Country Club Retirement Ctr Iv
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellaire, Ohio.
- Location
- 55801 Conno-mara Drive, Bellaire, Ohio 43906
- CMS Provider Number
- 365699
- Inspections on file
- 24
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Country Club Retirement Ctr Iv during CMS and state inspections, most recent first.
A hospice resident with advanced pancreatic cancer, severe pain, and total dependence for care was transferred from an inpatient hospice unit with active orders for multiple pain and anxiety medications, including Morphine, Roxanol, MS Contin, Ativan, and Oxycodone. On admission, the facility left key admission assessments and documentation blank, did not initiate an acute care plan, and failed to enter or implement most of the hospice medication orders, documenting only a scheduled Morphine regimen. The first Morphine dose was significantly delayed, only two doses were documented on the MAR despite three being signed out, and there was no documented Ativan order or administration even though hospice and pharmacy confirmed Ativan orders had been sent. A hospice RN later assessed the resident’s pain as 9/10, while the resident’s wife reported unanswered call lights, refusal or delay of requested pain medication, and staff comments minimizing her concerns. Photos showed the resident restless at the edge of the bed with facial grimacing, and hospice records after transfer back to the inpatient unit documented frequent administration of Morphine, Roxanol, Ativan, and Haldol for pain, anxiety, and restlessness until death.
A resident with a history of severe intractable migraines and hypertension was admitted with orders for multiple pain and blood pressure medications, including newly ordered Topamax for migraine prophylaxis and PRN Imitrex for acute migraines. Facility records showed incomplete vital sign and pain assessments, and the MAR/TAR documented that the ordered Topamax and Imitrex were never administered, while pain scores were marked as not applicable despite documented severe headaches, vomiting, and prior high pain ratings. On one shift, an LPN, covering both Assisted Living and the skilled unit, acknowledged not giving the ordered migraine medications or PRN Tylenol, administering only scheduled Gabapentin and being unaware of the Imitrex order. The resident’s daughter found the resident covered in vomit, requested transfer, and the resident was sent to the hospital without a completed transfer form, where she was admitted for intractable headaches/migraines and hypertensive emergency. The resident, her daughter, and the DON later confirmed that ordered migraine medications were not given and blood pressure monitoring was not performed in accordance with the facility’s pain management policy.
The facility failed to maintain a comprehensive infection prevention and control program with effective surveillance and trending. Infection tracking relied on a color-coded map that did not document specific infection types or details needed to identify patterns. Review of infection logs over several months showed multiple UTIs and other infections recorded without organisms or, at times, without the site of infection. The IP/LPN confirmed that infections were not monitored for trends and that most UTIs lacked culture results, and reported being instructed by a prior DON not to contact providers and to administer antibiotics as ordered, despite a written policy requiring detailed infection surveillance and pattern review in QA meetings.
The facility did not ensure a qualified IP was designated to effectively oversee its antibiotic stewardship program. An LPN identified as the IP had not served in that role for several years, could not produce a current IP certificate, and had not maintained biennial IP training, while the facility’s infection control logs showed noncompliance with antibiotic stewardship requirements, including poor use of hospital documentation and inaccurate McGeer’s evaluations. Another LPN held an IP training certificate but was not yet functioning as IP, and the facility’s IP policy lacked requirements for formal IP certification, ongoing education, and specific guidance on antibiotic stewardship.
The facility failed to maintain a call light system that stayed active until staff responded and to ensure timely responses to resident calls. A resident’s daughter reported that her mother waited an extended time for assistance despite using the call light and that she repeatedly observed CNAs not performing 2-hour checks as expected. In another case, a surveyor tested a resident’s call light and found it automatically reset after about 16 minutes, requiring the resident to reactivate it, with staff not answering until several minutes after the initial activation. Maintenance staff confirmed the automatic reset feature, and a staff member acknowledged that call lights were not answered promptly and that residents had complained, contrary to the facility’s call light policy.
A resident re-admitted after hip fracture surgery, with PVD, incontinence, impaired cognition, and full dependence for mobility, was assessed as at moderate risk for pressure ulcers but did not receive new preventive interventions such as pressure-reducing devices, a turning/repositioning program, or documented nutrition/hydration measures. No full skin assessment was documented after readmission until the resident’s daughter discovered a coccyx pressure ulcer that staff had not identified, and subsequent evaluations showed the wound progressed from Stage II to unstageable with infection, along with new suspected deep tissue injuries on both heels. Although orders were written for daily wound care, an air mattress, heel boots, offloading, and barrier cream, the TAR showed missed coccyx and heel treatments without documented refusals, and observation found heel boots not in place despite staff stating they were tolerated, while the care plan listed only providing treatments as ordered and did not reflect broader preventive measures.
A resident with a history of left femur fracture, dizziness, impaired gait, muscle weakness, and psychoactive medication use had a fall-risk care plan that included bright colored paper to cue use of the call light, bright colored tape on wheelchair brake handles, and dycem on the wheelchair seat. During surveyor observation with an RN, none of these interventions were in place on the resident’s new wheelchair or in the room, despite being listed in the care plan. The RN acknowledged that staff had not transferred these interventions to the new wheelchair, and the resident’s daughter reported she believed preventive measures were not implemented and that she had not received requested information about the fall and care plan, contrary to the facility’s written fall policy.
A resident with a history of UTIs, hypotension, protein-calorie malnutrition, and dysphagia had a dietary recommendation and physician order for an extra 240 ml of fluids with lunch and dinner to support hydration. Over an extended period, intake records showed low average daily fluid intake and no documentation that the ordered extra fluids were consistently provided. A supper meal ticket lacked the extra fluid order, observation showed only one standard beverage and a UTI supplement, and the DM reported being unaware of the extra fluid requirement, with no notation on the dietary reminder sheet. An LPN later confirmed the order existed, and the resident’s daughter reported ongoing concerns about inadequate hydration, dark urine, decreased urination, and recurrent UTIs.
The facility failed to maintain accurate and consistent medical records and treatment documentation for three residents. For a newly admitted resident, no medical diagnoses were entered into the record, medication orders, or care plan at the time of review. For a resident with a prior hip fracture, physician orders for nonskid strips in front of the commode and visual reminders to use the call light remained active, and staff signed treatment sheets twice daily as if these interventions were in place, even though the DON confirmed the strips and signage had been removed when the resident stopped using the bathroom. For another resident with multiple chronic conditions and a Stage II ankle pressure ulcer, there were two conflicting active physician orders for the same ankle area—one to pad and protect a healed ulcer and another for cleansing and duoderm application—and the DON verified that one of these orders did not appear on the treatment sheet for staff documentation.
The facility failed to implement an effective antibiotic stewardship program, resulting in multiple residents receiving antibiotics without timely or accurate application of McGeer criteria and incomplete infection surveillance documentation. When the Infection Preventionist (an LPN) was off duty, no one reviewed new antibiotic orders, so residents were started on systemic antibiotics before determining if infection criteria were met or before contacting a physician about non-qualifying cases. One resident with a toe wound was documented as meeting McGeer criteria for a wound infection even though only redness and swelling were recorded, contrary to the requirement for four signs or symptoms. Another resident with a breast abscess was started on Bactrim and topical mupirocin without an infection report form or log entry until several days later, and the form later contained an erroneous fever entry that conflicted with the infection log. A third resident on Levaquin for pneumonia initially lacked a completed McGeer form and log entry, and only later was documented as meeting all required pneumonia criteria, with the LPN acknowledging the review was not done in a timely manner despite an existing antibiotic stewardship policy requiring such review.
