Diplomat Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in North Royalton, Ohio.
- Location
- 9001 W 130th St, North Royalton, Ohio 44133
- CMS Provider Number
- 365432
- Inspections on file
- 34
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Diplomat Healthcare during CMS and state inspections, most recent first.
A resident with multiple comorbidities and dependent on staff for care developed a severe wound that was repeatedly documented as moisture-associated skin dermatitis (MASD) rather than a pressure ulcer, despite clear signs of deterioration. Nursing staff were instructed to continue this documentation, and no additional interventions were implemented to address the worsening condition. The resident was eventually hospitalized with an unstageable, necrotic pressure ulcer, dehydration, and malnutrition, leading to palliative care and death.
The facility did not conduct routine care plan conferences for two residents with severe cognitive impairment, resulting in a lack of participation by their representatives in the care planning process. Despite care plan updates, the responsible parties were not included in ongoing conferences, and the Director of Social Services acknowledged delays and missed communications.
The facility did not inform physicians or resident representatives about ongoing medication refusals and new medication orders for three residents with various cognitive and psychiatric conditions. Nursing staff documented medication refusals and new treatments in records, but failed to notify the appropriate parties as required by facility policy, as confirmed by interviews with the DON.
A resident with dysphagia and dementia was given crushed medication mixed with applesauce for pain, but the LPN who administered the medication left the room without confirming it was swallowed. A registered nurse observed the medication had not been swallowed and had to manually stimulate swallowing, highlighting a failure to monitor safe medication consumption.
A resident with multiple medical conditions experienced a fall resulting in injuries and abnormal vital signs, leading to hospital transfer. The facility's fall investigation contained conflicting information about the timing of the incident and when EMS was contacted, and staff could not explain these discrepancies. The investigation did not meet the facility's policy requirements for thorough review and documentation.
A resident dependent on staff for toileting and at risk for skin breakdown was found with dried stool and heavily soiled linens, and did not have the prescribed barrier cream applied after incontinence care. The CNA confirmed not following the care plan and physician orders for cleansing and barrier application, resulting in inadequate incontinence care.
A resident with dementia and other health conditions did not receive adequate fluids, with intake falling below estimated needs and resulting in hospital admission for dehydration and hypernatremia. Observations showed that multiple residents were not consistently provided with drinks during meals, and staff interviews revealed confusion about fluid distribution and documentation. Resident complaints about lack of water were also noted, indicating a systemic failure to follow the facility's hydration policy.
A resident with multiple chronic conditions experienced a delay in UTI treatment due to the facility's failure to promptly obtain and report laboratory results to the provider. The order for a urinalysis and culture was not placed until two days after symptoms were noted, and the final lab results were not reported to the nurse practitioner for an additional three days, resulting in a delay in starting antibiotic therapy.
A resident with cognitive impairment and multiple health issues experienced an acute change in condition when their contracted left arm became flaccid and painful. Despite a hospice-ordered x-ray, the facility delayed the examination for five days, during which the resident continued to experience pain. The x-ray eventually revealed a left humerus fracture, leading to the resident's hospitalization. Interviews indicated a lack of communication and adherence to facility policy regarding the resident's care.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents receiving meals except one. An observation revealed an overflowing trash can, a cart with a thick scummy buildup, and a dirty kitchen floor with sticky areas and a coffee spill. The Dietary Manager confirmed that items on the cart were used for cooking and serving food and drinks to residents. This was found during a complaint investigation.
A resident's representative was not timely notified of a change in condition involving a flaccid left upper arm, which was observed during incontinence care. Despite hospice being informed and an x-ray being ordered, the resident's wife was not notified until several days later, contrary to facility policy requiring prompt notification.
Two residents experienced a failure in maintaining a clean environment, with one resident's room having a strong urine odor due to a saturated brief left by the previous shift, and another resident's room having a foul stool odor with visible stool smears. The facility's policy requires immediate removal of soiled briefs and cleaning of spills, which was not adhered to.
The facility failed to timely report and investigate incidents involving two residents. One resident, with dementia and on hospice, had an unexplained arm injury that was not reported to the State Survey Agency until days later, despite initial signs of injury. Another resident, with Alzheimer's, was involved in a verbal altercation, but the investigation was not completed within the required timeline. The facility's policy mandates immediate reporting and completion of investigations within five days, which was not followed.
