Cridersville Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Cridersville, Ohio.
- Location
- 603 East Main Street, Cridersville, Ohio 45806
- CMS Provider Number
- 366171
- Inspections on file
- 20
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Cridersville Nursing And Rehab during CMS and state inspections, most recent first.
A resident with mobility and cognitive impairments sustained a laceration requiring hospitalization after a wall-mounted bathroom sink, previously reported as unstable, detached from the wall and caused a fall. The sink lacked support legs and had not been subject to routine maintenance checks, despite concerns raised by residents to staff and maintenance. The incident resulted in actual harm and highlighted the absence of preventive measures for accident hazards.
Several residents with physical and cognitive impairments were unable to access a working bathroom sink in their shared room for an extended period, requiring them to use distant facilities for daily hygiene. Staff and residents repeatedly reported the issue, but the repair was delayed despite the facility receiving a replacement sink, resulting in ongoing inconvenience and, in one case, a resident fall.
A resident with multiple complex medical conditions, including end stage renal disease and heart failure, was prescribed warfarin but did not have a care plan addressing anticoagulant use. Review of records and staff interview confirmed the absence of a care plan for this medication, resulting in a deficiency identified during a complaint investigation.
A resident with severe cognitive impairment was found in her room with her pants down while another resident, who was cognitively intact, was observed touching her in the peri-area. Staff immediately intervened and separated the residents. Interviews confirmed the incident, and it was determined that the resident who was touched lacked the cognitive capacity to consent. The facility had not provided abuse education to all staff or conducted follow-up monitoring, contributing to the failure to protect the resident from sexual abuse.
A resident with Full Code status was found unresponsive and pulseless, but staff delayed the initiation of CPR while confirming code status and failed to continue resuscitation until EMS arrived. The RN in charge stopped CPR after one cycle, despite objections from other staff and the absence of a physician's order to discontinue. Essential equipment was missing from the crash cart, and EMS found no CPR in progress upon arrival, resulting in serious harm.
A resident with a history of respiratory failure and COPD returned from the hospital with orders for BiPAP therapy, but staff failed to ensure a current physician's order was in place or to document consistent use of the BiPAP device. The resident experienced episodes of respiratory distress, including a hospitalization for acute hypercapnic respiratory failure, with records showing several nights without BiPAP use and no documentation of refusals or reasons for missed therapy.
A resident with multiple chronic conditions experienced a significantly elevated blood pressure, but staff did not notify the physician or document any follow-up, contrary to facility policy and care plan interventions. This deficiency was confirmed through record review and DON interview.
A resident with surgical incisions and a wound vac did not have goals or interventions for wound care documented in their care plan. This was confirmed by the DON during a review of medical records and staff interviews.
The facility failed to complete required weekly wound assessments for a resident with a diabetic ulcer, did not perform wound treatments as ordered for another resident with multiple wounds, and did not ensure a resident attended a scheduled outside physician appointment. Documentation was missing for some missed treatments, and staff confirmed these deficiencies during interviews.
A resident with hypertension and other medical conditions received Metoprolol Tartrate on several occasions when their systolic blood pressure was below the physician-ordered threshold. Despite clear instructions to hold the medication under certain conditions, staff administered it outside the prescribed parameters, as confirmed by the DON and ADON. No adverse effects were noted.
The facility failed to timely cohort COVID-19 positive residents, affecting four individuals. A resident tested positive and was placed in a room with two negative residents, leading to another resident testing positive. Similarly, another resident tested positive and was not isolated, resulting in their roommate also testing positive. The facility did not adhere to CDC guidance for isolating COVID-19 positive residents.
A facility failed to report an allegation of abuse involving a cognitively impaired resident to the Ohio Department of Health as required by policy. The incident involved a CNA reporting that an RN bumped shoulders with the resident. An internal investigation found no negative findings, but the Administrator did not report the incident, believing the facility was not out of compliance.
A resident in a LTC facility did not receive assistance to maintain regular bowel movements, despite not having a bowel movement for several days and requesting a laxative. The facility's bowel elimination policy was not followed, and there was no documentation of the required interventions being implemented.