A resident with dementia, a history of falls, and documented goal-directed wandering, who wore elopement alert bracelets, exited the building without staff awareness after previously attempting to leave through a dining room door on prior occasions. On the night of the incident, no door alarms sounded, and the resident was later found outside near the facility driveway. Staff and maintenance reported that exit door alarm systems, including Wander-guard and other alarms on the front and dining room doors, functioned inconsistently, sometimes requiring multiple attempts to activate, sometimes failing to lock or alarm, and sometimes remaining ajar so they did not secure or alarm at all. There was no documentation that staff checked the resident’s bracelets or the doors’ functioning at the time of the elopement.
Narcotic sheets and shift-to-shift count records for controlled substances were found to be incomplete and inconsistent, with missing signatures, incorrect counts, and documentation errors. LPNs reported inconsistent procedures for counting and documenting, and the DON identified blank spots and missing signatures for the administration of medications such as Tramadol and Ativan. These failures affected multiple residents receiving controlled substances.
Multiple residents with significant medical needs did not receive timely assistance with ADLs, such as toileting and bathing, due to inadequate CNA staffing. Call light audits and resident interviews confirmed prolonged wait times for help, missed showers, and episodes of incontinence, with only one CNA available during a critical period. The DON confirmed that the staffing shortage directly led to these delays in care.
The facility failed to maintain adequate CNA staffing, resulting in only one CNA being available to care for all residents during a critical period. This led to significant delays in call light response, missed showers, and unmet ADL needs for several residents with complex medical conditions. Staff and residents reported long wait times for assistance, episodes of incontinence, and missed activities, with documentation confirming the staffing shortfall and its impact on resident care.
Surveyors found that the facility did not accurately and completely document the administration of controlled substances for several residents. Controlled Drug Records showed that medications such as Hydrocodone-Acetaminophen, Tramadol HCL, Ativan, and Oxycodone-Acetaminophen were administered, but the corresponding entries were missing or incomplete in the MAR. The DON confirmed these discrepancies and acknowledged that all medication administrations should be properly documented according to facility policy.
A cognitively intact resident with multiple chronic conditions was involved in an incident where discrepancies were found between controlled drug records and MARs for Tramadol and Ativan, with the resident unaware of receiving pain medication. The DON identified suspicious documentation patterns and reported the concern to the Administrator, but the required self-report to state authorities was not filed within the mandated timeframe, resulting in a deficiency for failure to timely report suspected misappropriation.
A CNA did not follow infection control protocols during incontinence care for a resident with multiple health conditions, failing to wash hands or change gloves after perineal care and placing soiled linens on the floor instead of in a designated container. The DON confirmed these actions were not in line with facility policy.
The facility failed to properly assess and manage urinary incontinence for two residents, leading to deficiencies in care. One resident, with multiple diagnoses, was occasionally incontinent but not placed on a toileting program, with incomplete bladder assessments. Another resident, with severe cognitive impairment, had inaccurate bladder assessments and was not on a toileting program. The facility lacked procedures to determine eligibility for such programs, relying on nurse judgment, and did not effectively implement policies to restore bladder function and prevent infections.
A resident with chronic respiratory issues experienced a delay in response to an oxygen concentrator alarm, which was set to zero flow. Staff did not initially respond to the alarm or the call light, leading to the resident experiencing breathing difficulties. The issue was eventually addressed by an RN who replaced the concentrator and corrected a kinked oxygen tube, improving the resident's oxygen saturation.
A facility failed to obtain a physician's order for a resident using a reclining geri chair, as observed during a survey. The resident, with impaired cognition and multiple diagnoses, was using the chair for comfort and safety without a documented order. Staff interviews confirmed the absence of a required order and related policy.
The facility failed to update PASRR documents for two residents, leading to inaccuracies in reflecting new diagnoses and medications. One resident's PASRR did not include a dementia diagnosis, while another's did not reflect new diagnoses of adjustment disorder with depression and anxiety, nor the associated medications. These discrepancies were confirmed by a Corporate Registered Nurse.
The facility failed to accurately complete PASRR assessments for two residents. One resident was admitted with bipolar disorder and prescribed Lamictal, but the PASRR did not reflect this medication. Another resident with schizophrenia and anxiety was prescribed Valium and Seroquel, but the PASRR only noted schizophrenia and Seroquel. These discrepancies were confirmed by facility staff.
A resident with severe cognitive impairment and multiple health conditions did not receive a timely Furosemide injection as ordered by the physician to address swelling. Despite the medication being available in the facility's emergency supply, it was not administered until the following morning. The DON confirmed the delay.
A facility failed to maintain a resident's mobility and range of motion. The resident, with severe cognitive impairment and multiple diagnoses, was observed with her legs dangling from her wheelchair, unsupported by footrests. This was confirmed by the ADON, who repositioned the resident's legs. The care plan included interventions for repositioning due to osteoporosis, but the facility's positioning policy was not followed.
A resident with severe cognitive impairment and multiple health conditions, including a history of COVID-19, experienced shortness of breath and low oxygen saturation. Oxygen was administered without a physician's order, which the DON confirmed was a deficiency in respiratory care.
The facility failed to ensure proper laboratory monitoring and documentation for two residents receiving medication for hypothyroidism and hyperlipidemia. One resident did not have a lipid panel conducted for pravastatin monitoring, and their high thyroid levels were not addressed until much later. Another resident's low TSH levels were not addressed by the previous NP, despite increased agitation and confusion, until a new NP ordered a recheck.
A resident was prescribed Depakote without an appropriate indication, as there was no evidence of a seizure disorder diagnosis or evaluation justifying its use. The medication was initially used for a seizure disorder and later for hallucinations, despite the resident having no seizure history. Interviews confirmed the absence of any seizure diagnosis or activity.
A resident with mood disorder and anxiety was incorrectly administered an extra 500 mg of Depakote due to a transcription error in the medication orders. The psychiatric CNP had ordered an increase to two 250 mg tablets in the morning and 250 mg at night, but the error led to the resident receiving additional medication for two days.
A resident with a history of dysphagia and other conditions experienced issues with ill-fitting dentures and missing lower dentures, which were not promptly addressed by the facility. Despite having sores from the dentures, the resident's MDS inaccurately reported no dental problems. Staff were unaware of the missing dentures until a surveyor's visit, and there was no documented follow-up to offer alternative dental consultations after the resident refused the facility's services.
The facility failed to ensure appropriate antibiotic use for three residents, as their infections did not meet McGeer's criteria. Despite being informed, the physician continued prescribing antibiotics without documented clinical rationale, contrary to the facility's antibiotic stewardship policy.
A resident with severe cognitive impairment and multiple health conditions experienced shortness of breath and required supplemental oxygen. The facility failed to notify the resident's family representative and physician of this change in health status, as confirmed by the DON. This oversight was identified during a complaint investigation.
