Cumberland Pointe Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in St Clairsville, Ohio.
- Location
- 68637 Bannock Road, St Clairsville, Ohio 43950
- CMS Provider Number
- 366177
- Inspections on file
- 33
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Cumberland Pointe Care Center during CMS and state inspections, most recent first.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, resulting in residents not always receiving meals that met their individual dietary requirements.
The facility failed to maintain adequate staffing levels, affecting resident care. A resident with quadriplegia missed a shower due to staff shortages, while another with dementia had unkempt nails and hair, indicating insufficient personal care. A third resident did not receive a scheduled shower due to staffing constraints. Interviews revealed consistent concerns about inadequate staffing and delayed response to call lights, particularly on weekends.
The facility did not ensure an adequate emergency water supply, potentially affecting all 65 residents. The Administrator provided a document from the food service supplier indicating that in an emergency, the supplier might not be able to provide the necessary water. The facility had not arranged for an alternate water vendor.
The facility failed to complete criminal background checks for a nurse, an admission director, and a nursing assistant, potentially affecting all 65 residents. Despite fingerprint rejections, the employees continued working without completed checks, contrary to facility policy. The admission director had direct resident contact, highlighting the deficiency investigated under a specific complaint number.
The facility failed to maintain adequate staffing levels, particularly on weekends and night shifts, leading to delays in resident care and an increase in falls. Residents reported long wait times for assistance, and staff confirmed working with fewer aides than required. Despite management's awareness and attempts to hire more staff, the facility struggled to address the staffing deficiency.
The facility failed to follow infection control protocols during incontinence care and medication administration, and did not adhere to tuberculosis testing policies for staff. An STNA did not perform proper incontinence care and touched surfaces with contaminated gloves, while a nurse did not perform hand hygiene between residents. Additionally, two STNAs were not properly tested for tuberculosis before resident contact.
The facility failed to secure medications and manage insulin properly, affecting several residents. Keys to the medication room and narcotic cabinet were left accessible, and a medication cart was found unlocked. Insulin pens were not dated upon opening, leading to expired medications being used. These actions violated the facility's policies on medication storage and administration.
A facility failed to ensure resident dignity and respect when an STNA made an inappropriate comment to a resident with vascular dementia. The resident, who was moderately cognitively impaired, confirmed the comment but was not upset. The STNA had a history of unprofessional behavior, including cursing in front of residents. Despite the resident's lack of distress, the incident highlights a failure in maintaining a professional environment.
The facility failed to maintain a safe and clean environment for residents, with issues including a poorly fitted electric outlet cover, unclean conditions with smeared feces in a bathroom, and damaged furniture. These deficiencies were confirmed by staff and affected multiple residents.
A resident's missing dentures were not addressed by the facility, despite being reported by her representative. The facility lacked documentation and awareness of the issue, failing to follow their grievance policy. Staff interviews revealed confusion and a lack of coordination in addressing the resident's needs.
A facility failed to complete a new PASRR for a resident after a new diagnosis of delusional disorder was added. The resident, admitted from another facility, had previous diagnoses of unspecified psychosis, anxiety disorder, and vascular dementia. The Social Service Director confirmed the oversight, acknowledging that a new PASRR should have been completed.
Two residents with known constipation issues were not properly monitored for bowel movements, leading to significant gaps in documentation and lack of intervention. Despite care plans requiring regular monitoring and medication administration, one resident went 15 days without a recorded bowel movement, and another had a seven-day gap. The facility lacked a formal protocol for bowel movement tracking and intervention, contributing to these deficiencies.
A resident with a history of cerebral infarction and hemiplegia was not provided with necessary orthotic devices or restorative exercises to maintain or improve range of motion in the right lower extremity. The facility discontinued orders for a knee brace and ankle/foot orthotic (AFO) without implementing a comprehensive plan of care. Interviews revealed the resident's knee brace was ineffective, and therapy did not address the need for an AFO. The deficiency was identified when the resident's care plan was not updated upon re-admission.
A resident with Alzheimer's and a history of falls was observed multiple times without proper footwear, contrary to her care plan. Despite a physician's order to encourage wearing shoes, staff did not intervene until prompted by the DON. The facility's Fall Management policy was not followed, leading to a deficiency.
A resident with stage three kidney disease was incorrectly treated with antibiotics for a UTI despite not meeting treatment criteria. The facility continued administering Keflex, which was ineffective against the bacteria, and delayed notifying the physician about the resistance. This oversight occurred despite the facility's policy on antibiotic stewardship.