A facility failed to document and assess pressure ulcers for a resident, leading to a deficiency. The resident, admitted with multiple diagnoses, had a lesion on the upper back and a bed sore, but the medical record lacked a minimum data assessment and wound documentation until eight days later. The facility's policy required a complete skin check upon admission, which was not documented, resulting in the deficiency.
A resident with chronic pain and other health issues did not receive timely pain management due to a lack of Oxycodone in the medication cart. Despite having an active order, the resident was left in pain because the LPN did not contact the pharmacy or provider to resolve an issue with an expired prescription. The ADON confirmed the availability of Oxycodone in the emergency supply, but the LPN failed to act, delaying pain relief.
A resident with multiple health conditions was prescribed antibiotics for cellulitis without an end date, despite not having an active infection. The facility's infection control log did not list the resident as needing antibiotics, and the resident reported receiving them for unknown reasons. The RN confirmed the antibiotics were given preventatively for a resolved abscess.
A facility failed to document the administration of Oxycodone for a resident with multiple health issues, despite the medication being signed out on narcotic sheets. The ADON confirmed the documentation errors, although narcotic counts showed no discrepancies.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a surgical lesion site on the upper back. The resident's medical record lacked documentation about the wound, and the ADON was unaware of the need for EBP until information from a previous facility revealed the site was growing Staphylococcus. This oversight led to a deficiency in infection prevention and control.
A resident with a history of respiratory issues was not provided timely and appropriate care after refusing a non-invasive ventilator (NIV) and experiencing low blood pressure and oxygen saturation. The facility staff failed to notify the physician of these changes, and the resident was later found unresponsive and died after being sent to the hospital. Interviews revealed that staff were aware of the resident's non-compliance with the NIV but did not inform the physician.
The facility failed to notify physicians when residents were non-compliant with using non-invasive ventilators (NIVs) and when abnormal vital signs were recorded. Three residents with respiratory conditions were affected, as their refusals to use NIVs at night were not communicated to their physicians, despite facility policy requiring such notifications. Interviews confirmed the lack of documentation and communication regarding these issues.
Failure to Prevent Avoidable Fall Due to Unsafe Bathroom Sink
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, malnutrition, difficulty walking, and cerebral infarction sustained an avoidable fall resulting in actual harm. The resident, who required set-up only for daily hygiene and weighed 115 pounds, was in a shared shower room bathroom when she leaned on the wall-mounted sink. The sink detached from the wall, fell to the floor, and broke into pieces. The resident fell onto a sharp piece of the broken sink, sustaining a five millimeter laceration to her lower back that hemorrhaged and required hospitalization for sutures. Prior to the incident, the resident and other residents had reported concerns about the sink being in disrepair to staff, including the maintenance department. The maintenance director confirmed that no routine maintenance checks were performed on sinks in the facility before the incident. The sink involved was old, wall-mounted, and lacked support legs, being attached only to the wall studs. After the incident, an audit revealed three other similar sinks in the facility. The maintenance director and administrator both confirmed that there were no prior routine checks or reports of disrepair for the other sinks before the audit. The incident was unwitnessed, but other residents responded quickly to the resident's call for help, and staff provided prompt assistance and arranged for emergency medical services. The administrator and maintenance director both acknowledged the sink's failure and the lack of routine maintenance checks. The resident expressed frustration about the ongoing lack of access to a functional bathroom sink following the incident.
Failure to Maintain Functional Bathroom Facilities for Residents
Penalty
Summary
The facility failed to maintain a homelike environment for several residents due to a non-functional bathroom sink in a shared room. Multiple residents, including those with impaired cognition, physical disabilities, and chronic illnesses, were affected by the lack of access to a working sink for daily hygiene needs. Residents reported having to walk to distant shower rooms or visitor bathrooms to wash their hands or perform personal care, which was described as inconvenient and bothersome, especially during evenings or when other residents were using those facilities. Observations confirmed that the shared bathroom adjacent to the residents' room was missing a porcelain sink basin, with only water lines and a faucet present. Staff interviews revealed that the sink had been in disrepair since it fell off the wall, causing a break in the water lines. The maintenance department and administration were aware of the issue, and residents and staff had reported the problem multiple times. Despite the facility receiving a replacement sink, the repair had not been completed by the time of the survey, and the project was not listed on the facility's work order or repair list. Documentation review showed that the sink had been non-functional for over a month, and the lack of timely repair resulted in ongoing inconvenience and disruption to residents' daily routines. One resident reported a fall in the bathroom due to the sink's disrepair, and others expressed frustration with the prolonged wait for repairs. The deficiency was substantiated through observations, interviews, and review of facility records and invoices.