Failure to Provide Adequate End-of-Life Pain and Anxiety Management for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate end-of-life care, pain management, and monitoring for a hospice resident admitted for comfort-focused services. The resident had advanced pancreatic cancer with liver metastases, severe pain, depression, insomnia, and total dependence for care. Prior to transfer, the inpatient hospice facility documented severe pain (7/10), facial grimacing, restlessness, agitation, and multiple non-verbal pain indicators, and had the resident on an active regimen of Roxanol, Morphine, MS Contin, Ativan, and other medications for pain and anxiety. Hospice records show that on the morning of transfer, the resident received multiple doses of Roxanol, Morphine, and Ativan for pain, restlessness, and facial grimacing, and that hospice staff faxed all paperwork, including signed scripts for Roxanol and an e-scribed Ativan order, to the receiving facility and verbally informed an LPN that the Roxanol script was signed and should be available from the facility’s pharmacy. Upon admission to the facility, critical admission processes and assessments were not completed. The nursing admission checklist had blank sections for code status, consents, physician-verified orders, diet, and nursing assessments, and it was not signed by the nurse. Multiple required assessments, including admission, bowel and bladder, Braden, fall, oral, TB, vitals and pain evaluation, AIMS, and elopement, were left blank; only a functional assessment and a pressure ulcer assessment (completed the day after admission) were documented. There was no evidence that an acute plan of care was initiated. Admission orders showed no medication orders, no diet orders, and no urinary catheter orders, despite hospice transfer information listing multiple active pain and anxiety medications and catheter care instructions. A drafted progress note by an LPN stated that consents were signed, history obtained, and medications reviewed with the physician, but also stated “No medications were ordered at this time” while simultaneously referencing “Morphine and Ativan for comfort,” and there was no evidence that an Ativan order was actually entered. The only documented facility order for symptom control was Morphine 20 mg three times daily, and this order was not implemented in a timely or consistent manner. Pharmacy records show the Morphine order was sent to the pharmacy late in the morning, pulled from the emergency box in the afternoon, but the first documented administration did not occur until 7:30 p.m., several hours after admission and after the resident’s wife reported ringing the call light for pain medication without response. The MAR shows only two doses of Morphine 20 mg given (bedtime on the day of admission and the morning of the next day), both signed by a medication technician who documented a pain score of zero, with no evidence of a comprehensive pain assessment before administration. The Morphine control sheet, however, reflects three doses signed out, including a 1:50 p.m. dose on the second day that was not documented on the MAR. There was no documentation that Ativan was ordered or administered, despite hospice and pharmacy confirmation that Ativan orders were submitted, and despite an LPN telling the hospice nurse that an as-needed Ativan dose had been given. On the second day, a visiting hospice RN documented that the resident’s wife wanted him returned to inpatient hospice for pain control and that the resident’s pain level was 9/10. The hospice RN recorded that an LPN stated the resident “was fine until his wife got here” and described the wife as unrealistic about his decline. The LPN reported having given Ativan at 10:00 a.m. and that Morphine was due at 2:00 p.m., but there was no corresponding Ativan order, control sheet, or MAR entry. The resident’s wife reported that staff attempted to force feed the resident despite his having had no intake for two days, that call lights for pain medication were unanswered, and that when she requested liquid Morphine and Ativan for his obvious pain and restlessness, staff refused or stated it was not time for his medication and gave multiple excuses for the lack of Ativan. Photos provided by the wife and reviewed by facility leadership showed the resident at the edge of the bed, restless and trying to get up, with facial grimacing consistent with pain. After transfer back to the inpatient hospice facility later that day, hospice records show frequent administration of Morphine, Roxanol, Ativan, and Haldol for pain, anxiety, and restlessness until the resident’s death the following day. Corporate and hospice representatives confirmed that, while multiple pain and anxiety medications were ordered at the time of transfer, the facility only had a Morphine order in place, did not complete admission assessments or pain evaluations, and did not implement or document the full ordered pain and anxiety regimen during the resident’s stay. This deficiency represents non-compliance investigated under Master Complaint Number 2789590 and Complaint Number 2785293.
Failure to Administer Ordered Migraine Medications and Monitor Pain/Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, individualized, and effective pain management program for a resident with a known history of severe, intractable migraines. The resident was admitted with diagnoses including migraine without aura, intractable, with status migrainosus, anxiety, depression, cerebrovascular disease, fibromyalgia, and hypertension. Admission orders included Aspirin, Gabapentin, Losartan, Metoprolol, and PRN Acetaminophen for pain. Early documentation showed incomplete vital signs and pain assessments on 11/26, and on 11/27 the resident reported posterior neck pain rated 4/10, occurring daily, with an assessment indicating she was alert and oriented. The care plan for potential alteration in comfort related to fibromyalgia directed staff to administer medications as ordered and per resident preference/request, encourage early reporting of pain, and observe for signs and symptoms of pain. Over the next two days, the resident experienced escalating pain and migraine symptoms. On 11/27, an LPN documented administering Acetaminophen 325 mg (two tablets) for a headache unrelieved by environmental measures, with the medication noted as effective. On 11/28 at 3:16 A.M., another LPN documented the resident was vomiting and complaining of headaches causing her to vomit; Tylenol 325 mg (two tablets) was given and documented as effective. Later on 11/28, after discussion among the nurse, the resident, and the resident’s daughter with a nurse practitioner, new orders were obtained for Topamax for migraines, Imitrex PRN for acute migraines, Magnesium, and Perphenazine, along with a psychiatry consult. However, review of the MAR/TAR for November showed no evidence that Topamax or Imitrex were administered after these orders were written, and pain levels on 11/28 and 11/29 were marked as not applicable despite prior documentation of pain scores of 8 and 10 and the MDS indicating frequent severe pain affecting sleep and daily activities. On 11/29, the resident’s daughter contacted the facility reporting that her mother had not received her medications. The assigned LPN later stated she was responsible for both Assisted Living and the skilled unit that day, and that when the daughter called, she told her she was preparing to pull the resident’s medications. The LPN acknowledged she did not administer Topamax because she believed it was scheduled for the afternoon and was unaware of the new Imitrex PRN order from the previous day. She confirmed that neither Topamax nor Imitrex had been administered and that she did not give PRN Tylenol for the resident’s headache, only the scheduled Gabapentin. The daughter subsequently arrived at the facility, found the resident covered in vomit with vomit on the floor, and requested transfer to the emergency room. The LPN obtained an order to send the resident to the hospital but did not complete a transfer form. Hospital records documented admission for intractable headaches with vomiting and hypertensive emergency, with an emergency room blood pressure of 200/100 mm/Hg and severe headache rated 9/10. The resident, her daughter, and the DON later confirmed that ordered migraine medications were not administered and that blood pressure monitoring was not performed as required, in contrast to the facility’s pain management policy, which required daily pain monitoring and assessment before and after PRN pain medication administration. The resident and her daughter reported that the resident did not receive her migraine medications as ordered and that her blood pressure was not adequately monitored, leading to rehospitalization three days after admission. The daughter stated she frequently could not reach staff by phone and often could not find staff when visiting, and that her calls to the DON were not returned. The resident reported that she believed she was supposed to receive Hydralazine for migraines, as she had prior to admission and in the hospital, but did not think she was receiving all of her medications correctly at the facility. The DON confirmed that the resident did not receive her ordered medications and that staff failed to monitor her blood pressure, and the facility’s pain management policy specified recognition, evaluation, and management of pain consistent with assessment and care plan, including daily monitoring of pain levels and assessment of PRN pain medication effectiveness. These documented failures culminated in the resident’s transfer and hospitalization for intractable migraines with vomiting and hypertension.
Failure to Maintain Comprehensive Infection Surveillance and Trending
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program that included effective tracking and monitoring for infection trends, potentially affecting all 37 residents. Review of the infection control trending tools from 10/2025 to 03/2026 showed that the facility used a map with a color-coded key for different infection types (respiratory, gastrointestinal, UTI, wounds, and others), but there was no documentation of specific infection types or other details needed to identify patterns. This meant there was no evidence that infections were being trended in a way that would reveal patterns by type or location. Further review of the infection log from 12/2025 to 03/2026 showed that, after implementation of a new log, multiple UTIs and other infections were recorded without documentation of the causative organism or, in some cases, the site of infection. Specifically, in December there were four UTIs without organisms listed; in January, three UTIs without organisms; in February, seven UTIs without organisms and two infections without site or organism; and in March, one UTI without an organism. During an interview, the IP/LPN confirmed that infections were not being monitored for trends by type and that most UTIs did not have culture results to identify organisms, and reported having previously voiced concerns to the former DON but was told not to contact providers and to administer antibiotics as ordered. The facility’s infection control policy required investigation, monitoring, identification, control, and surveillance of infections, including completion of infection reports, obtaining antibiotic orders upon proper microorganism identification if necessary, updating the surveillance map with type and location of infections, and discussing patterns in weekly QA meetings, which was not reflected in the documented practice.