A facility failed to ensure a resident received the pneumococcal vaccine as recommended due to unclear documentation and verification issues. The resident's vaccination history was not properly recorded, leading to confusion about eligibility for the pneumococcal 13 or 20 vaccine. The Infection Preventionist had to contact the family and previous care facility to verify the resident's vaccination status, revealing a deficiency in the facility's record-keeping process.
The facility failed to provide written notification to residents, their representatives, and the Ombudsman regarding hospital transfers. Two residents were affected; one was transferred twice without proper notification to her guardian or the Ombudsman, and another was transferred without written notice to his wife. The Social Service Director admitted to not having evidence of the required notifications, indicating a failure to comply with regulations.
The facility failed to provide bed hold notices to residents or their representatives when residents were transferred to the hospital, affecting two residents. One resident with multiple diagnoses was hospitalized twice without a bed hold notice being issued to her guardian. Another resident was transferred to the hospital, and although his wife was notified, no bed hold notice was provided at the time of transfer.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of facility practices, which showed that residents were not always provided with meals that met their individual dietary needs and preferences.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents, affecting five specific residents and potentially impacting all 62 residents in the facility. Resident #27, who has multiple complex medical conditions including quadriplegia and congestive heart failure, did not receive a scheduled shower on a specific date, with the resident reporting that it was due to a staff shortage. The Director of Nursing confirmed the absence of documentation for the shower but attributed it to a communication issue rather than staffing shortages. Resident #31, diagnosed with conditions such as heart failure and dementia, was found to have long, unkempt nails and uncombed hair, indicating a lack of personal care. The resident reported insufficient staff to meet her needs, including assistance with activities of daily living (ADLs) and timely response to call lights. Observations confirmed the resident's nails were long and dirty, and her hair was unkempt, with staff acknowledging the need for immediate attention. Resident #16, with Alzheimer's disease and other health issues, did not receive a scheduled shower due to staffing constraints, as confirmed by a State Tested Nurse Aide (STNA) who was the only aide on the floor that day. Interviews with other residents and staff revealed consistent concerns about inadequate staffing, delayed response to call lights, and insufficient care, particularly on weekends. The facility's practice of sending staff home due to low census, without considering resident acuity, further exacerbated the staffing issues.
Failure to Ensure Emergency Water Supply
Penalty
Summary
The facility failed to ensure provisions were made to have water available in the event of an emergency, potentially affecting all 65 residents. During the entrance conference, the Administrator was asked about the facility's emergency water provisions. A document from the facility's food service supplier, dated 11/01/23, was provided, indicating that in an emergency, the supplier might not be able to provide the recommended amount of water. The document recommended that the facility ensure they had an alternate vendor set up. On 06/18/24, the Administrator confirmed that the facility had not made alternate arrangements for water provision in emergencies.
Failure to Complete Criminal Background Checks for Staff
Penalty
Summary
The facility failed to ensure that all staff had completed criminal background checks, which had the potential to affect all 65 residents. The criminal background check log revealed that fingerprint submissions for a Registered Nurse, an Admission Director, and a State Tested Nursing Assistant were rejected, and there was no evidence that the facility attempted to re-submit the fingerprints. The Human Resources Director confirmed that there were no completed criminal background checks for these employees and acknowledged that employees were not supposed to continue working if results were not received within 30 days. Despite the lack of completed background checks, the employees continued to work, with the Admission Director having direct contact with residents by greeting them on admission, taking them to their rooms, completing paperwork, and occasionally passing ice. The facility's policy required criminal background checks to be conducted before hiring new employees, in accordance with state law. This deficiency was investigated under Complaint Number OH00153674.