Failure to Initiate Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to initiate a care plan addressing anticoagulation medication use for a resident admitted with multiple complex diagnoses, including end stage renal disease, diabetes mellitus, hyperkalemia, dependence on renal dialysis, heart failure, and intellectual disabilities. Medical record review showed that the resident had physician orders for warfarin sodium, an anticoagulant, but the care plan dated after the medication order did not include any interventions or monitoring related to anticoagulant therapy. This omission was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan for anticoagulant use. The deficiency was identified during a complaint investigation and affected one of three residents reviewed for care plans.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents on a secured unit. One resident with severely impaired cognition and a history of dementia, cerebral infarction, and psychotic disorder was found in her room with her pants down, while another resident, who was cognitively intact, was observed touching her in the peri-area. Staff immediately separated the residents and notified the nurse, who performed a head-to-toe assessment and found no injuries. The family and physician were notified, and the resident declined medical attention. Interviews with staff confirmed the incident, with a CNA stating she witnessed the inappropriate contact and immediately intervened. The DON acknowledged that the facility had not provided abuse education to all staff or conducted follow-up audits or monitoring related to abuse concerns. The Social Service Director stated that the resident who was touched did not have the cognitive capacity to consent to a sexual encounter, and the resident herself could not recall if she had consented to the contact. The facility's policy defines sexual abuse as non-consensual sexual contact of any type with a resident and requires investigation of all alleged violations. Despite this, the Administrator concluded that the encounter was mutual and did not substantiate the allegation of abuse after completing the investigation. The police were notified but did not investigate further. The facility's actions and lack of comprehensive staff education and monitoring contributed to the failure to ensure the resident was free from sexual abuse.
Failure to Provide Immediate and Continuous CPR to Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to immediately initiate and continuously perform cardiopulmonary resuscitation (CPR) on a resident who was identified as Full Code status and was found unresponsive without vital signs. Upon discovery, staff delayed the start of CPR while attempting to confirm the resident's code status, and once CPR was initiated, it was not maintained until emergency medical services (EMS) arrived. Instead, the registered nurse in charge stopped CPR after only one cycle, despite the resident's Full Code status and the absence of a physician's order to discontinue resuscitative efforts. The resident involved had a history of chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder, and acute respiratory failure, and was noted to have intact cognition and independent ambulation prior to the incident. On the day of the event, the resident was found unresponsive, cyanotic, and pulseless by staff. Multiple staff interviews and statements revealed confusion and lack of coordination regarding the resident's code status, delays in retrieving and using the crash cart, and the absence of essential equipment such as a backboard, oxygen, and a face mask for the Ambu bag. Staff resorted to improvising with a paper towel for rescue breaths due to missing equipment. EMS arrived to find that CPR had been stopped for approximately five minutes prior to their arrival, and immediately resumed life-saving measures. Staff interviews consistently indicated that the registered nurse in charge directed staff to stop CPR, asserting authority to call the code, despite objections from other staff members who recognized that CPR should have continued until EMS arrival. The failure to provide immediate and continuous CPR as required by the resident's Full Code status and facility policy resulted in serious life-threatening harm and/or death.