Lack of Qualified Infection Preventionist and Inadequate Antibiotic Stewardship
Penalty
Summary
The facility failed to have a qualified, designated Infection Preventionist (IP) who effectively monitored and implemented the Antibiotic Stewardship Program for all 39 residents. Upon survey entrance, the facility identified an LPN as the IP, but review of the March 2026 infection control log showed the facility did not meet antibiotic stewardship requirements. Documentation revealed a lack of understanding of the need for hospital documentation to support antibiotic use when residents returned from the hospital, and problems with the timing and accuracy of completing McGeer’s evaluations, which led to errors in determining whether residents met criteria for antibiotic use. During interviews, the identified LPN stated she had not performed the IP role since 2019 and was hired in October 2025 as the MDS nurse, later taking over infection control in December 2025 at the request of the former DON. She reported completing an IP course in February 2021 but was unable to provide a certificate, and her former employer could not immediately supply documentation of her training or continuing education. She confirmed she had not renewed her IP training every two years and had only taken standard infection control bloodborne pathogen education through Relias with her former employer. During the survey, the facility did not provide an IP certificate for this LPN, although it did provide an IP Certificate of Training for another LPN who was not yet serving as IP. Review of the facility’s IP policy showed it did not require a certificate of completion of an IP program or ongoing professional education to maintain competency, and it did not specifically address antibiotic stewardship in the nursing home setting.
Failure to Maintain Functioning Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system that remained active until staff responded, affecting resident bathrooms and bathing areas and potentially all 37 residents. A resident’s daughter reported via email that her mother’s visitor had to ask someone in the hallway to check on the resident after waiting a long time for a response to the call light; the person who checked stated the resident was dry, but the visitor could smell urine and knew this was not accurate. The resident was later taken to the bathroom by others, including a physical therapist, who stated that because the resident was not bearing weight on her legs, they would not be able to continue taking her to the bathroom. The daughter expressed concern that her mother would be incontinent of urine and stool and remain so for hours before being changed, and that even when calling out for help, it took an extended time for assistance to arrive, if at all. She also stated that CNAs were supposed to check residents every two hours but did not, and that she had observed this pattern on each of her visits. During the survey, a state surveyor activated a resident’s call light and observed that it remained active for 16 minutes and 15 seconds before resetting, requiring re-activation by the resident. The surveyor activated the call light at 2:22 P.M., again at 2:33 P.M. while it was still red, and again at 2:38 P.M. after the red light disappeared, with staff not answering until 2:40 P.M. The CNA who responded confirmed she was alerted via walkie talkie but could not state when the call light was first activated. The maintenance director and assistant verified through the call system computer that the call light had been on for 16 minutes and 15 seconds before resetting and then was activated again, confirming the system automatically resets after that time. An anonymous staff member also confirmed that call lights were not answered timely and that residents had voiced concerns. The facility’s call light policy stated that call lights would be silent only after residents’ needs were met, which was not followed in these instances.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pressure ulcer prevention and treatment for a resident at risk for skin breakdown. The resident was re-admitted after a left hip fracture with open reduction and internal fixation and had known risk factors including peripheral vascular disease, incontinence, impaired cognition, dependence on staff for mobility and transfers, frequent urinary incontinence, and bowel incontinence. A Braden assessment completed after readmission identified the resident as at moderate risk for pressure ulcers, but there was no evidence that new preventive interventions were implemented at that time. The resident’s care plan called for weekly skin assessments and a pressure redistribution mattress, but after readmission there was no documented skin assessment until the resident’s daughter identified a coccyx skin alteration, and the resident did not have pressure-reducing devices for bed or chair, was not on a turning/repositioning program, and had no documented nutritional or hydration interventions for skin management. The resident’s daughter submitted a concern form reporting that after the resident’s return from the hospital, the RN did not properly check the resident back into the facility and that staff were unaware of a coccyx pressure ulcer the daughter observed, which she described as several inches in size and facility-acquired. A protective dressing was first applied only after the daughter brought the ulcer to staff attention. Subsequent assessment by a consulting wound nurse practitioner documented a new in-house acquired wound on the sacrococcygeal area initially staged as a Stage II pressure ulcer with moderate serosanguineous drainage, and later facility wound documentation described the same area as an unstageable pressure ulcer with extensive eschar. The wound later cultured positive for proteus and pseudomonas, and the resident was treated with antibiotics. The wound practitioner also documented new suspected deep tissue injuries on both heels, with measurements recorded for the left heel on the day of identification and delayed documentation of right heel measurements several days later. Treatment orders were initiated for cleansing and dressing the coccyx/sacral and buttock areas with mesalt and dry dressings daily, use of an air mattress, heel boots as tolerated, offloading, and barrier cream. However, the treatment administration record showed missed wound treatments on specific days for the coccyx/sacral area and missed heel treatments on at least one day, with no documentation that the resident refused care. Observation showed that heel boots ordered for prevention were not in place while the resident was in bed, despite no recorded refusals and staff confirmation that the boots were tolerated. The DON confirmed that staff did not administer certain ordered treatments, that the coccyx pressure ulcer was first identified by the family rather than staff, that no new interventions were implemented when the resident’s Braden score increased from low to moderate risk, and that the care plan for the pressure ulcers contained only the intervention to provide treatments as ordered, contrary to the facility’s wound and skin care policy requiring timely risk assessment, repeat skin assessment within 24–72 hours of admission, and implementation of resident-specific preventive interventions.
Failure to Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-prevention interventions as outlined in a resident’s care plan. The resident was admitted and later re-admitted with diagnoses including a displaced intertrochanteric fracture of the left femur, hypotension, urinary incontinence, dizziness, difficulty walking, and muscle weakness. The resident’s fall risk care plan, addressing dizziness, impaired gait, muscle weakness, and psychoactive medication use, was initiated on 03/02/18 and revised on 10/21/25 to include specific interventions: bright colored paper as a visual aid to prompt the resident to ask for help and use the call light system, bright colored tape on wheelchair brake handles as visual reminders, and dycem on the wheelchair seat. On observation, surveyors and RN #204 noted that these care-planned interventions were not in place. There was no bright colored paper in the resident’s environment to cue use of the call light, no bright colored tape on the wheelchair brake handles, and no dycem on the wheelchair seat, despite these being listed in the fall care plan. RN #204 reported that the resident had experienced a fall with fracture the previous month and had received a new wheelchair, but staff had not applied the bright colored tape or dycem to the new wheelchair, and the signs in the room were not bright colored as specified in the plan of care. The resident’s daughter stated she believed the facility failed to implement preventive measures to prevent her mother’s fall that resulted in a fracture and reported that, despite her request, she had not yet received information about the fall and the care plan. Review of the facility’s Fall Policy and Procedures confirmed that the interdisciplinary team is required to develop and implement fall interventions based on assessed risk factors and to update the fall care plan in the electronic record.
