Crestwood Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelby, Ohio.
- Location
- 225 W Main Street, Shelby, Ohio 44875
- CMS Provider Number
- 365284
- Inspections on file
- 48
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Crestwood Care Center during CMS and state inspections, most recent first.
The facility failed to ensure timely signing of consent to treat and admission agreements for two residents. One resident, with severe cognitive impairment, had their consent signed only on the day of their death. Another resident, who was cognitively intact, signed their admission agreement 11 days after admission due to the Director of Public Relations' absence and the resident's initial reluctance.
The facility failed to ensure timely wound treatment orders for three residents, leading to a deficiency in care. One resident had untreated non-pressure skin issues upon admission, another had delayed treatment for toe wounds, and a third had untreated skin issues including a buttock abrasion. The Director of Nursing confirmed the delay was due to the sudden departure of the wound nurse, resulting in ongoing non-compliance from a previous survey.
A resident with multiple medical conditions, including diabetes and vascular disease, experienced a delay in receiving timely wound treatment orders for pressure ulcers. The facility failed to promptly implement treatment for a stage III pressure ulcer and a deep tissue injury, as confirmed by the DON. The delay was attributed to the unexpected departure of the wound nurse responsible for obtaining treatment orders.
The facility failed to administer medications per physician orders for three residents, resulting in delays. A resident received Hydroxyzine late on two occasions, while another had multiple medications administered late. A third resident missed bedtime medications and received insulin after breakfast instead of before. The DON confirmed that medications could have been pulled from the contingency supply, and the facility's policy required timely administration within one hour of the scheduled time.
The facility failed to maintain clean food service areas and ensure proper hygiene practices during food preparation, affecting all residents receiving meals. Observations showed a microwave with dried food splatter, a refrigerator with spills and uncovered food, and a dietary staff member cooking without a beard net. These issues were verified by staff and violated the facility's cleanliness policy.
A resident with cerebral palsy and anxiety reported missing clothing and a comforter after laundry service, highlighting a deficiency in the facility's management of personal property. Staff interviews revealed systemic issues with the laundry process, including improper delivery and outdated room lists, leading to frequent misplacement of items.
The facility failed to develop and provide baseline care plans within 48 hours of admission for two residents with severe cognitive impairments, as required by policy. Both residents, admitted with various diagnoses, lacked established care plans and documentation that their representatives received the necessary information. The Administrator confirmed these deficiencies, indicating a lapse in adhering to protocols for addressing residents' immediate care needs.
The facility failed to provide routine activities for residents, affecting two individuals with cognitive impairments. One resident was not consistently offered activities despite a care plan, and another had multiple days without documented activities. Staff interviews revealed a lack of activities for residents with lower cognition and inconsistencies in offering activities, leading to unmet needs and a deficiency in care.
The facility failed to administer oxygen therapy per physician orders for two residents. One resident received oxygen without an active order, and their tubing was not changed weekly. Another resident had inconsistent documentation of oxygen saturation levels, and their tubing was undated. The facility's policy requiring physician orders for oxygen administration was not followed.
A facility failed to monitor a resident's dialysis care by not performing required pre- and post-dialysis assessments and failing to maintain communication with the dialysis center. The resident, with stage III kidney disease, did not have vital signs or weights checked as per the physician's order, and no communication was sent or received regarding dialysis sessions. Staff interviews confirmed these lapses, which were contrary to the facility's policy on Hemodialysis Care and Monitoring.
A facility failed to properly disinfect glucometers and implement enhanced barrier precautions during wound care. An LPN used alcohol wipes instead of an EPA-approved disinfectant for glucometers shared among residents. Additionally, during wound care, an LPN and a CNA did not wear the required PPE, and the LPN did not change gloves or wash hands between tasks, contrary to CDC guidelines.
The facility failed to follow physician orders for wound care for two residents. One resident with a neuropathic wound did not receive daily dressing changes as ordered, and another resident with multiple wounds received incorrect treatment when an LPN applied triple antibiotic ointment instead of the prescribed dressings. Interviews confirmed these lapses in care and documentation.
The facility failed to secure catheters for two residents as per their care plans and facility policy. One resident with chronic diastolic heart failure and neuromuscular dysfunction of the bladder, and another with chronic cystitis and obstructive uropathy, both had unsecured catheters, confirmed by an LPN. The facility's policy requires catheters to be secured to the leg, which was not followed.
The facility exceeded the acceptable medication error rate with incidents involving two residents. An LPN administered the wrong type of insulin to a resident with diabetes, leading to symptoms like tiredness and shakiness. Another resident with severe cognitive impairment received a blood pressure medication despite a heart rate below the prescribed threshold. These errors reflect a failure to follow physician orders and facility policy.
A resident with type II diabetes was mistakenly given 50 units of Lispro, a fast-acting insulin, instead of the prescribed Lantus, a long-acting insulin, along with 12 units of Insulin Aspart. This error led to symptoms such as tiredness and shakiness. The facility's policy on verifying medication was not followed.
The facility did not complete required annual performance evaluations for CNAs, affecting three staff members hired on different dates. This oversight was confirmed by the HR Director and had the potential to impact all 96 residents.
A facility failed to ensure a resident's advance directives were accessible and communicated to the interdisciplinary team. The resident, with a DNR-CC order, did not have the DNR documentation in their medical record. When the resident's condition changed, staff could not find the signed DNR paper, leading to confusion about the resident's code status. The DON confirmed the advance directive should have been accessible, as per facility policy.