Inadequate Staffing Levels Lead to Resident Care Delays and Increased Falls
Penalty
Summary
The facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents, as evidenced by the review of the facility's Payroll Based Journal (PBJ) submission data and interviews with residents and staff. The PBJ data indicated low weekend staffing during the first quarter of 2024, and the facility assessment showed staffing levels were based on resident acuity levels. However, interviews with residents revealed significant concerns about inadequate staffing, particularly on weekends and night shifts. Residents reported having to wait extended periods for assistance, with some having to remain in bed longer than preferred due to insufficient staff to assist with transfers. Staff interviews corroborated the residents' concerns, highlighting the challenges faced due to inadequate staffing. State tested Nursing Assistants (STNAs) reported working with fewer aides than required, leading to delays in providing care and supervision. The lack of sufficient staff was linked to an increase in resident falls, as there were not enough aides to monitor and assist residents adequately. The STNAs also noted that the facility's mandating system for call-offs was not being followed, exacerbating the staffing issues. The facility's management was aware of the staffing concerns, as confirmed by interviews with the Administrator and a Registered Nurse (RN). Despite attempts to hire additional staff through online ads and offering sign-on bonuses, the facility struggled to maintain adequate staffing levels. The Administrator acknowledged the difficulty in consistently scheduling an additional nurse on night shifts, which further contributed to the staffing deficiency. This deficiency was investigated under Complaint Number OH00153674.
Infection Control and Tuberculosis Testing Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, affecting the care of residents. An STNA was observed providing incontinence care to a resident without following proper procedures, such as cleaning from the top of the buttocks toward the vaginal area and touching multiple surfaces with the same gloves used during care. The facility's incontinence care protocol lacked specific instructions on the correct cleaning method and when to remove gloves and perform hand hygiene. Additionally, a nurse failed to perform hand hygiene between administering medications to different residents, despite the facility's hand hygiene policy requiring it. The facility also did not adhere to its tuberculosis testing policy for healthcare workers. An STNA was rehired without evidence of a mantoux skin test upon rehire, and another STNA began working with resident contact before completing the required tuberculosis testing. The facility's policy required a two-step baseline TST if a previous negative result was obtained more than 12 months before new employment, and a single TST if a documented negative result was obtained within 12 months. These deficiencies were identified during a complaint investigation.
Medication Security and Insulin Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications, specifically insulin, were properly secured and managed according to professional standards. Observations revealed that keys to the medication room, which also provided access to the emergency narcotic cabinet, were left hanging on the wall at the nurse's station, accessible to unauthorized individuals. This was confirmed by two registered nurses who demonstrated the ease of access to the medication room and narcotic cabinet. Additionally, a medication cart was found unlocked and unattended, further compromising the security of medications. The facility also failed to properly date insulin upon opening and discard it after expiration, affecting five residents. Insulin pens for several residents were either not dated or had conflicting dates, making it impossible to determine their expiration. Interviews with registered nurses confirmed that the insulins should have been discarded due to the lack of proper dating, as insulin typically expires 28 days after being opened. The facility's policies on medication storage and administration were not adhered to, as evidenced by the improper handling and storage of insulin.
Failure to Maintain Resident Dignity and Professional Conduct
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically affecting one resident diagnosed with vascular dementia, depression, and impulse disorder. The resident was moderately cognitively impaired but able to communicate and understand others. An incident involving a State tested Nursing Assistant (STNA) was reported, where the STNA made an inappropriate comment to the resident about his private parts. The comment was overheard by another STNA, who reported it to the nurses, but there was no documentation of any follow-up action regarding the inappropriate comment. The STNA involved had a history of unprofessional behavior, including cursing in a resident's room and being unprofessional with co-workers. During an interview, the STNA admitted to possibly using foul language in front of residents and visitors but denied making the specific inappropriate comment to the resident. The resident confirmed hearing the comment but stated it did not bother him, as he used to date the STNA. Despite the resident's lack of distress, the incident highlights a failure in maintaining a professional and respectful environment for residents.
Facility Fails to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents in the secure unit, affecting three residents. In one instance, an electric outlet cover in a resident's room was missing and later replaced with a cover that did not fit properly, as confirmed by the Housekeeping/Laundry Supervisor and the Administrator. This issue was initially identified by the Life Safety Surveyor, indicating a lapse in addressing safety concerns promptly. Another resident's room was found to be unclean, with food crumbs, a roll of toilet paper on the floor, and feces smeared on the bathroom floor and toilet. The resident reportedly placed food on the floor to feed nonexistent animals and used the sink to wash dirty linens. Additionally, a third resident's room had a gouged wall and a nightstand with peeling veneer, which were confirmed by the Administrator as needing repair. These observations highlight the facility's failure to ensure a clean and safe environment for its residents.