A resident with dementia and on hospice care was found with a flaccid left arm, indicating a possible injury. The facility failed to conduct a thorough investigation, omitting hospice records and witness interviews, and delayed obtaining an x-ray that later revealed a fracture. The Director of Nursing confirmed these investigative omissions, which did not comply with the facility's policy.
A resident with a foot wound did not receive proper care as ordered by the physician. The resident's foot was lying directly on a malfunctioning mattress, and the required heel boot was not used. Staff were aware of the mattress issue but did not promptly notify the hospice provider, and the heel boot was unavailable without seeking alternatives. This non-compliance with physician orders and facility policy potentially impacted the wound's healing.
A resident with high fall risk and on hospice care fell during incontinence care due to inadequate assistance. The care plan required two staff members, but only one CNA was present, leading to the resident slipping off the bed and sustaining a head injury. The incident was documented, and medical attention was provided.
A facility failed to provide necessary incontinence care for a cognitively impaired resident with a history of cerebral infarction and dementia. The resident, who was always incontinent, was found with a soiled brief and saturated bedding, indicating a lack of timely care. Interviews revealed the resident was particular about who provided her care, and effective interventions were not in place to manage her preferences. The facility did not provide evidence of care being refused or performed by night shift staff.
A facility failed to assess and provide appropriate wound care for a resident with a groin condyloma, resulting in a deficiency. The resident had a large verrucous mass with drainage, but no comprehensive assessment or wound care orders were documented. Staff interviews revealed that the ADON did not assess the resident due to time constraints, and the LPN who admitted the resident failed to inform the physician about the drainage. The facility's wound care policy was not followed.
The facility failed to report multiple resident-to-resident physical altercations to the State Agency, affecting ten residents in the secured memory care unit. Despite the facility's policy requiring all abuse allegations to be reported, incidents involving residents with cognitive impairments and behavioral disturbances were not documented in the state database. The Director of Nursing confirmed the lack of reporting, possibly due to the absence of major injuries.
The facility failed to provide individualized care-planned interventions for residents, leading to multiple resident-to-resident altercations in the secured memory care unit. The care plans lacked specific interventions tailored to individual stressors and responses, affecting nine residents with behavioral health needs.
The facility failed to secure medications appropriately, affecting all 99 residents. Observations revealed unsecured medications in carts on both the third and first floors, confirmed by LPNs as needing to be discarded. This was contrary to the facility's policy requiring orderly storage of medications.
An LPN failed to sanitize blood sugar glucometers after use, affecting five residents with diabetes. The LPN admitted to not sanitizing the device initially and used an alcohol wipe instead of the required disinfectant wipe. The facility's policy mandates sanitizing glucometers after each use, which was not adhered to.
A resident with severe cognitive impairment and dysphagia was not assisted with eating his breakfast for over two hours due to staffing issues. The delay occurred because one STNA was absent, leaving others to manage additional duties. LPNs were also occupied with medication administration, resulting in the resident's meal being left untouched, contrary to the facility's dining policy.
The facility failed to maintain effective pest control in the kitchen, with gnats observed in the dish room over several days. Despite attempts to address the issue, there was a lack of communication and action among staff, leading to the exterminator being unaware of the problem until informed by a surveyor.
A resident with impaired cognition was found with medications left unattended in their room, despite not being authorized to self-administer. The facility's policy required medications to be locked or supervised, but five pills and an inhaler were found on the bedside table and floor. Staff confirmed the resident should not self-administer, indicating a lapse in policy adherence.