Failure to Ensure BiPAP Orders and Implementation After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a BiPAP order was in place and implemented for a resident with a history of acute and chronic respiratory failure, COPD, and hypercapnia after returning from the hospital. The resident's care plan and hospital discharge orders specified the need for BiPAP therapy with specific settings, but upon review, there was no current physician's order for BiPAP, and the Medication Administration Record (MAR) did not reflect any BiPAP orders or documentation of its use for the relevant months. Staff interviews confirmed the absence of orders and documentation, and there was no record of resident refusals or consistent application of the BiPAP therapy as prescribed. The resident experienced episodes of respiratory distress, including an incident where she was found with an oxygen saturation of 38% and required emergency transfer to the hospital, where she was intubated for acute hypercapnic respiratory failure. Documentation from the BiPAP machine indicated several nights when the resident did not use the device, but there was no documentation explaining these gaps or indicating whether the resident refused therapy. Staff, including the DON and Respiratory Supervisor, were unable to provide evidence that the BiPAP was consistently applied or that refusals were documented. The lack of a current physician's order, absence of documentation in the MAR and progress notes, and failure to clarify or implement the recommended BiPAP settings after hospital discharge directly contributed to the resident's respiratory compromise and subsequent hospitalization. The deficiency affected one resident out of three reviewed for oxygen therapy in a facility with a census of 40.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to notify a physician of a significant change in a resident's condition, specifically an elevated blood pressure reading. Medical record review showed that a resident with a history of chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder, and acute respiratory failure had a documented blood pressure of 167/124. Despite care plan interventions requiring monitoring and reporting of cardiovascular symptoms, there was no documentation of physician notification or follow-up blood pressure readings in the medical record, Medication Administration Record, or progress notes for the relevant dates. Interviews with the Director of Nursing confirmed that staff did not notify the physician about the elevated blood pressure, as required by facility policy. The policy mandates that the nurse supervisor or charge nurse must notify the resident's medical practitioner of changes in condition and document these actions in the medical record. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for change in condition.
Failure to Develop and Implement Wound Care Plan
Penalty
Summary
The facility failed to ensure that a complete care plan was developed and implemented for a resident with multiple medical conditions, including surgical incisions and a wound vac in use. Medical record review showed that the resident had surgical incisions on both hips and a wound vac applied to the left hip, but the care plan did not include any goals or interventions related to wound care or the use of the wound vac. This omission was confirmed during an interview with the DON, who acknowledged that the care plan lacked the necessary components for wound management for this resident. The deficiency was identified during a review of the resident's medical records and staff interviews, affecting one of three residents reviewed for wound care in a facility with a census of 40.
Failure to Complete Wound Assessments, Treatments, and Ensure Attendance at Medical Appointments
Penalty
Summary
The facility failed to complete weekly wound assessments for a resident with a diabetic ulcer. Medical record review showed that no weekly wound assessments with measurements were completed for the resident during a specific month, despite the presence of an active wound and a care plan that included wound management interventions. The Director of Nursing confirmed the absence of these required assessments during staff interview. Additionally, the facility did not complete wound treatments as ordered for another resident with multiple wounds resulting from frostbite and amputations. Review of the Treatment Administration Records (TAR) and physician orders revealed that wound care was not performed on several occasions for various wounds, including the right hand, left foot, left hand, left hip, and right foot. Documentation was also missing for some of the missed treatments, and the resident reported that wound care was not completed timely, particularly on the night shift. The Assistant Director of Nursing verified that wound care was not completed as ordered by the physician. The facility also failed to ensure that a resident attended a scheduled outside physician appointment. The resident was scheduled for a follow-up with an orthopedic physician but did not attend the appointment. The administrator initially stated that the resident had canceled the appointment, but the resident denied this, and the physician's office confirmed that the resident did not call to cancel. Staff interviews revealed that the facility did not have a policy regarding resident appointments.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Staff failed to follow physician orders during medication administration for a resident with a history of hypertension, superficial frostbite, tissue necrosis, homelessness, and cerebral vascular accident. The resident's care plan required evaluation of blood pressure and heart rate, and a physician's order specified that Metoprolol Tartrate should be held if the systolic blood pressure was under 110 or the heart rate was below 60. Despite these instructions, the medication was administered multiple times when the resident's systolic blood pressure was below the specified threshold. Review of the Medication Administration Record showed that on several occasions, the resident received Metoprolol Tartrate even though their systolic blood pressure readings were below 110, contrary to the physician's order. The Director of Nursing and Assistant Director of Nursing confirmed that the medication was given outside the prescribed parameters. Facility policy required medications to be administered according to orders, including any specified time frames. No negative effects were documented as a result of the medication administration.
