personal hygiene, had dirty fingernails with dark debris under them on multiple occasions. Similarly, Resident #44, with moderately impaired cognition and dependent on staff for ADLs, was observed with long, jagged fingernails with black/brown debris and heavy facial hair growth. These observations were confirmed by staff interviews, indicating a failure to provide adequate personal hygiene care to these residents. The facility's policy on Quality Assurance and Performance Improvement (QAPI) stated that performance improvement activities should be monitored in QAA Committee meetings, but the repeated deficiencies suggest that these activities were not effectively implemented or sustained.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for its residents, as evidenced by several observations and interviews. Resident #36's room was found to have a strong urine odor, peeling paint, and exposed drywall, which was confirmed by both a Licensed Practical Nurse and the Maintenance Director. Resident #43's room was observed to have a foul odor, with soiled incontinence briefs, clothing, and linen on the floor, as well as a bathroom with soiled towels and toilet paper. A housekeeper verified the frequent soiled condition of the room. Resident #35 was observed multiple times seated in a wheelchair without an armrest pad on the left side, causing the resident's arm to rest on a thin pipe. A State-tested Nurse Aide confirmed the missing armrest and was unaware of its absence. Resident #46 reported dirt inside the air conditioning unit cover, which was confirmed by an observation that revealed dust rolling up from the filters. The Activities Director verified that maintenance was responsible for cleaning the air conditioning unit filters. Resident #47's air conditioning unit vents were coated with a brown substance, and the window blinds had a heavy buildup of dust. The resident stated that the facility had not cleaned the air conditioning unit in three years, although he had cleaned it himself once. An LPN confirmed the dirty condition of the air conditioning unit and window blinds. A housekeeper planned to deep-clean the room later in the day. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by these findings.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was practiced during meal service, affecting six residents. Observations revealed that a Licensed Practical Nurse (LPN) did not perform hand hygiene after assisting a resident with a wheelchair and before handling another resident's meal tray. The LPN confirmed the lapse in hand hygiene during an interview. Additionally, a State tested Nurse Aide (STNA) was observed delivering meal trays to multiple residents without performing hand hygiene between contacts. The STNA handled personal items and picked up a salt packet from the floor without cleaning her hands. During an interview, the STNA acknowledged not performing hand hygiene and misunderstood the facility's hand hygiene policy, which requires hand hygiene between resident contacts. The facility's policy review confirmed the requirement for hand hygiene between resident interactions.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for two residents. Resident #47, who was admitted with diagnoses of neoplasm of the brain and anxiety, had an annual MDS assessment indicating intact cognition and no functional limitations in the range of motion of the upper extremity. However, a physical therapy progress report and an updated therapy plan revealed that the resident had a limited range of motion in the left shoulder, from zero to 90 degrees, which was confirmed by the Rehabilitation Services Director. An interview and observation with the resident further confirmed the limited range of motion and associated pain. Resident #155, admitted with a diagnosis of a wound to the right forearm, had an MDS assessment indicating a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. However, a weekly wound evaluation and a skin observation tool indicated that the resident had a trauma injury to the right forearm. The Director of Nursing confirmed that the MDS assessments for both residents were documented incorrectly, highlighting inaccuracies in the facility's assessment process.
Inadequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for residents who were dependent on staff for assistance with activities of daily living (ADLs). Resident #24, who had diagnoses of type II diabetes mellitus and anxiety, was observed with long nails and dark debris under them on multiple occasions. Despite being dependent on staff for personal hygiene, her nails were not trimmed or cleaned as per her care plan, which indicated that nail care should be performed on bath days and as necessary. Interviews with staff confirmed that nail care was the responsibility of State Tested Nurse Aides (STNAs), but it was not consistently performed. Similarly, Resident #44, who had multiple diagnoses including schizoaffective disorder and vascular dementia, was observed with long, jagged fingernails with black/brown debris and heavy facial hair growth. This resident was also dependent on staff for ADLs, including personal hygiene. Staff interviews verified the observations of inadequate nail care. The facility's failure to ensure proper nail care for these residents highlights a deficiency in meeting the personal hygiene needs of residents who rely on staff assistance.
Failure to Follow Wound Care and Bowel Protocols
Penalty
Summary
The facility failed to adhere to physician orders for wound care and did not implement the bowel protocol as required, affecting three residents. Resident #155, who had a wound on the right forearm, did not receive the prescribed daily dressing change on 08/11/24, as confirmed by both the resident and LPN #426. The bandage was observed to be unchanged since 08/10/24, and there was no documentation of wound care on 08/11/24. Despite the wound showing improvement, the lack of adherence to the dressing change schedule was noted. For Resident #24, who was on narcotic pain medication, the facility failed to administer as-needed stool softeners despite the absence of documented bowel movements from 05/29/24 to 06/06/24. The facility's protocol required intervention after 72 hours without a bowel movement, but this was not followed. The resident expressed concerns about constipation due to pain medication, and the Director of Nursing confirmed the protocol was not implemented as it should have been. Similarly, Resident #49, who had a history of irritable bowel syndrome, did not receive additional interventions for constipation despite no documented bowel movements from 06/01/24 to 06/07/24. Although the dose of Senna S was increased, no further actions were taken according to the bowel protocol, which included administering Milk of Magnesia, suppositories, or enemas if necessary. Interviews with staff confirmed the lack of adherence to the bowel protocol, highlighting a systemic issue in monitoring and addressing bowel movements in residents.