A resident with a history of heart disease, diabetes, and lymphedema experienced a delay in medication implementation for bleeding concerns. Despite a change in megestrol dosage during a gynecology appointment, the updated order was not implemented for 21 days, leading to continued bleeding and a hospital visit for a transfusion. Interviews revealed communication lapses among staff, contributing to the delay. The resident eventually underwent a hysterectomy after bleeding for ten months.
A resident experienced severe pain and withdrawal symptoms after her Oxycodone was discontinued without notification. The facility failed to provide effective pain management, as the alternative medication, Percocet, was ineffective. Despite the resident's complaints and her son's intervention, the facility's physician was unresponsive, and no alternative pain solutions were provided.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours on two days, as required. A review of staffing reports showed no RN coverage on a Saturday and Sunday. The Director of Nursing confirmed the absence of RN coverage on those days, acknowledging the requirement for daily RN presence.
A resident with chronic pain was not informed of the discontinuation of her Oxycodone medication, leading to severe pain and withdrawal symptoms. Despite repeated requests from the resident and her family, the facility's physician did not provide alternative pain management until the resident's son intervened. The facility failed to adhere to its policies on pain management and notification of changes in condition.
A resident with alcohol-induced dementia and blindness exhibited severe behavioral issues, including aggression and inappropriate urination, which were not effectively managed by the facility. Despite having a care plan and orders for psychiatric and neurological consultations, the resident did not receive the necessary mental health services, leading to a deficiency.
The facility failed to ensure an RN was on duty for eight consecutive hours each day, seven days a week. A review of staffing reports revealed no RN coverage on two specific Saturdays. The RDCO confirmed the absence of the Director of Nursing and any other RN on those dates, verifying the requirement for daily RN coverage.
The facility failed to report, investigate, and document multiple incidents of resident-to-resident abuse involving a resident with severe cognitive impairment and a history of impulsive behavior. Incidents included physical and verbal altercations with other residents, which were not properly documented or reported to the state agency as required by the facility's policy.
The facility failed to maintain accurate records for four residents, including incidents of resident-to-resident altercations and behavior monitoring. Staff interviews revealed the DON instructed not to document certain incidents, leading to incomplete records.
A resident with mild dementia, chronic kidney disease, and muscle weakness was found soaked in urine and fecal matter, shivering and cold, due to a failure in timely incontinence care. The assigned STNA admitted to not checking on the resident for over four hours, despite the care plan requiring checks every two hours.
The facility failed to ensure physician-ordered treatments were applied as ordered for two residents. One resident with venous insufficiency did not receive compression wraps consistently, leading to swollen legs. Another resident with lymphedema and diabetes had incomplete wound care dressings, despite specific orders. Observations and interviews confirmed these deficiencies.
The facility failed to ensure timely completion of physician-ordered lab tests for a resident with schizoaffective disorder and aggressive behavior. A valproic acid level test was not transcribed or conducted, and a urinalysis was delayed without notifying the physician.
Two residents experienced medication administration errors. One resident did not receive the immunosuppressive medication Humira as documented on the MAR, with the medication reportedly discarded by a nurse. The DON confirmed the error and initiated an investigation. Another resident, under hospice care, did not receive the prescribed morphine for comfort measures due to a delay in pharmacy authorization, resulting in the resident's passing before administration. These incidents highlight issues in medication management and adherence to protocols.
A resident with a history of subdural hematoma, alcohol abuse, stroke, seizures, and dementia was improperly restrained in a Broda chair with a gait belt by an LPN without a physician's order. The incident was reported and confirmed by staff interviews, revealing non-compliance with the facility's policy on physical restraints.
A facility failed to ensure medications were stored and administered properly, affecting a resident with severe cognitive impairment. An LPN left a cup of medications at the resident's bedside and did not observe the resident take them, contrary to the facility's policy.
A facility failed to accurately document the administration of Humira for a resident with rheumatoid arthritis. The resident confirmed that a nurse was unable to administer the injection correctly and discarded the medication, but the MAR falsely indicated it was given. Another nurse administered the medication later, but this was not documented.
The facility failed to maintain daily posted nurse staffing data as required, potentially affecting all 104 residents. An observation revealed outdated staffing data, and the DON confirmed that the facility had been discarding the daily posted nurse staffing data instead of keeping them for the required 18 months.
Delayed Consent and Admission Agreement Signing
Penalty
Summary
The facility failed to ensure timely signing of consent to treat and admission agreements for residents. For Resident #89, who was admitted with severe cognitive impairment and multiple medical conditions, the consent to treat was not signed until the day of the resident's death, despite the resident being dependent for all activities of daily living and having a Power of Attorney present shortly after admission. The Director of Nursing confirmed that the nursing staff were responsible for obtaining the consent to treat upon admission, but this was not done in a timely manner. For Resident #51, who was cognitively intact and admitted with conditions such as cerebral infarction and diabetes, the consent to treat was signed two days after admission, but the admission agreement was not signed until 11 days post-admission. The Director of Public Relations acknowledged the delay, attributing it to the resident's initial reluctance to complete paperwork and her own absence from the facility due to marketing duties. This deficiency was investigated under Complaint Number OH00163843.