Failure to Cohort COVID-19 Positive Residents
Penalty
Summary
The facility failed to timely cohort COVID-19 positive residents, affecting four residents. Resident #39, who was admitted with multiple diagnoses including cerebral palsy and chronic obstructive pulmonary disease, tested positive for COVID-19 on April 11, 2025, and was sent to the emergency room. Upon returning the same day, Resident #39 was placed in a room with two COVID-19 negative residents, #11 and #19, and was not moved until April 14, 2025. Resident #11 subsequently tested positive for COVID-19 on April 13, 2025. The Director of Nursing confirmed these events during an interview. Similarly, Resident #29, who had diagnoses including heart disease and diabetes, tested positive for COVID-19 on April 11, 2025, and was not cooperative with isolation measures. Resident #29 shared a room with Resident #34, who was not moved until April 14, 2025, and tested positive for COVID-19 on April 15, 2025. The facility's policy and CDC guidance recommend that residents confirmed to have SARS-CoV-2 infection should be placed in a single room or housed with other COVID-19 positive residents, which was not adhered to in these cases.
Failure to Report Alleged Abuse to ODH
Penalty
Summary
The facility failed to report an allegation of resident abuse to the Ohio Department of Health (ODH) as required by their policy. The incident involved a resident with dementia, depression, anxiety disorder, and psychotic disorder with delusions, who was cognitively impaired and required maximal staff assistance with activities of daily living. On a specific date, a Certified Nursing Assistant (CNA) reported an allegation of abuse against the resident by a Registered Nurse (RN). The CNA did not witness the incident but was informed by another CNA. The alleged incident involved the RN rushing past the resident and bumping shoulders, without causing the resident to stumble or fall. The facility conducted an internal investigation on the same day, interviewing involved staff members, and found no negative findings. Despite this, the facility's policy required that all allegations of abuse be reported to ODH immediately, but no later than two hours after the allegation was made. The Administrator decided not to report the incident to ODH, believing the investigation showed the facility was not out of compliance. This decision was contrary to the facility's policy, which mandates reporting all allegations of abuse to the appropriate authorities.
Plan Of Correction
F-0609 On 3/21/2025, Administrator completed a review of the ODH gateway and all SRI's have been reported timely/appropriately since 3/21/2025. SRI for Resident #3 will be submitted to the ODH Gateway EIDC system on or before 3/21/2025 for POC compliance. The facility Administrator was educated by the Regional Director of Operations on company Abuse, Neglect, Exploitation, Mistreatment and Misappropriation prevention and reporting policy on 3/21/2025. The facility Administrator or facility designee will audit 2x's a week for a period of 2 weeks then 1x a week for a period of 2 weeks to ensure all submitted State Reportable Incidents were reported timely/appropriately per reporting policy. The DON or designee will educate all staff on abuse and abuse reporting by 3/28/2025. Education included Abuse Policy and Timeliness of Abuse Reporting for Cridersville Healthcare. The DON or designee will review resident records for the last 2 weeks to ensure that there were no other allegations of abuse that were not reported by 3/24/2028. There was a total of 52 residents that were reviewed because they were in the building during this timeframe. Administrator reviewed all abuse allegations for last 30 days to make sure there was nothing else that wasn't reported. All results will be submitted to QAPI for review and determined if any further action is needed.
Failure to Assist Resident with Bowel Movements
Penalty
Summary
The facility failed to ensure that a resident received assistance to maintain regular bowel movements, affecting one resident. The resident, who was cognitively intact, reported not having a bowel movement for several days and had requested a laxative, which he had not received. The medical record review confirmed that the resident had not had a bowel movement for four consecutive days, and there was no as-needed laxative order in place. The resident's diagnoses included back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia. The facility's bowel elimination policy outlined specific steps to be taken if a resident had no bowel movement within certain time frames, including administering prune juice or a bran mixture, assessing the abdomen, and considering osmotic and stimulant laxatives. However, there was no documentation indicating that these steps were followed for the resident in question. The Assistant Director of Nursing confirmed the lack of documentation of a bowel movement and the absence of initiation of the bowel protocol for the resident.