Failure to Identify and Document Pressure Ulcer Decline Resulting in Harm
Penalty
Summary
A deficiency occurred when facility staff failed to adequately and accurately identify, document, and respond to a significant decline in a resident's wound condition. The resident, who had diagnoses including Parkinson's disease, dementia, muscle weakness, and was dependent on staff for activities of daily living, was at risk for pressure ulcer development. Despite being identified as at mild risk for pressure ulcers and having a care plan that included interventions such as incontinence care, use of barrier cream, and weekly skin evaluations, the resident developed a wound that was initially documented as moisture-associated skin dermatitis (MASD) rather than a pressure ulcer. Wound assessments and progress notes indicated that the wound was described as MASD and treated accordingly, with no additional interventions implemented to address the resident's large, soft stools or to prevent prolonged moisture exposure. Staff interviews and text messages revealed that nursing staff were instructed to continue documenting the wound as MASD, despite observations that the wound had characteristics of a pressure ulcer, including necrosis, foul odor, and significant decline in condition. The wound nurse lacked official training or certification, and there was a lack of escalation or notification to the physician or responsible party regarding the true nature and severity of the wound. The resident was eventually transferred to the hospital with altered mental status, dehydration, malnutrition, and an unstageable pressure ulcer to the coccyx, which was found to be necrotic and infected. Hospital records and family interviews confirmed that the wound was severe and required surgical intervention, but the family declined surgery and opted for palliative care. The resident was admitted to hospice and subsequently passed away. The facility's failure to accurately assess, document, and communicate the decline in the resident's wound resulted in actual harm, as evidenced by the resident's hospitalization and subsequent death.
Failure to Conduct Routine Care Plan Conferences and Involve Resident Representatives
Penalty
Summary
The facility failed to ensure that routine care plan conferences were conducted for two residents with severely impaired cognition. For one resident with diagnoses including Parkinson's disease, schizophrenia, bipolar disorder, hypothyroidism, dementia, and muscle weakness, the care plan was updated multiple times, but the resident's Power of Attorney (POA) reported that no care conference had been held since March, despite attempts to contact the new Director of Social Services. The resident was unable to participate in care planning due to cognitive impairment, making POA involvement essential. Another resident with dementia, muscle weakness, hypertension, impulse disorder, and insufficient sleep syndrome had an admission care conference with their spouse, but no further care conferences were documented after the initial one, despite care plan updates. The spouse, listed as the responsible party, was not involved in subsequent care conferences. The Director of Social Services confirmed being behind on scheduling and conducting care conferences and was unaware of missed communications from the POA. Facility policy requires resident and representative participation in care planning to the extent practicable, with documentation if not possible, but this was not followed.
Failure to Notify Physician and Resident Representatives of Medication Refusals and New Orders
Penalty
Summary
The facility failed to notify residents' physicians and resident representatives of significant changes in condition and new medication orders for three residents. For one resident with intact cognition and diagnoses including bipolar and schizoaffective disorders, there were multiple refusals of a prescribed antipsychotic injection over several weeks. These refusals were documented in the Medication Administration Record, but there was no documentation in the progress notes regarding the refusals, nor evidence that the physician or family had been notified. Interviews with nursing staff and the Director of Nursing confirmed that the required notifications did not occur and were not documented. For two other residents with cognitive impairments and complex medical histories, new medication and treatment orders were initiated in response to changes in their conditions, such as skin rashes and inflammation. Progress notes documented the new orders but did not indicate that resident representatives had been informed of these changes. The Director of Nursing confirmed that there was no evidence of notification to the resident representatives, despite facility policy requiring such communication when there is a need to alter a resident's medical treatment.
Failure to Monitor Medication Consumption During Administration
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, left-sided weakness, dysphagia, and dementia was not properly monitored during medication administration. The resident had physician orders allowing medications to be crushed unless contraindicated and had an as-needed order for acetaminophen for pain. During an observation of wound care, the resident exhibited non-verbal signs of pain, prompting a nurse to instruct another nurse to administer pain medication as ordered. The nurse returned with crushed medication mixed in applesauce and administered it to the resident, then exited the room without confirming that the medication was swallowed. A registered nurse who remained in the room observed that the resident had not swallowed the medication and proceeded to manually massage the resident's throat to stimulate swallowing. The registered nurse stated that the nurse who administered the medication should have stayed to ensure the medication was swallowed before leaving the room. This failure to monitor medication consumption resulted in non-compliance with ensuring safe medication administration for the resident.