Delayed Wound Treatment Orders for Residents
Penalty
Summary
The facility failed to ensure timely wound treatment orders for three residents, leading to a deficiency in care. Resident #11, admitted with multiple diagnoses including peripheral vascular disease and diabetes, had a stage three pressure ulcer and an unstageable pressure ulcer upon admission. Despite documentation of non-pressure skin issues on the nursing admission evaluation, no treatment or monitoring was implemented for these areas, as confirmed by the Treatment Administration Record (TAR) for March 2025. Resident #51, with a history of cerebral infarction and diabetes with a foot ulcer, had a surgical incision on the left toes documented upon admission. However, the wound assessment completed by the wound nurse practitioner revealed additional wounds on the toes that were not treated until two days after they were acquired. The TAR confirmed that treatments for these wounds were not started until March 15, 2025, despite being acquired on March 13, 2025. Resident #89, who was severely cognitively impaired and dependent for all activities of daily living, had multiple skin issues documented upon admission, including a skin tear and hematoma. A wound assessment later revealed an abrasion on the left buttock, but treatment orders were not implemented until March 15, 2025. The Director of Nursing confirmed that the wound treatment orders for these residents were not put into place timely due to the sudden departure of the wound nurse, resulting in a delay in treatment. This deficiency was noted as ongoing non-compliance from a previous survey.
Delayed Wound Treatment Orders for Resident
Penalty
Summary
The facility failed to ensure timely pressure ulcer wound treatment orders for a resident, leading to a deficiency. The resident, who was admitted with multiple medical conditions including peripheral vascular disease and type two diabetes, had a stage three pressure ulcer and an unstageable pressure ulcer upon admission. The Nursing Admission Evaluation noted additional skin issues, but treatment orders for these were marked as not applicable. The wound assessment by a nurse practitioner later identified a stage III pressure ulcer on the sacrum and a deep tissue injury on the right great toe, both acquired shortly after admission. Despite the presence of these wounds, treatment orders were not obtained or implemented promptly. The physician orders for the sacrum and right great toe wounds were not initiated until several days after the wounds were acquired. Furthermore, the Treatment Administration Record indicated that the treatment for the sacrum wound was delayed and not consistently documented. The Director of Nursing confirmed the delay in obtaining and implementing wound treatment orders, attributing it to the sudden departure of the wound nurse responsible for acquiring these orders.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered per physician orders, affecting three residents. Resident #11, who was cognitively intact, had a physician order for Hydroxyzine 25 mg three times daily. However, the medication was administered late on two occasions, once at 11:49 P.M. instead of 9:00 P.M., and another time at 5:41 P.M. instead of 2:00 P.M. Resident #16, also cognitively intact, had multiple medications scheduled for 7:30 A.M., including Calcium with Vitamin D3, Tylenol, Pantoprazole, and Mometasone Furo-Formoterol inhalation aerosol. These medications were administered late at 9:52 A.M. Resident #51, who was cognitively intact, had several medications scheduled for bedtime on 03/13/25, which were not administered. Additionally, on 03/23/25, Humulin R insulin was scheduled before breakfast at 7:30 A.M. but was not administered until 9:31 A.M. after breakfast. The Director of Nursing confirmed that medications could have been pulled from the contingency supply for Resident #51, and verified that the medications for Residents #11, #16, and #51 were not administered timely. The facility's policy stated that medications should be administered within one hour before or after the scheduled time, and before meals, medications should be given thirty minutes prior to mealtime.
Deficiencies in Food Service Hygiene and Cleanliness
Penalty
Summary
The facility failed to maintain clean food service areas and ensure proper hygiene practices during food preparation, potentially affecting all 96 residents who received meals from the kitchen. Observations revealed that the microwave in the secured unit pantry had dried food splatter, and the snack refrigerator behind the nurses' station had dried liquid spills and uncovered, unlabeled, and undated food items. Additionally, a dietary staff member with a full beard was observed cooking without a beard net, which was against the facility's policy. These deficiencies were verified by staff members, including a Dietary Aide and an LPN, and were in violation of the facility's policy requiring all food preparation and service areas to be maintained in a clean and sanitary condition.
Failure to Secure and Return Resident's Personal Property
Penalty
Summary
The facility failed to ensure the security and timely return of personal property for a resident, leading to a deficiency in maintaining a safe, clean, comfortable, and homelike environment. Resident #18, who has diagnoses including generalized anxiety and cerebral palsy and requires assistance with activities of daily living, reported multiple clothing items and a comforter missing after being sent to the laundry. The resident also mentioned frequently receiving clothing belonging to other residents, indicating a systemic issue with the laundry process. Interviews with staff revealed that the laundry process was not properly managed, contributing to the misplacement of personal items. Laundry Aide #505 acknowledged that clean clothes were not consistently delivered to the correct rooms and that the list of residents' rooms was not properly updated, leading to errors in clothing delivery. Despite reporting these issues to the housekeeping supervisor, the problems persisted. The facility's policy on personal laundry handling and processing was not effectively implemented, as evidenced by the failure to maintain proper documentation and ensure timely delivery of cleaned items to residents.