Failure to Document and Assess Pressure Ulcers
Penalty
Summary
The facility failed to complete skin assessments and document skin alterations for a resident, leading to a deficiency in pressure ulcer care. Resident #81, who was admitted with diagnoses including back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia, was found to have a lesion on the upper back and a bed sore upon arrival. However, the medical record lacked a minimum data assessment and did not document the presence of a bed sore in the initial admission assessment. Physician orders were in place for wound care, but there was no evidence of a detailed description of the wounds until eight days after admission when the wound nurse assessed them. The wound nurse's assessment revealed a surgical biopsy site on the upper back and a stage three pressure ulcer on the coccyx. The facility's policy required a complete head-to-toe skin check upon admission, which was not documented for Resident #81. An interview with a registered nurse confirmed the absence of wound documentation until prompted by the surveyor. This oversight in documentation and assessment led to the deficiency noted by the surveyors.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident experiencing significant pain. The resident, who had a history of paraplegia, chronic pain, and other serious health conditions, was admitted with an order for Oxycodone 5 mg every 6 hours as needed for pain. Despite this, the resident reported experiencing pain levels of 6 to 8 out of 10 and stated that she had requested her pain medication the previous night but was informed by the night nurse that there was no supply of Oxycodone available. The nurse had contacted the pharmacy, but the medication had not yet been delivered, leaving the resident in pain since the previous evening. Further investigation revealed that the Licensed Practical Nurse (LPN) was aware of the resident's pain medication order but confirmed the absence of Oxycodone in the medication cart. The LPN mentioned the possibility of obtaining an emergency dose from the emergency supply, but this was not pursued due to an expired handwritten prescription. The Assistant Director of Nursing (ADON) later verified that the Oxycodone order was not expired and was available for refill, and that there was Oxycodone in the emergency supply. However, the LPN admitted to not having contacted the pharmacy or the provider to resolve the issue, resulting in a delay in administering the necessary pain relief to the resident.
Resident Received Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Resident #11, who has a medical history including paraplegia, chronic pain, obesity, pneumonia, bladder disorder, sepsis, heart failure, and neuromuscular dysfunction of the bladder, was prescribed Amoxicillin-Pot Clavulanate for cellulitis of the abdominal wall on 05/23/24. However, there was no end date specified for this medication in the orders. A review of the facility's infection control log from June 2024 to August 2024 did not list Resident #11 as having an active infection requiring antibiotics for cellulitis. An interview with Resident #11 revealed that they had been receiving antibiotics for an unknown reason and duration. Further, an interview with RN #158, the Infection Control Preventionist, confirmed that Resident #11 had been receiving the antibiotic since 05/23/24 without an end date until 08/20/24, despite not having an active infection. The antibiotics were being administered as a preventative measure for a resolved abscess.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation of narcotic medication administration in the medical records for a resident. This deficiency was identified during a review of records and staff interviews, affecting one of the five residents reviewed for medication administration documentation. The resident involved had multiple diagnoses, including paraplegia, chronic pain, and heart failure, and was prescribed Oxycodone for pain management. However, there were several instances where the administration of Oxycodone was not documented in the Medication Administration Records (MARs), despite being signed out on the narcotic sign-out sheets. The discrepancies were noted on specific dates in July and August, where the narcotic sign-out sheets indicated that Oxycodone was administered, but the MARs lacked corresponding documentation. An interview with the Assistant Director of Nursing (ADON) confirmed these documentation errors, although there were no discrepancies in the narcotic counts. The ADON verified that nurses are required to document the administration of narcotics in the electronic records when they sign them out from the locked box.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident, leading to a deficiency in infection prevention and control. The resident, who was admitted with diagnoses including back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia, had a surgical lesion site on the upper back. The medical record lacked documentation regarding the reason for the antibiotic ointment prescribed or a description of the wound. The Assistant Director of Nursing (ADON) was unaware of the nature of the surgical biopsy site until information was obtained from the previous facility, revealing that the site was growing Staphylococcus. Consequently, the resident was not placed in EBP as required by the facility's policy for residents with wounds.