Failure to Complete Accurate and Thorough Fall Investigation
Penalty
Summary
The facility failed to ensure an accurate and thorough fall investigation was completed for a resident with significant medical needs, including Parkinson's disease, dementia, muscle weakness, and dependence on staff for activities of daily living. The resident was found on the floor with lacerations and abnormal vital signs, including tachycardia and hypoxia, and was subsequently transferred to a hospital. Documentation and interviews revealed discrepancies in the reported time of the fall and when emergency medical services (EMS) were contacted. The facility's records indicated the fall occurred at approximately 3:00 A.M., while the EMS report showed a call was placed before midnight, and staff reported the resident had been assisted back to bed prior to EMS arrival. The facility's fall investigation did not reconcile these conflicting time frames, and staff were unable to provide an explanation for the discrepancies. The facility's policy required a thorough interdisciplinary review of falls, including assessment of causal factors and environmental review, but the investigation lacked clarity and completeness regarding the circumstances and timing of the incident. This deficiency affected the resident's care and did not meet the facility's own standards for fall prevention and management.
Failure to Provide Adequate Incontinence and Skin Care
Penalty
Summary
A resident with a history of stroke, muscle weakness, and dementia was found to be incontinent of bowel and bladder and fully dependent on staff for toileting. The resident's care plan included interventions for incontinence care and the application of a skin barrier ointment after incontinence episodes to prevent skin breakdown. Physician orders specified cleansing the buttocks with soap and water and applying a thick zinc barrier every shift and as needed. During an observation of incontinence care, a large amount of dried stool was found in the crease of the resident's buttocks, and the bed linens were heavily soiled with dried urine and other debris, accompanied by a strong odor of urine. The certified nursing assistant (CNA) responsible for the resident reported having provided incontinence care approximately one hour prior to the observation. However, the CNA confirmed that she had not applied the required barrier cream after the last care episode and had not noticed the soiled linens at that time. There was no evidence of barrier cream residue on the resident during the observation, despite the resident being at risk for skin breakdown and having a care plan and physician order for its use. Facility policy required thorough cleansing of the rectal area and application of a moisture barrier if care planned, but these steps were not followed, resulting in inadequate incontinence care for the resident.
Failure to Provide Sufficient Fluids to Maintain Resident Hydration
Penalty
Summary
The facility failed to ensure that residents were consistently offered sufficient fluids to maintain proper hydration and health. One resident with diagnoses including Parkinson's, dementia, and muscle weakness was identified as having a high risk for dehydration, with a registered dietitian estimating daily fluid needs between 2040-2380 ml. However, the resident's diet orders only provided 1440 ml, and actual intake was significantly lower on several days prior to hospital transfer. The resident was admitted to the hospital with acute hypernatremia and dehydration, as confirmed by laboratory results and interviews with facility nursing leadership, who acknowledged the decreased fluid intake. Observations in multiple dining areas revealed that several residents did not have drinks provided during meals, and some reported being thirsty with empty cups. Staff interviews confirmed that water was not consistently passed out during meal times, and there was confusion about documentation of fluid intake. Resident Council meeting records also documented complaints about water not being provided. Despite staff re-education, observations continued to show that water was not reliably offered, and the facility's hydration policy requiring sufficient fluid intake was not followed.
Delay in Reporting Lab Results Led to Delayed UTI Treatment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that laboratory results were obtained and reported to the provider in a timely manner, which delayed treatment for a urinary tract infection (UTI). A resident with multiple diagnoses, including chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder, hyperlipidemia, anxiety, hypertension, and malignant neoplasm of the large intestine, exhibited symptoms of a UTI and was seen by a nurse practitioner, who ordered a urinalysis with culture and sensitivity (UA C&S). However, the order for the UA C&S was not placed until two days after the initial assessment, and the urine sample was collected and sent to the lab on the same day the order was placed. The urinalysis indicated infection, and the urine culture, received by the facility three days later, confirmed the presence of Escherichia coli ESBL. Despite receiving the final urine culture results, the facility did not report these results to the nurse practitioner until three days after they were available. Only then was an antibiotic ordered and started for the resident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the delay in reporting the abnormal laboratory results to the provider, and the ADON was unable to provide a reason for the delay. Facility policy required prompt notification of the provider when there was a need to alter medical treatment, including changes in provider orders.