Failure to Develop and Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and provided to residents and their representatives within 48 hours of admission, as required by their policy. This deficiency affected two residents, both of whom had severe cognitive impairments and required assistance with activities of daily living. Resident #79, admitted with diagnoses including diabetes mellitus, vascular dementia, and hyperlipidemia, did not have a baseline care plan established, nor was there evidence that their representative received a copy. Similarly, Resident #81, admitted with major depressive disorder, unspecified dementia, and anxiety disorder, also lacked a baseline care plan and documentation that their representative was informed. The facility's policy, dated June 1, 2024, mandates the development of a baseline care plan within 48 hours of admission, including providing a written summary to the resident and their representative. However, interviews with the Administrator confirmed the absence of baseline care plans for both residents and the lack of documentation indicating that their representatives were provided with the necessary information. This oversight highlights a failure to adhere to established protocols for ensuring residents' immediate care needs are addressed upon admission.
Failure to Provide Routine Activities for Residents
Penalty
Summary
The facility failed to provide routine activities to all residents, specifically affecting two residents. Resident #15, who has significant cognitive impairment and requires assistance with daily activities, was not consistently offered activities. Despite a care plan that included transport to activities and one-on-one visits, the activity logs showed numerous days where no activities were offered. Observations confirmed that Resident #15 was often in her room during scheduled activities and was not aware of certain events, such as a drink cart. Interviews with staff revealed a lack of activities for residents with lower cognition and inconsistencies in offering activities. Resident #79, who has severe cognitive impairment and requires substantial assistance, also experienced a lack of documented activity offerings. The activity tracking for Resident #79 showed multiple days without any recorded activities. Interviews with the resident's wife and staff indicated that there were not many activities available, and there was no specific calendar for the secure unit where Resident #79 resided. The activity guide for the secure unit was not effectively utilized, leading to missed opportunities for engagement. The facility's policy on providing resident-centered care to meet psychosocial, physical, and emotional needs was not adhered to, as evidenced by the sporadic offering of activities and lack of documentation. Staff interviews highlighted gaps in the activity program, particularly for residents with cognitive impairments, and confirmed the deficiencies in the activity logs. The facility's failure to consistently offer and document activities for these residents resulted in unmet needs and a deficiency in the quality of care provided.
Oxygen Therapy Administration Deficiency
Penalty
Summary
The facility failed to ensure proper administration of oxygen therapy for two residents, Resident #12 and Resident #18, as per physician orders. For Resident #12, who was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, the facility did not have an active order for oxygen administration in the electronic medical record, despite the resident receiving oxygen at two liters per minute via nasal cannula. Additionally, the oxygen tubing for Resident #12 had not been changed since 02/10/25, contrary to the facility's practice of weekly changes, and there were no orders for how often to change the tubing and humidification. For Resident #18, who had a diagnosis of Arnold Chiari Syndrome and cerebral palsy, the facility failed to document oxygen saturation levels consistently, with only one recorded instance in February 2025. Although Resident #18 had an order for supplemental oxygen to maintain saturation above 94%, the oxygen tubing was undated, and there were no orders for oxygen as needed unless saturation dropped below 94%. The facility's policy required a physician's order for oxygen administration, including the route, liters per minute, and frequency, which was not adhered to in these cases.
Failure to Monitor Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate monitoring and communication for a resident requiring dialysis services. Specifically, the facility did not perform routine vital signs checks or pre- and post-dialysis assessments for Resident #66, who was diagnosed with stage III kidney disease and required hemodialysis. The medical records for November 2024, December 2024, and January 2025 showed no documentation of these assessments, and there was no communication noted between the facility and the dialysis center. The physician's order required assessments to be completed before and after dialysis sessions, but these were not adhered to. Interviews with Resident #66 and facility staff revealed that the resident did not receive pre- and post-dialysis weight and vital sign checks, and there was no communication sent with the resident to the dialysis center. The facility's policy on Hemodialysis Care and Monitoring, dated 2017, outlined the need for pre-dialysis evaluations and post-dialysis reviews, which were not followed. Staff interviews confirmed the lack of documentation and communication, indicating a systemic failure to comply with established protocols for dialysis care.
Infection Control Deficiencies in Glucometer Disinfection and Wound Care
Penalty
Summary
The facility failed to ensure proper disinfection of glucometers, which are used for multiple residents. During an observation, an LPN was seen using an alcohol wipe to clean a glucometer after checking a resident's blood sugar. The LPN confirmed that the glucometer was shared among residents and that she used alcohol wipes for sanitization. However, the facility's policy requires the use of an EPA-approved disinfectant effective against HIV, Hepatitis C, and Hepatitis B, which alcohol wipes do not meet. This improper cleaning practice was verified by the LPN Unit Manager, who stated that the glucometer should be cleaned with bleach sanitizer wipes and allowed to air dry completely. The facility also failed to implement enhanced barrier precautions (EBP) during wound care for a resident. An LPN was observed performing wound care without donning the required gown and gloves, as indicated by the EBP sign on the resident's door. The LPN did not change gloves between removing old dressings and applying new ones, and did not wash hands between tasks. Additionally, a CNA assisted with the dressing change without wearing a gown. The LPN admitted to not following the appropriate PPE protocol and not changing gloves or washing hands as required. The CDC guidance emphasizes the importance of using PPE to prevent the spread of multidrug-resistant organisms and the necessity of hand hygiene in healthcare settings. The facility's failure to adhere to these guidelines during wound care and glucometer disinfection poses a risk of infection transmission among residents. The observations and interviews confirm that the facility did not comply with its own policies and CDC recommendations, leading to deficiencies in infection prevention and control.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility failed to ensure wound treatments were completed per physician orders for two residents. Resident #28, who has type two diabetes mellitus, chronic obstructive pulmonary disease, and pulmonary fibrosis, had a non-pressure neuropathic wound on the left inner ankle. The physician's orders required daily cleansing and dressing changes, but documentation showed missed treatments on two occasions, and the dressing observed was not changed as per the schedule. Interviews with the resident and staff confirmed the lapses in treatment and documentation. Resident #54, diagnosed with type II diabetes mellitus, morbid obesity, and stage IV chronic kidney disease, had treatment orders for wounds on the right posterior thigh and bilateral posterior leg ulcers. The orders specified the use of specific wound cleansers and dressings, but during an observation, an LPN applied triple antibiotic ointment instead of following the prescribed treatment. The LPN confirmed the deviation from the physician's orders during an interview.