Failure to Provide Ordered Extra Fluids for Hydration
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered fluids to maintain a resident’s hydration status. The resident had diagnoses including recurrent urinary tract infections, hypotension, gastric reflux, protein-calorie malnutrition, and dysphagia, and had a dietary recommendation for 1950 ml fluid intake daily. After a hip fracture and readmission, the dietitian documented a recommendation and an order was obtained for an extra 240 ml of fluids with lunch and dinner, and this was also reflected on a diet order and communication form. Fluid intake records from 02/11/26 to 03/12/26 showed the resident’s intake per meal ranged from 60–240 ml, with an average daily intake of 760 ml, and there were days with missing meal intakes and several recorded refusals. There was no evidence in the records or care plans that the ordered extra 240 ml of fluids at lunch and dinner was being consistently provided or documented. Surveyor review of a supper meal ticket showed no indication of the extra 240 ml fluid order, and observation of the resident at supper revealed only one 240 ml cup of beverage and a 120 ml cup of UTI supplement, not the ordered additional fluids. The Dietary Manager stated she was unaware of the extra fluid order and confirmed that special dietary instructions should appear on the meal ticket and a reminder sheet in the kitchenette; the extra fluid order was not listed on that sheet. An LPN reviewed the orders with the surveyor and confirmed the resident was supposed to receive extra fluids with lunch and dinner, but this had not been communicated to dietary. The resident’s daughter reported concerns about inadequate hydration, including decreased urination, dark urine, and recurrent urinary tract infections, and stated she did not feel her concerns about her mother’s hydration needs had been addressed.
Failure to Maintain Accurate and Consistent Medical Records and Treatment Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents. For one newly admitted resident, the medical record contained no listed medical diagnoses under the diagnoses category, with the medication orders, or in the care plan at the time of review. The DON confirmed that the resident’s diagnoses were not entered at admission and were only added six days later. For another resident with a history of a fall and left femur fracture, physician orders included nonskid strips on the bathroom floor in front of the commode every shift and visual reminders in the bathroom to use the call light for assistance with transfers twice a day. March and April 2026 treatment sheets showed staff signing off twice daily that these interventions were in place. However, the DON verified that this resident did not have fall strips in front of the toilet or a sign as a reminder to call for assistance, and that the facility had removed these interventions from the plan of care after the resident returned from the hospital and was no longer using the bathroom. The DON acknowledged that the corresponding physician orders were not discontinued and that nursing staff continued to document completion of treatments that were not actually in place. For another resident admitted with multiple diagnoses including cerebral infarction, protein calorie malnutrition, adjustment disorder with anxiety, anorexia, GERD, constipation, glaucoma, vascular disease, history of falling, muscle weakness, and difficulty walking, the record showed an in-house Stage II pressure ulcer to the left outer ankle. Active physician orders included one to pad and protect a healed left lateral ankle pressure ulcer twice weekly and as needed, and another to cleanse the left outer ankle and apply duoderm on specified days. The DON confirmed there were two contradicting active orders and that the pad and protect order was present in the physician orders but did not appear on the treatment sheet for staff to sign off.
Failure to Implement Effective Antibiotic Stewardship and McGeer Criteria Review
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective antibiotic stewardship program that ensured appropriate antibiotic use and timely application of McGeer criteria. Surveyors found that the Infection Preventionist (an LPN) was off work over a weekend, and during that time multiple residents were started on antibiotics without any determination of whether they met McGeer criteria. The Director of Nursing and the Infection Preventionist acknowledged that when the Infection Preventionist is off, no one performs her infection control duties, including reviewing new antibiotic orders against McGeer criteria. As a result, residents were receiving antibiotics before any assessment of criteria, and the facility was administering antibiotics prior to notifying the physician if criteria were not met or obtaining a rationale for antibiotic use without meeting criteria. One resident had a history of multiple chronic conditions including acute respiratory failure with hypoxia, chronic pain syndrome, hypertension, hyperlipidemia, morbid obesity, syncope, chronic congestive heart failure, depression, GERD, insomnia, osteoarthritis, and weakness. This resident developed a full-thickness wound on the left third toe with serosanguinous drainage, erythema, exposed bone, tenderness, warmth, and slight edema. A wound nurse practitioner ordered clindamycin and transfer to the emergency room for suspected bone involvement and infection; the resident returned on doxycycline for wound infection. The resident was entered on the infection log as meeting McGeer criteria for cellulitis/soft tissue/wound infection, but the McGeer Infection Report Form showed only redness and swelling were documented. The Infection Preventionist incorrectly marked that the infection met McGeer criteria despite only two signs and symptoms being present, instead of the required four, and stated she had been told only one sign or symptom was needed and that she had not done infection control since 2019. Another resident, admitted with diagnoses including above-knee amputation, anxiety disorder, diabetes, hypertension, hyperlipidemia, major depressive disorder, and muscle weakness, was started on Bactrim DS and topical mupirocin for a large, purple/red, hard abscess under the right breast that was warm to touch and afebrile at the time. This resident was not initially entered on the infection log, and no McGeer Infection Report Form was completed when the antibiotic was ordered because the Infection Preventionist was off duty. Several days later, nursing documentation described drainage, yellow slough, surrounding redness, warmth, and a temperature of 99.2°F, and a McGeer Infection Report Form was then completed. The form indicated heat, redness, serous drainage, and fever, but the Infection Preventionist did not indicate on the form whether criteria were met, and the infection log was later revised to show the resident did not meet criteria. The DON later verified that only one temperature above 99°F had been documented, which would not meet the constitutional fever criterion, making the fever marking an error. A third resident was receiving Levaquin for a “culture infection” on an every-48-hour schedule. This resident was not initially listed on the infection log, and there was no completed McGeer Infection Report Form at the time of surveyor review. The Infection Preventionist stated she had started but not completed the form and believed the resident would not meet criteria because of an upper respiratory infection. A subsequent infection report form documented pneumonia, with all three required criteria checked: chest radiograph interpreted as pneumonia or new infiltrate, new or changed lung exam abnormalities, and leukocytosis. A revised infection log then listed this resident as meeting criteria for antibiotic use, with pneumonia, hypoxia, shortness of breath, and gram-negative rods noted. The Infection Preventionist confirmed that the McGeer Infection Report Form was not completed in a timely manner to determine antibiotic stewardship for this resident and that it was not timely identified whether the physician needed to be called if criteria were not met. Review of the facility’s Antibiotic Stewardship Program policy, revised in 2017, showed that all residents with newly diagnosed infections using antibiotics were to be reviewed for appropriate utilization, including review of infection symptoms prior to initiation, consideration of an antibiotic holiday when there was no proof of review, obtaining and reviewing culture and sensitivity results, and discussing results and treatment recommendations with the primary care physician to ensure responsible antibiotic use. The policy also required prescribers to document dose, duration, and indication for all antibiotic use. Despite this policy, the survey findings demonstrated that residents were started on antibiotics without timely or accurate application of McGeer criteria, infection logs were incomplete or delayed, and the Infection Preventionist lacked current knowledge of the criteria and did not consistently communicate with physicians regarding antibiotic appropriateness when criteria were not met.
Failure to Maintain Functional Exit Door Alarms Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to maintain exit doors and related elopement alarm systems in good repair to prevent elopement of a resident identified as an elopement risk. The resident had multiple diagnoses including dementia, psychotic and mood disturbances, unsteady gait, history of falls, and a documented history and pattern of goal-directed wandering and elopement or attempted elopement. Progress notes documented that on two consecutive days the resident had previously gone out or attempted to go out the dining room doors and had to be redirected back into the facility. The resident wore elopement alert bracelets intended to lock and alarm exit doors when in proximity. On the night of the elopement, staff last observed the resident sitting in front of the nurse station shortly before he was discovered outside. An anonymous neighbor alerted the facility that the resident had walked out of the building, and he was subsequently found at the end of the driveway near the entrance sign with his walker, fully dressed in outdoor clothing. Staff reported that no door alarms sounded to alert them when the resident exited. There was no documentation that staff checked the resident’s alert bracelets or the functioning of the exit doors and alarm systems at the time of the elopement. Subsequent review and interviews revealed that the facility’s exit door alarm systems, including the Wander-guard and other door alarms, were functioning inconsistently. Maintenance staff acknowledged that weekly alarm checks showed doors sometimes required multiple attempts to function properly and that some issues could not be fixed. Observations by surveyors showed that when elopement bracelets were brought near the front door, the door did not consistently lock or alarm, and staff could exit while holding the bracelets without activation. The front door was sometimes left ajar and therefore did not lock or alarm, and the dining room door’s different alarm system would sometimes alarm without locking and at other times neither lock nor alarm. Staff interviews confirmed that doors were fairly easy to open, did not always close fully, and that no alarms sounded on the night the resident left the building.