Failure to Address Missing Dentures Grievance
Penalty
Summary
The facility failed to address the concerns of a resident and her representative regarding missing dentures. The resident, who had a history of Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, intermittent explosive disorder, and major depressive disorder, was admitted to the facility with full upper and lower dentures. Despite the resident's representative reporting the dentures missing several months prior, the facility did not document this in their missing item reports, nor did they maintain a log for such incidents. Interviews with various staff members, including the Director of Nursing, State Tested Nursing Assistants, and the Housekeeping/Laundry Supervisor, revealed a lack of awareness and documentation regarding the missing dentures. The Director of Nursing admitted that the facility did not use a personal inventory sheet to track residents' belongings, which contributed to the confusion about whether the resident had dentures. The Housekeeping/Laundry Supervisor confirmed that the resident had reported the dentures missing, but no follow-up actions were documented. The facility's grievance policy, which outlines the process for addressing resident grievances, was not followed in this case. The policy requires a thorough investigation and documentation of grievances, but the facility failed to complete a missing item report or conduct an investigation into the missing dentures. The Administrator and Medical Records Employee were unaware of the missing dentures, and no steps were taken to coordinate a dental appointment to address the issue, despite the resident's representative's request for assistance.
Failure to Update PASRR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure a new resident review was completed for a resident after a newly diagnosed mental illness was added to their diagnoses. The resident, who was admitted from another nursing facility, had a history of unspecified psychosis, delusional disorder, anxiety disorder, and vascular dementia with behavioral disturbance. The initial PASRR identification screen completed at the prior facility did not indicate any serious mental illness, only a mood disorder. A subsequent PASRR screen before admission to the current facility also did not include the new diagnosis of delusional disorder. Upon review, it was found that no new PASRR Identification Screens were completed after the resident's admission to the facility, despite the new diagnosis of delusional disorder. The Social Service Director confirmed that a new PASRR should have been completed following the diagnosis but was not. This oversight affected the resident's care plan and the facility's compliance with PASRR requirements.
Failure to Monitor and Intervene for Constipation in Residents
Penalty
Summary
The facility failed to properly monitor and intervene for residents experiencing constipation, affecting two residents. Resident #5, diagnosed with vascular dementia and other conditions, was admitted with a known issue of constipation. Despite having a care plan that included monitoring bowel movements every shift and administering medications as ordered, there was a significant gap in documentation. The resident did not have a recorded bowel movement for 15 days, and there was no order for a prn laxative. Interviews with staff revealed inconsistencies in documentation and a lack of a clear protocol for bowel movement tracking and intervention. Resident #20, with diagnoses including Alzheimer's disease and constipation, also experienced a lapse in bowel movement monitoring. The resident's care plan required monitoring and recording bowel movements every shift, yet there was a seven-day period without a documented bowel movement. Although the resident had an order for a stool softener to be administered as needed, there was no evidence it was given during this time. Staff interviews suggested the possibility of undocumented bowel movements, but no additional evidence was provided to support this. The facility lacked a formal policy or protocol for bowel movement monitoring and intervention, relying instead on staff judgment and alerts from the electronic medical record system. This absence of a structured approach contributed to the failure to ensure timely and appropriate interventions for residents experiencing constipation, as evidenced by the prolonged periods without documented bowel movements for both residents.
Failure to Provide Orthotic Devices and Restorative Exercises
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain or improve range of motion (ROM) in the right lower extremity. The resident, who had a history of falling, heart failure, cerebral infarction, hemiplegia, muscle weakness, and other conditions, was not provided with orthotic devices or restorative exercises as needed. The resident's medical records showed that orders for a knee brace and an ankle/foot orthotic (AFO) were discontinued, and there was no evidence of a comprehensive plan of care addressing the resident's limited ROM. Interviews and observations revealed that the resident had lost his right leg brace and reported that therapy had taken his other brace. The therapy director was unaware of the resident's previous use of an AFO and confirmed that the resident had an over-the-counter knee brace that was not providing support. The therapy department had bought a new knee brace, but the resident did not like it, and it was returned. The resident was receiving active ROM through the restorative program, but there was no individualized plan of care for restorative services. Further investigation showed that the resident's AFO and knee brace plan of care had been discontinued in 2023, and upon the resident's return to the facility, these were not re-ordered or addressed. The therapy department screened the resident and referred him to orthotics for a new AFO and knee braces. The facility's failure to ensure the resident received necessary orthotic devices and restorative exercises led to the deficiency identified in the report.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident at risk for falls, as outlined in her care plan. The resident, who had Alzheimer's disease, dementia, and a history of falls, was observed multiple times without proper footwear, such as non-skid socks or shoes, which were part of her fall prevention plan. Despite having a physician's order to encourage the resident to wear shoes when out of bed, staff did not intervene to ensure compliance with this order. Observations revealed that the resident was seen walking in the hallway and sitting in the dining room without any footwear, and staff did not attempt to provide her with non-skid socks or shoes. It was only after the Director of Nursing inquired about the resident's slippers that a State Tested Nursing Assistant (STNA) approached the resident to offer socks, which the resident accepted. The STNA admitted that the resident had been ambulating without proper footwear for several days without staff intervention. The facility's Fall Management policy emphasizes the importance of assessing and implementing fall prevention strategies through an interdisciplinary approach. However, the staff failed to adhere to this policy by not ensuring the resident wore appropriate footwear, as outlined in her care plan. This lack of adherence to the care plan and policy contributed to the deficiency identified during the survey.