Failure to Provide Timely Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide appropriate and timely treatment, care, and services to a resident who was assessed with changes in condition. The resident, who had a history of respiratory failure, COPD, and other medical conditions, was ordered to use supplemental oxygen and a non-invasive ventilator (NIV) to aid her respiratory status. However, the resident refused the NIV, and the staff did not notify the physician of this refusal. Subsequently, the resident was assessed with low blood pressure and low oxygen saturation levels, but these were not timely or appropriately reassessed, reported to the physician, or rechecked before administering medications. On the day of the incident, the resident was hypotensive in the morning and had low oxygen saturation in the afternoon, yet no follow-up assessments or notifications to the physician were made. Despite these critical changes in condition, the resident was administered antianxiety and narcotic pain medications. Later, the resident was found in distress, with blue lips, removing her shirt and oxygen, and was unresponsive with no vital signs. CPR was initiated, and the resident was sent to the hospital, where she was placed on a ventilator in the ICU and subsequently died. Interviews with staff revealed that the facility's staff were aware of the resident's non-compliance with the NIV but did not notify the physician. The Medical Director confirmed he was not informed of the resident's low blood pressure or oxygen levels until after the resident was sent to the hospital. The facility's policy required notification of changes in a resident's condition, but this was not followed, contributing to the resident's untimely death.
Removal Plan
- An interdisciplinary team (IDT) Quality Assessment and Assurance (QAA) meeting was held to discuss and develop a plan with Medical Director #800.
- MD #800 was notified of the Immediate Jeopardy and review of the facility change in condition policy and plan for corrective action was reviewed with no changes made.
- The change in condition policy was reviewed by the Administrator and IDON #600 with no changes made.
- IDON #600 and Assistant Director of Nursing (ADON) #500 provided education to all Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), including managers, on the facility change in condition policy and staff response to a change in condition.
- All resident medical records were reviewed by IDON #600 and ADON #500 to review vital signs, oxygen saturation, and the resident's physical condition.
- All resident medical records were reviewed by IDON #600 and ADON #500 to review for change in condition.
- An audit tool was implemented to monitor resident charts relating to any change in condition, adverse effects, and specifically, assessments for changes in condition as it related to change in condition notification.
- Two (#20 and #25) additional resident medical records were reviewed for appropriate care and services with a change in condition with no concerns identified.
- LPN #203, LPN #206, ADON #500, and IDON #600, verified they were educated on the facility's policies related to treatment of a change in condition, physician notification of a change in condition, and to document all assessments, including follow up assessments, of all abnormal vital signs.
Failure to Notify Physicians of NIV Non-Compliance and Abnormal Vital Signs
Penalty
Summary
The facility failed to notify physicians when residents were not using non-invasive ventilators (NIVs) as ordered and when there were abnormal vital signs. This deficiency affected three residents who were dependent on NIVs due to conditions such as chronic obstructive pulmonary disease (COPD), respiratory failure, and paraplegia. The medical records and interviews revealed that the facility did not adhere to the policy of notifying the physician of significant changes in the residents' conditions. Resident #30, who had diagnoses including bipolar disorder, respiratory failure, and COPD, was not compliant with wearing her NIV as ordered. Despite multiple entries in the nursing progress notes indicating non-compliance and education provided to the resident, there was no documentation of the physician being notified. On one occasion, the resident's oxygen saturation dropped to 80%, yet the physician was not informed. The medical director confirmed that he was not notified of the resident's low oxygen level or her refusals to wear the NIV. Similarly, Resident #20 and Resident #25, both of whom required NIVs due to respiratory conditions, were non-compliant with using the devices at night. The progress notes for these residents also lacked documentation of physician notification regarding their refusals. Interviews with the assistant director of nursing and the interim director of nursing confirmed the absence of notifications to the physicians about the residents' non-compliance with NIV use, despite the facility's policy requiring such notifications.
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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