Failure to Accurately Document and Administer Controlled Substances
Penalty
Summary
The facility failed to safely administer and accurately document controlled substances for residents identified as receiving these medications. During a medication pass, it was observed that narcotic sheets on a medication cart were not accurately completed, and discrepancies in the shift-to-shift narcotic count records were noted. Documentation errors included incorrect counts, overwriting of numbers, missing signatures from incoming nurses, and incorrect dates on narcotic count forms. Interviews with LPNs confirmed that not all nurses were following the same procedures for counting and documenting controlled substances, making the records difficult to follow and leading to inconsistencies. Further review by the Director of Nursing revealed blank spots on narcotic sheets and missing signatures for the administration of controlled substances such as Tramadol and Ativan for a resident. The physical count of medications did not match the documentation, indicating further errors. The facility's policy required a physical inventory of all controlled substances by two licensed nurses each shift, with immediate reporting of discrepancies, but these procedures were not consistently followed, resulting in inaccurate recordkeeping and potential mismanagement of controlled substances for multiple residents.
Failure to Provide Timely ADL Assistance Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely staff assistance with activities of daily living (ADLs) for five dependent residents, as evidenced by record reviews, call light audit reports, and resident and staff interviews. Several residents with significant medical conditions, including acute kidney failure, Parkinson's disease, multiple sclerosis, and mobility impairments, required substantial or maximal assistance with toileting, bathing, and other ADLs. Documentation showed that call lights for assistance remained unanswered for extended periods, with one resident's call light active for over 52 minutes and another for over 36 minutes before staff responded. Residents reported having to wait for long periods, sometimes resulting in incontinence episodes and missed showers or baths, which caused them distress and humiliation. On the date in question, only one CNA was available to provide care for all residents during a specific time frame, despite several residents requiring two-person assistance. The CNA confirmed being unable to answer most call lights in a timely manner and was unable to provide scheduled showers or baths. The Director of Nursing acknowledged that the lack of adequate CNA staffing led to delays in providing necessary ADL assistance to multiple residents. Residents also reported a decline in the timeliness of staff response and the frequency of receiving scheduled showers compared to previous months. Care plans and medical records for the affected residents indicated a need for regular assistance with toileting, bathing, and skin assessments due to their medical conditions and risk factors such as incontinence and decreased mobility. However, documentation and resident interviews confirmed that these interventions were not consistently provided as scheduled, particularly on the day when staffing was insufficient. The deficiency was substantiated by both resident accounts and facility records, demonstrating a failure to meet the residents' needs for timely ADL support.
Failure to Maintain Sufficient Direct Care Staffing
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all residents, as evidenced by a period on a specific day when only one Certified Nursing Assistant (CNA) was available to care for 46 residents. The facility's own assessment indicated that an average of five CNAs were required to meet resident needs, and staffing was to be adjusted daily based on census and acuity. However, documentation and interviews confirmed that between 12:19 P.M. and 2:11 P.M. on the day in question, only one CNA was present, resulting in significant delays in responding to call lights and providing assistance with activities of daily living (ADLs), including toileting and bathing. The CNA on duty reported being unable to answer most call lights in a timely manner, with some residents waiting up to an hour for assistance, and was unable to provide scheduled showers or baths. Multiple residents with complex medical conditions, such as multiple sclerosis, chronic kidney disease, Parkinson's disease, and mobility impairments, were directly affected by the staffing shortage. Residents reported waiting extended periods for assistance with toileting, leading to episodes of incontinence and feelings of humiliation. For example, one resident's call light remained unanswered for over 36 minutes, and another resident waited over 52 minutes for help, ultimately resulting in a bowel movement before staff arrived. Residents also reported missing scheduled showers and being unable to participate in facility activities due to lack of timely assistance. Documentation, such as call light audit reports and shower logs, corroborated these accounts. Interviews with staff, including the DON and Administrator, confirmed the staffing shortfall and acknowledged that several residents required two-person assistance for ADLs, which could not be provided with only one CNA on duty. The DON stated that another CNA had been scheduled but was running late, and acknowledged that nurses should have assisted with resident care during the shortage. Residents and staff expressed frustration with the lack of timely response to call lights and unmet care needs, and facility records showed that concerns about staffing and call light response times had been raised by residents but were not adequately addressed.
Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete regarding the administration of controlled substances for multiple residents. Surveyors identified discrepancies between the Controlled Drug Record and the Medication Administration Record (MAR) for five residents who were prescribed and administered various controlled medications, including Hydrocodone-Acetaminophen, Tramadol HCL, Ativan, and Oxycodone-Acetaminophen. In each case, the Controlled Drug Record indicated that the medication had been administered at specific times, but the corresponding MAR entries were either missing or incomplete for those administrations. For example, one resident with diagnoses including hemiplegia, dementia, and heart failure had orders for Hydrocodone-Acetaminophen, which was documented as administered in the Controlled Drug Record but not reflected in the MAR for two doses. Another resident with multiple sclerosis, hypertension, and chronic kidney disease received Tramadol HCL and Ativan according to the Controlled Drug Record, but the MAR lacked documentation for these administrations on several dates. Additional residents with complex medical histories, such as chronic obstructive pulmonary disease, diabetes, and chronic pain, also had similar discrepancies between the Controlled Drug Record and the MAR for their prescribed controlled substances. During an interview, the Director of Nursing confirmed the discrepancies and acknowledged that all administered medications should be documented in the medical records at the time of administration, as required by the facility's medication administration policy. The facility's policy specifically states that after administration, documentation must occur in both the MAR and the controlled substance sign-out record. The failure to maintain accurate and complete records for controlled substance administration was observed for multiple residents during the survey.
Failure to Timely Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to timely report a suspicion of misappropriation of narcotics involving a resident with multiple chronic conditions, including multiple sclerosis, hypertension, major depressive disorder, diabetes mellitus, conversion disorder with seizures, and chronic kidney disease. The resident was cognitively intact at the time of the incident. The Director of Nursing (DON) discovered several blank entries with the same handwriting in the narcotic book, indicating a registered nurse's signature, and found discrepancies between the Controlled Drug Records and the Medication Administration Records (MAR) for both Tramadol and Ativan. The resident reported not knowing about or requesting pain medication. Despite these findings, the DON concluded there was not enough evidence to confirm misappropriation but noted a concerning pattern of documentation errors. The DON immediately reported the suspicion to the Administrator, who, along with the President of Operations, advised the suspension of the nurse involved. However, the Administrator did not timely file a Self-Reported Incident (SRI) with the Ohio Department of Health as required by facility policy, which mandates notification of all alleged violations involving misappropriation within 24 hours. The investigation did not yield sufficient evidence to prove misappropriation, but the failure to report the suspicion in a timely manner constituted the deficiency.