Failure to Provide Timely Treatment for Resident's Acute Condition
Penalty
Summary
The facility failed to provide adequate, necessary, and timely treatment for a resident with cognitive impairment following an acute change in condition. The resident, who was dependent on staff for activities of daily living and had a history of senile degeneration of the brain, dementia with agitation, reduced mobility, age-related osteoporosis, and muscle wasting, experienced a significant change when their normally contracted left arm became flaccid and painful. Despite a hospice-ordered x-ray examination on the day of the change, the facility did not complete the x-ray until five days later, after a visiting hospice nurse identified continued pain and bruising. The resident's medical records indicated multiple physician orders for pain management, including Oxycodone, Acetaminophen, and Morphine. However, there was no evidence of follow-up monitoring, assessment, or treatment by facility staff for the resident's flaccid arm from the time of the initial observation until the x-ray was finally conducted. The x-ray revealed a left humerus fracture, and the resident was subsequently transported to the hospital for further evaluation and treatment. Interviews with facility staff and hospice personnel revealed a lack of communication and follow-through regarding the resident's condition and the x-ray order. The facility's Director of Nursing was unaware of the x-ray order, and there was confusion among staff about the resident's care needs and the hospice's instructions. The facility's policy on resident change in condition was not followed, contributing to the delay in addressing the resident's acute change in condition.
Unsanitary Kitchen Conditions Found During Investigation
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all residents receiving meals, except for one resident who was not receiving anything by mouth. During an observation on December 10, 2024, at 11:33 A.M., the kitchen was found to have an overflowing trash can with a swivel lid, confirmed by Food and Nutrition Aide #229. Further observation and interview with Dietary Manager #221 revealed a tall cart across from the tray line with pudding, silverware, cups, and cereal stored on its shelves. Each shelf and the four legs of the cart had a thick scummy buildup covered in thick dust particles. The kitchen floor was dirty with multiple sticky areas, and there was a large coffee spill under the coffee pot. DM #221 confirmed that the items stored on the shelves were used for cooking and serving food and drinks to the residents. This deficiency was discovered incidentally during a complaint investigation.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to timely notify the representative of Resident #67 of a change in condition, which was a deficiency identified during a survey. Resident #67, who was on hospice services for senile degeneration of the brain and dementia with agitation, was observed by a caregiver to have a flaccid left upper arm during incontinence care. The resident vocalized pain and showed a grimace, prompting LPN #279 to notify the nighttime supervisor and hospice. However, there was no evidence that Resident #67's representative was informed of this change in condition on the same day. The hospice coordination notes indicated that LPN #279 believed the resident's left arm/shoulder was dislocated, and an x-ray was ordered. Despite this, the resident's wife was not notified until several days later, when the x-ray was ordered, and she was unaware of the situation until contacted by Hospice LPN #402. The facility's policy required family notification as soon as the resident was stable, but this did not occur in a timely manner, leading to the deficiency noted in the report.
Failure to Maintain Clean Environment and Proper Incontinence Care
Penalty
Summary
The facility failed to maintain a clean environment free of foul odors, affecting two residents. Resident #5, who has bipolar type schizoaffective disorder and dementia, was found in a room with a strong urine odor. A saturated brief was discovered behind the entrance door, which had been left there since the previous shift. The CNA confirmed the presence of the odor and the brief's condition, indicating a lapse in proper disposal and room cleanliness. Resident #39, who is cognitively intact and requires assistance due to an amputation and muscle weakness, experienced a similar issue. A foul stool odor was detected emanating from the resident's room into the hallway. Inside, a soiled brief with stool was found in the trash can, and stool smears were visible on the floor. The CNA confirmed that the room was often in this condition at the start of her shift, and the resident expressed discomfort due to the odor. The DON stated that soiled briefs should be removed immediately, and spills should be cleaned promptly, as per the facility's policy.