Failure to Secure Catheters for Residents
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, both of whom had indwelling catheters. Resident #46, who was admitted with diagnoses including chronic diastolic heart failure and neuromuscular dysfunction of the bladder, had a care plan that required the catheter to be secured to the leg with a security device. However, during an observation, it was noted that the catheter tubing was not secured to the resident's leg, a fact confirmed by an LPN. Similarly, Resident #69, admitted with chronic cystitis, dementia, and obstructive and reflux uropathy, also had a care plan that included securing the catheter to the leg. An observation revealed that the catheter was not secured, which was again verified by an LPN. The facility's policy on catheter care mandates that catheters be secured to the leg with a device or tape, which was not adhered to in these cases.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate of 7.41%, which exceeded the acceptable threshold of 5%. This deficiency affected two residents, one of whom was Resident #57, who had a diagnosis of type II diabetes mellitus with hyperglycemia. During a medication administration observation, an LPN administered 50 units of Lispro, a fast-acting insulin, instead of the prescribed 50 units of Lantus, a long-acting insulin, along with 12 units of Insulin Aspart per sliding scale. This error was confirmed by the Director of Clinical Operations and the LPN involved. Resident #57 experienced symptoms such as tiredness, numbness, and shakiness after the incorrect insulin administration. Another incident involved Resident #69, who had severe cognitive impairment and a diagnosis of paroxysmal atrial fibrillation, essential hypertension, and hyperlipidemia. The physician's order for Resident #69 included Diltiazem HCL ER, which was to be held if the heart rate was below 60. On the day of observation, the resident's heart rate was documented as 56, yet the LPN administered the medication without obtaining vital signs at the time of administration. This was a direct violation of the physician's order and the facility's medication administration policy. The facility's policy on medication administration requires licensed personnel to observe the five rights of medication administration, including verifying the right medicine and dose, and to record pertinent information such as blood pressure and heart rate before administering medication. The failure to adhere to these protocols resulted in medication errors for both residents, highlighting a significant deficiency in the facility's medication administration practices.
Significant Medication Error with Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting Resident #57. The resident, who had a diagnosis of type II diabetes mellitus with hyperglycemia and intact cognition, was prescribed Lantus, a long-acting insulin, to be administered twice daily. However, during a medication administration observation, an LPN mistakenly administered 50 units of Lispro, a fast-acting insulin, instead of the prescribed Lantus, along with 12 units of Insulin Aspart per the sliding scale. This resulted in a total of 62 units of fast-acting insulin being given to the resident. Following the administration error, Resident #57 experienced symptoms such as tiredness, numbness in the left arm, and shakiness. The resident reported feeling loopy and having difficulty eating breakfast. The CNP on-site confirmed the error and initiated frequent monitoring of the resident's blood sugar levels. The facility's policy on medication administration, which requires licensed personnel to verify the right medicine and dose by reading medication labels three times, was not adhered to, leading to this significant medication error.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for certified nursing assistants (CNAs) as required. This deficiency was identified through a review of personnel files and staff interviews. Specifically, the personnel files for three CNAs, hired on different dates, showed no record of annual performance evaluations for the year 2024. The CNAs affected were hired on 08/10/22, 11/19/19, and 01/05/22, respectively. The Human Resource Director confirmed the absence of these evaluations, which had the potential to impact all 96 residents in the facility.
Failure to Ensure Availability and Communication of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were readily available and communicated to the interdisciplinary team. Resident #100, who had a diagnosis of dementia and a Do Not Resuscitate-Comfort Care (DNR-CC) order, did not have the DNR documentation uploaded in their medical record. The plan of care indicated that copies of the advance directives should be obtained and filed, but there was no physician order related to the resident's code status, and the code status for DNR-CC was discontinued. The face sheet in the electronic charting also lacked the advance directive, although the hard chart indicated the resident was a DNR-CC. When Resident #100 experienced a change in condition, the nursing staff was unable to locate the signed DNR paper. A CNA and an LPN searched the chart but only found a hospital note indicating the resident's DNR status. The LPN, who was on duty when the resident passed away, did not initiate CPR based on the information found. The Director of Nursing confirmed that the advance directive should have been accessible to all nursing staff and that a valid DNR should have been in the resident's hard chart. The facility's policy required that advance directives be placed on the hard chart and communicated to staff, which was not adhered to in this case.