Failure in Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that a resident met the criteria for antibiotic treatment, which was identified during a review of records, interviews, and policy evaluations. The resident, who was admitted with stage three kidney disease, was sent to the hospital for chest and flank pain. Despite being asymptomatic for a urinary tract infection (UTI), the resident was prescribed Keflex, an antibiotic, upon return to the facility. The hospital later informed the facility that the bacteria in the resident's urine was resistant to Keflex and recommended switching to Cipro. However, the resident's physician was not notified of the resistance until several days later, and the resident continued to receive Keflex, which was ineffective against the bacteria. The facility's infection control log and McGeer and Loeb's worksheets indicated that the resident did not meet the criteria for UTI treatment. Despite this, the resident was administered antibiotics, and the facility's infection preventionist confirmed that the provider was not informed of the resistance until days after the initial prescription. The facility's policy on antibiotic stewardship, which aims to optimize infection treatment and reduce antibiotic-related events, was not adhered to, as the antibiotics were not reviewed for appropriateness upon the resident's readmission from the hospital.
Deficiency in Pneumococcal Vaccination Documentation
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal vaccine as recommended. The resident, who was admitted with multiple diagnoses including encephalopathy, dementia, and hypertension, had a pneumococcal consent form indicating prior vaccination, but it was unclear which vaccine was administered or when. The electronic medical record inaccurately showed the resident as ineligible for the pneumococcal 13 or 20 vaccine. The Infection Preventionist/Co-Director of Nursing was uncertain about the resident's vaccination history and had to contact the family and previous care facility for verification. The previous facility only documented a refusal, while the family believed the resident had been vaccinated. After further investigation, it was discovered that the resident had received the PPSV23 vaccine and previously the PCV13. This confusion and lack of clear documentation led to a delay in administering the appropriate pneumococcal vaccine, highlighting a deficiency in the facility's vaccination record-keeping and verification process.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their representatives, and the Ombudsman regarding hospital transfers, as required by regulations. This deficiency affected two residents who were hospitalized. Resident #5, who had multiple complex medical conditions including a urinary tract infection and cognitive impairments, was transferred to the hospital twice. The facility did not provide written notice to her guardian for the first transfer and failed to notify the Ombudsman for both transfers. Resident #68, who had several chronic health issues, was transferred to the hospital due to a medical emergency. Although his wife was notified by phone, the facility did not provide written notice of the transfer. The facility's policy requires that transfer notices include specific information and be provided in a language and manner understandable to the resident and their representative. Interviews with facility staff revealed that the Social Service Director was responsible for completing transfer notices and notifying the Ombudsman. However, the director admitted to not having evidence of providing the required notices for Resident #5's transfers and confirmed that no written notice was given for Resident #68's transfer. This lack of documentation and notification represents a failure to comply with regulatory requirements for resident transfers.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives when residents were transferred to the hospital, as required by policy. This deficiency affected two residents. Resident #5, who had multiple diagnoses including urinary tract infection, psychosis, and dementia, was hospitalized twice. The facility did not provide a bed hold notice to her guardian for either hospitalization. The Social Service Director confirmed that she did not issue the required notices for Resident #5's hospital admissions. Similarly, Resident #68, who had several medical conditions including cellulitis, diabetes, and leukemia, was transferred to the hospital. Although his wife was notified of the transfer, there was no documentation of a bed hold notice being provided at the time of transfer. The Social Services Designee confirmed that neither Resident #68 nor his wife received a bed hold policy at the time of transfer, despite being informed of the policy at admission.
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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