Failure to Timely Report and Investigate Incidents
Penalty
Summary
The facility failed to timely report an injury of unknown origin for Resident #67 to the State Survey Agency and did not complete the self-report incident investigation within the required five-day timeline. Resident #67, who had diagnoses including senile degeneration of the brain and dementia with agitation, was on hospice services. On 11/21/24, during incontinence care, a caregiver observed Resident #67's left upper arm to be flaccid, and the resident vocalized pain. Despite notifying hospice and receiving orders to treat for pain, there was no follow-up on the condition until 11/26/24, when an x-ray revealed a humeral fracture. The facility reported the injury to the State Survey Agency on 11/26/24, but the initial signs of the injury were not addressed as an injury of unknown origin in the investigation. Resident #78, who had Alzheimer's disease and severe cognitive impairment, was involved in a verbal altercation with a visitor on 10/14/24. The facility's self-reported incident investigation for this event was not completed within the required five-day period, as it was initiated on 10/14/24 and completed on 10/22/24. The Assistant Administrator acknowledged the delay was due to an oversight caused by a busy schedule. The facility's policy requires that all allegations of abuse or injuries of unknown origin be reported immediately to the Administrator, Director of Nursing, and applicable State Agency, with investigations completed within five working days. The failure to adhere to these timelines represents non-compliance, as investigated under Complaint Number OH00160241.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, which was identified during a review of a self-reported incident. The resident, who was on hospice care for senile degeneration of the brain and dementia with agitation, was found with a flaccid left upper arm during incontinence care. Despite the observation of pain and grimacing, the initial report by the LPN to hospice did not result in immediate action, and the x-ray revealing a fracture was not conducted until several days later. The facility's investigation into the incident was incomplete, as it lacked hospice records, did not address the initial findings by the LPN, and failed to include witness interviews. The Director of Nursing confirmed these omissions, acknowledging that the investigation did not comply with the facility's policy, which requires a comprehensive investigation including witness interviews and documentation of all medical reports. This deficiency was identified under Complaint Number OH00160241.
Failure to Implement Physician Orders for Wound Care
Penalty
Summary
The facility failed to implement physician orders to promote the healing of a wound on a resident's foot. The resident, who was admitted with diagnoses including senile degeneration of the brain and dementia, was dependent on staff for various activities, including personal hygiene and bed mobility. The resident had a skin tear on the left medial bunion, which was being treated with specific wound care orders, including the use of heel lift boots to offload pressure and promote healing. During observations, it was noted that the resident's left foot was lying directly on a malfunctioning low air loss mattress, which was partially deflated and beeping due to low pressure. The resident did not have the ordered heel boot on the left foot, and the wound was in direct contact with the mattress. Staff interviews revealed that the mattress had been malfunctioning for several days, and the hospice provider had not been notified promptly. Additionally, the heel boot was not available, and staff did not seek an alternative from the therapy department. The facility's policy on skin and wound care best practices required that pressure injuries and wounds be treated with evidence-based interventions as ordered by the provider. However, the failure to ensure the resident had the necessary pressure-relieving equipment and the delay in addressing the malfunctioning mattress contributed to non-compliance with the physician's orders and the facility's policy, potentially impacting the healing of the resident's wound.
Inadequate Assistance During Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received appropriate assistance during incontinence care, leading to an accident. Resident #67, who was on hospice services for senile degeneration of the brain and had a high risk for falls, was dependent on staff for toileting hygiene and bed mobility. The care plan for Resident #67 included the need for two staff members during incontinence care and repositioning. However, on the day of the incident, only one Certified Nursing Assistant (CNA) was present during incontinence care. As the CNA attempted to turn Resident #67 in bed, the resident's feet began to slip off the bed, resulting in a fall. The incident resulted in Resident #67 hitting their head and sustaining a skin tear with bruising and a bump. The CNA was unable to prevent the fall despite trying to use her body to stop it. The resident experienced generalized pain and required medical attention, including the application of steri strips to the skin tear. The incident was documented, and the physician and resident representative were notified. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with ensuring adequate supervision and assistance to prevent accidents.