Inadequate Supervision and Unsafe Maintenance of Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and safe maintenance of smoking materials for residents who smoke, affecting two residents. Resident #21, diagnosed with bipolar disorder, dementia, and schizophrenia, was observed smoking unsupervised in the designated smoking area. Despite requiring supervision due to impaired cognition, Resident #21 was seen smoking two cigarettes simultaneously, with ashes on his shorts and cigarette butts scattered around the area. Interviews with facility staff, including the MDS Coordinator and LPN, confirmed the absence of supervision and the requirement for Resident #21 to be supervised while smoking. Resident #156, with diagnoses of chronic obstructive pulmonary disease and hypertension, was found to have a half-smoked cigarette on a cardboard pizza box in his room while he was out at a doctor's appointment. Although Resident #156 was assessed as safe to smoke without supervision, the presence of smoking materials in his room was not in line with the facility's policy, which states that smoking materials for residents requiring supervision should be maintained by nursing staff. The LPN confirmed the observation of the cigarette in Resident #156's room.
Failure in Timely Incontinence Care and Perineal Hygiene
Penalty
Summary
The facility failed to provide timely incontinence care and interventions for a resident, identified as Resident #36, who was frequently incontinent of bowel and bladder. The resident, who had a history of multiple medical conditions including epilepsy, diabetes, and acute kidney failure, was found heavily soiled with urine during a night shift. The State tested Nurse Aide (STNA) #405, who was responsible for the resident during this shift, did not check the resident for incontinence and was unaware of the resident's incontinence history. Upon discovering the resident's condition, the STNA assisted the resident to the restroom but failed to provide necessary perineal care to cleanse the resident of residual urine before dressing them in clean clothing. The Director of Nursing (DON) confirmed that the resident required assistance with incontinence needs and that residents should be thoroughly cleansed following an incontinence episode. However, the facility lacked a specific policy or procedure to assess resident bowel and bladder needs, although a perineal care policy was in place to promote cleanliness and prevent infection. This deficiency in care was identified through observation, medical record review, and staff interviews, highlighting a lapse in the facility's adherence to its own care policies.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed during personal care for a resident with a stage four pressure ulcer and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The resident, who was dependent on staff for toileting and personal hygiene, had a physician order requiring staff to wear gowns and gloves during high-contact activities. Despite signage indicating the need for EBP, a State tested Nurse Aide (STNA) entered the resident's room and changed the resident's brief without wearing a gown, as required by the facility's policy. The STNA was observed carrying an unbagged soiled brief through the facility, past other resident rooms and the nurses' station, before disposing of it in the soiled utility room. The STNA admitted to not wearing a gown and carrying the brief unbagged because there was only one bag left in the resident's room. The Director of Nursing confirmed the resident's MRSA diagnosis and the requirement for EBP due to the infection in the resident's coccyx wound. The facility's policy mandates the use of gowns and gloves during high-contact care activities and requires soiled linens to be bagged at the bedside.
Failure to Offer COVID-19 Booster Vaccines
Penalty
Summary
The facility failed to offer COVID-19 booster vaccines to residents as indicated, affecting three residents out of five reviewed for COVID-19 vaccinations. The medical records for Residents #12, #15, and #34 showed that their last COVID-19 vaccination was administered on 08/19/22. There was no documentation of education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022 for these residents. An interview with the Director of Nursing confirmed that these residents were not offered COVID-19 vaccinations since 2022. The facility's policy, dated 05/23, stated that residents and staff would be offered the COVID-19 vaccine when supplies are available, and they would be screened for prior immunization, medical precautions, and contraindications. Education about the vaccine, including risks, benefits, and potential side effects, was to be provided before offering the vaccine. The CDC's updated guidelines recommend COVID-19 vaccination for everyone aged six months and older, with special considerations for those aged 65 and older to receive an additional dose of the updated vaccine.
Pest Control Deficiency in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an environment that was not free from pests. This deficiency was observed in the room of Resident #36, who was admitted with multiple diagnoses including epilepsy, type II diabetes mellitus, and acute kidney failure. The resident was assessed with moderately impaired cognition and required assistance with activities of daily living. Observations on two separate occasions noted the presence of gnats and house flies in the resident's room, including on the bed linen and in the restroom. During interviews, both a Licensed Practical Nurse and a State Tested Nurse Aide confirmed the presence of these pests in the resident's room. The Maintenance Director also verified the infestation but was unaware of the issue and could not provide documentation of any pest prevention treatments. This lack of awareness and documentation indicates a failure in the facility's pest control program, affecting the living conditions of Resident #36.
Deficiency in STNA Training on Dementia Care and Continuing Education
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) completed necessary training on dementia care and the required 12 hours of continuing education annually. This deficiency had the potential to affect all 61 residents in the facility. Specifically, the personnel file for STNA #409, hired on 09/20/18, lacked evidence of the required continuing education and dementia care training. Similarly, STNAs #479, #419, and #449, hired in 2023, had no documentation of dementia care training in their files. Interviews with the Human Resources Director and an STNA confirmed the absence of dementia training, with the HR Director noting that the facility did not provide such training due to the lack of a designated dementia unit.
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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