Delayed Medication Implementation for Resident with Bleeding Concerns
Penalty
Summary
The facility failed to ensure timely review and implementation of continuity of care for a resident, specifically regarding medication management. The resident, who had a history of heart disease, diabetes mellitus, and lymphedema, was admitted with ongoing bleeding concerns. A medication order for megestrol was changed during an obstetrics and gynecology appointment, but the updated order was not implemented until 21 days later. This delay occurred despite the resident's ongoing bleeding and low hemoglobin levels, which eventually required a hospital visit for a blood transfusion. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's medication orders. The Licensed Practical Nurse (LPN) acknowledged that the order was not updated in the system until much later, and the Director of Nursing (DON) confirmed that the nurse on duty should have contacted the physician if the paperwork was not returned with the resident. The Nurse Practitioner (NP) also did not mention any medication change during a follow-up visit, and the gynecologist's notes were not signed and uploaded until a week after the appointment. The resident eventually underwent a hysterectomy after experiencing bleeding for ten months. Interviews with the resident and the surgeon's office nurse indicated that the medication increase was intended to manage bleeding until the surgery could be performed. However, the delay in implementing the medication change contributed to the resident's continued bleeding and subsequent need for a transfusion. The deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance in managing the resident's care effectively.
Failure in Pain Management Leads to Resident Harm
Penalty
Summary
The facility failed to provide effective pain management for a resident, resulting in actual harm. The resident, who had a history of diabetes mellitus type two with diabetic neuropathy, osteoarthritis, and chronic pain syndrome, experienced withdrawal symptoms and severe pain after her physician discontinued her Oxycodone medication without notifying her. The resident's pain was inadequately managed with Percocet, which was not effective in controlling her pain, leading to her experiencing nausea, trembling hands, and severe pain. The resident's medical records indicated that she had been receiving Oxycodone 10 mg twice a day for pain management, which was discontinued on a specific date without her knowledge. Despite the resident's complaints of uncontrolled pain and withdrawal symptoms, the facility staff did not provide alternative pain solutions or non-pharmacological interventions as outlined in her care plan. The resident's son had to intervene to have her medication reinstated, highlighting a lack of communication and responsiveness from the facility's physician and staff. Interviews with the resident and staff confirmed that the resident was not informed of the medication change and that the facility's physician was unresponsive to the nurses' assessments and requests for alternative pain management. The facility's policy on pain management and assessments was not followed, as the resident's report of pain was not adequately addressed, and her care plan was not updated to reflect alternative measures for pain relief.
Failure to Ensure RN Coverage for Eight Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. This deficiency was identified through a review of daily staffing reports from September 17, 2024, to September 23, 2024, which revealed that there was no RN coverage on Saturday, September 21, 2024, and Sunday, September 22, 2024. An interview with the Director of Nursing (DON) on September 25, 2024, confirmed that she did not work in the building on those dates and verified the absence of an RN on duty during those days. The DON acknowledged that the facility should have an RN on duty every day for at least eight hours. This deficiency was investigated under Complaint Number OH00157343.
Failure to Inform Resident of Medication Change
Penalty
Summary
The facility failed to timely inform and allow Resident #100 to participate in their treatment, specifically regarding the discontinuation of Oxycodone HCL, a pain medication. Resident #100, who had intact cognition and was suffering from osteoarthritis and chronic pain syndrome, was not notified of the discontinuation of her Oxycodone medication until four days after it was stopped. During this period, the resident experienced severe pain, with levels ranging from six to ten on the pain scale, and was not provided with effective alternative pain management solutions. The medical records and interviews revealed that Resident #100 spent several days in significant distress, experiencing symptoms such as shaking, anxiety, and excruciating pain, which were not alleviated by the alternative medication, Percocet, or other interventions. Despite the resident's and her family's repeated requests for the reinstatement of Oxycodone, the facility's physician did not provide any alternative pain management until the resident's son intervened. The facility's staff, including LPN #3, confirmed that they had informed the physician of the resident's severe pain and withdrawal symptoms, but no action was taken until the family got involved. The facility's policies on pain management and notification of changes in condition were not adhered to, as Resident #100 was not informed of the medication change, nor was she involved in the decision-making process. The Director of Nursing confirmed that the resident and her family were not present during the meeting where the decision to discontinue Oxycodone was made, and there was no documentation of notification to the resident. This deficiency was investigated under Complaint Number OH00157343.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to timely implement effective and individualized interventions for a resident with behavioral health concerns, leading to a deficiency. The resident, who was blind and diagnosed with alcohol dependence with alcohol-induced persisting dementia, exhibited various behavioral issues such as urinating on the floor, verbal aggression, and physical threats. Despite having a care plan that included anti-anxiety medication and psych consults, the interventions were not effectively implemented, and the resident's behaviors were not adequately managed. The medical records revealed that the resident was not seen by the psychiatric services (Psych 360) as ordered, nor did they attend a scheduled neurology appointment. The resident's behaviors, including aggression and inappropriate urination, were documented multiple times, but there was no evidence of effective intervention or follow-up on the psychiatric and neurological consultations. The staff reported the incidents to the nursing staff, DON, and Administrator, but the necessary mental health services were not provided. Interviews with staff confirmed that the resident's severe behaviors were left untreated, and the facility lacked the resources or interventions to manage these behaviors. The DON verified that the resident had psychological needs that were not being properly addressed, and the facility's policy on behavior management was not effectively implemented. This deficiency was investigated under Complaint Number OH00157343.