Inadequate Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary incontinence care for Resident #11, who was cognitively impaired and dependent on staff for incontinence management. Resident #11 had a history of cerebral infarction, hemiplegia, aphasia, dementia, and muscle weakness, and was always incontinent of bowel and bladder. The care plan for Resident #11 required incontinence care after each episode, but observations revealed that the resident was found with a soiled brief and saturated bedding, indicating a lack of timely care. The resident's room had a strong foul urine odor, and the resident had moisture-associated skin damage (MASD) to the gluteal fold and bilateral buttocks, which was stable but not improving. Interviews with staff revealed that Resident #11 was particular about who provided her care, allowing only certain CNAs to assist her. CNA #290, who was assigned to Resident #11, had not provided incontinence care since the start of her shift, and there was no evidence that the resident had refused care during that time. The Director of Nursing stated that residents should be checked and changed every two hours, but the Assistant Director of Nursing confirmed that effective interventions were not in place to manage the resident's care preferences. The facility did not provide evidence of incontinence care being refused or performed by night shift staff prior to the morning shift.
Failure to Assess and Provide Wound Care for Resident with Groin Condyloma
Penalty
Summary
The facility failed to ensure appropriate assessments and care for a resident with a groin condyloma, which is a type of genital wart. The resident had a history of a large verrucous mass surrounding the penis, which was noted to have oozing and bloody drainage. Despite the presence of this condition, there was no comprehensive assessment or wound care orders documented in the resident's medical record during their stay at the facility. The resident had been admitted with multiple diagnoses, including condyloma latum, muscle weakness, and malignant neoplasm of the esophagus. Interviews with facility staff revealed that the Assistant Director of Nursing did not assess the resident for wounds due to time constraints and was unaware of any existing wounds. The LPN who admitted the resident noticed the dressing on the groin area and the clear fluid drainage but failed to inform the physician to obtain appropriate dressing orders. The facility's Skin and Wound Care Best Practices policy, which aims to provide evidence-based preventative skin care and wound treatment, was not adhered to in this case, leading to the deficiency.
Failure to Report Resident Altercations
Penalty
Summary
The facility failed to report resident-to-resident physical altercations to the State Agency as required, affecting ten residents in the secured memory care unit. The incidents involved residents with various cognitive impairments and behavioral disturbances, leading to physical altercations that were not reported to the Ohio Department of Health's Enhanced Information Dissemination Collection System (EIDC). Despite the facility's policy requiring all allegations of abuse to be reported, these incidents were not documented in the EIDC database. One incident involved a resident with Alzheimer's disease and dementia who was physically assaulted by another resident, resulting in a bruise and droopy eye. Although the local police and responsible party were notified, the incident was not reported to the state. Another case involved a resident with paranoid schizophrenia who was attacked by a resident with severe cognitive impairment, leading to a nosebleed and the need for staff intervention. This altercation was also not reported to the state. Additional incidents included a resident being struck in the mouth, another being hit in the face, and a resident being thrown to the floor. In each case, the facility's staff separated the residents and notified responsible parties, but failed to report the incidents to the state agency. The Director of Nursing, who had recently been promoted, confirmed that these incidents were not reported, possibly due to the absence of major injuries, despite the facility's policy requiring such reports.
Lack of Individualized Care Plans Leads to Resident Altercations
Penalty
Summary
The facility failed to ensure individualized care-planned interventions were in place to prevent resident behaviors resulting in resident-to-resident altercations on the secured memory care unit. This deficiency affected nine residents who were reviewed for behavioral health services. The care plans for these residents lacked specific interventions tailored to their individual stressors and responses, which contributed to multiple incidents of physical altercations between residents. For instance, Resident #28, diagnosed with Alzheimer's disease and other mental health disorders, was involved in a physical altercation with Resident #69 due to noise on the unit. The care plan for Resident #28 included general interventions but did not specify individualized stressors or responses. Similarly, Resident #30, with a history of dementia and behavioral disturbances, was involved in an altercation with another resident, yet their care plan also lacked specific triggers and responses. Other residents, such as Resident #39, #48, #57, #58, #69, #77, and #85, also experienced similar issues where their care plans did not include individualized interventions to manage and modify behaviors. These deficiencies were confirmed through interviews with MDS coordinators and nursing staff, who acknowledged the lack of individualization in the care plans and the ongoing efforts to improve them.