Failure to Follow Infection Control During Incontinence Care
Penalty
Summary
A Certified Nurse Aide (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident who required assistance with activities of daily living due to decreased mobility and multiple medical conditions, including heart disease, hypertension, cerebrovascular disease, and a femur fracture. During the observed care, after cleansing the resident's perineal area following a bowel movement, the CNA did not wash her hands or change gloves before applying barrier cream and a new incontinence brief. Additionally, the CNA placed soiled linens on the floor of the resident's room instead of placing them in a bag or soiled linen container as required. The CNA confirmed during the observation that she did not perform hand hygiene, change gloves, or use a linen bag for soiled linens during the care process. The Director of Nursing also confirmed that proper procedures were not followed, stating that hands should be washed between perineal care and donning new gloves, and soiled linens should be immediately placed in a bag or linen barrel. The facility's perineal care policy required gloves to be worn and soiled items to be placed on an impermeable barrier, with gloves to be removed and hands washed following care, but did not provide specific guidance on hand hygiene or glove changes when applying barrier cream or a new brief.
Inadequate Urinary Incontinence Management for Residents
Penalty
Summary
The facility failed to comprehensively assess and manage urinary incontinence for two residents, leading to deficiencies in their care. Resident #45, who was admitted with multiple diagnoses including diabetes and heart disease, was noted to be occasionally incontinent of urine. Despite being aware of the need to toilet, the resident was not placed on a toileting program. The bladder assessments for this resident were incomplete, with sections on the type of incontinence and a three-day tracker left blank. The Director of Nursing (DON) confirmed that the resident experienced a decline in urinary function and would have benefited from a toileting program, but the facility lacked a procedure to determine eligibility for such a program. Resident #57, who had severe cognitive impairment and was frequently incontinent of urine, also did not receive a toileting program. The resident's bladder assessments were inaccurate, with a three-day bladder tracker indicating no urination for three days. The assessments failed to identify the type of incontinence or develop a treatment plan to prevent decline or improve bladder function. The DON acknowledged these inaccuracies and the absence of a policy to determine program eligibility, relying instead on the judgment of the nurse completing the assessments. The facility's policies on bowel and bladder assessment and incontinence, as well as the incontinence policy, were not effectively implemented. These policies were intended to ensure residents received appropriate treatment to restore bladder function and prevent infections. However, the facility did not perform adequate incontinence assessments or provide appropriate treatment and services, as evidenced by the incomplete assessments and lack of toileting programs for the affected residents.
Plan Of Correction
The facility failed to ensure to comprehensively assess residents' urinary incontinence to determine the type of bladder incontinence and to develop and implement an appropriate treatment plan to maintain and/or restore the resident's bladder function. This affected Resident #45 and #57. Resident #57 no longer resides in the building. Resident #45's bowel and bladder were evaluated, and a program was started on 3/12/2025 by the Assistant Director of Nursing and Director of Nursing. To identify other potentially affected residents, an audit of residents' bowel and bladder patterns was conducted for all residents, completed on 3/20/2025 by the Assistant Director of Nursing. To prevent reoccurrence, education was conducted for all licensed nursing staff regarding bowel and bladder policy and monitoring, completed on 3/20/2025 by the Director of Nursing. To evaluate the preventative actions taken, audits of bowel and bladder assessments for three residents will be conducted three times a week for four weeks by the Director of Nursing or designee. Audit findings will be reviewed with the QAPI committee weekly for recommendations.
Failure to Address Oxygen Concentrator Alarm Timely
Penalty
Summary
The facility failed to address a resident's oxygen concentrator alarm in a timely manner, affecting a resident with multiple health conditions including dependence on supplemental oxygen, pneumonia, chronic respiratory failure with hypoxia, hypertension, heart disease, COPD, hyperlipidemia, and tobacco use. The resident's care plan required continuous oxygen at three liters via nasal cannula and regular oxygen saturation checks. During an observation, the resident's oxygen concentrator was alarming due to a low flow rate set at zero, but staff passing by did not respond to the alarm. The surveyor activated the call light, but it went unanswered for several minutes, during which the resident expressed difficulty breathing and opened a window for relief. Eventually, a CNA and an RN were alerted to the situation. The RN assessed the concentrator and determined a new one was needed. However, the new concentrator also failed to work properly due to the oxygen tubing being kinked around the resident's neck. After the tubing was straightened, the resident's oxygen saturation was initially low at 81 percent but improved to 90 percent with deep breathing instructions. The deficiency was confirmed by the RNs present during the observation.
Plan Of Correction
The facility failed to ensure a resident's oxygen concentrator alarm was addressed timely for resident #45. Resident #45 was evaluated immediately, and the issue was addressed with the concentrator by switching the concentrator and fixing kinked tubing, by the Assistant Director of Nursing on 3/10/2024. To identify other potentially affected residents, an audit of all residents was conducted by the ADON with oxygen on 3/10/2025 by the Director of Nursing/designee for kinked tubing or malfunctioning concentrators. To prevent reoccurrence, education was conducted for all licensed nursing staff regarding oxygen monitoring and observation of equipment and tubing on 3/20/2025 by the Director of Nursing/designee. To evaluate preventative actions taken, audits of call for 3 residents 3 times a week for 4 weeks will be conducted by the Director of Nursing/designee. Audit findings will be reviewed with the QAPI committee weekly for recommendations.
Lack of Physician's Order for Reclining Chair Use
Penalty
Summary
The facility failed to ensure that a physician's order was in place prior to the use of a reclining safety and enabling chair for a resident. This deficiency was identified during an annual survey, where a resident was observed using a reclining geri chair without a corresponding physician's order. The resident had a history of chronic obstructive pulmonary disorder, white matter disease, and diabetes mellitus, and was noted to have significantly impaired cognition. Despite an assessment completed earlier indicating the chair was used for comfort and safety, there was no evidence of a physician's order in the resident's medical record. Interviews with a registered nurse and the Director of Nursing confirmed the absence of a physician's order and a facility policy regarding the use of such chairs.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) documents accurately reflected new diagnoses and medications for two residents. Resident #38 was admitted with multiple diagnoses, including dementia, but the PASRR document incorrectly indicated there was no diagnosis of dementia. This discrepancy was confirmed by a Corporate Registered Nurse during an interview. The PASRR document did not reflect the resident's accurate medical condition, which was diagnosed months prior to the assessment. Resident #16 was admitted with schizophrenia and Parkinson's disease, and later received new diagnoses of adjustment disorder with depression and anxiety, which required medication changes. However, the PASRR completed prior to admission did not include these new diagnoses or the associated medications. The facility did not complete a new PASRR to reflect these changes, nor was the cumulative diagnoses list updated to include the resident's past history of anxiety or the new diagnoses. This oversight was confirmed by a Corporate Registered Nurse during an interview.
Inaccurate PASRR Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASRR) assessments for two residents upon their admission. Resident #20 was admitted with diagnoses including bipolar disorder and was prescribed Lamictal for mood stabilization. However, the PASRR completed did not reflect the current use of this medication, as confirmed by the Social Services Designee. This oversight indicates a discrepancy between the resident's medical records and the PASRR documentation. Similarly, Resident #16 was admitted with a history of schizophrenia and anxiety, and was prescribed Valium for anxiety and Seroquel for schizophrenia. The PASRR completed by the hospital staff only noted schizophrenia and the prescription of Seroquel, omitting the diagnosis of anxiety and the prescription of Valium. The Corporate Registered Nurse confirmed the inaccuracies in the PASRR, which did not align with the resident's medical history and current medication orders.