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week. This deficiency was identified through a review of daily staffing reports from 04/22/24 to 05/06/24, which revealed no RN coverage on Saturday 04/27/24 and Saturday 05/04/24. An interview with the Regional Director of Clinical Operations (RDCO) confirmed that the Director of Nursing was not present on those dates, nor was there any evidence of another RN working. The RDCO verified that the facility should have an RN on duty every day for at least 8 hours. This deficiency was investigated under Complaint Number OH00153688.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report, investigate, and document allegations of resident-to-resident abuse, affecting six residents. Resident #100, with severe cognitive impairment and a history of impulsive behavior following a stroke, was involved in multiple incidents of aggression towards other residents. These incidents included lunging towards Resident #97, pushing Resident #98, and engaging in a verbal altercation with Resident #80. Despite these events, there was a lack of timely documentation, investigation, and reporting to the state agency as required by the facility's policy. In one instance, Resident #100 lunged towards Resident #97, resulting in a red area on Resident #97's nose and chin. However, there was no follow-up documentation or notification to Resident #97's family or provider. Another incident involved Resident #100 pushing Resident #98 in the abdomen, which was witnessed by staff but not documented or reported to the state agency. Additionally, Resident #100 engaged in a verbal altercation with Resident #80, during which he used expletive language and swung his arms, hitting an LPN who intervened. This incident was reported late and not thoroughly investigated. Further incidents included Resident #100's physical altercation with Resident #83 and an altercation with Resident #101, both of which were not documented or reported in a timely manner. The facility's policy required immediate investigation, documentation, and reporting of such incidents, but these steps were not followed. The lack of proper documentation and timely reporting of these incidents highlights significant deficiencies in the facility's handling of resident-to-resident abuse cases.
Failure to Maintain Accurate Resident Records
Penalty
Summary
The facility failed to maintain accurate resident records, affecting four residents. Resident #84, diagnosed with dementia, anxiety, and schizophrenia, had no recorded behaviors in May 2024 despite an incident involving another resident. The Social Services Director (SSD) noted no adverse psychosocial effects, but the Treatment Administration Record (TAR) showed no behaviors monitored for the month. Resident #98, with severe dementia and other mental health issues, had no behavior monitoring on their Medication Administration Record (MAR) or TAR for April and May 2024. An incident on May 5, 2024, where Resident #98 placed hands around Resident #84's neck, was not documented in either resident's records. Staff interviews revealed the Director of Nursing (DON) instructed not to document the incident. Resident #101, with moderate dementia and other behavioral issues, had no documentation of an incident on May 6, 2024, where Resident #100 pulled their hair. The TAR for April and May 2024 also lacked behavior monitoring. Similarly, Resident #100's records did not document the incident, despite staff witnessing and reporting it. The DON confirmed the lack of documentation and denied instructing staff not to document, attributing it to prior concerns with staff documentation practices.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely and appropriate incontinence care for Resident #27, who was admitted with medical diagnoses including mild dementia, chronic kidney disease, and muscle weakness. The resident's care plan indicated he was incontinent of bowel and bladder and dependent on staff for toileting hygiene. During an observation, Resident #27 was found lying in bed soaked with urine, with a strong odor of urine and fecal matter in the room. The resident's clothing and bedding were wet, and he was shivering and stated he was cold. STNA #322, who was not assigned to the resident, provided incontinence care, while STNA #326, who was assigned to the resident, admitted she had not checked on him since 5:30 A.M., despite being required to check every 2 hours. STNA #326 was finishing a 16-hour shift and confirmed she had not provided the necessary incontinence care for Resident #27 between 5:30 A.M. and the time of observation at 9:50 A.M. The facility's policy on routine resident care mandates that residents receive routine daily care, including toileting and incontinence care, to maintain dignity and skin integrity. This deficiency was investigated under Complaint Number OH00153274.
Failure to Apply Physician-Ordered Treatments
Penalty
Summary
The facility failed to ensure physician-ordered treatments were applied as ordered for two residents. Resident #45, who has medical diagnoses including venous insufficiency, chronic pain, and muscle weakness, had an order for compression wraps to be applied daily. However, the Treatment Administration Record (TAR) showed that the wraps were not applied on multiple dates in April 2024. Observations and interviews revealed that Resident #45's legs were visibly swollen and unwrapped, and the resident reported difficulty in getting staff to consistently apply the wraps. The Social Services Director and a family member confirmed ongoing issues with the application of the leg wraps, despite previous complaints and attempts to resolve the issue. Resident #50, diagnosed with morbid obesity, lymphedema, and type II diabetes mellitus, had an order for a specific wound care regimen to be applied twice daily. The TAR indicated that the dressings were not documented as completed on several dates in May 2024. Observations showed that Resident #50's dressings were incomplete, and the resident reported that nursing staff failed to reapply the ordered treatment after a wound care provider's visit. The Regional Director of Clinical Operations confirmed the lack of documentation and incomplete dressings. The facility's policy stated that residents would receive treatments as ordered, but this was not adhered to in these cases.