Failure to Secure Medications in Facility
Penalty
Summary
The facility failed to secure medications appropriately, which had the potential to affect all 99 residents residing in the facility. During an observation on the third floor, a medication cart was found with 14 unsecured unidentified medications. An LPN verified that these loose medications should be discarded. A subsequent observation on the same floor revealed another medication cart with 19 unsecured unidentified medications, which was again confirmed by an LPN as needing to be discarded. Additionally, on the first floor, a medication cart was observed with 9 unsecured unidentified medications, with an LPN verifying the need for these medications to be discarded. The facility's policy titled 'Storage and Expiration Dating of Medications and Biologicals,' dated 2024, requires staff to ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, and refrigerators. The observations indicate a failure to adhere to this policy, as medications were not stored securely in the medication carts.
Failure to Sanitize Glucometers
Penalty
Summary
The facility failed to appropriately sanitize blood sugar glucometers, which had the potential to affect five residents who required blood sugar testing and monitoring. During an observation, an LPN was seen checking a blood glucose level for a resident and then placing the glucometer back in the medication cart without sanitizing it. Upon interview, the LPN confirmed that she did not sanitize the glucometer initially and then proceeded to clean it with an alcohol wipe, stating that bleach wipes were too strong for cleaning. This LPN was responsible for conducting blood sugar checks for five residents. The medical records of the affected residents revealed that they all had diagnoses of type two diabetes mellitus, with varying cognitive statuses. Each resident had specific orders for blood sugar testing, ranging from daily to three times a day. The facility's policy, dated 2020, required staff to sanitize the glucometer with a disinfectant wipe after each use, which was not followed in this instance.
Resident Meal Assistance Delay
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple medical conditions, including dysphagia, was assisted with eating his meal in a timely manner. The resident required substantial assistance with meals due to his condition, as indicated in his Minimum Data Set (MDS) assessment and care plan. On the day of the observation, the resident's breakfast tray was left untouched for approximately two hours and fifteen minutes before he was assisted with eating. This delay occurred because one of the State Tested Nursing Assistants (STNAs) assigned to the third floor did not arrive on time, leaving the remaining staff to manage additional responsibilities. The STNA who was present prioritized her assigned residents and then began assisting those assigned to the absent STNA. Licensed Practical Nurses (LPNs) on the floor were also occupied with their duties, including medication administration, and did not assist the resident with his meal. The facility's policy on dining experience at mealtimes requires staff to assist residents with their meals promptly, which was not adhered to in this instance. The deficiency was identified during a complaint investigation, highlighting a lapse in the facility's adherence to its dining policy.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control management system, specifically related to the presence of gnats in the kitchen, which has the potential to affect all 99 residents who receive meals from the kitchen. During an initial tour of the kitchen, approximately 10 gnats were observed flying around near the exit door in the dish room. This observation was confirmed by the Food Service Director (FSD). Subsequent observations on the following days revealed that gnats were still present in the dish room area, and these observations were confirmed by the Regional Dietitian and another staff member. Interviews with facility staff revealed a lack of communication and action regarding the ongoing gnat issue. The FSD had attempted to address the problem by power washing the dish room but did not notify the maintenance director or administrator about the continued presence of gnats. The Maintenance Director was unaware of the issue until informed by the surveyor, and the Assistant Administrator was also not aware of the problem. The exterminator, who visits the facility monthly, confirmed that the facility had been experiencing an ongoing issue with fruit flies, which had worsened in the past month. However, the exterminator had not been notified of the current concerns until after the surveyor's observation.
Medication Storage Deficiency in Resident Room
Penalty
Summary
The facility failed to ensure medications were not left unattended in resident rooms, specifically affecting one resident with impaired cognition. The resident, who had diagnoses including congestive heart failure, hypertension, chronic obstructive pulmonary disease, and acute kidney disease, was not supposed to self-administer medications. Despite this, an observation revealed five pills and an inhaler left unattended in the resident's room. The medications identified were Farxiga, aspirin, isosorbide mononitrate, Lisinopril-Hydrochlorothiazide, and a Symbicort inhaler. The facility's policy required all drugs to be maintained under locked security unless under direct supervision of a nurse. However, the medications were found on the bedside table and floor, indicating a lapse in adherence to this policy. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the resident was not to self-administer medications and that nurses were responsible for ensuring medications were taken under supervision. This incident highlights a failure in following the facility's drug storage regulations.
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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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