Failure to Administer Timely Medication
Penalty
Summary
The facility failed to provide timely treatment as ordered by the physician for a resident with multiple health conditions, including cardiomyopathy, hypertension, dementia, diabetes mellitus, and a history of COVID-19. The resident was admitted to the facility and had a severely impaired cognition as indicated by a BIMS score of 05. On a specific date, the physician ordered Furosemide 40 mg to be injected intramuscularly once a day for three days to address the resident's swelling. However, the resident did not receive the scheduled dose on the day the order was made. The nursing progress notes indicated that the resident had continued swelling of the legs and labored breathing, and the family was informed of the new medication order. Despite the availability of the medication in the facility's emergency supply, the resident did not receive the Furosemide injection until the following morning. The Director of Nursing confirmed the delay in administering the medication as per the physician's order.
Failure to Maintain Resident Mobility and Range of Motion
Penalty
Summary
The facility failed to provide appropriate care to maintain and improve the range of motion and mobility for a dependent resident. Resident #9, who was admitted with multiple diagnoses including dementia, osteoporosis, and difficulty walking, was observed on multiple occasions sitting in a wheelchair with her lower legs dangling and unsupported on the footrests. This observation was confirmed by the Assistant Director of Nursing, who then repositioned the resident's legs onto the footrests. The resident's medical record indicated severe cognitive impairment and total dependence on staff for certain activities, including transfers and lower body dressing. The care plan noted the potential for discomfort due to osteoporosis, with interventions to assist with repositioning as needed. However, the facility's policy on patient positioning, which aims to ensure comfort and maximize therapy benefits, was not adhered to, as evidenced by the resident's unsupported leg positioning.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for oxygen therapy for a resident, which constituted a deficiency in providing safe and appropriate respiratory care. The resident, who was admitted with diagnoses including cardiomyopathy, hypertension, dementia, diabetes mellitus, and a history of COVID-19, had a severely impaired cognition as indicated by a BIMS score of 05. On a specific date, the resident experienced shortness of breath with an oxygen saturation of 86% on room air and a respiratory rate of 24 breaths per minute, accompanied by audible wheezing. Oxygen was administered at 2 liters per minute via nasal cannula without a physician's order. The Director of Nursing confirmed the absence of a physician order for the oxygen therapy and acknowledged that the nurse should have notified the physician to obtain the necessary order.
Failure to Monitor and Address Abnormal Lab Results
Penalty
Summary
The facility failed to ensure proper laboratory monitoring and documentation for two residents receiving medication for hypothyroidism and hyperlipidemia. Resident #28 was admitted with hyperlipidemia and hypothyroidism, yet there was no documented evidence of a hypothyroidism diagnosis in the resident's records. The resident was prescribed pravastatin for hyperlipidemia and Synthroid for hypothyroidism, but there was no evidence of a lipid panel being conducted to monitor the pravastatin, and the last thyroid test was conducted in June 2023, which showed high levels. Despite this, there was no follow-up or adjustment to the Synthroid dosage until much later, and the pharmacy did not recommend any laboratory monitoring for these conditions. Resident #47, diagnosed with hypothyroidism, depression, and anxiety, was receiving Synthroid. The resident's TSH levels were found to be low, indicating a need for medication adjustment, but the previous nurse practitioner did not address this issue. The resident exhibited increased agitation and confusion, prompting a review of laboratory results, which confirmed low TSH levels. However, no immediate action was taken to adjust the medication until the facility reached out to a new nurse practitioner, who then ordered a recheck of the TSH levels.
Inappropriate Use of Depakote for a Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, affecting one resident out of five reviewed for medications. The resident, who was admitted with diagnoses including schizophrenia, anxiety, dementia, and diabetes mellitus, was prescribed Depakote, a medication for seizure and mood stabilization, without an appropriate indication for use. There was no evidence in the medical record or hospital records of a seizure disorder diagnosis or any evaluation by a physician or certified nurse practitioner justifying the initiation of Depakote. The Medication Administration Record indicated that Depakote was initially used for a seizure disorder and later for hallucinations, despite the resident having an independent and intact cognition level with no seizure disorder diagnosis. Interviews with the Director of Nursing and the resident confirmed the absence of any seizure diagnosis or activity, highlighting the inappropriate use of the medication.
Medication Administration Error for Psychotropic Medication
Penalty
Summary
The facility failed to administer psychotropic medications as ordered, affecting one resident out of five reviewed for medications. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, mood disorder, depression, and anxiety, was evaluated by a psychiatric certified nurse practitioner (CNP) who increased the dosage of Depakote to two 250 mg tablets in the morning and 250 mg at night. However, the new order was transcribed incorrectly into the medical record and Medication Administration Record (MAR), resulting in the resident receiving an additional 500 mg of Depakote every day, which was not ordered by the CNP. The error was identified during a review of the resident's medical record and confirmed through staff interviews. The psychiatric CNP confirmed that no order for an additional 500 mg of Depakote was made, and the registered nurse verified the transcription error. This error led to the resident receiving two doses of extra medication in error on two consecutive days, highlighting a failure in the medication administration process at the facility.
Failure to Provide Timely Dental Care and Denture Accessibility
Penalty
Summary
The facility failed to provide timely dental care for a resident with ill-fitting dentures and ensure the dentures were accessible. The resident, who had a history of dysphagia and other medical conditions, was admitted with upper and lower dentures and had sores from the dentures and tongue pain. Despite these issues, the resident's Minimum Data Set (MDS) assessment inaccurately indicated no dental problems. The resident's bottom dentures were missing after a hospital stay, and staff were unaware of this until it was discovered during a surveyor's visit. The resident had been using Lidocaine for throat pain, but the order should have been for mouth sores. Interviews with facility staff revealed a lack of awareness regarding the resident's missing dentures and the ill-fitting nature of the upper dentures. The Corporate Registered Nurse confirmed that the resident had refused the facility's dental services upon admission, but there was no documentation of any follow-up to see if the resident wanted to consult a dentist of his choice. The facility's failure to address the resident's dental issues promptly and accurately document the resident's condition contributed to the deficiency.
Inappropriate Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to ensure that residents had an appropriate indication for the use of antibiotics, affecting three residents out of eight reviewed for antibiotic use. The infection control log for July, August, and September 2024 revealed 28 resident infections that did not meet McGeer's criteria for antibiotic use. Specifically, Resident #3 was prescribed Macrobid for a urinary tract infection (UTI) on 07/17/24, despite not meeting the criteria for antibiotic use. The physician was notified but chose to continue the antibiotic treatment. Similarly, Resident #16 was prescribed Macrobid for a UTI on 08/22/24, and Resident #44 was prescribed Macrobid and later Augmentin for UTIs on 09/04/24 and 09/10/24, respectively, even though neither met the criteria for antibiotic use. In each case, the physician was informed of the lack of criteria but decided to continue the antibiotics. The facility's policy on antibiotic stewardship, revised on 11/01/19, requires that antibiotics be used in accordance with McGeer's criteria and that a clinical rationale be documented if antibiotics are continued without meeting these criteria. The Director of Nursing confirmed the deficiency during an interview.
Failure to Notify of Change in Resident's Health Status
Penalty
Summary
The facility failed to notify the resident's representative and physician of a change in health status for Resident #35. The resident, who was admitted with diagnoses including cardiomyopathy, hypertension, dementia, diabetes mellitus, and a history of COVID-19, exhibited a significant change in condition. On a specific date, the resident experienced shortness of breath while sitting on the side of her bed, with an oxygen saturation level of 86% on room air and a respiratory rate of 24 breaths per minute, accompanied by audible wheezing. Oxygen was administered at 2 liters per minute via nasal cannula. Despite these changes, the facility did not inform the resident's family representative or physician as required by their policy. The Director of Nursing confirmed that the notification should have been made according to the facility's policy on resident condition changes, which mandates immediate contact with the resident's physician and responsible party in the event of a perceived change in condition. This oversight was identified during a complaint investigation, affecting one of the three residents reviewed for notification of change.
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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