Failure to Ensure Timely Laboratory Testing
Penalty
Summary
The facility failed to ensure timely completion of physician-ordered laboratory testing for Resident #100, who had a history of cerebrovascular accident, depression, schizoaffective disorder, and insomnia. The resident was prescribed Depakote for schizoaffective disorder, and a psychiatric nurse practitioner ordered a valproic acid level test on 02/12/24. However, the order was never transcribed, and the blood test was not conducted. This oversight was confirmed during an interview with the Director of Nursing, Regional Director of Clinical Operations, and Corporate Nurse on 05/09/24. Additionally, Resident #100 exhibited aggressive behavior towards other residents on 04/24/24 and 04/25/24, prompting a physician to order immediate laboratory tests, including a complete blood count, basic metabolic panel, and urinalysis with culture and sensitivity testing. While the blood tests were completed on 04/26/24, the urinalysis was not performed until 05/04/24, and there was no documented notification to the provider about the delay. This was verified by the Regional Director of Clinical Operations, who stated that the physician should have been notified if the specimen could not be obtained timely.
Medication Administration Errors Impact Resident Care
Penalty
Summary
The facility failed to ensure medications were administered as ordered, impacting two residents (#14 and #110) out of five reviewed. For Resident #14, the medication error involved the immunosuppressive medication Humira, which was not administered as documented on the medication administration record (MAR). The resident reported that a nurse threw the medication in the trash after being unable to administer it correctly. The Director of Nursing confirmed the error and initiated an investigation. In the case of Resident #110, who was in declining health and under hospice care, the ordered narcotic pain medication morphine was not administered as needed for comfort measures. The nurse was waiting for pharmacy authorization to pull the medication, but the resident expired before receiving it, highlighting a critical lapse in medication administration. The facility's policy on Medication Administration emphasizes providing resident-centered care and administering medications only as prescribed by the provider. However, the deficiencies identified in the report indicate a failure to adhere to these guidelines, resulting in significant medication errors for the affected residents. The lack of proper medication administration for Resident #14 and the delayed administration of morphine for Resident #110 during a critical period of discomfort and decline in health raise concerns about the facility's medication management processes and staff adherence to protocols.
Improper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from improper physical restraints, affecting one resident. Resident #85, who had a medical history including subdural hematoma, alcohol abuse, stroke, seizures, and dementia, was admitted to the facility on 01/05/24. On 03/09/24, LPN #214 observed LPN #220 placing Resident #85 in a Broda chair at the nurses' station and securing her with a gait belt around her waistline. LPN #214 reported the incident to the Director of Nursing (DON), who instructed her to send LPN #220 home and remove the resident from the chair and gait belt. The resident was restrained for 10 to 20 minutes without a physician's order for such restraint. Interviews with staff confirmed the incident. LPN #220 admitted to placing the resident in the Broda chair with a gait belt because she was concerned the resident might hurt herself by crawling on the floor. STNA #225 confirmed that LPN #220 instructed her to strap the resident in the chair with a gait belt that had a click-closed secured latch, preventing the resident from standing up. The facility's policy on physical restraints defines them as any device that restricts freedom of movement and cannot be easily removed by the resident, which includes the use of belts in conjunction with a chair. This incident was investigated under Master Complaint Number OH00151966.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure medications were stored in a safe and proper manner, affecting one of five residents reviewed for medications. Resident #17, who was admitted with medical diagnoses including subdural hemorrhage, kidney failure, and convulsions, was observed with a cup full of medications left on the bedside stand. The resident's quarterly Minimum Data Set (MDS) assessment revealed severe cognitive impairment. On 04/02/24 at 9:31 A.M., an LPN was overheard telling the resident she would leave the medications for him to take later and was then observed moving the medication cart down the hallway. The LPN confirmed she left the medications at the bedside and did not observe the resident take them. The facility's undated medication administration policy stated that staff should remain with the resident until the medication was swallowed and not leave medication at the bedside.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for Resident #14, who was admitted with diagnoses including rheumatoid arthritis, diabetes, chronic pain, and chronic obstructive pulmonary disease. The resident's medical record indicated a physician order for Humira to be administered subcutaneously every 14 days. However, the medication administration record (MAR) for March 2024 showed that the Licensed Practical Nurse (LPN) #232 documented the administration of Humira on 03/27/24, despite the resident confirming that the nurse was unable to administer the injection correctly and discarded the medication. The Director of Nursing (DON) confirmed that LPN #232 did not administer the medication as documented. Further investigation revealed that the resident informed the Social Services Director about the incident on 03/28/24, prompting an internal investigation. Another nurse administered the Humira injection on 03/30/24, but there was no documented evidence of this administration in the MAR or progress notes. This deficiency was identified during a review related to Complaint Number OH00151892.
Failure to Maintain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to maintain daily posted nurse staffing data as required, which had the potential to affect all 104 residents residing in the facility. On 04/02/24 at 1:15 P.M., an observation of the front door of the facility revealed a message board with the daily posted nurse staffing data dated 04/01/24 and 04/02/24. During an interview with the Director of Nursing (DON) on 04/02/24 at 1:39 P.M., it was confirmed that the facility had been throwing away the daily posted nurse staffing data and not keeping them as required. The facility policy titled 'Nurse Staffing Information' identified that the facility will post the daily staffing information for public viewing and maintain the data for a minimum of 18 months. This deficiency was an incidental finding related to allegations contained in Master Complaint Number OH00152382 and Complaint Number OH00151892.
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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